Govt.

College of nursing, Siddhpur

Subject: Obstetrics Nursing
Topic: High risk Pregnancy

• Submitted to: Miss Tejal • Submitted by: Shwetal

Patel Panchal

• Principal of GCONS • 4th year b. Sc. Nursing

• Roll no. :16
 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 20-30℅ pregnancies belong to this category.
• If we desire to improve obstetrics results, this group
must be identified and given extra care.
 Cont...

• Even with adequate antenatal and intranatal care, this

small group is responsible for the 70-80% of perinatal
mortality and morbidity.
• Majority(70-90%) of fetal deaths occur before the
onset of labor due to chronic asphyxia(30℅) ,
congenital malformation(15℅) and with some
superimposed complications of pregnancy(30℅).
 DEFINITION

• “High-risk pregnancy is defined as the one

where pregnancy is complicated by a factor or factors
that adversely affect the outcome-maternal Or perinatal
or both. ”
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 peripheral health
center.
• Some risk factors may later appear and are detected at
subsequent visits.
 Cont...
• The cases are also reassessed near term and again in
labor for any new risk factors.
• The neonates are also assessed very soon after delivery
for any high-risk factor.
• It is obvious that all abnormalities don’t carry the same
risk; some have a lower risk as compared to others
carrying a very high-risk for the mother or the fetus.
 INITIAL SCREENING

• HISTORY:
• Maternal age – pregnancy is safest between the age of
20-29 year.
• Reproductive history -
• Pre-eclampsia, Eclampsia
 Cont...

• Anemia
• Third stage abnormality (PPH)
• Previous infant with Rh-isoimmunization or ABO
incompatibility
• Medical or surgical disorder
• Psychiatric illness
 Cont...

• Cardiac disease
• Viral hepatitis
• Previous operation:-
• Myomectomy
• Repair of complete perineal tear
• Repair of vesicovaginal fistula
 Cont...

• Family history-
• Socio economic status
• Family history of diabetes
• Hypertension
• Multiple pregnancy
• Congenital malformation
 High risk cases
• During pregnancy :
• Elderly primigravida (≥30 years)
• Short statured primi (≤140 cm)
• Threatened abortion and APH
• Malpresentations
• Pre-eclampsia and eclampsia
 Cont...
• Elderly grand multiparas
• Twins and hydramnios
• Previous stillbirth , IUD, manual removal of placenta
• Prolonged pregnancy
• History of previous cesarean section and instrumental
delivery
• Pregnancy associated with medical diseases
• During labor-

• PROM
• Prolonged labor
• Hand, feet or cord prolapse
• Placenta retained more than half an hour
• PPH
• Puerperal fever and sepsis
• 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, anemia, Rh-
isoimmunization, high fever, pyelonephritis, hemorrhage,
diabetes mellitus, large uterus; lack of uterine growth,
postmaturity; abnormal presentation, twin and history of
exposure to drugs or radiation, acute surgical problems.
• Complications of labor:

• Patients having no antenatal care

• Anemia, pre-eclampsia or eclampsia
• Premature or prolonged rupture of membranes
• Amnionitis
• Meconium-stained liquor
• Abnormal presentation and position
• Disproportion, floating head in labor
• Multiple pregnancy
• Premature labor
• Abnormal fetal heart rate
• Patients admitted with prolonged or obstructed labor
• Rupture uterus
• Patients having induction or acceleration of labor
• Certain complications may arise during labor and place
the mother or baby at high risk :
• Examples are:
• Intrapartum fetal distress
• Delivery under general anesthesia
• Difficult forceps or breech delivery
• Failed forceps
• Postpartum hemorrhage or retained placenta
 Cont...

• Prolonged interval from the diagnosis of fetal distress

to delivery.
• If more than 30 minutes elapse from the recognition of
fetal distress to delivery, the mortality increases three-
folds.
• Postpartum complications:

• An uneventful labor may suddenly turn into an

abnormal one in the form of,
• PPH-retained placenta
• Shock
• Inversion
• Sepsis may develop later on.
• High risk for neonate:

• Apgar score below 7

• Hypoglycemia
• Anemia
• Birth weight less than 2500 gm or more than 4 kg
• Major congenital abnormalities
• Convulsions
• Fetal infection
• Jaundice
• Respiratory distress syndrome
• Peraistent cyanosis
• Hemorrhagic diathesis
 Management of high-risk cases

• If we desire to improve our obstetrics results, the high-

risk cases should be identified nd given proper
antenatal, intranatal and neonatal care.
• This is not to say that healthy uncomplicated cases
should not get proper attention.
• But, in general, they need not be admitted to
specialized centers and their care can be left to properly
trained midwives and medical officers in health centers,
or general practitioners.
• It is necessary that all expectant mothers are covered by
the obstetric service of a particular area.
• The service of trained community health workers and
assistant nurse-cum—midwiwife of health centers
should be utilized to provide the primary care and
screening in rural areas and urban areas and semiurban
pockets.
• A simple checklist should be prepared for them to fill up;
arrangement should be made for early examination of
the high-risk cases by medical officers of health centers
in the health center itself or in small community
antenatal clinics situated in different rural area, catering
to a small group of population.
• The general practitioner or medical officer of health
centers, in collaboration with the specialists, will decide
what type of cases can be managed at home or health
centers.
• Cases with a significantly higher risk should be referred to
specialized centers.
• Cases having previous unsuccessful pregnancy should be
seen and investigated before another conception occurs.
• Investigations like hysterography, hysteroscopy,
laparoscopy or transvaginal ultrasonography should be
performed to rule out mullerian abnormality.
• Complete investigations for hypertension, diabetes, kidney
disease or thyroid disorders should be treated before
embarking on another pregnancy.
• Sexually transmitted diseases should be treated before
embarking on another pregnancy.
• Cervical tears should also be repaired in the
nonpregnant state.
• Serology for toxoplasma IgG, IgM and
antiphospholipid antibodies should be done and
corrected appropriately when found positive.
• Folic acid ( 4mg/day ) therapy should be started in the
prepregnant state and is continued throught pregnancy.
• Necessary advice should be given regarding diet,
activities, rest and medicines.
• Minimum medicines should be taken during pregnancy,
particularly in the early months.
 Organizational aspects Of management

• Strengthen midwifery skills, community participation

and referral system.
• Proper training of residents, nursing personnel and
community health workers.
• Arranging periodic seminars, refresher courses with
participation of workers involved in the care of these
cases.
• Concentration of cases in specialized centers for
management.
• Commumity perception, proper utilization of health
care manpower and financial resources, where it is
mostly needed.
• Availability of perinatal laboratory for necessary
investigations; availability of a good pediatric service
for the neonates.
• Lastly, improvement of literary rate, health awareness
of the community and economic status.
 Management of Labor
• It is evident that elective cesarean section is necessary in a
High-risk case.
• Some cases may need induction of labor after 37-38
completed weeks of gestation.
• Those cases who go into labor spontaneously or after
induction, need close monitoring during labor for the
assessment of progress of labor or for any evidence of the
fetal hypoxia.
• The condition of the fetus can be assessed by-

• Fetal heart rate monitoring:By stethoscope, fetoscope

or Doppler-continuous electronic monitoring
• Passage of meconium in the liquor
• Examination of fetal scalp bleed for pH values
• If there is any evidence of fetal anoxia in the first stage
or there is failure to progress, cesarean section is
necessary.
• The condition of the neonate is assessed immediately
after delivery.
• Many of these babies need expert neonatal care.
Delivery is conducted in an Institute with equipped
neonatal care unit.