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women health > Prenatal Care: Assessing Materanal & Fetal Well-Being > Flashcards

Prenatal Care: Assessing Materanal & Fetal Well-Being Flashcards

1
Q

Goals of Prenatal Care

A

Prevent maternal complications.

Improve fetal outcome.

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2
Q

Initial Visit:

A 
10-12 weeks in uncomplicated patient
Comprehensive history.
Detailed physical exam.
Initial prenatal lab work.
Patient education.
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3
Q

Initial Visit

A

Date the pregnancy.
Assess health of mother & fetus.
Develop plan of individualized care.

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4
Q

Antepartal Revisits:

A 
Serial monitoring of objective measurements of maternal & fetal well-being:
Maternal weight.
Blood pressure.
Fetal movement.
Urine – glucose/albumin
Fundal height.
Fetal heart rate.
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5
Q

AP revisits:

A

Monitor for common complaints & psychosocial adaptation to pregnancy.
Perform specific time-sensitive screening.
Administer immunizations or Rhogam.
Provide patient education.

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6
Q

Gravida/Para

A

Gravida - # of times a woman has been pregnant.
Para – 4 digit system
# term births.
# premature births. And baby 28-36 weeks or weighing between 1000 – 2499 grams.
# pregnancies ending in abortion – either spontaneous or induced. Any baby before 28 weeks or weighing less than 100grams.
# children currently alive.

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7
Q

Examples of GP

Currently pregnant, Hx of 2 full term births – one a twin gestation, no miscarriages or abortions

A

G3 P2003

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8
Q

Examples of GP

History of 3 full term births, 1 miscarriage, 2 terminations

A

G6 P3033

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9
Q

Examples of GP

Currently pregnant, 1 preterm birth – baby died of complications due to prematurity, 2 miscarriages, no terminations.

A

G4 P0120

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10
Q

Dating Pregnancy

A

Easiest method – use of gestation wheel.

Everyone at practice should be using the same EDD wheel

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11
Q

Naegele’s Rule

A

LMP + 7 days – 3 months + 1 year = EDD

LMP 12/14/08 + 7days = 12/21/08 – 3 months + 9/21/08 + 1 year = 9/21/09 EDD

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12
Q

Frequency of visit with gestation

A

8-12 weeks- initial visit
up to 28 wk- q 4 wks
28-36 wks- q 2-3 wks
36+ wks- q wk

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13
Q

Physiological Milestones

A 
1st trimester (1-2 wk)- Implantation of blastocyst
1st trimester (8wk)- fetal outline visible on US
1st trimester (10-12wk)- fetal heart audible by Doppler
2nd trimester (18-20wk)- quickenibg, fetal feart audible on fetoscope
3rd trimester (38wk) - lightening
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14
Q

Fundal Height Measurement

A

Week 12 – level of symphysis pubis.
Week 16 - Halfway between symphysis pubis & umbilicus.
Week 20 -1-2 fingerbreaths below umbilicus.
Week 24 – 1-2 fingerbreaths above umbilicus

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15
Q

Fundal Height

A

tape measure – after week 22-24
Zero line of a tape measure placed on superior border of symphysis pubis & tape extended up to and over the curve of the fundus.
# cms measured should approximately equal # weeks gestation ± 2 cms.

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16
Q

Leopold’s Maneuvers

A

Purpose – determine presentation, position, and attitude of fetus

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17
Q

Leopold’s Maneuvers

1st Maneuver

A

Stand at side of bed, facing patient.
Place both hands on fundus & palpate to identify fetal body part.
Smooth, firm object, moves independently – head.
Soft, irregular object that does not more freely – buttocks.

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18
Q

Leopold’s Maneuvers

2nd Maneuver

A

Move hands to side of maternal abdomen, palmar surface of one hand on each side of the abdomen.
Palpate one side of abdomen while using other hand to support abdomen.
Fetal back – hard & smooth.
Fetal extremities – irregular & nodular.

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19
Q

Leopold’s Maneuvers

3rd Maneuver

A

Place one hand above symphysis pubis & using thumb & fingers – attempt to grasp the presenting part of the fetus.
Head – hard, round.
Buttocks – soft, irregular
Attempt to move object to determine possible engagement. Free movement = not engaged.

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20
Q

Leopold’s Maneuvers

4th Maneuver

A

Turn towards patient’s feet.
Using 1st 3 fingers of each hand, palpate downward toward symphysis pubis along both sides of abdomen.
Identify degree of fetal flexion.
Hard bony area:
On opposite side of fetal back – attitude of flexion.
On side of back – attitude of extension.

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21
Q

Assessing Fetal Heart Rate

A

Document at every visit.

Normal range 120-160 beats/minute & regular rhythm

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22
Q

Prenatal Ultrasound

A

Used as both screening & diagnostic testing throughout pregnancy.
Research does not support routine screening of healthy pregnant women.
ACOG – ultrasound should be performed for specific indications in low-risk pregnancies.

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23
Q

Indications for Ultrasound:

18-20 weeks – Level II; Targeted ultrasound.

A 
Measure size of fetus.
Evaluate major organs.
Evaluate amount of amniotic fluid.
Evaluate size & condition of placenta.
Detect cervical changes that might indicate preterm labor.
And sex
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24
Q

Genetic ultrasound

A

Examines sonographic markers for possible chromosomal anomaly.
Possible abnormal findings → short humerus, short femur, pyelectasis, echogenic intracardial focus, echogenic bowel, absence of nasal bone, nuchal thickening.

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25
Q

Other indications for ultrasound:

A

Assessment in the first trimester.
Assessment of fetal well being in the third trimester.
Assessment of fetal growth.
Investigating and monitoring of multiple gestations
Investigation of suspected congenital anomalies beyond the second trimester.

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26
Q

indications for ultrasound:

A

Aid to invasive diagnostic or therapeutic procedures
Investigation of size-dates discrepancies beyond the second trimester
Assessment of post-term
pregnancy
Evaluation of placenta location.

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27
Q

Labs – Assess Maternal Well-Being

A

Initial visit – baseline labs to include:
Blood type & Rh
If known Rh negative – Indirect Combs’ test/antibody titer.
CBC
VDRL, RPR, or other serology test for syphilis.
Rubella titer.
Varicella antibody titer.
Hepatitis B surface antigen

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28
Q

Labs – Assess Maternal Well-Being

A

Cystic Fibrosis carrier screening – blood or saliva test. (recommended)
Sickle cell prep or hemoglobin electrophoresis – becoming routine in many settings.
Tuberculin test (PPD) in all public health settings.
HIV test – should be offered.
Pap, GC, & Chlamydia screening.
Urine culture & sensitivity – many settings.

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29
Q

Time-Sensitive Screening Tests

A

15 – 20 weeks – alpha fetoprotein or quad screening → trisomy 21(Down’s Syndrome); neural tube defects.
Tests 4 maternal serum markers → alpha fetoprotein, human chorionic gonatotropin, unconjugated estriol, inhibin A.
Calculation of result takes into account variables → ethnicity, maternal age, gestational age, # fetuses.
Abnormal results → indicate need for further testing – level II/targeted ultrasound; amniocentesis.
ACOG recommends ‘informed consent’ for this test.

30
Q

Glucose Screening

A

28 weeks – diabetic screening + repeat CBC.
Screen for gestational diabetes mellitus (class A1, gestational diabetes, GDM)
Standard practice in US prenatal care.
Done – 24-26 weeks gestation; earlier for those with risk factors.

31
Q

glucose screening

A

Initial screen → 50g oral glucose test with serum glucose 1 hour after ingestion.
Most institutions → cutoff point 140 mg/dl.
Some practitioners advocate positive screen at 125 mg/dl or 130 mg/dl.
Over cutoff point → diagnostic 100g 3 hour oral glucose tolerance test.

32
Q

3 hour glucose screening

A 
3 hour GTT
100g oral glucose load.
Diagnosis of GDM made with 2 abnormal values.
Cut-off values for 3 hour GTT: (vary with specific lab)
Fasting		>95 mg/dl
1 hour		>180 mg/dl
2 hour		>155 mg/dl
3 hour		>140mg/dl
33
Q

26-28 weeks – Indirect Combs’ test/antibody titer screen for Rh negative women.

A

If negative → 300 mcg of Rh immune globulin (Rhogam) should be given.
Decreases risk of developing antibody titers during the antepartal period in the event of maternal-fetal transfusion.
Provides protection against developing antibodies for @ 12 weeks.
Postpartum → Rhogam given again if baby is Rh +
If indirect Coomb’s test is positive → refer to MD.

34
Q

36 weeks – vaginal/rectal swab for Group Beta Strep screening.

A

ACOG (2002) → recommends screening of all pregnant women for GBS (rather than risk-based screening).
Common → asymptomatic carriers of GBS – can pass GBS to baby during pregnancy, labor, birth.
GBS transmission → leading cause of fetal infections & neonatal sepsis.
Antibiotic tx – penicillin G or ampicillin during labor assists in preventing neonatal transmission.

35
Q

Fetal Diagnostic Testing

A

Evaluate fetal chromosomes & genes.
Obtain fetal specimen for analysis & evaluation.
Invasive tests (CVS & amnio) – require clinical indication.
Testing includes:
Nuchal Translucency Scan + PAPP-A testing – not an invasive test.
Chrorionic villus sampling (CVS)
Amniocentesis

36
Q

Nuchal Scan

A

Noninvasive ultrasound.
Done 11-13 weeks gestation.
Assesses amount of fluid behind the neck of the fetus – “nuchal fold”
Fetuses with Down’s Syndrome tend to have higher amount of fluid around the neck.
65-85% trisomic fetuses will have a large nuchal thickness.

37
Q

Along with nuchal translucency, serum level of PAPP-A is done.

A

Pregnancy-associated plasma protein A, pappalysin 1, also known as PAPP-A
Low plasma level of this protein has been suggested as a biochemical marker for Down Syndrome

38
Q

CVS (chorionic villus sampling)

A

Usually performed between 10-12 weeks, sometimes done up to 14 weeks.
Originally offered starting @ 8 weeks gestation – possible link with early CVS & infants born with limb reduction defects.
Before differentiation of chorionic tissue into the organized structure of the placenta → villi cover entire surface of chorionic sac.
Gentle syringe suction through a needle (transabdominal approach) or catheter (transvaginal approach) to detach villi from chorionic sac.
Cytogenetic & molecular genetic testing is performed on villi.

39
Q

Advantages of CVS

A

Early diagnosis of genetic problems.
Opportunity to terminate pregnancy during 1st trimester.
May facilitate early bonding with reassurance that fetus is normal.

40
Q

Disadvantages of CVS:

A

Slightly ↑ risk of pregnancy loss compared with 2nd trimester amnio.
Also reported → oligohydramnios, rupture of amniotic membranes, subchorionic hematoma

41
Q

Additionally, after CVS:

A

Rh negative women should receive Rhogam.

Quad screening should also be done to rule out neural tube defects.

42
Q

Amniocentesis

A

Amniotic fluid removed from uterine cavity:
Genetic & biochemical analysis.
Assessment of fetal disease.
Evaluation of fetal maturity.
Procedure performed under direct ultrasound guidance to reduce risk of piercing fetus & avoid placenta

43
Q

Risks of Amniocentesis

A 
Fetal loss (0.5-1.0%)
Amnionitis (0.1%)
Fetal injury (rare)
44
Q

Additionally Amniocentesis

A

Rh negative women should receive Rhogam after the procedure.

45
Q

Third Trimester Fetal Assesment

A 
Fetal Well-Being Tests Include:
Fetal movement counting.
Nonstress test (NST).
Biophysical Profile (BPP).
Amniotic Fluid Volume.
46
Q

Fetal Movement Counting

A

Research has confirmed → fetal activity is reassuring – dramatic decrease in fetal activity or cessation of movements is worrisome.
Start kick counts:
34-36 weeks for low-risk women.
28 weeks for women with risk factors for uteroplacental insufficiency.

47
Q

Fetal Movement Counting

A

Everyone at facility should be advising patient to do kick counts the same way.
Results should be documented by practitioner at each visit.
Women reporting decreased movements need to be evaluated further:
NST and/or BPP

48
Q

Cardiff Count-to-Ten Movement Counting Method

A

One count session daily.
Same time each day.
Chart how long it takes to reach ten movements.
There must be at least ten movements identified in 10 hours.
If there are fewer than ten movements in 10 hours, if it takes an increasing amount of time to reach ten movements, or if no movements are felt within 10 hours, an NST should be performed asap.

49
Q

Nonstress Test (NST)

A

Indicated for women whose pregnancies are complicated by or have increased risk factors for uteroplacental insufficiency.
External fetal monitor used to record fetal heart rate → evaluate for FHR reactivity.
Reactive NST → best indicator of fetal well-being:
Fetus must receive adequate oxygenation through placenta in order to have accelerations of FHR associated with fetal movement.
FHR reactivity → developmental milestone of fetus usually reached between 28 & 32 weeks gestation.

50
Q

Indications for NST

A 
Preeclampsia
Multiple gestation.
Oligohydramnios.
Post dates.
Rh immunization.
PROM
Decreased fetal movement.
Previous stillbirth.
51
Q

Indications for NST

A 
Suspected IUGR.
History of IUGR in previous pregnancy.
Pregestational diabetes.
Gestational diabetes.
Chronic hypertension.
Pregnancy-induced hypertension.
52
Q

Interpretation Criteria for NST

A

Reactive → At least 2 FHR accelerations within 20-min period that are ↑ baseline for ≥ 15 seconds & with amplitude of ≥ 15 bpm.

Nonreactive → FHR tracing that fails to demonstrate above criteria.

Inconclusive → FHR tracing that is uninterpretable because of difficulty in obtaining the EFM tracing or tracing that does not demonstrate an FHR baseline. (e.g. very vigorous fetus)

53
Q

NST frequency

A

Frequency of testing depends on:
Indication for testing.
Severity of uteroplacental insufficiency.
Facility protocols.
Usually:
Done weekly.
Twice weekly on women with high risk of poor pregnancy outcome related to uteroplacental insufficiency.
Nonreassuring NST → follow-up with biophysical profile (BPP)

54
Q

Biophysical Profile

A

Utililzes both EFM & ultrasound.

BPP based on premise that when a fetus is fully oxygenated & neurologically intact, it has a variety of characteristics → muscle tone, gross movement, respiratory activity, & reactive NST.

Score 10/10 – reassuring fetal status.

55
Q

indications for BPP

A 
Known or suspected IUGR.
Oligohydramnios.
Insulin dependent diabetes.
Preeclampsia.
Postdates.
Nonreactive NST.
Multiple pregnancy.
56
Q

Recommendations

for BPP

A

Weekly testing.

Women at higher risk → twice weekly testing that includes a weekly BPP & then NST in midweek.

57
Q

BPP fetal breathing movements

A

At least one episode of breathing movements lasting at least 30 seconds in a 30-minute period
Normal score = 2
Absent respirations or no episode of breathing movements lasting at least 30 seconds in a 30-minute period.
Abnormal score = 0

58
Q

BPP Gross Body Movements

A

At least three separate and distinct episodes of body or limb movements in 30 minutes
Normal score = 2
Two or fewer episodes of body or limb movements in 30 minutes
Abnormal score = 0

59
Q

BPP Fetal Tone

A

At least one episode of extension and flexion of fetal extremities or the spine
Normal score = 2
Slow extension with return to partial flexion or move-ment of limb in full extension only or no movement
Abnormal score = 0

60
Q

BPP Amniotic fluid volume

A

At least one pocket of amniotic fluid measuring at least 2 cm in vertical diameter
Normal score = 2
Either pocket of fluid is less than 2 cm in vertical diameter or no pocket
Abnormal score = 0

61
Q

BPP FHR Reactivity

A

Reassuring NST
Normal score = 2
Nonreassuring or inconclusive NST
Abnormal score = 0

62
Q

Amniotic Fluid Volume (AFV)

A

Alterations in the volume of amniotic fluid are known to be associated with untoward outcomes.
Oligohydramnios has been associated with:
Uteroplacental insufficiency & fetal hypoxia.
Fetal genitourinary anomalies.
Fetal distress in labor, poor Apgar scores, meconium-stained fluid, and meconium aspiration.
Postmaturity syndrome.

63
Q

Ultrasound evaluation of amniotic fluid →

A 
uses amniotic fluid index (AFI) – assesses the depth of the fluid pockets in each quadrant of the uterus.
Polyhydramnios associated with:
Chromosomal disorders.
Tracheoesophageal fistulas.
Diabetes.
High % of unknown etiology.
64
Q

Amniotic Fluid Volume ranges at term

A

normally range between 5.0 cm and 23.0 cm.

65
Q

Patient Education

Throughout pregnancy

A 
Common discomforts.
Health promotion.
Anticipatory guidance.
Emotional & psychological issues.
Domestic violence screening.
66
Q

Patient education in 1st trimester

A

danger signs in early pregnancy

67
Q

Patient education in 2nd trimeter

A

signs of fetal well-being

S/Sx preterm labor

68
Q

Patient education in 3rd trimester

A

S/Sx labor
Preparation for birth & motherhood
Contraceptive choices

69
Q

Documentation of Prenatal Visit Subjective

A

Subjective info → maternal perception of:
Overall well-being.
Fetal movement.
S/Sx of preterm labor, labor, possible complications.

70
Q

Documentation of Prenatal Visit Objective information

A 
Maternal weight, B/P
Fundal height
FHR, fetal activity.
S/Sx any pregnancy complication.
Pertinent lab/diagnostic testing results.
Accurate assessment:
Date pregnancy.
Size = Dates?
Other pertinent info.
Document thorough management plan including pertinent patient teaching.

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