Antepartum and Intrapartum Care of the High-Risk Mother and Fetus
Core concepts
High-risk care begins with risk stratification: maternal age, parity, chronic disease, prior pregnancy loss or preterm birth, multiple gestation, hypertensive and diabetic disorders, and fetal growth abnormalities. Understand antenatal surveillance tools - daily fetal movement counts, nonstress test (NST) reactivity, biophysical profile (BPP) scoring, and umbilical artery Doppler - and what each detects. Know the categories of fetal heart rate (FHR) patterns per standard terminology: baseline rate, variability, accelerations, and decelerations (early, variable, late, prolonged). Late decelerations suggest uteroplacental insufficiency; variables suggest cord compression; early decelerations are benign head compression. Know the intrauterine resuscitation bundle: maternal repositioning, oxygen if hypoxemia, IV fluid bolus, stop oxytocin, and tocolysis for tachysystole.
Traps
Questions often confuse the cause of decelerations or ask for the first nursing action versus the definitive intervention. Another trap: assuming a reactive NST excludes all compromise - it is a short snapshot. Also watch for magnesium sulfate toxicity signs (loss of deep tendon reflexes, respiratory depression, oliguria) and the antidote, calcium gluconate.
Worked example
A laboring patient at 7 cm has repetitive late decelerations with minimal variability after oxytocin. Rule of thumb: stop the oxytocin first, reposition, bolus fluids, then reassess - persistent late decelerations with minimal variability warrant expedited delivery planning. Remember: variability is the single most reassuring feature; its loss is the most concerning.
Study focus
Link each monitoring finding to a physiologic cause, and practice prioritizing interventions in the correct sequence.