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Pregnancy and Child birth even though a joyous event, has faced with lot of problems, it may be within the mother itself or due to the influence of psychosocial factors. There has been significant reduction in MMR as a result of advances in the management of disorders that have an adverse effect on the pregnant woman. Assessment of existence of risks, together with appropriate & timely intervention can help to prevent disabling conditions. The united efforts of Medical and Nursing personnel are required to care for the high risk clients which help to reduce the MMR in our Country. It is estimated that approximately one out of every four pregnant women will experience complications, which leads to premature baby & maternal morbidity. About 78,000 woman die each year in India due to complicated pregnancy and child birth (UNICEF Jan 15, 2009). The major reason for this is malnutrition, infection, unregulated fertility & lack of adequate obstetric care.

INCIDENCE In India 35-50% of teenagers are married. In Bangladesh 90% of girls are married before the age of 18 years & 35% of them are mothers of 2 children before the age of 18 years. There are more prone to be victim of anemia, Toxaemia & Haemorrhage. (Coopland. A.T., et al., 2004) The studies shows that 58.7% of macerated stillbirth and 70-80% of prematurity new born is due to complicated pregnancy. (Journal of Prenatal medicine, 2006) In India, 75% of all maternal death occurred due to complication of pregnancy and 25% of maternal mortality is due to indirect obstetric cause & social factors. Early identification of these patients, followed by proper management & therapy can frequently modify or prevent a poor perinatal outcome. (Holland 1999)

Definition: High risk Pregnancy is defined as one in which the mother or the fetus has a significantly increased chance of death or disability. Is one in which the life of the health of the mother or infant is jeopardized by a disorder coincidental with or unique to the pregnancy

Identification of pregnancy: Several high risk identification systems have been proposed by different authors. Each scheme consists of a list of conditions known to be poor prognostic indicators in pregnancy. A high risk pregnancy can be identified only if the woman has access to prenatal care. Poverty limiting access to the health care system and lack of ability of society and government to provide medical coverage to those unable to pay for these services are powerful factors that prevent access to prenatal care. Once the women has access to prenatal care, the second limiting factor preventing the identification of those at risk is the quality of the prenatal care itself because, in many cases the services provided are of marginal quality and high risk patients are not aidentified. High risk pregnancies are a small segment of the obstetrical population that produces the majority of the maternal and infant mortality and morbidity. This denomination includes women with chronic hypertension , pregestational diabetes,anaemia, chronic lung disease, Rh alloimmunization,cardiac and renal disease,women ata risk for congenital abnormalities in the offspring and other conditions,that place the pregnancy.

PARTIAL LIST OF MEDICAL CONDITIONS THAT PLACE PREGNANCY AT HIGH RISK FOR A POOR OUTCOME: 1. Malnutrition 2. Anemia 3. Chronic hypertension 4. Diabetes 5. Asthma

6. Thrmobophilia 7. Cardiac disease 8. Seizure disorder 9. Familyhistory of genetic disorders 10. Hemoglobinopathy 11. Renal diseases 12. Psychiatric illness 13. SLE and other connective tissue disesases 14. Drug and alcohol abuse 15. Smoking 16. Rh alloimmunization 17. Hepatitis B 18. HIV 19. Syphills 20. Gonorrhea 21. Asymptomatic bacteriuria 22. Women with a poor obstetrical history are also at high risk for abnormal outcomes. OBSTERICAL HIGH RISK FACTORS: History of previous prolonged labour instrumental assited delivery History of obstructed labour /rupture of uterus traumatic delivery History of postpartum haemorrhage /obstetric shock History of puperal sepsis Prior preterm birth History of asphyxia /neonatal convlusions/birth injuries Prior still birth Prior fetal growth restricted infant Second trimester pregnancy loss Prior neonatal death Prior infant with cerebral palsy Prior cesarean delivery Diagnosis of incompetent cervix History of pre eclampasia before 32 weeks in prior pregnancy Anatomic abnormality of the uterus History of cervical trauma

Method: To facilate the identifaction of high risk pregnancies most prenatal records incorporate a list of high risk should be factors that should be systematically checked during the first prenatal visit to find women at risk. Some of these systems assign a numerical value to the high risk factors, depending on the pregnancy or the accuracy of the riskfactor in predicting outcome, resulting in a numerical score that is as follows.

Hobels High Risk Assessment tool : ( Obstetric risk factors, Medical risk factors, Family history, Physical risk factors & Current pregnancy risk). Daga A.S & Daga S.R : High risk scoring for Prediction of pegnancy outcome. The Merck Manuals Pregnancy Risk Assessment & Goodwins scale : Prenatal risk Indicator form. Approaches to identify risk factors: Depends on degree of danger & degree of intervention required. Since pregnancy is a dynamic & ever-changing state, risk may occur at any time. More than one risk factor can also present, that can precipitate the occurrence of another risk. A variety of high risk assessment tools are available Categories of high risk pregnancies: CATEGORY A : Universal CATEGORY B: Reproductive History CATEGORY C: Present Obstetrical History CATEGORY D: Intrapartum Factors. UNIVERSAL: Maternal age above 35 & below 17 Primiparity & grand multiparity

Height less than 140cm Low socio economic status. REPRODUCTIVE HISTORY: Long period of infertility Recurrent abortion Previous IUD, stillbirth ,CS, Hysterotomy or Myomectomy Neonatal death & preterm labour Previous Rh or ABO iso immunisation, pre eclampsia & Third stage complications. PRESENT OBSTETRICAL HISTORY: Unbooked mother, women with medical disorders Ectopic pregnancy, hydatidiform mole, IUGR, Hyramnios Malpresentation, obesity & prolonged labour. INTRAPARTUM FACTORS: PROM, Cord complications, fetal distress, PPH, Retained placenta Unskilled attendant. PRESENT OBSTETRICAL HISTORY: Unbooked mother, women with medical disorders Ectopic pregnancy, hydatidiform mole, IUGR, Hyramnios Malpresentation, obesity & prolonged labour. INTRAPARTUM FACTORS: PROM, Cord complications, fetal distress, PPH, Retained placenta Unskilled attendant.

Risk Factors For a High Risk Pregnancy can include: Elderly primi, short statured Being overweight or underweight History of problem in previous pregnancy Pre-existing health conditions Multiple pregnancy Mal Presentation Antepartum haemorrhage, threatened abortion Pre eclampsia & eclampsia Prolonged pregnancy Conceived while using an IUD Conceived by ART Having Child with a genetic disorder Having habit of smoking, alcohol consumption & drug abuse.

WATCH OUT:Any Pregnancy can become high risk: Vaginal bleeding or spotting Swelling in the face & Extremities A leakage of fluid or increased vaginal discharge Severe or persistent headaches Pain in the abdomen Persistent vomiting that is not related to morning sickness. Noticeable change in fetal movement Painful or urgent urination Any health problems ,Dizziness or faintness

Diagnosis of pregnancy: A Risk assessment sheet is utilized during prenatal period. This can be implemented from first prenatal visits, becomes a part of the womens record & is updated throughout the pregnancy. HIGH RISK SCORING SYSTEM (COOPLAND 1998) High Risk Evaluation Form Name _______________ Age _____________ LMP ____________ EDD _____________ Reproductive History Medical or Surgical Associated Conditions Age : <16 (1) 16-35 (0) > 35 (2) Parity : 1-4 (0) > 5 (2) Two or more abortions or history of infertility (1) Postpartum bleeding or manual removal 0 (1) Previous gynecological surgery (1) Chronic renal disease (1) Gestational diabetes A (1) Class B or greater diabetes (3) Other significant medical disorders (0-3) Bleeding : < 20 weeks (1) > 20 weeks (3) Anemia (<10g %) (1) Postmaturity (1) Hypertension (2) Premature rupture of membrane (2) Polyhydramnios (2) IUGR (3) Present Pregnancy


Reproductive History Previous low birth weight child (1) Toxemia or hypertension (2) Previous cesarean section (2) Abnormal or difficult Labour (2) TOTAL SCORE: _________ (Sum of the three columns) Low Risk High Risk

Present Pregnancy Multiple Pregnancy (3) Malpresentation (3) Rh isoimmunization (3)

0-2 3-6 7 or more

Severe Risk

Role of midwife Prenatal assessment & screening of risk cases Thorough antenatal assessment Review lab orders / investigations Obtaining USG reports Identification of high risk Prenatal interview Prompt referral Follow up

Conclusion: With proper care of medical & nursing personnel 90 to 95% of high risk pregnancies can produce healthy, viable babies & healthy mother.

IMPORTANCE OF INSTITUTIONAL DELIVERIES: India has the largest number of births per year (27 million) in the world.1 With its high maternal mortality of about 300500 per 100 000 births This is about 20% of the global burden hence Indias progress in reducing maternal deaths is crucial to the global achievement of Millennium Development Goal.

Indications: Medical: 1. 2. 3. 4. 5. 6. Cardiac diseases Renal diseases Essential hypertension Tuberculosis Habitual drug use STDS

Past obstetric history: 1. 2. 3. 4. Uterine surgery Difficult forceps delivery Postpartum haemorrhage Manual removal of placenta

Current pregnancy: 1. 2. 3. 4. 5. 6. 7. 8. CPD Placenta previa Pregnancy associated hypertension Multiple pregnancy Breech presentation Preterm labour Rh iso immunization A typical antibodies

Relative conditions: 1. Age under 18 to over 35 2. Parity 0 or more than 4 3. Height under5

OBSTACLES FOR LOW UTILIZATION OF DELIVERY SERVICES: Distance from health services; Costs, including user fees The cost of transport, Quality of care, Drugs availability & Supplies Attitudes of health personnel, Multiple demands on womens time; Womens lack of autonomy indecision-making. Factors influencing: POVERTY: Distance from health services; Costs, including user fees The cost of transport, Quality of care, Drugs availability & Supplies Attitudes of health personnel, Multiple demands on womens time; Womens lack of autonomy indecision-making.

NORMSAND BELIEFS: Prolonged labour is a punishment for past infidelity An unassisted delivery a sign of courage Traditional beliefs about childbirth, coupled with misconceptions and fears of medical institutions, have led many women to maintain reliance on home births in Indi

Shame in the first birth, and newly pregnant girls are expected to exhibit modest behaviour by remaining quiet in their vital condition and not talk at all about their pregnancy, the social pressure may create a major barrier to seeking antenatal care or delivering in hospital. Traditionally in rural India pregnancy is considered a natural state of being for a woman rather than a condition requiring medical attention and care. Such perceptions and beliefs constitute a lay-health culture that is an intervening factor between the presence of a morbidity condition and its corresponding treatment. QUALITY OF CARE: a woman with a complication is likely to delay or avoid accessing care from a health facility where she has experienced a good but disrespectful treatment in a previous normal birth. receiving one or more antenatal check-ups is the strongest predictor of institutional delivery

ssTRANSPORT: Transport cost and the opportunity cost of patients and caregiver(s), where necessary, had a significant negative impact on utilisation of delivery care services.

LITERACY: mothers education has a strong positive effect institutional deliveries womans education is a major factor affecting utilization of maternal health services in both north and south India high levels of husbands education increase the likelihood of health service

CASTE AND RELIGION: Muslim mothers are more likely than Hindu mothers to give birth in a medical institution in Andhra Pradesh and Gujarat, but Muslim mothers are much less likely than Hindu mothers to do so in Bihar and Rajasthan.

Rural mothers belonging to scheduled castes or scheduled tribes are much less likely to give birth in a medical institution than mothers not belonging to a scheduled caste or scheduled tribe. WOMENS AUTONOMY:

womans autonomy, as measured by decision making about her own health care, shows little association with institutional delivery.

According to Kutzin (1993) the inability of women in some developing countries to make decisions in relation to choice of medical care severely affects their choice of delivery care. A conflict between biomedical and traditionally perceived causes of health conditions also limits womens access to delivery care

ECONOMIC STATUS OF THE COMMUNITY: The level of community economic development may influence health directly, through an association between deprivation and poor health, and indirectly through access to health services and social support systems Some Demographic Factors Age:Increase in the Maternal age has a strong positive effect in utilizing delivery services Birth order :-

Increase in the birth order has a negative in the maternal service utilization , in Andhra Pradesh, 53 percent of first-order births but only 24 percent of fourth or higherorder births took place in medical institutions. Marital Status:Unmarried pregnant girls are less likely to utilize the services . High fertility:maternity health

High fertility may also reflect a lack of reproductive health services and a lack of awareness of such services, both of which have obvious implications for maternal health service use.


Working urban mothers are less likely to deliver in a medical institution than nonworking mothers. Mass media: Instructional delivery are higher for mothers who are regularly exposed to the electronic mass media than mothers who are not regularly exposed

Role of a midwife: The decision about where to have her baby should be made by the woman herself in consultation with her community midwife, general practioner and if necessary, the obstetrician. Educate mother during labour she needs to feel at ease in her surroundings and have confidence in her attendents. The choices will be influenced by mothers past and current history and previous experiences. Encourage mother to have an institutional delivery that women can taken care by the health professional to feel more secure ,knowing that emergency facilitie are close at hand.