This process involves systematically identifying pregnant women, women in labor, or postpartum mothers who have characteristics or conditions that place them and/or their babies at a higher than average risk of developing complications, adverse outcomes, or death.

Once identified, these “at-risk” mothers require timely referral to an appropriate level of healthcare where specialized monitoring, management, and interventions can be provided. This is a cornerstone of preventive maternal and child healthcare strategy, aiming to ensure that high-risk situations are anticipated and managed effectively.

Rasosns of Identifying At-Risk Mothers:

• Early Intervention: Allows for proactive management and interventions to prevent or mitigate potential complications.

• Reduced Maternal and Neonatal Mortality/Morbidity: Directs specialized care to those who need it most, improving outcomes.

• Appropriate Allocation of Resources: Ensures that limited healthcare resources (specialized personnel, equipment) are utilized for high-risk cases.

• Planned Delivery in Appropriate Facilities: Allows for high-risk mothers to be scheduled for delivery in facilities equipped to handle potential emergencies (e.g., those with C-section capabilities, blood banks, neonatal intensive care units – NICUs).

• Enhanced Monitoring: High-risk pregnancies often require more frequent and specialized monitoring (e.g., more frequent antenatal visits, ultrasounds, fetal surveillance).

• Empowerment of Women and Families: Educating women about their risk factors helps them understand the importance of adhering to medical advice and seeking timely care.

When to Identify At-Risk Mothers:

Risk assessment is an ongoing process throughout the continuum of maternal care:

1. Pre-conception Period: Ideally, some risk factors can be identified and managed even before pregnancy.

2. Antenatal Period (During Pregnancy): This is a critical time for systematic risk assessment during routine antenatal care (ANC) visits.

3. Intrapartum Period (During Labor and Delivery): New risks can emerge, or existing risks can escalate.

4. Postpartum Period (After Delivery): Mothers remain at risk for certain complications in the weeks following childbirth.

Categories of Risk Factors:

Risk factors can be broadly categorized:

A. Demographic and Socioeconomic Factors:

• Age:

  • Adolescent Mothers (<18-20 years): Increased risk of pre-eclampsia, eclampsia, obstructed labor, preterm birth, low birth weight babies, anemia.

  • Advanced Maternal Age (>35-40 years): Increased risk of gestational diabetes, hypertension, pre-eclampsia, chromosomal abnormalities in the fetus, C-section, postpartum hemorrhage.

• Parity (Number of Previous Births):

  • Nulliparity (Primigravida – first pregnancy): Higher risk of pre-eclampsia, prolonged labor, obstructed labor.

  • Grand Multiparity (≥5 previous births): Higher risk of malpresentation, placenta previa, abruptio placentae, uterine rupture, postpartum hemorrhage due to uterine atony.

• Short Inter-Pregnancy Interval (<18-24 months between birth and next conception): Increased risk of preterm birth, low birth weight, maternal anemia.

• Socioeconomic Status: Poverty, low education level, lack of social support can lead to poor nutrition, delayed care-seeking, and limited access to services.

• Marital Status: Unmarried mothers or those lacking partner support may face additional challenges.

• Geographical Location: Rural or remote areas with limited access to healthcare facilities.

B. Past Obstetric History:

• Previous Cesarean Section: Risk of uterine rupture in subsequent labor (if attempting VBAC – Vaginal Birth After Cesarean), placenta accreta spectrum.

• Previous Stillbirth or Neonatal Death: Increased risk of recurrence depending on the cause.

• Previous Preterm Birth: High risk of recurrence.

• Previous Low Birth Weight (LBW) or Intrauterine Growth Restriction (IUGR) Baby.

• Previous Baby with Congenital Anomaly or Genetic Disorder.

• History of Postpartum Hemorrhage (PPH).

• History of Pre-eclampsia or Eclampsia.

• History of Obstructed Labor or Difficult Delivery (e.g., shoulder dystocia).

• History of Uterine Surgery (e.g., myomectomy).

• History of Recurrent Miscarriages.

C. Current Pregnancy Complications:

• Hypertensive Disorders of Pregnancy:

  • Chronic hypertension.

  • Gestational hypertension.

  • Pre-eclampsia / Eclampsia / HELLP syndrome.

• Gestational Diabetes Mellitus (GDM).

• Multiple Gestation (Twins, Triplets, etc.): Increased risk of preterm labor, pre-eclampsia, anemia, PPH, malpresentation, C-section.

• Abnormal Placentation:

  • Placenta Previa: Placenta covers or is near the cervical os. Risk of severe antepartum and intrapartum hemorrhage.

  • Placenta Accreta Spectrum: Abnormally adherent placenta. Risk of massive PPH, need for hysterectomy.

  • Abruptio Placentae: Premature separation of the placenta. Risk of fetal distress/demise, maternal hemorrhage.

• Fetal Malpresentation: Breech, transverse lie, face/brow presentation. Risk of obstructed labor, cord prolapse, need for C-section.

• Polyhydramnios (Excessive Amniotic Fluid) or Oligohydramnios (Insufficient Amniotic Fluid).

• Intrauterine Growth Restriction (IUGR) or Fetal Macrosomia (Large Baby).

• Rh Isoimmunization or other Blood Group Incompatibilities.

• Anemia in Pregnancy (Severe).

• Infections During Pregnancy: Urinary tract infections, malaria, TORCH infections (Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes), HIV, syphilis, Hepatitis B.

• Premature Rupture of Membranes (PROM) or Preterm Premature Rupture of Membranes (PPROM).

• Preterm Labor.

• Post-term Pregnancy (>41-42 weeks).

• Reduced Fetal Movements.

D. Pre-existing Maternal Medical Conditions:

• Cardiac Disease: Can worsen during pregnancy due to increased cardiovascular load.

• Chronic Renal Disease.

• Diabetes Mellitus (Type 1 or Type 2).

• Thyroid Disorders (Hypo- or Hyperthyroidism).

• Epilepsy.

• Asthma (Severe or poorly controlled).

• Autoimmune Diseases (e.g., Systemic Lupus Erythematosus – SLE).

• Chronic Hypertension.

• HIV/AIDS.

• Sickle Cell Disease or other Hemoglobinopathies.

• Severe Malnutrition or Obesity.

• Mental Health Conditions (e.g., severe depression, bipolar disorder, schizophrenia).

E. Risk Factors Emerging During Labor and Delivery:

• Prolonged Labor (Failure to Progress).

• Obstructed Labor.

• Fetal Distress (Non-reassuring fetal heart rate patterns).

• Meconium-Stained Amniotic Fluid (if associated with other signs of distress).

• Intrapartum Hemorrhage (e.g., from placenta previa, abruption).

• Uterine Rupture (rare but life-threatening).

• Shoulder Dystocia.

• Cord Prolapse.

• Maternal Fever or other signs of intrapartum infection (chorioamnionitis).

F. Risk Factors in the Postpartum Period:

• Postpartum Hemorrhage (PPH).

• Postpartum Sepsis (Puerperal Sepsis).

• Postpartum Pre-eclampsia/Eclampsia.

• Thromboembolic Disorders (e.g., Deep Vein Thrombosis – DVT, Pulmonary Embolism – PE).

• Severe Anemia.

• Postpartum Psychosis or Severe Depression.

• Complications from Cesarean Section or operative vaginal delivery.

The Referral Process for At-Risk Mothers:

Once a mother is identified as “at-risk,” the following steps are generally involved in the referral:

1. Decision to Refer: Based on established protocols, clinical judgment, and the severity of the risk.

2. Counseling and Explanation:

   • Clearly explain to the mother (and her family) the reason for referral, the potential risks if not referred, and the benefits of seeking care at a higher-level facility.

   • Address any concerns or anxieties.

   • Obtain informed consent for referral.

3. Pre-Referral Stabilization:

   • Provide necessary immediate life-saving interventions and stabilization measures within the capacity of the referring facility (e.g., IV fluids, oxygen, anticonvulsants, antibiotics, initial management of hemorrhage).

4. Communication with Receiving Facility:

   • Contact the receiving facility to inform them about the incoming patient, her condition, interventions already provided, and expected time of arrival.

   • This allows the receiving facility to prepare (e.g., ready an operating room, alert specialists, prepare blood).

5. Arrangement of Transportation:

   • Facilitate timely and safe transport (e.g., ambulance, community transport).

   • Consider if an escort (health worker or trained family member) is needed.

6. Referral Documentation:

   • Complete a standardized referral form or letter containing essential information:

     • Patient identification details.

     • Reason for referral (summary of history, findings, risk factors).

     • Treatments and investigations already performed.

     • Vital signs and current condition.

     • Name of referring provider and facility.

7. Follow-up and Feedback:

   • The referring facility should ideally receive feedback from the receiving facility about the patient’s outcome. This helps in learning and improving the quality of care and the referral system.

Challenges:

• Late Identification: Mothers presenting late in pregnancy or labor with established complications.

• Under-utilization of Antenatal Care: Missed opportunities for early risk identification.

• Barriers to Referral: Financial, geographical, transport, cultural, or communication barriers.

• Weak Health Systems: Lack of trained personnel, equipment, or supplies at different levels.

• Poor Adherence to Referrals: Mothers may not complete the referral due to various reasons.