ERA’S COLLEGE OF

NURSING
HIGH RISK APPROACH IN MATERNAL
AND CHILD

PRESENTED BY:
NIDHI MAURYA
M.Sc. NURSING 1ST YEAR
Contents

1.Introduction
2.Screening of high risk cases
3.High risk cases (according to WHO)
4.Management of high risk cases
5.Risk approach (according to WHO)
6.Interventions to reduce maternal mortality
 Introduction to risk

• A dictionary definition of the word “risk” is hazard, danger, exposure to

mischance or peril”. It implies that the probability of adverse
consequences is increased by the presence of some characteristics or
factor.
• 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.
 Definitions

• “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.
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.
• If we desire to improve obstetric results, this group must be
identified and given extra care.
• Even with adequate antenatal and intranatal care, this small
group is responsible for 70 to 80 percent of perinatal mortality
and morbidity.
 Introduction

• The risk factors may be pre-existing prior to or at the time

of first antenatal visit or may develop subsequently in the
ongoing pregnancy labour or puerperium.
• Over 50 percent of all maternal complications and 60
percent of all primary caesarean sections arise from the
high risk group of cases.
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 centre.
• Some risk factors may later appear and are detected at
subsequent visits.
• The cases are also reassessed near term and again in labour
for any new risk factors.
 Initial screening History

• Maternal age
• Reproductive history
• Pre-eclampsia, eclampsia
• Anaemia
• Third stage abnormality
• Previous infant with Rh-isoimmunisation or ABO incompatibility
• Medical or surgical disorders
History cont…
• Psychiatric illness
• Cardiac disease
• Epilepsy
• Viral hepatitis
• Previous operations
• Myomectomy
• Repair of complete perineal tear
• Repair of vesico-vaginal fistula
• Repair of stress incontinence
Family history

• Socio-economic status
• Family history of diabetes, hypertension or multiple
pregnancy (maternal side), congenital malformation.
High risk cases
(According to WHO) During pregnancy

• Elderly primigravida (≥30 years)

• Short statured primi (≤ 140 cm)
• Threatened abortion and APH
• Malpresentations
• Pre-eclampsia and eclampsia
• Anaemia
 During pregnancy cont…

• Elderly grand multiparas

• Twins and hydramnios
• Previous still birth, IUD, manual removal of placenta
• Prolonged pregnancy
• History of previous caesarean section and instrumental delivery
• Pregnancy associated with medical diseases.
During labour

• PROM
• Prolonged labour
• Hand, feet or cord prolapse
• Placenta retained more than half an hour
• PPH
• Puerperal fever and sepsis.
Examination
General physical examination
• Uterine size- disproportionately
• Height smaller or bigger
• Weight • Genital prolapse
• Blood pressure • Lacerations or dilatation of the
• Anemia cervix
• Cardiac or pulmonary • Associated tumours
disease
• Pelvic inadequacy
• Orthopedic problems
• Pelvic examination
 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, anaemia, 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.
Complications of labour

• Anaemia, pre- eclampsia or • Multiple pregnancy

eclampsia • Premature labour
• Premature or PROM • Abnormal FHR
• Amnionitis • Patients admitted with prolonged
• MSL • Obstructed labour
• Abnormal presentation and • Rupture uterus
position
• Patients having induction or
• Disproportion, floating head in acceleration of labour
labour
 Complications…

• Certain complications may arise during labour and place the mother or baby at a
high risk
• Intrapartum fetal distress
• Delivery under GA
• Difficult forceps or breech delivery
• Failed forceps
• Prolonged interval from the diagnosis of fetal distress to delivery.
• PPH or retained placenta
Postpartum complications
• An uneventful labour may suddenly turn into an abnormal one in the
form of
• PPH
• Retained placenta
• Shock
• Inversion
• Sepsis may develop later on.
High risk newborn
• APGAR score below 7
• Persistent cyanosis
• Birth weight less than 2500gm or
more than 4 kg • Anaemia
• Convulsions • Major congenital abnormalities
• Respiratory distress syndrome • Jaundice
• Hypoglycaemia • Haemorrhagic diathesis.
• Fetal infection
 Management of high risk cases

• The high risk cases should be identified and give 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
centres and their care can be left to properly trained
midwives and medical officers in health centres, or general
practitioners.
 Management of high risk cases cont…

• It is necessary that all expectant mothers are covered by the

obstetric service of a particular area.
• The services of trained community health workers and assistant
nurse-cum-midwife of health centres should be utilized to provide
the primary care and screening in rural areas and urban and semi-
urban pockets
• Cases with a significantly higher risk should be referred to
specialized referral centres. Cases from rural areas may be kept at
maternity waiting homes close to the referral centres.
Management cont..

• Cases having a previous unsuccessful pregnancy should be

seen and investigated before another conception occurs.
• Complete investigations for hypertension, diabetes, kidney
disease or thyroid disorders should be undertaken and
proper treatment instituted in the nonpregnant state
• Sexually transmitted disease should be treated before
embarking on another pregnancy.
 Management cont…

• Cervical tears should also be repaired in the nonpregnant state.

• Serology for toxoplasma IgG, IgM and antiphosholipid
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 throughout the pregnancy
• Early in pregnancy after the initial clinical examination, routine
and special laboratory investigations should be undertaken.
 Management cont…

• Patient with history of previous first trimester abortion should

be advised rest and to refrain from sexual intercourse. Vaginal
examination should be avoided in first trimester in these
cases.
• Patients suspected to have cervical incompetence should have
sonographic evaluation early in second trimester so that
cervical encirclage, if necessary may be performed at
appropriate time.
Management cont…

• Patients having premature labour, unexplained stillbirth,

intrauterine growth restriction and may other abnormalities are
benefited by prolonged rest in hospital with close supervision.
Assessment of maternal and fetal well being
• This should be done at each antenatal visit, maternal
complications should be looked for and treated, if necessary.
Management of labour

• It is evident that elective caesarean section is necessary in a

high-risk case.
• Some cases may need induction of labour after 37-38 weeks
of gestation.
• Those cases who go into labour spontaneously or after
induction, need close monitoring during labour for the
assessment of progress of labour or for any evidence of the
fetal hypoxia.
Organizational aspect of management
• Strengthen midwifery skills, community participation and
referral system.
• Proper training of resident, 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 centres for
management.
Organizational aspect cont…
• Community participation, 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 paediatric service for the
neonates
• Lastly, improvement of economic status, literary and health
awareness of the community.
Risk approach (according to WHO)
• The main objective of the at- 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- TBA, CHW,
women’s group for example.
Risk strategy
• The risk strategy is expected to have far reaching
effects on the whole organization of MCH/FP services
and lead to improvements in both the coverage and
quality of health care, at all levels, particularly at
primary health care level.
 Risk approach cont..

• In developing local strategies for the delivery of family health care with
optimal coverage, efficiency and efficacy, the concept of risk groups and
individuals is a promising basis for a useful managerial approach.
• Its purpose is to:
Identify the real health needs of the population, define the roles and
functions of the different categories of health personnel, and develop
suitable training programmes.
Obtain a better diagnosis and measurement of human reproductive
casualties in communities where health information is deficient and
provide a mechanism for surveillance of the population “at risk” that
will facilitate the development of realistic standards of care.
Risk approach cont…
• Provide anticipatory care to individuals and groups
with characteristics indicative of a special risk to their
health welfare or life.
• Improve knowledge and develop criteria for the
allocation of health resources in order to contribute to
the rational planning, organization, administration and
evaluation of health services.
Interventions to Reduce Maternal Mortality
Historical Review
•Traditional birth attendants
•Antenatal care
•Risk screening Current Approach
•Skilled attendant at delivery The flawed
assumption:
Most life-threatening obstetric complications can be
predicted or prevented
Traditional Birth Attendants Advantages

• Community-based
• Sought out by women
• Low tech
• Teaches clean delivery Disadvantages
• Technical skills limited
• May keep women away from life-saving interventions
due to false reassurance.
Trained Birth attendants Health system
improvements:
• Introduction of system of health facilities
• Expansion of midwifery skills
• Decreased use of home delivery and delivery by untrained birth
attendants
• Spread of family planning “TBAs are useful in the maternal health
network, but there will not be a substantial reduction in maternal
mortality by TBAs delivering clinical services alone.”
 Antenatal Care

• Antenatal care clinics started in US, Australia, Scotland between 1910–1915

• New concept - screening healthy women for signs of disease
• By 1930’s large number (1200) ANC clinics opened in UK
• No reduction in maternal mortality
• However, widely used as a maternal mortality reduction strategy in 1980’s
and early 1990’s
• Antenatal care is important for early detection of problems and birth
preparation.
 Risk Screening Disadvantages

• Very-poorly predictive
• Costly: Removes woman to maternity waiting homes
• If risk-negative, gives false security
• Conclusion: Cannot identify those at risk of maternal
mortality — every pregnancy is at risk.