MATERNAL AND CHILD HEALTH NURSING Obstetrical History

Care of At-Risk / High Risk and Sick Mother and Child 1. Infertility

Pregnancy - is a time of many physiologic and psychological changes that can 2. Cervical insufficiency or incompetent cervix
positively or negatively affect the woman, her fetus, and her family. 3. Uterine or cervical anomaly
The ultimate goal of any pregnancy is the birth of a healthy newborn, and nurses 4. Previous preterm labor/birth
play a major role in helping the pregnant woman and her partner achieve this goal.
Ongoing assessment and education are essential. 5. Previous cesarean birth

High-risk Pregnancy - Is one which a concurrent disorder, pregnancy –related 6. Previous gestational hypertension
complication or external factor jeopardizes the health of the woman, fetus or both. 7. Previous infant over 4000g
o Majority of the high-risk pregnancies are identified during the first prenatal 8. 2 or more spontaneous or elective abortions
visit through careful history taking, complete physical examination, and
laboratory studies. 9. Previous ectopic pregnancy
10. Previous stillbirth/neonatal death
11. Previous multiple gestation
12. Pregnancy spaced less than one year apart do not give the woman’s body
time to recover.

Medical History
• Pre-existing medical conditions can predispose a pregnant woman to have
complications.
• There is an increased risk of gestational hypertension associated with chronic
hypertension, diabetes mellitus and renal or vascular disease.
• Sexually transmitted infections

High Risk Pregnancy • Infection during pregnancy can increase the risk of congenital anomalies,
may require a cesarean delivery and can increase the risk for preterm labor.
Areas to be assessed for high-risk factors include obstetrical history, medical history,
current obstetric status and social-personal characteristics. • A history of depression or bipolar disorder is a risk factor for postpartum
depression.
• Previous surgery of the reproductive organs can affect fertility, the ability to is more prone to anxiety, depression, alcohol or drug use, and is more likely
carry a pregnancy to term and method of delivery. to have inadequate prenatal care.

Social-Personal Characteristics Current Obstetrical Status

• Inadequate Prenatal Care- is care begun after the first trimester or • A total weight gain of 10 pounds or a weight loss of more than 5 pounds has
inconsistent attendance at appointments. This contributes to late recognition serious implications for fetal growth and indicates the need for dietary
of problems. intervention.
• Maternal age less than 16 increase the risk for premature labor, cesarean • Excessive weight gain can result from edema associated with gestational
delivery and IUGR (Intra-uterine growth restriction). hypertension or caloric intake above the recommended amount.
• The adolescent woman is also more likely to have less education and income. • Indications for IUGR should be evaluated for limited circulation to the
placenta.
• Maternal age over 35, there is an increase likelihood of chronic disease and
an increase risk of congenital or chromosomal abnormalities, PIH (pregnancy- • A fetus that is large for gestational age is often associated with gestational
induced hypertension), premature and cesarean delivery. diabetes and increases maternal risk for instrument–assisted birth or
cesarean delivery and fetal risk for birth injury.
• Primagravidas have an increased risk of PIH, prolonged labor and cesarean
delivery. • When fetal surveillances tests are abnormal, additional assessments for
chromosomal abnormalities, congenital defects and placental functioning are
• A history of multiparity greater than 3 and increases the risk for antepartum
performed at the physician’s direction
or postpartum hemorrhage.
• An abnormal fetal presentation such as breech or transverse lie requires a
• Socio-economic factors such as low education, low income, being unmarried
cesarean delivery.
and being nonwhite are associated with increase incidence of gestational
hypertension, inadequate prenatal care, preterm birth and Intra Uterine • Hydramnios or increased amount of amniotic fluid is associated with certain
Growth Retardation. conditions such as Rh sensitization, diabetes and fetal neurological or
gastrointestinal defects
• Being underweight at conception increases the risk of anemia, prolonged
labor, and IUGR; being overweight at conception increases the risk for • Oligohydramnios or a diminished amount of fluid is found with post maturity,
gestational hypertension, diabetes, cesarean delivery and macrosomia. IUGR and fetal abnormalities.
• Smoking contributes to IUGR and preterm labor or birth. • Maternal anemia can be an indication of inadequate iron intake or of a
hemoglobinopathy such as sickle cell anemia.
• Drug addiction or alcohol abuse increases the risk of preterm labor, IUGR,
inadequate maternal nutrition and abnormal fetal development. • Obstetrical complications during a pregnancy place the woman at significant
risk.
• Family violence leading to physical abuse increases the rate of spontaneous
abortion, preterm birth and stillbirths. The women who experiences violence
• Vomiting associated with hyperemesis gravidarum has an impact on • History of poor coping mechanisms
nutritional status.
• Cognitively challenged
• Gestational hypertension results in constriction of maternal blood vessels
• Survivor of childhood sexual abuse
that can cause decreased placental perfusion. Leading to low birth weight
and fetal distress. Social Factors
• Maternal risks from gestational hypertension include cerebral, renal, • Occupation involving handling of toxic, substances ( including radiation and
cardiovascular or hepatic problems anesthesia gases)
• Placental problems such as previa or abruption can interfere with circulation • Environmental contaminants at home
to the fetus, lead to maternal hemorrhage and require cesarean delivery.
• Isolated
• Rh sensitization causes destruction of fetal red blood cells that can lead to
• Lower economic level
fetal or neonatal complications.
• Poor access to transportation for care
• Preterm labor affects maternal physical and emotional well-being, and if it
progresses to preterm labor are premature rupture of membranes, multiple • High altitude
gestation and maternal infections.
• Highly mobile lifestyle
• Postdate pregnancy, a pregnancy continuing more than 2 weeks after due
• Poor housing
date can lead to complications in the fetus or newborn.
• Lack of support people
FACTORS THAT CATEGORIZES A PREGNANCY AS HIGH RISK
Physical Factors
• Psychological
• Visual or hearing challenges
• Social
• Pelvic inadequacy or misshape
• Physical
• Uterine incompetency, position or structure
Pre-pregnancy
• Secondary major illness (heart disease, diabetes mellitus, kidney disease,
Psychological Factors hypertension. Chronic infection such as tuberculosis, hemopoietic or blood
• History of drug dependence ( including alcohol) disorder, malignancy)

• History of intimate partner abuse • Poor gynecologic or obstetric history

• History of mental illness • History of previous poor pregnancy outcome ( miscarriage, stillbirth,
intrauterine fetal death)
• History of child with congenital anomalies Physical Factors
• Obesity ( BMI >30) • Subject to trauma
• Underweight ( BMI <18.5) • Fluid or electrolyte imbalance
• Pelvic inflammatory disease • Intake of teratogen such as a drug
• History of inherited disorder • Multiple gestation
• Small stature • A bleeding disruption
• Potential of blood incompatibility • Poor placental formation or position
• Younger than age 18 years or older than 35 years • Gestational diabetes
• Cigarette smoker • Nutritional deficiency of iron, folic acid, or protein
• Substance abuser • Poor weight gain

During Pregnancy • Pregnancy-induced hypertension

Psychological Factors • Infection

• Loss of support person • Amniotic fluid abnormality

• Illness of a family member • Post maturity

• Decrease in self esteem Labor and Birth

• Drug abuse ( including alcohol and cigarette smoking) Psychological Factors
• Poor acceptance of pregnancy • Severely frightened by labor and birth experience
Social Factors • Inability to participate because of anesthesia
• Refusal of or neglected prenatal care • Separation of infant at birth
• Exposure to environmental teratogens • Lack of separation for labor
• Disruptive family incident • Birth of infant who is disappointing in some way ( such as sex, appearance, or
congenital anomalies)
• Conception less than 1 year after last pregnancy
• Illness in newborn
Social Factors Prevention Before Pregnancy
• Lack of support person o Taking the time to treat or manage them before conceiving is the best way to
significantly reduce the risk of complications.
• Inadequate home for infant care
During Pregnancy
• Unplanned cesarean birth
Some of the best ways to stay healthy during pregnancy can include the following:
• Lack of access to continued health care
• Taking prenatal vitamins as soon as confirmed pregnancy.
• Lack of access to emergency personnel or equipment
• Undergoing regular doctor's check-ups and recommended prenatal testing
Physical Factors
• Maintaining a balanced and nutritious pregnancy diet
• Hemorrhage
• Keeping up with moderate-level pregnancy exercise (Doctor's approval
• Infection
needed)
• Fluid and electrolyte imbalance
• Ensuring a safe and healthy pregnancy weight gain
VULNERABLE GROUPS OF PREGNANT WOMEN: • Practicing various techniques for stress reduction during pregnant.
• Adolescent • Quitting addictions to alcohol, tobacco, and illicit drugs
• Mentally ill
Management of High-Risk Pregnancy
• 18 y/o and below
• More frequent prenatal visits and specialist consultations are a must in high-
• Women over 40 y/o risk pregnancies in order to closely monitor maternal health and fetal
development.
• Physically and cognitively challenge
• Additional or specialized prenatal testing might include laboratory work and
• Woman who is a substance dependent
diagnostic tests, like amniocentesis, biophysical profile, and others.
Prevention of High-Risk Pregnancy • Bed rest or hospitalization might be necessary to help a woman safely carry
It is not always possible to prevent complications that make a pregnancy her baby to term.
high-risk, there are several ways before and during pregnancy to ensure • Medications or surgery can be used to treat the underlying problem and
maternal and fetal safety and well-being. stop its progression.
s • A premature delivery might sometimes be the safest way to manage a high-
risk pregnancy and prevent further life-threatening complications.
IDENTIFYING AND/OR MONITORING HIGH RISK PREGNANCY
Prenatal Testing
• Prenatal testing can provide valuable information about the baby's health. Types of Prenatal Testing
• Understand the risks and benefits, and how prenatal testing might affect Prenatal testing includes both screening tests and diagnostic tests.
prenatal care.
• Screening tests
• Prenatal screening tests can identify whether the baby is more likely
to have certain conditions
• Usually, can't make a definitive diagnosis
• Screening tests pose no risks for mother or baby
• Diagnostic tests
• A more invasive prenatal diagnostic test
When are prenatal screening tests done? • The only way to be sure of a diagnosis
• First trimester screening tests can begin as early as 10 weeks. • Some tests carry a slight risk of miscarriage
• These usually involve blood tests and an ultrasound. hCG (Human chorionic gonadotropin)
• They test your baby’s overall development and check to see if your baby is at • Why is this test given?:
risk for genetic conditions, such as Down syndrome. 
• Confirms pregnancy.
• They also check your baby for heart abnormalities, cystic fibrosis, and other
developmental concerns. • Detects some birth defects

• This is all pretty heavy. But what’s much more exciting to many people is that • A blood test
these super early screening tests can also determine your baby’s sex. Note: Human chorionic gonadotropin (hCG) is a hormone that is produced by the
placenta after a woman becomes pregnant.
AFP (Alpha Fetoprotein)
• Why is this test given?:
• May indicate an increased risk for fetal neural tube defects
• Spina bifida
• a deformity of the spinal column
• Anencephaly
• the absence of all or part of the brain
• Down syndrome
• A blood test
• Note: AFP, hCG, and estriol are tested together and are referred to as a triple • Accuracy:
screen. The quad screen refers to a test that measures AFP, hCG, and estriol
• Depends on clarity of image
but adds inhibin to improve its accuracy.
• Technicians' ability to read image
• Risk:
• none
• High-frequency sound wave testing
• Discerns multiple pregnancy, placental location and gestational age by
measurement of bi-parietal diameters
• visualization during first 20 weeks of gestation is improved if the
bladder is full; a full bladder is not necessary after 20 weeks’ gestation
• a level II sonogram may be performed to assess formation of organs

Nursing Considerations
• Encourage fluid and refrain from voiding before the test

ULTRASONOGRAPHY
o 4D Ultrasound
o Biparietal Diameter
o Doppler Umbilical Velocimetry
o Placental Grading
o Amniotic Fluid Volume Assessment

Ultrasound
• Why is this test given?:
• Detect abnormalities in the baby.
• Can sometimes determine the baby's gender
• Uses sound waves to make an image of the baby.
• An underlying medical condition, such as type 1 diabetes, heart disease or
high blood pressure during pregnancy
• A pregnancy that has extended two weeks past your due date (post-term
pregnancy)
• A history of complications in a previous pregnancy
• A baby who has decreased fetal movements or possible fetal growth
problems
• Rh (rhesus) sensitization — a potentially serious condition that can occur,
typically during a second or subsequent pregnancy, when your red cell
antigen blood group is Rh negative and your baby's blood group is Rh
positive.
• Low amniotic fluid (oligohydramnios)

NONSTRESS TEST Procedure:

• is used to evaluate a baby's health before birth. Before the procedure

• The goal of a nonstress test is to provide useful information about your • Blood pressure taken before the nonstress test begins.
baby's oxygen supply by checking his or her heart rate and how it responds
• Assessment of
to your baby's movement.
• The test might indicate the need for further monitoring, testing or delivery.
• Recommended when it's believed that the baby is at an increased risk of
death.
• A nonstress test may be done after 26 to 28 weeks of pregnancy.
• Certain nonstress test results might indicate that you and your baby need
further monitoring, testing or special care.
Indication for Nonstress Test
• A multiple pregnancy with certain complications
variability are present
During the procedure
• During the nonstress test, patient will sit on a reclining chair. Blood pressure
taken at regular intervals during the test.
• A sensor will be place around the abdomen that measures the fetal heart
rate.
• Typically, a nonstress test lasts 20 minutes. However, if the baby is inactive
or asleep, you might need to extend the test for another 20 minutes — with
the expectation that the baby will become active — to ensure accurate
results. The baby will be stimulated by placing a noise-making device on your
abdomen.
After the Procedure Results Of A Nonstress Test Are Considered:
• Blood pressure taken after the nonstress test.  Reactive. 
• Notify the patient the procedure is done. • Before week 32 of pregnancy, results are considered normal
(reactive) if the baby's heartbeat accelerates to a certain level above
the baseline twice or more for at least 10 seconds each within a 20-
minute window.
• At week 32 of pregnancy or later, if the baby's heartbeat accelerates
to a certain level above the baseline twice or more for at least 15
seconds each within a 20-minute window, the results are considered
reactive.

 Nonreactive. 
• If the baby's heartbeat doesn't meet the criteria described above, the
results are considered nonreactive. Nonreactive results might occur
because your baby was inactive or asleep during the test.

Nursing considerations:
• Fasting is not necessary
• Observe the fetal monitor
• Explain test to decreased anxiety • For eight hours before the test, patient won’t be able to eat or drink
anything. Fasting overnight and schedule the test for early the following
• Evaluate response to procedure
morning.
Glucose Screening During the procedure
• Why is this test given: • The glucose tolerance test is done in several steps. Sample of blood will be
• To determine if the mother is developing gestational diabetes taken. This blood sample will be used to measure the fasting blood glucose
level.
• Occurs in 3%-5% of pregnant women
After the procedure
• A blood test
• After the glucose tolerance test, patient can return to usual activities
o Lack of insulin or insulin resistance causes higher than normal levels of glucose in immediately.
the blood.
o Under normal circumstances, the body will be able to maintain the ideal balance
of blood glucose. However, if any parts of the system are impaired, glucose can
rapidly accumulate, leading to high blood sugar (hyperglycemia) and diabetes.
Pregnancy Recommendations 
• The American College of Obstetricians and Gynecologists (ACOG)
recommends the routine screening for gestational diabetes in all pregnant
women between 24 and 28 weeks of gestation.
For the Three-Hour Test:
• The OGTT is a highly sensitive test that can detect imbalances that other tests
miss. • A normal fasting blood glucose level is lower than 95 mg/dL (5.3 mmol/L).

• Its ability to detect early impairment means that people with prediabetes can • One hour after drinking the glucose solution, a normal blood glucose level is
often treat their condition with diet and exercise rather than drugs. lower than 180 mg/dL (10 mmol/L).

Procedure • Two hours after drinking the glucose solution, a normal blood glucose level is
lower than 155 mg/dL (8.6 mmol/L).
• Note: It's important to eat and drink normally in the days leading up to the
glucose tolerance test. Let your doctor know if you're ill or taking any • Three hours after drinking the glucose solution, a normal blood glucose level
medications, as these factors can affect the results of your test. is lower than 140 mg/dL (7.8 mmol/L).

Before the procedure Amniocentesis

• Why is this test given:
• To detect genetic or chromosomal disorders • Needle injury. During amniocentesis, the baby might move an arm or leg into
the path of the needle. Serious needle injuries are rare, however.
• over age 35 or high risk
• Rh sensitization. Rarely, amniocentesis might cause the baby's blood cells to
• Removes a small sample of amniotic fluid for analysis
enter the mother's bloodstream. If you have Rh negative blood and you
• Accuracy: 98-99% haven't developed antibodies to Rh positive blood, you'll be given an
injection of a blood product called Rh immune globulin after amniocentesis.
• Risk:
This will prevent your body from producing Rh antibodies that can cross the
• 1/200 women who have this procedure miscarry placenta and damage your baby's red blood cells. A blood test can detect if
you've begun to produce antibodies.
• aspiration of amniotic fluid used to detect sex, chromosomal or biochemical
defects, fetal age, L/S ratio (2/1 ratio indicates lung maturity), increased • Infection. Very rarely, amniocentesis might trigger a uterine infection.
bilirubin level associated with Rh disease, and phosphatidylglycerol (PG),
• Infection transmission. If you have an infection — such as hepatitis C,
which appears in amniotic fluid after thirty-fifth week, indicating fetal lung
toxoplasmosis or HIV/AIDS — the infection might be transferred to your baby
maturity.
during amniocentesis.
• Test done with sonogram; usually after 12 to 15 weeks of gestation
Results
Complications associated with amniocentesis include the following:
• If the results of the amniocentesis are normal, the baby most likely doesn’t
• cramps  have genetic or chromosomal abnormalities. 

• a small amount of vaginal bleeding • In the case of maturity amniocentesis, normal test results will assure you that
the baby is ready to be born with a high likelihood for survival.
• amniotic fluid that leaks out of the body (this is rare)
•
• uterine infection (also rare)
Abnormal
Amniocentesis Carries Various Risks, including: results
may
• Leaking amniotic fluid. Rarely, amniotic fluid leaks through the vagina after mean
amniocentesis. However, in most cases the amount of fluid lost is small and
stops within one week, and the pregnancy is likely to continue normally.
• Miscarriage. Second-trimester amniocentesis carries a slight risk of
miscarriage — about 0.1 to 0.3 percent. Research suggests that the risk of
pregnancy loss is higher for amniocentesis done before 15 weeks of
pregnancy.
there’s a genetic problem or chromosomal abnormality. But that doesn’t
mean it’s absolute. Additional diagnostic tests can be done to get more
Nursing considerations:
information. 
• Provide emotional support
Nursing considerations:
• Evaluate response to procedure
• Have client void
• After test monitor for uterine contractions, vaginal discharge CVS (Chorionic Villi Sampling)

• Teach to observe for signs of infection • Why is this test given?

• Encourage rest • To detect birth defects in the baby.

• Can be done earlier in pregnancy than amniocentesis

Biophysical Profile (BPP)

• assess breathing movements, body movements, tone, amniotic fluid volume
and FHR reactivity (NST) • Or when amniocentesis is not possible

• a score of 2 is assigned to each finding, with a score of 8 to 10 indicating a

healthy fetus
1. Used for fetus that may have intrauterine compromise
• Such as when there is not enough amniotic fluid
• Removes a small sample of the placenta
• Accuracy: 98-99%
• Risk: 1/100 women who have this procedure miscarry
• supplies some data as amniocentesis but can be done after 10 weeks
• Aspiration of villi done during the eighth to twelfth week of pregnancy

Nursing Considerations:
• Instruct to drink fluid so that bladder is full
• After test, monitor for uterine contractions, vaginal discharge and teach to
observe for signs of infection