Chapter 10: Antepartum Fetal Assessment Flashcards
1
Q
why is an antepartum fetal assessment done?
A
- to detect congenital anomalies and evaluate the condition of the fetus
- but no antepartal testing or antepartal surveillance procedure can guarantee the birth of a perfect infant
2
Q
role of perinatal nurses in antepartal fetal assessments
A
- be prepared to offer clear explanations of diagnostic procedures and any problems the woman should report
- support for the family requiring fetal diagnostic tests can reduce their anxiety
3
Q
antepartum fetal assessment
A
- Each is an assessment to measure the presence or absence of fetal well being
- Potentially only for indications
- Some are within the scope of nursing practice to do
- Some are not, but a nurse is expected to participate in procedure and/or provide patient education
4
Q
goals of antepartum fetal assessment
A
- determine fetal health or compromise accurately
- reduce perinatal morbidity and mortality
- guide intervention by the OB team
5
Q
ultrasound
A
- can provide 2D or 3D imaging
- real time so able to observe fetal heart motion, fetal breathing, fetal movement
- can be done transabdominally or transvaginally
6
Q
levels of ultrasound
A
- standard (basic): general survey of fetus, placenta, and amniotic fluid volume
- specialized (comprehensive): done if abnormalities found during basic scan
- limited: done to address placental location, fetal cardiac activity, determine presentation, assess volume of amniotic fluid
7
Q
first trimester ultrasonography
A
- most used to:
- confirm pregnancy
- verify location of pregnancy and identify multifetal gestation
- determine gestation age
- determine location of uterus, cervix, placenta for chorionic villus sampling (CVS)
- crown rump (CRL) measurement is most reliable measurement of gestational age
- viability confirmed by fetal heartbeat which is visible when CRL is 5 mm
8
Q
second and third trimester ultrasonography
A
- usually transabdominal
- purposes:
- confirm viability
- evaluate anatomy
- confirm gestational age
- assess fetal growth
- locate placenta
- determine preseantation
- becomes more difficult to evaluate gestational age, but need accurate fetal age if assessing alpha getoprotein levels or looking at IUGR
9
Q
advantages of ultrasound
A
- shows clear visibility of the fetus and surrounding structures
- has been proven safe
- noninvasive
- comfortable
- results are immediate
- portable and available
10
Q
disadvantages of ultrasound
A
- cost
- if don’t get an ultrasound during 1st trimester, gestational age will not be calculated as accurately
- cannot identify all defects of fetal structure or function
- possible anxiety for new parents if abnormal results are found
11
Q
dopper ultrasound
A
- used when pregnancies are complicated by HTN or fetal growth restriction to identify abnormalities in blood flow
12
Q
alpha fetoprotein screening
A
- AFP is the predominant protein in the fetal plasma
- it diffuses from fetal plasma to fetal urine to the amniotic fluid
- some crosses the placenta, so it can be measured in maternal blood (MSAFP) or in amniotic fluid (AFAFP)
- low levels of MSAFP suggest chromosomal abnormalities, like trisomy 21
- elevated levels of MSAFP suggest neural tube defects like anencephaly or spina bifida
- done b/w 16 and 18 weeks gestation
- can be affected by gestational age, maternal weight, multifetal pregnancy, race, maternal diabetes, and ethnicity
13
Q
advantages of MSAFP evaluation
A
- simple
- not invasive to fetus
- economic
- early screening so allows time for more comprehensive screening if it comes back abnormal
14
Q
limitations of MSAFP evaluation
A
- screening test, not diagnostic
- benign conditions such as inaccurate estimation of gestational age can result in apparently abnormal levels in a health fetus
- timing: can only be done b/w 16-18 weeks
- normal levels of AFP do not guarantee that the baby is free of structural defects
15
Q
multiple marker screening
A
- test for hCG and unconjugated estriol (along with MSAFP): triple screen
- inc detection of trisomy 18 and 21, so noninvasive test for NTD
- samples taken b/w 16-18 weeks, and are considered positive for an anomaly if MSAFP and estriol are low and hCG is high
- quad screen: adds placental inhibin A which will help improve screening of trisomy 21 in women under 35
16
Q
chorionic villus sampling (CVS)
A
- the villi are fetal tissues that are projections of the outer membrane that burrow into endometrial tissue–>they have the chromosomal, metabolic, and genetic makeup of the fetus
- performed b/w 10-12 weeks
- must include genetic counseling about the specific defect which the CVS is being performed
- can be done by transcervical or transabdominal approach
- after CVS, fetal heart activity is documented to confirm viability
- maternal V/S are assessed
- RhoGAM is given if women is Rh negative
- small amount of vaginal bleeding may occur, need to rest at home and avoid sex for a few days
17
Q
advantages of CVS
A
- results are known early
- offers prenatal diagnosis early in pregnancy
- if a woman chooses abortion based on the results, it may be less physically and emotionally traumatic than a later procedure
18
Q
risks of CVS
A
- fetal loss
- limb reduction defects
- preliminary results available w/in 2-3 hours, but they are incubated for 2-4 days after
- if questionable results, may require a more expensive and invasive amniocentesis
19
Q
amniocentesis
A
- done b/w 15-20 weeks b/c of the need for adequate fluid volume and quantity of viable fetal cells
- complication: foot deformation (clufoot)
- if done in midtrimester: for chromosomal abnormalities, to diagnose intrauterine infections, maternal Rh sensization
- if done in early pregnancy, must be done with a full bladder
- if done in 3rd trimester: to determine fetal lung maturity and evaluate the fetal condition when the woman has Rh isoimmunization
- if done in late pregnancy, done with an empty bladder
- maternal BP and FHR are assessed prior to amniocentesis
- after: assess FHR and use ultrasound to verify reassuring FHR and amount of fluid
- RhoGAM is administered to Rh negative women
20
Q
test to determine fetal lung maturity
A
- done with amniocentesis when delivery is considered before 38 full weeks gestation
- lecithin/sphingomyelin (L/S) ratio is a test for estimating fetal lung maturity
- they are present in equal amounts until 30 weeks gestation, but at a ratio of at least 2:1, then there should be adequate surfactant and mature fetal lungs
- also test for phosphatidylglycerol (PG) and phosphatidylinositol (PI) which are components of surfactant
21
Q
test for fetal hemolytic disease
A
- done with an amniocentesis
- used to determine fetal bilirubin concentration with deltaOD450 test to measure optical density of the amniotic fluid stained by bilirubin if the mother is Rh neg and was sensitized after being exposed to Rh+ blood
22
Q
advantages of amniocentesis
A
- simple and reasonably safe
- painless
- few reported complications
23
Q
disadvantages and risks of amniocentesis
A
- disadvantages:
- timing
- done later in pregnancy, so may give woman little to to terminate before 20 weeks
- timing
- risks:
- pregnancy loss
- ultrasound guidance helps prevent the placenta or cord being pierced
- transfer of fetal blood to maternal circulation
- pregnancy loss
24
Q
percutaneous umbilical blood sampling
A
- “PUBS”: involves aspiration of fetal blood from the umbilical cord for prenatal diagnosis or therapy
- indications: diagnosis and management of Rh disease, diagnosis of abnormal blood clotting, and determination of acid base status of the fetus
- use ultrasound to guide needle insertion
- umbilical vein is more commonly used b/c it is larger
- need to know which vessel is sampled for acid base analysis
- umbilical vein is more commonly used b/c it is larger
- FHR is monitored electronically for 30-60 min after
- RhoGAM is administered
25
risk of PUBS
* fetal bradycardia
* sometimes can be severe if puncture the umbilical artery
* prolonged bleeding from cord
* cord laceration
* cord hematoma
* thrombosis
* thromboembolism
* preterm labor
* premature ROM
* maternal blood sensitization
26
nonstress test
* helps identify whether an inc in the FHR occurs when fetus moves which indicates adequate oxygenation, healthy neural pathway, and ability of heart to respond to stimuli
* if it doesn't accelerate, fetal hypoxemia and acidosis are concerns
* can help identify intraamniotic infections if membranes rupture prematurely
* involves 40 min of electronic fetal monitoring
* called non stress b/c just observation, so not challeneged or stressed under uterine contractions
* before test:
* woman should void and baseline V/S taken
* HOB elevated to at least 45 deg
* use transducers and the woman presses a button each time she feels fetal movemnt
* interpreted by physician:
* reassuring or reactive: at least 2 heart accelerations occur w/in a 20 min period, peak at least 15 bpm above baseline and last at leat 15 sec
27
advantages and disadvantage of a NST
* advantages:
* noninvasive
* painless
* no risk to mom or fetus
* fetal surveillance if pregnancy has uteroplacental insufficiency
* immediate results
* disadvantages:
* false positive test
* vibroacoustic stimulation can redce these
* sleep is often cause of lack of fetal movement
28
vibroacoustic stimulation (VAS)
* uses sound stimulation to elicit fetal movement
* can be used with a NST
* reactive test results can predict fetal well being
* applied over maternal abdomen at fetal head: can be repeated at 1 min intervals up to 3 times
* brain responses in fetus to auditory stimulation appear at 26-28 weeks
* appears to be safe
29
contraction stress test
* can be done if NST is nonreactive
* CST records the response of FHR to uterus induced by uterine contractions, identifying the fetus whose O2 reserves are insufficient to tolerate recurrent mild hypoxia or uterine contractions
* variability and accelerations are reassuring
* contraindications: preterm labor, preterm ROM, hx of extensive uterine surgery or classical C/S incision, placenta previa
* woman lies in semi fowler's
* check if already having at least 3 contractions in 10 min window lasting 40 sec, but if not, then have to induce contractions w/ either nipple stimulation (to secrete oxytocin) or IV piggy back oxytocin w/ LR
30
CST interpretation
* negative (normal/reassuring): no _late decels_, although the fetus is stressed by at least 3 contractions w/in 10 min at least 40 sec long
* positive (abnormal/nonreassuring): _late decels_ accompany at least 50% of contractions, even when fewer than 3 contractions in 10 min
* equivocal (suspicious): intermittent late decels and significant variable decels
* equivocal (hyperstimulation): FHR decels occurring in presence of contractions that are closer than Q2 min or longer than 90 sec
* unsatisfactory: fewer than 3 contractions in 10 min
31
advantages of CST
* minimally invasive
* if negative, then CST offers more than 99% reassurance that uteroplacental urit can support life for at least 1 more week
* positive CST allows physician to analyze options and make a birth plan
32
disadvantages of CST
* more time consuming than NST
* requires precision to get adequate contraction pattern
* cost is higher, esp if use oxytocin
33
biophysical profile (BPP)
* assess: FHR, fetal breathing movements, fetal gross movements, fetal muscle tone, and amniotic fluid volume
* evaluate both acute (FHR (w/ NST), fetal breathing movements (US), fetal gross movements (US), fetal muscle tone (US)) and chronic (amniotic fluid volume (US)) components
* scored from 0-10
* 10 is perfect, 0 is worst
* 8-10 is considered normal unless oligohydramnios is present which may indicate chronic hypoxia
34
what are the effects of gradual hypoxemia and worsening fetal pH?
* loss of FHR reactivity
* reduced, then absent fetal breathing movements
* reduced, then absent gross fetal movements
* reduced fetal tone
* prolonged hypoxemia: reduced amniotic fluid volume
35
maternal assess of fetal movement
* assessed by the mother and often called "kick counts"
* inc fetal movement is a reassuring sign of fetal well being
* most often perceived when lying on their left side
* assess by instructing the woman to lie on side with hands on largest part of abdomen, concentrate, and record number of movements
* influences on activity:
* sleep/wake cycles
* maternal activity
* obesity
* sound
* blood glucose
* time of day
36
advantages of kick counting
* free
* noninvasive
* may identify fetal problems early in the client who has no known risk factors
* convenient and validates her perceptions of fetal status
37
disadvantages of kick counting
* fetal resting state decreases movements
* maternal perception of movement may vary
* time of day may affect fetal movement (lower in the morning, higher in the evening)
* drugs taken by mother (methadone, heroin, cocaine, alcohol, tobacco)
* mother may evaluate fetal movements erratically, making counts less informative
