High Risk Pregnancies

Categories of High Risk Mothers

A midwife must be highly vigilant during history taking and physical examination to identify mothers who fall into the high-risk category. The following is a comprehensive list of mothers who are strictly considered high risk, along with the physiological reasons why:

• 1. Young Primigravida (Age 16 and below): Their pelvic bones are often not fully mature and developed, leading to a high risk of Cephalopelvic Disproportion (CPD), obstructed labour, and severe pre-eclampsia.
• 2. Elderly Primigravida (Age 35 and above): Increased risk of chromosomal abnormalities (like Down Syndrome), gestational diabetes, pregnancy-induced hypertension, and prolonged labour due to rigid pelvic joints.
• 3. Grand Multigravida (Gravida 5 and above): High risk of uterine atony leading to fatal Postpartum Hemorrhage (PPH), uterine rupture, abnormal presentations, and placenta praevia.
• 4. Mothers with 3 or more previous miscarriages: Indicates underlying issues such as cervical incompetence, chromosomal defects, or severe systemic diseases (e.g., syphilis, severe malaria).
• 5. Mothers of short stature (153cm / 5ft and below): Highly associated with a contracted or small pelvis, leading to CPD and obstructed labour.
• 6. Limping mothers: A limp often indicates a history of polio, rickets, or congenital hip dysplasia, which severely distorts the shape of the pelvis, making normal vaginal delivery impossible.
• 7. Mothers with a history of pelvic fractures: Previous trauma can alter the pelvic brim and outlet diameters, obstructing the birth canal.
• 8. Cephalopelvic Disproportion (CPD): When the baby's head is too large to fit through the mother's pelvis, necessitating a Caesarean section.
• 9. Multiple Pregnancy (Twins, Triplets): High risk of severe anemia, pre-eclampsia, premature labour, malpresentations, and severe PPH.
• 10. Mothers with Intrauterine Fetal Death (IUFD): A retained dead fetus can cause severe maternal bleeding disorders (Disseminated Intravascular Coagulation - DIC) and life-threatening sepsis.
• 11. History of PPH on previous deliveries: A mother who has bled heavily before is at a statistically much higher risk of bleeding again.
• 12. History of retained placenta on previous delivery: Indicates a risk of abnormal placental adherence (like placenta accreta) or recurring uterine atony.
• 13. Pre-eclampsia, Eclampsia, or history of Post-Eclamptic Toxemia: Severe hypertension threatens the mother with convulsions, cerebral hemorrhage, and fetal hypoxia.
• 14. Underlying Medical Conditions: Mothers with cardiac diseases (heart failure during pushing), renal diseases, essential hypertension, diabetes mellitus, severe anemia, asthma, APH, or who are Rhesus negative (risk of severe fetal jaundice/hydrops).
• 15. History of instrumental deliveries: Previous use of forceps or vacuum extractors indicates previous poor labour progress or CPD.
• 16. History of mental illness: High risk of puerperal psychosis, severe postpartum depression, and failure to bond with or care for the newborn.
• 17. History of premature deliveries or 2+ stillbirths: Indicates a hostile uterine environment, cervical incompetence, or untreated chronic maternal infections.

Roles of a Midwife/Nurse in High Risk Pregnancy

Aims of the Midwife

• To actively educate the community on risk factors.
• To educate individual mothers on their specific conditions.
• To safely care for mothers during pregnancy (ANC).
• To monitor and care for mothers during labour (Intranatal).
• To care for mothers after delivery (Postnatal).

1. At the Community Level

The midwife acts as a public health advocate to educate the community about the following:

• Value of the Girl Child: To value all children equally, ensuring the girl child is not neglected.
• Education and Nutrition: To educate all children and provide proper, balanced nutrition to young girls to ensure healthy pelvic bone development.
• Eradicate Harmful Practices: Teaching the extreme dangers of harmful cultural practices (like Female Genital Mutilation or early marriage) to girls before, during, and after pregnancy.
• Transport Logistics: Encouraging village leaders to organize and provide ready transport for pregnant women in emergencies.
• Utilization of Services: Persuading the community to abandon traditional, unsterile birth locations and utilize available health facilities.
• Danger Signs: Teaching the community (especially TBAs and VHTs) how to accurately recognize the danger signs of pregnancy and refer mothers to health units immediately.

2. To the Mother (Individual Level)

The midwife provides specialized, individual education to the high-risk mother:

• Preparation: The extreme importance of planning and physically preparing her body for pregnancy.
• Family Planning: Using family planning services so as to only conceive when her body is fully healed and she is medically ready.
• Service Utilization: Emphasizing that she must utilize all antenatal, intranatal, and postnatal services without skipping appointments.
• Dietary Needs: Teaching her how to eat well, including how to affordably source, prepare, and properly store a balanced diet to fight anemia.
• Self-Monitoring: Teaching her to recognize personal danger signs (e.g., bleeding, severe headaches, swollen face, loss of fetal movements).
• Lifestyle: Strict avoidance of substance abuse (alcohol, smoking, unprescribed native herbs).

3. At the Health Centre

During Pregnancy (Antenatal Care)

Health workers must ensure the following clinical protocols are strictly followed:

• Proper ANC: Conducting thorough physical exams, lab tests (Hb, syphilis, HIV, blood group), and accurately filling out the maternal passport.
• Health Education: Continual counseling on proper nutrition, adequate rest, sleep, and rigorous personal hygiene.
• Early Detection: Promptly detecting danger signs (like a sudden spike in BP or trace proteins in urine) and managing them before they escalate.
• Emergency Care & Referrals: Stabilizing the mother and organizing rapid referrals to higher-level hospitals for specialized care.
• Prophylactic Medication: Giving Tetanus Toxoid (TT) to prevent neonatal tetanus; Iron and Folic Acid to prevent severe anemia; Fansidar (IPTp) to prevent malaria in pregnancy; and Mebendazole for deworming.
• Discourage Native Medicine: Strongly warning mothers against herbal oxytocics, which can cause violent, uncoordinated contractions and fatal uterine rupture.
• Psychological Counseling: Counseling mothers not to place blame on themselves or feel guilt for their high-risk situations (such as unavoidable medical diseases or frequent childbearing).

During Labour (Intranatal Care)

• Provide absolutely safe, clean, and sterile delivery services.
• Show continuous kindness, emotional support, and understanding to calm the anxious mother.
• Provide proper hydration and energy (nutrition) during early labour.
• Strict Monitoring: Monitor mothers intensely during labour. Always use a Partograph for early detection of obstructed labour, fetal distress, or poor progress.
• Rapid Referral: Follow proper referral systems to prevent any delay in accessing surgical medical care if the partograph crosses the alert/action lines.
• Actively anticipate and prevent complications (e.g., active management of the third stage of labour to prevent PPH).

The Roles of a Husband in Safe Motherhood

Safe motherhood is not just a woman's issue. The active involvement of the husband or male partner drastically reduces maternal mortality. His roles are categorized into five crucial phases:

1. During Pregnancy

• Empathy: To deeply understand and appreciate the physical discomfort, extreme anxiety, and severe tiredness that pregnancy causes his wife.
• Physical Relief: Take over physically tiring tasks (e.g., digging in the field, lifting heavy jerrycans of water, washing, and scrubbing floors) to avoid exhausting the pregnant woman.
• Childcare: Take an active role in taking care of the older children.
• Emotional Support: Provide constant encouragement. Try not to make heavy demands on her and completely avoid criticizing her changing body or moods.
• Education: Learn about pregnancy-related conditions alongside his wife so he can help her more effectively and recognize the critical danger signs of pregnancy.
• Accompanying to ANC: Escort his wife to the health center for Antenatal Care and actively participate in the health education sessions.
• Financial Provision: Understand that good nutrition and medical care are paramount. He must provide the necessary money to buy healthy food, pay for transport, and purchase needed medication.
• Emergency Readiness: Pre-arrange and secure ready transport in case of any sudden emergency during the day or the middle of the night.

2. During Labour and Child Birth

• Ensure all required delivery materials (mama kits, clothes, transport money) are ready.
• Stay by her side: Stay with his wife at the hospital during labour and delivery to provide physical comfort, massage her back, and offer immense emotional support.

3. After Delivery (Puerperium)

• Adaptation: Adapt to the new baby in his life and actively help meet the baby’s demands, especially by supporting the mother while she is breastfeeding.
• Attention and Help: Give the mother understanding and attention. Help her with daily tasks so she can heal from the wounds of childbirth.
• Nutrition and Health: Contribute to a happy family by ensuring the mother is fed highly nutritious, blood-building foods, and that both she and the baby receive their postnatal medical care.
• Vigilance: Be highly aware of postnatal danger signs (like heavy bleeding, foul-smelling discharge, or high fever) that necessitate rushing back to the hospital.

4. In Family Planning

• Birth Spacing: Ensure the mother has fully recovered from the massive physical depletion of pregnancy and birth. He must protect her from becoming pregnant for at least 2 years after the birth of the last baby.
• Seek Advice Together: Go together with the mother to seek professional advice from the doctor or family planning clinic about the best methods of contraception.
• Support the Choice: Give full support and cooperation when using whichever method the couple selects.
• Male Involvement: He should bravely accept male family planning methods (like condoms or vasectomy) or fully cooperate without complaint when the woman is using a female method.

5. During Child Rearing

• Protect the family and provide essential resources (food, clothing, shelter, school fees).
• Actively participate in the daily upbringing and disciplining of the children.
• Involve the wife in all major household decision-making.
• Counsel and advise the children as teenagers, openly discussing crucial issues like sex education, when to get married, and choosing a career.
• Gender Equality: Ensure that his daughters are given the exact same opportunities as his sons in terms of education, healthcare, and benefits.
• Be emotionally and physically available at home for his wife and children, showing warmth and love.

Management of High Risk Factors

When an emergency arises in a high-risk pregnancy, seconds matter. The general principles applied in this management include strict preparedness, rapid action, and systemic stabilization.

1. Readiness and The Emergency Tray

The facility must be perfectly ready with everything used in the management of obstetric emergencies. The Emergency Tray must always be fully stocked, unexpired, and immediately accessible. It must contain:

2. Immediate Actions (The Nursing Process)

• Stay Calm: The midwife/nurse must be calm, quick, and knowledgeable. Shout and summon for extra help immediately.
• Prioritize (ABC): Start with the most urgent, life-saving need first (e.g., clearing the airway, arresting massive hemorrhage, establishing IV lines for rapid rehydration, or urgent delivery of the baby).
• Rapid Assessment: Perform quick general history taking, examination, and essential investigations while simultaneously treating.
• Systematic Care: Apply essential care systematically based on the emergency (e.g., preparing for a vacuum delivery, manual removal of a retained placenta, or CPR for the newborn).
• Reassurance: Continuously reassure the terrified mother and her panicking relatives. Keep them informed.

Prevention of High Risk Pregnancies

Preventing high-risk pregnancies and their complications requires a tightly coordinated effort between the midwife, the husband, and the community at large.

• Midwife Competence: The midwife/nurse must be highly knowledgeable on exactly how to identify and deal with HRPs.
• Continuous Medical Education: She must actively update herself on the latest guidelines and protocols for managing modern obstetrical conditions.
• Facility Readiness: The midwife must ensure her maternity center is perfectly equipped with drugs, sterile supplies, and an organized transport plan to deal with such cases efficiently and without fatal delays.
• Community Empowerment: Educating families to delay early marriage, stop adolescent pregnancies, space births through family planning, and ensure women give birth in hospitals under skilled supervision.