Detecting

High Risk Pregnancy

Dr. Varsha L. Deshmukh

Assoc. Prof & Unit Incharge
Govt. Medical College,
AURANGABAD
 Introduction
• Pregnancy including labour & delivery is itself
a high risk event.
• The aim of risk assessment is to identify the
factors that may constitute greater than
average risk to a pregnancy.
• This permits the prediction of potential
adverse pregnancy outcomes & enables the
process of selecting women who may benefit
from extra researches.
 Receiving quality antenatal,
intranatal & postnatal services
is one of the reproductive
rights of women
 Introduction
• It is impossible for the process of risk
assessment to predict every perinatal event.
• WHO recommends that a risk assessment
approach be used in the mgt. of maternal,
fetal health care.
• It also suggest arrangement for delivery at
tertiary care center for high risk obst. pts.
.
 Aim

• To identify women with maternal

complications & obst. risk factors.
 Why to Identify or
Detect Women with
High Risk Factors
• It will reduce the number of cases
brought in a state of emergency when
t/t is most difficult & least effective.
• If t/t is started in time, it is possible to
save life of both mother & baby.
• Timely referral after appropriate
medication is important improving the
prognosis.
 Maternal Mortality

Major causes of maternal mortality are

• PIH
• Eclampsia
• APH
• PPH
• Puerperal sepsis
• Obstructed labour
• Unsafe abortions
Maternal mortality is a gender issue
& speaks about the status of women
in the society.

Maternal mortality is an equity issue

as maximum maternal death are
reported from people living below
poverty line from under privilege
community
Except for hemorrhage other causes of
maternal mortality can be identified &
treated effectively, thus maternal
mortality can be greatly reduced.
 Obstetric Emergencies
The obst. emergencies are life threatening
• Fatality rate is more
• Difficult to treat
• Surgery rate is increased
• BT rate is increased
• Hospitalization prolonged
• Morbidity more
 Cost Effectiveness
• Early diagnosis leads to less
emergencies hence less drug
requirement & less morbidity
• Thus the risk assessment system along
with timely referral is highly cost
effective.
 What to Do ?
1. Early diagnosis
2. Community awareness about
antenatal care
3. Early initiation of appropriate therapy
4. T/t plan stream lining
5. Early identification
6. Timely referral
 What to Tell ?
Every clinic must emphasize the following
1. ANC it is essential need
2. Eat more
3. Rest more
4. Get immunized (Inj TT)
5. Take Tab. FS
6. Hospital delivery
 Ante-natal care
• Periodic check-ups
• Risk factors identified on time
• Treatment started early
• Hospital delivery
• Maternal complications diagnosed early
• Maternal & fetal mortality less
 Early Registration
• Early – before 12 wks (preferably)
• Before 20 wks
• At 32 wks
• At 36 wks
• Encourage to visit more often in 3 rd
trimester
 ANC
• Careful history
• Physical examination
• Pregnancy progressing normally
• Complications if occurs diagnosed early
• Timely referral
• Institutional delivery
 History
• LMP/EDD
• Age of the patient < 18 yrs. > 35
yrs.
• Order of pregnancy primigravida or
grand multi.
• Interval of < 2 yrs since last
pregnancy
• H/o cardiac disease, diabetes,
chronic hypertension
 Past Obst. History
• Parity
• H/o still birth
• IUFD
• BOH
• Preterm labour
• Macrosomic baby
• IUGR baby
• Sev. PIH
 Life Threatening Situations

• H/o PPH
• H/o APH
• H/o MRP
• H/o Eclampsia/HELLP
• H/o Other complications
associated with
pregnancy which were life
threatening
 Complaints
• Breathlessness
• Excessive tiredness
• Palpitation
• Puffiness of face
• Headache
• Blurring of vision
• Bleeding p/v
• Leaking p/v
• Pain in abdomen
 Physical Examination

• Maternal weight
• Maternal height < 140 cm
• Look for pallor, puffiness
of face, oedema of feet.
• Blood pressure 120/80
mmHg > 140/90 mmHg
after 20 wks. S/o PIH
Pallor
 Abdominal Examination
• Abdominal examination is done to
monitor the progress of pregnancy, fetal
growth, fetal lie and fetal presentation.
• Height of uterus 12 wks just palpable
24 wks at umbilicus
36 wks at xiphisternum
Gravidogram
 Fetal Lie
• Vertical
• Transverse
• Oblique
 Fetal
Presentation
• Vertex
• Breech
• Shoulder
• Cord
• Hand
• Compound
 FHS
• Normal 120-160 b.p.m.
• Fetal tachycardia > 160 b.p.m.
• Fetal bradycardia < 120 b.p.m.
• Loss of fetal movement
• Passage of meconium
• All suggestive of fetal distress
 Advise to Mothers
• Food and rest
 Advise to Mother
• Anaemia prophylaxis
• Tab. FS + FA 100 mg 1OD x 3 mths.
• S/o anemia present - Tab. FS + FA 100
mg one B.D. x 3 mths.
• Tab. Mebendazol 1 B.D. x 3 days.
• Dietary advise
 Advise to Mother
• TT immunization
• Preparation for labour
 Laboratory Test
• Anemia (Hb < 10 gm%)
• Rh –ve blood group
• Blood sugars
• HIV
• Hepatitis B
• Urine microscopy
 Current Pregnancy Status

• Multiple gestation
• Vaginal bleeding
• Decreased fetal movements
• Preterm labour or cervical change
• PIH
• Abnormal uterine size (IUGR/V mole)
• Abnormal amniotic fluid volume
• Postdatism
High Risk Pregnancy
 Low Risk Labour
• Spontaneous onset at 37 to 40 wks
• Single fetus with vertex presentation
• Estimated fetal weight average
• Normal vital signs
• No pregnancy complications
• No abnormal intrapartum bleeding
 Normal Low Risk Labour
• Acceptable rate of cervical dilatation
• FHS normal
• Head engaged at full dilatation
• Normal delivery within 2 hrs of good
expulsive force
• Third stage < 30 min
• Total blood loss < 500 ml
 High Risk Labour
• Abnormal FHS
• Meconium stained liquor
• Malpresentation
• Intrapartum hemorrhage
• PROM
• Instrumental delivery
• PIH
 High Risk Labour
• Multiple pregnancy
• Cord prolapse
• Fetal macrosomia
• Dysfunctional labour
• Previous LSCS
• Prolonged labour
• CPD
• Rupture uterus
• Chorioamniotis
 Labour

5 Cs
• Clean hands
• Clean surface
• Clean razor
• Clean cord tie
• Clean cord stump
Partogram
 Partogram

• Cervical dilatation
• Descent of head
• Uterine contractions
• Drugs given
• Fetal heart rate record
 Partogram
• Concept of alert line
• Concept of action line
• Assessment of maternal
condition
• Assessment of fetal
condition
• Timely referral
 Each and every one working
in the health department is
committed to reduce the
maternal mortality and to
realize the reproductive rights
of a women.
•
Obst.
ANC
• Anemia Emergencies
• PIH
• Eclampsia
• Placenta previa
• Abruptio placenta
• PPH
• Retained placenta
• Malpresentations
• Obstructed & prolonged labour
• Rupture uterus
 Referral Obst. Emergencies
• Position of the patient
• Left lateral position
• Mouth gag
• Start IV fluid – ringer lactate
• First dose of broad spectrum antibiotics
• Other specific medication as indicated e.g.
inj. MgSo4 in eclampsia
• Breast feeding to be continued during transfer
in cases of PPH
 Referral Note
• Should mention salient
points about the
history
• Main clinical findings
• Medications (dose,
route, time of
administration)
• If telephonic facility is
available should alert
the referral hospital
Advise to Family Members

• About high risk situation

• About blood donation
• About financial aspects
• Blood donors
• Senior members for consent
 Referral
• Should be transported by the quickest
mode of transport
• 3 delays
Through a team approach all of the skills
of the health care members involved can
be combined to provide the best possible
approach to meet the pregnancy’s need.
The role of patient education can not be
over emphasized. Incorporating the
mother as an active member in her health
care is an investment in time and effort
that is cost effective both during
pregnancy and labour.
 A systematic & a well begun
programme with a positive thinking
will definitely show road to success
to accept this challenge