NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
HIGH RISK PRENATAL CLIENT
Identifying Client at Risk.
1. Assessment of Risk Factors
a. Demographic Factors
 AGE: Under 16 or over 35 y/o
 WEIGHT: overweight or underweight
 HEIGHT: less than 5 feet.
 FAMILY HISTORY of inherited
disorder
b. Socio economic status
 Inadequate finances
 Overcrowding, poor standards of
housing, poor hygiene.
 Nutritional deprivation
 Unwed condition/marital status
 Severe social problem
 Unplanned and unprepared pregnancy,
especially among adolescents.
 Poor support system.
c. Obstetric History
 History of infertility or multiple
gestation.
 Grand multiparity
patient who has had ≥5 births (live or
stillborn) at ≥20 weeks of gestation.
 Previous abortion or ectopic pregnancy
 Prior spontaneous abortions
increased the risk of ectopic
pregnancy, especially for women
with three or more sponta- neous
abortions.
 The risk of ectopic pregnancy was
higher in women with previous
induced abortions.
 After an ectopic pregnancy, there's
about a 10% chance it
will happen again. So, one important issue
to think about is the reason for your previous
ectopic pregnancy.
 Previous loses: fetal death, still birth, neonatal
or perinatal death.
 Previous operative OB: CS, mid-forceps
delivery.
 A mid forceps delivery occurs when the
head is engaged, but less than +2 cm
station. A high forceps delivery, when the
fetal head is unengaged, is no longer
performed in modern obstetrics.
 Previous Uterine or cervical abnormality
 the abnormal test result means there have
been cell changes caused by the human
papilloma virus (HPV).
 Uterine abnormality;
 uterus didelphys (double uterus)
 arcuate uterus (uterus with a dent on
the top part)
 unicornuate uterus (one-sided uterus)
 bicornuate uterus (heart-shaped
uterus)
 septate uterus (uterus with partition in
the middle)
 absent uterus.
 Previous abnormal labor: premature labor, post
mature labor, prolonged labor.
 Previous high risk infant : LBW,LGA, with
neurologic deficit, birth injury or malformation.
 Previous h-mole
 A molar pregnancy — also known as
hydatidiform mole — is a rare
complication of pregnancy characterized
by the abnormal growth of trophoblasts,
the cells that normally develop into the
placenta. There are two types of molar
pregnancy, complete molar pregnancy and
partial molar pregnancy.
 What causes h mole? It is usually due to
two sperm fertilising one normal ovum
(which should not usually happen). This
means that there is too much genetic
material present. There is also too much
trophoblastic tissue. The growth of the
trophoblastic tissue overtakes the growth
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
of any fetal tissue and the fetus does
not develop normally.
 because hydatidiform moles grow
much faster than a fetus, the
abdomen becomes larger much
faster than it does in a normal
pregnancy. Severe nausea and
vomiting and vaginal bleeding are
common.
 
d. Current OB status
 Late or no prenatal care
 What happens at every prenatal
visit?
 At each visit, your blood pressure,
weight and baby's heartbeat will be
measured, and the position of your
baby will be checked. You may
receive an ultrasound to determine
growth of the baby in this trimester.
29 – 34 weeks: You will discuss
aspects of childbirth, breastfeeding
and postpartum care with your
provider.
 Check your urine sample for
infection and to confirm your
pregnancy. Check your blood
pressure, weight, and height.
Calculate your due date based on
your last menstrual cycle and
ultrasound exam. Ask about your
health, including previous
conditions, surgeries, or
pregnancies.
 Maternal anemia
 Severe iron deficiency anemia
during pregnancy increases the risk
of premature birth (when delivery
occurs before 37 complete weeks of
pregnancy).
 Iron deficiency anemia during
pregnancy is also associated with
having a low birth weight baby and
postpartum depression.
 A baby with anemia.
 most common causes of anemia during
pregnancy are iron deficiency and folate
acid deficiency.
 An alternative mechanism could be that
iron deficiency increases oxidative damage
to erythrocytes and the fetoplacental unit.
 Iron deficiency may also increase the risk
of maternal infections, which can stimulate
the production of CRH and are a major
risk factor for preterm delivery.
 Anemia can leave you feeling tired and
weak.
 Without iron supplementation, iron
deficiency anemia occurs in many
pregnant women because their iron stores
need to serve their own increased blood
volume as well as be a source of
hemoglobin for the growing fetus.
 
 RH sensitization
 If your blood mixes with Rh-positive
blood, your immune system will react to
the Rh factor by making antibodies to
destroy it.
 Rh sensitization can occur when a person
with Rh-negative blood is exposed to Rh-
positive blood. Most women who become
sensitized do so during childbirth, when
their blood mixes with the Rh-positive
blood of their fetus.
 RhIG (Rh immune globulin) is given as an
injection to the mother in the first 72 hours
after birth of an Rh-positive child to
further prevent the woman from forming
natural antibodies.
 Special immune globulins, called
RhoGAM (RhoGAM is one brand of Rh
immunoglobulin (RhIg) ), are now used to
prevent RH incompatibility in mothers
who are Rh-negative. If the father of the
infant is Rh-positive or if his blood type is
not known, the mother is given an
injection of RhoGAM during the second
trimester.
 You can prevent the effects of Rh
incompatibility by getting an injection of
Rh immune globulins (RhIg) during your
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
first trimester, during a miscarriage,
or while having any bleeding during
your pregnancy. This blood product
contains antibodies to the Rh factor.
 Possible Complications
 Brain damage due to high levels of
bilirubin (kernicterus)
 Fluid buildup and swelling in the
baby (hydrops fetalis)
 Problems with mental function,
 movement, hearing, speech, and
seizures.
 
 Antepartal bleeding: placenta previa and
abruptio placenta
 If you have placenta previa, you
might bleed throughout your
pregnancy and during your delivery.
 How does placenta previa affect the
baby?
 If you have placenta previa, when
the cervix begins to thin out (efface)
and open up (dilate), blood vessels
connecting the placenta to the
uterus may tear.
 This can cause severe bleeding
during labor and birth, putting you
and your baby in danger.
 Placental abruption can deprive the
baby of oxygen and nutrients and
cause heavy bleeding in the mother.
In some cases, early delivery is
needed.
 
 PIH (Pregnancy Induced Hypertention)
 PIH can also lead to fetal problems
including intrauterine growth
restriction (poor fetal growth) and
stillbirth.
 If untreated, severe PIH may cause
dangerous seizures and even death
in the mother and fetus. Because of
these risks, it may be necessary for
the baby to be delivered early,
before 37 weeks gestation.
 Complications from high blood pressure
for the mother and infant can include the
following:
 For the mother: preeclampsia , eclampsia ,
stroke, the need for labor induction (giving
medicine to start labor to give birth)
 placental abruption (the placenta
separating from the wall of the uterus).
 
 Multiple gestation
 a term used to describe a pregnancy with
more than one foetus. It includes twins,
triplets, quadruplets, or more.
 Multiple pregnancy has a physiologic
impact on both the mother and the fetus.
The mother is at increased risk for adverse
outcomes such as iron deficiency anemia,
gestational diabetes, gestational
hypertension, placental abnormalities,
preterm delivery, cesarean delivery, and
postpartum hemorrhage.
 Over 60 percent of twins and nearly all
higher-order multiples are premature (born
before 37 weeks). The higher the number
of fetuses in the pregnancy, the greater the
risk for early birth.
 Premature or post mature
 Polyhydramnios
 Most cases of polyhydramnios are mild
and result from a gradual buildup of
amniotic fluid during the second half of
pregnancy. Severe polyhydramnios may
cause shortness of breath, preterm labor, or
other signs and symptoms.
 POLYHYDRAMNIOS = esophageal
atrasia for the baby.
 Polyhydramnios is also associated with
various genetic disorders, including Down
syndrome (Trisomy 21) and Edward's
syndrome (Trisomy 18), but only when the
baby also has a duodenal atresia (closure in
the first part of their small intestines
(duodenum). The closure causes a
mechanical blockage that prevents the
passage of milk and digestive fluids) or
other blockage in the gastrointestinal tract.
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
 
 PROM
 Premature rupture of membranes
(PROM) is a rupture (breaking
open) of the membranes (amniotic
sac) before labor begins. If PROM
occurs before 37 weeks of
pregnancy, it is called preterm
premature rupture of membranes
(PPROM).
 
 Fetus inappropriate large or small;
 Abnomality in testes for fetal being
 In presentation
 Normal position of the baby in
the uterus: upper right or left of
the uterus
 
e. Maternal Medical History /
Status
 Cardiac or pulmonary disease
 As blood volume increases,
congestive heart failure can
worsen.
 Congenital heart defect If you were
born with a heart problem, your
baby has a greater risk of
developing some type of heart
defect, too.
 You might also be at risk for heart
problems occurring during
pregnancy and of premature birth.
 Pregnancy is not recommended in
patients with certain types of
heart disease -- for example,
pulmonary arterial hypertension,
severely dilated aorta, or severely
reduced ability of the heart to pump
blood. Women with heart disease
who want to have a baby need pre-
pregnancy risk assessment and
counselling.
 Metabolic disease :
 Diabetes
 Diabetes during pregnancy—
including type 1, type 2, or gestational
diabetes—can negatively affect the
health of women and their babies. For
women with type 1 or type 2 diabetes,
high blood sugar around the time of
conception increases babies' risk of
birth defects, stillbirth, and preterm
birth.
 Thyroid disease
 Thyroid disease is the second most
common endocrine disorder affecting
women of reproductive age, and when
untreated during pregnancy is associated
with an increased risk of miscarriage,
placental abruption, hypertensive
disorders, and growth restriction.
 When the thyroid makes too much thyroid
hormone, your body uses energy too
quickly. This is called hyperthyroidism.
 The two main hormones your thyroid
releases —
 thyroxine (T4)
Thyroxine is the main hormone secreted
into the bloodstream by the thyroid gland. It
plays vital roles in digestion, heart and muscle
function, brain development and maintenance
of bones. responsible for your metabolism,
mood, and body temperature
 triiodothyronine (T3)
It is involved in calcium and bone
metabolism. T3 and T4 increase the basal
metabolic rate. They make all of cells in the
body work harder, so the cells need more
energy too.
 Endocrine Disorder: pituitary, adrenal
 Endocrine adaptation to pregnancy
involves changes in the activities of the
hypothalamic-pituitary-adrenal and renin-
angiotensin-aldosterone axes.
 The pituitary is responsible for the
release of oxytocin which helps the uterus
contract during childbirth. This gland also
releases prolactin which stimulates breast
milk production.
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
 Why are adrenal hormones
essential during pregnancy?
Needed for correct development of
many fetal organs including the
lungs, liver and kidneys.
Stimulating the growth and correct
function of the placenta. Promoting
growth of maternal breast tissue
(along with progesterone) and
preparing the mother for lactation
(breastfeeding).
 Cortisol.
 Aldosterone.
 DHEA and Androgenic
Steroids.
 Epinephrine (Adrenaline) and
Norepinephrine
(Noradrenaline)
 Adrenal Insufficiency.
 Congenital Adrenal
Hyperplasa.
 Overactive Adrenal Glands.
 Excess of Cortisol: Cushing
Syndrome.
 Chronic Renal disease; repeated UTI,
Bacteriuria
 Chronic hypertension
 Venereal and other infection disease
 Having an STI during pregnancy
can cause: Premature labor (labor
before 37 weeks of pregnancy).
Early (preterm) birth is the number
one cause of infant death and can
lead to long-term developmental
and health problems in children.
Infection in the uterus (womb) after
birth.
 
 Major congenital anomalies of the
reproductive tract.
 Transverse Vaginal Septum.
 Cervical Agenesis. "absence of a
cervix"
 Uterine Duplication.
 
 Hemoglobinopathies
 Hemoglobinopathies are inherited
conditions that affect the number or shape
of the red blood cells in the body. These
conditions can be very different from one
another. Some hemoglobinopathies can
cause life-threatening symptoms, while
others do not cause medical problems or
even signs of the condition.
 Example: sickle cell anemia.
 
 Seizure disorder
 
 Malignancy
 
f. Major emotional disorder, mental
retardation
 Habits/Habituation
 Smoking during pregnancy
 Regular alcohol intake -FASD (Foetal alcohol
syndrome disorder)
 Drug use/ abuse
2. Screening Test
 
 URYNALYSIS
 Urine is tested during pregnancy for presence
of sugar, proteins, ketones, bacteria, blood cells
to make sure that conditions such as UTI,
gestational diabetes and preeclampsia do not
exist.
 
 Blood Examination
 Your midwife or doctor will want to do a blood
test in early pregnancy to find out your blood
type and check for some infections and other
health concerns. These include your rubella
immunity, and whether you have anaemia,
HIV, hepatitis B, hepatitis C or syphilis.
 
3. Diagnostic Tests Pregnancy/
Prenatal in High Risk
Determination of Fetal Status.
 
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
a. Utrasonography
 Description: a non-invasive diagnostic
procedure utilizing high frequency
sounds waves to detect intrabody
structures.
 Purposes:
 In early pregnancy: to confirm
pregnancy
 To detect the fetus's: viability,
growth, Number (multiple
pregnancy)
 Position , presentation
 Abnormalities (structure)
 Heart tones (fht)
 Age of gestation by determining the
biparietal diameter of the fetal head
 Most accurate at 12 to 24
weeks
 Biparietal diameter of 9.5 cm=
mature fetus
 Detect placental position (placenta
previa) or placental abnormality (H-
mole)
 An important aid in high risk
procedures like amniocentesis,
 Amniocentesis is a procedure
used to take out a small sample
of the amniotic fluid for
testing.
 Amniocentesis is a test you
may be offered during
pregnancy to check if your
baby has a genetic or
chromosomal condition, such
as Down's syndrome, Edwards'
syndrome or Patau's syndrome.
 Preparation:
 Advice mother to drink one quart
of water 2 hours before the
procedure
 Hydration is the key to getting
quality pictures.
 A full bladder creates a
reservoir of fluid that
enhances the movement of
sound waves through the
abdominal cavity. This creates
a clearer view of the structures that
need to be observed
 Instruct not to void
 Transmission of gel is spread over
the abdomen
Psychological support is given to the mother/ father
(couple)
 
b. Non-Stress Test
 Determines the response of the fetal heart rate
to the stress of activity.
 Indications:
 Pregnancy is at risk for placental
insuficiency.
 PIH, diabetes
 Warning signs noted during DFMC (daily
fetal movement count)
 Maternal history of smoking, inadequate
nutrition.
 Acceleration of FHR occur with fetal
movement, uterine contractions, or in
response to external stimuli.
 Acceleration: cause by fetal movement,
maternal position or administration of
analgesic.
 Deceleration: caused by pressure on to the
fetal head
 Late deceleration: ominous sign,
uteroplacental inssuficiency
 Prolonged Deceleration: cause by cord
compression or maternal hypotension
 Variable Deceleration: cord compression.
 Procedure:
 Done with 30 minutes where in the mother
is placed in semi-fowler's position
 Eternal monitors are applied to document
fetal activity.
 Tocotransducer: over fundus to
detect uterine contractions and fetal
movements.
 Ultrasound transducer: over the
abdominal site where most distinct
fetal heart sounds are detected.
 Mother activates the mark button on the
electronic monitor when she feels fetal
movement
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)

 Monitor until at least 2 FMs are  Reactive Non-Stress Test

detected in 20 minutes
 If no FM after 40 minutes provide
woman with a light snack or gently
stimulate fetus through abdomen.
 If no FM after 1 hour further testing
may be indicated, such as
contraction stress test (CST)
 Interpretation:
Reactive (Normal)
 Baseline fetal heart rate between
120- 160 beats/minute
 At least 2 accelerations of the FHR
of at least 15 beats/minute lasting at
least 15 seconds in a 10-20 minutes
period as result of fetal movement
 Good variability – normal
irregularity of cardiac rhythm
representing a balanced interaction
between parasympathetic
(decreased FHR) and sympathetic
(increase FHR) nervous systems:
noted as uneven line on the rhythm
strip.
 Result indicates a healthy fetus
with an intact nervous system.
Non-reactive
 Stated criteria for a reactive result
are not met
 Monitoring for two 20 minutes
periods and neither periods yield
adequate accelerations.
 Could be indicative of a
compromised fetus
 Adjuncts to assist fetal activity fail
(acoustic stimulation, manual
stimulation, glucose drink)
 Requires further evaluation with
another NST, biophysical profile
(BPP) or contraction stress test
(CST)
 Management
 Reassuring for fetal wellbeing for 3-4
days
 Follow daily fetal kick count
 Non-Reactive Non-Stress Test
 Perform oxytocin challenge test
(OCx`T)
 Perform biophysical profile
c. Contraction Stress Test or Oxytocin
Challenge Test (OCT)
 The oxytocin challenge test (OCT) is done by
intravenously infusing dilute oxytocin until 3
contractions occur within 10 minute.
 Technique:
 Oxytocin (Pitocin)
 start: 0.5 to 1.0 minutes
 Titrate (continuously measure and
adjust the balance): increase 1U every
20 mins.
 Goal: 2 contractions every 10 minutes
 Nipple Stimulation
 After a woman gives birth,
stimulation of the nipples by a breast-
feeding baby triggers the release of
oxytocin.
 The test is interpreted as follows
 Normal :Negative
 No late decelerations of FHR with
each of three contraction during a 10
minutes interval
 Abnormal: Positive
 With late decelerations of FHR with
3 contraction in 10 minute.
d. Nipple Stimulation Contraction
 Determines feto-placental function/wellbeing
 Breast is stimulated with rolling of nipples or
warm towel application
 The baseline data are obtained through
monitoring as in OCT procedure
 Interpretation: same as in OCT
 
e. Biophysical Profile
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
 A prenatal test used to check on a baby's
well-being
 5 main areas to check your baby's
health: body movements, muscle tone,
breathing movements, amniotic fluid,
and heartbeat.
 
f. Amniocentesis
 Entering the amniotic sac to aspirate
amniotic fluid for a variety of diagnostic
exams to detect fetal wellbeing or lack
thereof:
 Major Risk
 Trauma
 Infection
 Abortion
 Preterm Labor
 Preparation:
 Secured informed consent
 Prepare for UTZ ( fetal
ultrasound ) : To locate placenta
 Client need to void
 Increase oral fluids: 1 quart water 2
hours before
 Prepare needle: 20- 22; 3''- 6''
 Prepare for admnistration of local
anesthesia of the abdomen
 Provide psychological support.
 Amount of amniotic fluid to be
aspirated
 Up to 30 ml at 15 to 18 weeks
gestation
 Implication of bloody tap
 Decreased L/S ratio
The lecithin/sphingomyelin (L:S)
ratio is the traditional standard for
fetal lung maturity testing. A ratio
of greater than 2:1 is 98%
predictive of fetal lung maturity.
Falsely mature values can be
obtained in mothers with diabetes
(classes A through C), asphyxiated
infants, or in cases of Rh
isoimmunization.
Fetal blood- false high levels of alpha
fetoprotein AFP
 After care
 Monitor for 30 to 60 minutes
 Observe for side effect
 Vaginal discharge
 Increased uterine / fetal acrivity
 Fever and chills
 Analysis of Amniotic fluid
 Most commonly used today to determine
fetal lung maturity
 Determination of age of gestation as in:
 Creatinine Levels: 2.0 mg – 36 weeks
AOG; more than 2.0 mg – greater
than 36 weeks
 Nile blue stain (lipid cells): 20% of
cells are stained with orange, it means
the fetal weight is at least 2,500 g
 Note! Normal Birth Weight: 2,500 g
to 4,500 g
 
 Alpha Feto-Protein (AFP) level
 High levels may indicate the presence of a
neutral defect such as spinal cord bifida
(occurs when the spine and spinal cord
don't form properly) or tracheoesophageal
atresia.
 Genetic Disorders: For chromosomal studies
 RH Incompatibility: High levels of bilirubin
identified is immunization
 Inborn Errors of Metabolism: biochemical
analysis of fetal cell enzymes
 Fetal Distress: passage of meconium in cephalic
presentation
 Sex-Linked Disorder: Sex chromosome
disorder
g. X - Ray: Lateral Pelvimetry
 Indication for radiography to determine pelvic
size and shape
 Suspected cephalopelvic disproportion.
 History of injury/disease of the pelvis and
spine
 Previous difficult delivery
 Cases of maternal deformity
 
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)
h. Serial Estriol Determination
 Measure feto-placental wellbeing
 Specimens: Serum or 24 hour urine
(most commonly used)
 Result
 Normal: Gradual increase in serial
estriol which is 12-50 mg/day at
term
 Abnormal: Sudden drop of less
than 50% of the previous level
means fetal distress
 Persistent low level means fetal
wellbeing is compromised.
 
i. Chorionic Villi Sampling
 Earliest test possible on fetal cells
 Sample obtained by slender catheter
passed through cervix to implantation
site
 Chorionic villus sampling (CVS), or
chorionic villus biopsy, is a prenatal test
that involves taking a sample of tissue
from the placenta to test for
chromosomal abnormalities and certain
other genetic problems.
j. Percutaneous umbilical Blood
Sampling (Pubs)
 Used in 2nd and 3rd Trim
 Uses ultrasound to locate umbilical cord
 Cord blood aspirated and tested
 
FREQUENCY OF PRENATAL
 Month 1-7 = once a month
 Month 8-9 = twice a month
 10 months = every week
 Post term = twice a week
SCABS - danger signs of
pregnancy
 S = swelling or edema sa upper
extremities = preeclampsia
 C = chills and fever = sign of infection
 C = Cerebral disturbances "headache" sign of
preeclampsia.
 A = abdominanl pain "epigastric pain" is an
aura of impending convulsion.
 Broad-like abdomen = abruptio placenta
 Blurred vission = preeclampsia.
 BP increase = hypertension
 BLEEDING
 1st tri = abruption placenta, ectopic
pregnancy
 2nd tri = hydatidiform mole, incompetent
cervix.
 3rd tri = placental anomalies.
 S = sudden gush of fluid = premature
rupture of the membrane (PROM)
NUTRITION
 Follic acid is recommended in the
preconceptional and early prenatal period to
prevent neural tube defect.
 400 g of follic acid.
 A standard multivitamins of most pregnant
woman.
 Nutritional recommendations is based sa
prepregnancy BMI nya.
 UNDERWEIGHT
 Weight gain = 12.5- 18 kg (28 -40
lbs)
 BMI < 19.8
 OVERWEIGHT
 Weight gain = 7 - 11.5 kg ( 15 t- 25
lbs)
 BMI > 26
 AVERAGE WEIGHT
 Weight gaine 11. 5 - 16 kg (25 to 35
lbs)
 BMI 19.8 - 26
SEXUAL ACTIVITY
 Pede naman sya but in moderation lang dapat
 Avoid 6 weeks prior to EDD (cervix is slightly
dilated, Operculum might be dislodge = prone
infection
 Avoid blowing air during cunnilingus to
prevent embolism.
 NCM 109- Care of the Mother, Child at Risk or with
Problems ( Acute or Chronic)

 Middle of 8 months bawal na mag sex.  

 POSITION:  
 Spooning position  
 Dogie style  
 Cowgirl position- nasa top  
 Against the wall  
 Reversed cow girl  
 Contraindications:  
 Vaginal spotting- Threatened  
abortion, Incomplete cervix,  
Placenta Previa  
 Preterm labor  
 PROM  
 Sexual appetite:
 1st tri - decrease due to body
changes.
 2nd tri- increase due to increase
level of estrogen.
 3rd tri - decrease due to enlarging
uterus.
EXERCISE
 To strengthen muscles that will be used
during the delivery process
 Walking- best form of exercise
 Squatting - strengthen perineal muscle
and increase circulation sa perineum.
 Do not stand abruptly it leads to
postural hypotension, hence, raise
buttocks first before the head.
 Tailor sitting
 Kegels Exercise- strengthen
pubococcegeal muscle
 Abdominal Exercise
 Shoulder Exercise- strengthen muscle of
the chest
 Plevic rocking