High risk approach in maternal and child health

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1. 1. High Risk Approach in Maternal and Child Health Shrooti Shah M.Sc. Nursing
Batch 2011 College of Nursing BPKIHS
2. 2. Contents 1. Introduction 2. Screening of high risk cases 3. High risk cases
(according to WHO) 4. Management of high risk cases 5. Risk approach (according to
WHO) 6. Interventions to reduce maternal mortality 7. Referral system and
identification by various level workers 8. MNCH policies and programs in Nepal 9.
References
3. Introduction to risk
• A dictionary definition of the word “risk” is hazard, danger, exposure to mischance
or peril”. It implies that the probability of adverse consequences is increased by the
presence of some characteristics or factor.
• Though all mothers and children are vulnerable to disease or disability, there are
certain mothers and infants who are at increased or special risk of complications of
pregnancy/labor or both.

4. Definitions “A risk factor is defined as any ascertainable characteristic or

circumstance of a person (or group of such persons) known to be associated with an
abnormal risk of developing, or being adversely affected by a morbid process” -
(WHO, 1973). High risk pregnancy is defined as one which is complicated by factor
or factors that adversely affects the pregnancy outcome –maternal or perinatal or both.

5. Introduction • All pregnancies and deliveries are potentially at risk. However, there
are certain categories of pregnancies where the mother, the fetus or the neonate is in a
state of increased jeopardy. About 20 to 30 percent pregnancies belong to this
category.
• If we desire to improve obstetric results, this group must be identified and given
extra care. • Even with adequate antenatal and intranatal care, this small group is
responsible for 70 to 80 percent of perinatal mortality and morbidity.
• The risk factors may be pre-existing prior to or at the time of first antenatal visit or
may develop subsequently in the ongoing pregnancy labour or puerperium. • Over 50
percent of all maternal complications and 60 percent of all primary caesarean sections
arise from the high risk group of cases.
6. Screening of high risk cases
• The cases are assessed at the initial antenatal examination, preferably in the first
trimester of pregnancy. • This examination may be performed in a big institution
(teaching or non-teaching) or in a peripheral health centre. • Some risk factors may
later appear and are detected at subsequent visits. • The cases are also reassessed near
term and again in labour for any new risk factors.
7. Initial screening History
• Maternal age • Reproductive history • Pre-eclampsia, eclampsia • Anaemia • Third
stage abnormality • Previous infant with Rh-isoimmunisation or ABO incompatibility
• Medical or surgical disorders
• Psychiatric illness • Cardiac disease • Epilepsy • Viral hepatitis • Previous operations
• Myomectomy • Repair of complete perineal tear • Repair of vesico-vaginal fistula •
Repair of stress incontinence

8. Family history • Socio-economic status • Family history of diabetes, hypertension or

multiple pregnancy (maternal side), congenital malformation.

9. High risk cases (According to WHO)

During pregnancy • Elderly primigravida (≥30 years) • Short statured primi (≤ 140
cm) • Threatened abortion and APH • Malpresentations • Pre-eclampsia and
eclampsia • Anaemia • Elderly grand multiparas • Twins and hydramnios • Previous
still birth, IUD, manual removal of placenta • Prolonged pregnancy • History of
previous caesarean section and instrumental delivery • Pregnancy associated with
medical diseases.

During labour • PROM • Prolonged labour • Hand, feet or cord prolapse • Placenta
retained more than half an hour • PPH • Puerperal fever and sepsis.

10. General physical examination • Height • Weight • Blood pressure • Anaemia • Cardiac
or pulmonary disease • Orthopaedic problems • Pelvic examination • Uterine size-
disproportionately smaller or bigger • Genital prolapse • Lacerations or dilatation of
the cervix • Associated tumours • Pelvic inadequacy

11. Course of the present pregnancy • The cases should be reassessed at each antenatal
visit to detect any abnormality that might have arisen later. • Few examples are- pre-
eclampsia, anaemia, Rh- isoimmunisation, high fever, pyelonephritis, haemorrhage,
diabetes mellitus, large uterus, lack of uterine growth, postmaturity, abnormal
presentation, twins and history of exposure to drugs or radiation, acute surgical
problems.

12. Complications of labour

• Anaemia, pre- eclampsia or eclampsia • Premature or PROM • Amnionitis • MSL •
Abnormal presentation and position • Disproportion, floating head in labour •
Multiple pregnancy • Premature labour • Abnormal FHR • Patients admitted with
prolonged • Obstructed labour • Rupture uterus • Patients having induction or
acceleration of labour
 Certain complications may arise during labour and place the mother or baby at a high
risk • Intrapartum fetal distress • Delivery under GA • Difficult forceps or breech
delivery • Failed forceps • Prolonged interval from the diagnosis of fetal distress to
delivery. • PPH or retained placenta

Postpartum complications • An uneventful labour may suddenly turn into an abnormal

one in the form of • PPH • Retained placenta • Shock • Inversion • Sepsis may
develop later on.

13. High risk newborn

• APGAR score below 7 • Birth weight less than 2500gm or more than 4 kg •
Convulsions • Respiratory distress syndrome • Hypoglycaemia • Fetal infection •
Persistent cyanosis • Anaemia • Major congenital abnormalities • Jaundice •
Haemorrhagic diathesis

14. Management of high risk cases

• The high risk cases should be identified and give proper antenatal, intranatal and
neonatal care. • This is not to say that healthy uncomplicated cases should not get
proper attention. • But in general they need not be admitted to specialized centres and
their care can be left to properly trained midwives and medical officers in health
centres, or general practitioners.
• It is necessary that all expectant mothers are covered by the obstetric service of a
particular area. • The services of trained community health workers and assistant
nurse-cum-midwife of health centres should be utilized to provide the primary care
and screening in rural areas and urban and semi-urban pockets • Cases with a
significantly higher risk should be referred to specialized referral centres. Cases from
rural areas may be kept at maternity waiting homes close to the referral centres.
• Cases having a previous unsuccessful pregnancy should be seen and investigated
before another conception occurs. • Complete investigations for hypertension,
diabetes, kidney disease or thyroid disorders should be undertaken and proper
treatment instituted in the nonpregnant state • Sexually transmitted disease should be
treated before embarking on another pregnancy.
• Cervical tears should also be repaired in the nonpregnant state. • Serology for
toxoplasma IgG, IgM and antiphosholipid antibodies should be done and corrected
appropriately when found positive. • Folic acid (4mg/day) therapy should be started in
the prepregnant state and is continued throughout the pregnancy • Early in pregnancy
after the initial clinical examination, routine and special laboratory investigations
should be undertaken.
• Patient with history of previous first trimester abortion should be advised rest and to
refrain from sexual intercourse. Vaginal examination should be avoided in first
trimester in these cases. • Patients suspected to have cervical incompetence should
have sonographic evaluation early in second trimester so that cervical encirclage, if
necessary may be performed at appropriate time.
 • Patients having premature labour, unexplained stillbirth, intrauterine growth
restriction and may other abnormalities are benefited by prolonged rest in hospital
with close supervision. Assessment of maternal and fetal well being • This should be
done at each antenatal visit, maternal complications should be looked for and treated,
if necessary.

15. Management of labour • It is evident that elective caesarean section is necessary in a

high-risk case. • Some cases may need induction of labour after 37-38 weeks of
gestation. • Those cases who go into labour spontaneously or after induction, need
close monitoring during labour for the assessment of progress of labour or for any
evidence of the fetal hypoxia.
16. Organizational aspect of management • Strengthen midwifery skills, community
participation and referral system. • Proper training of resident, nursing personnel and
community health workers. • Arranging periodic seminars, refresher courses with
participation of workers involved in the care of these cases. • Concentration of cases
in specialized centres for management
• Community participation, proper utilization of health care manpower and financial
resources where it is mostly needed. • Availability of perinatal laboratory for
necessary investigations; availability of a good paediatric service for the neonates •
Lastly, improvement of economic status, literary and health awareness of the
community.

17. Risk approach (according to WHO)

• The main objective of the at- risk approach is the optimal use of existing resources
for the benefit of the majority. It attempts to ensure a minimum of care for all while
providing guidelines for the diversion of limited resources to those who most need
them. • Inherent in this approach is maximum utilization of all resources, including
some human resources, that are not conventionally involved in such care- TBA,
CHW, women’s group for example.
18. Risk strategy
• The risk strategy is expected to have far reaching effects on the whole organization
of MCH/FP services and lead to improvements in both the coverage and quality of
health care, at all levels, particularly at primary health care level.
• In developing local strategies for the delivery of family health care with optimal
coverage, efficiency and efficacy, the concept of risk groups and individuals is a
promising basis for a useful managerial approach.
• Its purpose is to: • Identify the real health needs of the population, define the roles
and functions of the different categories of health personnel, and develop suitable
training programmes. • Obtain a better diagnosis and measurement of human
reproductive casualties in communities where health information is deficient and
provide a mechanism for surveillance of the population “at risk” that will facilitate the
development of realistic standards of care
• Provide anticipatory care to individuals and groups with characteristics indicative of
a special risk to their health welfare or life. • Improve knowledge and develop criteria
 for the allocation of health resources in order to contribute to the rational planning,
organization, administration and evaluation of health services.

19. Interventions to Reduce Maternal Mortality Historical Review

• Traditional birth attendants • Antenatal care • Risk screening Current Approach •
Skilled attendant at delivery The flawed assumption: Most life-threatening obstetric
complications can be predicted or prevented
Traditional Birth Attendants Advantages • Community-based • Sought out by women
• Low tech • Teaches clean delivery Disadvantages • Technical skills limited • May
keep women away from life-saving interventions due to false reassurance

20. Trained Birth attendants Health system improvements:

• Introduction of system of health facilities • Expansion of midwifery skills •
Decreased use of home delivery and delivery by untrained birth attendants • Spread of
family planning “TBAs are useful in the maternal health network, but there will not
be a substantial reduction in maternal mortality by TBAs delivering clinical services
alone.”
21. Antenatal Care • Antenatal care clinics started in US, Australia, Scotland between
1910–1915 • New concept - screening healthy women for signs of disease • By 1930’s
large number (1200) ANC clinics opened in UK • No reduction in maternal mortality
• However, widely used as a maternal mortality reduction strategy in 1980’s and early
1990’s • Antenatal care is important for early detection of problems and birth
preparation
22. Risk Screening Disadvantages • Very-poorly predictive • Costly: Removes woman to
maternity waiting homes • If risk-negative, gives false security • Conclusion: Cannot
identify those at risk of maternal mortality — every pregnancy is at risk
23. Skilled Attendant at Childbirth • Proper training, range of skills • Assess risk factors •
Recognize onset of complications • Observe woman, monitor fetus/infant • Perform
essential basic interventions • Refer mother/baby to higher level of care if
complications arise requiring interventions outside realm of competence • Have
patience and empathy
24. Referral Services • Linking the different levels of care was an essential element of
primary health care (PHC) from the very beginning. • The referral system was meant
to complement the PHC principle of treating patients as close to their homes as
possible at the lowest level of care with the needed expertise (King 1966).
• As emphasised by the (WHO 1994), this back-up function of referral is of particular
importance in pregnancy and childbirth, as a range of potentially life-threatening
complications require management and skills that are only available at higher levels
of care. • The following levels of care have been identified: (1) family/community, (2)
health centre and (3) district hospital (WHO 1996).

25. Continuum of care model • The continuum of care can be defined over the dimension
of time (throughout the lifecycle), and over the dimension of place or level of care. •
The continuum of care over time includes care before pregnancy during pregnancy;
 and through the most vulnerable 5 years of a child’s life. • The continuum of care for
service delivery includes integration of health service delivery, including care
provision taught to families, services provided at the community level, outreach
services, and services at all facilities from sub-health post to referral hospitals.
26. 43. Continuum of care model in india
27. 44. Referral Chain
28. 45. MNCH policies and program in india