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>- 6 \J /2015
:-High Risk R|-£|"ctH
19 ^cf 20 2015
^THlftd
if
frTaft
-0-
^ AHS 2012 244 t (5ffct
642 22.9%
ANC
2014-1519.6% ^ y^Tcf ef> ?H cTSTT 57.5% ̂ PNC
<J>H?I: PPH, Hypertensive Disorders, Obstructed labour, Sepsis, Severe
anaema
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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
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