Biophysical Profile Scoring PDF

Biophysical Profile Scoring Using Sonogram Criteria of score = 2 Fetal Breathing Normal: 1ep every 30sec. Sustained breathing movements within 30 mins Fetal Movement Normal: 3 separate ep of limb and trunk movement every 30 mins Fetal Tone - Abili...

Biophysical Profile Scoring Using Sonogram Criteria of score = 2 Fetal Breathing Normal: 1ep every 30sec. Sustained breathing movements within 30 mins Fetal Movement Normal: 3 separate ep of limb and trunk movement every 30 mins Fetal Tone - Ability of the fetus to flex and extend extremities or Spine. Normal: at least once every 30 mins. Amniotic Fluid Volume - Fluid environment which fetus floats. Normal: pocket should measure >1cm vertical diameter, Using Non-Stress Test Fetal Heart Reactivity - Fetal heart acceleration Normal: 2 or more of at least 15bpm ↑baseline & of 15 sec Duration c fetal mvmnt. In 20 mins period. Assessment Non-stress Contraction Criterion for Measurement Effect of FM to FHR Effect of uterine contra. due to nipple stimu. On FHR\ - If stressed = (+) response of FM to ↑FHR Normal Findings 2 or ↑ acceleration of No late deceleration c contra. FHR:15bpm for 15 or ↑ times after FM within 20mins  FETAL GROWTH AND DEVELOPMENT Stages of development “Human fetal Development” 1. Zygote - Conception to 2 weeks 2. Embryo - 2 weeks to 2 months 3. Fetus - 2 months to full term or until delivery of baby. Emphasis on development 1st trimester: Organogenesis - dev. of basic organs (heart and brain) 2nd trimester: Fetal length 3rd trimester: Rapid growth and development - In preparation for the outside world. Month Description of Developement 1st month 1. Germ layer formation Stem Cells: a. Ectoderm - the skin (connective tissues) b. Mesoderm - composes muscle c. Endoderm - internal organ 2. Brain and NS dev. 3. FHbeat (x) audible {can be viewed in sonogram) 4. Dev. of trachea and lungs 2nd month 1. Complete organogenesis 2. Placenta Dev. 3. Dev of sex organ (not visible in sonogram) 3rd month 1. Complete placenta and Barrier (fetus is protected) 2. Amniotic fluid prod. 3. Audible FHT (doppler)  4. Bone formation 4th month 1. FHT by fetoscope 2. Visual Skeletal outline 3. Human face 4. Dev of external genitals 5. Lanugo (fine hair of baby) 5th month 1. Quickening (1st fetal mov felt by mother) 2. Vernix caseosa (cheese-like covering) dev. 3. FHT by steths 6th month 1. Term size 2. Scalp hair dev. 3. Pinkish, wrinkled skin (premature) 7th month 1. Alveoli dev. for preparation to outside environment 2. Surfactant production to enable child to live outside 8th month 1. ↓lanugo and vernix 2. Rapid fat deposition to sustain temp. outside the womb 3. Viable for Delivery 9th month 1. Disappearance of vernix caseosa 2. ↓Amniotic feeling 3. Birth position assumed (head is positioned in cervix) 4. Lightening due to fetus ↓pressure on diaphragm Fetal Circulation Structure Location Function Placenta Attached to uterus Primary gas exchange for fetal life - Contains 2 umbilical arteries Umbilical Arteries Two arteries in cord “2A” Carry un-O2 blood from fetus to placenta Umbilical Vein One vein in the cord “1V” Carry O2 blood to fetus Foramen Ovale Opening in the interatrial septum Allows blood to pass from RA to LA to (between R & L atrium) supply the brain, heart, and kidney Ductus venosus Accessory vein connects umbi vein Blood supply (shortcut) to the liver. to fetal liver and IVC Ductus Arteriosus Connection of fetal lungs and aorta Allows large portion blood away from lungs and directly into aorta INTRAPARTUM (PROCESS OF LABOR & DELIVERY) A.k.a Childbirth/parturition Series of events by which uterine contractions and abd pressure expel a fetus &placenta from woman's body EUTOCIA - Normal Labor THEORIES OF LABOR ONSET Theory Description Uterine Stretch Theory Any hollow organ (uterus) tends to contract and empty itself when distended. “Rubber” - Once stretched, it has a max point of stretching and automatically returns. Oxytocin Theory ↑Oxytocin before pregnancy that initiates labor by contra, in myometrium. It also stipulates contra. in sealing ruptured membranes = (x) bleeding. Progesterone Deprivation ↓Progesterone inhibits relaxation effect of prostaglandins, Prostaglandin + Progesterone = relaxation Prostaglandin = contra. Aging Placenta Theory Aging P cannot support the growing fetus Prostaglandin Theory Amnion & decidua - source of prostaglandin.  ↑Fetal Cortisol level → ↑formation of prosta. = contraction. Prostaglandins - causes smooth muscle contrxn. Preliminary/Premonitory Signs of Labor Signs Description Lightening Fetus descent into pelvis. Uterus → lower and more anterior. May experience: ○ Shooting leg pains ○ ↑venous stasis ○ ↑vaginal secretions ○ Urinary Frequency, and; ○ Pelvic pressure. Braxton Hicks contrxn. Irreg, intermittent contrxn. Felt in abd or inguinal; region May mistake for true labor. Cervical ripening Internal Sign determined on pelvic exam. IE Throughout gravida, Cervix feels softer than normal (Goodell’s) At term, cervix still softer (butter-like) & tips forward Bloody Show Pink - tinged secretions and mucus plug (often expelled) = small amount f blood loss Rupture of Membrane Clear/odorless and contains white specks (vernix) and lanugo ○ Yellow-tinged = infxn or fetal passage of meconium → pediatrician for further assess. and FHR monitoring Ruptures one labor is well established ○ Spontaneously or amniotomy Sudden Burst of Energy Prepares the woman’s body for labor ○ 24-28 hrs. Before labor. Comparison of True and False Labor pains True Labor False Labor Contrxn Regular Irregular (x) ↓Contrxn even c rest Relieved by rest and warm and warm bath. bath. Intervals Shortened Long Intensity ↑contrxn c change of act. No change Walking may ↓pain Dilation/effacement Progressive No changes in cervix Discomfort ↓back radiating to abd. ↓abdomen, Causes of Labor onset 1. ↓Placental function due to aging. 2. ↑’s prostaglandin = stimulate contrxn 3. ↓progesterone = ↓relax effect (progesterone + prosta) of prostaglandin 4. ↓ oxytocin -> further contrxn 5. ↓uterine stretch = rebound contrxn These theories aids to expel fetus from the uterus COMPONENTS OF LABOR 1. The passage (birth canal) 2. The passenger (fetus) 3. The relation between maternal pelvis & presenting part of fetus. 4. The powers of labor 5. Position of the mother 6. Psyche/psychological outlook PASSAGE Route of fetus to travel from uterus → cervix & vagina → external perineum Must be of adequate size Two pelvic measurements to determine adequate size: 1. Diagonal conjugate a. AP diameter of inlet (measurement of front and back) 2. Transverse diameter of outlet Critical Factors Size of maternal pelvis (diameter of pelvic inlet, midpelvis, and outlet). Type of maternal pelvis ○ Gynecoid - best fit for delivery ○ Platypelloid - wide and flat ○ Android - heart shaped ○ Anthropoid - pointed areas giving a square look. Ability of the cervix to dilate and efface Ability of vaginal canal and introitus to distend PASSENGER “The Fetus Movement of fetus → birth canal is determined by several factors: Assessment of the Passenger Presentation Attitude Part of fetus in the ↓pole of uterus Posture of fetus ○ Cephalic (head) ○ Flexion “naka-tupe” ○ Breech (buttocks) ○ Deflexion “away from center” ○ Verte (Side-lying) ○ Extension “naka-unat” Lie Position Relation of the long axis of the fetus to Relation of presenting part to mother’s the mother. pelvis ○ Longitudinal (Normal) One area of the presenting part FETAL HEAD Sutures - natural areas and spaces between cranial bones - Allows the skull to be deformed during delivery to avoid damages 1. Frontal - 1 suture between 2 frontal bones. 2. Coronal - between frontal and parietal bones 3. Sagittal - between 2 parietal bones (midline) - Most important suture - Overrides or allows molding in labor 4. Lambdoidal - “posterior” suture - Between parietal and occipital bones, Membranes - Filled spaces called fontanels/fontanelles - Where sutures intersect. FONTANELLES: 1. Posterior fontanelle 2. Anterior fontanelle ANTERIOR AND POSTERIOR FONTANELLES ○ Used in clinical sutures ○ identify position of fetal head in pelvis ○ Compresses during deliver to aid in molding FETAL ATTITUDE/HABITUS - degree of flexion - Relation of fetal body parts to each other. Flexion - head flexed on chest (towards umbilicus) Extension - head extended (away from the chest); occiput touches the back TYPES: 1. (A) - Complete flexion  2. (B) - Moderate Flexion 3. (C) - Poor Flexion 4. (D) - Hyperextension \ FETAL LIE relation of é long axis of é fetal body and é long axis of é mother body. ○ Longitudinal/vertical lie: cephalic or breech - parallel ○ Transverse/horizontal lie: shoulder - perpendicular ○ Oblique lie: becomes longitudinal or transverse during labor, Types of Cephalic Presentation 1. Vertex - occiput is the presenting part 2. Sinciput - fetal head is partially flexed, with the anterior fontanel, or bregma, presenting.  3. Brow - fetal head is partially extended; the sinciput (forehead) is the presenting part. 4. Face - fetal head is hyperextended; the face is the presenting part. Types of Breech Presentation 1. Complete - both legs are flexed. 2. Incomplete - 1 leg flexed, one leg extended 3. Frank - 2 legs are extended 4. Footing - 1 foot “nakalaylay” FETAL POSITION - relation of presenting part to specific quadrant on woman’s pelvis 4 quadrants of maternal pelvis 1. Right Anterior 2. Left Anterior 3. Right posterior 4. Left posterior Indicated by 3 letter abbreviations. 1st letter: Landmark point at mother’s (R) right or (L) left.  Middle Letter: Fetal landmark (O) occiput, (M) mentum or chin, (Sa) sacrum, & (A) acromion process. Last letter: whether landmarks points (A) anterior, (P) posterior or (T) transversely. Four parts of fetus as landmarks 1. Vertex presentation - occiput 2. Face presentation - chin (mentum 3. Breech “ - sacrum 4. Shoulder “ - acromion process STATION - relation of presenting part to level of Ischial Spine (IS) - Measure the degree of descent. Floating (-3): above the inlet “false pelvis” Dipping (-2): Minus (-): above é IS Fixed (-1): below inlet, “true pelvis”, not moving but not engaged. Station (-5): at pelvic inlet ENGAGED/STATION 0 Plus (+): below IS (+4): at perineum, “crowning” Station (+5): at pelvic outlet Leopold’s Maneuver Method of observation & palpation of fetal position (Systematic) Nursing Responsibilities 1. Empty bladder (patient) 2. Supin + slightly flex knees = relaxed abd. 3. Warm hands = (x) contraction 4. Gently but firm touch Maneuver Purpose  1st maneuver (Fundal Grip) - Asses fetal presentation 2nd maneuver (Umbilical “) Check the: - Fetal back - FHR - Fetal Lie 3rd maneuver (Pawlick’s “) - Check fetal engagement 4th maneuver (pelvic “) - For fetal attitude POWERS OF LABOR Voluntary + involuntary powers = expel of the fetus, fetal membranes, and placenta. Primary power/primary force Refers to 3 phases of contrxn: 1. Increment - increasing power 2. Acme - peak power 3. Decrement - decline DURATION: beginning to end of 1 contrxn. FREQUENCY: beginning of one contrxn to the beginning of the next. INTENSITY: Mild - Fundus indents easily (like tip of the nose) Moderate - Fundus indents less easily (firm & difficult “chin”). Strong - fundus cannot be indented (like forehead). WOF: Contrxn occurring ↑every 2 mins and persistent contrxn (↑90 sec duration) = ↓fetal O2 supply. “EMERGENCY” Factors responsible for fetus descent. 1. Effacement shorteming and thinning of cervix (1st stage of labor) 2. Dilation/dilatation. Enlargement or widening of cervical opening (once labor began). Secondary power/Secondary Force  1. Abdominal muscle, to push during 2nd stage of labor 2. Voluntary bearing down efforts by women. 3. Change in contrxn (expulsive), when presenting part reaches pelvic floor, 4. Not fully dilated cervix, may cause cervical edema (retarded dilation), possible tearing and bruising. Positions: Upright position Lateral Position Lithotomy position Semi-recumbent position Sitting position Kneeling or squatting position. STAGES OF LABOR I - onset of true labor -> full cervical dilation - “Kapag meron nang sustained contrxn” II - full cervical dilation -> delivery of baby “Pushing Stage” III - birth of baby -> placental delivery IV - delivery of placenta -> 6 weeks of post-partum (puerperium) First Stage: Latent Active Transitional Dilation 0-3 cm 4-7 cm 8-10 cm Frequency Q5-10 mins Q3-5 mins Q2-3 mins Duration 20 - 40 seconds 40 - 60 seconds 60 - 90 seconds Intensity MIld Moderate - severe Severe Fetal Heart Rate (FHR) Variability: FHR PATTERN DESCRIPTION CAUSE INTERVENTION (N) Early deceleration ↓FHR at onset of Compression of the Monitoring Maternal uterine contrxn (UC) Head V/S and FHR. then return to baseline at end. LAte Deceleration ↓FHR after UC → IVC compression (RL - Lateral position beyond end of UC part) = Placental - Give Oxygen (oral) insufficiency - ↑fluids (IV) Variable Deceleration ↓FHR is unpredictable Cord compression & - Knee chest position in relation to UC cord prolapse (knee is flexed towards “EMERGENCY” the chest of the mother) Should not be flat on bed due to ↑Prolapse by compressing the abdomen.  - then Trendelenburg (FOB is elevated) - Give O2 - ↑fluids Nursing Responsibilities: 1. Assessment: Mother “V/S”; Baby “FHR” 2. Nutrition: Ice chips (promote comfort), Yogurt (for Cephalic ONLY) = relieve of dehydration 3. Position: Semi or High-Fowlers with both Legs flexed 4. Sacral Pressure: relieves back pain Effleurage - Light Massage (abd/thight) Breathing techniques ○ Latent - chest breathing ○ Active - Abdominal Breathing ○ Transitional - pant pant blow 5. Encourage voiding = space for contrxn & avoid rupture of bladder. SECOND STAGE Intrapartal care Full dilattio (10cm) and cervical effacement Cardinal movements of labor (De-F-IR-E-R-ER-E) 1. Descent - ad enters inlet in occiput (back of head) or oblique (side) position 2. Flexion - Fetal chin flexes down to chest. 3. Internal Rotation - Occiput usually rotates L to R & sagittal suture aligns in A-P pelvic diameter. 4. Extension - head is born in extension as occiput slides under symphysis pubis. 5. Restitution - once head is out and free from pelvic resistance, the neck untwists, turning head to one side & aligns with position of back of birth canal. 6. External Rotation - head rotates back to diagonal/transverse = shoulders into A-P position. 7. Expulsion - Anterior and posterior shoulders are born = quickly followed by rest of body. Medication given 1. Analgesic DOC: Nalbuphine HCl (nubain)/Meperidine/Demerol - 2 to 3 hrs before delivery to reach fetal blood WOF: Respiratory Depression (RR of Mother) Contraindicated: Preterm labor due to immaturities of Fetus Antidote: Naloxone for opioid toxicity (when RR ↓ that may = death of mother and child) 2. Anesthesia - Pudendal block for episiotomy Epidural - Side-lying position WOF: Hypotension - Give: Ephedrine (stimulate HR and peripheral vasoconstriction to ↑heartbeat). Position into side-lying, give O2 and Fluids, (+) leg compression/Elevation Spinal - Sitting with back arch WOF: Headache and hypotension due to disturbance in spinal vertebral pressure which adjusts intracranial pressure - same management but flat on bed for 10-12 hours w/o pillow. Nursing responsibilities for 2nd Stage of Labor 1. Sterile Vaginal Examination = prevent toxic shock syndrome 2. Monitor BP q30, FHT q15 mins 3. Provide Support, reassurance, and clear directions to follow. Provide info. Regarding the process of her labor. 4. When contrxn begins - tell mother to take 2 breaths, then 3rd breath is held while knees are pulled back to chest, and pushing down using abdominal muscles. 5. Assist into comfort position for pushing (Dorsal Recumbent/Lithotomy) 6. Pain level 7. Assist in Episiotomy THIRD STAGE “Placental Stage” Placental separation/delivery. Start “birth of infant” ends at “delivery of placenta” Phases Placental Separation Sudden gush of blood from vagina (separation of placenta form uterus) Lengthening of umbilical cord Calkin’s sign: Uterus shape changes Firm contrxn of uterus Appearance of placenta at vaginal opening. Placental Delivery Technique used to facilitate Delivery Brandt-andrews: fingers of one hand at ↓uterine segment (to prevent inversion/ prolapse “pagluwa ng uterus”), uterus is pushed ↑ into abd while maintaining gentle traction on clamped cord. Modified crede’s: apply gentle pressure on fundus (4 fingers at back and the thumb anteriorly) of contracted uterus, separated placenta is pushed down to the vagina. Schultze: Placenta separates from inside to the outer margin, and it is delivered with fetal side presenting the first and most common method of placental perfusion. Presentation 1. Schultze “Shiny” side: fetal; separation: center 2. Duncan “Dirty” side: maternal; separation: edges Physical Examination To ensure the is no fragment Should have no indentation (Complete cotyledons: 15-20) Nursing Responsibilities 1. Placental delivery: 5 to 10 mins (max 20). 2. Evaluate Placental Completeness upto 30 coty, about 400-600g (1lb) and ⅙ of fetal weight. 3. Observe signs of placental separation (5 mins after birth) 4. Palpate uterus for ballooning 5. Vagina and Cervix are inspected for laceration & any needed repairs. Take BP for hypotension. Degree of Perineal Laceration 1st degree - limited to fourchette and superficial perineal skin.  2nd degree - beyond fourchette, perineal skin &vaginal mucosa to peri muscles & fascia, but not anal sphincter 3rd Stage - Torn up to anal sphincter 4th degree - Torn up to rectal mucosa 6. Give oxytocin as order (Stimulates contrxn = stop bleeding) 10-20 units IV or 10 u IM. Assess and record BP before and after administration of oxytocin and assess amt. Of bleeding, FOURTH STAGE 6 weeks after childbirth Mother’s reproductive organ returns to normal “prepregnancy state” Nursing Responsibilities 1. Place clean absorbent pad beneath her and apply maternity pads(1 saturated pad= 100 ml blood) 2. Apply cold pack over perineum 3. Palpate uterus q15 for the first 1-2 hrs. Monitor V/S q15 4. Inspect lochia 5. A heated bath b;anket/Warm drink 6. Encourage rest 7. Systemic medications.