ch. 26 high risk pregnancy Flashcards
assessment of risk factors: psychosocial (what, risks (3)
1) maternal behaviors and adverse lifestyles that have a negative effect on health of mother or fetus (what is home environment)
2) risks:
- emotional distress
- hx. depression or other mental health problems (BPD)
- disturbed interpersonal relationships such as intimate partner violence, substance use or misuse, inadequate social support, unsafe cultural practices
TIP:
- cortisol levels increase, catecholamines -> can lead to preterm labor
assessment of risk factors: biophysical (3)
- originates with the pregnant woman OR the fetus
- may affect development and functioning of either one or both
- genetic disorders, nutritional and general health status, and medical or obstetric related illnesses
TIP:
- stay physically fit during pregnancy
- folic acid
assessment of risk factors: sociodemographic (2)
- arise from the context in which the pregnant woman and family live
- lack of prenatal care (basic right), low income, single marital status, ethnicity (bed on floor)
assessment of risk factors: environmental (2)
- hazards in workplace and woman’s general environment
- may in environmental chemicals (eg. lead, mercury), anesthetic gases, and radiation
antepartum testing: biophysical assessment daily -> fetal movement count (DFMC) (aka, use, protocols, if abnormal, signal)
- AKA “kick counts”
- used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation (assess for fetal adequate oxygenation)
- several different protocols are used for counting
- when a pregnant woman reports decreased fetal activity -> nonstress test performed
- fetal alarm signal
- when: 7th month pregnancy (28th week), 2 1/2 Ibs
kick counts (when, time, position, how, numbers, abnormal, none)
- initiated at 28 weeks (7 months)
- same time every day, preferably after a meal (babies LOVE food)
- left lateral position (vena cavae syndrome)
- mother counts for one to two hours
- 6 counts in 60min (1 hour)
- if <6 -> count 6 again in 2nd hour
- if none -> CONTACT PROVIDER
fetal movement (affects (4))
affects:
- tobacco smoke
- drugs
- alcohol
- caffeine (higher energy caffeine drinks affect fetal brain)
glucose levels UNRELATED to fetal movement
antepartum testing: biophysical assessment -> ultrasonography (considered, 2 types, indications (4))
considered by many to be the MOST valuable diagnostic tool used in obstetrics
- abdominal: transducer on woman’s abdomen, 10-13 weeks
- transvaginal: probe inserted into vagina against the cervix, 18-22 weeks
indications:
- fetal heart activity
- gestational age (growing)
- fetal growth
- fetal anatomy
transvaginal ultrasound (what, bladder, position, indication, relevant to)
- produces clearer image
- EMPTY BLADDER
- lithotomy position
- indication: better assessment of cervix (cervical tunneling: thinning of cervix)
- relevant to 1st trimester
transabdominal ultrasound (bladder, indication, water, time, hcg)
- FULL BLADDER: except for localizing placenta before amnio
- indication: vaginal bleeding with suspected previa
- 1-1.5 quarts water
- uncomfortable
- takes 20-30 minutes
- hcg >1800
antepartum testing: biophysical assessment -> ultrasonography indications (3)
1) fetal genetic disorders and physical anomalies:
- nuchal translucency (NT) screening: if >3mm nuchal folds -> down syndrome
2) placental position and function
3) adjunct to other invasive tests
- amniocentesis risks are reduced with use of ultrasound (LAST RESORT)
antepartum testing: fetal wellbeing (3)
- doppler blood flow and analysis
- amniotic fluid volume: amount?
- biophysical profile (BPP): modified biophysical profile (nonstress test + amniotic fluid index)
antepartum testing: biophysical assessment -> ultrasonography nursing role
primarily counseling and educating women about procedure (reason, benefits, risk)
antepartum testing: biophysical assessment nonmedical ultrasounds (2 types)
1) 3D/4D increasingly popular with pregnant women and their families (more expensive, real life time)
2) (ACOG) have published statements that strongly discourage this practice dut to exposure of the fetus to high frequency sound waves w/o a clear medical indication (CAN AFFECT HEARING)
- often performed by people who are NOT qualified health care professionals
antepartum testing: biophysical assessment magnetic resonance imaging (MRI) (what, evaluates (6), affect)
1) noninvasive radiologic technique
2) examiner can evaluate the following:
- fetal structure, overall growth
- placenta
- quantity of amniotic fluid
- maternal structures
- biochemical status of tissues and organs
- soft tissues, metabolic, or functional anomalies
3) MRI has little effect on the fetus
EXPENSIVE
antepartum testing: biochemical assessment biological examination/chemical determinations (5)
- amniocentesis
- percutaneous umbilical
- blood sampling
- chorionic villus sampling
- maternal sampling
maternal assays: multiple marker screens (screens for, types)
1) screening to detect fetal chromosomal abnormalities (TRISOMY 21)
2) quad test: only widely used multiple marker test in the US, to screen for fetuses with trisomy 21 and trisomy -> MSAFP, unconjugated estriol, hCG, inhibin(glycoprotein -> facilitates other 3, enhanced results)
maternal assays: maternal serum alpha-fetoprotein (MSAFP) (screens, all cases, screening recommended for, performed between)
- maternal serum levels used as screening tool for neural tube defects (NTDs) in pregnancy
- approximately 85-92% of open NTDs and almost all cases of anencephaly can be detected early
- screening recommended for all pregnant women
- MSAFP screening can be performed between 15-20 weeks of gestation (16-18 weeks ideal)
chorionic villus sampling (CVS) (technique for, 5, risk)
technique for genetic studies in 1st trimester
- earlier diagnosis, rapid results
- 10-13. weeks gestation
- involves removal of small tissue specimen from the placenta
- transcervically OR transabdominal
- CVS is a relatively safe procedure
RISK: miscarriage
percutaneous umbilical blood sampling (PUBS) (aka, 6)
AKA cordocentesis
- direct access to the fetal circulation during the second and third trimesters
- safer, easier, and faster alternatives
- insertion of needle directly into fetal umbilical vessel under ultrasound guidance
- most common complication: bleeding from the cord puncture site
- transient fetal bradycardia
- fetal loss occurs following PUBS
amniocentesis (what, complications (4), indications (3))
obtains amniotic fluid
1) potential complications: injure the fetus, induce premature labor, fetal loss, miscarriage
2) indications for use:
- genetic concerns
- fetal lung maturity (L/S ratio >2:1)
- fetal hemolytic disease (blood dysgracia)
maternal assays: coomb’s test (screening tool, 3)
screening tool for Rh incompatibility
- detects other antibodies that may place fetus at risk for incompatibility with maternal antigens (built against baby)
- antigen (maternal)/ antibody (fetal)
- fetal (Rh+) responds to maternal (Rh-)
quad screen (4)
- alpha fetoprotein (AFP)
- estriol
- b-hCG
- inhibin A (glycoprotein): produced by the corpus luteum
- lowers the false positive rate and increases the detection of down’s
abnormal MSAFP screen (3)
- abnormal check dates and recalculate if possible
- ultrasound to confirm dates and evaluate for anomalies
- amniocentesis
maternal assays: cell-free DNA screening in maternal blood (tests for, screens for, when, extra)
- newest screening test for aneuploidy
- cfDNA is used to screen: trisomy 13, 18, 21 mainly
- optimally performed at 11-13 weeks of gestation
- less sensitive to women who are obese
fetal care centers (2)
- fetal care centers have evolved in response to provide diagnostic and therapeutic option as well as support services for families with a fetal anomaly diagnosis
- assess to support services such as genetic counseling, social work, chaplain services, a palliative care team, and ethics consultation because of the complex emotional stressors they face
antepartum assessment using electronic fetal monitoring indications (goal of which trimester, 3)
goal of third trimester testing is to determine whether the intrauterine environment continues to support the fetus
- nonstress test
- vibroaccoustic stimulation (VAS)
- contraction stress test (CST)
nonstress test (procedure, interpretation (3), what to look for, indication, extra)
1) procedure: place monitor on mom
2) interpretation:
- REactive: GOOD -> normal
- NONreactive: BAD -> requires further evaluation (flat line, decreased HR)
- premature (<32wks): increase 10 seconds then comes down
non-stress test:
- accelerations in 20 minute window
- indication: intact autonomic and central nervous system -> not affected by intrauterine hypoxia
- <32 weeks -> 10 beats above baseline x10 sec
- >32 weeks -> 15 beats above baseline x15 sec
- reactive vs. nonreactive
- vibroacoustic stimulation (VAS): music, pitch fork
contraction stress test (CST) (procedure, goal, interpretation, evaluates, indications (5)
(if nonreactive NST)
1) procedure: nipple stimulated contraction test -> releases oxytocin to stimulate contractions (pitocin)
2) oxytocin-stimulated contraction test -> goal: 3 contractions in a 10 minute window
3) interpretation:
- negative (desired result)
- positive (late FHR decels are present) -> can’t tolerate CST, will go into c section
contraction stress test:
- evaluated uteroplacental function
- indications: IUGR (fetal growth restriction), diabetes, postdates (>42 weeks)(post term pregnancy), nonreactive NST, abnormal or suspicious BPP
FHT/quickening (when, felt when for primips/multips)
- fetal heart tones first heard by doppler at 10-12 weeks gestation
- quickening felt by primips (first time pregnancy) at 18-20 weeks gestation (4 1/2 -> 5 months)
- quickening felt by multips at 16 weeks or more (d/t uterine muscle stretched out)
CST contraindications (6)
third trimester bleeding
- previous C/S with classical (up/down through abdominal muscles) uterine incision
- PROM
- incompetent cervix
- multiple gestation
- risk: uterine rupture
CST procedure (5)
- electronic fetal monitor
- stimulate contractions (pitocin - oxytocin, nipple stimulation)
- 3 contractions in a 10 minute window
- negative (good), positive (bad), unsatisfactory (not enough data)
- equivocal - suspicious, hyper-stimulatory (no clear pattern)
negative CST
3 contractions in 10 minutes with NO signs of late decelerations
positive CST
repetitive persistent late decelerations occurring with more than half the contractions
equivocal
FHR decelerations with uterine hyper-stimulation
unsatisfactory
fewer than 3 contractions in 10 minutes
NST/reactive FHR (normal, abnormal)
normal
- at least two accelerations in 20 minutes
abnormal
- less than two accelerations to satisfy the test in 20 minutes
U/S: fetal breathing movements (normal/abnormal)
normal
- at least one episode of >30s or >20s in 30 minutes
abnormal
- none or less than 30s or 20s
U/S: fetal activity/gross body movements (normal/abnormal)
normal
- at least 3 discrete body/limb movement in 30 minutes (episodes of active continuous movement considered a single movement)
abnormal
- less than three or two movements
U/S: fetal muscle tone (normal/abnormal)
normal
- at least one episode of active extension with return to flexion of fetal limb(s) or trunk, opening and closing of hand considered to be normal tone
abnormal
- either slow extension with return to partial flexion or movement of limb in full extension or absent fetal movement
U/S: qualitative AFV (amniotic fluid volume)/AFI (normal/abnormal)
normal
- at least one vertical pocket >2 cm in the vertical axis or AFI of 5 cm
abnormal
- largest vertical pocket </= 2 cm, or AFI </= 5 cm
10/10: ideal
6/10: borderline
amniotic fluid
- olihydraminos: <300cc
- polyhydraminos: >2000cc
evaluation of fetal growth (what, fetoplacental (3), maternal (6))
1) FGR: ultrasound estimation of weight
- <10 percentile, fetus <10% of that gestation age
2) fetoplacental:
- infections
- genetic abnormalities
- placental abnormalities
3) maternal:
- HTN
- poor maternal weight gain
- poor nutrition
- substance use (tobacco, medications)
- anemia
- chronic illness
macrosomia (5)
(large baby)
- fetal weight 4000-4500 (8Ibs 13oz, 9Ibs 4oz)
- shoulder dystocia: jammed d/t size leading to compromised lungs
- leopold’s maneuver
- fundal height
- U/S
TIP:
- mcRoberts maneuver: take fist and push shoulder in
- issue with maternal pelvis (above pelvic bone)
psychologic considerations r/t high risk pregnancy (3)
- label of high risk often increases the patient’s sense of vulnerability
- may exhibit anxiety, low self esteem, guilt, frustration, and inability to function
- may affect parental attachment, accomplishment of the tasks of pregnancy, and family adaptation to the pregnancy
the nurse’s role in assessment and mgmt of the high risk pregnancy (5)
- provide education
- anticipatory guidance
- counseling for family adaptation
- planning and implementation of appropriate interventions
- in many settings nurses perform the following: NST, CST, BPP
