Psychosocial Adaption in Pregnancy, Antepartum Testing, & Fetal Monitoring Flashcards
Factors that affect Maternal Adaptation
Physical
Psychological
Social
Prenatal Classes
Bradley (partner coached childbirth): goal is to have the best, safest, most rewarding birth experience
Lamaze: empowers women to make informed choices, assume responsibility for health, and trust in inner wisdom
HypnoBirthing: eliminating fear, stress-free, calm, gentle environment that resembles nature’s design.
Prenatal Assessment for Risk Factors
Biophysical factors: genetic, nutritional, medical, and obstetric issues that can originate from mother or fetus and subsequently impact mother or fetus
Psychosocial factors: maternal behaviors or lifestyles that can negatively impact the fetus
-ex) use of substances, high stress lifestyle, relationship with violence
Sociodemographic factors: variables that place the mother and fetus at increased risk
-ex) access to care, income, parity, type of housing, homelessness, not having a car, financial means to provide food
Environmental factors: hazards in the environment or workplace that impact pregnancy outcomes
-ex) oncology nurse that is around chemotherapy agents or radiation
Assessing Fetal Status in First Trimester
Viability Confirmation:
- serum beta hCG test repeated every 48-72 as it should double regularly, present in virtually all pregnancies by 11 days
- Progesterone: should be high in pregnancy
- U/S: to confirm intrauterine pregnancy and take measurements for due date confirmation and first trimester screen
- Genetic testing
Assessing Fetal Well-Being in Second Trimester
most advantageous time for basic U/S
done at 18-24wks
looks at:
- uniformity of growth (biometric measurement, accurately estimate gestation age and growth)
- volume of amniotic fluid offers good images
- fetal anatomy shown in detail
*genetic testing can be ordered at this time if it was not previously done
Assessing Fetal Well-Being in Third Trimester
Testing type: U/S, NST, CST, BPP
*determined by specific condition (not done with routine pregnancies) and HCP determines what tests to do
Assessing lung maturity
Screening vs. Diagnostic Tests
Screening tests: aren’t perfect, can have false negatives and false positives
Diagnostic tests: have genetic information (tissue) that can be evaluated to confirm
NIPT
Non-Invasive Prenatal Testing (aka cell-free fetal DNA testing)
looks at fetal DNA in mom’s blood
can do 9 weeks through delivery
being offered more routinely (original for “at risk populations”)
does NOT screen for neural tube defects
if done, then should be offered AFP later in second trimester
*sensitive and specific for trisomy 18 and 21
First Trimester Screening
most accurate between 6-12wks:
- confirm intrauterine pregnancy, viability, # embryos
- establish gestational age (crown to rump length)
- first trimester screening = combined u/s + serum testing w/ plasma-protein A and HcG
- evaluates causes of vaginal bleeding
- assessment of uterine anatomy
*may opt for this if NIPT not covered by insurance
Second Trimester U/S
for purpose of anatomic scan
CVS
Chorionic Villus Sampling
offered typically between 10-13wks (first trimester DIAGNOSIS)
needle aspiration of chorionic villi from placenta (u/s to guide and transcervical or transabdominal approach)
*invasive procedure so need to admin rhogam w/in 72 hours for Rh negative women
spontaneous abortion ~7% chance
- cannot test for neural tube defects
- can determine gender b/c you’ll get chromosomes
Amniocentesis
done at 14-20wks
amniotic fluid obtained through needle aspiration under u/s guidance
- invasive procedure so admin rhogam to Rh negative women w/in 72 hours of procedure
- can detect neural tube abnormalities and assess fetal lung maturity
Risks of Amniocentesis
spontaneous abortion: 1 in 200
transient vaginal spotting, cramping
amniotic fluid leakage
chorioamnionitis
Assessing Fetal Lung Maturity
Done by amniocentesis
looking for presence of lecithin & sphingomyelin
l/s ration > 2:1 indication fetal lung maturity (<3) 5wks
MSAFP Testing
second trimester, done between 15-22wks
aka "Quad Screen", looks at: estriol HcG inhibin A Alpha feto-protein (AFP)
low estriol and high AFP = associated with neural tube defects
high hCG and high inhibin A = associated with trisomy 21
*Screening test only, abnormalities need to have diagnostic testing
AFP
glycoprotein produced in fetal liver, GI tract, and yolk sac in early gestation.
tested between 15-22 wks
- increased levels noted in NTD’s anencephaly, omphalocele, and gastrochisis (neural tube defects)
- decreased levels are associated with down’s syndrome
- if woman opted for first trimester screen for chromosomal abnormalities or NIPT, they should be offered this test.
- abnormal findings require further evaluation
How to measure FHR
mean FHR during 10 minute period
rounded to 5 bpm
excludes accelerations and decelerations
must be observed for at least 2 minutes
Intervention for Fetal Tachycardia
administer meds as ordered ice packs check hydration status and hydrate prn explain procedures position change O2 stop pitocin notify provider
Intervention for Fetal Bradycardia
verify maternal HR assess maternal VS reposition O2 d/c pitocin
Accelerations
visually apparent abrupt increase in baseline FHR
onset to peak < 30 seconds
>32 weeks = 15bpm x 15s
<32wks = 10bpm x 10s
Prolonged accelerations = 2-10min
*longer than 10 minutes indicates a new baseline
cause = stimulation of autonomic NS, specifically SNS response to fetal movement
Early Decelerations
gradual decrease
nadir occurs at same time as peak of contraction
cause: vagal nerve stimulation from head compression
normally reassuring and no intervention needed
Variable Decelerations
most common!
visually apparent abrupt decrease in FHR and return abruptly, varying in intensity and duration (>15bpmx15s)
can be u, w, or v shaped
cause: cord compression triggers vagal response
Intervention: change positions, cervical exam, amnioinfusion, administer O2, IV bolus, stop pitocin, administer tocolytics prn, modify pushing and notify provider
Prolonged Decelerations
Decels that last between 2–10 minutes.
cause: interruption of uteroplacental perfusion (tachysystole, maternal hypotension, placental abruption) or umbilical blood flow (cord compression, cord prolapse), vagal stimulation (profound head compression, rapid fetal descent)
intervention: change positions, IV fluids, d/c pitocin, O2, perform sterile vaginal exam, tocolysis if ordered
Late Decelerations
nadir occurs after peak of contraction
cause: uteroplacental insufficiency (decreased blood flow and/or oxygen transfer to fetus through the intervillous space)
intervention: change positions, d/c pitocin, administer terbutaline (if ordered), assess hydration and fluid bolus prn, administer O2, notify provider
Assessing Intensity of Contractions
Palpations -
Mild: nose
Moderate: chin
Strong: forehead
Disadvantages to this method:
- subjective differences in interpretations
- no permanent record which can hinder interpretation by others
Tachysystole
uterine hyperstimulation
> 5 contractions within 10 minutes OR
contractions within 1 minute of each other or contractions lasting 2 min or longer
cause: spontaneous or from induction meds
intervention: change position, provide hydration, administer tocolytics as ordered
FHR Tracing Categories: Category I
normal
Criteria: ALL of the following
baseline HR in normal range (110-160bpm)
baseline variability is moderate
late or variable decelerations absent
FHR Tracing Categories: Category III
Abnormal and require action
Criteria: ABSENT variability with any of the following recurrent late decelerations recurrent variable decelerations bradycardia sinusoidal pattern
FHR Tracing Categories: Category II
anything not in I or III
indeterminate and need surveillance
Intrauterine Resuscitation
intervention for Category II and III FHR patterns
Assess first:
- cervical exam to assess for umbilical cord prolapse, rapid cervical dilation, rapid descent of fetal head
- assess for uterine activity for uterine tachysystole
- assess maternal vital signs, especially temp (for fever), BP for hypotension
Interventions: change position administer IV fluid correct hypotension reduce uterine activity if UCs are too frequent alter pushing effort amnioinfusion support woman to decrease anxiety/pain
NST
Reactive: 2 or more accelerations in 20 min
Nonreactive: insufficient accelerations after 40 min (not diagnostic of fetal compromise)
*only shows where the baby is at at that point in time, could be during the baby’s sleep cycle
CST
screening test used to assess fetal well being and uteroplacental function in women with nonreactive NST
looks at spontaneous or induced contractions
Contraindications: 3rd trimester VB, previa
Negative test is good (no late or significant variable decelerations).
Positive is bad
AFI
Amniotic Fluid Index
volume of amniotic fluid determined by:
- placental perfusion
- fetal urine output
- fetal swallowing
BPP
Biophysical Profile: an u/s assessing fetal status with an NST. Looks at fetal reflex activity controlled by CNS (sensitive to hypoxia). Takes 30min.
5 components:
- FHR acceleration (NST)
- Fetal breathing movements
- Fetal gross body movements
- Fetal Tone
- Amniotic Fluid Volume
max score = 10 (higher score is better)
Other methods of fetal assessment:
stimulation: scalp, acoustic, maternal abdominal palpation
cord blood analysis: immediately after birth
