1.3 Monitoring complicated pregnancies

The term “complicated” refers to pregnancies 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 ante-partum intrauterine foetal death.
– Progressive associated pathology 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 1.40 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 (risk of uterine rupture, uterine atony, uterine atony-related haemorrhage).

Note: it is essential that all maternity hospitals without an operating room 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 with vertical (classical) incision or more than two caesarean births.
• Transverse lie.
A planned caesarean should be done at 39 weeks LMP or later. Before 39 weeks LMP, caesarean births without labour – even when not premature (37-38 weeks LMP) – are associated with a high risk of neonatal respiratory distress. That risk exists regardless of the estimated foetal weight.

When the due date is uncertain:
• If there is a very high risk of uterine rupture (e.g., history of severe uterine rupture or more than three prior caesarean sections), consider scheduling a caesarean section prior to labour during the ninth month, with preparation for managing neonatal respiratory distress.
• In other cases it is better to wait until the woman goes into labour to do the caesarean section. Under those circumstances, if the patient lives far away, suggest that she move near the facility where she will deliver during her ninth month, either with family or at a residential facility (maternity waiting home).

– In situations where there is a high risk that emergency caesarean or complex obstetrical manoeuvres will be needed:
• History of 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.

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

– History of abruptio placentae, severe pre-eclampsia or eclampsia (for secondary prophylaxis with aspirin, Chapter 4, Section 4.5.6).

– Pre-eclampsia (risk of eclampsia, coagulopathy, maternal death, abruptio placentae, intrauterine growth retardation, 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 retardation and postpartum haemorrhage). Advise rest.

– Premature rupture of membranes (risk of infection, preterm delivery and intrauterine foetal death).