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Guideline for High risk pregnancy managementRationale

Chhattisgarh has implemented the maternal death review both; facility based andcommunity based. The data shared from the districts reveals that more than 50 percentof deaths occur during the child birth had one or the other complication during

pregnancy; Eclampsia, severe anemia being the most important causes of maternaldeath in Chhattisgarh. Mobilizing and admitting the women with risk factors in a

functional CEmONC centres well before the EDO is an effective strategy to providequality CEmONC services to such mothers in time. Due to lack of space in DistrictHospitals and Medical College Hospitals all these women could not be admitted for aweeks' time. If such women are identified in time and admitted in 30 Bedded CHCs,proper monitoring of vital parameters can be done effectively.

Identification of High risk pregnancies

During the Ante- Natal Clinics conducted at the facilities SHCs/PHCs/CHCs/DHs High

Risk Pregnancies should be identified early by:

1. Careful History taking2. Auscultation of Cardio- Vascular System and Respiratory System by the

Medical Officer/RMA/ANM3. Systematic Clinical Examination of the Ante-Natal Mother by the

Medical Officer/RMA/ANM4. Compulsory Measurement and documentation of BP by Medical Officer/RMA

/ANM during each ANC visit5. Routine Hemoglobin est imat ion d u r i n g every Ante-Natal visit

(compulsory at 1st Trimester, 2nd & 3rd Trimester & During Labour).

6. Routine monitoring of albuminuria during every visit (including when sheis admitted for delivery)

7. Routine weight monitoring of pregnant for early identification of complications.8. Compulsory abdominal examination of pregnant women by Medical

officer/RMA/ANM for knowing the status of foetus and mother.9. Ultra sound examination of all high risk mothers to know development o f

the baby & congenital anomalies.lO.Ensuring blood group and Rh typing, test for syphilis and voluntary HIV

screening, sickling test.

High Risk Pregnancy - Conditionsa m

It is also to be noted that the following condi t ions requ i re more attention

and are considered as High Risk Pregnancies.

• Pregnancies at extremes of age - <18 years and >35 years of maternal

age (Teenage Pregnancy and elderly gravida)

• Bad Obstetric History (2 or more spontaneous abortions/IUD)

P a si e 1 1 4

• Pregnancy following previous caesarean section (including other scarred

uterus like myomectomy).

• Anemia complicating pregnancy (with/without failure)

• Gestational Diabetes Mellitus

• Pre - Eclampsia/Severe Pre- Eclampsia/Eclampsia

• Grand Multi - Gravida (Gravida Five and above)

• Malpresentations (Breech/Transverse lie)

• Multiple Pregnancy (Twins, Triplets etc)

• Ante-partum Haemorrhage (Placenta Previa, Abrubtio placenta etc)

• Fetus with congenital malformations

• Pregnant woman with infections like Malaria, hepatitis, syphilis, HIV etc.

• Pregnancy following infertility for 3 years or more (whether conceived

following treatment or without treatment).

• Pregnant women with any pelvic/lower limb or skeletal abnormalities leading

on to contracted pelvis like polio, malunion following acc idents or surgery

etc.

• Heart Disease complicating pregnancy (with / without failure)

• Pregnancy following any laparatomy.

• Pregnancy following any vaginal surgery.

• Post- partum Hemorrhage and other Third stage complications like

retained placenta, adherent placenta in the previous pregnancy

• Preterm labour, Premature Rupture of Membranes at term (PROM)

and preterm (PPROM) in the present or previous pregnancy.

• Pregnancy with Sickle cell disease.

• Other Medical complications complicating pregnancy.

All these High Risk pregnancies require constant observation during the Ante- Natal

period especially during the last few weeks of pregnancy

• Pregnancy Induced Hypertension (PIH)with BP 150/100 to 140/90 mm of

Hg

• Moderate anemia at term Hb7.1 to 9gm

• Mothers with heart diseases without fa i lu re

• Previous caesarean section or other surgeries on the uterus like myomectomy

and also with history of laparatomy and vaginal surgery.

• Mothers with CPD/contracted pelvis

• Bad obstetric history (No live child or recurrent abortions)

• Teenage pregnancies «20 years) and elderly primigravida (>35 years)

• Breech (particularly Primi). Transverse lie

• Twins, triplets

• Gestational Diabetes Mellitus (GDM) pregnancy(with diet management/Insulin)

P a g e 2 |4

Ante-Natal mothers with above high risk factors should be admitted in the CMC andthey should be transferred to the appropriate Medical College/DH/CEmONC centerswell before the EDO to plan the strategy for the individual case management and toprovide quality CEmONC services. In case if the mother develops complication duringadmission they should be immediately referred to the MC CEmONC/DH center.

On admission the mother should be examined and individual c a s e sheet shouldbe maintained. During the stay at CMC all the high risk mothers should be observedfor the following vital indicators at the specified periodicity both by the MedicalOfficer and Staff Nurse/ANM.

Vital indicators to be monitored:

Vital/ActivityFH

BP

Urine AlbuminWeightTemperature/Pulse/RespirationKick chart to be maintainedBlood SugarAbdominal girth and Height of uterus

IntervalTwo HourlyFour Hourly forEight hourly for

PIH mothersothers

Twelve HourlyDaily morningEight Hourly9am to 9pmEight Hourlyonce in a week

(PV should not be done unless the mother is in labour)The time of admission of the mother and the period of referral to the higherCentre depends on the High Risk Factor of the individual Ante-Natal mother. A

detailed outline is as follows.Type of Risk Factor - Admission and Referral guideline -

Type of Risk Factor - Admission and Referral guidelines.

s.No.

1

2

3

4

Type of Risks

Pregnancy InducedHypertension (PIH)with BP 150/1 00 to1 40/90 mm of Hg

Moderate anemia atterm Hb 7.1 to 9gm.

Mother with heartdiseases withoutfailure

Previous caesareansection or othersurgeries on the uteruslike myomectomy,laparotomy andvaginal surgery

Admission

No. of Daysbefore EDO

3 weeks

3 weeks

1 month

15 Day's

Place ofAdmission

CHC

CHC

DH

FunctionalCEmONC

Centre

Specific Observation

Blurring of vision/Epigastric Pain/RightHypochondriac painMonitor urine output

Fatigue/Shortness ofbreath/Dizziness

Monitor urine output/early recognition ofsigns of failure pedaloedema/tachycardia

—

Transferred to HigherFunctional Centres

(DH/MC/CEmONC)No. of Daysbefore EDD

1 0 Day's

7 Day's

15 Day's

_-

Place ofTransfer

DH

FRUCHC/CH/

DH

MedicalCollege

—

P a c e 3 1 4

5

6

7

8

9

10

Mother with CPD/Contracted Pelvis

Bad obstetric history(No live Child orrecurrent abortions)Teenage pregnancies(<20 years) andelderly primigravida(>35 years)Breech (particularlyprimi), Transverse lie

Twins, Triplets

GDM pregnancy(with dietmanagement/Insulin)

10 Day's

15 Day's

15 Day's

1 5 Day's

3 weeks

1 month

FunctionalCEmONC

Centre

CMC

—

—

—

"**-~

—

_

•—

—

—

Observe for signsand symptoms ofHypoglycemia —Cold clammy skin,palpitation,sweating, anxiety,hunger,Hyperglycemia-Excessive thirst,frequent urination,dry mouth blurredvision, coma

—

1 0 Day's

7 Day's

7 Day's

15 Day's

1 5 Day's

-.

FRU CMC/DH

FRU CMC/DH

FRU CMC/DH

FRU CHC/DH

DH/MC

Monitoring and Treatment of the High Risk Ante-Natal mother

The following proceeding may be followed with reference to the High Risk Ante-

Natal mother in the CHCs. During the Stay Along with the above monitoring, the

treatment appropriate to the High Risk Condition prescribed to the mother should

be given. Case - sheet should be maintained for all the High Risk Ante-Natal

mothers admitted. Charts to be maintained & is attached with the case sheet. Diet

should be provided to the Ante-Natal mother along with the attender at

Rs.l 60/day/person. as per treating doctors advice. When referring the mother to

the higher Centre (as per the Guidelines) or due to labour pains, the High Risk

Ante-Natal mother should be referred to higher Centre being accompanied by a

ANM. While providing diet to the Ante-Natal mother, diet pertaining to the High

Risk Condition to be followed. (Eg-GDM).

• During Ante-Natal clinic awareness should be created among the Ante-Natal

mothers regarding the facilities provided in the CHC for admission of the

High Risk Ante-Natal mothers and one attendant.

• Mitanin/ANM should motivate the HR mothers to get admitted in the CHC.

• Counselling of the High Risk Ante-Natal mother with family by the Medical

Officer to motivate them to get admitted in the f a c i l i t i e s with birth waiting

home.

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