Normal Pregnancy + Fetal Risk Assessment pt 3
Discomfort of Pregnancy
First Trimester
Urinary Frequency (Can be 1st sign)
Fatigue
N/V
Breast Tenderness
Constipation
Nasal stuffiness, Bleeding gums, epistaxis (Nose bleeds)
Increase cravings
Leukorrhea (Acidic white discharge)
Second Trimester - lots of baby growth
Backache
Varicosities of the vulva and legs
Hemorrhoids: varicosities of rectum
Flatulence/bloating
Third Trimester
Return of 1st trimester discomforts
shortness of breath/dyspnea
heartburn/indigestion
dependent edema - raise extremities, TEDs
Braxton Hicks contractions
starts at back - build to front
BACKACHES
B - Backaches, breast tenderness
A - Anorexia, N&V in first trimester
C - constipation
K or C = contractions = braxton Hicks
A - Anemia
C - Cramping in legs
H - Heartburn, has urinary frequency, hemorrhoids
E - Edema in lower extremities, epistaxis
S - Shortness of breath, supine hypotension
Nursing Management to promote care
personal hygiene/perineal care/ breast care/ clothing
Avoidance of sauna & hot tubs \
Sleep and rest
dental care (NO X-rays)
Sexual activity/sexuality
Travel
Exercise
best: walking + swimming
seat belt safety
employment
vaccines/immunizations/medication use
Preparation for labor & Birth
perinatal education
Childbirth education
Lamaze: psychoprophylactic method: focus os on the fear-tension-pain cycle while breathing/relaxation tech’s
Bradley: partner-coached childbirth method; focus is on exercise, breathing & Relaxation
Dick-Read: natural childbirth method; focus is on fear reduction with knowledge and abdominal breathing techniques
BIrth setting
Home birth, birthing centers, or hospital birth
care providers
obstetrician, midwife, doula
Feeding options
breastfeeding, bottle feeding
Final preparation for birth
transportation, suitcase, home/pet/child care, support person, birth plan
Fetal RIsk Assessment
Ultra-sound (US)
Doppler Flow studies
Nuchal Translucency
Amniocentesis
CHronic VIlli Sampling (CVS)
Percutaneous Umbilical COrd Sampling (PUBS)
Non-stress est (NST) & Contraction stress test (CST)
Fetal kick counts
Biophysical Profile
Ultrasound
uses high-frequency sound waves to observe fetal organs/structures
Used for diagnostic and evaluative purposes
Done 2 ways: abdominally or vaginally
transabdominal/pelvic US
Transvaginal US: 1st trimester
uses a transducer
used to:
validate the pregnancy/confirm viability
determine dates
anatomy scan 18-20 weeks
check fo fetal anomalies/abnormalities
observe the placenta location/fetal growth
measure AFI (Amniotic fluid index)
biophysical profile
Second & Third Trimester US (transabdominal)
confirm fetal viability
anatomy scan
determine gestational age
evaluate amniotic fluid level
assess serial growth
Twins - Compare growth, AFI
placenta location
BPP
presentation
fetal ling maturity
Chronic Villus sampling (CVS)
A sample of chorionic Villus from the placenta; done transabdominally or transcervically
prenatal diagnosis (10-13 wks)
Benefits: earlier than amnio, early dx
risks: infection, bleeding, miscarriage, limb deformity if done before 9 weeks, more difficult to do, contraindicated with Rh sensitization
checks genetic make up/information
a catheter is placed vaginally with ultrasound guidance
must consider risk/benefit ratio
Amniocentesis
Amniocentesis; amniotic fluid is aspirated from the amniotic sac
evaluates genetic well being, disorders, or lung maturity
1st trimester (11-14 weeks) for genetic anomalies
2nd trimester (15-20 weeks) to detect chromosomal abnormalities
3rd trimester after 35 weeks to determine fetal lung maturity via analysis of lecithin-to-sphingomeylin ratios to determine eligibility for induction of labor prior to 39 weeks or for cesarean delivery
empty bladder prior to procedure
educate about risks vs benefits
Risks: infection, bleeding, preterm labor, PROM, fetal loss
Benefits: early dx, decrease maternal stress, care plan for anomalies/fetal death, abortion
for RH- mothers, administer RhoGAM r/t risk of maternal and fetal blood mixing
Percutaneous Umbilical Blood Sampling (PUBS)
used for prenatal dx: fetal hemolytic disease, fetal infections, chromosomal or genetic disease, fetal hypoxia, blood factor abnormalities.
can be used to txt the fetus; transfusion, administer drugs
blood withdrawn from umbilical cord by U/S guidance after 20 weeks
risks: same as Amnio and CVS
Fetal movement/kick counts
maternal report of fetal movement
done after 28 weeks
procedure is safe, simple, cost free, & non-invasive
good predictor of fetal well being
decrease or no movement = cause for concern
movement is affected by drugs, sleep states, maternal glucose and maternal hydration status
evaluate 1 hour after meal, side-lying, 3X/day; Sanovsksky’s protocol: 4+ movements in 30 min
Kick count - maternal perception of movements
count to 10 - should feel 10 distant movements in a 1-2 hour period
if decreased fetal movements perceived, drink something cold and sweet, lie on left side in a quite place and count movements.
if 6-10 movements are not felt in 1-hour call your provider
Non-stress Test (NST)
evaluates fetal heart response to fetal movement non-invasive; use EFM
indications: postadtes, PIH, DM, IUGR, decreased fetal movement
rective = two or more accelerations of 15 bpm lasting at least 15 seconds within 15-20 minutes (the “15 X 15 rule”)
Nonreactive = FHR fails to demonstrate the above in a 40 minute time frame; needs further evaluation (CST, BPP)
no fetal movement @ same time as acelerations
FHR can be affected by: smoking, fetal sleep, meds, & fetal anomalies
Biophysical Profile (BPP)
It’s all or none
uses US to evaluate 5 fetal variabel to assess fetal risk; good predictor of fetal well being or distress
scoring 0-2 for a total of 10
fetal breathing movements: one or more in 30 minutes; none=0, present = 2
gross body/limb movements
three or more in 30 minutes; non=0, present = 2
fetal muscle tone
+1 episodes of flexion/extension in 30 min; none=0, present =2
AFV: at least one fluid pocket of 2 cm; none = 0, present = 2
reactive NST = 2
nonreactive NST = 0
score of 8-10 is normal in the absence of oligohydramnios
oligohydramnios = low amniotic fluid
6 is equivocal; repeat testing
4 or less is abnormal
Contraction Stress Test (CST)
used to assess fetal response to contraction
sometimes called oxytocin challenge test (OCT)
done in hospital with EFM with oxytocin or nipple stim
contraindications: placental problems, previous uterine surgery, previous classical c-section, < 37 weeks, multiples, risk of PTL
Negative test: no late or variable decelerations
nothing bad happens - want to see accels with contractions
Positive test: persistent late decels with 50% or more of the contractions
something bad happens
1. ger patient to left side/reposition
2. open primary IV (LR)
3. get simple mask with 8-10L oxygen
4. If PITT is on - turn it off
Doppler Flow studies
ultrasound evaluation of the feus using 2D color doppler
prenatal diagnosis of structural anomalies, rhythm abnormalities, altered fetal circulation
detects fetal compromise in high risk pregnancies and abnormalities in diastolic flow in umbilical vessels
Electronic fetal monitoring
showing baby HR and contractions on one strip
Nadir = lowest point of deccel
Late decels = the fetal heart tones return to the baseline after end of contraction
Internal fetal monitoring
fetal scalp electrode (FSE)= an internal fetal heart monitor
Intrauterine pressure catheter (IUPC) = an internal contraction monitor
VEAL CHOP
V - Variable C - cord compression
E- earlu H - head
A - Acceleration O - oxygenation
L - Late P - placenta/uterine insufficiency
Nuchal Cord Translucency
1st trimester test between 11-14 weeks
done during US
identifies an increase in nuchal translucency due to a subcutaneous accumulation of fluid behind the fetal neck
allows early detection and diagnosis of some fetal chromosomal and structural abnormalities, genetic syndromes, high risk of abortion and fetal death
increased nuchal cord translucency is associated with chromosomal abnormalities such as:
trisomy 21, 18, 13
diaphragmatic hernias
cardiac defects
fetal skeletal and neurologic abnormalities