This document discusses high risk approaches in maternal and child health. It defines high risk pregnancies and cases according to the WHO. It describes screening high risk cases and managing them, including proper antenatal, intranatal and neonatal care. It discusses interventions to reduce maternal mortality such as skilled birth attendants. It also discusses referral systems and maternal, newborn and child health policies and programs in Nepal.

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: