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106 terms

Assessment of fetal well-being

maternal nursing
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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