Chapter 26
Assessment for Risk
Factors in Pregnancy
High risk
pregnancies
such as due to
maternal
illness
Definition & Scope of the
Problem
High risk pregnancy:
advanced maternal age, diabetes, Hypertension, epilepsy
• Life or health of the mother or fetus is jeopardized
by a disorder coincidental with or unique to
pregnancy
• Care of these patients requires the combined efforts
of medical and nursing personnel (interprofessional
health care team)
• Factors associated with high-risk childbearing are
grouped into broad categories based on threats to
health and pregnancy outcomes
Assessment of Risk Factors
*imp. 1) Biophysical Risks:
problem with the mom or baby
• Originates with the mother or the fetus
• May affect development and functioning of both
• Genetic disorders, nutritional and general health
status, and medical or obstetric-related illnesses
Assessment of Risk Factors
2) Psychosocial Risks
Maternal behaviors and adverse lifestyles that have
a negative effect on health of mother or fetus
Risks may include: Social support
Emotional health problems
History of depression
Other mental health issues
Intimate partner violence
Substance abuse/misuse
Inadequate social support
Unsafe cultural practices
Assessment of Risk Factors
3) Sociodemographic Risks
• Arise from mother and her family
• Lack of prenatal care, low income, marital
status, and ethnicity (certain cultural practices can be unsafe
for the baby)
4) Environmental Risks
• Hazards in workplace and woman’s general
environment
• May include chemicals, anesthetic gases, and
radiation
Antepartum Testing
1) Daily fetal movement count (DFMC)
• Used to monitor fetus in pregnancies
complicated by conditions that may affect
oxygenation
• Also called ‘kick counts’
• A count of fewer than 3 kicks in 1 hour
OR voiced concerns of decreased
movement warrants further evaluation
by a nonstress test (NST)
ACCELERATIONS- good thing. Felt by mom!!
What we see are FETAL MOVEMENTS.
Done once a day- Usually after eating. Baby most active
when mom has eaten- esp juice or something sweet.
Baby moves about 30 times/hour but moms don’t feel all
movements as they get distracted doing other things
throughout the day.
How we know is concern?
LESS Than 3 kicks /hour. Sometimes not a concern ‘coz if baby is
sleeping not to worry !!
That’s why…. We say…. 10 movements in 2 hours … is a good way
to calculate !!
Antepartum Testing
2) Ultrasonography
• Types
• Abdominal: for 2 and 3 trimester
nd rd
• Transvaginal: for 1 trimester
st
• Indications for use
• Fetal heart activity
• Gestational age
• Fetal growth: esp diabetic moms (large babies); women
who have growth restriction problems
• Fetal anatomy: Done at 20 weeks gestation (brain, heart,
spine, kidney, pelvis). Takes about an hour to do.
My notes:
ABDOMINAL U/S- having a full bladder (beneficial) as it lifts the uterus during
exam.
U/S in 1st trimester:
1. to determine if they are pregnant,
2. the location of pregnancy (uterus or fallopian tubes, etc),
3. how many babies in uterus,
4. presence of a yolk sac (helps determine gestational age of the baby)
5. Any abnormalities in the uterus (any cysts, etc.)
U/S in 2nd and 3rd trimester:
-For growth and development – ANATOMY SCAN !!
-Gender
-Any genetic concerns
-Is baby viable?
-Amniotic fluid abnormalities
Antepartum Testing
Ultrasonography
• Indications for use
• Fetal genetic disorders and physical
anomalies
* Imp for exam
• Nuchal translucency (NT) screening:
amount of fluid in nape of the baby’s neck. A high amount of
fluid is directly related DOWN SYNDOME. If this test is
POSITIVE, then they can do further invasive tests.
• Placental position and function
• Adjunct to other invasive tests
The nuchal translucency
test measures the nuchal
fold thickness. This is an
area of tissue at the back
of an unborn baby's neck.
Measuring this thickness
helps assess the risk for
Down syndrome and other
genetic problems in the
baby.
This is the fetal nuchal translucency test
Antepartum Testing
Ultrasonography
• Indications for use: Fetal well-being
• Doppler blood flow analysis: there is more fluid
going through the arteries, to the baby, and how
much is going away. You see RED & BLUE going
through the veins. Done when moms have condition
that causes poor blood flow to the baby: like
HYPERTENSION & Diabetes.
• Amniotic fluid volume –measures the largest
pocket of amniotic fluid in all four quadrants are totaled
(AFI – amniotic fluid index)
• <5cm = oligohydramnios – may be associated
with IGUR, Rupture of membrane, anomalies such as
renal. (diabetes or neural tube defects)
• >25cm = polyhydramnios – gastrointestinal and
CNS anomalies, placental abnormalities
**know for exam what the components are
• Biophysical profile (BPP):
non-invasive U/S for well-being of the baby
1)AFV
2)fetal breaths : where babies have more problems
3)fetal movements : if baby is not moving it is
a problem.
4)fetal tone : they should have good tone of
their muscles. FLACCID is ABNORMAL.
Amniotic Fluid Volume (AFV) checks how much
fluid surrounds the baby in the womb. Too little
(oligohydramnios)may mean placenta problems
or baby kidney issues. Too much
(polyhydramnios) can be linked to diabetes or
baby’s swallowing issues. A normal AFV means
the baby is likely doing well.
Biochemical Assessment
Amniocentesis: Done after 14 weeks gestation
containing fetal cells
Obtains amniotic fluid
Indications for use:
• Genetic concerns * most commonly
• Fetal lung maturity – measuring L/S ratio
• Fetal hemolytic disease (not so common in Canada)
My notes:
We feel their skin, done after 14 weeks. Go in through the
abdomen, through uterine cavity.
Amniotic fluid should solidify again once needle comes out.
RISKS:
Miscarriage Infection (rare but possible)
Leakage of amniotic fluid
Needle injury to the baby (very rare, as ultrasound guides the
procedure)
Rh sensitization (if mother is Rh-negative, may need Rh immunoglobulin)
Cramps or mild pain (common but usually temporary)
Biochemical Assessment * EXAM
• Chorionic villus sampling (CVS) : optional test
• Done earlier like 12 weeks GESTATION
REMOVES A PIECE OF PLACENTAL TISSUE.
1) THROUGHT THE VAGINA
• Technique for genetic studies or
2) ABDOMINALLY
• Earlier diagnosis, rapid results
3) GOOD FOR GENETIC TESTING. RELATVELY SAFE
PROCEDURE !!!!
• Performed ‘ideally’ between 10 and 13 weeks of
gestation (can be done in 2nd trimester)
• Involves removal of small tissue specimen from the
placenta
Biochemical Assessment
• Maternal assays *** exam
• Maternal serum alpha-fetoprotein
(MSAFP)
• Screening tool for neural tube defects
(NTDs) and chromosomal abnormalities in
pregnancy
• Screening recommended for all
pregnant women ideally between 16-
18 weeks
• If it is elevated, we do an U/S after
Electronic Fetal Monitoring
• Indications
• Used to determine whether the intrauterine
environment continues to be supportive of the
fetus during the 3rd trimester
• Nonstress test: tells us if the baby is
good inside. Getting a fetal heart tracing.
• Procedure
• Interpretation: Reactive (normal) or
nonreactive (requires further evaluation)
• TERM PREGNANCY: 15 high lasting 15 secs.
REACTIVE !!
Psychologic Considerations Related High-
Risk Pregnancy
• Label of high risk often increases the
patient’s sense of vulnerability
• May exhibit anxiety, low self-esteem, guilt,
frustration, and inability to function
• May affect parental attachment,
accomplishment of the tasks of pregnancy,
and family adaptation to the pregnancy
