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 and 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
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, 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 • multiple pregnancy (maternal side)
drugs or radiation, acute surgical problems. • congenital malformation.
Complications of labor Diagnostic Tests
 Anemia, pre-eclampsia or eclampsia - premature - Are tests done to establish the presence (or absence)
labor of disease as a basis for treatment decisions in
 PROM - Abnormal FHR symptomatic or screen positive individuals
 Amnionitis – admitted with prolonged labor (confirmatory test).
 Abnormal presentation and position - Obstructed
labor Diagnostic Tests for High Risk Pregnancy
 Disproportion, floating head in labor - Rupture Non-invasive diagnostic tests
uterus  Fetal ultrasound or ultrasonic testing
 Multiple pregnancy – having induction or  Cardiotocography(CTG)
acceleration of labor  Non-stress test (NST)
Certain complications may arise during labour and  Contraction stress test (CST)
place the mother or baby at risk
• Intrapartum fetal distress Invasive diagnostic tests
• Difficult forceps or breech delivery  Chorionic villus sampling
• Prolonged interval from the diagnosis of fetal  Amniocentesis
distress to delivery.  Embryoscopy
• PPH or retained placenta  Fetoscopy
• Postpartum complications  Percutaneous umbilical cord blood sampling.
uneventful labour may suddenly turn into an abnormal
one in the form of Non-Invasive Diagnostic Tests
• PPH 1. Ultrasonography
• Retained placenta  -which measures the response of sound waves
• Shock against solid objects, is a much-used tool in modern
• Inversion obstetrics, although the recommendations for its
• Sepsis may develop later on use are being questioned because of unproven
SCREENING/ASSESSMENT benefits in the face of added expense (Neilson,
• Initial screening History 2009). It can be used to:
• Maternal age  Diagnose pregnancy as early as 6 weeks’ gestation
• Reproductive history  Confirm the presence, size, and location of the
• Pre-eclampsia, eclampsia placenta and amniotic fluid
• Anemia  Establish that a fetus is growing and has no gross
• Third stage abnormality anomalies, such as hydrocephalus, anencephaly, or
• Previous infant with Rh-isoimmunization or ABO spinal cord, heart, kidney, and bladder defects
incompatibility  Establish sex if a penis is revealed
• Medical or surgical disorders  Establish the presentation and position of the fetus
• Psychiatric illness  Predict maturity by measurement of the biparietal
• Cardiac disease diameter of the head
• Viral hepatitis  can also be used to discover complications of
• Previous operations pregnancy, such as the presence of an intrauterine
• Myomectomy device, hydramnios or oligohydramnios, ectopic
• Repair of complete perineal tear pregnancy, missed miscarriage, abdominal
• Repair of vesico-vaginal fistula pregnancy, placenta previa, premature separation
Family History of the placenta, coexisting uterine tumors, multiple
• Socio-economic status pregnancy, or genetic disorders such as Down
• Family history of diabetes syndrome.
• hypertension
 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
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.
o normal rate is 120 to 160 bpm
o fluctuates slightly (5 to 15 bpm) when a fetus
moves or sleeps
o abnormal patterns in the baseline rate include
fetal bradycardia and fetal tachycardia
o - 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
o marked bradycardia (less than 100 bpm) is a sign
of possible hypoxia and is potentially dangerous
o moderate tachycardia is 161 to 180 bpm
o 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
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.
 Rarely used today
 Measures the response of FHR to contraction
 The test requires 3 contractions in 10 minutes
 A positive or abnormal test results in decelerations
in more than half of the contractions
 Negative result: no deceleration with the
contractions
 Contraindication: any case where labour is not
allowed
Invasive Diagnostic test
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.