1st Lecture High Risk Prenatal Client (NCM102)

Care of Mother, Child, Family and Population Group at Risk with Problems High-risk Prenatal Client A High Risk Pregnancy • Is defined as one in which a concurrent disorder, pregnancy related complication or external factor jeopardizes the health of the mother, fetus or both.

Identifying Clients AT RISK Ways for identifying clients at risk  a. Physiological b. Psychological c. Social RISK ASSESSMENT TOOL @_@... haha Lol… (Didn’t copy)

Diagnostic Tests 1.

Transvaginal Ultrasound: Transabdominal Ultrasound: Ultrasonography EMPTY BLADDER FULL BLADDER A. Transvaginal Ultrasound  Uses a probe inserted into the vagina  Used to visualize the baby  Used for placental grading  Instruct client to VOID FIRST B. Transabdominal Ultrasound  The transducer is moved across the woman’s abdomen  Instruct client to HAVE A FULL BLADDER Nursing Responsibility~  Inform~  Provide COMFORT and PRIVACY

2. Alpha-Fetoprotein Testing (AFP)  ARMED FORCES OF THE PHILIPPINES!! \m/  Level of fetal protein in the pregnant woman’s serum or in a sample of amniotic fluid  Done in 16 – 18 weeks (AFP mnemonic)  Major protein produced by baby  Yolk – 1st  Liver of the Fetus – 2nd  Levels of Protein (GAS) - Spina bifida - Anencephaly 3

Gastroschisis

 Levels of Protein (CDG) - Chromosome abnormalities - Gestational Throphoblastic Disease (Hydatidiform mole) H-Mole - Down’s Syndrome

Chorionic Villi Sampling (CVS)  Obtaining a small part of the developing placenta to analyze fetal cells at 10 – 12 weeks of gestation  Use: Chromosomal Abnormalities  BUT! Cannot detect SPINAL CORD ABNORMALITIES  (Nobody’s Perfect)

Nursing Responsibility~  Rh(D) immune globulin (RhoGam) is given to the Rh negative woman  RhoGam – Inhibits ANTIBODY production of the mother against the Rh positive or negative of the baby  (galing tlga~)  Assess!!!!  Bleeding  Spontaneous Abortions  Rest! ( :

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Amniocentesis  Done when in 15 – 17 weeks of gestation  Aspirates 20mL of fluid from the amnion of the mother  Instruct mother to INCREASE oral fluid~  Use of Amniocentesis Early Pregnancy 1. Identifies chromosomal abnormalities

Late Pregnancy 1. Identifies severity of maternal fetal blood incompatibility and assesses fetal lung maturity

2. Check color of amniotic fluid - Yellow = Rh Incompatibility Nursing Responsibility~  Informed consent  Provide comfort and privacy  Aseptic technique  Skin  Assess – Infection, FHR, Fetal Movement, VS of mother  RhoGam – Nag prick kasi 20 Weeks  EMPTY BLADDER

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20 Weeks  FULL BLADDER

Non-Stress Test (NST)  Measures the response of the Fetal HR to the Fetal Movement  After 1 or 2 movements, HR  15 Bpm for 15 Secs within 10 – 20 minute period Interpretation:

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Reactive (GOOD!! ) o At least 2 accelerations of FHR with fetal movement of 15 bpm lasting 15 secs/more for over 20 mins o 2 – 15beats – 15 secs – 20 mins o Used to determine if the fetus is oxygen compromised Non-Reactive (BAD!! ) o No acceleration after movement o No movement  If no movement, instruct client to • Eat HIGH Carbohydrate foods like orange juice (glucose~) • Make NOISE! RAAAAAHH!!!!~~~ o Low Fetal HR variability

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Unsatisfactory Test – If the data cannot be interpreted or there was an inadequate fetal activity Non-reactive = Non-stress Test= NOT GOOD!  Reactive = Non-stress Test= Really GOOD! 

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Contraction Test  Means of evaluating the respiratory function of the placenta  Use:  Identifies the fetus at risk for intrauterine asphyxia by observing the response of the FHR to the stress of the uterine contractions (spontaneous or induced)  Perform Nipple Rolling Interpretation: A. Negative (GOOD!! )  Shows 3 contraction of good quality lasting for 40 / more secs on 10 minutes WITHOUT EVIDENCE OF FETAL HR DECELERATION  Implication: Fetus can handle the hypoxic stress of uterine contractions B. Positive (BAD!! )  Shows repetitive persistent late decelerations with more than 50°0 of the contractions  Implication: The hypoxic stress of the uterine contraction causes slowing of the FHR… DONE in LATE PREGNANCY C. Equivocal / Suspicious  Shows non-persistent late deceleration or decelerations associated with hyperstimulation

(Contraction frequency of every 2 mins or duration of longer than90 seconds) Nursing Responsibility  Explain!  Semi-fowlers!  Assess and monitor! 7

Percutaneous Umbilical Blood Sampling (PUBS)  Obtaining a fetal blood sample from a placental vessel of from the umbilical cord  May be used to give a blood transfusion to an anemic fetus :O!  Use: 1. Identifies fetal conditions that can be diagnosed only with a blood sample 2. Blood transfusion for fetal anemia

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Lecithin-to-Sphingomyelin (L/S) Ratio I. Use:  Evaluate: Lungs ----- mature  22nd – 24th week of pregnancy: Production of SURFACTANT  2:1 Ratio (2L:1S)  Amniocentesis  SHAKE!  If there are bubbles, it means the lungs are mature  For DM Clients  L/S is not ACCURATE!!

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Biophysical Profile I. FHR and Reactivity (NST) II. Fetal Breathing, Movement III. Fetal Body Movements IV. Fetal Tone (Closure of the hand)

V.

Volume of amniotic fluid (AFI)  Biophysical profile is used to check the CNS function of the FETUS~

Use: o

Fetal oxygenation with poor placental function

o  Placental function is poor -  amniotic fluid o Fetal hypoxia   FHR changes occur 1st followed by cessation of fetal breathing movement, cross body movement and finally loss of fetal tone Observation 1. Non-Stress Test 2. Fetal Breathing Movement

Scoring the Biophysical Profile Normal (2 pts) Reactive One breathing period lasting at least 60 seconds

Abnormal (0 pts) Non-reactive Breathing period less than 60 seconds or no breathing observed

During 30 minute observation period

3.

Fetal Body Movement During 30 minute observation period

4.

Fetal Muscle Tone During 30 minute observation period

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Amniotic Fluid Volume

3 Discrete and definite movements of the arms, legs or body Arms and legs are usually flexed with head on chest. One definite extension and return to flexion Largest pocket of fluid is greater than 1 cm in vertical diameter without containing loops of cord

Less than 3 discrete movements of arms/legs or body Arms and legs are usually flexed with head on chest – No flexion Largest pocket is less than 1 cm in vertical diameter without loops of cord

Scoring: • 8 – 10: Maximal score • 0 – 4: Severe fetal compromise; delivery indicated

“It’s a new beginning ….”