HIGH RISK PRENATAL CLIENT

Prepared By: Prof. Elizabeth D. Cruz RN, MAN

High Risk Pregnancy

=Is a pregnancy complicated by a disease or disorder that may endanger the life, or affect the
health of the mother, the fetus or newborn
Ways for identifying clients at risk
a. Physiological
b. Psychological
c. Social

ASSESSMENT OF RISK FACTORS

A. DEMOGRAPHIC FACTOR
I. Age
- 20-30 optimal age for bearing
- below 16 / 35 up
II. Weight
- overweight
- underweight
III. Height
- Less than 5ft (high risk because of pelvic shape

B. SOCIO-ECONOMIC FACTOR
1. Inadequate finances
2. Overcrowding
3. Poor standards of housing
4. Poor hygiene
5. Unplanned and prepared pregnancy esp. among adolescent
6. Poverty and low educational status
C. OBSTETRIC HISTORY
1. History of infertility or multiple gestation
2. Grand multiparity
3. Previous abortion or ectopic pregnancy
4. Previous loses : fetal death, stillbirth, neonatal or perinatal death
5. Previous operative OB, CS, and mid forceps delivery
6. Previous uterine or cervical abnormality
7. Previous abnormal labor : Premature labor or postmature labor, prolonged labor
8. Previous high-risk infant : low birth wt. (LBW), macrosomia (LGA) w/ neurologic deficit, birth
injury or malformation
9. Previous hydatidiform mole (H-mole)
D. CURRENT OB STATUS
1. Late or No prenatal care
2. Maternal anemia
3. Rh sensitization
4. Antepartum bleeding, placenta previa and abruption placenta
5. Pregnancy-induced hypertension
6. Multiple gestation
7. Premature or post-mature labor
8. Polyhydramnios
9. PROM
10. Fetus inappropriately large or small; abnormality in tests for fetal well being; abnormality in
presentation

E. MATERNAL HISTORY STATUS

1. Cardiac or pulmonary disease
2. Metabolic disease : DM, thyroid disease
3. Endocrine disorder : pituitary, adrenal
4. Chronic renal disease : repeated UTI, bacteriuria
5. Chronic hypertension
6. Venereal and other infectious disease
7. Major congenital anomalies of reproductive tract

SCREENING, DIAGNOSTIC TESTS AND LABORATORY EXAMS

A. Alpha-fetoprotein (AFP) enzyme blood test

- elevated levels may identify the pregnant woman carrying a baby with neural tube defects
(spina bifida and anencephaly)
- if the AFP is elevated for two samples, it is followed by ultrasonography and amniocentesis for
further confirmation done at 14 to 16 weeks gestation
B. Ultrasonography
1. high-frequency sound wave testing
-discerns multiple pregnancy, placental location and gestational age by measurement of
bi-parietal diameters
a. visualization during first 20 weeks of gestation is improved if the bladder is full; a full
bladder is not necessary after 20 weeks of gestation
b. a level II sonogram may be performed to assess formation organs.
Nursing considerations​:
1. encourage fluid and refrain from voiding before the test

C. Chorionic villi sampling (CVS):

- supplies some data as amniocentesis but can be done after 10 weeks
 1. aspiration of villi done during the eighth to twelfth week of pregnancy
2​. Nursing Considerations​:
a. instruct to drink fluid so that bladder is full
b. after test, monitor for uterine cont5ractions, vaginal discharge and teach to observe
for signs of infection

D. Amniocentesis
- aspiration of amniotic fluid used to detect sex, chromosomal or biochemical defects, fetal age,
L/S ratio (2/1 ratio indicates lung maturity), increased bilirubin level associated with Rh disease,
and phosphatidylglycerol (PG), which appears in amniotic fluid after thirty-fifth week, indicating
fetal lung maturity.
1. Test done with sonogram; usually after 12 to 15 weeks of gestation
2. ​Nursing considerations​:
a. have client void
b. after test monitor for uterine contractions, vaginal discharge
c. teach to observe for signs of infection
d. encourage rest

E. Non-tress test (NST)

- done to observe for accelerations of FHR in response to fetal movement over a 30 to
40-minute period
1. Classification of results:
a. a test is negative or reactive if
=Baseline FHR is 120 to 160
= baseline there are two accelerations in 10
minutes, each increasing the FHR by 15 and lasting 15 seconds
=the tracing shows variability of 10 or more beats per minute
b. test is positive or non-reactive if the three criteria
are not met
2​. Nursing considerations​:
a. fasting is not necessary
b. observes the fetal monitor
c. explain test to decreased anxiety
d. evaluate response to procedure

F. Contraction stress test (CST):

- to demonstrate whether a healthy fetus can withstand a decreased oxygen supply during the
stress of a contraction produced by exogenous oxytocin (Pitocin) or stimulation of nipples
manually or by moist heat; if late decelerations appear, the fetus maybe compromised because
of uteroplacental insufficiency
1. Classification of results
a. Negative: no late decelerations with a minimum of three contractions in 10 minutes;
 indicates that the fetus has good chance of surviving labor
b. Positive: persistent and late decelerations occurring with more than half the
contractions;
indicates need for considering premature intervention.
c. Suspicious: late decelerations occurring in less than half the contractions; test should
be
repeated in 24 hours
2.​ Nursing considerations:​
a. void before test
b. monitor fetal heart rate for 30 minutes before test
c. monitor ,mother after test to observe for possible initiation of labor
d. evaluate response to procedure

G. Biophysical Profile (BPP):

- assess breathing movements, body movements, tone, amniotic fluid volume and FHR
reactivity (NST)
- a score of 2 is assigned to each finding, with a score of 8 to 10 indicating a healthy
fetus
1. used for fetus that may have intrauterine compromise
2. ​Nursing considerations:
a. provide emotional support
b. evaluate response to procedure
H. Maternal Assessment of Fetal Activity:
need to contact physician or nurse midwife when there are fewer than 10fetal
movements in a 12-hour period
fewer than three fetal movements in an 8-hour period, or no fetal movements in the
morning
1. used to determine viability of fetus
2. ​Nursing considerations:​
a. teaches how to record and report movements

Categories of High-Risk Pregnancies:

UNIVERSAL:
Maternal age above 35 & below 17
Primiparity & grand multiparity
Height less than 140cm
Low socio economic status.
REPRODUCTIVE HISTORY:
Long period of infertility
Recurrent abortion
Previous IUD, stillbirth, CS, Hysterotomy or Myomectomy Neonatal death & preterm
labor
Previous Rh or ABO iso immunization, pre-eclampsia & Third stage complications.
PRESENT OBSTETRICAL HISTORY
women with medical disorders
Ectopic pregnancy, hydatidiform mole, IUGR, Hydraenids
Malpresentation, obesity & prolonged labor
INTRAPARTUM FACTORS:
PROM, Cord complications, fetal distress,
PPH, Retained placenta
Unskilled attendant.
Risk Factors for a High-Risk Pregnancy can include:
Being overweight or underweight
History of problem in previous pregnancy
Pre-existing health conditions
Multiple pregnancy
Mal Presentation
Antepartum hemorrhage, threatened abortion
Elderly primi, short statured
Pre-eclampsia & eclampsia