High Risk Pregnancy Operation Guidelines (Ministry of Health & Family Welfare, Chhattisgarh & India & UNICEF)

1. Training of Master Trainers
November 2021

2. High Risk Pregnancy
• Definition: HRP is a pregnancy complicated by a disease or disorder that
may endanger the life, or affect the health of the mother, the fetus or
newborn.
• Prologue:
Receiving quality antenatal, intra natal & postnatal services is one of the
reproductive rights of a woman.
Each and every one working in the health department is committed to
reduce the maternal mortality and to realize the reproductive rights of a
women

3. Objective & Guiding Principle
• Prevention of High-Risk Pregnancies
• Early detection of HRP and initiation of treatment
• Tracking of HRP throughout the pregnancy
• Ensuring institutional delivery at higher level facility
• Functional referral linkages

4. Strategy
HRP
Strategy
Prevention
of HRP
Early and
correct
detection
of high risk
Tracking ,
follow up
and review
Manageme
nt of HRP
Preconception care: All
eligible couples
Quality ANC: Early registration and
quality ANC services to all pregnant
woman – Strengthening VHSND
Governance, monitoring, SS :
State/District/Block/Sector/PRI and
others – ANMOL for tracking
Skills and Capacity building

5. 1. Prevention of HRP (Preconception care)
• Eligible couple: currently married couple wherein the wife is in the
reproductive age (i.e. 15 - 49 years of age) aspiring to have a healthy child.
• Achieving normal BMI prior to conception
• Preventing and treating anaemia with iron and deworming tablet
• Periconceptional folic acid and to reduce neural tube defects
• Detecting Sickle cell disease and malaria
• Quitting tobacco, alcohol to reduce LBW and other complications
• Preventing pregnancy in adolescent girls and ensuring optimal inter-pregnancy
interval following miscarriage or childbirth
• Detecting and treating RTI/STIs before pregnancy following syndromic case
management
• Detecting and managing chronic diseases before pregnancy – diabetes, hypertension
etc
• All eligible couples will be screened during annual eligible couple survey
and counselling
• Once annual screening is well established, preconception care to be
integrated with VHSND services

6. 2. Early and correct detection of high risk (Quality ANC)
• Strengthening of VHSNDs for providing quality ANC is essential for
quality ANC
• Microplanning of VHSNDs to ensure no area is left out
• Availability of ANMs and trained to detect HRPs and manage HRP
• Availability of all equipment and logistics including examination table at all
VHSNDs
• Counselling of pregnant woman on the high risk detected, precautions to be
taken and birth preparedness for safe delivery

7. Protocols for HRPs
1. ANC protocol
2. Hypertensive disorders of pregnancy – PIH, Eclampsia
3. Anemia
4. APH
5. Breech presentation
6. Malaria
7. H/O previous LSCS
8. Sickle cell anemia
9. Gestational Diabetes

8. 3. Tracking, follow up and review (Governance,
monitoring, Supportive supervision)
• A nodal person for HRP for implementation to be identified in every block
• Sector MO will be overall responsible for HRP implementation
• Roles of responsibility of Mitanin, ANM, PHC, FRU, District level and State level will be
defined for tracking, follow and review at various levels
• System supervisors will visit frequently as per approved supportive supervision plan to
monitor VHSNDs and quality of intrapartum care at delivery points/FRUs
• All high-risk pregnant mother will be tracked for admissions in FRU/DH/MCs in advance
before the EDD
• ANMOL and RCH portal date will be analysed to generate list of identified HRPs and used
for tracking of all HRPs
• Analysis of RCH portal data to identify SHCs with less than 7% of HRP detected and
reviewed every month by MO-PHC and BMO
• Analysis of RCH portal data to identify sectors with less than 7% of HRP detected and
reviewed every month by BMO at block level and CMHO at district level

9. Supportive supervision framework
• Analyse and review poor
performing SHCs .
• 3 officials in each block visit
VHSND once every week
•Analyse and review poor performing SHCs
and resistant pockets
•Sector MO/MTs/Sector supervisors must be
in field during VHSND days
• Block nodal for each block
• Analyse and supervise poor
performing sectors
• Identification of poor performing
blocks / facilities as per data from
RCH portal.
• Block nodal officer - 2 visits to
VHSND in 2 different sector, 1
block review meeting/month
• RCH nodal and RMNCHA
consultant – 1 VHSND visit every
week in different blocks, one
block meeting every month
• District nodal for each district
• Analyse and supervise poor
performing blocks
• District Nodal officer – 1 visit to
VHSND, I district review
State
Level
District
Block
Sector

10. 4. Management of HRP (Skills and Capacity building)
• Well defined treatment protocols for health care workers and specialists
• Ensuring minimum of 1 ANC and 1 USG under guidance of specialist of all
HRPs, through PMSMA or teleconsultation
• No HRP delivery will be conducted in SHC/HWC
• Clinical helpline to be established for ANMs, staff nurses and MOs for technical
guidance
• Training of block level master trainers for HRP/District master trainers can train
the entire district
• Modular incremental learning approach to train ANMs/SNs during sector level
meetings
• SBA/BEmOC/CEmOC/LSAS – training, refresher training
• Training of supervisors – for Supportive supervision

11. Implementation
• District RMNCHA Consultant overall responsibility – under the guidance
of RCH Nodal and CMHO
• The ANM must ensure availability of diagnostic test kits, drugs &
consumables as per micro plan for VHSND, outreach & fixed day services
- CMHO responsible for procurement and supply
• LMP register should be maintained by all Mitanin – visit eligible couples
before VHSND day for early history of missed period and ensuring early
ANC
• Eligible couple register – with ANM, line list with mitanin – all eligible
couples to be mobilized to VHSND
• Due list before every VHSND – with Mitanin and ANM
• ANC every month for all pregnant woman

12. Implementation
• Ensure regular and timely entry of data – ANMOL/RCH Portal - ANM and
BDM
• Line listing of HRP to be maintained by, Mitanin, ANM and PHC MO
• EDD calendar – of all pregnancies in the coming month for institutional
deliveries, of HRPs for delivery at FRUs – update every week – ANM, PHC
MO
• PMSMA –
• all pregnant woman for USG at PMSMA,
• all HRPs for every ANC
• use JSSK for free services during ANC

13. Roles and responsibilities within a sector
Mitanin
LMP Register
House visit of eligible couples
– day before VHNSD
Mobilize PW to VHSND as per
due list
Escort HRP to PMSMA
Escort HRP to Birth waiting
homes at FRU prior to EDD
ANM
VHSND Micro plan
Conduct VHSND
Identification of HRP
Due list
EDD list
Counselling of danger signs
MO-PHC
Leadership
PHC VHSND microplan
SC wise review of HRP
SS visits mandatory
Arrange referral during ANC
and for delivery

14. Supportive Health Systems
• Functional referral linkages – each HRP will be linked to nearest FRU
irrespective of inter district or interstate border
• Birth waiting homes at delivery points – priority at FRUs/DHs for HRPs
• Maternal Death Surveillance and response to review every maternal
death

15. Referral mechanism
• Review the existing ambulances based on time to care approach
• 108/102 and ambulances of health facilities – optimally used
• JDS and JSSK funds – reimbursement of cost if 102/108 not available based on
approved rate/km
• Private vehicles can be empaneled for referral – JSSK/JDS funds
• Referral slip with treatment details before referral of all referrals from any HF
• I/C of HF responsible to ensure availability of staff at referral facility before
referral
• The HF receiving referral should inform the facility from where PW had referred
after discharge/outcome
• The higher facility should do referral audit of lower facilities and report every
month

16. Use of technology
• 104 helpline may be used for tele counselling of HRP’s in order to
ensure at least 8 ANC services to each HRP.
• 104 will also ensure post referral follow-up of HRP cases from
PMSMA .
• Call center for continued support – The districts may plan to
establish a centralized call center at district headquarter manned by
ANM or SN . The responsibility of the call center will be to do follow
up on HRP’s in terms of their condition & guide them on importance
of further checkups .
• The call center will also provide details of nearest referral point to the
beneficiaries if need be.
• WhatsApp groups to be created at district/Block, & below the block
level at facilities for prompt communications.

17. • HRP treatment protocols
• VHSND – SS tool
• HRP monitoring checklist
• At SHC
• At Sector
• At PHC
• At Block
• At District/State
Tools to be made available for HRP

19. Thank You