HR Pregnancy Assessment: NST and CST

Assessment of HR pregnancy

• Non-stress Test (NST) and Contraction Stress Test (CST) are used to assess heart rate (HR) during pregnancy.
• Reactive indicates a good result, while nonreactive indicates a bad result.

Non-stress Test (NST)

• It's a widely used antepartum technique for evaluating fetal well-being, especially during the 3rd trimester.
• It's a noninvasive procedure.
• It monitors the fetal heart rate (FHR) response to fetal movement.

Indications for NST

• Decreased fetal movement
• Intrauterine growth restriction (IUGR)
• Post-maturity
• Gestational diabetes mellitus (GDM)
• Gestational hypertension (GHTN)
• History of fetal demise
• Advanced maternal age (AMA)
• Sickle cell disease (SCD)

Performing an NST

• It should be performed after the woman has eaten because babies are more active.
• Avoid smoking before the test.
• It takes at least 20 minutes to complete, with the woman in a semi-Fowler's or side-lying position; may take up to 40 minutes.
• Place a tocodynamometer (toco) on the uterine fundus and use ultrasound (US) to record FHR.
• The patient pushes a button when she feels fetal movement.

NST Results

• Reactive (Good):
  • Two or more fetal heart accelerations occur within a 20-minute period.
  • FHR acceleration must be at least 15 beats per minute above the baseline for at least 15 seconds.
• Nonreactive (Bad):
  • Insufficient FHR accelerations occur over a 20-minute period.

Contraction Stress Test (CST)

• It evaluates the respiratory function of the placenta, specifically oxygen and carbon dioxide exchange.
• It identifies fetuses at risk for intrauterine asphyxia by observing FHR response to contractions.
• Contractions are induced via nipple stimulation or IV oxytocin administration.
• An electronic fetal monitor records contractions and FHR.
• The setup involves positioning the woman in a semi-Fowler's position with toco and US monitors.
• Baseline rate and variability are assessed for 10-20 minutes before starting.

Indications for CST

• Nonreactive NST
• High-risk pregnancy, like GDM, post-term pregnancy
• Vaginal bleeding.

Interpretation of CST Results

• Negative CST (Normal):
  • Three uterine contractions last 40-60 seconds within a 10-minute period.
  • No late deceleration of the FHR.
• Positive CST (Abnormal):
  • Persistent and consistent late decelerations occur with 50% or more of the contractions.
  • Indicates placental insufficiency, and the provider may decide to induce labor or perform a cesarean section.

Biophysical Profile (BPP)

• BPP uses real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe fetal biophysical responses to stimuli (combo of US & NST)
• A normal score is 8-10.
• An abnormal score is 4-6, and a score of less than 4 indicates an immediate need for interventions.
• Five components are assessed: fetal movement, fetal breathing, amniotic fluid index (AFI), fetal tone, and NST.

BPP Scoring Criteria

• Fetal Breathing Movements:
  • Normal = At least one episode of rhythmic breathing lasting ≥30 seconds within 30 minutes.
  • Abnormal = <30 seconds of breathing in 30 minutes.
• Gross Body Movements:
  • Normal = At least three discrete body or limb movements in 30 minutes.
  • Abnormal = ≤2 movements in 30 minutes.
• Fetal Tone:
  • Normal = At least one episode of extension of a fetal extremity with return to flexion, or opening or closing of hand.
  • Abnormal = No movements or extension/flexion.
• Reactive Fetal Heart Rate:
  • Normal = ≥2 accelerations of ≥15 bpm for ≥15 seconds in 20-40 minutes.
  • Abnormal = Zero or one acceleration in 20-40 minutes.
• Amniotic Fluid Volume:
  • Normal = At least one pocket of amniotic fluid ≥2 cm, AFI ≥5.
  • Abnormal = Less than one pocket of amniotic fluid measuring <2 cm.

Fetal Movement Assessment (Kick Counts)

• Reassuring to count the number of movements using different methods based on provider preference.
• Methods include counting once a day for 60 minutes, 2-3 times daily for 2 hours, or counting all movements in a 12-hour period (minimum of 10).
• Perform in a side-lying position.
• Decreased fetal movement for 30 minutes might indicate a fetal sleep cycle.

Ultrasound for Placental Assessment

• Location: Identify where the placenta is implanted.
• Doppler Studies: Assesses fetal heart tones and blood flow.
• Placental Grading: Assign a grade from 0-3 (3 being most mature with extensive calcifications).
• Placentas with multiple calcifications may not function properly.

Factors That Can Cause Placental Maturity

• Smoking
• Post-term pregnancy
• Pre-eclampsia
• Gestational diabetes mellitus (GDM).

Ultrasound for Gestational Age

• Cardiac Activity: Detectable around 6 weeks via transvaginal ultrasound.
• Crown-Rump Length: Used in the 1st trimester.
• Biparietal Diameter (BPD), Head Circumference, Abdominal Circumference, Femur Length: Used after the 1st trimester.

Additional Ultrasound Assessments

• Fetal Growth: Assess for IUGR or macrosomia.
• Fetal Anatomy: Detects anomalies and measures nuchal translucency (fluid in the nape of the neck) between 10-14 weeks.
  • A measurement >3 mm is considered abnormal.
• Amniotic Fluid Volume (AFV): Normal is around 500 mL; polyhydramnios vs. oligohydramnios.

Amniocentesis: Prepping the Mother

• Empty the bladder to reduce size and chances of accidental puncture.
• Breathe normally to prevent the diaphragm from lowering against the uterus.
• Administer RhoGAM if the client is Rh-negative.

Data Obtained from Amniocentesis

• High levels of polyhydramnios may indicate neural tube defects, but could be high with a normal multifetal pregnancy.
• Low levels of oligohydramnios are associated with chromosomal disorders or molar pregnancy.
• Fetal lung maturity is indicated by a Lecithin to sphingomyelin ratio of 2.1 or greater.
• Avoid before 13-14 weeks due to increased risks of pregnancy loss, amniotic fluid leakage, and fetal talipes equinovarus (clubfoot).

Chorionic Villus Sampling (CVS)

• CVS is useful for genetic studies in the first trimester but cannot be used for maternal serum marker screening due to lack of fluid.
• Earlier and faster results compared to amniocentesis.
• Riskier than amniocentesis, with about 2 times the risk of abortion (22%).
• Potential for fetal limb abnormalities if done before 9 weeks.
• It can be done earlier, between 10-13 weeks, either transabdominally or transvaginally.

Maternal Serum Alpha-Fetoprotein (MSAFP) and Quad Screen

• Maternal assay detects neural tube defects and trisomy disorders.
• MSAFP is a screening tool for neural tube defects; if results are abnormal, further testing is needed.
• The ideal screening time is 16-18 weeks gestation.
• High levels of MSAFP may indicate a neural tube defect, while low levels may indicate Down syndrome.
• Quad Marker Screening is a blood test for likelihood of fetal birth defects, more reliable than MSAFP, but blood testing is includes:
  • Human chorionic gonadotropin (hCG)
  • Alpha-fetoprotein (AFP)
  • Estriol
  • Inhibin A

Gestational Conditions: Hypertension

• Gestational hypertension: Systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, or both, recorded on two occasions at least four hours apart, without proteinuria, after the 20th week of pregnancy.
• Preeclampsia: Hypertension and proteinuria develop after 20 weeks of gestation in previously normotensive women is a vasospastic systemic disorder categorized as mild or severe based on symptoms and labs.
• Eclampsia: Seizure activity or coma in preeclamptic women without a history of preexisting pathology, can occur before, during, or after birth.

Medical Treatments for Gestational HTN and Preeclampsia

• Magnesium Sulfate: Used in preeclampsia to prevent seizures.
• Labetalol: Avoid if the patient has asthma, CHF, or heart disease.
• Nifedipine: May cause profound hypotension.
• Hydralazine: Requires close BP monitoring. May trigger late decelerations.
• Calcium Gluconate: Antidote for magnesium sulfate.

Nursing Interventions for Preeclampsia

• Identifying and preventing preeclampsia
  • Low-dose aspirin therapy.
  • Early prenatal care is to identify risks.
• Implement precautions like a quiet, non-stimulating environment with subdued lighting.
• Assemble an emergency birth pack due to the risk of precipitous/sudden delivery and seizures.
• Manage gestational hypertension and preeclampsia without severe features by focusing on the safety of the mother and fetus.
  • This includes delivering at near term (37 weeks) and providing outpatient/home management.

Maternal and Fetal Assessment includes

• Lab testing
• Assessment for signs/symptoms
  • BP twice weekly and fetal movement counts
  • Nonstress testing
  • Activity restrictions—No evidence to support benefit.

Nursing Interventions for Severe Gestational Hypertension and Preeclampsia

• Manage severe gestational hypertension and preeclampsia, given the greater risk for pregnancy complications.
• Consider expectant management, and Perinatologist services for specialist care for high-risk obstetric situations -Use of Corticosteroids to stimulate fetal lung maturity.

Intrapartum Care

• Administer magnesium for seizure prevention (not as an antihypertensive).
• Antihypertensives: Use to manage blood pressure and prevent stroke.
• After birth care consists of seizure prophylaxis for 24-48 hours after delivery
• Some women develop hypertension postpartum.

Nursing Priorities During a Seizure

• Implement seizure precations
• Raise bed rails and padding, and ensure emergency equipment is available
• Stay with the patient, maintain airway and safety.
• Turn patient to side, protect from injury.
• Do not suction or place anything in the mouth.
• After stabilizing mother: -Lower head of bed (HOB), provide airway support, and call code if apneic. -Assess fetal status. -Evaluate FHTs, contractions, SVE, ROM; recognize rapid dilatation and delivery. -Administer magnesium sulfate and infusion.

Signs of HELLP Syndrome

• HELLP syndrome manifests as epigastric or right upper quadrant (RUQ) pain.
• HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelets.
• Diagnosed via serum lab values, not clinical signs or symptoms.

Disseminated Intravascular Coagulation (DIC)

• Arises when the body's blood clotting proteins become abnormally active throughout the body due to an underlying cause like inflammation, infection, or cancer.
• Often seen in the event of maternal and/or fetal complications like:
  • Placental abruption
  • Amniotic fluid embolism
  • HELLP syndrome
  • Retained stillbirth
  • Acute fatty liver of pregnancy

Miscarriage or Spontaneous Abortion

• Refers to the loss of a pregnancy from natural causes before fetal viability

Types of Miscarriage

• Threatened: Slight bleeding, mild cramping, no tissue passage, cervical dilation is closed
• Inevitable: Moderate bleeding, mild to severe cramping, no tissue passage, cervical dilation is opened
• Incomplete: Heavy, profuse bleeding, severe cramping, tissue passage, cervical dilation is opened
• Complete: Slight bleeding, mild cramping, tissue passage, cervical dilation is closed
• Missed: No bleeding, no cramping, no tissue passage, cervical dilation is closed
• Spreic: Varies Amount of bleeding , usually malodouous with varies cramping ,Varies tissue passage ,Varies - cervical dilation is opened

Management of Miscarriage

• Treatment varies depending on whether progression to actual miscarriage occurs.
• For pain, bleeding, or infection - prompt surgical termination.
• Repetitive transvaginal ultrasounds & hormone level assessments to determine if the fetus is still alive. *Misoprostol and suction curettage are also used.
• Expelled Sac not identified: perform ultrasound
• Expectant Management: Pregnancy terminated using misoprostol or dilation and suctions curettage if a miscarriage.
• Immediate termination in cases of septic shock

Care After Miscarriage

• Treatment depends on the type of miscarriage and patient is prescribed bed-rest and pelvic rest w/ Abstinence from coitus
• Nothing in the vagina nor dilation
• The patient will be prescribed immune globulins, especially with negative negative- mothers

Patient Teaching For Care-After Miscarriage

• Clean the perineum, shower.
• Avoid tampons, douching, and vaginal discomfort
• Eat foods high in iron and protein high and
• Notify Health care provider for high temperatures
• Seek assistance from support groups
• Allow self to prepare/grieve

Cervical Insufficiency

• Passive, painless dilation of cervix due to structural or functional defect
• Requires cerclage can be done via various surgical reasons

Cervical Insufficiency Etiology

• Multifactorial
• Acquired
• Biochemical, and/ or hormonal
• Congenital

Diagnose:

• OB hystory& cervical
• Cervical cerclage: to prevent fetal loss, but doesn't reduce risk.

Surgical option for Cervical Insufficency

• Elective: uncomplicated& outpatient procedure
• Rescue Emergent reasons

Progesterone Therapy

• Essential therapy taken, meta-analysis& decreased need for mechanical, and preterm
• Clinical mainestation" delayed period, bleeding, spotted on ateral pelvic side

Four Symptoms; Classiz

• Severe, unilateral abdominal or shoulder
• Hemoperitoneum

Ectopic Pregnancy

• Factors that Increase ectopic pregnancy: high progestrone intake, tubes, STI,device

Therapy

• Methylate

Instructions for Women Receiving Methotreate

• dissolves ectopoc by destroying rapidly- dividign
• Teach the women to aavoid getting 72 and
• also explain that stools may contain residual drug for up to 7days
• avoid food with follicle and expose to sun

Admin of drug'

Methotrexate

• Standard dose for ectopic"50 give IN

surgical mangaemnt depnds on location of pregnancy

If surgery planned" GENERAL AND postopoeratove Care

Molar 5 Pregnancy ( Hydatidiform

Chromosomal abnormality for tilization, appears like typical pregnancy, high ICN, uterus, D +c

Place + previa

Plac + abruption

Type'

marginal +central and complte + class Type 1 maternal

High risk perinatal conditions: preexisting CH 11

gestational diabetes mellitus

Risks Factors

High glucose intake

Goal, bbgs Acl

11140

Interventions

oet therapy

Anemia iron deficrky is he most common type: low high and ferritin

if hb less than 6 Low birth weight infant

New born ch 22

high and Pulse Ox High and Pulse R" 304*2760 breaths

Respiratory

climpijfg temp pressure much Clumping the Umbria "not sure "retracking central Cyano

Cardiovascucar major structural

increases hemoglobin levels at birth

B whY 415.39 delarye cord clamp?

thermoggulation

Wht do infants struggle to maintain that

INtak E and output

• voids after d41
• meconwum transito milk

6 bilirubine

A? WhY are new borns at increased risk for elevated Bilirabin "caput"

Hyperbilirubinemia

Transcutanious momtoring of Bilirubin, test works 4-6 hrs, diaper anD 'photathapy worjs w. "ehe the infact "feeding

what treatment for elevated TSB? found in ch 2.3 Integument

• R" Ve,a7x38/4

how is Pain assessed in the neonate, what w as ballard score

what is meconium-stained and Why a problem

cord Variations

7% of I with Two vessel cords have anomalies? &55cm, short cord, ling cords

Why neonatal weight Sga

Lga has the most maternal diabetes? Is Kangeroo's +what

How is Neonate Withdraws

• Irritiability
• Hypertensitivity
• High pitched cry
• Tremors .poor feeding
• Frantic sucking
• Comity And Dinrhea
• Vasal Stuffiness

What are the Nursing Interventions for a Baby with Neonate Abstinence Syndrome?

Vihrotactile stimulation And acupuncture Wast terapy 'The fat sleep

What is gavage feeding and why is it used

Ectopic surgery