High-risk approach with screening and assessment

HIGH RISK APPROACH
WITH SCREENING AND
ASSESSMENT
ANAMIKA RAMAWAT
M.SC. NURSING PREV.
BATCH 2017-18
GCON, JODHPUR

Introduction
All pregnancies and deliveries are
potentially at risk.
However, there are certain categories of
pregnancies where the mother, the fetus or
the neonate is in a state of increased
jeopardy.

About 20 to 30 percent pregnancies
belong to this category.

Though all mothers and children are vulnerable to
disease or disability, there are certain mothers and
infants who are at increased or special risk of
complications of pregnancy/labor or both. If we desire
to improve obstetric results, this group must be
identified and given extra care.

Definition
“A risk factor is defined as any ascertainable characteristic
or circumstance of a person (or group of such persons)
known to be associated with an abnormal risk of developing
or being adversely affected by a morbid process”
-(WHO, 1973).
High risk pregnancy is defined as one which is complicated
by factor or factors that adversely affects the pregnancy
outcome –maternal or perinatal or both.

Introduction to Assessment,
Screening & Risk Approach
i) Assessment-
Assessment is a process for defining
the nature of that problem,
determining a diagnosis, and
developing specific treatment
recommendations.

ii) Screening-
• Screening is a process of
identifying apparently healthy
people who may be at increased
risk of a disease or condition.
• They can then be offered
information, further tests and
appropriate treatment to reduce
their risk and/or any complications
arising from the disease or
condition.

Screening of high risk cases-
The cases are assessed at the initial antenatal examination,
preferably in the first trimester of pregnancy.
This examination may be performed in a big institution
(teaching or non-teaching) or in a peripheral health center.
Some risk factors may later appear and are detected at
subsequent visits.
The cases are also reassessed near term and again in labour for
any new risk factors.

Risk approach (according to WHO)-
The main objective of the risk approach is the
optimal use of existing resources for the benefit of
the majority. It attempts to ensure a minimum of
care for all while providing guidelines for the
diversion of limited resources to those who most
need them.
Inherent in this approach is maximum utilization of
all resources, including some human resources, that
are not conventionally involved in such care e.g.,-
TBA, women’s group.
WHO)-
approach is the
for the benefit of
ensure a minimum of
guidelines for the
those who most
maximum utilization of
human resources, that
in such care e.g.,-

High risk cases (According to WHO)
i) During pregnancy-
1. Elderly primigravida (≥30 years) 7. Elderly grand multiparas
2. Short statured primi (≤ 140 cm) 8. Twins and hydramnios
3. Threatened abortion and APH 9. Previous still birth, IUD, manual
removal of placenta
4. Malpresentations & Malposition's 10. Prolonged pregnancy
5. Pre-eclampsia and eclampsia 11. History of previous caesarean
section and instrumental delivery
6. Anemia 12. Pregnancy associated with medical
diseases.

ii) During labour-
 PROM
 Prolonged labour
 Hand, feet or cord prolapse
 Placenta retained more than half an hour
 PPH
 Puerperal fever and sepsis.

iii) Course of the present pregnancy-
 The cases should be reassessed at each antenatal visit to detect
any abnormality that might have arisen later.
 Few examples are- pre-eclampsia, anemias, Rh- isoimmunization,
high fever, pyelonephritis, hemorrhage, diabetes mellitus, large
uterus, lack of uterine growth, post maturity, abnormal
presentation, twins and history of exposure to drugs or radiation,
acute surgical problems.

iv) Complications of labour –
1. Anemia, pre- eclampsia or eclampsia 7. Premature labour
2. PROM 8. Abnormal FHR
3. Amnionitis 9. Clients admitted with prolonged labour
4. Abnormal presentation and position 10. Obstructed labour
5. Disproportion, floating head in labour 11. Rupture uterus
6. Multiple pregnancy 12. Clients having induction or
acceleration of labour

v) Certain complications may arise during
labour and place the mother or baby at a
high risk-
Intrapartum fetal distress
 Difficult forceps or breech delivery
 Prolonged interval from the diagnosis of fetal distress to
delivery.
 PPH or retained placenta
 Postpartum complications

vi) An uneventful labour may suddenly turn
into an abnormal one in the form of –
PPH
 Retained placenta
 Shock
 Inversion
 Sepsis may develop later on

vii) High risk newborn –
APGAR score below 7
Birth weight less than 2500gm or more than 4 kg
Convulsions
Respiratory distress syndrome
Hypo glycaemia
Fetal infection
Persistent cyanosis
Anemia
Major congenital abnormalities
Jaundice

Screening/ Assessment-
Initial screening History
◦ Maternal age
◦ Reproductive history
◦ Pre-eclampsia, eclampsia
◦ Anemia
◦ Third stage abnormality
◦ Previous infant with Rh-isoimmunization
or ABO incompatibility
◦ Medical or surgical disorders
◦ Psychiatric illness
◦ Cardiac disease
◦ Viral hepatitis
◦ Previous operations
◦ Myomectomy
◦ Repair of complete perineal tear
◦ Repair of vesico-vaginal fistula

Family history-
◦Socio-economic status
◦Family history of diabetes,
◦hypertension
◦multiple pregnancy (maternal side),
◦congenital malformation.

Diagnostic test-
It is a test is to establish the presence (or absence) of disease as a basis
for treatment decisions in symptomatic or screen positive individuals
(confirmatory test).

Diagnostic tests for high risk pregnancy
Noninvasive diagnostic tests
◦Fetal ultrasound or ultrasonic testing
◦Cardiotocography(CTG)
◦Non-stress test (NST)
◦Contraction stress test (CST)

Invasive diagnostic tests
◦Chorionic villus sampling
◦Amniocentesis
◦Embryoscopy
◦Fetoscopy
◦Percutaneous umbilical cord blood sampling.

I) Noninvasive diagnostic tests
A) Fetal ultrasound or ultrasonic testing

oFetal ultrasound is a test done
during pregnancy that uses
reflected sound waves to produce
a picture of a fetus camera.gif, the
organ that nourishes the fetus
(placenta), and the liquid that
surrounds the fetus (amniotic
fluid).
oThe picture is displayed on a TV
screen and may be in black and
white or in color.
oThe pictures are also called a
sonogram, echogram, or scan, and
they may be saved as part of
baby's record.

oFetal ultrasound camera is done to learn
about the health of the fetus.
oDifferent information is gained at different
times (trimesters) during pregnancy.
oThis exam is typically done between weeks
18 and 20 of pregnancy. However, the timing
of this ultrasound might be altered for
reasons such as obesity or prior surgical
incision at the scanning site, which could
limit visualization of the foetus.
oMost women get an ultrasound in their
second trimester at 16 to 20 weeks of
pregnancy. Some also get a first-trimester
ultrasound (also called an early ultrasound)
before 14 weeks of pregnancy.

1st-trimester fetal ultrasound is done to:
Determine how pregnancy is progressing.
Find out if female is pregnant with more than 1 fetus.
Estimate the age of the fetus (gestational age).
Estimate the risk of a chromosome defect, such as Down
syndrome.
Check for birth defects that affect the brain or spinal cord.

High-risk approach with screening and assessment

2nd-trimester fetal
ultrasound is done to:
Estimate the age of the fetus (gestational
age).
Look at the size and position of the fetus,
placenta, and amniotic fluid.
Determine the position of the fetus,
umbilical cord, and the placenta during a
procedure, such as an amniocentesis
camera.gif or umbilical cord blood sampling.
Detect major birth defects, such as a neural
tube defect or heart problems.

3rd-trimester fetal
ultrasound is done to:
Make sure that a fetus is alive
and moving.
Look at the size and position of
the fetus, placenta, and amniotic
fluid.

B) Cardiotocography(CTG)
It is a technical means of-
recording (-graphy),
the fetal heartbeat (cardio-) and
the uterine contractions (-toco-)
during pregnancy, typically in the third
trimester. The machine used to perform
the monitoring is called a
cardiotocograph, more commonly known
as an electronic fetal monitor (EFM).

Interpretation of a CTG tracing requires both
qualitative and quantitative description of:
• Uterine activity (contractions)
• Baseline fetal heart rate (FHR)
• Baseline FHR variability

C) Non-stress test(NST)
• A nonstress test is a common prenatal
test used to check on a baby's health.
During a nonstress test, also known as fetal
heart rate monitoring, a baby's heart rate is
monitored to see how it responds to the
baby's movements.
• Typically, a nonstress test is
recommended for women at increased risk
of fetal death. A nonstress test is usually
done after week 26 of pregnancy. Certain
nonstress test results might indicate that
client and baby need further monitoring,
testing or special care.

D) Contraction stress test(CST)
It is performed near the
end of pregnancy to
determine how well the
fetus will cope with the
contractions of childbirth.
The aim is to induce
contractions and monitor
the fetus to check for heart
rate abnormalities using a
cardiotocograph.

II) Invasive diagnostic tests
A) Chorionic villus sampling
Chorionic villi are small structures
in the placenta that act like blood
vessels.
These structures contain cells from
the developing fetus. A test that
removes a sample of these cells
through a needle is called chorionic
villus sampling (CVS).
CVS is a form of prenatal diagnosis
to determine chromosomal or
genetic disorders in the fetus.

It entails sampling of the
chorionic villus (placental
tissue) and testing it for
chromosomal
abnormalities.
CVS usually takes place at
10–12 weeks' gestation,
earlier than amniocentesis
or percutaneous umbilical
cord blood sampling.
It is the preferred
technique before 15 weeks.

B) Amniocentesis
Amniocentesis is a test that can be
done during pregnancy to look for
birth defects and genetic problems in
the developing baby.
Amniocentesis removes a small
amount of fluid from the sac around
the baby in the womb (uterus).
It is most often done in a doctor's
office or medical center.
Do not need to stay in the hospital.
Amniocentesis is most often offered
to women who are at increased risk
for bearing a child with birth defects.

This includes women who:
◦Will be 35 or older when they give birth
◦Had a screening test result that shows there may be a birth defect
or other problem.
◦Have had babies with birth defects in other pregnancies
◦Have a family history of genetic disorders
◦It may choose genetic counseling before the procedure.
This will allow to:
◦Learn about other prenatal tests
◦Make an informed decision regarding options for prenatal
diagnosis

This test:
Is a diagnostic test.
Is 99% accurate for diagnosing Down syndrome
Is usually done between 14 and 20 weeks.
◦ Amniocentesis can be used to diagnose many different gene and chromosome
problems in the baby, including:
• Anencephaly
• Down syndrome
• Rare, metabolic disorders that are passed down through families
• Other genetic abnormalities, like trisomy 18.

C) Embryoscopy
It is the examination of the embryo at 9-10
weeks' gestation through the intact
membranes by introducing an endoscope into
the exocoelomic space/cavity transcervically
or transabdominally.
This is likely to remain confined to the
management of early pregnancy in selected
families affected by recurrent genetic
syndromes with recognizable external fetal
abnormalities.
The procedure-related risk of fetal loss is
around 12 per cent.

D) Fetoscopy
Fetoscopy is the examination of the
fetus after 11 weeks' gestation.
This is performed transabdominally
in the amniotic fluid.
The technique has evolved with the
miniaturization of the optical device
by using fibre-optics technology.
This procedure is likely to find new
applications with the development of
ultrasound examination at 10-14
weeks' gestation in order to, either
confirm, or rule out suspected
external fetal abnormalities.

E) Percutaneous umbilical cord blood
sampling/ Cordocentesis
Cordocentesis, also sometimes called Percutaneous
Umbilical Cord Blood Sampling (PUBS), is a 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.
Cordocentesis is usually done when diagnostic information
cannot be obtained through amniocentesis, CVS, ultrasound
or the results of these tests were inconclusive.
Cordocentesis is performed after 17 weeks into pregnancy.
Cordocentesis detects chromosome abnormalities (i.e.
Down syndrome) and blood disorders (i.e. fetal hemolytic
disease.).

Cordocentesis may be
performed to help diagnose
any of the following
concerns:
◦Malformations of the fetus
◦Fetal infection (i.e.
toxoplasmosis or rubella)
◦Fetal platelet count
◦Fetal anemia
◦Rh-Isoimmunization

Management of high risk cases
The high-risk cases should be identified and give proper antenatal,
intranatal and neonatal care.
This is not to say that healthy uncomplicated cases should not get
proper attention.
But in general, they need not be admitted to specialized centers
and their care can be left to properly trained midwives and medical
officers in health centers, or general practitioners.
It is necessary that all expectant mothers are covered by the
obstetric service of a particular area.

The services of trained community health workers and
assistant nurse-cum-midwife of health centers should be utilized
to provide the primary care and screening in rural areas and
urban and semi-urban pockets.
Cases with a significantly higher risk should be referred to
specialized referral centers. Cases from rural areas may be kept
at maternity waiting homes close to the referral centers.
Cases having a previous unsuccessful pregnancy should be
seen and investigated before another conception occurs.
Complete investigations for hypertension, diabetes, kidney
disease or thyroid disorders should be undertaken and proper
treatment instituted in the nonpregnant state.

Sexually transmitted disease should be treated before
embarking on another pregnancy.
Cervical tears should also be repaired in the nonpregnant
state.
Serology for toxoplasma IgG, IgM and antiphospholipid
antibodies should be done and corrected appropriately
when found positive.
Folic acid (4mg/day) therapy should be started in the
prepregnant state and is continued throughout the
pregnancy

Early in pregnancy after the initial clinical examination,
routine and special laboratory investigations should be
undertaken.
Client with history of previous first trimester abortion
should be advised rest and to refrain from sexual
intercourse. Vaginal examination should be avoided in first
trimester in these cases.
Clients suspected to have cervical incompetence should
have sonographic evaluation early in second trimester so
that cervical encirclage, if necessary may be performed at
appropriate time.
Clients having premature labour, unexplained stillbirth,
intrauterine growth restriction and may other abnormalities
benefited by prolonged rest in hospital with close
supervision.

Organizational aspect of management
oStrengthen midwifery skills, community participation and
referral system.
oProper training of resident, nursing personnel and
community health workers.
oArranging periodic seminars, refresher courses with
participation of workers involved in the care of these cases.

oConcentration of cases in specialized centers for
management
oCommunity participation, proper utilization of health care
manpower and financial resources where it is mostly
needed.
oAvailability of perinatal laboratory for necessary
investigations; availability of a good pediatrics service for
the neonates.
oLastly, improvement of economic status, literary and health
awareness of the community.

High-risk approach with screening and assessment

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