HIGH RISK

PREGNANCY

Prepared by:

GRENCHEN FAITH D DAYAO, DNS (ue) MAN, RN, LPT

Nursing Care of Women
with Complications
During Pregnancy
Objectives:
 Identify the factors that
contribute to high-risk
pregnancy.

 Discuss the application of

the different screening and
diagnostic tests.
 Describe common illness
that can result in
pregnancy complications.

 Explain dependent,
independent and
collaborative
management to high-risk
pregnancy and
complications.
Objectives
 Integrate knowledge
of high-risk
pregnancy and
nursing process in
achieving maternal
and child health
nursing care.
Introduction

 A high-risk pregnancy
is defined as one in
which the health of
the mother, fetus or
both is in jeopardy.
 Early and consistent
assessment for risk
factors during
prenatal visits is
essential for a
positive outcome for
the mother and the
fetus.
Identifying Clients at Risk
 Ways for identification clients at risks:

1. Assessment of risk factors

a. Physiological
b. Psychological
c. Social
 Categories:

 Biophysical
 Behavioral

 Psychological status

 Socio-demographic
 Socio-demographic
 Maternal Age
 Parity

 Marital status

 Residence

 Ethnicity

 Income

 Racial and ethnic origin

 Occupational Hazards
What is the role of the Nurse?

Identify risk factors and estimate the

potential effect of the pregnancy
outcome.
Causes of Maternal Mortality:

 Normal delivery and other

complications related to pregnancy
occurring in the course of labor,
delivery and puerperium.
Causes of Maternal Mortality:
 Hypertension complicating pregnancy,
childbirth and puerperium.

 Postpartum Hemorrhage.

 Pregnancy with abortive outcome.

 Hemorrhage related to pregnancy.

Fetal Diagnostic Tests
Fetal Well-Being
 Fetal movements are directly related to the
infant’s sleep-wake cycle and vary from the
maternal sleep-wake cycle.

 The typical active fetal period lasts 40 minutes

and peaks between 9:00 PM and 1:00 AM in
response to maternal hypoglycaemia (Moses,
2003).
 1. Ultrasound
 Uses high frequency
sound waves to visualize
structures within the
body.

 Abdominal ultrasound
during early pregnancy
requires a full bladder for
proper visualization (1-2
quarts of water).
 Ultrasonography is also used to predict fetal
maturity by the measurement of the biparietal
diameter of the fetal head.

 Placental grading can also be done through

ultrasound as 0 (12 to 24 weeks), 1 (30 to 32
weeks), 2 (36 weeks), and 3 (38 weeks).

 The amount of amniotic fluid present can also

be detected through ultrasonography and is
also a way to estimate fetal health.
1.1 Transvaginal Ultrasound

 uses a probe inserted into the vagina

 internal visualization can also be used as a
predictor for preterm birth in high-risk cases
(Berghella, Talucci, Desai, 2003)
 Use to detect
shortened cervical
length or funneling is
helpful in predicting
preterm labor,
especially in women
who have a history of
preterm birth
(Berghella et al, 2003)
1.2 Transabdominal Ultrasound

 the transducer is
moved across the
woman’s abdomen

 is often scanned with

a full bladder  drink
a full glass of water
every 15 minutes 90
minutes before the
examination.
Nursing Responsibility:

 Inform the patient about the procedure.

 Provide comfort and privacy.
- Empty bladder (transvaginal UTZ);
- Full bladder (transabdominal UTZ)
- Proper positioning  supine
- Proper draping
2. Magnetic Resonance Imaging

 MRI does not have any harmful effects to both

the mother and the fetus, and is now largely
considered as one of the preferred fetal
assessment techniques.
 MRI can diagnose complications like ectopic
pregnancy and trophoblastic disease or H-mole
because fetal movements could hide the
findings later in pregnancy.
 3. Maternal Serum Alpha
Fetoprotein

 AFP is found in the amniotic fluid and the

maternal serum and is produced by the
fetal liver
 MSAFP levels start to increase at 11 weeks’
gestation and increases steadily until term.
 The MSAFP level is abnormally high if there is
a spina bifida defect or abdominal defect.
 The MSAFP level is low if the fetus has a
chromosomal defect such as Down
syndrome

 The MSAFP is assessed at the 15th week of

pregnancy and can detect 85% to 90% of
neural tube defects and 80% of Down
syndrome.
4. Chorionic Villi Sampling
 Obtaining a small part of the developing placenta
to analyze fetal cells at 10-12 weeks of gestation

 Results of chromosome studies are available 24-

48 hours later

 Cannot be used to determine spina bifida or

anencephaly
 Identify chromosome abnormalities or other
defects that can be determined by analysis of
cells.
 Reports of limb reduction defects in newborn
 Rh(D) immune globulin (RhoGam) is given to
the Rh-negative woman
 Higher rate of spontaneous abortion after
procedure than after amniocentesis
 5. Amniocentesis

 Insertion of thin needle through the

abdominal and uterine walls to obtain a
sample of amniotic fluid, which contains
cast-off fetal cells and various other
fetal products
 Before the procedure, instruct the woman to
void, and then place her on a supine position.
 Fetal heart rate and uterine contraction

monitors are attached to the woman,

and blood pressure and fetal heart rate are
taken.
 An ultrasound is performed first to determine

the position of the fetus and the location of a

pocket of amniotic fluid and the placenta.
 Antiseptic solution is applied to the abdomen
and local anesthetic is injected.

 Inform the woman that she might feel

pressure as the needle is introduced, but do
not advise her to take a deep breath and
hold it in.

 About 15 mL of amniotic fluid is aspirated.

 Amniotic fluid is analyzed for AFP, bilirubin
determination, chromosome analysis, color, fetal
fibronectin, inborn errors of metabolism, lecithin-
sphingomyelin ratio, and phosphatidylglycerol and
desaturated phosphatidylcholine.

Color:
 Normal = color of water
 Late in pregnancy = slightly yellow tinge
 Strong yellow color suggest a blood incompatibility
 Green = suggest meconium staining, associated
with fetal distress
 Usage of Amniocentesis
Early pregnancy

 Identify chromosome abnormalities, biochemical

disorders (such as Tay-Sachs’ disease), and level
of AFP
 A fetus can’t be tested for every possible disorder
 Spontaneous abortion following the procedure is
the primary risk
 Usage of Amniocentesis
Late pregnancy

 Identify severity of maternal-fetal blood

incompatability and assess fetal lung maturity
 Rh(D) immune globulin is given to the Rh-
negative woman
 Nursing Responsibility
 Obtain informed consent
 What? Why? How? Possible complications?
 Provide comfort and privacy

full bladder, position, draping

 Aseptic technique

 handwashing, sterile gloving

 Skin preparation
6. Daily Fetal Movement Counting
(DFMC)

 also known as Fetal Kick Count / Cardiff

Count-to-Ten Method

 test sensitive for fetal well-being at 27 weeks

 physiology of normal third trimester fetal
movement

 fetus spends 10% of its time making gross fetal

movement

 fetal activity peaks with maternal hypoglycemia

 techniques
 expected findings:
 10-12 movements in 1 hour or less than an hour
 warning signs:
 more than 1 hour to reach 10 fetal movements
 less than 10 fetal movements in 12 hours

 longer times to reach 10 fetal movements than on

previous days
 movements are becoming weaker, less vigorous

 movement alarm signal <3 fetal movements in 12

hours
7. Contraction Stress
Test
 In contraction stress testing, the
fetal heart rate is assessed in
conjunction with uterine
contractions.

 The woman is attached to an

external uterine contraction and
fetal heart rate monitor.
 Nipple Stimulation

 The woman is instructed to roll a nipple between

her fingers and thumb to produce uterine
contractions.

 Within a 10-minute window, three contractions

with a duration of 40 seconds or longer must be
present.
 Oxytocin Challenge Test (OCT)

 done by intravenously infusing dilute

oxytocin until 3 contractions occur within 10
minutes

 oxytocin / pitocin
 start: 0.5 - 1.0 mU/min
 titrate: increase 1 mU every 20 minutes

 goal: 3 contractions every 10 minutes

 The test is negative or normal if there
are no decelerations in the fetal heart
rate during contractions.

 It is positive or abnormal if there is a

late deceleration at the end of a
contraction and even after the
contraction.
 8. Non-Stress Test (NST)
 Measures the response of the fetal heart rate
to the fetal movement

 Evaluation with an electronic fetal monitor of

the fetal heart rate (FHR) for accelerations of
at least 15 beats/min lasting 15 seconds in a
10 to 20-minute period
 In a nonstress testing, the response of the fetal
heart rate is measured in response to the fetal
movement.
 The woman is attached to a fetal heart rate and
uterine contraction monitor.
 The woman should push the button of the
monitor whenever she feels the fetus move.
 The nonstress test is done for 10 to 20 minutes.
 Normally, when the fetus moves, the fetal
heart should increase for about 15 beats per
minute and remain elevated for 15 seconds.
 The result is reactive:

 if there are two accelerations of fetal heart rate

lasting for 15 seconds that occurs after
movement. (2x in 20mins)
 It should decrease to its average rate again as

the fetus quiets

 The result is non reactive:
 if there are no fetal accelerations after a fetal
movement, or there is no fetal movement or if
there is low short-term fetal heart rate variability
(<6beats /min)
 Unsatisfactory test:
 if the data cannot be interpreted or there was an
inadequate fetal activity
 If a 20 minute period passes without any fetal
movement, it may mean only that the fetus is
sleeping
 Usage of NST
a. Identify fetal compromise in conditions associated
with poor placenta function, such as
hypertension, diabetes mellitus, or postterm
gestation.

b. Adequate accelerations of the FHR are

reassuring that the placenta is functioning
properly and the fetus is well oxygenated
9. Percutaneous Umbilical
Blood Sampling

 Obtaining a 1-4ml fetal blood sample

from a placental vessel or from the
umbilical cord
 May be used to give a blood transfusion
to an anemic fetus
 Usage of PUBS
 Identify fetal conditions that can be
diagnosed only with a blood sample

 Blood transfusion for fetal anemia caused by

maternal-fetal blood incompatability,
placenta previa, or abruption placentae
10. Lecithin / Sphingomyelin
ratio

 Protein components of the lung

enzyme surfactant that the alveoli
begin to form at about 22-24th weeks
of pregnancy
 L/S ratio of 2:1 = lung maturity
 Evaluate whether the fetus is likely to have
respiratory complications in adapting to
extrauterine life

 May be done to determine whether the fetal

lungs are mature before performing an
elective caesarean birth or inducing labor if
the gestational age is questionable
L/S Ratio Fetal Lung Risk for
RDS
> 2.0 Mature Minimal

1/5 to 2.0 Transitional Moderate

Zone
< 1.5 Immature High
 Also used to evaluate whether the
fetus should be promptly delivered
or allowed to mature further when
the membranes rupture and the
gestation is at less than 37 weeks or
if the gestation is questionable
11. Phosphatidyl glycerol &
Desaturated Phosphatidylcholine

 Compounds, in addition to lecithin and

sphingomyelin, that are found in
surfactant
 Pathways for these compound matures

at 35-36 weeks of gestation

 12. Biophysical profile
 The biophysical profile combines five
parameters into one assessment
1. Fetal reactivity
2. Fetal body movement
3. Fetal heart rate
4. Breathing measure = short-term central nervous
system function.
5. The amniotic fluid volume = measures long-term
adequacy of placental function
 The biophysical profile is more accurate than
any other single assessment method.
 The score ranges from 2-10, with 10 as the
highest.
 If the fetus has a score of 8 to 10, it is doing
well.
 If the score is 6, this is considered suspicious.
 A score of 4 denotes that fetus might be in
jeopardy.
 The assessment is similar to that of an Apgar
scoring, and it is commonly called as fetal
Apgar.
 Fetal assessment is just one of the many

assessments that a pregnant woman must

undergo to ensure the health of the fetus and
even her own health. Undergoing these tests
can give comfort to the mother regarding the
status of her baby’s health, and compliance of
her health care provider’s orders is the key to a
healthy and safe pregnancy.
 INTERPRETATION:
 BPS: 8-10
 low risk or normal result
 repeat BP profile weekly

 indications to rpt BPS weekly

 gestational diabetes

 gestational age >42 weeks

 INTERPRETATION:
 BPS: 7
 needs to undergo anotehr test such as CST

 INTERPRETATION:
 BPS: 6
 suspect asphyxia
 rpt BPS in 24 hours
 delivery indications:
 rpt BPS 6
 INTERPRETATION:
 BPS: 4
 suspect asphyxia
 delivery indications:
 gestational age > 36 weeks
 lung maturity test positive (L/S ratio >2)

 INTERPRETATION:
 BPS: 0-2
 likely asphyxia
 continue monitoring for 2 hours
 delivery indications:
 BPS <4
Biophysical Profile
 Identify reduced fetal oxygenation in
conditions associated with poor placental
function.

 As fetal hypoxia gradually increases, FHR

changes occur first, followed by cessation of
fetal breathing movement, gross body
movements, and finally loss of fetal tone
 Biophysical Profile

 Amniotic fluid volume is reduced when placental

function is poor (shows pockets of low or absent
amniotic fluid
13. Amniotic Fluid Bilirubin

 Use to analyze blood incompatibility

14. Blood Studies

 Complete blood count should be taken to

assess the hemoglobin, hematocrit, and
red cell index and determine the presence
of anemia

 White blood cell count and platelet count

must also be obtained to assess
for infection clotting ability.
 Blood typing with Rh factor is also
important because blood needs to be
available if ever the woman
experiences bleeding during pregnancy.

 Antibody titers for rubella and hepatitis B or

HBsAG determine whether the woman is
protected against rubella and if
the newborn would have a chance of
developing hepatitis B.
 15. Glucose Tolerance Test
 A woman with a history of diabetes, large for
gestational age babies, obese, or has glycosuria
should undergo glucose tolerance test.
 A 50-g oral toward the end of the first trimester

should be performed to rule out gestational

diabetes.
 The plasma glucose level should not exceed

140mg/dl at 1 hour.
 16. Urinalysis

 Urinalysis is performed to
assess proteinuria, glycosuria, and pyuria.

 These can be done through test strips or

microscopic examination of the urine
TAPOS NA…THE END…