01.+the+High Risk+Prenatal+Client

Prepared By: NURS103 Team 2011-12

OVERVIEW

OVERVIEW

TWO GROUPS OF HIGH-RISK PRENATAL CLIENTS 1. Women with preexisting or newly acquired illness such as: - CVD, DM, Substance Abuse, HIV/AIDS, RH Incompatibility and Anemia 2. Women who develop complications of pregnancy such as: - Hyperemesis Gravidarum - PROM - Ectopic Pregnancy - PIH - Hydatidiform Mole - Multiple Pregnancies - Premature Cervical Dilatation - DIC - Abortion - APAS - Placenta Previa - HELLP Syndrome - Abruptio Placenta

ASSESSMENT OF RISK FACTORS BIOPHYSICAL risks Factors that originate within the mother or fetus and affect the development or functioning of either or both.

ASSESSMENT OF RISK FACTORS PSYCHOSOCIAL risks Comprised of maternal behaviors and adverse lifestyles that have a negative effect on the health of the mother or fetus (both).

ASSESSMENT OF RISK FACTORS SOCIODEMOGRAPHIC risks Factors arising from the mother and her family and place the mother and fetus at risk.

ASSESSMENT OF RISK FACTORS ENVIRONMENTAL risks Risks that include hazards of the workplace and the woman’s general environment.

RHYTHM STRIP TESTING • Assessment of the FHR for whether a good baseline rate and a degree of variability are present • Variability Categories: – Absent – Minimal – Moderate – Marked

None apparent Extremely small fluctuations Amplitude range: 6-25 bpm Amplitude range: > 25 bpm

Rhythm Strip of Fetal Heart Rate

NONSTRESS TESTING • Measures the response of the FHR to fetal movement RESULT

INTERPRETATION

Reactive

• 2 accelerations of FHR (by 15 beats or more) lasting for 15 seconds occur after movement within the chosen time period • No accelerations occur with the fetal movements

Nonreactive

• No fetal movements occur or if there is low short-term fetal heart rate variability (less than 6 bpm) throughout the testing period

NONSTRESS TESTING

VIBROACOUSTIC STIMULATION • Producing a sharp sound of approximately 80 decibels at a frequency of 80 Hz, startling and waking the fetus • Done in conjunction with a nonstress test

CONTRACTION STRESS TESTING • Analysis of FHR accompanied by contractions RESULT

INTERPRETATION

Negative (Normal)

• No fetal heart rate decelerations are present with contractions

Positive (Abnormal)

• No accelerations occur with the fetal movements • 50% or more of contractions cause a late deceleration

CONTRACTION STRESS TESTING

COMPARISON OF THE NONSTRESS AND CONTRACTION STRESS TESTS Area of Assessment

Nonstress Test

Contraction Stress Test

Response of FHR in relation to Response of FHR in relation to uterine contractions as the fetal movement What is measured nipples are stimulated Two or more accelerations of fetal heart rate of 15 bpm lasting No late decelerations with Normal findings 15 secs or longer following fetal contractions movements in a 20-min period In addition to preventing supine Woman should not lie supine to hypotension syndrome, observe prevent supine hypotension the woman for 30 min Safety considerations afterward to see that syndrome contractions are quiet and preterm labor does not begin

ULTRASONOGRAPHY • Used to: – Diagnose pregnancy – Confirm the presence, size, and location of the placenta and amniotic fluid – Establish that a fetus is growing – Establish sex – Establish the presentation and position – Predict maturity

ULTRASONOGRAPHY

ULTRASONOGRAPHY

----Ultrasonography----

BIPARIETAL DIAMETER

----Ultrasonography----

DOPPLER UMBILICAL VELOCIMETRY

----Ultrasonography----

PLACENTAL GRADING

----Ultrasonography----

AMNIOTIC FLUID VOLUME ASSESMENT

----Ultrasonography----

AMNIOTIC FLUID VOLUME ASSESMENT Guidelines for measuring AFI: • For gestations < 20 wks., uterus is divided into 2 vertical halves – Measure the vertical diameter of the largest pocket of amniotic fluid present on each side in cm, then add

• For gestations > 20 wks., uterus is divided into 4 quadrants – Measure the vertical diameter of the largest pocket of amniotic fluid present on each quadrant in cm, then add

ELECTROCARDIOGRAPHY • Fetal ECGs may be recorded as early as the 11th week of pregnancy • Rarely used unless a specific heart anomaly is suspected

MAGNETIC RESONANCE IMAGING • Has the potential to replace or complement ultrasonography as a fetal assessment technique • Most helpful in diagnosing complications such as ectopic pregnancy or trophoblastic disease

MAGNETIC RESONANCE IMAGING

MSAFP • Begins to rise at 11 weeks’ gestation and then steadily increase until term • Levels are abnormally high in maternal serum if the fetus has an open spinal or abdominal defect • Levels are abnormally low if the fetus has a chromosomal defect

TRIPLE AND QUAD SCREENING • Triple Screening: – Estriol – Beta-human chorionic gonadotropin – Alpha-fetoprotein

• Quad Screening: – Estriol – Beta-human chorionic gonadotropin – Alpha-fetoprotein – Inhibin A

CHORIONIC VILLUS SAMPLING

AMNIOCENTESIS

---- Amniocentesis ----

Amniotic Fluid is Analyzed for: • • • • • • • • •

AFP Bilirubin Determination Chromosome Analysis Color Fetal Fibronectin Inborn Errors of Metabolism L/S Ratio Phosphatidyl Glycerol Desaturated Phosphatidylcholine

PUBS • a.k.a. cordocentesis or funicentesis

FETOSCOPY • The procedure is used to: –Confirm the intactness of the spinal column –Obtain biopsy samples of fetal tissue and fetal blood samples –Perform elemental surgery

FETOSCOPY

AMNIOSCOPY • Visual inspection of the amniotic fluid • Used to detect meconium staining

BIOPHYSICAL PROFILE • A biophysical parameters:

profile

– fetal reactivity – fetal breathing movements – fetal body movement – fetal tone – amniotic fluid volume

combines

five

BIOPHYSICAL PROFILE Assessment

Instrument 

Fetal breathing

Ultrasound 

Fetal movement

Ultrasound 

Fetal tone

Ultrasound

Amniotic fluid volume

Ultrasound

 

Fetal heart reactivity

Nonstress test

Criteria for a Score of 2 At least one episode of 30 sec of sustained fetal breathing movement within 30 min of observation At least 3 episodes of fetal limb or trunk movement within a 30 min observation The fetus must extend and then flex the extremities or spine at least once in 30 min A range of amniotic fluid between 5 and 25 cm must be present Two or more fetal heart rate accelerations of at least 15 beats/min above baseline and of 15 sec duration occur with fetal movement over a 20 min time period

BIOPHYSICAL PROFILE • A result of 8-10 indicates that the fetus is doing well • A score of 6 is considered suspicious • A score of 4 denotes a fetus probably in jeopardy

Test

Purpose

Significance

Blood Grouping

To determine blood type and Rh

Identifies possible causes of incompatibility with the fetus that may cause jaundice.

Hgb / Hct

To detect anemia; often checked several times during pregnancy

Hgb