High-Risk Pregnancy Nursing Care
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Direct answer
A high-risk pregnancy is one in which a maternal, fetal or situational condition raises the chance of an adverse outcome for the mother, baby or both, so it needs extra surveillance, planned delivery at a higher centre and often specialist drugs. Classic examples are severe anaemia, pre-eclampsia, gestational diabetes, heart disease, multiple pregnancy, extremes of maternal age and a previous caesarean or stillbirth. The nurse's job is systematic risk screening at every antenatal contact, teaching danger signs, preparing a birth plan that names a functioning referral facility, and monitoring therapies such as magnesium sulphate with its narrow safety margin.
What you must remember
- Anaemia in pregnancy: haemoglobin below 11 g/dL (WHO); below 7 g/dL is severe and demands referral. Indian programme guidance advises daily iron-folic acid started early, now extended toward 180 days per current guidance.
- Pre-eclampsia: new blood pressure of 140/90 mmHg or more after 20 weeks with proteinuria; gestational hypertension has the high pressure without protein.
- Danger signs demanding immediate reporting: headache with blurred vision, epigastric pain, swelling of face and hands, vaginal bleeding, reduced fetal movements, leaking liquor, fever and convulsions.
- Gestational diabetes screening in India: 75 g oral glucose irrespective of fasting status; 2-hour value of 140 mg/dL or more diagnoses GDM (DIPSI criterion).
- Magnesium sulphate for severe pre-eclampsia or eclampsia, Pritchard regimen: loading 4 g IV plus 10 g IM (5 g each buttock), then 5 g IM 4-hourly. Before each dose check respiratory rate 16 or more, patellar reflexes present, urine output at least 30 mL per hour; keep calcium gluconate 10% at the bedside as antidote.
- Grand multipara (five or more births), age under 18 or over 35, previous two caesareans, Rh-negative mother, cardiac disease NYHA class III-IV and multiple pregnancy all warrant specialist antenatal care.
- Symphysis-fundal height lagging the gestational age by 4 weeks or more suggests intrauterine growth restriction; recommend ultrasound referral.
- Birth preparedness for every high-risk mother: identified facility with blood and operative capability, transport, money, blood donor and a companion.
A typical ANM clinic triage
A 24-year-old second-grade mother arrives at 26 weeks for her village health and nutrition day contact. Screening finds pallor of palms and conjunctiva, blood pressure 148/96 on repeat after rest, weight gain of 4 kg in one month, and pitting oedema of the feet. The urine dipstick shows 2+ protein. You classify severe pre-eclampsia with probable anaemia: this woman cannot be managed at the sub-centre. While arranging referral to the community health centre, you take a haemoglobin sample, ask about headache and visual symptoms, place her in the left lateral position, and record fetal heart tones. Your referral note states the findings, the time of onset and the treatment given, because the receiving facility builds on your baseline. Contrast her with the 30-year-old at 22 weeks whose only finding is haemoglobin of 9.8 g/dL with no other risk: she is classified moderate anaemia, receives intensified iron-folic acid, deworming per schedule, dietary counselling and review in two weeks, with clear instructions to return immediately if breathlessness, pallor worsening or any danger sign appears. The skill being tested is not treating everything aggressively but sorting women into stay, treat and escalate groups.
Where students slip
Pre-eclampsia nomenclature causes the most errors: gestational hypertension is pressure alone, pre-eclampsia adds proteinuria or end-organ features, and eclampsia adds convulsions — oedema alone is no longer a diagnostic criterion. Students also quote the non-pregnant anaemia cutoff of 12 g/dL instead of 11 g/dL for pregnancy, forget that magnesium toxicity announces itself through respiratory depression before anything else, and miss that anti-D immunoglobulin 300 micrograms must reach the Rh-negative unsensitised mother within 72 hours of delivery or any sensitising event. A recurring MCQ trap is the first nursing action for a convulsing pregnant woman: position her lateral, maintain airway and suction, then give magnesium sulphate — oxygen and drug follow airway.
Frequently asked questions
What haemoglobin level defines severe anaemia in pregnancy?
Below 7 g/dL, requiring urgent referral; 7 to 10.9 g/dL is moderate and treatment is intensified iron therapy with review.
What must the nurse check before each maintenance dose of magnesium sulphate?
Respiratory rate of at least 16 per minute, presence of patellar reflexes and urine output of at least 30 mL per hour, with calcium gluconate kept ready as the antidote.
Which test screens for gestational diabetes in the Indian programme?
A 75 g oral glucose load irrespective of fasting state, with a 2-hour value of 140 mg/dL or more diagnosing gestational diabetes.
List the danger signs a pregnant woman must report immediately.
Bleeding, severe headache or blurred vision, convulsions, epigastric pain, reduced fetal movements, leaking liquor, fever and breathlessness.
Why does the fundal height lag in intrauterine growth restriction?
Because the growing uterus mirrors fetal size; a lag of 4 weeks or more from the expected gestational height prompts ultrasound assessment of fetal growth and wellbeing.