Prenatal Care

• Ensure health of mother and baby and set them up for success

  • Physiological Health

  • Socioeconomic health

• ACOG Goals

  • Ensure healthy baby and minimize maternal risk

  • Early, accurate estimate of gestational age

  • Identify patients at risk for complications

  • Anticipate and prevent problems before they occur

  • Patient education and communication

• Mothers who don’t get prenatal care:

  • 3x more likely low birth weight baby

  • 5x more likely to have baby that dies

  • More likely to have miscarriages

• Early and adequate prenatal care important

Frequency of Prenatal Visits

• Low Risk Pregnancies:

  • Initial visit in first trimester: early prenatal care at 6-10 weeks

  • First 2 months: come back every 4-6 weeks

  • Trimester 3:

    • first 2 months: every 2 weeks

    • Last month (36-40): every week

  • “Early and adequate PNC”

    • “Adequate”: 80% of visits

    • “Late” starts in 3rd trimester

1st Prenatal Visit: Comprehensive

• Prenatal History

  • Current and Past Pregnancies

    • LMP → EDD

    • Complications/Problems

    • Discomforts, concerns, questions

  • Past Pregnancies

    • G/P and G-TPAL

      • Notation systems to quickly see numbers and know past history

      • G/P least amount of info

      • TPAL is standard

    • Insightful into what might happen

• GYN History

  • Contraception

  • Hx STIs

  • Last pap/ Hx

• Medical History

• Mental Health Screening

  • Before and Postpartum influential especially when serious illness

• Occupational History

• Genetic history

• Significant FOB health history

  • Dad’s blood type (rh negative?)

• Social Profile

  • Family setting- DV? (3-10% women DV during pregnancy)

• Support Systems

• Occupational/Educational

• Psychological/emotional health (past & present)

  • Depression has high risk for PPD

• Cultural/Religious

• Personal Habits/Risks

  • Alcohol, drugs, smoking: [marijuana not safe for pregnancy]

• Birth and feeding preference

  • encourage breast feeding, but know early on if they can’t

  • Preferences → demands → baby dies at times if they refuse care

• Plan for care of baby

• Blood Work

  • Blood Type

    • ABO Rh (D antigen) ± factor

    • Antibody screen (indirect coombs for anti)

    • want to be negative

  • Infection

    • Rubella Titer: antibodies

      • -/+ immune or non-immune

        • Want it positive

      • Not a vaccine we can give to newborns or progressed pregnant woman, so offered early on

    • Syphilis: antigens (serology)

      • want to be negative

    • Hep B: antigens

      • want to be negative

    • HIV offered: different types

      • look at antigens and antibodies

    • CBC: baseline

    • Sickle cell screen PRN

    • Toxicology screen PRN

      • test for substance use

    • Serum Glucose (HgBAIc)

      • high risk women

  • Other lab screening

    • Gonorrhea/chlamydia

    • Pap smear

    • Urinalysis and culture

    • COVID-19

• Immunizations

  • Recommend screenings: Hep B, Rubella, varicella (not mmr)

  • Vaccines: Flu (inactivated)

  • Tdap

  • Hep A B

  • COVID

• Physical Examination

  • Vital Signs

  • Heigh/weight

  • Head-toe assessment

  • Pelvic and breast exam

    • vulva

    • Cervix

  • Possible ultrasound- now standard

• Determine risk status

• Recognize and analyze the cues for concerning risks

  • Do they need to see a specialist?

  • Do they need supplements?

• Anticipatory guidance: education.

G/P System: On Handout

• 20 weeks (22-24weeks) usually considered viable

• can’t add para till baby is out

• Sometimes right after birth, still 1:0

G/TPAL

• 36 6/7 cutoff 37.0 weeks and beyond: Term

  • Before counts as preterm

  • Post-term is still in with term

Subsequent Prenatal Visits

• common discomforts vs warning signs

• Pregnancy Danger Signs

  • Fever of 101* <

    • Infection

    • high risk for preterm labor

  • Sudden severe or continuous pain/cramping in the lower abdomen

    • ectopic pregnancy, PTL, labor, placental abruption, non-pregnancy causes- UTI (risk for preterm labor) or appendicitis

  • Bleeding or spotting from your vagina

    • SAB, placent previa, abruption, friable cervic, labor

  • Sudden severe swelling of hands, feet, face, generalized edema

    • pre-eclampsia

    • A little swelling is normal

  • Vs. Common discomforts

• Fundal height measurements

  • 10 wks: orange

  • 12 wks: grapefruit

  • 16 wks: midway btw symphysis pubis and umbilicus

  • 18-32 wks: measurement in cm roughly corresponds w/week’s gestation

  • If not growing, ultrasound

• FHR 10 weeks onwards

  • 110-160 bpm for fetus and newborn

• “Quickening'“

  • Mom starts to feel ~16-20 weeks

  • Movement slows down closer to term because there is less room for it to move

  • Fetus has a sleep cycle

Fetal Activity: Kick Counts

• Late second trimester, third trimester

• COunt same time each day when baby is active, like 1hour after meal/activity

• Lie in side or sit

• Call provider in decreased movements

• Wait for 1-2 hours till you feel 4 movements in 1 hr/ 10 movements in 2 hours

Maternal Assays

1. Noninvasive Prenatal Genetic Testing (NIPT): Blood Test

   • Done at 10 wks

   • Fetal DNA found in maternal serum that crossed from the placenta

   • Very accurate, not considered diagnostic

   • Trisomies 13,18,21 other rare chromosomal abnormalities

2. Ultrascreen/ “First trimester screen”: Ultrasound on fetus

   • Btw 11-1/7 wks to 12-6/7 wks

   • For chromosomal abnormalities

   • Nuchal translucency plus 2 maternal serum biomarkers (free beta hCG, PAP, P-A)

3. Maternal Serum Alpha Fetoprotein (MSAFP)

   • 15-20wks (16-18 ideal)

   • Elevated AFP: neural tube defects

   • Decreased AFP: chromosomal trisomies like Down's syndrome

4. Multiple Marker Screening (Tiple, quad, penta)

   • Alpha biomarkers but more; more in-depth

   • Trisomies

Lab Screening: 2nd Trimester

• Diabetes screen for GDM at 24-28 wks

  • Earlier for high-risk women

  • “Glucose challenge test”

  • 1hr 50 g oral glucose challenge test (OGCT)

  • 3 hr 100g OGTT, if 1hr GTT is >140

• Heaglobin/hematocrit at 24-28 weeks

• Antibody Screen: for Rh negative patients

  • Give antibody for passive immunity to prevent active immunity

• Rhophylac (RhoGAM) administration - as needed

• Group B Streptococcus (GBS)

  • 10-30% asymptomatic carriers, but it can make the baby sick during vaginal birth

  • Check at 35-37 weeks

  • Vaginal and rectal swab

  • Antibiotic prophylaxis during labor if positive

• Repeat if indicated

Birth Preferences

There are lots of social determinants of health, SSE

Prenatal Tests

• antepartum fetal surveillance

  • NST

Who Needs Additional Testing?

• Younger or older moms

• Maternal disease

• Rh isoimmunization

  • antibodies can cause harm to fetus

• Previous poor pregnancy outcome

• Suspected IUGR

• Post-dates pregnancy

• Multiple gestation

• Demographic/diversity factory

Screening test

• identifies those not affected by a disease or abnormality

• identifies those at risk

• if positive-usually warrants further testing

Diagnostic tests

• identifies a disease

Key Concept to Tests: Fetal Oxygenation

• Many things can go wrong through placenta and umbilical cord

• Fetus reacts to hypoxia in a very predictable manner

  • Oxygen through placenta and ubillical

• How to watch the oxygen?

  • Toco transducer (contractions) and Ultrasound transducer (FHR)

Fetal Movements

• Muscle tone 7-8wks

• General movement 8-9 wks

• Breathing movement 11-12 wks

• Sucking 12-14 wks

• FHR Reactivity 28-32 wks

  • Accelerates in response to movement

• Fetal Hypoxia will cause these behaviors to stop or reverse order

Non-stress Test

• Done in third trimester

• Use of external FHR monitor to observe for FHR reactivity w/wo fetal movement

• FHR with accelrations is good

• Results:

  • Increase 15 bpm for 15 sec with 2 episodes in 20 min

  • Non-reactive is non-reassuring

• Prior to 32 weeks- use “10×10” rule

• High “false positive” rate (or other way)

  • vibroacoustic stimulation to stimulate fetal movement

Contraction Stress Test

• Same equipment as NST

• Contractions to observe for late declarations

  • Use oxytocin to induce contractions

    • Dip in FHR

• Hypoxic baby will show signs of distress when squeezed

• Negative test (want): no FHR late decelerations within 3 contractions lasting at least 40 seconds

• Positive test (bad) late deceleration with 50% or more contractions

Third Trimester: Biphysical Profile (BPP)

• evaluate for:

  • FHR

  • Fetal breathing movements (US)

  • Gross fetal movement (US)

  • Fetal Tone (US)

  • Amniotic fluid volume/index (AFI) via US)

    • Healthy baby will have plenty of urine bc healthy kidney blood flow

      • >10 cm: reassuring

      • <5 cm: not reassuring (oligohydramnios)

  • Each given a score of 0-2, max 10

    • 8/10: normal

    • 6/10 delivery may be recommended

    • 4/10 delivery recommended

    • 2/10 immediate delivery recommended

Ultrasound

• noninvasive

• transvaginl: used in early pregnancy

• transabdominal: later

• Sound waves bounce off fetus and anatomical structures → picture

• Doppler, color

• No known risks

• Adds expense to prenatal care

• First Trimester:

  • validate pregnancy

  • measure thickness of back neck to indicate chromosomal abnormality

• Second Trimester:

  • Also to aid amniocenteses to guide needle placement (only can start at 15-20 wks)

    • Genetic Testing

    • May increase spontaneous abortion <15wks

    • Trauma to fetus, umbilical cord or placenta

    • Need Seperate consent form

• Third Trimester:

  • Growth

  • Amniocentesis for lung maturity testing

    • Can also test fluid for infection and check for Rh sensitization

  • Suspected IUFD, bleeding, suspected abruption

• Doppler:

  • Color and sound to see bloodflow

Chorionic Villus Sampling

• Done at 10-13 weeks

• Chorionic Villi: make connection with the uterus

• Sample taken vaginally or transabdominally

• Used for prenatal genetic diagnosis

• Faster cell growth, results within 1 week

• Alight increased risk of spontaneous abortion

• Nursing care: very similar to amniocentesis

Percutaneous Umbilical Blood Sampling (PUBS)

• Take blood from fetus and give blood to fetus

Other Tests:

• Magnetic Resonance Imaging: of fetal structures

• Delta OD 450: predicts severe fetal anemia via amniotic fluid exam

• Middle cerebral artery doppler US flow study: indicator of fetal anemia

Electronic Fetal Monitoring

• Too for visualizing FHR patterns on a screen or printed tracing

• To assess fetal well being (oxygenation)

• 5 essential components

  • Baseline FHR

  • Variability

  • Accelertions

  • Declerations

  • Changes in FHR over time

• ADEQUATE FETAL OXYGENATION

Principles of Fetal Monitoring

• Support maternal coping and labor progress

• maximiaze uterine blood floor

• maximize umbilican blod floor

• maximize oxygenation

• maintain appropriate uterine actiivty

Methods of Fetal Monitoring

• Intermittent Auscultation (IA) and palpation (of cx’s)

• Continuous Electronic Fetal Monitoring (EFM)

  • Monitors uterine contractions and FHR

  • Intermittent or continuous

  • External or internal FHR monitoring

    • Non-invasive

      • “Toco” transabdominal for contractions

      • Ultrasound transducer detects FHR

    • Invasive (internal)

      • Membranes must be ruptured already, cervix sufficiently dilated and presenting low

      • Spiral electrode for FHR

      • Internal uterine pressure catheter (IUPC) for uterine contractions

      • Top: Fetus Bottom: Contractions

Assessing Uterine Contraction (UC) Tracing

• Bottom Tracing on fetal monitor strip

• Frequency, duration, tone, intensity via palpation

  • Mild or 1+ (easily dented)

  • Moderate 2+ (slightly indent)

  • Strong 3+ (can’t indent uterus)

  • Can’t tell contraction strenght (tone) from monitor strip without an IUPC

• Want a resting of 5-15

• Frequency:

  • 3-5 contractions/ 10 min

  • tachysystole

• Resting time: >30 sec btw contractions

• Duration:

  • 45-60 seconds in active phase

  • 60-90 sec transitional phase and pushin

  • Need adequate resting time between

Assessing FHR

• top

• Baseline FHR

  • tachycardia, bradycardia, variability

  • 110-160 bpm

  • Variability: irregular fluctuations in the baseline

  • Tachycardia

    • Common causes: infection, hypoxia, maternal fever, dehydration, ect.

    • Non-reassuring when with late decelerations, severe variable decelerations or absence of variability

  • Bradycardia

    • Common causes: fetal hypoxia, maternal supine position, umbilical prolapse or collapse, ect.

    • Non-reassuring with loss of variability and late decelerations

  • Variability: irregular fluctuations in the baseline FHR resulting from relationship btw sympathetic and parasympathetic nervous systems

    • Most important characteristic of FHR monitoring

    • Primary indictor of adequate oxygenation and fetal reserve

    • Not reliably predicts of hypoxia

    • NICHD Definition:

      • Irregular Fluctuatons in baseline FHR

      • Visually quantified (seen with our eyes)

      • Absent: undetectable

      • Minimal: detectable but 5< bpm

        • Mostly considered non-reassuring, but consider the three S’s:

          • Baby asleep?

          • Mother sedated?

          • Baby is sick?

      • Average/Moderate: 6/25 bpm

        • Ideal

      • Marked: >25 bpm

        • Rare: sign of early mild hypoxia

        • Indicates more monitoring and intervention

    • Moderate variability strongly associated with adequate cerebral oxygenation

• Periodic changes with Cx’s bv episodic changes w/o cx’s

• Accelerations

• Decelerations

  • Early

  • Late

  • Variable

  • Prolonged

• Analysis- “reassuring” v “non-reassuring”

  • “Category 1,2,3” tracing

Periodic Changes in the FHR: VEAL CHOP

• Accelerations:

  • Temporary increases in the FHR

    • if goes up 15 bpm for 15 seconds

  • Usually caused by fetal movement or in response to uterine contraction

  • Reassuring: like accelerations

• Deceleration:

  • Periodic decrease in FHR below the normal baseline

    • Early decels

      • uniform in shape (mirror contraction)

      • gradual onset and recovery

      • Seen in early stages in labor

        • Due to head compressions

        • No interventions needed

    • Late decels

      • Caused by uteroplacental insufficiency

      • Onset occurs after onset of contraction

      • FHR returns to baseline after contraction ends

      • Uniform in shape, gradual onset and recovery

      • May be shallow or deeper, usually proportional to contraction, rarely HR <100 bpm

      • NOT benign

        • required intervention

          • Repositioning

          • Hydrate

          • Oxygen

          • Discontinue Oxytocin

          • Notify Provider

        • Always non-reassuring

        • Related to fetal hypoxemia

    • Variable decels: NOT RELATED TO VARIABILITY

      • Caused by umbilical cord compression

      • Abrupt decrease in FHR variable in duration, intensity, timing related to uterine contraction

      • Usually a V or U shape

      • More common following ROM

      • Nursing interventions

        • Reposition

        • Hydrate

        • Oxygen

        • Notify Provider if repetitive

        • Amniofusion

    • Prolonged decels

      • Prolonged cord compression, but can also be other causes

        • Prolapsed cord

        • knot

        • maternal respiratory arrest

      • Abrupt decrease in FHR of >15 bpm below baseline, lasting 2-10 minutes

Putting It All Together

• Reassuring:

  • Baseline FHR 110-160 bpm

  • Moderate Variability 6-25 bpm

  • Accelerations with FM (15 bpm above baseline for 15 sec or more)

  • Variable decelerations

• NonReasuring

  • Tachycardia

  • Bradycardia

  • Absent or minimal variability

  • Late decelerations

  • Variable decelerations that fall less than 60 bpm for longer than 60 seconds

  • Prolonged decelerations

  • Hypertonic uterine activity

• Nursing Intercentions

  • Intrauterine resucitation

  • Avoid supine position

  • Hypotension, HTN, fever

  • Hydrate- IV fluids, maximize Ivasculr volume

  • Oxygen via facemask at 8-10L/minute: not done as often

  • Stop oxytocin or other uterine stimuants

    • tocolysis may be ordered- terbutaline

  • Notify CNM/MD

  • Expedite delivery when warranted

  • Communicate with your faily

  • Document

• Other Interventions to Clarify FHR Data

  • Fetal scalp stimulation

  • Vibroacoustic stimulation (VAS)

  • Fetal scalp blood sampling

  • Umbilical cord blood gases (done after birth)

• Categories:

  • I: Normal/ reassuring

  • II: Indeterminate/ non-reassuring

  • III: abnormal/non-reassuring

5 Steps for Interpretation of FHR Patterns

Pregnant Woman:

• Baby and placenta push against the bladder, so peeing is more often

• DIzziness is common

  • Getting up is common time for dizziness, baby presses against vena cava, which slows the blood flow to the head and lowers to blood pressure

    • supine hypotension; postural hypotension; orthostatic hypotension

• Feeling tired and out of breath

  • Baby pressing against diaphragm, making less room for lungs to expand. Baby is also heavy to carry

• UTI → crawls up to kidneys easily → nephritis

  • Hurts to pee, cloudy pee