At Risk Pregnancy

3rd trimester testing, pre-existing conditions, bleeding in pregnancy

high risk pregnancy

a situation where the life, health, and welfare of the mother and/or developing fetus are at risk d/t medical, social, or environmental factors, can be preexisting or develop in pregnancy

reasons for antepartum testing in the 1st/2nd trimesters

• detection of chromosomal aneuploidies and fetal anomalies

• prenatal screening

• biochemical dx → positive results of screening or if pt over 40

reason for 3rd trimester assessment of fetal wellbeing (FWB)

• determine if fetus is thriving in the uterine environment

• informs decisions about timing of birth

when is 3rd trimester fetal wellbeing assessment done

if there is increased risk of maternal or fetal mortality/morbidity

when are 3rd trimester fetal wellbeing assessments NOT done

uncomplicated pregnancies <41 weeks gestation

what is assessed in 3rd trimester fetal wellbeing assessments

• fetal movement counting

• electronic fetal monitoring

• ultrasound

types of electronic fetal monitoring in 3rd trimester fetal wellbeing assessment

• non-stress test (NST)

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

what is assessed via ultrasound in a 3rd trimester assessment of fetal wellbeing

• biophysical profile (BPP)

• amniotic fluid volume (AFV)

• doppler blood flow analysis

fetal movement counting ideal

at least 6 movements in a 2 hr period

how to do fetal movement counting

person picks a time (often when they know baby is active), get comfortable and then count fetal movements, once get to 6, then can stop before 2 hrs

what do you do if a person has less then 6 fetal movements in 2 hrs

contact HCP or get person to go to obstetrical triage. put the person on FHR monitor and do non-stress test to monitor ctx and FHR

when do you do a non-stress test

≥32 weeks of gestation

acme

top of the wave on a NST

normal NST results

1. 2 or more accels with acme of >15 bpm, lasting 15 seconds in <40 mins of testing

2. normal baseline rate (110-160)

3. moderate variability 6-25 bpm, ≤5 bpm for <40 mins

4. no decelerations or occasional variable <30 secs

examples of atypical NST

1. <2 accels with acme of 15 bpm x 15 seconds in 40-80 mins

2. absent or no variability

3. variable decels 30-60 sec duration

4. baseline 110-160 bpm, >160 bpm <30 mins, or rising baseline

example of abnormal NST

1. <2 accels with acme of 15 bpm x 15 secs in >80 mins

2. erratic baseline, bradycardia (<100) or tachycardia (>160) for over 30 mins

3. late decels or variable decels for > 60 secs

4. variability ≤5 bpm for ≥80 mins, or ≥25 min >10 mins or sinosoidal

what action needs to be taken for an atypical NST result

further assessment

what action needs to be taken for an abnormal NST result

urgent action required, further assessment and possible delivery

contraction stress test (cst) aka oxytocin challenge test (OCT)

observation of FHR response to 3 1 min ctx within 10 mins, induce ctx to see how well baby would do in response to labour

how to stimulate ctx in a contraction stress test/oxcytocin challenge test

induce via nipple stimulation or IV oxytocin

positive contraction stress test/oxytocin challenge test

late decels with ≥ 50% of ctx → 15 15 rule

15 15 rule for deccels

decel of 15 bpm within 15 sec

negative contraction stress test/oxytocin challenge test

normal baseline and no late decels

contraindications to contraction stress test/oxytocin challenge test

• preterm labour

• placenta previa

• multiple gestation

• previous classic uterine incision

shape of variable decels

V shape

what do variable decels suggest

cord compression

what do late decels suggest

uteralplacental insufficiency → problem with blood flow to the uterus and placenta, baby is compensating by slowing HR, the more severe the insufficiency the more compensation

what is tested in a biophysical profile (BPP)

• physical exam of fetus

• fetal breathing movements

• anmiotic fluid volume

• fetal tone

• fetal movements

• may include NST

what does the results of a BPP (biophysical profile) tell us

if 4 criteria are intact (fetal breathing movements, anmiotic fluid volume, fetal tone, fetal movement), indicatyes CNS is intact and functioning, the fetus is well oxygenated, overall wellbeing

assessment of fetal tone

looks at flexed position of arms, leg, fingers, etc

point breakdown of biophysical profile

total of 8, each section gets 2 points, if also doing NST then total of 10

BATMaN

Breathing movements

Amniotic fluid volume

Tone of fetus

Movement of fetus

and

Nonstress test

how to score biophsyicaal prophile

if normal, score of 2, if abnormal score of 0

ideal biophysical profile score

8/8 or 10/10 if NST included

score criteria for fetal breathing movements in BPP

normal (2) → one or more episodes in 30 mins, each lasting ≥ 30 secs

abnormal (0) → episodes absent or no episode ≥ 30 sec in a 30 min period

score criteria for fetal movements in BPP

normal (2) → at least 3 trunk or limb movements in 30 mins

abnormal (0) → fewer then 3 episodes of body or limb movements in 30 mins

score criteria for fetal tone in BPP

normal (2) → at least one episode of active extension with return to flexion of fetal limb or trunk, opening and closing of hand is considered normal fetal tone

abnormal (0) → absence of movement or slow extension/flexion

score criteria for amniotic fluid index in BPP

normal (2) → at least one cord and limb free pocket that is 2cm ×2cm in 2 measurements at right angles

abnormal (0) → no single pocket of fluid that is 2cm ×2cm

criteria for nonstress test in BPP

normal (2) → normal results

abnormal (0) → atypical or abnormal results

what does a BPP score of 8-10 indicate? management?

• normal result, low risk fort chronic asphyxia

• manage with repeat testing as needed

what does a BPP score of 6 with normal fluid mean? management?

• repeat testing in 24 hrs

what does a BPP score of 6 with abnormal fluid indicate? management?

• suspect chronic asphyxia

• if fetus over 34 weeks, bifrth of fetus should occure

• if fetus <34 weeks, intensive survenlence and birth considered → want to let lungs mature as much as possible

what does a BPP score of <6 indicate? management?

• abnormal, suspect chronic asphyxia

• deliver for fetal indications → need to get baby out ASAP

when is BPP testing NOT done

in normal, ‘boring’ pregnancies’ → will have a 20 week US and then none for the rest of pregnancy

amniotic fluid volume (AFV) test

part of 3rd trimester assessment of fetal wellbeing, done via US

oligohydramniois

decreased amniotic fluid volume

issues associated with oligohydramnios

• congenital anomalies → renal agenesis

• intrauterine growth restriction

• premature rupture of membranes

polyhydramnios

increased amniotic fluid volume

issues associated with polyhydramnios

• GI obstruction/blockage by excess fluid

• neural tube defects

• multiple fetuses

• fetal hydrops

doppler blood flow analysis

assess blood flow in maternal uterine arteries and fetal umbilical and middle cerebral arteries, measures the rate of blood flow

what does abnormal blood flow through maternal uterine arteries tell us in a doppler blood flow analysis

prediction of fetal growth restriction

what does restricted blood flow through umbilical artery in a doppler blood flow analysis suggest

associated with intrauterine growth restriction

what does high peal volume/higher speed of blood flow through middle cerebral arteries in a doppler blood flow analysis indicate

suggests fetal anemia

nursing role in antepartum testing

• pt teaching

• assist and perform testing

• interpret findings

• initiate necessary interventions as needed

• notify MD/ midwife PRN

• interpret findings for family/ answer questions

• patient and family support

level 1 maternal-newborn services

maternal

• term, low risk

• cesarean births not always available

newborn

• term, healthy babies

level 2 maternal-newborn services

maternal

• moderate risks

• uncomplicated twins

newborn

• ≥ 34 weeks gestation and 1800 g

• ≥ 32 weeks gestation and 1500 g

• ≥ 30 weeks gestation and >1200 g

level 3 maternal-newborn services

maternal

• complex medical surgical, or obstetrical complications

• on-site adult ICU

newborn

• any gestational age and birth weight

criteria for all sites providing maternal-newborn services

• competent to provide maternal and newborn care - resuscitation and stabilization

• clear referral path and process to higher levels of care

• clear pt transfer protocol

• appropriate staff education

pre-existing conditions in at risk pregnancies

• obesity

• anemia

• pulmonary disorders

• integumentary disorders

• neurological disorders

• autoimmune disorders

• spinal cord injury

• HIV/AIDS

• substance use

prenatal risks in patients with obesity

• infertility

• spontaneous abortion

• recurrent pregnancy loss

pre-conception care for patients with obesity

• ideally weight within normal range → not realistic often

• 5-10% weight loss prior to pregnancy = better outcomes

• discontinue weight loss drug therapy

• wait 24 months after bariatric surgery to become pregnant

• screening for T2DM, HTN, CV disease, other comorbidities

• smoking cessation

• 0.4 mg/day of folic acid starting 3 months prior to conception

antenatal risks in patients with obesity

• gestational diabetes

• hypertension

• preeclampsia

antenatal care in patients with obesity

• nutritional counselling → no weight loss programming

• regular exercise

• recommended weight gain for 5.0-9.0 kg (11-20 lbs) with minimal weight gain in 1st trimester

• repeat US if difficult to visualize, can go transvaginal as well → for dates and anatomy

• GFM screening early

• careful screening for HTN and preeclampsia

  • low dose aspirin prior to 16 wks gestation for moderate or high risk

• serial US for FWB and growth at 28, 32, and 36 weeks, then weekly

• if BMI ≥ 40 kg/m2 → induction at 39 weeks to minimize c-section and stillbirths

intrapartum risks for person with obesity

• passenger factors → macrosomia (>4000g) , shoulder dystocia

• altered uterine contractility

  • prolonged active phase

  • induction of labour

  • may need higher doses of oxytocin

• higher risk of c-section

• challenge to implement interventions

  • monitoring FHR and ctx

  • administering epidural

  • intubation

intrapartum care for patients with obesity

• planning

  • larger BP cuff

  • bariatric bed/wheelchair

  • larger gown

  • longer needle for epidural, can do with US

• EFM in active labour when BMI >35 kg/m2

• maximize pulmonary function and minimize O2 consumption

  • pulse ozymetry

  • good pain control

  frequent repositioning

• c-section

  • AVOID general anaesthesia

  • monitor healing

why do you want to avoid general anesthesia when performing a c-section on a patient with obesity

• airway management can be more difficult

• more difficult to locate veins

• may need more medication

• sleep apnea can be a problem → often comorbid

postpartum risks in patients with obesity

• PPH → may be harder to palpate and assess uterine contraction

• difficulties breastfeeding → may not feel comfortable breastfeeding socially

• venous thromboembolism

  • DVT

  • PE

• infection → harder to keep dry and clean d/t extra issue, wound dehiscence

  • c-section incision

  • episiotomy infection

  • endometritis

  • vaginal infection

why is there a higher risk of infection PP for patients with obesity

• more tissue in area makes it harder to keep clean and dry

• wound dehiscence → can be more difficult to keep edges well approximated

postpartum care for patient with obesity

• consider lactation consultant, referral to PH for ongoing support

• vaginal birth → early mobilization

• c-section birth → may need physio consult

  • consider compression boots

  • consider thromboprophylaxis → heparin

• teaching

  • inspection of incision

  • keeping area clean and dry

  • s/s of infection

risks to neonate when CBP has obesity

• still birth

• neural tube, heart, ventral wall anomalies

• macrosomia → >4000g

  • higher risk of gestational diabetes = higher risk of big babies

• shoulder dystocia

• meconium aspiration → higher risk of fetal distress during labour can cause fetus to expel meconium

• interventions and admission to NICU

what do care providers need to be aware of when caring for a patient with obesity

weight bias and stigmatization

causes of anemia

• RBC production is inadequate d/t insufficient dietary intake

• poor absorption of iron

• excessive blood loss

physiological anemia of pregnancy

increase in plasma volume is more then the increase in RBCs, causes decreased hematocrit

anemia in pregnancy vs non pregnant

non pregnant → hemoglobin ≤120

pregnant → hemoglobin ≤110

hb and hct requirements to be considered physiological anemia of pregnancy

hb above 110 and hct above 0.32

severe anemia

hemoglobin under 60g/L

body response to decreased oxygen carrying capacity of the blood

increased cardiac output, can strain the heart and lead to HF in severe situations

most common type of anemia

iron deficiency anemia

why do we screen for iron deficiency anemia in pregnancy

present in 25% of pregnant people

how do we diagnosis iron deficiency anemia

Hb, Hct, ferritin (iron reserves), if hb <110g/L and serum feritin <12 mcg/L = iron deficiency anemia

recommended in pregnancy to prevent iron deficiency anemia

• iron intake of 27 mg/day → meats, poultry, tofu, beans, spinach

• daily iron supplement

• vegetarians may need more

maternal risks of iron deficiency anemia

• further depletion of stores d/t fetal needs

• less capacity to tolerate blood loss at birth

newborn risks from iron deficiency anemia

• preterm birth

• low birthweight d/t poor growth/fetal stress

how to treat iron deficiency anemia in pregnancy

• prenatal vitamin that includes 30 mg/day of iron OR supplemental elemental iron of 60-120 mg/day

• changes to diet alone may not be enough

potential issue with PO iron supplements in pregnancy

can cause N/V, may not be tolerated well by pregnant person and will need to be given IM

folate vs folic acid

folate occurs naturally, folic acid is synthetic form, both are forms of vitamin B9

folic acid deficiency anemia

deficiency in vitamin B9

why do we encourage pregnant people to take folic acid and increase folate in diet

deficiency can cause neural tube defects, cleft lip and palate

how to increase folate

• 0.4 mg folic acid supplement for all people of childbearing age, taken prior to conception until end of first trimester

• increase dietary folate

  • leafy green veggies

  • legumes

  • eggs

  • whole grains

  • seeds and nuts

who would need a higher dose of folic acid

• patients with obesity

• pregnancies with multiples

• people who have had a child with neural tube defects prior

• if person has had multiple pregnancies close together

sickle cell hemoglobinopathy

• hereditary disease

• formation of sickle-shaped RBCs that are prone to breakdown

• causes hemolytic anemia and occlusion of small vessels

• vascular occlusion → tissue ischemia → acute pain crisis

risks in pregnancy if a patient has sickle cell anemia

• pain crisis

• intrauterine growth restriction

• pre-eclampsia

• infections → pneumonia, meningitis

treatment plan for pregnant patients with sickle cell

• pain management, oxygen, hydration

  • dehydration increases risks

• serial US/testing for growth and fetal wellbeing

• treat infections aggressively with antibiotics

• prophylactic low dose aspirin to prevent pre-eclampsia

• don’t give routine iron

thalassemia

• hereditary

• abnormal synthesis of hemoglobin

• can cause severe anemia in pregnancy

• 2 forms

types of thalassemia

• thalassemia minor

• thalassemia major

impacts of thalassemia minor on pregnancy

• usually asymptomatic/milk, persistent anemia

• no complications during pregnancy if stable

impacts of thalassemia major on pregnancy

• shorter lifespan

• infertility common

• if pregnant → significant risk for sevre anemia, HF/ major cardiac issues

causes of early pregnancy bleeding

• miscarriage aka spontaneous abortion

• ectopic pregnancy

• hydatidform mole aka molar pregnancy

causes of late pregnancy bleeding

• placenta previa

• placental abruption or abruptio placentae

how much blood flows through the placenta at term

~15% of maternal cardiac output (1L/min) flows through placenta