1.3 Monitoring complicated pregnancies

The term “complicated pregnancy” refers to any pregnancy in which the mother or infant is at increased risk due to a particular obstetric or medical pathology or history.

Complicated pregnancies may require higher level monitoring and/or special arrangements for delivery in a medical/surgical setting.

1.3.1 Situations requiring higher level monitoring

In the following situations, the increased risk exists mainly during pregnancy itself rather than delivery:

• History of preterm delivery or multiple miscarriages (risk of recurrence).
• History of unexplained intrauterine foetal death.
• Progressive pathology associated with pregnancy such as upper urinary tract infection (risk of preterm delivery), anaemia (possible exacerbation), hypertension, pre-eclampsia, etc.

1.3.2 Situations requiring special precautions for delivery

In the following situations, the increased risk exists mainly during delivery rather than during pregnancy.

Arrange for delivery in a BEmONC facility:

• History of intra-partum intrauterine foetal death or death in the first day of life (risk of recurrence).
• History of haemorrhage during a prior delivery (risk of recurrence and maternal death).
• History of forceps or vacuum delivery (risk of recurrence).
• Height less than 1.50 m (risk of foeto-pelvic disproportion).
• Primiparity (risk of obstructed labour).
• Limp, hip dislocation, polio sequelae with frank pelvic asymmetry (risk of obstructed labour).
• Grand multiparity i.e. 5 deliveries or more (risk of uterine atony, uterine atony-related haemorrhage, uterine rupture).

Note: it is essential that all BEmONC facilities have an effective system for referring patients to a CEmONC facility.

Arrange for delivery in a CEmONC facility:

• In situations that routinely require caesarean section:
  •  History of uterine rupture;
  •  History of caesarean section with vertical (classical) incision or more than two caesarean births;
  •  Transverse lie.
• In situations where there is a high risk that emergency caesarean or complex obstetrical manoeuvres will be needed:
  •  History of caesarean section with low uterine segment transverse incision;
  •  History of uterine scar (perforated uterus or myomectomy);
  •  History of vesico-vaginal fistula;
  •  History of symphysiotomy;
  •  History of third or fourth degree tear;
  •  Breech presentation, in particular in primipara.

1.3.3 Situations requiring closer monitoring during pregnancy AND special precautions for delivery (CEmONC)

• History of abruptio placentae, severe pre-eclampsia or eclampsia.
• Pre-eclampsia (risk of eclampsia, coagulopathy, maternal death, abruptio placentae, intrauterine growth restriction, intrauterine foetal death) or eclampsia.
• Bleeding (risk of preterm delivery, foetal distress, intrauterine foetal death, anaemia, maternal death).
• Severe anaemia (risk of small foetus, prematurity, neonatal anaemia, increased vulnerability in case of haemorrhage). Transfusion should be available in case of severe anaemia during the third trimester.
• Multiple pregnancy (risk of obstructed labour, preterm delivery, hypertension, diabetes, intrauterine growth restriction and postpartum haemorrhage).
• Preterm rupture of membranes (risk of infection, preterm delivery and intrauterine foetal death).