High-Risk Pregnancy: Assessment & Interventions

• Perinatal nurses require a strong understanding of pregnancy physiology, the impact of complications, and current interventions due to the unpredictable nature of perinatal nursing and potential for rapid deterioration of maternal and fetal health.
• Nurses play a collaborative role in caring for women with pregnancy complications, advocating for them and their families.
• Pregnancy complications can increase future health risks for both women and their children.
• Assessments, rapid interventions, and collaborative approaches are essential for optimizing health outcomes.

Risk Assessment

• A high-risk pregnancy poses a greater risk to the mother or fetus compared to uncomplicated pregnancies.
• Risk assessment tools help identify women at risk for complications but don't establish cause-and-effect relationships.
• Racial and ethnic disparities exist in adverse obstetric outcomes.
• Social determinants of health (SDOH) significantly impact health outcomes, influenced by historical, social, political, and economic factors.

Birth Equity

• Birth equity advocates seek to address structural racism and social determinants to improve maternal and infant health.
• Social and structural factors, rather than solely behavioral causes, contribute to disparities in birth outcomes.
• America’s health environment affects Black children negatively from the earliest stages of life.
• Toxic stress, caused by chronic adversity, contributes to higher rates of premature birth in the Black community.
• Preventive and supportive group prenatal care can reduce PTB among Black women.

Common Risk Factors

• Existing health conditions like high blood pressure, diabetes, or HIV increase risk.
• A history of prior pregnancy complications, complications that arise during pregnancy, being overweight or obese, carrying multiple fetuses (twins and higher-order multiples), or being younger than 18 or older than 35 increase risk.
• Advanced maternal age increases risk due to pre-existing health problems.
• The accumulation of environmental exposures, starting in utero, may determine differential risks across the life course, placing women at risk of adverse pregnancy outcomes and affecting the infant's health throughout life.

Nursing Activities to Promote Adaptation to Pregnancy Complications

• Assessment of the emotional status and coping mechanisms of the entire family is essential for providing comprehensive care.
• Responses to high-risk pregnancy can include stress & anxiety, threats to self-esteem, disappointment & frustration, conflict and crisis.
• General nursing actions include:
• Providing time for the woman and family to express their concerns and feelings.
• Provide information repeatedly with the patient and significant other(s) to facilitate a realistic appraisal of events.
• Facilitate referrals related to the condition.
• Encourage the woman and her family to participate in decision making.
• Be a skilled communicator.
• Nurses play a role in improving access to care for all women, regardless of race, socioeconomic status, or environment.
• Nurses should be aware of barriers to health-care access and strive to reduce disparities through advocacy work.
• Nurses can provide support, information, and referrals to women from underserved communities.

Preterm Labor and Birth

• Preterm labor (PTL)is regular contractions causing cervical changes before 37 weeks of gestation while preterm birth (PTB) is birth between 20 0/7 and 37 0/7 weeks of gestation.
• The U.S. PTB rate rose to 10.02% in 2018, and rates remain significantly higher among Black women.
• The PTB are attributed to leading hypothesis relates to underlying social and economic inequalities.
• PTB is the leading cause of neonatal mortality and antenatal hospitalization.
• Financial burdens and substantial family changes occurs after the birth of a preterm infant.

Identifying women who will give birth preterm

• Identifying women who will give birth preterm is an inexact science.
• Causes of PTL may include individual behavioral and psychosocial factors, neighborhood characteristics, environmental exposures, medical conditions, and genetics.
• Three-quarters of all PTBs occur spontaneously and the remainder are a result of medical intervention.

There are three main situations in which PTL and premature birth may occur

• Spontaneous PTL and birth is unintentional delivery before the 37th week triggered by unknown events which may include decidual hemorrhage (abruption), mechanical factors such as uterine overdistention or cervical incompetence, hormonal changes indicated by fetal or maternal stress, infection, and inflammation
• Medically indicated PTB is when healthcare provider recommends preterm delivery due to a serious medical condition while still monitoring the mother and fetus for health issues.
• Non-medically indicated (elective) preterm delivery is inducing labor or having a cesarean delivery in the absence of a medical reason to do so, which should be avoided.

Premature infant Classifications

• A preterm or premature infant is born before 37 weeks (36 6/7 weeks) of gestation.
• Late preterm infant: An infant born between 34 and 37 weeks of gestation (34 0/7 to 36 6/7 weeks)
• Very preterm infant: An infant born before 32 completed weeks of gestation
• Viability: The threshold for viability is at 25 and, rarely, fewer completed weeks of gestation
• Periviability: Approximately 0.5% of all births occur before the third trimester of pregnancy; periviable birth is delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation
• Long-term sequelae for preterm infants include cerebral palsy, hearing and vision impairment, and chronic lung disease.
• The goal to reduce the PTB rate to 9.4%, championed by Healthy People 2020 and the MOD, was not achieved.

Pathophysiological Pathways of Preterm Labor

• Medical, psychosocial, and biological factors may play a role in PTL and birth.
• Spontaneous PTB may be characterized by a syndrome composed of several components including uterine (PTL), chorioamnionic-decidual (premature rupture of membranes [PROM]), and cervical (cervical insufficiency).
• PTL is characterized as a series of complex interactions of factors; multiple factors interact to initiate a cascade of events that result in PTL and birth.
• The four major factors leading to PTL are excessive uterine stretch or distention, decidual hemorrhage, intrauterine infection, and maternal or fetal stress.
• Inflammatory cytokines or bacterial endotoxins can stimulate prostaglandin release.
• Prenatal stress has been associated with contributing to the development of PTL.

Risk Factors for Preterm Labor and Birth

• Risk factor assessment alone has a limited utility for identifying who will deliver preterm because 50% of women who deliver preterm have no risk factors.
• Factors include Behavioral, psychosocial, sociodemographic, ­medical, biological, and pregnancy conditions.
• The most consistently identified are Prior PTB, Multiple gestation and uterine or cervical abnormalities, shortened cervical length, history of diethylstilbestrol (DES) exposure.

Additional Risks and factors

• Fetal anomalies, History of second-trimester loss, incompetent cervix, or ­cervical insufficiency, IVF pregnancy, Hydramnios or oligohydramnios, Infection, especially genitourinary infections and periodontal disease, Premature ROM, Short pregnancy interval (less than 9 months), Pregnancy-associated problems, Chronic health problems also factor in.
• Spontaneous PTB includes birth that follows PTL, preterm spontaneous ROM, and cervical insufficiency, but does not include indicated preterm delivery for maternal or fetal conditions
• 75% of PTBs are a result of spontaneous PTL (40%) or preterm premature rupture of membrane (PPROM) (35%) and related diagnoses.
• 25% of PTBs are clinically indicated for complications and are therefore medically indicated PTB.

Early detection of pregnant women who will give birth prematurely

Tests include Transvaginal cervical ultrasonography, fetal fibronectin and placental alpha microglobulin-1 (PAMG-1).

• Transvaginal cervical ultrasonography can be performed via:
• In symptomatic women, a cervical length of greater than 30 mm reliably excludes PTL.
• A cervical length of less than 25 mm has strong positive predictive value.
• Fetal fibronectin has a low positive predictive value but a high negative predictive value, thereby making it a useful test to predict those women who will NOT deliver preterm.
• Risks for the Woman Related to Preterm Labor and Birth is Complications related to treatment with tocolytics such as cardiac arrhythmias, pulmonary edema, and even congestive heart failure.
• Risks for the Fetus and Newborn Related to Preterm Labor and Birth is Complications of prematurity and long-term sequelae associated with prematurity

Assessment Findings

• Change in type of vaginal discharge (watery, mucus, or bloody)
• Increase in amount of discharge
• Pelvic or lower abdominal pressure
• Constant low, dull backache
• Mild abdominal cramps, with or without diarrhea
• Regular or frequent contractions or uterine tightening, often painless
• Possible ruptured membranes

Diagnosis of Preterm Labor

• PTB is defined as birth between 20 0/7 weeks of gestation and 36 6/7 weeks of gestation.
• Diagnosis is based on clinical criteria of regular UCs accompanied by a change in cervical dilation- or effacement, or initial presentation with regular contractions and cervical dilation of at least 2 cm.
• interventions to reduce the likelihood of delivery should be reserved for women with PTL at a gestational age at which a delay in delivery will provide benefit to the newborn.

Medical Management

• Management focuses on delaying delivery for 48 to 72 hours to administer antenatal steroids and allow time to facilitate fetal lung maturity.
• Tocolytic drugs are medications used to suppress uterine contractions (UC) in PTL for short-term prolongation of pregnancy (up to 48 hours) to allow for the administration of antenatal steroids.
• Tocolytic therapy is typically administered between 24 to 34 weeks’ gestation.
• Antibiotics should not be used to prolong gestation or improve neonatal outcomes in women with PTL and intact membranes which differs when using antibiotics for PPROM.
• Progesterone supplementation may prevent PTB for women with a history of spontaneous PTB.
• Cerclage placement before 24 weeks is associated with significant decreases in PTB in women with a history of PTB, a current singleton pregnancy, and short cervical length.
• Neonatal neuroprophylaxis with intravenous magnesium sulfate administration is recommended to reduce microcapillary brain hemorrhage in premature birth of the neonate if administered when birth is anticipated before 32 weeks of gestation
• A single course of corticosteroids is recommended for pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days, including those with ruptured membranes and multiple gestations.

Medication Antenatal Corticosteroids

• A Cochrane meta-analysis concluded neonates whose mothers receive antenatal corticosteroids have significantly lower severity, frequency, or both of respiratory distress syndrome, intracranial hemorrhage, necrotizing enterocolitis, and death.
• Indication is Given to women at 24 and 34 weeks’ gestation with signs of PTL or at risk to deliver preterm in the next 7 days.
• Actions: Stimulate the production of more mature surfactant in the fetal lungs to prevent respiratory distress syndrome (RDS) in premature infants with a optimal therapeutic window for delivery after corticosteroid administration of 2 to 7 days.
• Route and dose: Betamethasone 12 mg IM every 24 hours × 2 doses or dexamethasone four 6-mg doses IM every 12 hours.

• Contraindications to treating PTL include:
• Intrauterine fetal demise
• Lethal fetal anomaly
• Nonreassuring fetal status
• Severe preeclampsia or eclampsia
• Maternal bleeding with hemodynamic instability
• Chorioamnionitis
• PPROMs in the absence of maternal infection.
• Tocolysis is generally contraindicated when the maternal and fetal risks of prolonging pregnancy or the risks associated with these drugs are greater than the risks associated with PTB

Nursing Actions

• Immediate care includes Review the prenatal record for risk factors, Assess the woman and fetus for signs and symptoms and assess fetal heart rate (FHR) and UCs while maintaing strict input and output (I&O) while on tocolytics and provide oral or IV hydration.
• Position the patient on her side to increase uteroplacental perfusion.
• Monitor the woman’s response to treatment including FHR baseline and variability and UCs, maternal vital signs and lab results such as urine and cervical cultures to provide ongoing reassurance and explanations to the woman and her family.
• Long Term care Evaluate laboratory reports, Facilitate family interactions, Assist the family in participating in a plan of care and providing referral information about online support groups.
• Discharge teaching should include a review of warning signs and how and when to call the provider.

Periviable Birth

• Periviable birth is delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation and management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation.
• Treatment and resuscitation between 24 and 26 weeks’ gestation for periviable births.

Preterm Premature Rupture of Membranes and Prelabor Rupture of Membranes

• Premature rupture of membranes (PROM) is rupture of membranes before the onset of labor; it is also termed prelabor rupture of membranes while preterm PROM is rupture of membranes with a premature gestation (less than 37 weeks) which occurs in about 3% of pregnancies.
• Latency refers to the time from membrane rupture to delivery.
• PPROM contributes to up to 40% of preterm (before 37 weeks) births and is secondary to ascending infection.
• Bacterial infections are thought to weaken the membranes leading to rupture.
• Optimum approach to clinical assessment remains controversial, and management includes either initiating birth soon after preterm PROM or, alternatively, adopting a “wait and see” approach (­expectant management).
• Regardless of obstetric management or clinical presentation, birth within 1 week of membrane rupture occurs in at least one-half of patients with preterm PROM.
• Women presenting with PROM before neonatal viability should be counseled regarding the risks and benefits of expectant management versus immediate delivery.
• Risks for the Woman include, maternal infection (i.e., chorioamnionitis, endometritis), Abruptio placenta and retained placenta, increased rates of cesarean birth.
• Risks for the Fetus and Newborn include; Fetal or neonatal sepsis, hypoxia or asphyxia and fetal deformities if preterm PROM before 26 weeks’ gestation

Assess Findings, and Medical Management

• Confirm premature gestational age by prenatal history and ultrasound
• Confirm ROM with speculum exam and positive ferning test
• Oligohydramnios on ultrasound may be seen but is not diagnostic
• Medical treatment is aimed at balancing the risks of prematurity and the risks of infections for the woman who is not in labor, not infected, and not experiencing fetal compromise.

Nursing Action:

• Asses FHR and UC, and assess for signs of infection including maternal and/or fetal tachycardia, Maternal fever, Early signs and symptoms of intraamniotic infection may be subtle.

Cervical Insufficiency

• Cervical insufficiency is the inability of the uterine cervix to retain a pregnancy in the absence of clinical contractions, or labor, depending upon the severity of insufficiency.
• Diagnosis is based on a history of painless cervical dilation after the first trimester with subsequent expulsion of the pregnancy in the second trimester, typically before 24 weeks of gestation, without contractions or labor and in the absence of other clear pathology such as bleeding, infection, or ruptured membranes.
• Cervical incompetence may be congenital or acquired and may be congenital or acquired.
• The most common congenital cause is a defect in the embryological development or collagen deficiency that causes inadequate cervical performance.The most common acquired cause is cervical trauma.

Risks

• Risks to the Woman is Repeated second trimester or early third trimester births while Risks to the Fetus and Newborn is PTB and consequences of prematurity
• Patients are usually asymptomatic, but some report nonspecific symptoms such as backache, UCs, vaginal spotting, pelvic pressure, or mucoid vaginal discharge.
• Certain nonsurgical approaches, including activity restriction, bed-rest, and pelvic rest, have not been proven effective; Surgical treatment is cerclage, a type of purse-string suture placed cervically to reinforce a weak cervix.
• A history-indicated cerclage can be considered in a patient with a history of unexplained second-trimester delivery. Most patients at risk of cervical insufficiency can be safely monitored with serial transvaginal ultrasound examinations in the second trimester, beginning at 16 weeks and ending at 24 weeks of gestation.