WEEK 5 PRELIM 5.

Previous operative OB, Cesarean Section (CS),

HIGH RISK PRENATAL CLIENT midforceps delivery
6. Previous uterine or cervical abnormality
HIGH RISK PREGNANCY is: 7. Previous abnormal labor: premature labor or
postmature labor, prolonged labor
 It is when the life or well being of the woman or 8. Previous high-risk infant: low-birth wt (LBW),
fetus has a significantly increased risk of harm, macrosomic (LGA) with neurologic deficit, birth
damage, injury or disability (morbidity) or loss injury or malformation
of life or death (mortality) by a disorder 9. Previous hydatidiform mole ( H-mole)
coincidental with or unique to pregnancy
D. CURRENT OB STATUS
 Is one in w/c the mother or fetus has a 1. Late or no pre-natal care
significant increased chance of harm, damage, 2. Maternal anemia
injury, or disability 3. Rh sensitization
4. Antepartal bleeding; placenta previa & abruptio
 A high-risk pregnancy is one in which: placenta
● a concurrent disorder, 5. Pregnancy-induced hypertension (PIH)
● pregnancy-related complication, or 6. Multiple gestation
● external factor jeopardizes the health of the 7. Premature or postmature labor
woman, the fetus, or both. 8. Polyhydramios
9. PROM
I. RISK FACTORS 10. Fetus inappropriately large or small; abnormality
in tests for fetal well-being; abnormality in
A. DEMOGRAPHIC FACTORS presentation

1. AGE E. MATERNAL MEDICAL HISTORY/STATUS

 under 18 or over 35 year old 1) Cardiac or pulmonary disease
 Studies have shown that the optimal age for 2) Metabolic disease: DM, thyroid disease
childbearing is bet 20-30 yo 3) Endocrine disorders: pituitary, adrenal
4) Chronic renal disease: repeated UTI, bacteriurea
2. WEIGHT – overweight or underweight before 5) Chronic hypertension
pregnancy 6) Venereal and other infectious diseases
7) Major congenital anomalies of the reproductive
3. HEIGHT – less than 5 ft tract
8) Hemoglobinopathies: sickle cell anemia,
B. SOCIOECONOMIC STATUS thalassemia
1. Inadequate finances 9) Seizure disorder
2. Overcrowding 10) Malignancy
3. Poor standards of housing 11) Major emotional disorders, mental retardation
4. Poor hygiene
5. Unplanned and prepared pregnancy, especially F. HABITS / HABITUATION
among adolescents 1. Smoking during pregnancy
 At the root of these problems are poverty 2. Regular alcohol intake
and low educational status. 3. Drug use/abuse

C. OBSTETRIC HISTORY II. DIAGNOSTIC TESTS IN HIGH-RISK

1. Hx of infertility or multiple gestation PREGNANCY/ PRENATAL DETERMINATION
2. Grandmultiparity OF FETAL STATUS
3. Previous abortion or ectopic pregnancy
4. Previous loses: fetal death, stillbirth, neonatal or A. ULTRASONOGRAPHY
perinatal deaths A non-invasive diagnosis procedure utilizing a high-
frequency sound waves to detect intrabody structures
Purposes: 3. Explain:
1. In an early pregnancy: to confirm pregnancy  Procedure takes 30 to 60 minutes to finish
2. To detect fetus:  Mother needs to activate “ mark button”
 Viability, growth with each fetal movement
 Number (multiple pregnancy)  Does not need hospitalization – ambulatory
 Position, presentation basis
 Abnormalities (structure) 4. Requires external electronic monitoring of FHT
 FHT with ultrasound transducer and tocodynamometer
 AOG by determining the biparietal diameter to trace fetal activity and/ or uterine activity.
of the fetal head
 Most accurate at 12 to 24 wks Interpretation:
 Biparietal diameter 9.5 cm = mature
fetus 1) Normal: Reactive
3. Detects placental location (placenta previa) or  Increased FHT (acceleration) Greater than
placental abnormality (H-mole) 15bpm above Baseline – lasting 15 seconds
4. An important aid in high-risk procedures like or more in a 10- to 20- minute Period with
amniocentesis fetal Movement
2) Abnormal: Non-reactive
Preparation:  No FHR acceleration with fetal movement
1) Advise mother to drink 1 quarter of water 2
hours before the procedure. Implication of Results:
2) Instruct not to void. In Amniocentesis w/ 1. Normal: high-risk pregnancy continues
ultrasound to offer visualization, the mother 2. Abnormal results: mother needs another test,
should void to prevent injuring the distended may be biophysical profile
bladder w/ needle insertion.
3) Transmission gel is spread over maternal C. OXYTOCIN CHALLENGE TEST (OCT) or
abdomen. CONTRACTION STRESS TEST (CST)
4) Psychological support is given to the
mother/father (couple): Purposes:
 Explain the reasons for the procedure 1) Observation of response of the fetus to induced
together w/ its benefits & the preparations. uterine contractions
 Explain that there is no known risk w/ 2) A test of feto-placental well-being
infrequent & brief exposure to high
frequency sound waves. Preparation:
 Encourage verbalization of fears & concerns. 1. Semi-Fowler’s or left lateral position
Explain further that: 2. BP is checked priorly and q15 minutes during
 Procedure is non-invasive & safe for test.
mother & fetus 3. Explain:
 Confinement is not needed  Procedure takes 1 to 3 hours to finish.
 No need for dye & there is no x-ray  Mother receives oxytocin of increasing
irradiation dosage “piggybacked” to the mainline and
 Procedure takes a short time (about 30 aimed to cause 3 uterine contractions in 10
mins) to accomplish. minutes.
 May be done on outpatient basis.
B. NON-STRESS TEST (NST) 4. Requires external electronic FHT monitoring
 Observation of FHT related to movement with ultrasound transducer and tocodynamometer
 A test of fetal well-being to detect uterine activity

Preparation:
1. Position – semi-Fowler’s or Left Lateral position
slightly turned to the left.
2. Check BP
Interpretation:

1. Normal: Negative
 No late decelerations of FHR with each of
three contractions during a 10 minute
interval
2. Abnormal: Positive
 With late decelerations of FHR with three
contractions in 10 minutes

Implication of Results:
1. Normal: Pregnancy continues; normal result of
OCT may require weekly tests
2. Abnormal result: may indicate a need to
terminate pregnancy

D. NIPPLE-STIMULATION CONTRACTION F. AMNIOCENTESIS

TEST Entering the amniotic sac to aspirate amniotic fluid
for a variety of diagnostic exams to detect fetal well-
1. Determines feto-placental function/well-being. being or lack thereof.
2. Breasts are stimulated with rolling of nipples or
warm-towel application. Stimulation of the Major Risks
nipple causes stimulus to be sent to the posterior 1. Trauma: fetus, placenta, umbilical cord
pituitary gland which in turn secretes oxytocin. 2. Infection
This oxytocin, in addition to causing contraction 3. Abortion
of the breast tubules also has a direct effect in 4. Preterm labor
uterine musculature causing it to contract. The
fetal response to uterine contraction is tested in Preparation
this test. 1. Secure an informed consent.
3. The baseline data are obtained through 2. Prepare for ultrasonography; to locate placenta
monitoring as in OCT procedure. and to provide visualization to a blind procedure.
4. Interpretation: as in OCT: the absence of late  Ultrasound in amniocentesis: client needs to
decelerations in 3 contractions in 10 minutes is void
the desired result.  Pelvic ultrasound only: clients should not
void.
E. BIOPHYSICAL PROFILE (BPP) 3. Increase oral fluids: Take 1 quart water 2 hours
(Manning et al., 1981; 1985) before
4. Prepare needle: g 20-22; 3”-- 6” procedure
A scoring combining ultrasound assessment of: 5. Prepare for administration of local anesthesia of
1. Fetal breathing the abdomen
2. Fetal movement 6. Provide psychological support.
3. Fetal tone
4. Reactivity of the heart rate  Amount of Amniotic Fluid to be Aspirated up to
5. Amniotic fluid volume BPP - could be used to 30 mL at 15 to 18 weeks gestation.
predict fetal well-being in a high-risk pregnancy.
Implications of Bloody Tap
Scores 1. Decreased L/S ration
 8-10: Normal, low risk for chronic asphyxia 2. Fetal blood – false high levels of
 4-6 : Suspected chronic asphyxia alphafetoprotein (AFP)
 0-2 : Strong suspicion of chronic asphyxia
Aftercare H. SERIAL ESTRIOL DETERMINATION
1. Monitor 30 to 60 minutes
2. Observe for side-effects such as:  Measures feto-placental well-being
 Vaginal discharge  Specimens : serum or 24 hour urine (most
 Increased uterine/fetal activity commonly used)
 Fever and chills
Results:
Analysis of Amniotic Fluid 1. Normal: gradual increase in serial estriol which
1. Most commonly used today to determine fetal is 12 to 50 mg/day at term
lung maturity 2. Abnormal: sudden drop of less than 50% of the
level means fetal distress pelvis and spine
 Foam Stability Test of Shake Test 3. Persistent low levels means fetal well-being is
Result – L/S ration of 2:1 means mature lungs compromised

2. Determination of age of gestation as is I. CHORIONIC VILLI SAMPLING (CVS)

 Creatinine levels: 2.0 mg- 36 weeks AOG; more  Earliest test possible on fetal cells
than 2.0mg – greater than 36 weeks  Sample obtained by slender catheter passed
 Nile blue stain (Lipid cells): when 20% of cells through cervix to implantation site
are stained with orange, it means the fetal weight
is at least 2,500 g J. PERCUTANEOUS UMBILICAL
BLOOD SAMPLING (PUBS)
3. Alpha-Fetoprotein (AFP) levels: increasing /
high levels may indicate the presence of a neutral  Used in 2nd and 3rd trimesters
defects such as spina bifida or tracheoesophageal  Uses ultrasound to locate umbilical cord
atresia  Cord blood aspirated and tested increase in serial
estriol which is 12 to 50 mg/day at term
4. Genetic Disorders: for chromosomal studies
2. Abnormal: sudden drop of less than 50% of the
5. Rh incompatability: increased levels of level means fetal distress pelvis and spine
bilirubin identified isoimmunization; evaluated 3. Persistent low levels means fetal well- being is
for intrauterine transfusion or delivery compromised

6. Inborn errors metabolism: biochemical

analysis of fetal cell enzymes

7. Fetal distress: passage of meconium in cephalic

presentation (not significant in breech
presentation)

8. Sex – linked Disorder: sex chromosome

determination

G. X-RAY LATERAL PELVIMETRY

INDICATIONS FOR RADIOGRAPHY TO

DETERMINE PELVIC SIZE AND SHAPE

A. suspected cephalopelvic disproportion

B. history of injury/disease of the pelvis and spine
C. Previous difficult delivery
D. cases of maternal deformity or limp