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Fetal Assessment During Pregnancy

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Limited ultrasounds

3 Levels of ultrasounds: § ___________________ are performed to determine a specific piece of information about the pregnancy, like identifying fetal position during labor or estimating AFV. These are usually done by the obstetric health provider or someone with very little training in a clinic or labor and birth unit

Targeted, specialized, or detailed (Level 2) ultrasounds

3 Levels of ultrasounds: § _____________________ are performed if a woman is suspected of carrying an anatomically or physiologically abnormal fetus. Indications include abnormal lab history or abnormal results of previous exams

Standard/ Basic ultrasounds

3 Levels of ultrasounds: § _____________________ can be performed by doctors, nurses, or other healthcare members who are trained to do so (ultrasound tech). In the 2ndand 3rd trimesters, it is used to evaluate fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal growth parameters, and number of fetuses · OFTEN USED FOR A STANDARD PREGNANCY ASSESSMENT

C. NST reactive

A nurse is caring for a client at full term who says her fetus is not moving as much as usual. Which test result would lead the nurse to reassure the client that the fetus is okay? A. Positive CST B. AFI = 4 C. NST reactive D. BPP is 3/10

B. Lecithin/sphingomyelin (L/S) ratio

A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? A. Alpha-fetoprotein (AFP) B. Lecithin/sphingomyelin (L/S) ratio C. Keilhauer-Betke test D. Indirect Coombs' test

A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Post-maturity

A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (SATA) A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Post-maturity D. Placenta previa E. Amniotic fluid emboli

D. "It awakens the sleeping fetus."

A nurse is caring for a client who is pregnant and is undergoing a non-stress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? A. "It is used to stimulate uterine contractions." B. "It will decrease the incidence of uterine contractions." C. "It lulls the fetus to sleep." D. "It awakens the sleeping fetus."

B. Fetal breathing movement C. Fetal tone E. Amniotic fluid volume

A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (SATA) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Fetal position E. Amniotic fluid volume

C. "You should empty your bladder prior to the procedure."

A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? A. "You will lay on your right side during the procedure." B. "You should not eat anything for 24 hours prior to the procedure." C. "You should empty your bladder prior to the procedure." D. "The test is done to determine gestational age."

· Infection - red, sore, fever · labor: cramping, vaginal bleeding, water leakingbaby: less movement · *if rh neg mom, give rh0 d immunoglobulin (rhogam)

Amniocentesis · Amniocentesis is a Sampling of amniotic fluid, once enough accumulates (from 13-14 week to full term). This is done through insertion of a needle transabdominally into a client's uterus and amniotic sac under ultrasound guidance to locate the placenta and fetus · Under direct ultrasonographic visualization, a needle is inserted transabdominally into the uterus and amniotic fluid is withdrawn into a syringe. · Indications: prenatal diagnosis of genetic disorders or congenital anomalies (NTD) assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease · Preprocedure: explain the purpose and obtain informed consent. Teach the client to empty the bladder prior to the procedure to reduce risk of inadvertent puncture · Intraprocedure: § Obtain baseline vital signs and FHR prior to procedure § Assist client into a supine position and place a wedge under the right hip and place a drape over the client to expose only the ABD § Prepare the client for an ultrasound to locate placenta § Clean client's ABD with antiseptic solution prior to administration of local anesthetic by the provider § Tell the client there will be a feeling of pressure as the needle is inserted. They need to continue breathing because holding the breath will lower the diaphragm against uterus and shift uterine contents · Postprocedure: § Monitor vitals, FHR, and uterine contractions 30 minutes after § Have the client rest for 30 minutes § Administer Rho(D) immune globulin if they are Rh-negative § Teach the client to report fever, chills, leakage of fluid or bleeding from insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after procedure § Drink plenty of fluids and rest for 24 hours after procedure § POST "Amnio" care: does it hurt? Some cramps for an hour § What to watch out for: - - - - § Administering RhoD immunoglobulin to Rh negative moms after amniocentesis is standard practice to prevent mom's production of antibodies against the baby's blood.

§ Maternal: leakage of amniotic fluid, hemorrhage fetomaternal hemorrhage with Rh incompatibility, infection, labor, placental abruption, inadvert damage to intestines or bladder, amniotic fluid embolism § Fetal: death, hemorrhage, infection (amnionitis, and direct needle injury

Amniocentesis · Amniocentesis is a Sampling of amniotic fluid, once enough accumulates (from 13-14 week to full term). This is done through insertion of a needle transabdominally into a client's uterus and amniotic sac under ultrasound guidance to locate the placenta and fetus · Under direct ultrasonographic visualization, a needle is inserted transabdominally into the uterus and amniotic fluid is withdrawn into a syringe. · Indications: prenatal diagnosis of genetic disorders or congenital anomalies (NTD) assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease · Preprocedure: explain the purpose and obtain informed consent. Teach the client to empty the bladder prior to the procedure to reduce risk of inadvertent puncture · Intraprocedure: § Obtain baseline vital signs and FHR prior to procedure § Assist client into a supine position and place a wedge under the right hip and place a drape over the client to expose only the ABD § Prepare the client for an ultrasound to locate placenta § Clean client's ABD with antiseptic solution prior to administration of local anesthetic by the provider § Tell the client there will be a feeling of pressure as the needle is inserted. They need to continue breathing because holding the breath will lower the diaphragm against uterus and shift uterine contents · Postprocedure: § Monitor vitals, FHR, and uterine contractions 30 minutes after § Have the client rest for 30 minutes § Administer Rho(D) immune globulin if they are Rh-negative § Teach the client to report fever, chills, leakage of fluid or bleeding from insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after procedure § Drink plenty of fluids and rest for 24 hours after procedure § POST "Amnio" care: does it hurt? Some cramps for an hour § What to watch out for: · Infection - red, sore, fever · labor: cramping, vaginal bleeding, water leakingbaby: less movement · *if rh neg mom, give rh0 d immunoglobulin (rhogam) § Administering RhoD immunoglobulin to Rh negative moms after amniocentesis is standard practice to prevent mom's production of antibodies against the baby's blood. · Complications of Amniocentesis: 1. Maternal:_________ 2. Fetal:_________

Oligohydramnios

Amniotic Fluid Abnormalities - _____________ = decreased amniotic fluid; too low § Detected by a fundal height that is small for gestational age, easily palpated fetus, maximum vertical pocket of amniotic fluid is less than 1-2cm § Fetus Not making fluid: · Renal agenesis (no kidneys) (Potter Syndrome) · IUGR · Maternal hypertension · Uteroplacental insufficiency · Postdates pregnancy § Losing fluid: Premature rupture of membranes

Polyhydramnios

Amniotic Fluid Abnormalities · _______________ = too much § Detected by fundal height that is large for gestational age, a fetus that cannot be palpated or is ballotable, and pockets of amniotic fluid measure more than 8 cm § Poorly controlled diabetes § Fetal congenital anomalies · Gastrointestinal obstruction · Twin-Twin transfusion syndrome

factors that originate within the mother/fetus and affect development or functioning

Assessment of Risk Factors; Categories of risk factors include: · Biophysical risk factors include ________________________________ § Genetic factors: anomalies, defective genes, inherited disorders, chromosome abnormalities, multiple gestation, large fetal size, ABO incompatibility § Nutritional Status: young age, 3 pregnancies in 2 years, tobacco, alcohol, drug use, inadequate intake due to illness or allergies, excess weight gain, hematocrit value less than 33% § Medicinal and obstetric disorders: complications of pregnancies, obstetric illness, pregnancy losses

maternal behaviors and adverse lifestyles

mother and her family that put the fetus at risk

Assessment of Risk Factors; Categories of risk factors include: · Biophysical risk factors include factors that originate within the mother/fetus and affect development or functioning § Genetic factors: anomalies, defective genes, inherited disorders, chromosome abnormalities, multiple gestation, large fetal size, ABO incompatibility § Nutritional Status: young age, 3 pregnancies in 2 years, tobacco, alcohol, drug use, inadequate intake due to illness or allergies, excess weight gain, hematocrit value less than 33% § Medicinal and obstetric disorders: complications of pregnancies, obstetric illness, pregnancy losses · Psychosocial risk factors are maternal behaviors and adverse lifestyles § Smoking: LBW, high rate of neonatal mortality, miscarriage, premature rupture of membranes § Caffeine: high intake (over 200mg) of caffeine can increase risk for intrauterine growth restriction (UGR) § Alcohol: fetal alcohol syndrome, alcohol defects, learning disabilities, hyperactivity § Drugs: teratogenic drugs, metabolic disturbances, chemical effects, alteration of CNS function § Physiologic Status: emotional distress, psych disturbances, addiction, history of abuse, inadequate support, family problems, maternal role changes, noncompliance with cultural norms, unsafe cultural practices, situational crisis · Sociodemographic risk factors arise from the _____________________________________ § Low income: related to poor health, increased risk of complications, adverse environment § Lack of prenatal care: risk of lack of knowledge of pregnancy needs § Age: very young and very old § Adolescents: complications include anemia, preeclampsia, prolonged labor, contracted pelvis § Mature mothers: older mothers have increased risk for chronic illness and complications of pregnancy § Parity: the number of previous pregnancies, especially if 1st pregnancy was at old or young age § Marital status: increased risk of mortality and morbidity with single mothers § Residence: mothers in metropolitan areas have more neonatal visits than those in rural areas. § Ethnicity: African Americans have high rates of preterm births · Environmental risk factors include work hazards and general environment § Infections, radiation, chemicals (mercury and lead), therapeutic drugs, illicit drugs, industrial pollutants, cigar smoke, stress, diet

§ Obtain informed consent § Provide education and support § Teach the client to drink 1-2 glasses of fluid prior to the test and avoid urination for several hours prior to testing because a full bladder is needed for testing

Chorionic Villi Sampling (CVS) · Chorionic Villi Sampling (CVS) is a technique used in the first trimester and involves obtaining some tissue from villi (fetal portion of the placenta), which contains genetic material from embryo · Chorionic Villi Sampling (CVS) is an assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the ABD wall or intravaginally through the cervix under ultrasound guidance · Chorionic Villi Sampling (CVS) is a 1st trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities · Chorionic Villi Sampling (CVS) is ideally performed at 10-13 weeks of gestations · Nursing Interventions for Chorionic Villi Sampling (CVS): 1. 2. 3. · Screens for genetic & chromosomal problems · Results earlier in pregnancy than amniocentesis · Risks of miscarriage, fetal limb defects, spontaneous abortion, chorioamnionitis, rupture of membranes

10-13 weeks of gestations

Chorionic Villi Sampling (CVS) · Chorionic Villi Sampling (CVS) is a technique used in the first trimester and involves obtaining some tissue from villi (fetal portion of the placenta), which contains genetic material from embryo · Chorionic Villi Sampling (CVS) is an assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the ABD wall or intravaginally through the cervix under ultrasound guidance · Chorionic Villi Sampling (CVS) is a 1st trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities · Chorionic Villi Sampling (CVS) is ideally performed at _______________________ · Screens for genetic & chromosomal problems · Results earlier in pregnancy than amniocentesis · Risks of miscarriage, fetal limb defects, spontaneous abortion, chorioamnionitis, rupture of membranes

Endoscopic

Endoscopic Fetal Interventions · _____________ surgeries are rare and can be dangerous, but can be used to treat: § Twin separations § Cord ligations § Tracheal occlusion § Ablation or embolization of fetal tumors § Sealing of premature rupture of membranes § Coverage of spina bifida defects § Fetal gene therapy

10-14 weeks of gestation

Fetal Genetic Disorders and Physical Anomalies Detected by Ultrasound · A prenatal screening called nuchal translucency (NT) uses ultrasound measurements of fluid in the nape of the fetal neck between _______________________ to identify abnormalities · A fluid collection greater than 3mm is abnormal § Elevated NT indicates risk for chromosomal abnormalities and heart defects

Stillbirth

Fetal Growth Problems · Intrauterine growth restriction (IUGR) - 2 types: § Symmetric Intrauterine growth restriction is where the fetus is small in all parameters · This reflects a chronic, long standing causes · Can be caused by low genetic growth potential · Can be caused by Intrauterine infection · Can be caused by Chromosomal anomaly · Can be caused by Heavy smoking · Can be caused by Poor nutrition § Asymmetric Intrauterine growth restriction occurs when the growth of the head and body don't match · Fetal head is proportionally larger than body, growth does not match · This suggests an acute cause, or happens in late-pregnancy · Late pregnancy deprivations include deprivations, placental insufficiency, renal disease, cardiovascular disease · Placental insufficiency (HTN, Renal Disease, Cardiac Disease) · Reduced fetal growth is associated with _____________________! (intrauterine fetal demise IUFD)

Asymmetric Intrauterine growth restriction

Fetal Growth Problems · Intrauterine growth restriction (IUGR) - 2 types: § Symmetric Intrauterine growth restriction is where the fetus is small in all parameters · This reflects a chronic, long standing causes · Can be caused by low genetic growth potential · Can be caused by Intrauterine infection · Can be caused by Chromosomal anomaly · Can be caused by Heavy smoking · Can be caused by Poor nutrition § _________________________________ occurs when the growth of the head and body don't match · Fetal head is proportionally larger than body, growth does not match · This suggests an acute cause, or happens in late-pregnancy · Late pregnancy deprivations include deprivations, placental insufficiency, renal disease, cardiovascular disease

Symmetric Intrauterine growth restriction

Fetal Growth Problems · Intrauterine growth restriction (IUGR) - 2 types: § _____________________________ is where the fetus is small in all parameters · This reflects a chronic, long standing causes · Can be caused by low genetic growth potential · Can be caused by Intrauterine infection · Can be caused by Chromosomal anomaly · Can be caused by Heavy smoking · Can be caused by Poor nutrition

· "NON-REASSURING" results that suggest the fetus is not okay · "DISTRESS" results that indicate that the fetus is not okay

How do we Know if the Fetus is Okay? · Goals of prenatal (antepartum) testing - 2 sides of the coin: § Fetus in trouble: identify fetuses at risk from acute or chronic interruption of oxygenation to prevent permanent injury or death · _________________ results that suggest the fetus is not okay · _________________ results that indicate that the fetus is not okay § Healthy fetus: identify appropriately oxygenated fetuses so unnecessary intervention can be avoided; "REASSURING" results

1. Count once a day for 60 minutes & record all movements 2. Count 2-3 times per day (after meals, before bed) for 2 hours or until 10 movements are recorded 3. Count all fetal movements in 12 hours or until 10 movements are recorded

decrease in fetal movements § cease of movement for 12 hours = fetal alarm signal § count of fewer than 3 fetal movements in 1 hour

Low Tech Assessment: Kick counts · Daily Fetal Movement Counts (Kick Counts): assessment of fetal activity by the mother. It is: 1. Non-invasive 2. Inexpensive and 3. Simple and easy to follow § During the 3rd trimester, the fetus makes about 30 gross movements each hour · Several protocols for testing Daily Fetal Movement Counts (Kick Counts), the best method is to be consistent: 1. Count once a day for 60 minutes & record all movements 2. Count 2-3 times per day (after meals, before bed) for 2 hours or until 10 movements are recorded 3. Count all fetal movements in 12 hours or until 10 movements are recorded · Any ______________________, you must investigate with an Non-Stress Test (NST)! - - · Obesity decreases perception of fetal movements and ability to count movements · Fetal movements are not present in the fetal sleep cycle · Fetal movements may be reduced if the mother takes depressant drugs, drinks alcohol, or smokes · FETAL MOVEMNTS NEVER DECREASE AS THE WOMAN NEARS TERM

Fetus's indications for prenatal testing

Mother's indications for prenatal testing Why Do We do Prenatal Testing? When there is a reason to worry about baby! · Mother's indications for prenatal testing: Mostly vascular changes that affect circulation to placenta: § Diabetes - excess sugar and vascular changes make problems (fetus too large, likely to be stillborn) § Chronic Hypertension § Preeclampsia (HTN due to pregnancy that accelerates damage to vascular system) § Detachment of placenta (abruption) § Systemic Lupus Erythematosus § Renal Disease § Cholestasis of pregnancy · _____________________ indications for prenatal testing: § Fetal Growth Restriction: fetus is too small for its development § Multiple Gestation § Oligohydramnios: too little amniotic fluid § Preterm premature rupture of membranes § Postdates, late-term, or post term gestation: placenta is getting older/less functional, and the baby is getting large and needing more nutrients § Previous stillbirth § Decreased fetal movement

· Advanced Maternal Age (after age 35): aging eggs · Parental chromosomal rearrangements · Previous pregnancy with autosomal trisomy · Abnormal ultrasound findings during the current pregnancy § Fetal structure § IUGR § Amniotic fluid abnormalities · Increased risk based on screening tests: § First trimester screen: nuchal translucency on ultrasound!!!!!!!!!!!! § Alpha-fetoprotein (AFP), Triple marker or Quad test

Risk Factors for Chromosomal Anomalies : - - - -

Placenta Previa

Signs and Symptoms of _________________: § Causes episodes of vaginal bleeding. § Repeat ultrasounds needed § Aging placenta, poor condition § Calcium deposits § Clots

Abdominal ultrasound

Ultrasound · Ultrasound is a safe, method of antepartum fetal surveillance that uses sound waves to assess fetal activity, gestational age, normal vs. abnormal fetal growth curves, fetal and placental anatomy, fetal-wellbeing, and visual assistance with which invasive tests can be done more safely · 2 types of ultrasound: - _______________________________ is more useful after the 1st trimester when the uterus becomes an ABD organ. During the exam, the mom should have a full bladder to displace the uterus upward to get the best image of the fetus. She is positioned with small pillows under the head and knees. And the display panel is in view § Client Preparation: · Explain that there are no risks to self/fetus · Advise the client to drink 1 quart of water prior to the ultrasound to fill the bladder, lift the uterus, displace bowels, and act as an echolucent to better reflect sound waves to obtain a better image of the fetus · Assist the client into a supine position with a pillow under head/knees § Ongoing care: · Apply gel to the ABD before the transducer is moved over the skin to obtain a better fetal image, and make sure the gel is room temp/warm · Allow the client to empty the bladder at the termination of the procedure · Provide the client with a washcloth to wipe away the gel afterwards

Transvaginal ultrasound

Ultrasound · Ultrasound is a safe, method of antepartum fetal surveillance that uses sound waves to assess fetal activity, gestational age, normal vs. abnormal fetal growth curves, fetal and placental anatomy, fetal-wellbeing, and visual assistance with which invasive tests can be done more safely · 2 types of ultrasound: § Abdominal ultrasound is more useful after the 1st trimester when the uterus becomes an ABD organ. During the exam, the mom should have a full bladder to displace the uterus upward to get the best image of the fetus. She is positioned with small pillows under the head and knees. And the display panel is in view § _________________________ involves placing a wand-shaped probe into the vagina to evaluate pelvic anatomic figures in great detail and intrauterine pregnancy to be diagnosed earlier. This does not require the mom to have a full bladder. It is very useful for obese women with thick ABD layers. This can be done in the lithotomy position or with the pelvis elevated by towels, cushions, or pillows. · Commonly used in early pregnancy (6-8 weeks), where the uterus is not very large · Client Preparation: assist into lithotomy position. The probe is covered with a protective cover and lubricant and inserted by the examiner Ongoing care:position the probe or tilt of the table to get a complete view of the pelvis. Teach the client they may feel pressure as the probe is moved

· Confirming pregnancy and viability · Determining gestational age · Number, size, location of gestational sacs (normally in the uterus vs. ectopic pregnancy) · Presence or absence of fetal heartbeat (starting at 8 weeks) and movements · Ruling out or detecting Maternal abnormalities § Uterine abnormality (bicornuate uterus), ectopic pregnancies, ovarian cysts, fibroids § Mass in ovary, tubes · Pregnancy dating: earlier the ultrasound is done, is more accurate the pregnancy dating (by measuring crown to rump) · Determining causes of vaginal bleeding · Visualization during chorionic villus sampling

Ultrasound Uses During The First Trimester - - - -

· Number of fetus(es) · Is fetus alive (viability)? Heartbeat, movements (fetal movement count) · Position & gestational age of fetus (most accurate before the 22nd week of pregnancy) · Growth of fetus · Fetal anomalies · Amniotic fluid volume · Placental location (should be in the top, fundus of the uterus) & condition (needs healthy vessels, with no calcifications) · Cervical length: normally about 2-2.5 inches thick · Masses in mother's ovaries or tubes (uterine fibroids or anomalies

Ultrasound Uses During the Second Trimester · Establish or confirm dates · Confirm viability · Detect polyhydramnios or oligohydramnios · Detect congenital anomalies · Detect intrauterine growth restriction (IUGR) · Assess placental location · Visualization during amniocentesis · Evaluated for preterm labor Ultrasound Uses During the Third Trimester · Confirm gestational age · Confirm viability · Detect macrosomia · Detect congenital anomalies · detect intrauterine growth restriction (IUGR) · determine fetal position · detect placenta previa or placental abruption · visualization during amniocentesis · biophysical profile · amniotic fluid volume assessment · doppler flow studies · detect placental maturity · evaluate for preterm labor Ultrasound: Second and Third Trimester - - - - -

Ultrasound for Amniotic Fluid Volume · Amniotic Fluid Index (AFI): used to determine amniotic fluid volume; the vertical depths in centimeter of the largest pocket of amniotic fluid in all 4 quadrants surrounding the maternal umbilicus are totaled § Used to determine amniotic fluid volume § Measure fluid in all 4 quadrants of the uterus · Normal Amniotic Fluid Index (AFI): 10-25cm · AFI less than 10 is indicative of Oligohydramnios · AFI of greater than ___________ is indicative of Polyhydramnios

10-25cm

(<22 weeks) by ultrasound is more accurate and reliable than LMP, but after 22 weeks gestation, it is less reliable due to variations in fetal size

Ultrasound for Dating Pregnancy and Gestational Age · REASONS for Gestational dating/Dating Pregnancy: § Uncertain LMP date § Recently stopped oral contraceptives § Bleeding episode during the first trimester § Uterine size that does not match dates § Any other high risk conditions · Gestational dating by ultrasound can be done by obtaining ultrasound measurements and ignoring menstrual dates · Early dating/gestation age testing _________________________________________________________ · Ultrasound Measurements for dating pregnancy/gestational age and size of fetus include: § Crown Rump Length (CRL) in the 1st trimester § Biparietal Diameter (BPD): side-to-side on the skull from parietal bones § Femur length § Head circumference: useful for determining baby size (overweight, underweight) § Abdominal circumference: useful for determining baby size § Femur length after the first trimester

6 weeks gestation

Ultrasound for Heart Activity · Fetal Heart activity can be detected vaginally at _____________________________ · When the fetus is in good position, good views of fetal cardiac anatomy with transvaginal ultrasound are capable at 13 weeks gestation · Fetal death is confirmed by absence of cardiac activity, presence of fetal scalp edema/maceration, and overlap of cranial bones · Echocardiogram, heart function studies

head (ventricles and blood vessels), neck, spine, heart, stomach, small bowel, liver, kidneys, bladder, and limbs

Ultrasound to Check Fetal Anatomy · Anatomic structures that can be seen by ultrasound include: ____________________ · It can detect normal and abnormal anatomy · The presence of abnormal anatomy may influence the location of birth and the method of birth to optimize outcomes · Example: plans are made for a fetus needing immediate surgery to have the baby in a hospital

Environmental factors may limit growth

Ultrasound to Check Fetal Growth · Ultrasound use to detect fetal growth is determined by intrinsic growth potential and environmental factors · Conditions that require ultrasound assessment of fetal growth include poor maternal weight gain, previous pregnancy with intrauterine growth restriction (IUGR), chronic infections, ingestion of drugs, maternal diabetes, hypertension, multifetal pregnancy, other complications · Checking for something wrong INSIDE the fetus: Fetal growth potential may be poor - infections, anomalies, chromosomal or genetic problems, OR · Checking for something wrong OUTSIDE the fetus: __________________________ § Poor maternal weight gain, poor nutrition § Chronic infections of mother § Ingestion of drugs - esp. vasoconstrictors like cocaine § Poor placental functioning (infection, clots, postdates) § Poor blood flow to uterus, which can be caused by: · Maternal diabetes, Type 1 - poor vascular system · Maternal hypertension · Other chronic illnesses affecting vascular system § Multi-fetal pregnancy: shared food supply decreases blood flow to each baby

Placenta Previa

Ultrasound to Check Placental Position and Function · __________________: Between 18-23 weeks of gestation, the edge of the placenta extends to or covers the internal os of the cervix in 2% of pregnancies § Most cases of placenta previa diagnosed in the 2nd trimester resolve by term. Thus, if placenta previa is diagnosed in the 2nd trimester, repeated ultrasounds are performed as pregnancy progresses until the placenta moves away from the cervical os or it becomes clear that the previa will persist. · Ultrasound can assess placental appearance. A globular placenta with narrow base is associated with increased risk of IGUR, fetal death, and complications.

Fetal Lung Maturity

What can we learn from "The Waters"? · Amniotic fluid comes from fetal kidneys · Reflects renal function, and hydration · Contains fetal cells · Contains surfactant from the lungs (helps keep baby's lungs from collapsing at first breath) · Contains overabundant chemicals, like bilirubin · Meconium: the baby's first poop! · And infectious particles like bacteria, virus · Alpha-Fetoprotein: high levels are associated with neural tube defects or multifetal pregnancies; low levels are associated with chromosome disorders · ___________________________: tested to see if fetal lungs are mature enough to adapt after birth - Lecithin/sphingomyelin (L/S) ratio: a 2:1 ratio indicates maturity - Phosphatidylglycerol (PG): absence of PG is associated with respiratory distress

Mother's indications for prenatal testing

Why Do We do Prenatal Testing? When there is a reason to worry about baby! · ____________________________ indications for prenatal testing: Mostly vascular changes that affect circulation to placenta: § Diabetes - excess sugar and vascular changes make problems (fetus too large, likely to be stillborn) § Chronic Hypertension § Preeclampsia (HTN due to pregnancy that accelerates damage to vascular system) § Detachment of placenta (abruption) § Systemic Lupus Erythematosus § Renal Disease § Cholestasis of pregnancy

Coombs Test (Indirect)

__________: blood test on mother to screen for Rh incompatibility. § If maternal titer is 1:8 showing increased antibodies to fetal blood, amniocentesis is used to test for bilirubin in the amniotic fluid This establishes severity of fetal hemolytic anemia

Low-lying Placenta Previa

· "Placenta Previa": when the placenta settles at the bottom of the uterus § Marginal Placenta Previa: Margin of the placenta is at the cervix § Complete Placenta Previa: the placenta completes covers the cervix § ___________________: very close to covering the cervix

Complete Placenta Previa

· "Placenta Previa": when the placenta settles at the bottom of the uterus § Marginal Placenta Previa: Margin of the placenta is at the cervix § _____________________: the placenta completes covers the cervix

Marginal Placenta Previa

· "Placenta Previa": when the placenta settles at the bottom of the uterus § ____________________: Margin of the placenta is at the cervix

§ Older maternal age (35 or older) § Older paternal age (40-50 or older) § Parents affected by or are carriers of genetic disorders (sickle-cell, Tay-Sachs, cystic fibrosis) § Women with a prior child with a structural birth defect or fetal defect identified by ultrasound § Women with a prior child with a chromosomal abnormality

· Amniocentesis is a Sampling of amniotic fluid, once enough accumulates (from 13-14 week to full term). This is done through insertion of a needle transabdominally into a client's uterus and amniotic sac under ultrasound guidance to locate the placenta and fetus · Under direct ultrasonographic visualization, a needle is inserted transabdominally into the uterus and amniotic fluid is withdrawn into a syringe. · Indications: prenatal diagnosis of genetic disorders or congenital anomalies (NTD) assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease · Amniotic Fluid contains fetal cells, for genetic and chromosomal analysis · Amniotic Fluid may contain other things too, like alpha-fetaprotein · Amniocentesis is done for many different reasons: - - - - - · Complications of Amniocentesis: § Maternal: leakage of amniotic fluid, hemorrhage fetomaternal hemorrhage with Rh incompatibility, infection, labor, placental abruption, inadvert damage to intestines or bladder, amniotic fluid embolism § Fetal: death, hemorrhage, infection (amnionitis, and direct needle injury

8/8 or 10/10

· Biophysical Profile (BPP) is a noninvasive dynamic assessment of a fetus based on acute and chronic markers of fetal disease. It includes amniotic fluid volume (AFV), fetal breathing movements (FBM), fetal movements, and fetal tone determined by ultrasound and fetal heart rate (FHR) reactivity determined by the nonstress test. § FHR reactivity, FBMs, fetal movement, and fetal tone reflect the CNS status § AFV demonstrates adequacy of placental function over a long period of time. § It is used frequently in the last 2nd trimester for antepartum fetal testing because it predicts fetal well-being · Biophysical Profile (BPP) is a Non-invasive dynamic assessment of fetus using ultrasound & fetal monitor (EFM) · 5 parts/evaluations, 0 - 2 points for each part/evaluation · "Normal- 2 point" requirements: § 1. Amniotic fluid volume (AFV): deepest vertical pocket is greater than 2cm § 2. Fetal breathing movements: at least one episode of fetal breathing of at least 30 second duration in a 30 minute observation § 3. Fetal movements: at least 3 trunk/limb movements in 30 minutes § 4. Fetal muscle tone: at least one episode of active extension with return to flexion of fetal limb or trunk; opening and closing of hand § 5. Non-stress test: reactive FHR to stress test · _________________________ with a normal AFV is normal with low risk of fetal asphyxia · 4-6 is abnormal, suspect chronic fetal asphyxia · Less than 4/10 is abnormal, strongly suspect chronic fetal asphyxia · IF abnormal, must intervene, probably deliver, fetus is dying soon · Is fetus reacting to its environment, or in a coma? If it is in a coma, it is not getting enough oxygen, and needs intervention soon or it will die

Oxytocin-stimulated contraction test

· Contraction Stress Test (CST) this test provides an earlier warning of fetal compromise than the NST and is invasive if oxytocin stimulation is needed. It SHOULD NOT be done on a woman who cannot give birth vaginally at the time of testing. § Contraindications: anytime labor is contraindicated, preterm labor, placenta previa, twins, uterine scars § CAUTION: could cause labor · Client Preparation: § Obtain a baseline FHR, fetal movement, and contractions for 10-20 minutes. Explain the procedure and obtain informed consent · Care During Procedure: initiate nipple stimulation unless the client is having spontaneous contractions. The client should stop stimulation when a uterine contraction begins. Provide rest periods to avoid hyperstimulation of the uterus · Procedure: the woman is placed in semi-fowlers position or sits in a reclining chair with a slight lateral tilt. She is monitored with a fetal ultrasound and a uterine tocodynamometer. - _____________________________: exogenous oxytocin is given IV to stimulate contractions; usually used when nipple stimulation fails. Contractions started with oxytocin can be difficult to stop and can cause preterm labor § Contraindications: placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incision from C-section, and reduced cervical competence § Interventions: · Monitor for contractions lasting longer than 90 seconds or occurring more frequently than every 2 minutes · Administer tocolytics as prescribed · Maintain bed rest during procedure Observe the client for 30 minutes after to ensure contractions cease

Nipple-stimulated contraction test

· Contraction Stress Test (CST) this test provides an earlier warning of fetal compromise than the NST and is invasive if oxytocin stimulation is needed. It SHOULD NOT be done on a woman who cannot give birth vaginally at the time of testing. § Contraindications: anytime labor is contraindicated, preterm labor, placenta previa, twins, uterine scars § CAUTION: could cause labor · Client Preparation: § Obtain a baseline FHR, fetal movement, and contractions for 10-20 minutes. Explain the procedure and obtain informed consent · Care During Procedure: initiate nipple stimulation unless the client is having spontaneous contractions. The client should stop stimulation when a uterine contraction begins. Provide rest periods to avoid hyperstimulation of the uterus · Procedure: the woman is placed in semi-fowlers position or sits in a reclining chair with a slight lateral tilt. She is monitored with a fetal ultrasound and a uterine tocodynamometer. § _______________________________: woman applies warm, moist compress to both breasts for several minutes and massage one nipple for 10 minutes, which causes a release of oxytocin and contractions. She can also brush the hands across one nipple for 2 minutes and then stop when uterine contraction begins · Analysis of FHR response to contractions determines how the fetus will tolerate labor. A pattern of at least 3 contractions within a 10-minute time period with duration of 40-60 seconds each must be obtained to use for assessment data Hyperstimulation of the uterine (contraction longer than 90 seconds or 5 or more contractions in 10 minutes) should be avoided by stimulating the nipples intermittently

neural tube defect, abdominal defect, or umbilical defect

· Maternal serum Alpha-fetoprotein (msAFP), or Quad Marker: Blood test on mother at 14-34 weeks (16-18 weeks is ideal) for AFP secreted by fetus § If high Maternal serum Alpha-fetoprotein (msAFP), indicates possible ______________________ § If low Maternal serum Alpha-fetoprotein (msAFP), indicates possible chromosomal defect or poor growth § Quad Marker Screening: a blood test that ascertains information about the likelihood of birth defects. It does not diagnose the actual defect · Tests for: HCG, AFP, Estriol, Inhibin A · Quad Marker Screening is preferred at 16-18 weeks gestation · Low AFP can indicate down syndrome · High AFP can indicate neural tube defects · High inhibin A indicates risk for Down syndrome · Low estriol can indicate Down syndrome § There is a HIGH FALSE POSITIVE RATE

chromosomal defect or poor growth

· Maternal serum Alpha-fetoprotein (msAFP), or Quad Marker: Blood test on mother at 14-34 weeks (16-18 weeks is ideal) for AFP secreted by fetus § If high Maternal serum Alpha-fetoprotein (msAFP), indicates possible neural tube defect, abdominal defect, or umbilical defect § If low Maternal serum Alpha-fetoprotein (msAFP), indicates possible __________________________________ § Quad Marker Screening: a blood test that ascertains information about the likelihood of birth defects. It does not diagnose the actual defect · Tests for: HCG, AFP, Estriol, Inhibin A · Quad Marker Screening is preferred at 16-18 weeks gestation · Low AFP can indicate down syndrome · High AFP can indicate neural tube defects · High inhibin A indicates risk for Down syndrome · Low estriol can indicate Down syndrome § There is a HIGH FALSE POSITIVE RATE

bleeding through cord puncture cite, amnionitis, hemorrhage, cord laceration, preterm labor, amnionitis, hematoma, fetomaternal hemorrhage

· Percutaneous Umbilical Blood Sampling (PUBS): is a test for fetal blood sampling and transfusion; involves direct access to fetal circulation through the umbilical vessel under ultrasound guidance during the second and third trimesters § Used for fetal blood sampling or to give a fetal blood transfusion · Prenatal diagnosis of inherited blood disorders · Karyotyping of malformed fetuses · Detection of fetal infection or fetal anemia · Assessment and treatment of isoimmunization · Thrombocytopenia: CBC with differential · Coomb's test for Rh antibodies · Blood gases or blood typing § Can assess for fetal anemia, infection, and thrombocytopenia; chromosome disorders § Complications: _________________________________

ABNORMAL is POSITIVE

· Results of Contraction Stress Test (CST): § NORMAL is NEGATIVE CST, meaning no signs of problems and no late decelerations of FHR § ___________________ CST, meaning abnormal late decelerations of FHR are present with more than half of contractions, showing lack of oxygenation in the fetus with any stress (utero-placental insufficiency) · Positive CST: Indicated with persistent and consistent late decelerations with 50% or more of the contractions. This suggests uteroplacental insufficiency · Variably deceleration can indicate cord compression · Early decelerations can indicate fetal head compression · If abnormal, considerdelivery by inducing labor, or cesarean section.

NORMAL is NEGATIVE

· Results of Contraction Stress Test (CST): § _______________________ CST, meaning no signs of problems and no late decelerations of FHR

Non-Reactive

· Results of The Nonstress test (NST): either reactive or nonreactive § Results are "Reactive" , healthy if the FHR accelerates at least 15/min (10/min if prior to 32 weeks) for at least 15 seconds AND there are 2 accelerations in 20 minutes. This shows normal brain oxygenation § Results are "_____________________" if there are less than 2 accelerations in 20 minutes; not reacting to changes means either sleep, or less oxygenation & possible coma · Wake up the fetus: Vibroacoustic stimulation (VAS) or fetal scalp stimulation during a pelvic examination - Vibroacoustic stimulation (VAS) uses sound and vibrations to waken the fetus from the sleep state § Most common reason to do test: decreased fetal movement § If non-reactive, FURTHER TESTING IMMEDIATELY (BPP or CST)

Reactive

· Results of The Nonstress test (NST): either reactive or nonreactive § Results are "_______________________" , healthy if the FHR accelerates at least 15/min (10/min if prior to 32 weeks) for at least 15 seconds AND there are 2 accelerations in 20 minutes. This shows normal brain oxygenation

during a uterine contraction less blood flows to the placenta, and this may trigger FHR patterns that show fetus cannot tolerate this decrease in perfusion

· Why do we perform a Contraction Stress Test (CST): _____________ · How do we perform a Contraction Stress Test (CST): Apply fetal monitor and get a baseline. Use IV oxytocin or nipple stimulation to get 3 contractions in 10 minutes, like in labor

Amniocentesis

· __________________: Using a needle through the maternal abdomen to get amniotic fluid (checking water from the water bag) § For genetics it can only be done after amniotic fluid accumulates, after 13 + weeks § Risks: bleeding, infection, miscarriage § Also used to check bilirubin, surfactant, meconium other in fluid

Chorionic Villi Sampling (CVS)

· ___________________: taking a few chorionic villi to sample around 10 weeks of gestation § Early pregnancy test to obtain fetal cells to check for genetic or chromosomal problems § Small catheter passed through cervix to get sample of placental tissue § Risks: bleeding, miscarriage, limb defects/loss,

Percutaneous Umbilical Blood Sampling (PUBS)

· _______________________: is a test for fetal blood sampling and transfusion; involves direct access to fetal circulation through the umbilical vessel under ultrasound guidance during the second and third trimesters § Used for fetal blood sampling or to give a fetal blood transfusion · Prenatal diagnosis of inherited blood disorders · Karyotyping of malformed fetuses · Detection of fetal infection or fetal anemia · Assessment and treatment of isoimmunization · Thrombocytopenia: CBC with differential · Coomb's test for Rh antibodies · Blood gases or blood typing § Can assess for fetal anemia, infection, and thrombocytopenia; chromosome disorders

Doppler umbilical flow studies (doppler blood flow analysis)

· __________________________ uses systolic/diastolic flow ratios and resistance indices to estimate blood flow in varies arteries, such as the vessels in the umbilical cord. § Umbilical artery § Middle cerebral artery § Maternal uterine arteries · Severe restriction of umbilical artery flow is indicated by absent or reversed flow during diastole, and is associated with intrauterine growth restriction · Reported as ratios of blood flowing into and out of fetus through umbilical vessel · Mostly used in DIAGNOSING INTRAUTERINE GROWTH RESTRICTION

Biophysical Profile (BPP)

· ______________________________ is a noninvasive dynamic assessment of a fetus based on acute and chronic markers of fetal disease. It includes amniotic fluid volume (AFV), fetal breathing movements (FBM), fetal movements, and fetal tone determined by ultrasound and fetal heart rate (FHR) reactivity determined by the nonstress test. § FHR reactivity, FBMs, fetal movement, and fetal tone reflect the CNS status § AFV demonstrates adequacy of placental function over a long period of time. § It is used frequently in the last 2nd trimester for antepartum fetal testing because it predicts fetal well-being · Biophysical Profile (BPP) is a Non-invasive dynamic assessment of fetus using ultrasound & fetal monitor (EFM) · 5 parts/evaluations, 0 - 2 points for each part/evaluation

The Nonstress test (NST)

· ______________________________ is a technique for antepartum evaluation of the fetus. The basis for this test is that the normal fetus produces characteristic heart rate patterns in response to fetal movement, uterine contractions, or stimulation. - Procedure: the mother is seated in a reclining chair with slight lateral tilt, or in semi-fowlers or a left-lateral position. Conduction gel is applied to the ABD, and two belts are applied to the ABD with monitors to test uterine contractions and FHR. The fetal heart rate (FHR) is recorded with a doppler and a tocodynamometer is applied to detect uterine contractions or fetal movements. § The client should be instructed to press the button every time they feel the fetus move. § If there are not fetal movements (fetus is sleeping), vibroacoustic stimulation (sound source, laryngeal stimulator) can be activated for 3 seconds on the maternal ABD over the fetal head to awaken the sleeping fetus § The test usually takes 20-30 minutes · !!!! How do we do a _______________: Continuously monitor fetal heart rate for 20-40 minutes · !!!! Why do we do a _______________: Variability and accelerations (increases) in FHR show good brain oxygenation · _______________ is Non-invasive, so there are NO risks

Contraction Stress Test (CST)

· ________________________________ this test provides an earlier warning of fetal compromise than the NST and is invasive if oxytocin stimulation is needed. It SHOULD NOT be done on a woman who cannot give birth vaginally at the time of testing. § Contraindications: anytime labor is contraindicated, preterm labor, placenta previa, twins, uterine scars § CAUTION: could cause labor · Client Preparation: § Obtain a baseline FHR, fetal movement, and contractions for 10-20 minutes. Explain the procedure and obtain informed consent · Care During Procedure: initiate nipple stimulation unless the client is having spontaneous contractions. The client should stop stimulation when a uterine contraction begins. Provide rest periods to avoid hyperstimulation of the uterus · Procedure: the woman is placed in semi-fowlers position or sits in a reclining chair with a slight lateral tilt. She is monitored with a fetal ultrasound and a uterine tocodynamometer.

Fetal Assessment During Pregnancy

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