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Appendix

Contents

Guidelines for the management of patients with risk factors and medical problems during pregnancy, labour and the puerperium

The following tables list most of the risk factors and medical problems which may occur during pregnancy, labour, and the puerperium. They also give the possible adverse effects of these conditions, indicate the actions needed, and suggest the level of care required in the last column. The list also serves as a useful guide to management, and can be referred to when risk factors are present or develop during pregnancy. The management of many of the problems is discussed in more detail elsewhere in the Perinatal Education Programme. The tables should be read, but need not be learned. These tables provide a very useful reference for both midwives and doctors who are caring for a patients with risk factors.

The level of care needed is shown as follows:

1 = For low-risk patients.

2 = For intermediate-risk patients.

3 = For high-risk patients.

Risk factors

Possible adverse effects during pregnancy and associated problems

Action

Level of care

Risk factors identified from the patient’s history

Maternal age

15 years or less

Pregnancy may have a detrimental effect on the development of the patient’s personality.

Determine the duration of pregnancy. If 20 weeks or less termination may be indicated.

2

16–19 years

Poor social circumstances.

Pre-eclampsia.

Anaemia.

Refer to social worker for support. Watch for proteinuria and a rise in blood pressure from 28 weeks.

Regular Hb checks.

1

37 years or more

Medical conditions such as hypertension and diabetes are commoner.

Chromosome abnormalities are commoner, e.g. Down syndrome

Carefully look for medical problems at the first visit, and at 28 and 34 weeks.

Motivate for sterilisation.

 

Determine the duration of pregnancy:

If 13 weeks or less, an ultrasound examination for nuchal thickness is done, followed at 22 weeks looking for structural defects.

2*
If more than 13 weeks, a genetic amniocentesis should be done between 16 and 22 weeks. 2*

Before referral, make sure that the patient will agree to termination of pregnancy, if this is indicated.

*Refer back to level 1 if medical and genetic screening is normal and less than 40 years.

1

General history

Allergies

Penicillin allergy with an anaphylactic reaction is always dangerous, but rarely occurs.

Allergies must always be clearly documented on the folder and antenatal card.

1

Body Mass Index (BMI)

Cephalopelvic disproportion and shoulder dystocia.

Hypertension and diabetes

Use weight, height and attached BMI table.

When reading BMI off table:

With 1st visit in 2nd trimester, subtract 4 kg

With 1st visit in 3rd trimester, subtract 8 kg

Ultrasound examination for accurate gestational age estimation at 18-22 weeks.

Monitor for hypertension and glycosuria.

 
BMI below 40 1
BMI above 40 but below 50 2

BMI above 50

3

Diabetes mellitus (in the patient)

Pregnancy worsens the diabetes.

Insulin requirements increase.

Higher incidence of fetal death.

Large babies with obstructed labour and birth injuries.

Neonatal hypoglycaemia.

Careful control of the diabetes, in order to keep the blood glucose levels as close to normal as possible is absolutely essential.

3

Diabetes mellitus (family history)

There is an increased risk of the patient developing diabetes during pregnancy.

Careful screen for glycosuria:  

If absent –

1

If present –

Glucose profile at 28 weeks.

2

Epilepsy

Convulsions may occur more frequently in pregnancy. Some anticonvulsant drugs may cause congenital abnormalities.

The dose of anticonvulsant drugs may need to be increased.

Put the patient on a safe drug before pregnancy (e.g. carbamazepine). The drugs are not changed during pregnancy because of the danger of convulsions.

2

Congenital abnormalities (in the family)

Serious abnormalities tend to recur.

Determine the duration of pregnancy:  

If 13 weeks or less, an ultrasound examination for nuchal thickness is done, followed at 22 weeks looking for structural defects.

1

If more than 13 weeks, a genetic amniocentesis should be done between 16 and 22 weeks.

2

Drugs or medication

Danger of teratogenesis.

Points towards a disease not mentioned in the history.

Get accurate details and consult a doctor.

1

HIV

Mother-to-child transmission of HIV.

With AIDS the mother’s clinical condition may deteriorate.

Commence patient on FDC if no contra-indications.

If contra-indications refer to an antiretroviral (ARV) clinic.

1

The stage of disease needs to be determined and noted. Check at each visit for symptoms and signs indicating progression at a more advanced stage of disease.

2

Auto-immune diseases

Raised perinatal mortality rate.

Early onset of severe pre-eclampsia.

Get detailed information about the disease and medication.

3

Psychiatric illness

Suicide is commoner.

Illness may become worse during pregnancy.

Get detailed information about the disease and medication.

Termination of pregnancy may be indicated (if duration of pregnancy is less than 20 weeks).

2

Rubella

Congenital abnormalities.

Ask about fever and a skin rash in the first trimester of pregnancy and also about contact with rubella.

Rubella antibody titres can confirm or exclude diagnosis.

1

Thyrotoxicosis (hyperthyroidism)

Thyrotoxicosis and/or goitre in the neonate.

Get detailed information about the illness and medication. Request maternal thyroid hormone levels.

Thyroid hormone levels in cord blood.

2

Systematic history

Respiratory System

Asthma

Prostaglandin F2 alpha is contraindicated.

Asthma usually improves during pregnancy.

Ask about medication and symptoms:  
Asymptomatic and not on steroids – 1

Symptomatic and on steroids –

2

Chronic cough more than 14 days. Night sweats, fever and weight loss.

Possible tuberculosis and/or AIDS.

Single X-ray chest with fetus screened off and sputum for GeneXpert or acid fast bacilli.

A rapid test if HIV status unknown.

1

Active tuberculosis

Spread to other family members and the newborn infant.

If stable and on treatment.

The newborn infant must be given isoniazid.

1

Cardiovascular System

Hypertension:

1. Diastolic 90 and/or systolic 140 mm Hg or more.

2. Antihypertensive treatment.

Pre-eclampsia, abruptio placentae, and IUGR or perinatal death.

Change to alpha methyldopa and stop diuretics:  
With good control and no proteinuria – 2

With diastolic 90 mm Hg or more or proteinuria –

3

Dyspnoea and orthopnoea

Symptoms of heart failure.

Underlying heart disease must be excluded or confirmed by the doctor.

2

Rheumatic heart disease

Cardiac output increases with increased risk of cardiac failure and maternal death.

No symptoms or signs of heart failure, and no stenotic heart valve lesions – 2

Symptoms and signs of heart failure and/or stenotic heart valve lesions –

3

Varicose veins

May indicate previous venous thrombosis.

Become worse during pregnancy.

Watch for possible thrombosis.

Bed rest and elastic stockings.

1

Thrombo-embolism

Increased incidence in pregnancy with risk of maternal death.

Anticoagulant therapy during pregnancy may have to be considered.

3

Alimentary System

Haemorrhoids

May get worse in pregnancy.

May prolapse and thrombose.

Only conservative management needed.

1

Jaundice

Determine if the patient is a carrier of the hepatitis B virus.

Can infect the infant during delivery.

Test for the hepatitis B antigen:  
If antigen absent – 1

If antigen present (the infant must be given hyperimmune globulin and be immunised) –

2

HIV positive and on FDC

High risk for serious liver damage

Stop FDC and refer to an ARV clinic

2

Urinary system

Pyelonephritis

High risk of recurrence.

Midstream urine (MSU) for culture to be sure that the infection is completely treated.

1

Cystitis

Common in pregnancy.

MSU for culture if symptomatic.

Treat with single dose antibiotics

1

Surgical History

Myomectomy

Danger of ruptured uterus.

Elective Caesarean section indicated.

2

Thyroidectomy

Hypothyroidism can develop during pregnancy with the danger of abortion and neurologic impairment of the fetus.

If hyperthyroidism was the indication for surgery, manage as for thyrotoxicosis.

Look carefully for an operation scar.

Thyroid function tests are indicated.

2

Chest surgery

High risk of thrombosis of artificial heart valves in pregnancy.

Warfarin: danger of teratogenesis in the 1st and bleeding in the 3rd trimester.

Correct use of anticoagulant therapy.

3

Previous obstetric history

Abruptio placentae

Tends to recur:

10% chance after previous abruption.

25% chance after 2 previous abruptions.

Advise the patient:  
Induce labour at 38 weeks. 2

Deliver at 34 weeks, antenatal steroids for lung maturity must be given.

3

Diabetes mellitus

Recurs in successive pregnancies. Complications already mentioned.

Random blood glucose if there is glycosuria.

Glucose profile at 28 weeks.

2

Ectopic pregnancy

High risk of recurrence.

Gynaecological examination to confirm intra-uterine pregnancy (ultrasound if uncertain).

1

Grande multiparity (five or more pregnancies have reached viability)

Medical conditions are commoner.

Obstetric complications are commoner: IUGR, multiple pregnancy, abnormal lie, obstructed labour and postpartum haemorrhage.

Motivate for sterilisation.

Look for medical conditions at the first visit.

Look for abnormal lie after 34 weeks.

Additional oxytocin following 3rd stage and observe closely.

2

Infertility

Ectopic pregnancy and multiple pregnancy commoner.

Gynaecological examination to confirm intra-uterine pregnancy and the size of the uterus. (Ultrasound examination is indicated.)

2

Caesarean section(s)

Danger of ruptured uterus with previous vertical uterine incision, or with two or more Caesarean sections.

Get details of the indication and type of incision from old records.

Elective Caesarean section at 39 weeks if 2 previous Caesarean sections or a vertical incision.

2

Congenital abnormalities

Possible genetic inheritance.

High risk of recurrence.

Genetic counselling.

Determine the duration of pregnancy:

If 13 weeks or less, an ultrasound examination for the nuchal thickness is done, followed at 22 weeks looking for structural defects.

If more than 13 weeks an amniocentesis should be done between 16 and 22 weeks.

2

Abortion

More than two first trimester abortions.

One or more mid-trimester abortions.

Test parents for chromosomal abnormalities.

If history indicates an incompetent cervix, a MacDonald stitch may be indicated (inserted at 14-16 weeks ).

2

Perinatal death

Highest risk group for another perinatal death to occur (especially when the cause is unknown).

Get a detailed history and the notes from the previous pregnancy.

2

Postpartum haemorrhage and retained placenta

Tend to recur in successive pregnancies.

Deliver in hospital.

Additional oxytocin following 3rd stage and observe closely.

2

Pre-eclampsia

Two groups:    
1. Primigravidas with pre-eclampsia close to term. Low risk of recurrence. 1

2. Previous pregnancy with pre-eclampsia developing in late 2nd or early 3rd trimester of pregnancy.

High risk of recurrence. Low dose aspirin (Disprin) 75 mg daily from 14 weeks.

2 weekly antenatal clinic visits from 24 weeks.

2

Primigravida

Higher incidence of pre-eclampsia late in pregnancy.

Careful attention to blood pressure and proteinuria.

1

Vacuum extraction or forceps delivery

May indicate cephalopelvic disproportion.

Careful use of the partogram in labour.

1

Preterm labour

High risk of a recurrence in the same pregnancy.

Assess the cervix regularly from 26 to 32 weeks for changes, more regular bed rest, no intercourse in the second half of pregnancy. If there is cervical incompetence, a MacDonald suture may be indicated.

3

Present obstetric history

Antepartum haemorrhage

Abruptio placentae and placenta praevia are both serious complications. Local causes, e.g. vaginitis, cervicitis, can also cause bleeding.

If not currently bleeding and there is no fetal distress:

1. Do speculum examination:

 

No local cause.

2
Treatable local cause present. 1

2. Ultrasound shows placenta praevia.

3

Asymptomatic bacteriuria

33% incidence of pyelonephritis in these patients.

High risk of preterm labour.

Single dose antibiotics.

Repeat urine culture at next antenatal visit.

1

Diastolic blood pressure of 90 and/or systolic of 140 mm Hg or more

Hypertension or pre-eclampsia.

Repeat after 30 minutes rest on her side:  
If diastolic 90-99 and systolic 140–149 mm Hg without proteinuria, start alpha methyldopa. 2

If diastolic 100 and systolic 150 mm Hg or more or proteinuria, admit to hospital.

2

Reduced fetal movements

Fetal distress or intra-uterine death.

Duration of pregnancy 28 weeks or more. Repeat kick charts:  
Good count without IUGR. 1
Good count with IUGR. 2

If count remains poor, admit to hospital.

2

Glycosuria 1+ or more

Possible diabetes.

Random blood glucose estimation:  

Less than 8 mmol/l is normal.

8 to 11 mmol/l – arrange for fasting blood glucose estimation.

1

11 mmol/l or more = diabetes.

Admit to hospital for control if diabetes diagnosed.

2

Haemoglobin less than 10 g/dl

Anaemia in pregnancy.

Arrange full blood count.

If confirmed anaemia – Refer.

2

Haematuria

Possible cystitis.

Bilharzia, if endemic in the area.

Urine microscopy and culture. Treat cystitis.

1

Multiple pregnancy

Greater risk of preterm labour.

High incidence of perinatal death and pre-eclampsia.

Anaemia.

Regular vaginal examinations from 26 weeks for cervical effacement and dilatation.

Careful monitoring of proteinuria and rising blood pressure.

Do Hb more frequently.

Ultrasound examination for growth and chorionicity:

 
Monochorionic (one placenta) 3

Dichorionic (two placentas)

2

Pyelonephritis in current pregnancy

High risk of recurrence.

Follow-up urine culture to ensure that treatment was successful.

2

Polyhydramnios

Congenital abnormalities.

Multiple pregnancy.

Diabetes mellitus.

Rh sensitisation may be present.

Ultrasound examination and glucose profile are indicated. Check blood groups, and possible sensitisation.

Exclude oesophageal atresia in the infant immediately after birth.

2

Proteinuria

Pre-eclampsia or renal disease, e.g. chronic nephritis or nephrosis, may be present.

Exclude urinary tract infection. Test urine for protein:  
Trace (150 mg/l) can be normal. 1
1+ (500 mg/l) and blood pressure normal. 2

More than 1 + indicates pre-eclampsia or serious kidney disease. Admit to hospital.

2

Ruptured membranes

Preterm labour and chorioamnionitis.

If 36 weeks or more admit to hospital, wait until the membranes have been ruptured for 24 hours, then induce labour with oxytocin. 1

If 34 weeks or less transfer to level 2 hospital.

2

Rhesus negative

Rh-sensitisation with hydrops fetalis.

If no antibodies, retest for antibodies at 26, 32 and 38 weeks.

If antibodies present:

1

Titre less than 1:16.

2

Titre above 1:16 or more.

3

Preterm labour

Preterm infant.

If 34 weeks or more deliver in level 2 hospital. 2

If less than 34 weeks admit to level 3 hospital. Consider suppression of labour and steroids for lung maturity.

3

Rapid syphilis test positive and

VDRL titre 1:16 or more

Congenital syphilis.

Patient must receive full treatment.

1

Rapid syphilis test positive and VDRL titre less than 1:16

No history of full treatment of woman and partner in past 3 months.

Patient must be fully treated.

1

Uterus larger than dates

Multiple pregnancy.

Polyhydramnios.

Diabetes.

Large fetus.

Incorrect dates.

Arrange for ultrasound and glucose profile.

With a large fetus there is a danger of disproportion.

Be ready to manage shoulder dystocia.

2

Uterus smaller than dates

IUGR.

Oligohydramnios

Fetal death.

Incorrect dates.

Careful measurement of fundal growth and fetal movement counts:  
Good growth over a period of 2 weeks. 1
No growth over a period of 2 weeks. 2

With few or no fetal movements, admit to hospital.

2

Abnormal lie

Breech, oblique or transverse lies suggest possible placenta praevia, multiple pregnancy or disproportion.

Less than 34 weeks, not important.

If more than 34 weeks: exclude the named complications, and refer to a doctor for external cephalic version at 36 weeks, if there are no contraindications.

 
Successful version. 1

All others.

2

Social history

Alcohol

Fetal alcohol syndrome.

Counselling: no alcohol should be drunk during pregnancy.

1

Religion (Customs)

Fear that certain customs will not be fulfilled, e.g. with regard to abortions, placenta, etc.

Counselling: Religious beliefs will be respected.

1

Single mother and/or unwanted pregnancy

Complications of pregnancy are commoner because of usually poorer socio-economic circumstances.

Counsel about termination of pregnancy if less than 14 weeks.

Social support may be needed.

Advise about an effective method of family planning.

Sterilisation may be indicated in a multipara.

1

Smoking

Danger of IUGR.

Advice to the patient: strongly advise her to stop smoking. Encourage her if she stops.

Careful attention to fundal growth.

1

Poor socio-economic circumstances

Pregnancy complications will occur more commonly.

Malnutrition, infection, and anaemia also occur commonly.

Social support necessary.

Advise on effective method of family planning.

Sterilisation may be indicated in a multiparous patient.

1

BMI table

Height →
Weight ↓
140 cm 145 cm 150 cm 155 cm 160 cm 165 cm 170 cm 175 cm 180 cm 185 cm 190 cm 195 cm 200 cm 205 cm
48 kg 24.5 22.8 21.3 20.0 18.7 17.6 16.6 15.7 14.8 14.0 13.3 12.6 12.0 11.4
51 kg 26.0 24.3 22.7 21.2 19.9 18.7 17.6 16.7 15.7 14.9 14.1 13.4 12.8 12.1
54 kg 27.6 25.7 24.0 22.5 21.1 19.8 18.7 17.6 16.7 15.8 15.0 14.2 13.5 12.8
57 kg 29.1 27.1 25.3 23.7 22.3 20.9 19.7 18.6 17.6 16.7 15.8 15.0 14.3 13.6
60 kg 30.6 28.5 26.7 25.0 23.4 22.0 20.8 19.6 18.5 17.5 16.6 15.8 15.0 14.3
63 kg 32.1 30.0 28.0 26.2 24.6 23.1 21.8 20.6 19.4 18.4 17.5 16.6 15.8 15.0
66 kg 33.7 31.4 29.3 27.5 25.8 24.2 22.8 21.6 20.4 19.3 18.3 17.4 16.5 15.7
69 kg 35.2 32.8 30.7 28.7 27.0 25.3 23.9 22.5 21.3 20.2 19.1 18.1 17.3 16.4
72 kg 36.7 34.2 32.0 30.0 28.1 26.4 24.9 23.5 22.2 21.0 19.9 18.9 18.0 17.1
75 kg 38.3 35.7 33.3 31.2 29.3 27.5 26.0 24.5 23.1 21.9 20.8 19.7 18.8 17.8
78 kg 39.8 37.1 34.7 32.5 30.5 28.7 27.0 25.5 24.1 22.8 21.6 20.5 19.5 18.6
81 kg 41.3 38.5 36.0 33.7 31.6 29.8 28.0 26.4 25.0 23.7 22.4 21.3 20.3 19.3
84 kg 42.9 40.0 37.3 35.0 32.8 30.9 29.1 27.4 25.9 24.5 23.3 22.1 21.0 20.0
87 kg 44.4 41.4 38.7 36.2 34.0 32.0 30.1 28.4 26.9 25.4 24.1 22.9 21.8 20.7
90 kg 45.9 42.8 40.0 37.5 35.2 33.1 31.1 29.4 27.8 26.3 24.9 23.7 22.5 21.4
93 kg 47.4 44.2 41.3 38.7 36.3 34.2 32.2 30.4 28.7 27.2 25.8 24.5 23.3 22.1
96 kg 49.0 45.7 42.7 40.0 37.5 35.3 33.2 31.3 29.6 28.0 26.6 25.2 24.0 22.8
99 kg 50.5 47.1 44.0 41.2 38.7 36.4 34.3 32.3 30.6 28.9 27.4 26.0 24.8 23.6
102 kg 52.0 48.5 45.3 42.5 39.8 37.5 35.3 33.3 31.5 29.8 28.3 26.8 25.5 24.3
105 kg 53.6 49.9 46.7 43.7 41.0 38.6 36.3 34.3 32.4 30.7 29.1 27.6 26.3 25.0
108 kg 55.1 51.4 48.0 45.0 42.2 39.7 37.4 35.3 33.3 31.6 29.9 28.4 27.0 25.7
111 kg 56.6 52.8 49.3 46.2 43.4 40.8 38.4 36.2 34.3 32.4 30.7 29.2 27.8 26.4
114 kg 58.2 54.2 50.7 47.5 44.5 41.9 39.4 37.2 35.2 33.3 31.6 30.0 28.5 27.1
117 kg 59.7 55.6 52.0 48.7 45.7 43.0 40.5 38.2 36.1 34.2 32.4 30.8 29.3 27.8
120 kg 61.2 57.1 53.3 49.9 46.9 44.1 41.5 39.2 37.0 35.1 33.2 31.6 30.0 28.6
123 kg 62.8 58.5 54.7 51.2 48.0 45.2 42.6 40.2 38.0 35.9 34.1 32.3 30.8 29.3