Colegio de San Gabriel Arcangel
City of San Jose del Monte, Bulacan, Philippines
COLLEGE OF MEDICAL ALLIED COURSES
Program
Course Code
Description
Bachelor of Science in Midwifery
M104
Clinical Management of Obstetrical Emergencies and High Risk Pregnancies
LEARNING SHEET NO. 1
Name
Score
Date
Section
Topic
High Risk Pregnancy
Learning
Outcomes
1.
2.
3.
4.
References
Pillitteri, Adele,(2007), Maternal and Child health Nursing: Care of the Childbearing &
Childrearing Family (5th ed.),
Identify what is High Risk Pregnancy and Obstetric Emergencies
Enumerate the Risk factors of high risk pregnancy
Discuss the importance of assessment for high risk pregnancy
Explain the difference between biophysical monitoring and biochemical monitoring for
high risk pregnancy
Discussion
High Risk Pregnancy is a pregnancy complicated by a disease or a disorder that may endanger the life or
affect the health of the mother, the fetus or the newborn.
In a high risk (at-risk) pregnancy, the mother, the fetus or neonate is at increased risk of morbidity mortality
before and after delivery.
Maternal Death
WHO – A maternal death is a death of woman while pregnant or within 42 weeks of termination of pregnancy
irrespective of the duration and the site of the pregnancy, from any course related or aggravated by the
pregnancy or in the management but not from accidental or incidental causes.
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20-25% deaths occur during pregnancy
40-50% deaths occur during labor and delivery
25-40% deaths occur after childbirth (more during the first seven days)
What is Obstetrical Emergency?
Obstetrical emergencies are life threatening medical conditions that occur in pregnancy or during labor or
after delivery.
It is a suddenly developing pathologic condition in a patient, due to accident or disease, which requires urgent
medical or surgical therapeutic intervention.
In any population of pregnant woman at least 15% will experience obstetric complications.
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City of San Jose del Monte, Bulacan, Philippines
COLLEGE OF MEDICAL ALLIED COURSES
Pregnancy Changes
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Hyperdynamic, hypervolemic maternal circulation
Cardiac output increases by 50%, blood volume by 45% (peak at 32-34 weeks)
30% loss of fluid may be tolerated without any tachycardia
Obstetric Emergencies
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Maternal
Fetal
Both maternal and fetal
Maternal Complications of Pregnancy
First Trimester
1. Ectopic Pregnancy
2. Abortion
3. Molar Pregnancy
4. Uterine Rupture
Second Trimester
1. Abortion
Third Trimester
1. Placenta Previa
2. Placenta Accreta
3. PPH
4. Uterine Inversion
5. Uterine rupture
6. Hypertensive crisis
Risk Factors for High Risk Pregnancy
Problems related to previous pregnancies
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LBW (low birth weight)
Over-weight
Birth defects
LCSC
Stillbirth
Rh-incompatibility
Miscarriage
Post-term
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City of San Jose del Monte, Bulacan, Philippines
COLLEGE OF MEDICAL ALLIED COURSES
Problems during pregnancy
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Drugs
Radiation
Infection
Chemicals
Pregnancy Complications
Physical Factors
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Age at the time of delivery
< 19 yrs old
>36 yrs old
Short stature (<145 cms)
Weight <40 kgs or >80 kgs
Medical Factors
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APH, PPH
Grand Multi-para
Multiple Pregnancy
Abnormal Presentations
Polyhydramnios
Anemia
Rh-incompatibility
PIH, Eclampsia
Previous LSCS
Retained Placenta
Prolonged labour
Recurrent abortions
Ectopic pregnancy
Diabetes
Heart disease
High Risk Labor
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Preterm labor
Post term labor
Previous LSCS
CPD (Cephalopelvic Disproportion)
Malposition
Prolonged Labor
Obstructed Labor
Shoulder Dystocia
Inversion or Uterus
Rupture of Uterus
Perineal tear
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Assessment of High Risk Factors
1. History Taking and Physical Examination
Contraception
-uterine devices (IUCDs) can produce adverse effects:
o Perforation of uterine wall
o Cramping and bleeding
o Infection – PID
o Tubular infertility
– generally accepted failure rate of 2:1000
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– synthetic versions of oestrogen and progesterone
o Prevents uterus from releasing an ovum (egg) each month
o Also thickens the mucus in the cervix preventing sperm from getting through
Previous Medical History
o Diabetes
o HT (140/90)
o Seizure disorders
(pre-eclampsia/eclampsia)
o Infections
o Drug use (narcotic OD)
o Smoking
o Embolisms
o Previous ectopic pregnancies
o Ask about each pregnancy
o Length of previous labours?
o How many pregnancies?
arity)
o Were there any problems?
o What were they?
o How were they resolved (or not)?
o Any previous:
o “gravis” = burdened or heavy
o Gravida1 = 1 child (primigravida)
o Gravida2 = 2 child (secundigravida)
o Gravida3 = 3 child (tertigravida)
o Multigravida
o Birthed a child 20 weeks or more
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o Nulliparae – a woman who has never given birth
o Primipara – woman who has given birth to one child
o Multipara – woman who has borne two or more children
Menstrual History
od, mucus and cellular debris from uterine mucosa
-60mls per cycle (4-6 days)
o Assess color; bright red vs. dark red
o Amount: assess pads/tampons soaked per hour
o Duration of bleeding episode
o Sudden abdo pain can = ectopic pregnancy until proven otherwise (ectopic = after 6-8 weeks)
menstruation considered normal for the pt:
o Menorrhagia (heavy)
o Metrorrhagia (prolonged irregular)
o Polymenorrhoea (frequent)
o Oligomenorrhoea (infrequent)
o Unilateral, (L) or (R) LQ abdo pain that may occur just before, during or after ovulation
o Causes:
irritation of the abdominal lining
o Pain switches sides each month as ovaries alternate
o Usually distinctive sharp, cramping and in rare occasions severe pain
o Can last minutes to hours (up to 24-48hours)
o S&S: Symptoms usually occur at the start of menstruation and typically last for the first 24-48 hours of
menstruation
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Current Pregnancy
o Calculated from 1st day of woman’s last menstrual cycle
etus
o Where is the fetus lying?
o Regular contractions?
o Braxton Hicks?
pre and antenatal care
o PV (post vaginal) loss
o Hypotension/Hypertension
o Oedema
o Pain
o Trauma
o Labour
o Placenta location
o When did contractions begin
o Duration and frequency – how long are they and how far apart are they
o Fetal movement felt by mother (+ or -)
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City of San Jose del Monte, Bulacan, Philippines
COLLEGE OF MEDICAL ALLIED COURSES
o Colour of fluids? – clear or degree of discolouration, heavily blood stained, meconium staining
o Is there evidence of a show?
Emotional Distress
o Personal health issues
o Mental status:
o Financial worries
o Relationship issues
o Pregnancy concerns:
ut current pregnancy
Sexual Assault
physical and psychological implications
-13% of women are sexually abused by their partners during pregnancies
o Soft tissue injury or trauma to genitals and or anus
o Loss of consciousness, episode of amnesia or drug related blackout
o #s to face, long bones, ribs
o Abdominal trauma
o Bites to hands, chest, face, back
o Scratched, generalised bruising
n lead to organ rupture, life –threatening
hypovolemic and septic shock
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COLLEGE OF MEDICAL ALLIED COURSES
Endometrium
adhesions between the opposed walls of the myometrium; maintain patency of
uterine cavity
-vessel rich, glandular tissue layer, providing
the perfect environment for blastocyst implantation upon its arrival in the uterus o Blastocyst = Cell prior to
becoming an embryo
Fallopian Tubes
ised whilst in the fallopian tubes if sperm is present
Ovary
Uterus (Womb)
of the embryo and fetus during pregnancy
Cervix
Placenta
Organ that connects foetus to uterine wall
Umbilical Cord
tuses stomach to the placenta
of;
o One vein which carries blood rich in oxygen and nutrients from the placenta to fetus
o Two arteries which return deoxygenated blood and waste products (CO2) from the fetus back to placenta
Biophysical Monitoring
A biophysical profile may be scheduled for women whose pregnancies are considered high-risk.
What is a Biophysical Profile?
The biophysical profile, or BPP, is a test that checks fetal health in high-risk pregnancies. The BPP combines a
non-stress test with an ultrasound exam, and it's usually done after the 28th week of pregnancy.
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City of San Jose del Monte, Bulacan, Philippines
COLLEGE OF MEDICAL ALLIED COURSES
Several decades ago there were only two ways to check the health of the fetus -- by measuring the size of the
uterus and listening to the fetal heartbeat.
In the late 1960s and early 1970s, doctors discovered that changes in fetal heart rate could predict certain
problems. Electronic fetal heart-rate monitoring is now widely used to evaluate the health of the fetus.
A test called the non-stress test (NST) is commonly performed to evaluate the health of the fetus. The non-stress
test involves placement of a fetal monitor on the mother's abdomen and interpretation of the fetal heart rate in
response to fetal movements. It generally takes only 20 to 30 minutes and doesn't require hospital admission.
Interpretation of the non-stress test can sometimes be misleading; there is a relatively high rate of false-positive
results, which means that the test may come back positive but the fetus is actually well. Oftentimes, the nonstress test is abnormal, even though there are no problems with the baby, and it's difficult to decide what to do
next.
The biophysical profile (BPP) decreases the likelihood of false-positive results by combining the non-stress test
with an ultrasound exam. The BPP typically takes 30 minutes, and like the non-stress test, can be done on an
outpatient basis.
The ultrasound exam checks four different indicators:
Fetal tone
Fetal breathing
Fetal movements
Amniotic fluid volume
Each of these four parameters, plus the non-stress test, gets a score from 0 to 2. The scores are then added up
for a combined maximum of 10. The interpretation of the BPP score depends on the clinical situation. In
general, a score of 8 or 10 is considered normal, while a score below 8 usually requires further evaluation or
delivery of the baby.
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COLLEGE OF MEDICAL ALLIED COURSES
The indications for both the non-stress test and the BPP are similar, and your doctor will decide which test is
appropriate for your situation.
Reasons to Do a Biophysical Profile
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Overdue pregnancy
Maternal medical conditions, such as high blood pressure, diabetes, and heart or kidney disease
Multiple gestation (twins, triplets)
Decreased amniotic fluid (oligohydramnios)
Small baby (intrauterine growth restriction)
Placental abnormality
Previous unexplained fetal death
Maternal perception of decreased fetal movement
Premature rupture of fetal membranes
Concern for fetal well-being
Biochemical Monitoring
Pregnancy induces major physiological, hormonal and biochemical changes to achieve an optimal outcome
for the baby and its mother. When the pregnancy deviates from its normal course, there are many biochemical
markers which can be used to assess these abnormalities. As biochemistry is only one part of obstetric care,
results should be interpreted in conjunction with clinical and medical imaging data. Imaging is especially
important and can be used to assess many placental and fetal abnormalities. Ultrasonography continues to
improve and be refined in the early detection of fetal structural defects. It has equalled, if not superseded,
biochemical testing in many aspects of obstetric care.
Biochemical markers are used to assess maternal, placental and fetal health. They help to diagnose and
monitor maternal conditions such as gestational diabetes and pre-eclampsia, trophoblastic disease and fetal
chromosomal abnormalities such as Down's syndrome (Table 1). These biochemical and hormonal tests
constitute only one aspect of obstetric care. They should be used together with clinical findings and imaging,
particularly ultrasonography.
Table 1 Biochemical tests for common maternal, placental and fetal conditions
Condition
Test
Maternal
Gestational diabetes
Glucose screening tests at 24-28 weeks: 50 g
challenge test
or
2-hour 75 g oral glucose tolerance test
Pre-eclampsia*
1. Urinary protein (by dipstick testing or formal
quantitation)
2. Serum uric acid
3. Renal function tests
4. Full blood count (for Hb concentration and
platelet count)
Placental
Trophoblastic disease*
1. HCG
(hydatidiform mole or
2. Free β-HCG
choriocarcinoma)
3. Urinary HCG when indicated
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Condition
Fetal
Test
Down's syndrome*
Neural tube defects
Maternal serum alpha fetoprotein, HCG,
pregnancy-associated plasma protein-A, and
transnuchal ultrasound between 11 and 13 weeks
gestation
Maternal serum alpha fetoprotein, HCG,
pregnancy-associated plasma protein-A, and
serum unconjugated oestriol in various
combinations between 15 and 18 weeks gestation
1. Maternal serum alpha fetoprotein
or
2. Amniotic fluid alpha fetoprotein (less common)
* potential use of fetal DNA in maternal circulation HCG human chorionic gonadotrophin
Biochemical assessment of fetal health
The major aim of fetal assessment is to ensure satisfactory growth in utero. There are many factors which can
cause fetal growth retardation. These range from poor maternal nutritional state to placental insufficiency and
fetal abnormality. Similar to placental function, medical imaging is increasingly used to detect fetal
abnormalities, thus reducing the utility of biochemical markers.
Alpha fetoprotein
Alpha fetoprotein is a fetal protein arising from the yolk sac and fetal liver. It can be detected in increasing
concentrations in maternal serum until 32 weeks of normal gestation.
Neural tube defects
In neural tube defects such as spina bifida8 and anencephaly, the concentration of alpha fetoprotein in the
maternal serum is unusually high in the first trimester because cerebrospinal fluid leaks into the amniotic fluid.
Other causes of elevated alpha fetoprotein, such as incorrect gestational date and multiple pregnancy, need
to be excluded. As a marker of neural tube defects maternal serum alpha fetoprotein, ideally, should be
measured between 15 and 18 weeks of gestation. Any suspicion of a neural tube defect can be further
assessed with ultrasound, usually at 18-20 weeks. This scan also assesses for other fetal morphological
abnormalities and placental placement.
Down's syndrome
Down's syndrome is one of the common causes of fetal growth retardation. It is the result of either partial or
total trisomy of chromosome 21 and is a major obstetric concern, particularly in older women. Important
biochemical markers include alpha fetoprotein, HCG, unconjugated oestriol, pregnancy-associated plasma
protein-A, serum inhibin-A and free β-HCG. These markers are used in various combinations and together with
ultrasound to increase the detection rate of Down's syndrome. It cannot be over emphasised that the
gestational age must be correct in order for screening parameters to be accurate.
Between 11 and 13 weeks (that is late first trimester), serum pregnancy-associated plasma protein-A, free βHCG and ultrasound assessment of nuchal thickness (the physiological space between the back of the neck
and the overlying skin of the fetus) are most commonly used in the assessment of Down's syndrome. Due to the
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COLLEGE OF MEDICAL ALLIED COURSES
changing concentrations of these markers in the normal pregnant population, the results are mathematically
corrected for easy comparison. The nuchal thickness is increased in Down's syndrome and approximately 70%
of cases will be detected by ultrasound in experienced centres. In combination with biochemical markers, the
detection rate increases to 85-90%.9,10 Abnormal results can be followed up with direct karyotyping using
chorionic villous sampling, but this carries a 0.5-1.0% risk of pregnancy loss in the first trimester.
In the second trimester, screening for Down's syndrome traditionally employs the triple test of maternal serum
HCG, serum unconjugated oestriol and alpha fetoprotein at 15-18 weeks of gestation. Some laboratories also
measure serum pregnancy-associated plasma protein-A. The combination of these markers and maternal age
delivers a 60-65% detection rate, but this includes the 5% of women who have a false positive result.
Transnuchal thickness in the mid to late second trimester does not correlate well with Down's syndrome and
does not add to the value of biochemical markers.
The results of Down's syndrome screening in the first and second trimester are expressed as the proportion of
affected pregnancies, for example 1 in 488 chance of having Down's syndrome. This is accomplished using a
risk-assessment program that incorporates nuchal thickness (only in the first trimester), biochemistry results and
maternal age.
Other approaches
Another biochemical method of assessing fetal health is the analysis of amniotic fluid. The measurement of
bilirubin concentration in amniotic fluid is critical for assessing fetal intravascular haemolysis in the presence of
Rhesus incompatability. The lecithin-to-sphingomyelin ratio in amniotic fluid can be used to assess fetal lung
maturity in preterm labour but is rarely used these days due to the widespread availability of synthetic
surfactant.
Recently, there has been a resurgence of interest using maternal growth hormone and insulin-like growth factor
levels during the first and second trimester of pregnancy as predictors of fetal outcome, but these are yet to be
of routine clinical use.
Fetal DNA
A major advance in molecular biology has been the possible detection and isolation of fetal DNA in the
maternal circulation. This exciting discovery has opened up new horizons in the 'non-invasive' assessment of
fetal-maternal health. High concentrations of fetal DNA in the maternal circulation have been found in Down's
syndrome, pre-eclampsia, invasive placenta and preterm labour. This technique has also allowed for the
prenatal non-invasive diagnosis of Rhesus D genotype, myotonic dystrophy and achondroplasia.
Review Questions
1. What is the difference between High risk pregnancy and obstetric emergencies
2. Why is it necessary for a midwife to have an in-depth knowledge about high risk pregnancy and
obstetric emergencies?
3. What is Maternal Death according to WHO?
4. What is the importance of knowing the Risk Factors for High Risk Pregnancy?
5. What are the importance of history taking and physical examination?
6. What is Biophysical Monitoring?
7. What is Biochemical Monitoring?
8. What is Biochemical assessment for Fetal Health?
9. What is the difference between Biophysical and Biochemical Monitoring?
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COLLEGE OF MEDICAL ALLIED COURSES
Activities
In a piece of paper, answer the following based on the discussion.
1.
2.
3.
Discuss the importance of History Taking and Physical Assessment.
Enumerate the Risk Factors for High Risk Pregnancy.
Write an essay on the scenario given.
A client at 30 weeks of gestation complains of shortness of breath and an unusually rapid
enlargement of uterus. A tense uterus noted by the midwife during assessment. Palpation of the
small parts of the fetus and auscultating the fetal heart rate are difficult. The midwife suspect severe
hydramnios. What interventions are appropriately to be included in the care plan? Discuss your
answer.
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