High Risk Prenatal Client » PROM, PIH, Multiple Pregnancies, DIC,

High Risk Pregnancy APAS, HELLP Syndrome (life

ª Concurrent disorder, pregnancy related threatening and a type of
complication or external factor jeopardizes the preeclampsia).
health of the mother, the fetus, or both.
» Lifestyle is affected
» Existing conditions at the same time Assessment of Risk Factors
» Poverty can affect the health status of Biophysical Risks
the woman since it reduces the proper ª Factors that originate within the mother or
nutrient and vitamin requirement, and fetus and affect the development or
prenatal check-ups due to financial functioning of either or both.
problems. ª Genes – interference with fetal development =
» Chronic illness = superimposed congenital anomalies
pregnancy = high risk ª Nutritional Status – important determinant of
» Healthy women can have a chance to the mother’s health status.
have high-risk pregnancy since she can ª Medical and Obstetric disorders – current
have a possibility to develop pregnancy and past pregnancies
complications.
» If the mother has complications, it can Psychosocial Risks
pose the baby at risk. ª Comprised of maternal behaviors and adverse
» Teenage pregnancy can result to lifestyles that have a negative effect on the
preterm neonate and could have health of the mother or fetus (both).
complications since the baby is ª Smoking – causes liver problems, premature
preterm. neonate, and SGA.
ª Involves at least one of the ff: ª Coffee – limited; if the woman exceeds 2-3
» The woman or baby is more likely to cups per day, the baby can be SGA.
become ill or die than usual. ª Alcohol – Fetal Alcohol Syndrome = learning
» Complications before or after delivery disability and hyperactive.
are more likely to occur than usual. ª Drugs – teratogenic for the baby which
ª High-Risk pregnancy can be grouped into equates to death or abnormalities.
two: ª Psychological Status – depression, addictive
» Women with preexisting or newly lifestyle, history of abuse
acquired illness.
» Women who develop complications of Sociodemographic Risks
pregnancy. ª Factors arising from the mother and her family
and place the mother and fetus at risk.
Two groups of High-Risk Prenatal Clients ª Domestic abuse, low income, lack of prenatal
ª Mild, moderate, high risk = it will depend on care, single parent.
the situation and can be differentiated.
1. Women with preexisting or newly Environmental Risks
acquired illness such as: ª Risks that include hazards of the workplace and
» CVD, DM, Substance Abuse, HIV/AIDS, the woman’s general environment.
RH incompatibility, and anemia. ª Pesticides, radiation, harmful chemicals,
» Diabetes Mellitus can cause the fetus pollution
to be LGA (Large for Gestational Age),
illness, maternal and child attachment Screening and Laboratory/Diagnostic
since they are sick. Examinations
2. Women who develop complications of 1. Rhythm Strip Testing
pregnancy such as: ª Record FHR for 20 minutes.
» Hyperemesis Gravidarum (hard to ª Assessment of the FHR for whether a good
control vomiting), Ectopic Pregnancy baseline rate and a degree of variability are
(outside the uterus), Hydatidiform present.
Mole, Premature Cervical Dilatation, ª Variability Categories:
Abortion, Placenta Previa, Abruptio » Absent – Nonapparent
Placenta. » Minimal – Extremely small fluctuations

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 » Moderate – Amplitude range: 6-25 This will create a dark mark on the paper
bpm tracing at these times.
» Marked – Amplitude range: > 25 bpm ª When the fetus moves, the fetal heart rate
should increase about 15 beats per
Procedure: minute and remain elevated for 15
ª A woman is positioned into a semi-fowler’s seconds. It should decrease to its average rate
(either in a comfortable lounge chair or on an again as the fetus quiets. If no increase in
examining table or bed with an elevated beats per minute is noticeable on fetal
backrest) to prevent her uterus from movement, poor oxygen perfusion of the fetus
compressing the vena cava and causing is suggested. An additional test such as
supine hypotension syndrome during the contraction test and biophysical profile maybe
test. Attach an external fetal heart rate done to further investigate the condition of the
monitor abdominally. fetus.
ª An average fetus moves about twice every
10 minutes, and movement causes the heart
rate to increase, there will typically be two or
more instances of fetal heart rate acceleration
in a 20-minute rhythm strip.
ª Rhythm strip testing requires a woman to
remain in a fairly fixed position for 20
minutes. Keep her well informed of the
purpose of the test, how it is interpreted, and
the meaning of the results after the test. The
more she understands about the process, the
better she can cooperate to make it successful. Result Interpretation
Reactive - 2 accelerations of FHR (by 15
beats or more) lasting for 15
seconds occur after movement
within the chosen time period.
Nonreactiv - No accelerations occur with the
e fetal movements.
- No fetal movements occur or if
there is low short-term fetal
heart rate variability (less than 6
bpm) throughout the testing
Rhythm Strip of Fetal Heart Rate period.
ª The baseline reading refers to the average rate
of the fetal heartbeat per minute. Result varies 3. Vibroacoustic Stimulation
but slight only and refers to the changes in rate ª Producing a sharp sound of approximately 80
that occur if the fetal parasympathetic and decibels at a frequency of 80 Hz, startling ad
sympathetic nervous systems are receiving waking the fetus.
adequate oxygen and nutrients. ª Done in conjunction with a nonstress test.
ª Expected response – acceleration of FHR
2. Nonstress Testing ª During a standard nonstress test, if a
ª Done for 10-20 minutes. spontaneous acceleration has not occurred
ª Measures the response of the fetal heart rate within 5 minutes, apply a single 1- to 2- second
to fetal movement. sound stimulation to the lower abdomen. This
can be repeated again at the end of 10 minutes
Procedure: if no further spontaneous movement occurs, so
ª Position the woman (supine position, head that two movements within 20-minute window
slightly elevated or supported with a pillow) can be evaluated.
and attach both a fetal heart rate and a uterine
contraction monitor. Instruct a woman to push 4. Contraction Stress Testing
a button attached to the monitor (similar to a ª External fetal heart monitor is applied and
call bell) whenever she feels the fetus move. obtain baseline FHR.
ª May be done if NST results are non-reassuring

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 ª Involves nipple stimulation until uterine see that
contraction begin. contractions are
ª The fetal heart rate is analyzed in conjunction quiet and
with contractions. It is done by initiating preterm labor
contractions thru intravenous infusion of does not begin.
oxytocin.
ª However, once started, contractions begun this
way were sometimes difficult to stop and led to 5. Ultrasonography
preterm labor. For this reason, the pregnant ª Measures the response of sound waves against
woman is encouraged to perform nipple solid objects.
stimulation. Gentle stimulation of the ª Ultrasound is usually advised if the date of the
nipples releases oxytocin in the same way as last menstrual period is unknown, a woman will
with breastfeeding. be scheduled for a sonogram to confirm the
ª With external uterine contraction and fetal pregnancy length and document healthy fetal
heart rate monitors in place, the baseline fetal growth at 7-11 weeks of pregnancy.
heart rate is obtained. Then, the pregnant ª Between 16 and 20 week’s gestation UTZ is
woman rolls a nipple between her finger and done to verify healthy fetal structures and
thumb until uterine contractions begin, which gender. A sonogram done under 8 weeks will
are recorded by a uterine monitor. Three show only the presence of a gestational
contractions with a duration of 40 sac.
seconds or longer must be present in a
10-minute window before the test can be Procedure:
interpreted. ª Before an ultrasound examination, be sure that
ª After a contraction stress test, encourage a a woman has received good explanation of
woman to remain in the health care facility for what will happen and reassurance that the
about 30 minutes, to be certain that process does not involve x-rays. This means
contractions have quiet and preterm labor is it is also safe for the father of the child to
not a risk. remain in the room during the test.
ª For the sound waves to reflect best and the
Comparison of the Nonstress and Contraction uterus to be held stable, it is helpful if the
Stress Tests woman has a full bladder at the time of
Area of Nonstress Test Contraction the procedure. To ensure this, have her drink
Assessment Stress Test a full glass of water every 15 minutes
What is Response of FHR Response of FHR beginning 90 minutes before the procedure and
measured in relation to in relation to not void until after the procedure.
fetal movement. uterine ª Help the woman up to an examining table and
contractions as drape her for modesty, but with her abdomen
the nipples are exposed. To prevent supine hypotension
stimulated. syndrome, place a towel under her right
Normal Two or more No late buttock to tip her body slightly so that
Findings accelerations of decelerations the uterus will roll away from the vena
fetal heart rate with cava. A gel is then applied to her abdomen to
of 15 bpm contractions. improve the contact of the transducer.
lasting 15 secs
or longer Uses of Ultrasonography
following fetal ª Diagnose pregnancy
movements in a ª Confirm the presence, size, and location of the
20-min period placenta and amount of amniotic fluid.
Safety Woman should In addition to ª Establish that a fetus is growing and has no
Considerati not lie supine to preventing gross anomalies
ons prevent supine supine ª Establish sex
hypotension hypotension ª Establish the presentation and position
syndrome. syndrome, ª Predict maturity – biparietal diameter
observe the ª Discover complications of pregnancy e.g.
woman for 30 presence of an intrauterine device, hydramnios
min afterward to or oligohydramnios, ectopic pregnancy, missed

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 miscarriage, abdominal pregnancy, placenta Because it will limit the number of nutrients
previa, premature separation of the placenta, that can reach the fetus, decreased velocity is
coexisting uterine tumors, multiple pregnancy, an important predictor of poor neonatal
or genetic disorders such as Down syndrome. outcome.
ª Fetal anomalies such as neural tube disorders,
diaphragmatic hernia, or urethral stenosis also Ultrasonography: Placental Grading
can be diagnosed. ª Based particularly on the amount of calcium
ª Fetal death can be revealed by a lack of deposits in the base of the placenta, placentas
heartbeat and respiratory movement. can be graded by ultrasound as 0 (a placenta
ª After birth, an ultrasound may be used to 12-24 wks), 1 (30-32 wks), 2 (36 wks), and 3
detect a retained placenta or poor uterine (38 wks).
involution in the new mother. ª Because fetal lungs are apt to be mature at 38
weeks, a grade 3 placenta suggests that the
fetus is mature.

ª Like regular ultrasounds, 3D and 4D

ultrasounds use sound waves to create an
image of the baby in the womb.
ª 3D ultrasounds create a three-dimensional Ultrasonography: Amniotic Fluid Volume
image of the baby, while 4D ultrasounds create Assessment
a live video effect, like a movie that you can ª The amount of amniotic fluid present is yet
watch the baby smile or yawn. another way to estimate fetal health
ª Parents often want 3D and 4D ultrasounds. because a portion of the fluid is formed
They let you see your baby's face for the first by fetal kidney output.
time. Some doctors like 3D and 4D ultrasounds ª If a fetus is becoming stressed in utero so that
because they can show certain birth defects, circulatory and kidney functions are failing,
such as cleft palate that might not show up on urine output and, consequently, the volume of
a standard ultrasound. amniotic fluid volume puts the fetus at risk for
compression of the umbilical cord and
Ultrasonography: Biparietal Diameter interference with nutrition.
ª By measuring the biparietal diameter (side-to-
side measurement) of the fetal head, fetal Guidelines for Measuring AFI:
maturity is determined. ª For gestations < 20 weeks, uterus is
ª In 80% of pregnancies in which the biparietal divided into 2 vertical halves.
diameter of the fetal head is 8.5 cm or greater, » Measure the vertical diameter of the
it can be predicted that the infant will weigh largest pocket of amniotic fluid present
more than 2500g (5.5 lbs.) at fetal age of 40 on each side in cm, then add.
weeks. ª For gestations > 20 weeks, uterus is
ª Two other measurements commonly made by divided into 4 quadrants.
ultrasound to predict maturity are head » Measure the vertical diameter of the
circumference and femoral length. largest pocket of amniotic fluid present
on each quadrant in cm, then add.
Ultrasonography: Doppler Umbilical Velocimetry ª Interpretation of the result:
ª Measures the velocity at which RBC in the » Ave. index =12-15 cm bet. 28-40 wks.
uterine and fetal blood vessels travel. » Index > 20-24 cm = hydramnios
ª Assessment of the blood flow through the » Index < 5-6 cm = oligohydramnios
uterine blood vessels is helpful to determine » Index 8-18 cm = normal
the vascular resistance present in women
with diabetes or hypertension of 6. Electrocardiography
pregnancy and whether resultant
placental insufficiency is occurring.
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 ª Fetal ECGs may be recorded as early as the ª A sample of the chorionic villi can be removed
11th week of pregnancy (inaccurate before 20 through the cervix (transcervically) or the
weeks). abdominal wall (trans-abdominally).
ª Rarely used unless a specific heart anomaly is ª With both methods, ultrasonography is used for
suspected. guidance and the tissue sample is suctioned
through a needle or catheter with a syringe and
7. Magnetic Resonance Imaging then sent for laboratory analysis. Many women
ª Has the potential to replace or complement have light spotting for a day or two afterward.
ultrasonography as a fetal assessment
technique. Advantage of Chorionic Villus Sampling
ª Most helpful in diagnosing complications such ª Its results are available much earlier in the
as ectopic pregnancy or trophoblastic disease. pregnancy than those of amniocentesis. Thus,
if no abnormality is detected, the couple's
8. Maternal Serum Alpha-Fetoprotein anxiety can be relieved earlier. If an
ª Begins to rise at 11 weeks’ gestation and abnormality is detected earlier and if the
then steadily increase until term. couple decides to terminate the pregnancy,
ª Levels are abnormally high in maternal serum if simpler, safer methods can be used.
the fetus has an open spinal or abdominal ª The risk of CVS is miscarriage.
defect because the open defect allows more
AFP to enter the mother’s circulation. 11. Amniocentesis
ª Levels are abnormally low if the fetus has a ª Pertains to the aspiration of amniotic fluid from
chromosomal defect such as Down syndrome the pregnant uterus for examination. The
or hydatidiform mole. procedure can be done in a physician’s office or
in an ambulatory clinic.
9. Triple and Quad Screening ª It is typically scheduled between the 14th
ª Help estimate risk of down syndrome. and 16th week of pregnancy to allow for a
ª Screening at 15-20 weeks of pregnancy. generous amount of amniotic fluid to be
ª If the risk is high, amniocentesis is considered. present.
Quad screening results are abnormal (positive) ª The technique can also be used again near
in almost 80% of Down syndrome cases. Triple term to test for fetal maturity.
screening detects almost as many cases. ª It is a technically easy procedure, but it can be
ª Triple Screening frightening to a woman.
» Estriol » Because it involves penetration of the
» Beta-human chorionic gonadotropin integrity of the amniotic sac. There also
» Alpha-fetoprotein are risks to the fetus, although the
ª Quad Screening incidence of these is low (less than
» Estriol 0.5%).
» Beta-human chorionic gonadotropin ª Possible Complications are:
» Alpha-fetoprotein » Fetus: Hemorrhage from penetration of
» Inhibin A the placenta, infection of the amniotic
fluid, and puncture.
10. Chorionic Villus Sampling » Mother: If it leads to irritation of the
ª Removes a small sample of the chorionic villi, uterus, it can initiate premature labor.
which are tiny projections that make up part of
the placenta.
ª Used to diagnose some disorders in the fetus,
usually between 10 and 12 weeks of
pregnancy.
ª Before the chorionic villus sampling,
ultrasonography is done to determine
whether the fetus is alive, to confirm the
length of the pregnancy, to check for
obvious abnormalities, and to locate the
placenta.

Procedure: Amniotic Fluid is Analyzed for:

ª AFP
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 ª Bilirubin Determination addition, ultrasound is used during the
ª Chromosome Analysis procedure to monitor for any bleeding.
ª Color
ª Fetal Fibronectin 13. Fetoscopy
ª Inborn Errors of Metabolism ª Fetus is visualized through fetoscope
ª L/S (lecithin, sphingomyelin) Ratio ª Insertion of a fiber optic fetoscope through a
ª Phosphatidyl Glycerol small incision in the mother’s abdomen into the
ª Desaturated Phosphatidylcholine uterus and membranes, usually under local
anesthesia.
12. Percutaneous Umbilical Blood Sampling ª Can be performed at the 16th or 17th week
ª Cordocentesis or funicentesis AOG.
ª It is the aspiration of blood from the umbilical ª The procedure is used to:
vein for analysis. » Confirm the intactness of the spinal
ª Because the fetal vein is fragile early in column.
pregnancy, PUBS is performed no earlier » Obtain biopsy samples of fetal tissue
than 17 weeks into pregnancy. and fetal blood samples.
ª This procedure carries a little additional risk to » Perform elemental surgery
the fetus or woman over amniocentesis and ª The fetus is visualized by inspection through a
can yield information not available by any fetoscope.
other means, especially about blood » An extremely narrow, hollow tube
dyscrasias. inserted by amniocentesis technique,
which can be helpful to assess fetal
well-being.
» If a photograph is taken through the
fetoscope, it can document a problem
or reassure parents that their infant is
perfectly formed.
ª Risk: Fetoscopy carries a small risk of
premature labor however, amnionitis (infection
of the amniotic fluid) may occur due to
penetration of mechanical device into the
amniotic sac.
» To avoid this, the woman may be
Procedure:
prescribed 10 days of antibiotic
ª After the umbilical cord is located by
therapy after the procedure.
ultrasound, a thin needle is inserted by
» The number of procedures performed
amniocentesis technique into the uterus and is
by fetoscopy is limited because of the
guided by ultrasound until it pierces the
manipulation involved and the ethical
umbilical vein.
issues that is concerned in performing
ª A sample of blood is then removed for blood
this procedure.
studies, such as a complete blood count, direct
Coomb’s test, blood gases, and karyotyping.
Procedure:
ª To ensure that the blood obtained is fetal blood,
ª The mother is prepared and draped as for
it is submitted to Kleihauer-Betke test which
amniocentesis. A local anesthetic is injected
measures the difference between adult and
into the abdominal skin.
fetal blood.
ª The fetoscope is then inserted through a minor
» If the test reveals that a fetus is
abdominal incision. If the fetus is very active,
anemic, blood may be transfused using
meperidine (Demerol) may be administered
this same technique.
to the woman to help sedate the fetus to avoid
ª Risk: Because the umbilical vein continues to
fetal injury by the scope and to allow better
ooze for a moment after the procedure, fetal
observation.
blood could enter the maternal circulation after
the procedure, so RhIG is given to Rh-negative
women to prevent sensitization.
ª Before and after the procedure the fetus is
monitored by a nonstress test to be certain
that uterine contractions are not present. In
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 Fetal Nonstress Two or more fetal heart
heart Test rate accelerations of at
reactivity least 15 beats/min above
baseline and of 15 sec
duration occur with fetal
movement over a 20 min
time period.
ª 10 would be the highest score possible.
ª A biophysical profile is more accurate in
predicting fetal well-being than any single
14. Amnioscopy
assessment.
ª Visual inspection of the amniotic fluid through
ª It is also called a fetal Apgar because the
the cervix and membranes with an amnioscope
scoring system is similar to that of the Apgar
(small fetoscope).
score determined at birth on infants. This may
ª Used to detect meconium staining.
be done as often as daily during a high-risk
ª The main use of the technique is to detect
pregnancy.
meconium staining. It carries some risk of
ª A result of 8-10 indicates that the fetus is
membrane rupture.
doing well.
ª A score of 6 is considered suspicious
Biophysical Profile
ª A score of 4 denotes a fetus probably in
ª Combines five parameters into one
jeopardy.
assessment:
» Fetal heart reactivity
Daily Fetal Movement Count/Kick Count
» Fetal breathing
ª Maternal assessment of fetal movement
» Fetal body movement
ª Several protocols are used for counting:
» Fetal tone
» Count once a day for 60 minutes.
» Amniotic fluid volume
» Count 2 or 3 times daily for 2 hours or
until 10 movements are counted or all
fetal movements in a 12 hour period
each day until a minimum of 10
movements are counted.
ª Fetal alarm signal – fetal movements cease
entirely for 12 hours.
ª Count fewer than 3 fetal movements within 1
hour or cessation of fetal movement for 12
hours warrants further evaluation.

Important things to consider:

Assessme Instrume Criteria for a Score of 2 ª This can be assessed at home and is
nt nt noninvasive, inexpensive, simple to
Fetal Ultrasoun At least one episode of 30 understand, and usually does not interfere w/
Breathing d sec of sustained fetal daily routine.
breathing movement ª It is frequently used to monitor the fetus in
within 30 min of pregnancies complicated by conditions that
observation. may affect fetal oxygenation.
Fetal Ultrasoun At least 3 episodes of fetal ª The presence of movements is generally a
Movemen d limb or trunk movement reassuring sign of fetal health.
t within a 30 min ª During the 3rd trimester the fetus makes
observation. about 30 gross body movements each
Fetal tone Ultrasoun The fetus must extend hour and the mother is able to recognize
d and then flex the 70% to 80% of these movements.
extremities or spine at ª In assessing fetal movements, it is important to
least once in 30 min. remember that they are usually not present
Amniotic Ultrasoun A range of amniotic fluid during fetal sleep cycle and that they may be
fluid d between 5 and 25 cm temporarily reduced if the woman is taking
volume must be present. depressant medications, drinking alcohol, or

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 smoking cigarette. This the reason why blood incompatibility. is Rh-positive or
pregnant women are prohibited from taking antibodies are present,
such substances during pregnancy. additional testing and
ª Also, be reminded that fetal movements do not treatment are required; if
decrease as the woman nears term. However, Rh (-) and unsensitized,
in the case of obese mothers, their ability to RhoGAM will be given at
perceive fetal movement may be decreased. 28 weeks.
VDRL and RPR (Rapid Plasma Reagin)
Purpose: To screen for Significance: Treat if
syphilis. results are positive;
retest at 36 weeks.
Rubella Titer
Purpose: To determine Significance: If titer is
immunity. 1:8 or less, mother is not
immune; immunize
postpartum if not
immune.
Examples for Recording Kick Counts
Skin Test
Purpose: To screen for Significance: If results
Day Time Fetal Time Duratio
tuberculosis. are positive, refer for
Started Kicks Ended n
additional testing or
Mo 9:00 AM XXXXXXXX 9:32 AM 32 min.
therapy.
n XX
Hemoglobin Electrophoresis
Tue 12:00 XXXXXXXX 12:45 45 min.
Purpose: To screen for Significance: If mother
PM XX PM
sickle cell trait if client is is positive, check
We 9:00 AM XXXXXXXX 10:00 1 hr.
of African-American partner; infant is at risk
d XX AM
descent only if both parents are
Thu 9:00 AM XXXXXXXX 11:15 2 hrs.
positive.
rs XX AM 15 min.
Hepatitis B Screening
Purpose: To detect Significance: If present,
Other Laboratory Examinations
presence of antigens in infants should be given
maternal blood. hepatitis immune
Blood Grouping
globulin and vaccine
Purpose: To determine Significance: Identifies soon after birth.
blood type and Rh possible causes of
Urinalysis
incompatibility with the
Purpose: To detect renal Significance: Reassess
fetus that may cause
disease or infection. if positive for more than
jaundice.
a trace protein (renal
Hgb/Hct
damage, preeclampsia,
Purpose: To detect Significance: Hgb or normal), ketones
anemia; often checked <11g/dl in the 1st and 3rd (fasting or dehydration),
several times during trimesters or <10.5g/dl or bacteria (infection).
pregnancy. in the 2nd trimester may
Papanicolaou Test (Pap Smear)
indicate a need for
Purpose: To screen for Significance: Treat and
additional iron
cervical neoplasia. refer if abnormal cells
supplementation.
are present.
CBC
Cervical Culture
Purpose: To detect Significance:
Purpose: To detect Significance: Treat and
infection, anemia, or cell 12,000/mm3 or more
group B streptococci and retest as necessary,
abnormalities. white blood cells or
sexually transmissible treat group B
decreased platelets
diseases. streptococci during labor.
require follow up.
Maternal Blood Glucose (Glucose Challenge
Rh factor and Antibody Screen
Test)
Purpose: To check for Significance: If mother
Purpose: To screen for Significance: If elevated,
possible maternal-fetal is Rh-negative and father
possible gestational a 3-hour glucose
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diabetes. tolerance test is
recommended.