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High risk approach in maternal and child health

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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.The risk factors may be pre-existing prior …

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.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.

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  • 1. High Risk Approach in Maternal and Child Health Shrooti Shah M.Sc. Nursing Batch 2011 College of Nursing BPKIHS
  • 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.
  • 6. Introduction • 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.
  • 7. 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.
  • 8. 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
  • 9. History cont… • Psychiatric illness • Cardiac disease • Epilepsy • Viral hepatitis • Previous operations • Myomectomy • Repair of complete perineal tear • Repair of vesico-vaginal fistula • Repair of stress incontinence
  • 10. Family history • Socio-economic status • Family history of diabetes, hypertension or multiple pregnancy (maternal side), congenital malformation.
  • 11. 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
  • 12. During pregnancy cont… • 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.
  • 13. During labour • PROM • Prolonged labour • Hand, feet or cord prolapse • Placenta retained more than half an hour • PPH • Puerperal fever and sepsis.
  • 14. Examination 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
  • 15. 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.
  • 16. 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
  • 17. Complications… 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
  • 18. 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.
  • 19. 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
  • 20. 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.
  • 21. Management of high risk cases cont… • 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.
  • 22. Management cont.. • 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.
  • 23. Management cont… • 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.
  • 24. Management cont… • 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.
  • 25. Management cont… • 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.
  • 26. 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.
  • 27. 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
  • 28. Organizational aspect cont… • 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.
  • 29. 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.
  • 30. 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.
  • 31. Risk approach cont.. • 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
  • 32. Risk approach cont… • 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.
  • 33. 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
  • 34. 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
  • 35. 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.”
  • 36. 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
  • 37. 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
  • 38. 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
  • 39. Skilled Attendant at Childbirth: Proven effective • Malaysia: basic maternity services 320 to 157 • Cuba: national priority 118 to 31 • China: facility based childbirth 1500 to 50 “Skilled attendant at childbirth is the most effective intervention”
  • 40. 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).
  • 41. Referral services • 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).
  • 42. 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.
  • 43. Continuum of care model in Nepal • In Nepal, the level of care exists at five tiers 1) at household level 2) at community level 3) at village level 4) at first level referral (sub-district or Ilaka) 5) at second level referral district hospital
  • 44. Referral Chain
  • 45. MNCH policies and program in Nepal • The NHSP-II 2010-2015 which follows on Health Sector Strategy-Agenda for Reform and NHSP Implementation Plan I 2004-2009 provides guidance for “more focus on a community-based programs and strengthening of referral sites, integrating newborn interventions with child health and maternal health programs; strengthening the district management capacity for effective implementation of packages and engaging the private sector for more holistic programming”.
  • 46. MNCH policies cont… • The National Safe Motherhood and Neonatal Long Term Plan 2006-2017 plans to strengthen and expand delivery by skilled birth attendant, basic and comprehensive obstetric care services (including family planning) at all levels through development of infrastructure, protocols, strengthening human resource capacity and referral management system from communities to district hospitals for obstetric emergencies and high-risk pregnancies
  • 47. The policies, plans and strategies call for an approach including a continuum of care from mother to newborn to children and from household to hospital. However, no clear direction has been given on how such a continuum of care model would be implemented within the existing health system.
  • 48. Health Systems to deliver the MNCH program • The MOHP defines the sector wide policy and programs while the FHD and CHD are the technical leads in the DOHS responsible for delivering maternal, newborn and child health and nutrition services. • The piloting, implementation, and scaling up of these programs throughout the country are planned and resourced through these divisions. • The Family Health Division is responsible for reproductive health program-adolescent, maternal and newborn health program,
  • 49. Health systems cont… • The CHD is responsible for child health program-EPI, CB-IMCI Package, CB-NCP and Nutrition programs . • The district public health office is responsible for implementation at the district level. This includes planning, implementation, managing commodities, and providing financing for implementation of programs at district level and below. • Furthermore, the district hospital links both to higher referral-level health facilities within the national health system, and with primary health care centers and peripheral health facilities under the district system.
  • 50. References 1. Park K. preventive and social medicine. Seventeenth edition. Banarsidas Bhanot Publishers; Premnagar: 2002 2. State of Maternal, Newborn and Child Health Programmes in Nepal: What May a Continuum of Care Model Mean for More Effective and Efficient Service Delivery? KC A, Bhandari A, Pradhan YV, KC NP, Upreti SR Thapa K, Sharma G, Upreti S, Aryal DR,6 Dhakhwa JR, Pun A. J Nepal Health Res Counc 2011 Oct;9(19):92-100 3. Referral in pregnancy and childbirth: concepts and strategies. Albrecht Jahn and Vincent De Brouwere 4. Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al (eds). Blackwell Science Limited: London. 5. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: