IDENTIFYING CLIENTS

AT RISK
PRESENTED BY:
ROSELLE JOY C. BALAQUIT, RN
 IDENTIFYING CLIENTS AT RISK

Assessment of risk factors

Screening procedures
Diagnostic tests and laboratory
exams
Introduction
• All pregnancies and deliveries are potentially at risk.
However, there are certain categories of pregnancies where
the mother, the fetus or the neonate is in a state of increased
jeopardy.
• About 20 to 30 percent pregnancies belong to this category.
• Though all mothers and children are vulnerable to disease or
disability, there are certain mothers and infants who are at
increased or special risk of complications of
pregnancy/labor or both. If we desire to improve obstetric
results, this group must be identified and given extra care.
Definition
• “A risk factor is defined as any ascertainable
characteristic or circumstance of a person (or group
of such persons) known to be associated with an
abnormal risk of developing or being adversely
affected by a morbid process” -(WHO, 1973).
• High risk pregnancy is defined as one which is
complicated by factor or factors that adversely affects
the pregnancy outcome –maternal or perinatal or
both.
Assessment, Screening & Risk Approach
• Assessment- is a process for defining the nature of
that problem, determining a diagnosis, and developing
specific treatment recommendations.
• Screening- is a process of identifying apparently
healthy people who may be at increased risk of a
disease or condition.
-They can then be offered information,
further tests and appropriate treatment to reduce their
risk and/or any complications arising from the disease
or condition.
Screening of high risk cases-
• The cases are assessed at the initial antenatal
examination, preferably in the first trimester of
pregnancy.
• This examination may be performed in a big institution
(teaching or non-teaching) or in a public health centers.
• Some risk factors may later appear and are detected at
subsequent visits.
• The cases are also reassessed near term and again in
labor for any new risk factors.
Risk approach (according to WHO)
• The main objective of the risk approach is the
optimal use of existing resources for the benefit of
the majority. It attempts to ensure a minimum of care
for all while providing guidelines for the diversion of
limited resources to those who most need them.
• Inherent in this approach is maximum utilization of
all resources, including some human resources, that
are not conventionally involved in such care e.g.,-
TBA, women’s group.
 High risk cases (According to WHO)
During pregnancy
• Elderly primigravida (≥30 years) & Elderly grand multiparas
• Short statured primi (≤ 140 cm)
• Threatened abortion and APH
• Malpresentations & Malpositions
• Pregnancy associated with medical diseases (like PIH, metabolic
disorders, and/or any systemic co-morbidities)
• Twins and hydramnios
• Previous still birth, IUD, manual removal of placenta
• Prolonged pregnancy
• History of previous caesarean section and instrumental delivery
 High risk cases (According to WHO)
During labor
• PROM
• Prolonged labor
• Hand, feet or cord prolapse
• Placenta retained more than half an hour
• PPH
• Puerperal fever and sepsis.
 High risk cases (According to WHO)
Course of the present pregnancy
• The cases should be reassessed at each antenatal visit
to detect any abnormality that might have arisen
later.
• Few examples are- pre-eclampsia, anemias, Rh-
isoimmunization, high fever, pyelonephritis,
hemorrhage, diabetes mellitus, large uterus, lack of
uterine growth, post maturity, abnormal presentation,
twins and history of exposure to drugs or radiation,
acute surgical problems.
 High risk cases (According to WHO)
Complications of labour
Anemia, pre- eclampsia or eclampsia Premature labour
PROM Abnormal FHR
Amnionitis admitted with prolonged labor
Abnormal presentation and position Obstructed labour
Disproportion, floating head in labour Rupture uterus
Multiple pregnancy having induction or acceleration of
labor
 High risk cases (According to WHO)
Certain complications may arise during labour and place the
mother or baby at a high risk
• Intrapartum fetal distress
• Difficult forceps or breech delivery
• Prolonged interval from the diagnosis of fetal
distress to delivery.
• PPH or retained placenta
• Postpartum complications
 High risk cases (According to WHO)
uneventful labour may suddenly turn into an abnormal one in the
form of

•PPH
•Retained placenta
•Shock
•Inversion
•Sepsis may develop later on
 SCREENING/ ASSESSMENT
• Initial screening History
• Maternal age • Psychiatric illness
• Reproductive history
• Cardiac disease
• Pre-eclampsia, eclampsia
• Anemia • Viral hepatitis
• Third stage abnormality • Previous operations
• Previous infant with Rh- • Myomectomy
isoimmunization or ABO • Repair of complete
incompatibility perineal tear
• Medical or surgical disorders • Repair of vesico-vaginal
fistula
 Family history
•Socio-economic status
•Family history of diabetes
•hypertension
•multiple pregnancy (maternal side)
•congenital malformation.
 Family history
•Socio-economic status
•Family history of diabetes
•hypertension
•multiple pregnancy (maternal side)
•congenital malformation.
 DIAGNOSTIC TESTS
- Are tests done to establish the presence (or absence)
of disease as a basis for treatment decisions in
symptomatic or screen positive individuals
(confirmatory test).
DIAGNOSTIC TESTS FOR HIGH RISK
PREGNANCY
•Non-invasive diagnostic tests
Fetal ultrasound or ultrasonic testing
Cardiotocography(CTG)
Non-stress test (NST)
Contraction stress test (CST)
DIAGNOSTIC TESTS FOR HIGH RISK
PREGNANCY
•Invasive diagnostic tests
Chorionic villus sampling
Amniocentesis
Embryoscopy
Fetoscopy
Percutaneous umbilical cord blood sampling.
NON-INVASIVE DIAGNOSTIC TESTS
ULTRASONOGRAPHY
-which measures the response of sound waves against solid objects, is a
much-used tool in modern obstetrics, although the recommendations
for its use are being questioned because of unproven benefits in the
face of added expense (Neilson, 2009). It can be used to:
• Diagnose pregnancy as early as 6 weeks’ gestation
• Confirm the presence, size, and location of the placenta and amniotic
fluid
• Establish that a fetus is growing and has no gross anomalies, such as
hydrocephalus, anencephaly, or spinal cord, heart, kidney, and bladder
defects
• Establish sex if a penis is revealed
• Establish the presentation and position of the fetus
• Predict maturity by measurement of the biparietal diameter of the
head
• can also be used to discover complications of pregnancy,
such as the presence of an intrauterine device, hydramnios
or oligohydramnios, ectopic pregnancy, missed miscarriage,
abdominal pregnancy, placenta previa, premature separation
of the placenta, coexisting uterine tumors, multiple
pregnancy, or genetic disorders such as Down syndrome.
• fetal anomalies such as neural tube disorders, diaphragmatic
hernia, or urethral stenosis also can be diagnosed.
• fetal death can be revealed by a lack of heartbeat and
respiratory movement.
• after birth, an ultrasound may be used to detect a retained
placenta or poor uterine involution in the new mother.
intermittent sound waves of high frequency (above the
audible range) are projected toward the uterus by a
transducer placed on the abdomen or in the vagina
sound frequencies that bounce back can be displayed on an
oscilloscope screen as a visual image
frequencies returning from tissues of various thicknesses
and properties present distinct appearances
a video or photograph can be made of the scan
B-mode scanning- gray-scale imaging
Real-time mode- whole fetal imaging in real-time
intermittent sound waves of high frequency (above the
audible range) are projected toward the uterus by a
transducer placed on the abdomen or in the vagina
sound frequencies that bounce back can be displayed on an
oscilloscope screen as a visual image
frequencies returning from tissues of various thicknesses
and properties present distinct appearances
a video or photograph can be made of the scan
B-mode scanning- gray-scale imaging
Real-time mode- whole fetal imaging in real-time
1st-trimester fetal ultrasound is done to:
•Determine how pregnancy is progressing.
•Find out if female is pregnant with more than 1
fetus.
•Estimate the age of the fetus (gestational age).
•Estimate the risk of a chromosome defect, such
as Down syndrome.
•Check for birth defects that affect the brain or
spinal cord.
2nd-trimester fetal ultrasound is done to:
•Estimate the age of the fetus (gestational age).
•Look at the size and position of the fetus,
placenta, and amniotic fluid.
•Determine the position of the fetus, umbilical
cord, and the placenta during a procedure, such
as an amniocentesis, camera.gif or umbilical
cord blood sampling.
•Detect major birth defects, such as a neural tube
defect or heart problems.
3rd-trimester fetal ultrasound is done to:
•Make sure that a fetus is alive and moving.
•Look at the size and position of the fetus,
placenta, and amniotic fluid.
 CARDIOTOCOGRAPHY(CTG)
-recording (-graphy),
-fetal heartbeat (cardio-)
-uterine contractions (-toco-)
-during pregnancy, typically in the third
trimester. The machine used to perform
the monitoring is called a cardiotocograph,
more commonly known as an electronic fetal
monitor (EFM)
 FETAL HEART RATE AND UTERINE
CONTRACTION RECORDS
 monitors trace both the FHR and the duration and interval of uterine contractions
onto an oscilloscope screen and produce a permanent record on paper rolls.
Fetal Heart Rate Patterns:
 Baseline Fetal Heart Rate
 Variability
 Periodic Changes
Accelerations.
Accelerations.
Late Decelerations.
Prolonged Decelerations.
Variable Decelerations.
 Sinusoidal Fetal Heart Rate Pattern
Baseline Fetal Heart Rate- determined by analyzing the
range of fetal heartbeats recorded on a 10-minute tracing
that was obtained between contractions.
- normal rate is 120 to 160 bpm
- fluctuates slightly (5 to 15 bpm) when a fetus
moves or sleeps
- abnormal patterns in the baseline rate include fetal
bradycardia and fetal tachycardia
 - moderate bradycardia of 100 to 119bpm is not
considered serious and is probably because of a vagal
response elicited by compression of the fetal head
during labor
- marked bradycardia (less than 100 bpm) is a sign of
possible hypoxia and is potentially dangerous
- moderate tachycardia is 161 to 180 bpm
- marked fetal tachycardia may be caused by fetal
hypoxia, maternal fever, drugs, fetal arrhythmia, or
maternal anemia or hyperthyroidism
Variability- the variation or differing rhythmicity in the heart
rate over time and is reflected on the FHR tracing as a slight
irregularity or “jitter” to the wave
 Periodic Changes

Accelerations-Nonperiodic accelerations are temporary normal

increases in FHR caused by fetal movement change in maternal
position, or administration of an analgesic.
Early Decelerations- are normal periodic
decreases in FHR resulting from pressure on the fetal head
during contractions

Late Decelerations- are delayed until 30 to 40 seconds after the

onset of a contraction and continue beyond the end of a
contraction
 Periodic Changes

Early Decelerations- are normal periodic

decreases in FHR resulting from pressure on the fetal head during
contractions

Late Decelerations- are delayed until 30 to 40 seconds after the

onset of a contraction and continue beyond the end of a
contraction
 Periodic Changes

Prolonged Decelerations- are decelerations that last longer

than 2 to 3 minutes but less than 10 minutes

Variable Decelerations- refers to decelerations that occur at

unpredictable
times in relation to contractions
Sinusoidal Fetal Heart Rate Pattern

-a fetus who is severely anemic or hypoxic, central

nervous system control of heart pacing may be so
impaired that the FHR pattern resembles a
frequently undulating wave
 NON-STRESS TEST(NST)
• A nonstress test is a common prenatal test used to check
on a baby's health. During a nonstress test, also known as
fetal heart rate monitoring, a baby's heart rate is
monitored to see how it responds to the baby's
movements.
• Typically, a nonstress test is recommended for women at
increased risk of fetal death. A nonstress test is usually
done after week 26 of pregnancy. Certain nonstress test
results might indicate that client and baby need further
monitoring, testing or special care.
 CONTRACTION STRESS TEST(CST)
 It is performed near the end of pregnancy to
determine how well the fetus will cope with the
contractions of childbirth.
 The aim is to induce contractions and monitor
the fetus to check for heart rate abnormalities
using a cardiotocograph.
 CONTRACTION STRESS TEST(CST)
 It is performed near the end of pregnancy to
determine how well the fetus will cope with the
contractions of childbirth.
 The aim is to induce contractions and monitor
the fetus to check for heart rate abnormalities
using a cardiotocograph.
INVASIVE DIAGNOSTIC TESTS
 CHORIONIC VILLI SAMPLING

 Chorionic villi are small structures in the placenta that

act like blood vessels.
 These structures contain cells from the developing
fetus. A test that removes a sample of these cells
through a needle is called chorionic villus sampling
(CVS).
 CVS is a form of prenatal diagnosis to determine
chromosomal or genetic disorders in the fetus.
 AMNIOCENTESIS
 a test that can be done during pregnancy to look for
birth defects and genetic problems in the developing
baby
 the withdrawal of amniotic fluid through the
abdominal wall for analysis at the 14th to 16th week of
pregnancy (Alfirevic, Mujezinovic, & Sunberg, 2009)
 removes a small amount of fluid (200mL) from the sac
around the baby in the womb (uterus).
 most often offered to women who are at increased risk
for bearing a child with birth defects.
 has the advantage over CVS of carrying only a 0.5%
risk of spontaneous miscarriage
 Women with an Rh-negative blood type need Rh
immune globulin administration after the procedure to
protect against isoimmunisation in the fetus
 women need to be observed for about 30 minutes after
the procedure to be certain that labor contractions are
not beginning and that the fetal heart rate remains
within normal limits
 PERCUTANEOUS
UMBILICAL BLOOD
SAMPLING (PUBS)
 or cordocentesis, is the removal
of blood from the fetal umbilical
cord at about 17 weeks using an
amniocentesis technique
 allows analysis of blood
components as well as more
rapid karyotyping than is
possible when only skin cells are
remove
 FETOSCOPY
 is the insertion of a fiberoptic
fetoscope through a small
incision in the mother’s abdomen
into the uterus and membranes
to visually inspect the fetus
 can be used to confirm an
ultrasound finding, to remove
skin cells for DNA analysis, or to
perform surgery for a congenital
disorder such as a stenosed
urethra.