HIGH-RISK PRENATAL CLIENT

HIGH-RISK PREGNANCY- is one in which a concurrent disorder, pregnancy-related complication, or

external factor jeopardizes the health of the woman, the fetus, or both

Factors That Categorize a Pregnancy at Risk (p. 515)

Prepregnancy

PSYCHOLOGICAL

Hx of drug dependence (incl. alcohol)

Hx of intimate partner abuse

Hx of mental illness

Hx of poor coping mechanisms

Cognitively-challenged

Survivor of childhood sexual abuse

SOCIAL

handling of toxic substances (incl radiation & anesthesia gases)

Environmental contaminants at home

Lower economic level

Poor access to transportation for care

High altitude

Highly mobile lifestyle

Poor housing

Lack of support people

PHYSICAL

Visual or hearing challenges

Pelvic inadequacy or misshape

Uterine incompetency, position or structure

2° major illnesses(heart ds, DM, kidney ds, HPN, malignancy, blood disorders)

Poor gynecologic or obstetric Hx

Hx of poor pregnancy outcome (miscarriage, IUFD, stillbirth)

Obesity (BMI >30)

Underweight (BMI < 18.5)

PID, Hx of inherited disorder

Small stature

Potential of blood incompatibility

<18yo or >35 yo

Cigarette smoker, substance abuser

Pregnancy

PSYCHOLOGICAL

Loss of support person

Illness of a family member

Decrease in self-esteem

Drug abuse (incl cigarette & alcohol)

Poor acceptance of pregnancy

SOCIAL

Refusal of or neglected prenatal care

Exposure to environmental teratogens

Disruptive family incident

Decreased economic support

Conception <1 yr after last pregnancy

PHYSICAL

Subject to trauma
F & E imbalance

Intake of teratogen such as a drug

Multiple gestation

Bleeding disruption

Poor placental formation or position

Gestational diabetes

Nutritional def( Fe, FA, protein)

Poor weight gain

PIH

Infection

Amniotic Fluid abnormality

Postmaturity

Labor and Birth

PSYCHOLOGICAL

Severely frightened by L & B experience

Inability to participate due to anesthesia

Separation of infant at birth

Lack of preparation for labor

Birth of infant who is disappointing in some way (sex, appearance, deformity)

Illness in NB

SOCIAL

Lack of support person

Inadequate home for infant care

Unplanned CS

Lack of access to continued HC

Lack of access to ER personnel or equipment

PHYSICAL

Hemorrhage

Infection

F & E imbalance

Dystocia

Precipitous birth

Lacerations of cervix/vagina

CPD

Internal fetal monitoring

Retained placenta

IDENTIFYING CLIENTS AT RISK

It begins with the 1st prenatal visit & continues throughout the pregnancy

It involves subjective as well as objective assessment techniques such as screening procedures,

laboratory and diagnostic examinations

Standard Examinations Done in a Prenatal Visit

Complete Blood Count- screens for anemia

Edema Check

-normally in LE (if found on leg; in arms & feet, may indicate pre-eclampsia)

Fetal heart Rate (N= 120-160 bpm)

Fundic Height- measured from 22-34 weeks & correlates with gestational age with normal
pregnancy

Height- during initial visit

Leopold’s Maneuver

Pelvic adequacy examination

Urinalysis and culture

-screening for asymptomatic bacteruria as early as 1st prenatal visit; if (+), culture is
done Vital Signs

Weight- pattern of weight gain/loss is recorded

What is diagnostic test

Radioimmunoassay

Commonly used lab test to detect HCG levels in the urine or serum of the pregnant woman

95-98% accurate

Other techniques

ELISA (Enzyme-linked immunosorbent assay)

RRA (Radio receptor assay)

 Trace amount of HCH is detected in the serum as early as 24-48h after implantation

 Levels peak @ about 100 mIU/ml between the 60th and 80th day of gestation

Home Pregnancy Test- several brand name kits for pregnancy based on immunologic reactions

work in similar ways; user may hold a stick in the urine stream. Others involve collecting urine in a cup
and then dipping the stick into it. One brand tells to collect urine in a cup and put a few drops into a
special container with a dropper.

Testing the urine first thing in the morning may help boost accuracy.

Available over the counter

Color change on the strip denotes pregnancy

3-5 minutes to perform

97% accurate

Detects 50-150 mIU/ml of HCG

Ultrasound scan is currently considered to be a safe, non-invasive, accurate and cost-effective

investigation in the fetus. It has progressively become an indispensible obstetric tool and plays an
important role in the care of every pregnant woman.

The main use of ultrasonography are in the following areas:

Diagnosis and confirmation of early pregnancy.

Vaginal bleeding in early pregnancy.

Determination of gestational age and assessment of fetal size.

Diagnosis of fetal malformation.

Placental localization

Multiple pregnancies

Hydramnios and Oligohydramnios.

Other [Link] is of great value in other obstetric conditions such as:

a) confirmation of intrauterine death.

b) confirmation of fetal presentation in uncertain cases.
c) evaluating fetal movements, tone and breathing in the Biophysical Profile.
d) diagnosis of uterine and pelvic abnormalities during pregnancy e.g. fibromyomata and ovarian cyst.

- TRANSVAGINAL UTZ
-probe placed in the vagina of the patient
- usually provides better images (obese aegs / early stages of pregnancy
- closer proximity to the uterus and the higher frequency
-Fetal cardiac pulsation can be clearly observed as early as 6 weeks of gestation.
-early diagnosis of ectopic pregnancies

Doppler Ultrasound

The doppler shift principle has been used for a long time in fetal heart rate detectors.

Further developments in doppler ultrasound technology -enabled a great expansion in its application in
Obstetrics,

in assessing and monitoring the well-being of the fetus, its progression in the face of intrauterine
growth restriction, and the diagnosis of cardiac malformations.

Doppler ultrasound is most widely employed in the detection of fetal cardiac pulsations and

"Doptone" fetal pulse detector is a commonly used handheld device to detect fetal heartbeat using the
same doppler principle.

fetoscopy

Fetoscopy allows a doctor to see the fetus through a thin, flexible instrument called a fetoscope
fetoscope is inserted into the uterus through a small cut is made in the belly.

Fetal ultrasound is used to guide the placement of the fetoscope to protect the fetus. A camera can be
attached to the fetoscope to take pictures.

done during or after the 18th week of a pregnancy when the placental structures and the fetus are
developed enough to be able to diagnose a serious problem.

an endoscopic procedure during pregnancy to allow access to the fetus, the amniotic cavity, the
umbilical cord, and the fetal side of the placenta.

A small (3-4 mm) incision is made in the abdomen, and an endoscope is inserted through the abdominal
wall and uterus into the amniotic cavity. Fetoscopy allows medical interventions such as a biopsy or a
laser occlusion of abnormal blood vessels.

Cordocentesis : Percutaneous Umbilical Blood Sampling (PUBS)

diagnostic test that examines blood from the fetus to detect fetal abnormalities.

An advanced imaging ultrasound determines the location where the umbilical cord inserts into the
placenta. The ultrasound guides a thin needle through the abdomen and uterine walls to the umbilical
cord. The needle is inserted into the umbilical cord to retrieve a small sample of fetal blood. The sample
is sent to the laboratory for analysis, and results are usually available within 72 hours.

The procedure is similar to amniocentesis except the objective is to retrieve blood from the fetus versus
amniotic fluid.

usually done when diagnostic information can not be obtained through amniocentesis, CVS, ultrasound
or the results of these tests were inconclusive.

cordocentesis

performed after 17 weeks into pregnancy.

detects chromosome abnormalities (i.e. Down syndrome) and blood disorders (i.e. fetal hemolytic
disease.).Performed to help diagnose any of the following concerns:

Malformations of the fetus

Fetal infection (i.e. toxoplasmosis or rubella)

Fetal platelet count in the mother

Fetal anemia

Isoimmunisation
This test is different from amniocentesis in that it does not allow testing for neural tube defects.

Amniocentesis (also referred to as amniotic fluid test or AFT

is a medical procedure used in prenatal diagnosis of genetic abnormalities and fetal infections

a small amount of amniotic fluid, which contains fetal tissues, is extracted from the amnion or amniotic
sac surrounding a developing fetus, and the fetal DNA is examined for genetic abnormalities.

local anesthetic is sometimes given to relieve the pain when inserting the needle

amniocentesis

With ultrasound, a physician aims towards the sac that is away from the fetus and extracts a small
amount of amniotic fluid for testing.

The puncture heals, and the amniotic sac replenishes the liquid over a day or so.

the fetal cells are then separated from it using a centrifuge, and the fetal chromosomes are examined
for abnormalities. Various genetic testing may be performed, but the three most common abnormalities
tested for are Down's syndrome, Trisomy 18 and spina bifida. Amniocentesis can be performed as soon
as sufficient amniotic fluid surrounds the fetus to allow a sample to be recovered relatively safely,
usually no earlier than the 14th week of pregnancy. Often, genetic counseling is offered in conjunction
with amniocentesis.

Electronic fetal heart rate monitoring

Diagnostic tests for high risk pregnancy

FETAL ULTRASOUND

CARDIOTOGRAPHY

NON STRESS TEST