What nursing interventions are appropriate for the prenatal patient in terms of prenatal care

Group Prenatal Care

In the US, the most common prenatal clinical scenario is one provider to one patient, and was established in 1912 when the Children's Bureau recognized the importance of prenatal care in reducing infant and maternal deaths. This traditional model of care has been successful in improving mortality rates, but not equally across all racial and ethnic groups. Lack of access, transportation, social support, and social determinants of health are some reasons cited for late or no prenatal care, and differences in mortality. Hence, innovative prenatal care models have been developed as an alternative to traditional prenatal care. Alternative models include group prenatal care, initially described in the early 1990s and primarily limited to low-risk patients cared for by a midwife. Group prenatal care allows more time for provider-patient interaction to address not only clinical issues but behavioral, social, and psychological topics in a setting that allows for time for social support.97 Over the last decade, other formats of group prenatal care have evolved to supplement the care delivered outside of the prenatal care visit, including telephone calls, home visits, and text messaging.98Table 5.2 summarizes the various types of prenatal care programs. Although in some studies African American women participating in group prenatal care have demonstrated lower rates of PTB, most meta-analyses have shown similar rates of PTB, LBW, and NICU admission across the variety of prenatal care delivery models.98a,99 This suggests group prenatal care is at least equivalent to traditional prenatal care, and that more trials are needed to definitively demonstrate improved outcomes with specific populations.

Efficacy of prenatal care also depends on the quality of care provided by the caretaker. If a blood pressure is recorded as “elevated,” and no therapeutic maneuvers are recommended, the outcome will remain unchanged. Recommendations must be made and carried out by the patient, whose compliance is essential to alter outcome. Using national survey data, Kogan and colleagues reported that women received only 56% of the procedures and 32% of the advice recommended as part of prenatal care content, whereas poor women and black women received even fewer of the recommended interventions. Site of care was also an important determinant, suggesting that infrastructure must be geared to address population-specific needs, and these differences likely contribute to health disparities.

Prenatal care is healthcare provided to a woman during pregnancy. It consists of a series of clinical visits and ancillary services designed to promote the health and well-being of the mother, fetus, and family. Its major components include early and continuing risk assessment, health promotion, and medical and psychosocial interventions and follow-up. Risk assessment includes comprehensive evaluation of the woman’s or couple’s reproductive history, medical risks, medication use, family history and genetic risks, psychosocial factors, nutritional and behavioral risks, and laboratory testing. Health promotion includes alleviating unpleasant symptoms during pregnancy, providing lifestyle advice, promoting healthy nutrition, reducing environmental exposures, promoting family planning and breastfeeding. Medical and psychosocial interventions address identified medical and psychosocial risks. Ideally, prenatal care should begin before pregnancy (preconception care) and continue after (postpartum care) and between pregnancies (internatal care), as part of a longitudinally and contextually integrated strategy to promote optimal development of women’s reproductive health not only during pregnancy, but over the life course.

History

After pregnancy is confirmed, it is extraordinarily important to determine the duration of pregnancy and the estimated date of confinement (EDC). Further care is heavily predicated on this estimate. The history begins with ascertaining the first day of the last normal menstrual period and calculating the EDC by assuming duration of pregnancy averages 280 days (40 weeks). Because a first-trimester dating ultrasound (US) is accurate to within 5 days at confirmation or determination of an accurate EDC, its value cannot be overestimated.

The documentation of prior obstetric history includes prior complications, route of delivery, and estimated birth weights. Maternal medical disorders are often exacerbated by pregnancy; cardiovascular, renal, and endocrine disorders require evaluation and counseling concerning possible treatments required. A history of previous gynecologic surgery, including cesarean delivery, is important to consider. A family history of twinning, diabetes mellitus, familial disorders, or hereditary disease is relevant.

Current medications (prescription and nonprescription) are reviewed, along with any herbals or supplements. Certain prescription medications are known teratogens and should be discontinued. Examples include isotretinoin (Accutane), tetracycline (Sumycin), quinolone antibiotics (ciprofloxacin [Cipro], levofloxacin [Levaquin]), “statin” cholesterol-lowering medications such as atorvastatin (Lipitor) and rosuvastatin (Crestor) and warfarin (Coumadin). Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) should not be used in pregnancy because they can be associated with fetal renal agenesis.

It is important to determine the pregnant patient’s risks for developing preeclampsia during the first trimester prenatal visit because starting low dose aspirin (81 mg) between 12 to 28 weeks (ideally before 16 weeks’ gestation) can prevent morbidity and mortality from preeclampsia. One or more of the following high-risk factors is an indication for beginning low dose aspirin after 12 weeks: a history of previous preeclampsia, multifetal gestation, renal disease, autoimmune disease, diabetes, and chronic hypertension. Consideration of low dose aspirin should be given for patients with more than one of moderate-risk factors for preeclampsia including obesity, advanced maternal age, history of low birth weight infants or adverse birth outcomes, and low socioeconomic status or African American race.

Open discussion of substance abuse (alcohol, tobacco, and illicit drugs) is an integral part of the patient interview. Counseling patients about smoking cessation is vital in early pregnancy. Smoking increases the risk of fetal death or damage in utero. It is also associated with increased risk of placental abruption and placenta previa, each of which put both mother and child at risk, along with premature birth. The interest that pregnant women have in delivering a healthy infant can be a potent motivator for change at this point.

Introduction

Prenatal care has existed for over 100 years as an approach to improve maternal and newborn outcomes. Traditionally, risk factors such as family history, social and behavioral factors, and the identification of existing risk factors (sexually transmitted disease, anemia, blood incompatibility) and intercurrent problems such as hypertension, fetal growth restriction, and pre-term labor have been the core of prenatal care. With advances in knowledge and tools of modern genetics, a major emphasis has become prenatal and recently preconception screening of hereditable diseases. The goal of prenatal screening is to counsel patients about their screening and diagnostic options, to provide reassurance to patients at low risk, and to identify high-risk patients who may benefit from diagnostic or therapeutic procedures.

Maternal Antepartum/Intrapartum Care

1.

All pregnant, HIV-infected women should receive combination ARV drugs ante partum, starting as early as possible during pregnancyregardless of their HIV RNA levels and CD4 T lymphocyte counts. A French cohort study, which looked at factors associated with mother-to-child transmission of HIV despite low viral load at the time of delivery, showed that women who transmitted the virus to their offspring were less likely to have had viral loads less than 500 copies/mL and were also less likely to have received ART at the time of becoming pregnant and early in the pregnancy.261 It is also known that mother-to-child transmission is possible even with low RNA levels and in mothers on ART. There have been reports of discordance between the viral loads in blood and those in the genital tract; women with undetectable levels in blood have been found to shed the virus in the genital tract.197,275

Resistance testing is indicated in women whose RNA levels are above the resistance testing threshold (>500-1000 copies/mL) before starting or modifying ARV drug regimens in patients with known HIV infection and those diagnosed early in pregnancy. However, if HIV infection is diagnosed late in pregnancy, therapy should be started even if the results of resistance testing are not available. In all pregnant patients on ARV, the importance of strict adherence to the ARV regimen should be strongly emphasized.

IV zidovudine continuous infusion (2 mg/kg IV over 1 hour followed by continuous infusion of 1 mg/kg until delivery) isrecommended for HIV-infected mothers withviral loads greater than 1000 copies/mL near delivery, those in whom viral loads are unavailable near the time of delivery, or in women who did not receive any antepartum ART regardless of the antepartum regimen or mode of delivery.

Women who are on ART and have well-controlledviral loads less than 50 copies/mL consistently during late pregnancy and near delivery and in whom compliance has not been a problem,do not need IV zidovudine and should continue their drug regimen orally on schedule as much as possible during labor and even before a scheduled cesarean section. This can be accomplished by taking the medication with small sips of water.

For women withviral loads between 50-999 copies/mL, the current available data are not sufficient to determine whether IV zidovudine offers additional protection to the infant. Some studies have shown lower maternal-to-fetal transmission in women with viral loads below 50 copies/mL as compared with those with 50-1000 copies/mL; 0.25 versus 2%.181 Experts, therefore, recommend that IV zidovudine beconsidered in this group of patients, but this is left to the clinical judgment of the provider.

In women who are scheduled for a cesarean section and require IV zidovudine, it should be started 3 hours before the surgery (1-hour loading dose and 2-hour continuous infusion). For emergency cesarean section, the aim is to try to complete the 1-hour loading dose before proceeding with the cesarean section.

Expedited testing for HIV should be performed in all mothers without documentation of their HIV status unless they “opt out.” Women who are considered to be at increased risk for acquiring HIV (partner with HIV infection, multiple sexual partners during pregnancy, illicit drug use, exchange of sex for money, or living in an area with high incidence of HIV infection in childbearing age) should also be tested at the time of labor, even if testing earlier in pregnancy yielded negative results. Testing should be done with HIV-1 and HIV-2 antigen/antibody combination immunoassay and an HIV RNA assay. These testing modalities should be available in institutions that offer maternity and neonatal intensive care and nursery services. For women who test positive, IV zidovudine should be started immediately.

Health Care

Prenatal care can improve infant health by identifying conditions that can harm health such as low weight gain and by providing health and nutrition information to the mother. Athough it is well documented by researchers that policy levers can improve rates of prenatal care utilization, it is still unclear whether increased prenatal care translates to better infant health. Examinations of Medicaid expansions yield mixed results, but other policy changes that increased care have resulted in improvements in birth outcomes. Access to prenatal care appears to improve birth outcomes for those most at risk for poor birth outcomes such as low-income women and minority women who would have otherwise had minimal or low-quality prenatal care. A primary mechanism through which prenatal care improves birth outcomes is to reduce maternal smoking, which is the leading cause of growth retardation for fetuses. Health care at the time of birth is associated with a decline in the neonatal mortality rate, likely a result of access to life-saving technology.

Public health insurance programs such as Medicaid in the USA and National Health Insurance (NHI) in Canada provide prenatal and delivery care with the goal of improving both infant and maternal health. Introduction of universal health insurance in Canada during the 1960s and 1970s reduced infant mortality by 4% and reduced low birth weight classification on average, with single mothers experiencing a substantial reduction in the incidence of low birth weight. In the 1980s and 1990s, Medicaid significantly expanded its eligibility threshold to include a larger share of low-income, pregnant women. The program expansion initiated cost-saving measures, changing the insurance structure from fee-for-service to managed care for some enrollees. Evaluations of the changes consistently show impacts on prenatal care utilization but yield differing results on birth outcomes, with some researchers concluding that the changes improved birth outcomes and others finding no effect. Physician incentives to provide care are influenced by the type of payment structure Medicaid uses. Of particular interest is the relative incentives of Caesarian versus vaginal deliveries. Reduced incentives to provide care have been shown to increase the probability of low birth weight, prematurity, and neonatal mortality; however, studies that examine increased incentives to provide care find no effect on infant health.

The 1964 Civil Rights Act mandated desegregation of hospitals and greatly improved the quality of prenatal care available to blacks, particularly in the southern USA where hospitals for non whites were of poor quality. Desegregation reduced postneonatal mortality rates with gains driven by reductions in preventable deaths from pneumonia and gastroenteritis. The health of infants at birth also improved, as evidenced by reduced incidence of low birth weight and improved APGAR scores for the cohort born after desegregation. The narrowing of the black–white test score gap in the 1980s can be traced back to improved health of black cohorts born after desegregation, indicating that access to care that improved birth outcomes translated to increased human capital development later in life.

Another way to identify whether increased care translates to better outcomes is to examine infants on either side of the 1500 g very low birth weight classification. Infants below 1500 g receive more intense care than infants just above the threshold, resulting in lower mortality rates for infants classified as very low birth weight. In line with the findings that improved care after desegregation increased the test scores of black children, very low birth weight infants just below 1500 g who received additional care outperform their peers with birth weights exceeding 1500 g.

Prenatal

Prenatal care should begin as soon as the mother is aware that she is pregnant; however, in the US approximately one in seven women do not attend until the second trimester. Usually, 7–11 visits are scheduled per pregnancy, and incorporate estimation of the expected date of delivery; education and counseling to reduce risk behaviors and promote health; and assessment of fetal growth through measurement of fundal height and ultrasound monitoring.

Screening is undertaken for maternal anemia, and for serum markers of neural tube defects and some chromosome abnormalities, with option for amniocentesis or chorionic villous sampling for women at increased risk. Genetic counseling is offered where indicated. Vitamin supplementation is commenced or continued, together with education about breastfeeding, the process of delivery, and early newborn care. Like well-child care, many of the current recommendations about prenatal care are derived from expert opinion, with varied strength of the scientific evidence behind a number of common practices.

Prevention

Prenatal care for populations at highest risk (including adolescent and other women <25 years of age, and older women with new or multiple sex partners), should include screening for cervical chlamydial infection.16 Cervical screening with NAATs should be performed during the third trimester, to reduce chances for re-infection and to ensure treatment before delivery. Repeat testing (preferably by a NAAT) should be performed 3 weeks after completion of therapy in all pregnant women to ensure therapeutic cure. One-dose treatment with azithromycin has efficacy equivalent to multi-dose doxycycline regimens, and ensures adherence (Table 16.11). The frequent gastrointestinal side-effects associated with erythromycin might discourage adherence with the alternative regimens.

Prophylaxis effective for gonococcal ophthalmia is recommended, but it is unclear whether it impacts risk for C. trachomatis neonatal conjunctivitis (Table 16.9).

Universal Screening

Prenatal care in the United States includes routine screening for serologic evidence of syphilis and rubella infection; culture or antigen evidence of Chlamydia trachomatis, group B streptococcus, or HBV infection; screening for urinary tract infection; and skin testing for tuberculosis. Evidence that treatment of the HIV-infected mother significantly reduces virus transmission to the fetus has led to recommendations by the U.S. Public Health Service and others for universal HIV screening for all pregnant women in the United States. Current CDC guidelines support voluntary HIV testing under conditions that simplify consent procedures, while preserving a woman's right to refuse testing [5,108,109].

Pregnant women with known HIV infection should be monitored and given appropriate treatment to enhance mother and fetal well-being and to prevent maternal-to-fetal transmission. Pregnant women should be examined carefully for the presence of HIV-related infections, including gonorrhea, syphilis, and C. trachomatis. Baseline antibody titers should be obtained for opportunistic infections, such as T. gondii, which are observed commonly in HIV-infected women and which may be transmitted to their fetuses. More detailed information on management of the HIV-infected pregnant woman and her infant is given in Chapter 21.

Pregnancy Care

The goals of prenatal, delivery, neonatal, and infancy care are to provide the mother and child with the optimal conditions and supervision to ensure the best possible outcome of the pregnancy, preserving the health and well-being of the mother and providing the newborn with the greatest chance of survival and optimal development. Since pregnancy is fraught with potential problems for the mother and the fetus, professional prenatal care and equally important self-care by the pregnant woman are necessary.

Prenatal care should be built around principles suggested by the American Congress (formerly College) of Obstetricians and Gynecologists (ACOG) and a Delphi Group Panel, US Department of Health and Human Services, in the late 1980s and periodically updated up to 2013, including:

preparation for pregnancy

early and continuous risk assessment

health promotion

medical and psychological intervention as needed.

Public health programs have the responsibility to assure prenatal care for the entire population either through direct provision of care or by obstetric services in managed care or private practice settings. Pregnancy is often a planned event, so that preparation for pregnancy is feasible. Pre-pregnancy and prenatal care should be early and complete for the health of the mother and the child. Preparation for pregnancy includes a general examination; inquiry as to possible allergies, infections, past obstetric history, and genetic problems; STI and HIV testing; nutrition status assessment and counseling; folic acid and iron supplements before and during pregnancy; smoking, alcohol, and drug use cessation; and mental health and social support systems with counseling as required. Other issues to explore are: undiagnosed, untreated, or poorly controlled medical conditions; immunization history, medication and radiation exposure in early pregnancy, nutritional issues, family history and genetic risk; tobacco, alcohol and substance use and other high-risk behaviors, occupational and environmental exposures; and social and mental health issues. Perinatal care standards recommended by ACOG are seen in Table 6.8.

TABLE 6.8. American College of Obstetrics and Gynecology-Based Perinatal Care Guidelines Summary

Note: Visiting schedule for an uncomplicated pregnancy: every 4 weeks for week 4–28; every 2–3 weeks for week 39–35; every week for week 36 to delivery. Frequency of visits may vary with individual needs and risks. Postpartum visit: 4–6 weeks after delivery for uncomplicated delivery; visit advisable 7–14 days after delivery for complicated delivery or caesarean.

HCT = hematocrit; HGB = hemoglobin; Pap = Papanicolaou; VDRL = Venereal Disease Research Laboratory; RPR = rapid plasma reagin; HBsAg = surface antigen of hepatitis B virus; HIV = human immunodeficiency virus; CVS = chorionic villus sampling; MSAFP = maternal serum α-fetoprotein; GBS = group B Streptococcus.

Source: American College of Obstetricians and Gynecologists (ACOG). Guidelines for perinatal care, 6th edition (2007). Revised January 2013. Developed by American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG). Available at: http://www.anthem.com/provider/noapplication/f2/s2/t0/pw_ad094972.pdf?refer=ahpprovider&amp;state=in (accessed 26.11.2013)

The parents should be provided with user-friendly reading material on pregnancy and parenting. Pre-existing medical conditions and obstetric history are important to determine hypertension, diabetes, previous fetal or infant deaths, previous exposure to hepatitis C, and other medical or social risk factors. Good prenatal care presupposes a basic program of visits with extra care for those at special risk.

Prenatal care in the community includes early presentation, high-risk assessment and referral, and continuous care throughout the pregnancy. Early diagnosis of pregnancy is important in permitting the woman to attend prenatal care as early as possible, hopefully in the first trimester. Early presentation for prenatal care provides the opportunity to assess the health of the mother and to advise her on appropriate nutrition and self-care. In addition, it establishes a working relationship between the mother and the caregiver. Both the mother and the father should become involved in prenatal preparation, including prenatal classes and exercises. Early detection of potential complications offers better outcomes of care and genetic disorders can be diagnosed early. Great success has been achieved in the early twenty-first century with antiretroviral treatment for HIV-positive women, which protects against transfer of the virus perinatally to their newborns and in the first weeks of life, reducing the vertical transmission rate from 25 percent to 2 percent or less. Even instituting maternal prophylaxis during labor and delivery, or neonatal prophylaxis within 24–48 hours of delivery, or both, can substantially decrease rates of infection in infants.

ACOG also recommends pre-pregnancy consultation to discuss pregnancy and infant care issues, especially related to counseling on the hazards to the fetus of smoking, alcohol and other drugs, the need for folic acid and multivitamin supplements as well as healthful diet, activity and rest levels. Prenatal care for a normal pregnancy should include a total of 13–15 visits to trained health providers, prenatal classes on physical care, and preparation for delivery, breastfeeding, and infant care. The mother’s routine checkups should include gynecological, medical and family history, occupational and environmental exposures, tests for sexually transmitted diseases, prior pregnancies and infant health, nutritional status, weight gain, alcohol consumption, smoking, alcohol use, emotional well-being, partner or family support systems and potential complications; physical examination includes weight, height, blood pressure, fetal heart tones, fundal height, and fetal activity; and tests for anemia, blood type, Rhesus (Rh) factor, rubella, hepatitis B antibodies, syphilis, and HIV status; and ultrasound scans.

The frequency of visits and the content of normal prenatal care for healthy women vary widely among countries and are sometimes considered “excessive”. However, good care should not be taken for granted. The achievement of low maternal mortality and morbidity along with low rates of risk for the newborn from low birth weight (LBW) and associated developmental problems should reinforce the importance of close supervision throughout a pregnancy. ACOG also recommends routine HIV screening for all pregnant patients unless they decline. Counseling is an important part of prenatal care, especially relating to lifestyle such as smoking alcohol and drug use, good nutrition with vitamin and mineral supplements, and preparation for motherhood with breastfeeding and infant care (ACOG Clinical Practice Guidelines for Prenatal and Postpartum Care, 2010). The CDC recommends that unvaccinated pregnant women receive a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) to protect the newborn until the baby is old enough to receive routine vaccination.

In some countries, such as Israel, prenatal care is separated from regular primary care and is offered in maternal and child health centers (MCHs) or women’s clinics with nursing supervision, medical examinations, and free hospital delivery, mainly by midwives; public health nurses are the major providers of prenatal care. In France attendance is mandatory before 14 weeks and during the remainder of pregnancy to receive full maternity benefits including maternity and family allowances and postpregnancy leave from work. Special care services are provided to LBW or other risk factors for the mother and infant, including social and financial assistance if needed. In some countries, such as the Netherlands and the UK, family practitioners provide prenatal and obstetric services. In others, such as the USA and Canada, specialist obstetricians and general practitioners both provide prenatal and delivery services. Whether prenatal care is part of primary care services or a separate public health service, the goals must include universal coverage starting before or very early in pregnancy, risk assessment with referral and care, and ready access to specialized care. Health education provided in prenatal classes for the pregnant woman and her partner offers additional counseling and peer group support.

The pregnant woman should be provided with a complete medical record of her prenatal care during scheduled visits, so that when she arrives in the maternity unit, the provider of care will have adequate information. Therefore, even if she has not been seen previously by the new caregiver, the record grants a measure of continuity beneficial to both the woman, who knows that her record of previous care is available when needed, and the provider, who has the use of all her previous documentation. A public health system should ensure adequate records systems for maternity care to reduce unnecessary complications and mortality in the birth process.

In developing countries, improved access to prenatal care and increased use of midlevel health workers in “baby-friendly” birth centers, coupled with training and supervision of traditional birth attendants, spacing of pregnancies, risk assessment, and referral, are all needed to lower the present high rates of maternal and perinatal mortality. As discussed in the context of maternal mortality, progress in this regard has been extremely disappointing over the past several decades, even in countries with substantial economic growth and increased governmental revenues such as Nigeria and India.

High-Risk Pregnancy

Low-risk pregnancies are those in healthy women between the ages 18 and 34, who present at least once in the first trimester, who have had no more than three previous normal live births, no previous stillbirths or obstetric complications such as gestational diabetes or pre-eclampsia, and who have no history of drug or alcohol abuse, and no major medical conditions such as hypertension or kidney disease. Such women should be followed in a routine prenatal care program.

High-risk pregnancies (HRPs) are defined as those pregnancies with pre-existing or current conditions that put the mother, the fetus, and the newborn baby at higher than normal risk for complications during or after the pregnancy and birth. These include very young and older women, those with low levels of education and nutrition, as well as those with previous or current medical and obstetric complications and those in poverty or unstable living arrangements. HRPs should be identified as early as possible so that the patient can be given special care for her benefit and especially for the well-being of the fetus and newborn. Identification and management of high-risk factors initially and throughout pregnancy improve pregnancy outcomes for the mother and the newborn. Some predictors of HRP are maternal age (too young or too old), primiparas or grand multiparas, previous obstetric difficulties, other medical conditions (e.g., HIV, hypertension, heart disease, diabetes, kidney disease, or mental illness such as depression), malnourishment, poverty, women who attend STI clinics, and use of cigarettes, alcohol, or other drugs. Risk factors may include social and economic factors such as adverse family circumstances, housing, financial status, and working conditions.

The medical and obstetric history provides evidence of previous risks such as frequent abortion, complications in pregnancy, or medical conditions that could affect the mother during the pregnancy or at the time of delivery. Pregnancy under the age of 16 or 17 or over the age of 35 should automatically define the pregnancy as being at higher than normal risk. Grand multiparity (i.e., more than five previous births) or a first pregnancy (primigravida) should also be considered as an extra risk for the mother, but more so for the newborn.

A scoring system provides a set of standards or guidelines for risk assessment to assist the primary care provider in early detection and referral of patients on the basis of a reasonably objective set of criteria for high-risk factors. Detailed guidelines are needed to implement this kind of standard for HRP and monitoring is of value to improved pregnancy care. The form and guidelines developed should take into account local risk factors, such as high consanguinity rates in some societies or chronic malnutrition in the population. Scoring systems produce a cumulative risk assessment by adding those factors that by themselves would not mean the pregnancy is high risk, but taken together indicate potential problems. The actual cut-off points for age, parity, and education levels can be adjusted to conditions in each country, but the principle of national standards is important. Fetal and neonatal monitoring is vital in developing countries, as neonatal mortality is a major part of total infant mortality. Low-cost, technologically adequate respirators and incubators are now being made and distributed, and training to support such efforts is crucial.

The HRP assessment and referral form outlined in Table 6.9, developed and used in a rural primary care setting, was adopted throughout a governmental health system in a developing area (West Bank and Gaza) for maternal and child health nurses and CHWs to promote early referral of HRPs (see Chapter 14). This record summarizes medical, obstetric, and prenatal care, especially parity, date of last menstrual period, risk factors, and prenatal care findings. In this case, A = low risk, B = medium risk, and C = high risk. Clear definitions and staff training and instruction are required. In some cases one C (e.g., hypertension) requires referral, or several Cs or Bs mean mandatory referral. The format and scoring system can vary, such as scoring each topic from 1 to 10 with systematic compilation of the score. Referral to HRP clinics needs not only a clear indication or reasons for referral, but also thorough assessment by specialists and feedback to the referring physician or other primary care provider. The HRP clinic should send the patient back to the referring center with a report of findings and a clear recommended plan of action. The HRP clinic may continue to follow the patient because of the risk factors, but the referring provider should have this information and assist in its implementation. A mother-carried record is desirable, since access to prenatal clinic records may be limited and may not include care given by other providers, such as emergency departments or private physicians.

TABLE 6.9. High-Risk Pregnancy Assessment and Referral Form

I. Personal Data	II. Social/Personal	III. Obstetric History
Name	Age (< 17, > 35 years)	Gravida (1 or > 5)
Identity Number	Education (< 6 years)	Para (0 or > 5)
	Marital status	Abortions (> 2)
Date of Birth	Economic status	Miscarriages (1+)
Address	Consanguinity	Fetal deaths (1)
	Smoking	Bleeding in T3
City/Town/Village	Alcohol	Stillbirths (1)
	Drug use	Previous caesarean (1)
Clinic	Home conditions	Preterm deliveries
Date last menstrual period	Summary	Birth weights
Date of first visit	_____________________________ _____________________________ _____________ A B C	Infant deaths (1) Toxemia (1) Birth defects (1) Summary _________________________ A B C
IV. Medical and Family History	V. Present Pregnancy	VI. Summary of Risk Factors
Diabetes	Last menstrual period	I. Personal A B C
Hypertension	Number of present pregnancy
Renal disease	Time of first visit T1 T2 T3	II. Social A B C
Heart disease	Weight before pregnancy < 50 kg
Chronic chest disease	Height < 145 cm	III. Obstetric history A B C
Blood disorder	Blood pressure
Endocrine disease	Bleeding	IV. Medical history A B C
Phlebitis	Pre-eclampsia
STDs	Rh	V. Present pregnancy A B C
Other	Multiple pregnancy
Summary __ ____________________________	Abnormal presentation	VI. Total score A B C
________________________ A B C	Summary _______________________ A B C
Summary of Reasons for Referral: _________________________ _______________________________________________________________ Date: ________________________ Signature: ______________________________ Position: ___________________ Report of High-Risk Clinic: _______________________________________________ ______________________________________________________________________ ______________________________________________________________________ Date: _______________________ Signature: _________________________________ Position: ______________________________________

Note: This is intended as a model for primary care early identification of high risk and prompt referral on the basis of history and basic findings. Full prenatal care recommendations are available from the American College of Obstetrics and Gynecology.

A well-developed HRP assessment, referral and follow-up system contributes to improved outcomes for both mothers and newborns, preventing costly long-term consequences of maternal and infant morbidity and mortality. Its role in preventing complications during and following delivery is well justified on medical, public health, and economic grounds.

The issues may be different in developing and developed countries, but the principles are similar. In the USA, there are substantial population groups that cannot obtain prenatal care for financial or bureaucratic reasons, including those who may be at highest risk. A comparison of several European region countries (Figure 6.6) shows dramatic progress in Romania and considerable progress in Russia, with reduced maternal mortality from 74 (in 1990) to 16.9 per 1000 live births in 2010.

FIGURE 6.6. Maternal mortality (maternal deaths per 100,000 live births) in selected countries of the WHO European Region, 1970–2010.

Source: World Health Organization. European Region. Health for All database; July 2013. Available at: http://data.euro.who.int/hfadb/ [Accessed 22 November 2013].

Maternal mortality does respond to improved access to medical care, as seen in its rapid decline in Italy and Portugal during the 1970s following introduction of their national health services. Countries with both universal access and well-developed obstetric care and risk assessment have low rates of maternal and infant mortality (e.g., Australia, Belgium, Denmark, Israel, and Norway). Despite great progress in reducing maternal mortality during the twentieth century (CDC, 1999), the USA has a comparatively poor showing of maternal mortality, being placed well behind almost all industrialized countries of Europe and Asia. This not only is due to a lack of universal health insurance, but also relates to many social and economic issues of a society that is prejudiced against mothers and children of minority groups and others living in poverty.