M104-HIGH-RISK-CLIENT Maternal health care.pdf

REVIEWER

1. HIGH RISK
CLIENT

2. Definition:
- a mother or a fetus who has
significant increased chance of harm,
injury, or disability (morbidity), and
loss of life or death (mortality)
- one who has a concurrent
disorder, pregnancy related
complication, or external factor which
jeopardizes health

3. RISK FACTORS
A. DEMOGRAPHIC FACTORS
1. Age
2. Weight
3. Height

4. B. SOCIOECONOMIC STATUS
1. Inadequate finances
2. Overcrowding, poor standards
of housing, poor hygiene
3. Nutritional deprivation
4. Severe social problems
5. Unplanned and unprepared
pregnancy

5. C. OBSTETRIC HISTORY
1. History of infertility or multiple
gestation
2. Grandmultiparity
3. Previous abortion or ectopic
pregnancy
4. Previous loses: fetal death,
stillbirth, neonatal or perinatal
deaths
5. Previous operative OB: Cesarean
section, midforceps delivery

6. C. OBSTETRIC HISTORY
6. Previous uterine or cervical
abnormality
7. Previous abnormal labor: premature
labor, or postmature labor,
prolonged labor
8. Previous high-risk infant: low-birth-
weight (LBW), macrosomic (LGA), with
neurologic deficit, birth injury or
malformation
9. Previous hydatidiform mole

7. D. CURRENT OB STATUS
1. Late or no prenatal care
2. Maternal anemia
3. Rh sensitization
4. Antenatal bleeding: placenta
previa and abruptio placenta
5. Pregnancy induced hypertension

8. 6. Multiple gestation
D. CURRENT OB STATUS
7. Premature or postmature labor
8. Polyhydramnios
9. PROM
10.Fetus inappropriately large or
small; abnormality in tests for
fetal well-being; abnormality in
presentation

9. E. MATERNAL MEDICAL HISTORY/
STATUS
1. Cardiac or pulmonary disease
2. Metabolic disease: diabetes, thyroid
disease
3. Endocrine disorders: pituitary,
adrenal
4. Chronic renal disease: repeated UTI,
bacteriurea
5. Chronic hypertension
6. Venereal and other infectious diseases

10. E. MATERNAL MEDICAL HISTORY
7. Major congenital anomalies of the
reproductive tract
8. Hemoglobinopathies
9. Seizure disorder
10. Malignancy
11.Major emotional disorders, mental
retardation

11. F. HABITS/HABITUATION
1. Smoking
2. Regular alcohol intake
3. Drug use/ abuse

12. C.ASSESSMENT OF THE
HIGH RISK FACTORS
A. ULTRASONOGRAPHY
1. Description
A non-invasive diagnostic
procedure utilizing
high –frequency sound
waves to detect
intrabody structures

13. 2. Purposes
a. In early pregnancy: to confirm pregnancy
b. To detect the fetus’s:
• Viability, growth
• Number (multiple pregnancy)
• Position, presentation
• Abnormalities (structural)
• Heart tones (FHT)

14. 2. Purposes
•Age of gestation by determining the
biparietal diameter of the fetal head
•Most accurate at 12 to 24 weeks
•Biparietal diameter of 9.5 cm –
mature fetus
c. Detects placental location (placenta
previa) or placental abnormality (H-
mole)
d. An important aid in high risk
procedures like amniocentesis

15. 3. Preparation:
a.Advise mother to drink one quart of
water 2 hours before the procedure.
b. Instruct not to void. In amniocentesis
with ultrasound to offer visualization,
the mother should void to prevent
injuring the distended bladder with
needle insertion.
c. Transmission gel is spread over
maternal abdomen.

16. d. Psychological support is given to the
mother/father (couple):
•Explain the reasons for the procedure
together with its benefits and the
preparations.
•Explain that there is no known risk
with infrequent and brief exposure
to high-frequency sound waves.

17. •Encourage verbalization of fears and
concerns. Explain further that:
•Procedure is noninvasive and safe
for mother and fetus.
•Confinement is not needed
•No need for dye and there is no
X-ray irradiation
•Procedure takes a short time (about
30 minutes) to accomplish.

18. B. NON-STRESS TEST (NST)
1. Description
a. Observation of
FHT related to
fetal movement
b.A test of fetal
well-being
2. Preparation
a. Position – semi-Fowler’s
or left lateral position
slightly turned to the left

19. b. BP is checked first.
c. Explain:
•Procedure takes 30 to 60 minutes
to finish
•Mother needs to activate “mark
button” with each fetal movement
•Does not need hospitalization –
ambulatory basis
d. Requires external electronic monitoring
of FHT with ultrasound transducer and
tocodynamometer to trace fetal activity
and/or uterine activity

20. 3. Interpretation
a. Normal : Reactive
•Increased FHT (acceleration) greater
that 15 bpm above baseline -
lasting 15 seconds or more in a 10 – to
20- minute period with fetal
movement
b. Abnormal: Non-reactive
•No FHR acceleration with fetal
movement

21. 4. Implication of Results
a. Normal: high-risk pregnancy continues
b. Abnormal results: mother needs
another test, may be biophysical profile
C. OXYTOCIN CHALLENGE TEST (OCT)
or CONTRACTION STRESS TEST (CST)
1. Purposes
a.Observation of response of the fetus
to induced uterine contraction
b. A test of feto-placental well-being

22. 4. Implication of Results
a. Normal: high-risk pregnancy continues
b. Abnormal results: mother needs
another test, may be biophysical profile
C. OXYTOCIN CHALLENGE TEST (OCT)
or CONTRACTION STRESS TEST (CST)
1. Purposes
a.Observation of response of the fetus
to induced uterine contraction
b. A test of feto-placental well-being

24. 2. Preparation
a. Semi-Fowler’s or left lateral position
b. BP is checked priorly and every 15
minutes during the test
c. Explain:
•Procedure takes 1 to 3 hours to finish.
•Mother receives oxytocin of increasing
dosage “piggybacked” to the mainline and
aimed to cause 3 contractions in 10 minutes
•May be done on outpatient basis

25. d. Requires external electronic monitoring
of FHT with ultrasound transducer and
tocodynamometer to trace fetal activity
and/or uterine activity
3. Interpretation
a. Normal: Negative
• No late decelerations of FHR with
each of three contractions
during a 10-minute interval
b. Abnormal: Positive
• With late decelerations of FHR with
three contractions in 10 minutes

26. 4. Implication of Results
a.Normal: pregnancy continues; normal
result of OCT may require weekly tests
b.Abnormal result: may indicate a need
to terminate pregnancy
D. NIPPLE-STIMULATION
CONTRACTION TEST
1.Determines feto-placental function/well-
being

27. 2. Breasts are stimulated with rolling of
nipples or warm-towel application.
Stimulation of the nipple causes
stimulus to be sent to the posterior
pituitary gland which in turn secretes
oxytocin. This oxytocin, in addition to
causing contraction of the breast
tubules, also has a direct effect on
uterine musculature causing it to
contract. The fetal response to uterine
contraction is tested in this test.

28. 3. The baseline data are obtained through
monitoring as in OCT procedure
4. Interpretation: same as in OCT: the
absence of late decelerations in 3
contractions in 10 minutes is the desired
result.

29. E. BIOPHYSICAL PROFILE ( BPP)
1.A scoring combining
ultrasound assessment of:
a. Fetal breathing
b. Fetal movement
c. Fetal tone
d. Reactivity of the heart rate
e. Amniotic fluid volume BPP could be
used to predict fetal well-being in a
high-risk pregnancy

30. Biophysical
Variable
Normal (Score=2) Abnormal (Score=0)
Fetal breathing
movements
Greater than or equal to 1 episode of 30
seconds or more of fetal breathing
Absence of 30 seconds or
longer of fetal breathing
movement in 30 minutes
Gross fetal
movement
3 or more discreet movements of the
body or any limb in 30 minutes
2 or less discreet movement
of body or a limb in 30
minutes
Fetal tone 1 or more episodes of extension and
flexion of fetal limb(s) or trunk. Opening
and closing of hand is considered normal
tone
either slow extension with
return to partial flexion or
movement of limb in full
extension or absent fetal
movement
Reactive fetal
heart rate
2 or more episodes of accelerations of 15
bpm or more lasting for 15 seconds or
longer in 20 min.; associated with fetal
movement
Less than 2 episodes of
acceleration of fetal heart rate
or acceleration of less than 15
bpm in 20 min.
Qualitative
amniotic fluid
volume
1 pocket or more of fluid measuring 1 cm
or more in two perpendicular planes
Either no pockets or a pocket
of 1 cm or lesser in two
perpendicular planes

31. 2. Scores
• 8 - 10: Normal, low risk for chronic
asphyxia
• 4 – 6: Suspected chronic asphyxia
• 0 - 2: Strong suspicion of chronic
asphyxia

32. F. AMNIOCENTESIS
1. Entering the amniotic sac to aspirate
amniotic fluid for a variety of
diagnostic exams to detect fetal well-
being or lack thereof.
2. Major Risks
a.Trauma: fetus, placenta, umbilical
cord, and maternal surface
b. Infection
c. Abortion
d. Preterm labor

34. 3. Preparation
a.Secure an informed consent.
b.Prepare for ultrasonography; to
locate placenta and to provide
visualization to a blind procedure
•Ultrasound in amniocentesis:
client needs to void
•Pelvic ultrasound only: clients
should not void

35. c. Increase oral fluids: Take 1 quart water 2
hours before.
d. Prepare needle: g 20 – 22; 3” = 6”.
e. Prepare for administration of local
anesthesia of the abdomen.
f. Provide psychological support
4.Amount of Amniotic Fluid to be
Aspirated
up to 30 ml at 15 to 18 weeks
gestation

36. 5. Implications of Bloody Tap
1. Decreased L/S ratio
2. Fetal blood – false high levels of
alphafetoprotein (AFP)
6. Aftercare
a. Monitor for 30 to 60 minutes
b. Observe for side-effects such as:
•Vaginal discharge
•Increased uterine/fetal activity
•Fever and chills

37. 7. Analysis of Amniotic Fluid
a. Most commonly used today to
determine fetal lung maturity
Foam Stability Test or Shake Test
Result – L/S ratio of 2:1 means
mature lungs

38. b. Determination of age of gestation
• Creatinine levels:
2.0 mg – 36 weeks AOG
More than 2.0 mg –
greater than 36 weeks
•Nile blue stain (Lipid cells): when 20%
of cells are stained with orange, it
means the fetal weight is at least
2,500 g

39. c. Alpha-Fetoprotein (AFP) levels:
increasing/high levels may indicate
the presence of a neural defects such
as spina bifida or tracheoesophageal
atresia
d. Genetic disorders: for chromosomal
studies
e. Rh incompatibility: increased levels of
bilirubin identified in isoimmunization;
evaluated for intrauterine transfusion or
delivery

40. f. Inborn errors of metabolism: biochemical
analysis of fetal cell enzymes:
g. Fetal distress: Passage of meconium in
cephalic presentation (not significant
in breech presentation)
h. Sex-linked Disorder: sex chromosome
determination

42. G. X-RAY: LATERAL PELVIMETRY
1.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

43. H. SERIAL ESTRIOL DETERMINATION
1. Measures feto-placental well-being
2. Specimens: serum or 24 hour urine
(most commonly used)
3. Results:
a. Normal: gradual increase in serial estriol
which is 12 to 50 mg/day at term
b. Abnormal: Sudden drop of less than
50% of the previous level means fetal
distress
c. Persistent low levels means fetal well-
being is compromised

45. I. CHORIONIC VILLI SAMPLING (CVS)
1. Earliest test possible on fetal cells
2. Sampling obtained by slender
catheter passed through cervix to
implantation site
J.PERCUTANEOUS UMBILICAL
BLOOD SAMPLING (PUBS)
1. Used in 2
nd
and 3
rd
trimesters
2. Uses ultrasound to locate umbilical cord
3.Cord blood aspirated and tested

46. Thank you!