High-Risk Pregnancies

A high-risk pregnancy is one that is likely to result in complications, death of the mother or baby or both. Mothers with high-risk pregnancies must be cared for or deliver in a well-equipped health unit under a doctor’s supervision.

Key Terms

1. Risk: The possibility that an event will occur. In this context, it refers to unavoidable events, e.g., becoming pregnant when one has a serious underlying medical condition like diabetes, which puts the mother’s and unborn child’s lives in danger.

2. Risk Factors: Anything that causes or increases the chances of complications, e.g., diabetes increases the chances of maternal morbidity and mortality.

Categories of High-Risk Mothers

1. Young primigravida (first pregnancy) age 16 or below

2. Elderly primigravida age 35 and above

3. Multigravida (multiple pregnancies) of 5 and above

4. Mothers who have had 3 or more miscarriages

5. Mothers of small stature (153 cm and below)

6. Mothers with a limp

7. Mothers with a history of pelvic fractures

8. Cephalopelvic disproportion (when the baby’s head is too large to fit through the mother’s pelvis)

9. Multiple pregnancy (twins, triplets, etc.)

10. Mothers with intrauterine fetal death (IUFD)

11. Mothers with a history of postpartum hemorrhage (PPH) on previous deliveries

12. Mothers with a history of retained placenta on previous delivery

13. Mothers with pre-eclampsia, eclampsia, or a history of toxemia

14. Mothers with cardiac or renal diseases, essential hypertension, diabetes, anemia, asthma, antepartum hemorrhage (APH), or who are Rhesus negative (medical conditions)

15. Mothers with a history of instrumental deliveries (e.g., forceps, vacuum)

16. Mothers with a history of mental illness

17. Mothers with a history of premature deliveries

18. Mothers with a history of 2 or more stillbirths

Roles of a Midwife/Nurse in High-Risk Pregnancy

Aims

• Educate the community

• Educate mothers

• Care for mothers during pregnancy

• Care for mothers during labor

• Care for mothers after delivery

At the Community Level

Educate the community about the following:

1. The value of all children, especially girls

2. The importance of educating children and providing proper nutrition, including for girls

3. The dangers of harmful practices to girls before, during, and after delivery

4. The need to provide transport for pregnant women and to support them

5. The importance of utilizing available health facilities and services

6. The importance of recognizing danger signs in pregnancy and referring women to health units

To the Mother

Educate mothers about the following:

1. The importance of preparing for pregnancy

2. The use of family planning services to conceive when ready

3. The importance of utilizing antenatal, intranatal, and postnatal services

4. The importance of eating well and learning how to prepare a balanced diet, as well as food sources and storage

5. How to recognize danger signs of pregnancy

6. Avoiding substance abuse

At the Health Centre

During Pregnancy

Health workers must ensure the following:

1. Proper antenatal care (ANC)

2. Health education about proper nutrition, rest, sleep, and good hygiene

3. Early detection of danger signs and appropriate management

4. Emergency care and referrals to facilities/hospitals

5. Administration of tetanus toxoid (TT), iron, folic acid, Fansidar, and mebendazole to prevent complications like anemia and tetanus at birth

6. Discouraging the use of traditional medicine

7. Counseling mothers not to blame themselves for situations like frequent childbearing

During Labor

Health workers should do the following:

1. Provide safe and clean delivery services

2. Offer kindness and understanding

3. Ensure proper nutrition

4. Monitor mothers in labor properly, including early detection of problems, using a partograph, and appropriate management

5. Follow proper referral systems to prevent delays in accessing medical care

6. Prevent complications

Care of the Newborn

Offer the 9 needs of a newborn baby:

1. Establish and maintain respirations

2. Dry and keep the baby warm

3. Initiate immediate breastfeeding

4. Provide early immunization

5. Ensure clean cutting of the cord and provide further cord care

6. Prevent blindness by instilling tetracycline eye ointment

7. Maintain warmth

The Roles of a Husband in Safe Motherhood

During Pregnancy

1. Understand and appreciate the discomfort, anxiety, and tiredness that pregnancy may cause.

2. Take over physically tiring tasks like working in the field, lifting heavy loads, washing, and scrubbing floors.

3. Take care of other children.

4. Provide encouragement and emotional support, avoiding making demands or criticizing.

5. Learn about pregnancy-related conditions along with the mother to understand what she is going through, especially danger signs.

6. Accompany his wife to the health center for antenatal care and health education.

7. Understand the importance of good nutrition and medical care during pregnancy and provide it.

8. Provide money for transport fees or medication.

9. Arrange to have transport ready in case of emergencies during pregnancy and postnatal care.

During Labor/Childbirth

1. Provide money, clothing, transport, etc.

2. Stay with his wife during labor and delivery to provide comfort and support.

After Delivery

1. Adapt to the new baby and help meet the baby’s demands and needs, especially breastfeeding.

2. Give the mother and baby understanding, support, attention, and help with day-to-day tasks.

3. Contribute to a healthy and happy family by ensuring the mother is well-fed and that both mother and baby receive medical care.

4. Be aware of danger signs that might necessitate seeking medical help.

In Family Planning

1. Ensure the mother has fully recovered from the demands of pregnancy and birth (ideally 2 or more years after delivery) and protect her from becoming pregnant for at least 2 years after the birth of the last baby.

2. Seek advice from a doctor or family planning clinic about contraception methods, either alone or, even better, with the mother.

3. Support and cooperate when using the selected method.

4. Accept male family planning methods or cooperate when the woman is using one.

During Child Rearing

1. Protect and provide resources (food, clothing, shelter, school fees) for the family.

2. Participate in the upbringing of the children.

3. Involve the wife in decision-making.

4. Counsel and advise children as teenagers, discussing issues like marriage and career choices.

5. Ensure daughters are given the same opportunities as sons in education, healthcare, and other benefits, including home education and sex education.

6. Be available at home for his wife and children and show warmth.

Management of High-Risk Factors

General Principles

1. Readiness: Ensure everything needed to manage high-risk pregnancies is readily available, including facilities such as:

   • Emergency Tray: Containing drugs like ergometrine, hydrocortisone, diazepam, dexamethasone, mannitol, digoxin, Lasix, dextrose 5%, 50%, vitamin K, aminophylline, atropine, pethidine, morphine, Pitocin, magnesium sulfate, adrenaline; oxygen cylinder; solutions like normal saline; needles and syringes; adequate staff; Ambu bags; and any facility needed for resuscitation.

2. Competent Staff: The midwife/nurse should be calm, quick, knowledgeable, and able to summon help when needed.

3. Prioritize: Start with the most urgent need first (e.g., arresting hemorrhage, rehydration, or delivery of the baby).

4. Assessment: Perform quick general history taking, examination, and investigations.

5. Systematic Care: Apply essential care systematically according to the emergency (e.g., delivery, manual removal of the placenta, resuscitation) using the nursing process.

6. Reassurance: Reassure the mother and relatives.

7. Referral: Some mothers with high-risk pregnancies are cared for in the maternity center during pregnancy and referred at full term for delivery in the hospital. Others are referred on the first contact.

8. Early Detection: Early detection and referral are crucial.

9. Transport: Prepare for transport if necessary.

10. Referral Notes: Write referral notes including:

    • Time of arrival

    • Personal history of the mother

    • General condition on arrival

    • Findings on examination and admission

    • Treatment given, plus obstetrical management

    • Reasons for referral

    • Condition at referral

Prevention of High-Risk Pregnancies

1. Midwife, Husband, and Community Roles: Emphasize the roles of the midwife, husband, and community in safe motherhood.

2. Knowledgeable Midwife: The midwife/nurse should be knowledgeable about how to deal with high-risk pregnancies.

3. Continuing Education: The midwife/nurse should update herself on obstetrical conditions.

4. Equipped Maternity Center: The midwife/nurse should ensure her maternity center is well-equipped and be able to deal with high-risk cases efficiently.