PPN 301 Class 3 Pregnancy at Risk: Social & Physiological Factors PDF

PPN 301 Class 3: Pregnancy at Risk: Social & Physiological Factors  Age Considerations: Adolescent Pregnancy Risk Impact of adolescent Adolescent individuals (ages 10 to 19 Pregnancy years) are at increased risk for Social factors...

PPN 301 Class 3: Pregnancy at Risk: Social & Physiological Factors  Age Considerations: Adolescent Pregnancy Risk Impact of adolescent Adolescent individuals (ages 10 to 19 Pregnancy years) are at increased risk for Social factors Meeting developmental eclampsia, puerperal endometritis, and systemic infections milestones Still developing own Maternal mortality Perinatal complications are the independence Social isolation leading cause of death for 15 to 19 Lack of social support years-old girls globally Fear of child services Early pregnancy or marriage cause Stigma (actual & perceived) an estimated 5 to 33% of girls (aged Need to be perceived as a 15 to 24 years) to drop out of school “good mother” (World Bank, 2017). Even if this means not asking for help/staying with a non-supportive partner/not  Adolescent Friendly Perinatal Care See: NFB video- bridge film: Unxpected https://www.nfb.c a/film/unexpecte d https://www.nfb.ca/film/unexp Age Considerations: Advance Maternal Age Pregnancy > 35 years Increased risk of: Maternal death (even higher over 40) Miscarriage Stillbirth Preterm Low birth weight Perinatal mortality Down syndrome Despite higher risk, overall risks are still low for women who are healthy, and free of pre-existing disease What are the reasons people delay pregnancy and parenthood? https://dudemom.com/advanced-maternal-age-35-pregnant/ Women with Disabilities Higher risk for social, economic & physical problems Stigma/assumptions of care providers & family Higher risk for social service involvement Need for pre-planning, social support Think about: How can a CHN’s assumptions & biases affect care for a pregnant woman with disabilities? What should a CHN assess when working with a pregnant woman with physical disability? Developmental/cognitive disability? How could a CHN support a pregnant woman with physical disability? Developmental/cognitive disability?  Intimate Partner Violence and Pregnancy People at risk during pregnancy: Pre-pregnancy abuse Women under 25 Substance use by woman or partner Single or lone parents Recently separated or process of ending a relationship Indigenous women Women with disability Lesbian, bisexual, transgendered Low SES Associated with preterm labour, prematurity, LBW, Neonatal & infant/maternal mortality  IPV Screening Tools RADA R Tool HITS Tool (Deshpande & Lewis-O'Connor,  Role of CHN and IPV uty to report if there is a child under 16 in house More likely to disclose if she feels comfortable & trusts CHN Show that you believe the woman Reassure that there is help Do NOT JUDGE: Leaving an abusive relationship is a process that takes time Reinforce that abuse is not her fault; abuse is a crime Reinforce that partner’s apologies will not end the abuse Explain (without blaming) that abuse affects the developing fetus & other children in the house Reinforce that woman’s safety is paramount; ask if you can consult with local police if risk of immediate danger is support Explore immediate concerns & needs to develop a plan of action Offer referral, provide information, leave numbers of resources Document interaction Application A person comes to your clinic with their partner who insists on being present during prenatal visits. You suspect that the client is being abused. What would be the best approach to use? A. Confront the partner with your suspicions B. Ask the client, in front of their partner, if they are afraid of their partner C. Try to have a colleague engage the partner outside the room so that you can broach the subject of abuse D. Tell the partner to go outside as you want to talk to the client alone  Substance Use During Pregnancy Alcohol and other drugs can easily pass from mother to baby through the placenta. Cocaine, heroin, Met, Alcohol Poses a serious health risk: Bleeding complications Miscarriage Stillbirth Prematurity Low birth weight Sudden infant death syndrome Congenital anomalies (Basso, 2022b; Rutman et al., 2020)  Substance Use During Pregnancy May result in lack of prenatal care Barriers to treatment Guilt, fear, shame, fear of losing custody of child Substance-use treatment programs usually do not address issues affecting pregnant women. Long waiting lists for treatment and lack of women-only recovery spaces are further barriers to treatment. Legal considerations Non-judgemental and person-centred approach Harm reduction model Nurses should encourage prenatal care, counselling, and treatment Drug testing during pregnancy No legal requirement in Canada  Substance Use - Nursing Care Assess for a history of violence, abuse, and mental health concerns, poverty and lack of housing and social supports Ensure confidentiality Non-judgemental, trauma-informed approach Harm reduction: supporting a patient's desire to stop using as well as assisting them in reducing risks Person-focused framework Women are more receptive to making lifestyle changes during pregnancy than at any other time. Opioid agonist therapy (OAT) – methadone or buprenorphine treatment recommended Cannabis users need to be educated on the effects of cannabis use in pregnancy Maternal–infant attachment Breastfeeding Discharge planning Postpartum follow-up visits Application You are a nurse working with a client who continues to smoke during pregnancy. You know that this has implications for the baby. What would be the best approach to address the issue of smoking during pregnancy? A. Advise the client to request the “patch” from their doctor B. Tell client that smoking is dangerous as it may cause preterm birth or a baby that is small for gestational age. C. Explore ways in which the client can reduce the amount they smoke during pregnancy. D. Tell the client’s doctor that the client is continuing to smoke despite the risks.  Early Pregnancy Bleeding Types of pregnancy loss: Miscarriage (spontaneous abortion): Loss of A: Threatened pregnancy before 20 weeks gestation or less than B: Inevitable C: Incomplete 500-g fetal weight D: Complete E: Missed Incidence – 10-15% pregnancies. 80% occurs before 12 weeks of gestation Early loss: before 12 weeks Majority related to chromosomal abnormalities, teratogenic drugs, faulty implantation, maternal abnormalities of reproductive tract, cervical insufficiency, placental abnormalities, chronic maternal illness, endocrine imbalances (hypothyroidism, DM etc), maternal infections e.g. varicella, malaria Late loss: 12-20 weeks  Assessment and care Early Pregnancy Initial/general assessment Confirmation of pregnancy with Vital signs laboratory testing Number of pregnancies, number of Bleeding (bright or dark, spotting or live births continuous) Last menstrual period/estimated Pain (type, intensity, location, date of birth persistence) Pregnancy history (previous and Vaginal discharge current) Late Pregnancy Allergies Estimated date of birth Nausea and vomiting Bleeding (amount, pinky, menstrual- Pain (onset, quality, precipitating like, heavy) event, location) Pain (location, severity, intermittent, Bleeding or coagulation issues continuous) Level of consciousness Vaginal discharge Emotional status and need for Amniotic membrane status (Basso, Uterine activity support  Management of Incomplete Expectant management: allows miscarriage to expel on its own. Nearly 50% of patients will miscarry on their own within 2 weeks of a diagnosis of pregnancy demise in the first trimester. Medical management: involves the use of 2-drug combination Mifepristone helps to prepare your uterus for miscarriage Misoprostol is given 24-48 hours later which helps the cervix soften and dilate to expedite the miscarriage. Surgical management: Dilation and curettage (D&C) is a surgical procedure in which the cervix is gently opened (dilation) and the pregnancy is removed with a suction device (curettage) Discharge Teaching After Pregnancy Loss Advise the patient to report any heavy, profuse, or bright red bleeding A scant, dark discharge may persist for 1 to 2 weeks. Avoid putting anything into the vagina for 2 Acknowledge the patient loss. Encourage client to speak with family and weeks or until bleeding has stopped (e.g., no tampons, no vaginal intercourse). seek support from friends. Take antibiotics as prescribed. Refer the patient to support groups, Report to health care provider- elevated clergy, or professional counselling, as temperature or a foul-smelling discharge needed. Advise the patient to eat foods high in iron Postponed pregnancy for at least 2 and protein. months to allow body to recover. (Basso,  Incidence and etiology Ectopic Pregnancy Fertilized ovum implanted outside uterine cavity 95% occur in uterine (fallopian) tube Most located on ampullar Clinical manifestations Abdominal pain Missed menstrual period Abnormal vaginal bleeding (spotting) indication of rupture referred shoulder pain is present (diaphragmatic irritation) one-sided, or deep lower-quadrant acute abdominal pain Diagnosis: Ultrasonography, Serum progesterone, and β-hCG levels Medical management: Methotrexate: antimetabolite and folic acid antagonist is administered to destroy rapidly (Basso,  Teaching for Patients Receiving Methotrexate Therapy Advise the patient to do the following: Avoid intake of foods and vitamins containing folic acid. Avoid eating “gas-forming” foods. Avoid sun exposure. Avoid sexual intercourse until the β- hCG level is undetectable. Keep all scheduled follow-up appointments. Contact health care provider immediately if experience severe abdominal pain, which may be a sign of impending or actual tubal rupture. (Basso,  Premature Dilation of the Cervix Cervical insufficiency- Passive and painless dilation of the cervix without contractions or labour ⮚ structural weakness of the cervix tissue resulting from collagen disorder or uterine anomalies ⮚ cervical trauma (birth or mechanical dilation) Nursing and interdisciplinary care Cervical cerclage (placed at 12 to 14 weeks of gestation). Importance of continuous close observation and supervision for the rest of the Fig. 14.7 A: Cerclage correction pregnancy. of recurrent premature Report signs of preterm labour, rupture of dilation of cervix. B: Cross section of membranes, and infection. closed internal os. Visit the hospital immediately: presence of (Basso,  Late Pregnancy Bleeding: Placenta Previa Placenta implanted in lower uterine segment near or over internal cervical os Classification is based on degree by which the internal cervical os is covered by placenta Complete placenta previa Marginal placenta previa Low-lying placenta Clinical presentation Bright red bleeding Pain absent Uterine is normal Normal fetal HR Diagnosis transabdominal or vaginal ultrasound Major complication: Bleeding, Preterm birth and IUGR (Basso, 2022a) https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-c auses/syc-20352768  Nursing and interprofessional care Bleeding is assessed by checking Potential emergency due to risk of the amount of bleeding on perineal massive blood loss pads (Weighing of pad; 1 gram is Expectant management (i.e., equal to 1 mL of blood) reduced activity and close Fetal surveillance may include NST observation) Patient is less than 36 weeks of or BPP once or twice weekly gestation Antepartum steroids Not in labour and the bleeding is (betamethasone) may be ordered minimal or has stopped, to promote fetal lung maturity if May remain in the hospital or be at the patient is at less than 34 home if bleeding is stable. weeks of gestation No vaginal or rectal examinations Active management Caesarean birth (fetus is mature, are performed (Basso, excessive bleeding develops, or Ultrasound examinations may 2022a) be  Late Pregnancy Bleeding-Placental Abruption Placental abruption (premature separation of placenta) Incidence and etiology 1 in 100 births Classification system Grades: 1 (mild), 2 (moderate), 3 (severe) Clinical presentation: vaginal bleeding, abdominal pain, uterine tenderness, and contractions Major cause of antepartum haemorrhage (Basso, 2022a)  Maternal hypertension/Preeclampsia Risk Age Increasing parity factors for Multiple gestations Placenta Polyhydramnios (excess amniotic fluid) Abruption Chorioamnionitis Preterm PROM Trauma (assault or motor vehicle collusion) Substance use e.g cocaine History of abruption  Complications Maternal complications Hemorrhage, Fetal complication: hypovolemic shock, IUGR, preterm birth, hypofibrinogenemia and hypoxemia, and stillbirth thrombocytopenia present in severe Risks for neurological defects, abruption. cerebral palsy, and death from sudden infant death syndrome Couvelaire uterus DIC Infection may occur. Rh negative can become sensitized if the fetal blood type is Rh positive (Basso, 2022a)  Nursing and interprofessional care Expectant management if the fetus is less than 36 weeks of gestation and not in distress Patient is hospitalized and closely observed for signs of bleeding and labour. Fetal status monitoring with intermittent FHR monitoring and NST or BPP until fetal maturity is achieved Continuous electronic fetal monitoring is mandatory Maternal vital signs should be monitored frequently for signs of declining hemodynamic status, Use of corticosteroids to accelerate fetal lung maturity Immediate birth is indicated if condition deteriorates. Rh negative patient may be given Rho(D) immunoglobulin if fetal blood is Rh positive. (Basso, 2022a)  Clotting Disorders in Pregnancy: DIC Disseminated intravascular coagulation Stage one,- overactive (DIC): Is a rare disorder in which clotting leads to blood clots proteins that control blood clotting throughout the blood vessels. become overactive and utilizing all the clots can reduce or block clotting factors, causing widespread blood flow, which can damage external and internal bleeding organs. DIC is most often triggered by the Stage two-as DIC progresses, release of large amounts of tissue the overactive clotting uses thromboplastin cause by: up platelets and clotting  placental abruption (the most common factors that help the blood to cause of severe consumptive clot. coagulopathy in obstetrics) With the absence of platelets  Retained dead fetus syndrome and clotting factors, DIC leads  Amniotic fluid embolus (anaphylactoid to bleeding just beneath the syndrome of pregnancy). skin, in the nose or mouth, or Physical Examination Findings Coagulation Screening Test Spontaneous bleeding from gums, nose Platelets: Decreased Oozing, excessive bleeding from Fibrinogen: Decreased venipuncture site, intravenous access Factor V (proaccelerin): Decreased site, or site of insertion of urinary catheter Factor VIII (antihemolytic factor): Petechiae (e.g., on arm where blood Decreased pressure cuff was placed) Prothrombin time: Prolonged Other signs of bruising Partial prothrombin time: Prolonged Hematuria Fibrin degradation products: Increased Gastrointestinal bleeding d-dimer test (specific fibrin degradation Tachycardia fragment): Increased Red blood smear: Fragmented red blood Diaphoresis cells (Basso,  Nursing and interprofessional DIC involves correction of the underlying care Vital signs are assessed frequently. cause (treatment of existing severe Continuous electronic fetal infection, pre-eclampsia, or eclampsia, or removal of a placental abruption or dead monitoring is necessary. fetus) Side-lying to maximize blood flow Volume expansion, rapid replacement of to the uterus. blood products and clotting factors, Oxygen may be administered Continued reassessment of laboratory Keep patient warm with a forced- parameters are the usual forms of air warming system, warmed treatment. blankets and fluid warmers Vitamin K administration, recombinant Patient and family support is activated factor VIIa, fibrinogen crucial by offering explanations concentration about care and providing Protecting the patient from injury. emotional support (Basso, Urinary output needs to be carefully 2022a)  Hypertensive Disorders in Pregnancy Occur in 7% of pregnancies and is leading cause maternal mortality SBP of 140 mm Hg or greater and/or DBP of 90 mm Hg or greater, taken at two separate measurements and at least 15 minutes apart Severe hypertension: systolic BP >160 mm Hg and diastolic BP >110 mm Hg Chronic hypertension: prepregnancy hypertension is present prior to 20 weeks of gestation Gestational hypertension: develops after 20 weeks’ gestation Absence of proteinuria Pre-eclampsia/eclampsia (gestational hypertension with proteinuria and/or other target organ involvement). (Basso, 2022a) 2 key components Pre-eclampsia & Eclampsia Gestational or chronic hypertension and Risk factors Nulliparity new onset proteinuria (concentration of Age > 40 years greater than 0.3 g/L per 24 hours) Pregnancy with assisted reproductive Additional organ dysfunction may be technology present: Interpregnancy interval > 7 years a) Acute kidney or liver dysfunction Family history of pre-eclampsia Patient born small for gestational age b) Neurological complications such Obesity/gestational diabetes mellitus as seizures, Multifetal gestation blindness, stroke, severe headaches Pre-eclampsia in previous pregnancy c) Hematological complications Poor outcome in previous pregnancy such as Pre-existing medical/genetic thrombocytopenia, disseminated conditions intravascular Chronic hypertension Renal disease (Basso, coagulation (DIC) or hemolysis Type 1 (insulin-dependent) diabetes Pre-eclampsia - Etiology The main pathogenic factor is not an increase in BP but poor perfusion resulting from vasospasm. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP. Function in placenta, kidneys, liver, and brain is depressed by as much as 40 to 60%. Fig. 14.1 Etiology of pre-eclampsia.  Complications Maternal: Fetal multi-organ failure Preterm birth CNS: Seizure, cerebral Still birth (IUFD) oedema, cerebral Fetal distress hemorrhage, stroke Uteroplacental insufficiency Kidney: renal failure, oliguria, Placenta abruption hypo-proteinuria IUGR Lungs: pulmonary oedema Hypoxic neurological Lever: hepatic failure, hepatic rupture Hematological: DIC, HELLP (Basso, 2022a)  Severe pre-eclampsia accompanied by: Hemolysis (H) Elevated liver enzymes (EL) Low platelets (LP) HELLP hypertension and proteinuria (80% to 85%), epigastric/right upper quadrant (RUQ) pain Syndro (possibly related to hepatic ischemia) nausea, vomiting, headache, and malaise Nausea and vomiting me Associated with increased risk for: Placental abruption Renal failure Pulmonary edema Ruptured liver hematoma Disseminated intravascular coagulation (DIC) Nursing Care Pre-eclampsia & HELPP Blood pressure assessment Deep tendon reflexes: Biceps reflex, Patellar reflex with patient’s legs hanging freely and test for ankle clonus. Fetal health surveillance (nonstress test [NST], contraction stress test [CST], biophysical profile [BPP]), FHR, ultrasonography, fetal movement counting Nursing Care Pre-eclampsia-Patient Teaching Report any increase in blood pressure, protein in urine, or decreased fetal movement. Monitor Blood Pressure Dipstick Test Clean-Catch Urine Sample to assess proteinuria Decreased activity (five or fewer movements in 2 hours) may indicate fetal compromise. Regular appointments need to be kept so that any changes in condition of the patient or fetus can be detected immediately.  Nursing Care Pre-eclampsia & HELPP Severe pre-eclampsia and HELLP syndrome: Hospital care Eclampsia/Seizure precautions High-risk unit Quiet Invasive monitoring Non stimulating Seizure precautions Lighting subdued Control of BP Seizure precautions (have Hydralazine magnesium sulphate available) Labetalol Suction equipment tested and Methlydopa ready to use Adalat Oxygen administration Magnesium sulphate (Antiseizure) equipment tested and ready to Observe for signs of toxicity (Loss use Call button within easy reach of patellar reflexes, respiratory and muscular depression, oliguria, and a decreased level of consciousness (Basso, 2022a)  Nursing Care -Eclampsia Eclampsia: usually preceded persistent headache, blurred vision, photophobia, severe epigastric or right upper quadrant abdominal pain, and fits, altered mental status. Immediate care Ensure patent airway Medication (administer magnesium sulphate and observe for signs of toxicity ) Assess fetal status Postpartum nursing care (assessment of vital signs, intake and output, reflexes, level of consciousness, uterine tone, and lochia flow) Future health care Prenatal care assessment and early interventions (Basso, 2022a)  Seizure: Immediate and After Immediate care during seizure Administer magnesium sulphate or Keep airway patent: turn head to one anticonvulsant medication as ordered. side, place pillow under one shoulder Insert in-dwelling urinary catheter and or back if possible. Call for assistance. monitor hourly output. Do not leave bedside. Monitor blood pressure. Protect patient from injury during Monitor fetal and uterine status. seizure by having padded side rails Expedite laboratory work as ordered to raised and safely locked. monitor kidney function, liver function, Observe and record convulsion coagulation system, and medication activity. levels. After care Provide hygiene and a quiet Do not leave patient unattended until environment. they are fully alert. Support patient and family and keep Observe for post convulsion coma, incontinence. them informed. Be prepared to assist with birth as Use suction as needed. Administer oxygen via face mask at needed. 10 L/min (Basso,  Gestational Diabetes Mellitus (GDM) Elevated glucose levels that are first recognized during pregnancy Obesity (a body mass index Patients with GDM increased risk of [BMI] greater than or equal to developing glucose intolerance later in 30) life Gestational diabetes in a Increased incidence of adverse maternal previous pregnancy and fetal outcomes Given birth to a baby that Risk factors weighed more than 4 kg Being 35 years of age or older A parent, brother, or sister with Being a member of a high-risk group type 2 diabetes (African, Arab, Asian, Latin-American, Polycystic ovary syndrome or Indigenous, or South Asian) acanthosis nigricans (darkened Using corticosteroid medication patches of skin) associated Pregestational diabetes insulin resisntance (Basso, 2022a)  Screening and Interventions for GDM Interventions Screening for gestational diabetes Antepartum Screen for pre-existing Aim of therapy is good blood diabetes before 12 weeks gestation glucose control Diet – mainstay of therapy Universal screening between Exercise 24-28 weeks is recommended in Canada + Oral Glucose Monitoring blood glucose levels Tolerance Test Pharmacological therapy (Insulin, Initial screening at 24 weeks glyburide, metformin) Repeated 24-28 weeks Fetal surveillance Multiple risk factors-should Intrapartum: macrosomia, birth injuries screen in the fist trimester due to shoulder, newborn hypoglycemia Postpartum: (Basso, Women dx with GDM – test again 6- 2022a) 12 weeks postpartum  Rh incompatibility/Alloimmunization Rh Positive - Rh blood group is present on In subsequent pregnancy – Rh the surface of erythrocytes antibodies cross the placenta into Rh Negative – without RH factor on fetal circulation. erythrocytes Causing severe hemolysis & Isoimmunization: when about 0.1 mL of anemia in fetus Rh-positive fetal blood mixes with maternal Prevention Rh negative Good hx of past pregnancies to Occurs when Rh negative woman carries assess for incompatibility potential an Rh-positive fetus either to term or Determine mother’s blood type & termination (miscarriage/abortion) Rh factor; routine Rh antibody Can also occur if Rh negative woman screen receives Rh positive blood Rh [D] immune globulin (RhoGAM) RBCs from fetus invade maternal is given to pregnant Rh-negative circulation, stimulating production of Rh women who are not sensitized or antibodies and formation(Watts, anti-Rh 2022) when the Rh factor of the dad is positive or unknown  Hyperemesis Gravidarum Hyperemesis Gravidarum: Protracted vomiting that causes severe dehydration, weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria Usually begins between 4 and 8 weeks of pregnancy and resolves by 20 weeks Require hospitalization. fetal complication (LBW,SGA, preterm) Maternal (vit k deficiency, thiamine) Etiology  Nursing care Assessment (vital signs, signs of dehydration, Interventions may include initiating deep stick test for ketones) and monitoring IV therapy Clear liquids, slowly introducing small, Medications frequent bland meals that are high in protein ∙ Pyridoxine (vitamin B6) alone or in or carbohydrates but low in fat. combination with doxylamine Patients should be counselled to avoid odours, ∙ Diphenhydramine, promethazine, tastes, or other activities that can trigger chlorpromazine, and nausea E.g (stuffy room, visually stimulating prochlorperazine ∙ Metoclopramide to accelerates lights, or strong perfume etc) gastric emptying HG needs calm, compassionate, and ∙ Antiemetic and medications to sympathetic care control heartburn or reflux  hyperemesis can be physically and (antacids, histamine blockers, and emotionally debilitating and stressful proton pump inhibitors) Support for patient and family ∙ Ondansetron if above medication (Basso, are not effective 2022a) Danger Signs in Pregnancy Danger sign Concern/possible cause Vaginal bleeding First trimester miscarriage; implantation bleeding; placenta previa; abruptio placenta; “bloody show” Any time: STI; after intercourse Dysuria, urgency &/or frequency UTI, STI Fever & chills Infection Intractable vomiting Hyperemesis gravidarum Severe headaches Pre-eclampsia; eclampsia Visual disturbances (spots, blurry vision) Pre-eclampsia Epigastric pain Pre-eclampsia Vaginal loss of fluid Premature rupture of membrances Uterine contractions, abdominal pain, pelvic Preterm labour; abruptio placenenta pressure, backache before 37 weeks Biochemical Assessment During Pregnancy Coombs' Test: screening tool for Rh incompatibility Amniocentesis: Indications: Genetic concerns, Fetal maturity, Fetal hemolytic disease Amniocentesis has the potential for maternal and fetal complications: Maternal complications Fetal complications Leakage of amniotic fluid Death Hemorrhage Hemorrhage, fetomaternal hemorrhage Infection (amnionitis) Infection Injury from needle Maternal Rh isoimmunization Placental abruption Inadvertent damage to intestines or bladder Amniotic fluid embolism Chorionic villus sampling (CVS): (test chromosomal abnormalities and other genetic disaorders Earlier diagnosis and rapid results Ideally performed between 10 and 13 weeks of gestation Removal of small tissue specimen from fetal portion of placenta Tissue reflects genetic makeup of fetus Third-Trimester Assessment for Fetal Well-Being Preterm premature rupture of To determine whether the intrauterine environment continues to be supportive to the membranes fetus. The testing is often used to determine the Abnormal maternal serum screen in timing of childbirth for patients at risk for absence of confirmed fetal anomaly uteroplacental insufficiency Motor vehicle accident during pregnancy Fetal movement counting, Vaginal bleeding Nonstress test (NST), Morbid obesity Contraction stress test (CST), Biophysical profile (BPP) Advanced maternal age Ultrasound tests Assisted reproductive technologies Indications Fetal Late-term pregnancy (> 294 days, > 41 Decreased fetal movement weeks) Intrauterine growth restriction Hypertensive disorders of pregnancy Suspected Pregestational diabetes Insulin requiring gestational diabetes oligohydramnios/polyhydramnios Chronic (stable) abruption Multiple pregnancy Isoimmunization Preterm labour (Watts, 2022) Fig. 13.9 Fetal movement algorithm. AFV, amniotic fluid volume; BPP, biophysical profile; CST, contraction stress test; IUGR, intrauterine growth restriction; NST, nonstress test.  Non-Stress Test A nonstress test (NST) is used to measure the fetal Reactive/Normal nonstress test. (Fetal heart rate accelerations with fetal heart rate in response to the movement of the movement) fetus Involves monitoring of fetal heart rate in response to the fetal movements using electronic fetal monitor. Heart rate of a healthy fetus should increase when the fetus moves. Reactive (normal)- at least two FHR accelerations lasting at least 15 seconds and rising at least 15 beats/minute above the established baseline heart rate. Non-reactive/abnormal Nonreactive- lacks sufficient fetal heart rate nonstress test accelerations over a 40-minute period. (no fetal heart rate accelerations).  Biophysical Profile - BPP Indications The pregnancy has gone past Recommended for women at increased risk 40 weeks gestation of problems that could lead to complications or pregnancy loss. Multiple gestation pregnancy The test is usually done after week 32 of Previous Stillbirth pregnancy but can be done when Polyhydramnios or pregnancy is far enough along for delivery to be considered — usually after week 24. Oligohydramnios Non-invasive test using ultrasound and fetal Gestational Diabetes (GDM) heart monitoring. Preeclampsia or other A low score on a biophysical profile might hypertensive disorder in indicate that further testing is needed. In pregnancy some cases, early or immediate delivery IUGR might be recommended. Other Pregnancy (Watts, 2022) Complications Bio-physical Profile Indications Five components of the biophysical profile are as follows:  nonstress test  fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes)  fetal movement (three or more discrete body or limb movements within 30 minutes);  fetal tone (one or more episodes of extension of a fetal extremity with return to flexion, or opening or closing of a hand  determination of the amniotic fluid volume (a single vertical pocket of amniotic fluid exceeding 2 cm is considered evidence of adequate amniotic fluid). Each components is given a score of 2 (normal or present or 0 (abnormal, absent or insufficient). Biophysical Profile Scoring Contraction stress test (CST) Contraction stress test (CST) Use to measure the response of the fetus (FHR) after the uterus is stimulated to contract Is done to ensure during labor the fetus can handle contractions and get the oxygen needed from the placenta. Procedure: Negative contraction stress Nipple-stimulated contraction test test Oxytocin-stimulated contraction test (normal external fetal heart rate Interpretation tracing Negative test: FHR does not show deceleration or late decelerations Positive test: FHR is showing decelerations and late decelerations Indicated when there is abnormal nonstress test or biophysical profile. Provides a warning of fetal compromise than NST Positive contraction stress test (late decelerations with uterine contractions Ultrasound for Fetal Well-Being Biophysical profile (BPP) Assesses fetal breathing movements, fetal movements, fetal tone, and AFV Amniotic fluid volume (AFV) Abnormalities in AFV are frequently associated with fetal disorders. Oligohydramnios (less than 300 mL of amniotic fluid, associated with fetal renal abnormalities polyhydramnios (more than 2 L of amniotic fluid, associated with gastrointestinal and other malformations) Nursing Role in Antepartum Assessment for Risk Psychological considerations Patients undergoing antenatal assessments are anxious. Tests may show suspected fetal compromise, deterioration of maternal condition, or both. Third-trimester patients are concerned about protecting themselves and their fetuses and consider themselves vulnerable and can lead to ambivalence. When a patient is diagnosed with high-risk pregnancy, they and their family will likely experience stress related to the diagnosis. The patient may exhibit various psychological responses: Anxiety Low self-esteem and guilt Frustration Inability to function References All images, except as noted, Images: @ CC Unsplash Basso, M. (2022a). Pregnancy at Risk: Gestational Conditions. Chapter 14. In L. Keenan-Lindsay, C.A. Sams, C.L. O’Connor, S.E. Perry, M.J. Hockenberry, D.L. Lowdermilk and D. Wilson (Eds). Maternal child nursing care in Canada (5th ed.). Elsevier Canada. Basso, M. (2022b). Pregnancy at Risk: Pre-existing Conditions. Chapter 15. In L. Keenan-Lindsay, C.A. Sams, C.L. O’Connor, S.E. Perry, M.J. Hockenberry, D.L. Lowdermilk and D. Wilson (Eds). Maternal child nursing care in Canada (5th ed.). Elsevier Canada. Best Start (2016). Abuse in Pregnancy: Information and Strategies for the Prenatal Educator. https://resources.beststart.org/product/h04e-abuse-in-pregnancy-prenatal-educator-booklet/ Deshpande, N. A., & Lewis-O'Connor, A. (2013). Screening for intimate partner violence during pregnancy. Reviews in Obstetrics and Gynecology, 6(3-4), 141-148. Howells, L. (July 14, 2020). Ontario to end practice of birth alerts that's led to babies being seized from new mothers. CBC News. https://www.cbc.ca/news/canada/toronto/ontario-ends-birth-alerts-1.5648940 McKenzie, A. (Feb. 2, 2021). Birth alerts explained: Anishinaabe social work prof clarifies ‘illegal’ and ‘unconstitutional’ practice. Toronto Star. https://www.thestar.com/news/canada/2021/02/02/birth-alerts-explained-anishinaabe-social-work-prof-clarifies-illegal-and- unconstitutional-practice.html Quosdorf, A., Peterson, W. E., Rashotte, J., & Davies, B. (2020). Connecting with adolescent mothers: Perspectives of hospital-based perinatal nurses. Global Qualitative Nursing Research, 7. https://doi.org/10.1177/2333393619900891 Rutman, D., Hubberstey, C., Poole, N., Schmidt, R. A., & Van Bibber, M. (2020). Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming. BMC Pregnancy and Childbirth, 20(1), 1-441. https://doi.org/10.1186/s12884-020-03109-1