Assessment of fetal well-being

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maternal nursing

Transabdominal Ultrasound

Can detect gestational sac at 4-6 weeks. Must have full bladder., Transabdominal approach, a transducer is moved accors the woman's abdomen. The woman is often scanned with a full bladder.

1 - 1.5 quarts of water 2hrs before exam

Transmission gel, not laid supine,,, elevating her upper body during test... watch for dizziness due to postural HTN due to inferior vena cava compression.

Transvaginal ultrasound

ultrasound using a transducer inserted into the vagina to view the internal female reproductive organs
Useful for early embryonic development, fetal heart beat and visualizing intrapelvic structures. crown to rump length, gestational age,sac.
CERVICAL FUNNELING - CONE SHAPED INDENTATION, INDICATIONG RISK OF PRETERM LABOR

EMPTY BLADDER...

Limited or standard, basic ultrasound

Basic screening - gestational age, # of fetuses, fetal death, status of placenta

specialized or detailed ultrasound

Comprehensive screening - looking for specific abnormalities

Biophysical variables of fetus

Breathing movement, body movement, tone (flexion of extremities), amniotic fluid volume, FHR reactivity. All are assessed by ultrasound except FHR reactivity

Fetal heart rate reactivity

Is tested with a non-stress test

Fetal Movement

Kick count done by mom. Fetal alarm sign if there is no movement for 12 hours. Count kicks for 60 minutes should feel >3 movements during that time.

Non-stress test

Observing for acceleration of fetal heart rate with movement. Shows intact central and autonomic nervous systems.

Non-stress test = Reactive

Means at least 2 accelerations of FHR with fetal movement.

Non-stress test = Non-reactive

Accelerations not seen or accelerations were not wide enough (>15 beats per min).

To encourage fetal movement

Pushing on abdomen, music or vibratory device. give something to drink, baby may be reacting to increased sugar level.

Contraction stress test

Used to evaluate placental/fetal reserve. Observation of fetal heart rate to stress of uterine contractions. evaluating the respiratory function of the placenta..o2 and co2 exchange, identify fetus at risk for intrauterine asphyxia.

Reasons to do a CST

High risk pregnancy, IUGR (intrauterine growth restriction), diabetic mother, non-reactive NST, abnormal biophysical profile. DM, Post dates

Reasons to NOT do a stress test

Bleeding, placental previa or abrupti), classical c-section, risk of pre-term labor, incompetent cervix, PROM, Multiple gestation

Procedure for CST stress test

Not before 28weeks usually after 32 weeks. informed consent, semi fowler or left lateral. Record FHR and UC's. monitor BP and HR. Spontaneous or induced (oxytocin), breast self stimulation(BSST), contractions lasting 40-60 seconds 3 times in 10 minutes. Induced - Pitocin or Nipple stimulation

Negative stress test results

No late or variable decelerations, good also be reactive NST or non- reactive NST

Negative CST with reactive NST is good
Negative CST with Non-reactive NST is ok.. but need to be monitored

positive stress test results

Late decelerations with contractions. Discontinue test if there are 3 or more late decels & notify MD... do not induce more...

Early amniocentesis

15-20 weeks..Done to detect chromosome & biochemical abnormalities - Down's syndrome

Late amniocentesis

30-39 weeks Done to detect lung maturity - for fetal viability

Amniocentesis procedure

Ultrasound is used to locate fetus, cord, fluid & placenta. Withdrawal of 15-20 cc of fluid, fluid is shielded from light to prevent breakdown of bilirubin. Fetal & maternal VS monitored, Rhogam given to Rh negative mother. performed between 15-20 weeks for genetic testing, 30-39 for lung maturity

Amniocentesis complications

Can trigger early labor - #1 reason why women refuse. Bleeding, transfer of Rh factor, infection, fetal distress.

Alpha-fetoprotein (AFP)

Blood test - not diagnostic! Maternal blood test done at 16-18 weeks, gestational age accuracy is important

Increased levels of alpha-fetoprotein

May indicate neural tube defects, anencephaly or abdominal wall defect. Would follow up with level 2 ultrasound.

Low levels of alpha-fetoprotein

May indicate fetal chromosome abnormalities such as Down's syndrome. Would follow up with amniocentesis if mother agrees.

Possible abnormal AFP level results

Can be caused by multiple gestation, incorrect gestational age, dead fetus, abdominal wall defect, Rh sensitization, fetal distress

Chorionic villi sampling

Done for the same reasons as amniocentesis, but can be done earlier at 8 weeks.

mother records the time interval it takes to feel ten fetal movements

count to ten/ cardiff method

what is the normal fetal heart rate?
- can be heard as early as 12 wks with doppler

120-160

<110 bpm for 10 minutes

bradycardia

>160 bpm for 10 minutes

tachycardia

irregularity or fluctuations of fetal heart rate

variability

increase of FHR by 15 bpm above the baseline lasting 15 seconds or longer

acceleration

decrease of FHR by 15 bpm below the baseline lasting 15 seconds or longer

deceleration

FHR measured in response to fetal movement
- non-invasive, generally done @ 28 wks, similar to fetal heart monitoring

non stress test (NST)

two accelerations of FHR lasting 15 sec occurring after movement - good

reactive NST

no accelerations of the FHR with movement of fetus - not good

non-reactive NST

usually done after NST, invasive
- assess ability of fetus to withstand the stress of uterine contractions, how will the fetus withstand labor?
- performed if NST is abnormal,
- gain c-section consent forms before

contraction stress test (CST) or oxytocin challenge test (OCT)

represented with no late decelerations of FHR, FHR stays within baseline during test, good sign

negative CST

late decelerations/invariabilities of the FHR for more than half of the contractions, will do c-section, baby would not be able to withstand labor, bad sign

positive CST

________ CST indicates that the fetus can survive labor

negative

________ CST indicated that the fetus is unlikely to tolerate labor

positive

Used to determine:
- diagnosis of pregnancy
- confirm presence, size and location of placenta
- presentation and position of fetus
- fetal gross defects

ultrasound useful after 1st trimester

physician inserts a needle into amniotic sac and removes amniotic fluid
- patient has to sign consent form, needs to void before procedure, RhoGAM (if indicated) should be given after procedure
- risks: hemorrhage, infection, puncture of fetus

amniocentesis

amniotic fluid should be what color?

clear/ like water

yellow amniotic fluid may indicated what?

blood incompatibility

green amniotic fluid may indicate what?

meconium

genetic testing for various abnormalities

chromosome analysis

blood test done prenatally (16-18 wks), some Dr's do and some don't, good way to begin to rule out genetic abnormalities, need to have a value somewhere in the middle, may or may not be accurate, serum test

alpha-fetoprotein test (AFP)

____ levels of AFP indicate open spinal (spina bifida) or abdominal defects

high

___ levels of AFP indicate chromosomal defects

low level downs syndrome

What are the five parameters of biophysical profile?

fetal breathing movements
fetal movements
fetal tone
amniotic fluid volume
fetal heart reactivity

biophysical profile score of 8-10 means?

good/normal

biophysical profile score of 6 means?

satisfactory but be aware

biophysical profile score of 4 or less means?

fetus is compromised

ultrasound

using the reflections of high-frequency sound waves to construct an image of a body organ (a sonogram)
A non invasive test used to outline the shape and determine the consistency of various organs and diagnose pregnancy; it can also be used to determine the exact position, size, and gender of the fetus and to identify some developmental anomalies.

sonograms

use sound waves to create an image of a structure; for observing a fetus; echocardiogram for observing heart movement; harmless; inexpensive

limited ultrasound information

determine placental location
determine fetal presentation
confirm fetal viability
detects presence/absence of fetal heart activity
assess amniotic fluid index
determine presenting part
identify problems
diagnose multiple gestation
Evaluate interval growth
assist with amniocentesis

when are ultrasounds done

usually in the second and third trimesters

crown to rump

measure from head to end of buttcok of three centimeter (1.2 inches)

Viability

ability of the fetus to survive outside the womb

serial quantitative beta HcG testing

A product of the trophoblast or placenta that is detected through serum testing and is a very accurate marker of the presence of pregnancy and placental health.
Doubles every 2 days
tests taken 48 hours apart-if Beta Hcg falls, a miscarriage or ectopic pregnancy should be suspected

when is serial quantitative HcG indicated (first trim)

risk of ectopic preg
spont. abortions
intrauterine divice in place
Hx of PID
reversal or tubal sterilization
spotting
conceived through reproductive methods

progesterone

secreted in early from the corpus luteum to prepare and sustain the endometrium of the uterus for pregnancy for approximately 8weeks at which point the placenta starts to produce it

progesterone level testing (First Trim)

low levels associated with spontaneous abortions and ectopic pregnancy
Progesterone seals the sac and creates the placenta
25ng is normal <5 indicates non viable

Ultrasound during first Trim

landmarks presence of gestational sac, cardiac motion, embryo development of normal early pregnancy. crown to rump accurate estimator of EDB if performed within 6-10 weeks of gestation, after first trim US uses measurements from femur, AC,BPD. Cervical length/incompetence

accurate estimator of EDB

crown to rump accurate estimator of EDB if performed within 6-10 weeks of gestation

BPD

measures babies head across

AC

abdominal circumference

Nuchal Translucency Testing

A combination of an ultrasound and maternal serum test that is used to screen fetuses between 11 weeks and 1 day and 13 weeks and 6 days to determine if a fetus is at risk for a chromosomal disorder, such as Down syndrome (trisomy 21) and trisomy 18.
Nuchal folds > 3mm increases incidence of down
syndrome - NON invasive
Presence of Nasal Bone

Less accurate

biophysical profile

A test that assess five variables; fetal breathing, fetal movement, fetal tone, amniotic fluid volume, and FHR acceleration

FHR done with NST
the other 4 with Ultrasound

Why is BPP done and when?

BPP helps identify the compromised fetus and confirm the healthy fetus.
Indications for BPP:
1. When NST and CST would be done
2. Decreased fetal movement (non reactive NST)
3. mangaement for IUGR, PTL, DM, post term, prom

what does NST reflect

intactness of nervous system

what does AFI reflect (amniotic fluid volume index)

kidney perfusion

Cordocentesis

sampling of fetal blood drawn from the umbilical vein and performed under ultrasound guidance, procedure to obtain a fetal blood sample; also called a percutaneous umbilical blood sampling

why cordocentesis

dx. hemophilia, fetal infection, hemolytic disorders, platelet disorders, fetal hgb, hct, chromosome of gene abnormalities, dx of fetal anemia, fetal blood grouping, dx and tx fro isoimmunization, assessment of fetal well being, fetal metabolic disorders.
avoid deep breathing
pregnancy loss: 1 in 100 pregnancies

isoimmunization

The term for the mixture of fetal and maternal blood causing anti-D antibodies to be produced

Chorionic Villus sampling

guided by the ultra sound, sampling of placental tissue for microscopic and chemical examination to detect fetal abnormalities, and genetic disorder. Cannot detect neural tube defects. Higher rates of pregnancy loss than amnio, risk of fetal limb defects.

amniocentesis/ cordocentesis NMGT

clarify physicians instructions, responding to woments need for reassurance, anticipatory guidance, relaxation techniques like shallow breathing during procedure, assessment during and after procedure like fetal and maternal well being

when is chorionic villus sampling done

performed at 10-12 weeks (after 9 weeks to minimize fetal limb reduction defects)

advantages/disadvantages of CVS

--Advantages of CVS include early detection of certain fetal disorders with a decreased waiting time for results.
--Disadvantages include an increased risk to the fetus, inability to detect neural tube defects, and the potential for repeated invasive procedures.
miscarriage, fetal limb anomalies, rh incompatibility, hemorrhage, infection

indications for amniocentesis

The following indications for {this} test:
Pregnant women 35 or older on their due date - the risk of having an infant with a chromosomal problem
Couples who already have a child with a birth defect or have a family history of certain birth defects
Pregnant women with other abnormal screening or genetic test results.

Assessment for lung maturity for preterm births

procedure for amniocentesis

clarify procedure/indication
informed consent/if not verify the doc has explained the procedure and ask sign consent
22-guage spinalneedle with stylet
amber colored test tubes (protect it from sunlight to prevent breakdown of bilirubin)
sterile procedure
obtain baseline vitals for mom and fetus and monitor during procedure
pregnant woman should be placed in a left lateral tilt position by placing a wedge under her right hip to prevent hypotension during procedure.
cleanse abdomen, doc done procedure, collect testube, monitor vitals after, risk for hypotension
administer Rh immune globulin if indicated

educate pt. to report any adverse reactions

Adverse reactions of amniocentesis

unusual fetal hyperactivity of lack of fetal movment
vaginal discharge, clear or bleeding
uterine contractions or abdominal pain
Fever/chills (infection)

MSAFP

maternal serum alpha-fetoprotein, screens for NTDs, abdomial wall defects
Blood test - not diagnostic! Maternal blood test done at 15-16 weeks, gestational age accuracy is important
Screening not diagnostic
first marker in the quad screen

Elevated:
-underestimation of gestinational age
-twins
-dead fetus
-placental bleed
-maternal tumor
- NTD neural tube defect

conditions warranting fetal surveillance in third trim (maternal conditions)

Maternal conditions
-htn
-dm
-renal disease
-heart disease
-SLE
-hyperthyroidism
-antiphospholipid syndrome (APL)
-Hemoglobinopatthies

pre-eclampsia

a condition during pregnancy where there is a raised blood pressure, albumin in the urine and oedema of the face and body (also known as toxaemia of pregnancy) - it precedes eclampsia

conditions warranting fetal surveillance in third trim (pre-natal conditions)

-preeclampsia (headache, protein in the urine)
-decreased fetal movement
-oligohydraminios
-hydramnios
-IUGR
-Postterm
- Rh isoimmunization
- previous fetal demise
-multiple gestation
- known fetal anomaly
- abnormal Biochemical test result

hydramnios

more than 2000 ml of amniotic fluid in the uterus. can cause maternal diabetes; esophageal atresia (diminishes or prevents fetal swallowing); and kidney disorders that affect kidney output.

oligohydraminios

condition in which the amount of amniotic fluid is significantly less than the amount expected for the third trimester of pregnancy
(less than 400 ml) or less than 5 cm total of a four-quadrant sonographic assessment

IUGR

Intrauterine growth retardation caused when a baby is malnourished during the last few weeks of development (symmetrical) or throughout the entire process (asymmetrical). Leads to small size, diminished structures.

fetal movement assessment

10 times in 3 hours
3 movements 20-30 min 3 times a day (if less than three.. count for 1 hour)

contact HCP
- <10 movements in 3 hours
- <no movements in the morning
-< 3 movements in 8 hours

Kick counts

movements are perceived until approximately 16 weeks for multipara and upto 20 weeks for primipara. monitoring may begin in 28 weeks , eat, empty bladder, lie down on left side. fetal movements peak at 26-32 weeks and then starts to decrease

low fetal movements

problems with placental funciton
hypoxia
fetal resting state- sleep cycle (40 min)
medications
exercise
glucose
smoking

Evaluate with NST, BPP

Non stress test interpretation

You want to see 2 or more accelerations of 15 beats/min with fetal movement. Each increase should last for 15 seconds and is recorded for 20 mins. The increase is >15 beats above baseline and lasts for at least 15 seconds.

why non stress test NST

to observe accelerations of FHR, with or without fetal movement, to determine adequacy of fetal oxygenation and CNS. Fetal activity will lead to Accels in FHR which indicates intact CNS

when is NST performed

30-32 weeks and after

advantages/disadvantages of NST

Adv: outpatient settting, noninvasive, painless, w/o risk to fetus or mother, easy to administer, fast, low false negative.
Disadv: high rate of false-positive due to sleeping fetus (nonreactive results in well-oxygenated fetus), poor tracing, not diagnostic, lower sensitivity to fetal compromise than CST, BPP

NST procedure

1) record pulse and BP
2) pt lies in semi-fowler or left lateral
3) apply external fetal monitor
4) monitor for 30-40m
5) mark fetal accelerations and movements on graph, women are requested to be non-fasting and to have refrained from recent cigarette smoking because this can adversely affect test results. explain procedure, ask client void. The NST is typically performed with the women in the semi-Fowler's position with a small pillow or blanket under the right hip to displace the uterus to the left. The FHR is monitored by the placement of an electronic fetal monitor.
-The FHR is usually monitored for 20 minutes, but monitoring may be extended to 40 minutes if the fetus is in a sleep cycle.

reactive NST

2FHR accels of 15 beats per minute for 15 seconds within a 20 minute period

nonreactive NST

FHR does not accelerate with fetal movement after 2 attempts (40 min) further assessment needed such as CST or BPP... follow up with BPP

Contraction stress test

method for evaluating fetal status during the antepartum period by observing the response of the fetal heart to intermittent stress of uterine contractions.

First trimester assessments

1. serial quantitative beta HCG testing
2. Progesterone level testing
3. Early ultrasound
4. Nuchal translucency testing

Second trimester assessments

Ultrasound between 18-24 usually around 20 weeks

Ultrasound in second trimester

1. fetal lie
2. fetal number
3. fetal presentation
4. Presence of abnormal heart rhythm
5. Evaluation of Fetal anatomy
-head for anencephaly
-spine for spina bifida
-Thorax and ches: 4 chambers of heart
-abdomen: bladder, stomach, kidneys visualized
-extremities
6. Gestational age and growth
7. AF volume
8. placental location in relation to the cervical os - low lying placenta or placenta previa
9. Umbilical cord, # of vessels
10. Uterine anatomy

placenta previa

pregnancy in which the placenta is implanted in the lower part of the uterus (instead of the upper part) no intercourse or anything inside the uterus.

Third trimester Assessment

Fetal movement Assessment
NOn stress test
Contraction stress test
Biophysical profile

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