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Methods in Assessing the Fetal Well-Being A. FETAL MOVEMENT (Kick counts)  Quickening – begins at 18 – 20 wks. AOG; peaks at 28 – 38 wks. AOG  Average fetal movement = 10 – 12x/ day  Decreased fetal movement = placental insufficiency  SANDOVSKY METHOD  Counting...

Methods in Assessing the Fetal Well-Being A. FETAL MOVEMENT (Kick counts)  Quickening – begins at 18 – 20 wks. AOG; peaks at 28 – 38 wks. AOG  Average fetal movement = 10 – 12x/ day  Decreased fetal movement = placental insufficiency  SANDOVSKY METHOD  Counting & recording the number of fetal movements in an hour after meal (mother in left recumbent position)  Normal: 2x/ 10 min. or 10 – 12x/ hr.  Needs Referral: 10 fetal movements in 2 hours 1   CARDIFF METHOD (Count-to-Ten)  Recording the time interval it takes for the pregnant woman to feel the fetal movement.  Normal: 10 fetal movements/ hr. B. FETAL HEART RATE  As early as the 10th – 11th wk. AOG by Doppler  Normal: 120 – 160 beats/ min. 1) RHYTHM STRIP TESTING  Determine the presence of good baseline rate, long & short term variability by the use of external fetal heart rate & uterine contraction monitors for 20 min.  Position: SEMI – FOWLERS  SHORT-TERM VARIABILITY – small changes in FHB from second to second  LONG-TERM VARIABILITY – differences in FHR that occur over 20 min. period. 2 3 2) NONSTRESS TESTING  Response of FHR to fetal movement in which the FHR and Uterine Contraction Monitors are attached.  Position: SEMI-FOWLERS/ LEFT LATERAL  Normal : REACTIVE NONSTRESS TEST 2 – 4 FHR accelerations in 10 min.  Abnormal: NON-REACTIVE NONSTRESS TEST No accelerations with the fetal movements 3) VIBROACOUSTIC STIMULATION  Test used to stimulate fetal movement by the use of acoustic stimulator especially if a spontaneous acceleration has not occurred within 20 min. during NONSTRESS TEST. 4 4) CONTRACTION STRESS TESTING  Assessing FHR response to uterine contractions  Purpose: to assess the fetal ability to tolerate the stress of labor.  Position: LEFT LATERAL/ SEMI-FOWLERS  Normal result: NEGATIVE > No late FHR decelerations present by 3 contractions in 10 min. period  Abnormal: POSITIVE > presence of late FHR decelerations by 50% or more of uterine contractions.  Contraindication:  Placenta previa  Multifetal pregnancy  Incompetent cervix  Rupture of membranes 5 C. ULTRASONOGRAPHY  Purposes: 1. To diagnose pregnancy as early a s 6 wks. 2. To confirm the size, presence, & location of placenta & amniotic fluid 3. To establish that a fetus is growing and has no gross anomalies. 4. To establish sex of the fetus. 5. To establish the presentation and position of the fetus. 6. To predict the maturity of the fetus. 7. To discover complications of pregnancy 6 Preparation for Ultrasound 1. Explain the procedure 2. Encourage to have a full bladder at the time of procedure (drink a full glass of water every 15 min. beginning 90 min. before the procedure) 3. Position patient in supine 4. Place a rolled towel or blanket under the right buttock (prevent supine hypotension syndrome). 5. The gel must be at room temp. or slightly warm before applying on the abdomen 7 C.1. BIPARIETAL DIAMETER  8.5 cm. = 40 wks. Of fetal age C.2. DOPPLER UMBILICAL VELOCIMETRY  Measures the velocity at which RBCs in the uterine and fetal vessels and traveling.  velocity = poor neonatal outcome C.3. PLACENTAL GRADING  Grade 0 = 12 – 24 wks. AOG  Grade 1 = 30 – 32 wks.  Grade 2 = 36 wks.  Grade 3 = 38 wks. 8 C.4. AMNIOTIC FLUID VOLUME ASSESSMENT  The sum of the largest pocket measurements of amniotic fluid.  Average fluid index = 12 – 15 cm bet. 28 – 40 wks.  Abnormal Finding:  Hydramnios = > 20-24 cm fluid index  Oligohydramnios = < 5 – 6 cm fluid index 9 D. MATERNAL SERUM ALPHA-FETOPROTEIN  Alpha-fetoprotein (AFP)  A substance produced by the fetal liver that is present in amniotic fluid and maternal serum.  MSAFP = spina bifida  An AFP multiple of the median (MoM) or =2.5 (singleton and twin pregnancies) are reported as screen positive.  MSAFP = down syndrome E. TRIPLE SCREENING  An analysis of 3 indicators: 1) MSAFP 2) Unconjugated estriol 3) hCG 10 F. CHORIONIC VILLI SAMPLING  A biopsy & chromosomal or DNA analysis of chorionic villi done at 10 – 12 wks. AOG  An invasive procedure, Ultasonography is used to direct the procedure.  COMPLICATIONS: 1) Infection 2) Bleeding 3) Threatened miscarriage 11 Chorionic Villi Sampling 12 G. AMNIOCENTESIS  An invasive procedure that involves withdrawal of amniotic fluid through the abdominal wall at 14th – 16th wk. of pregnancy.  Women with Rh – blood type need Rh immune globulin adm. after the procedure to protect fetus from isoimmunization  Ultrasonography is used to direct the procedure  PURPOSE:  To evaluate fetal status (maturity, congenital anomalies) 13 Amniocentesis 14  INDICATIONS: 1. Maternal age of 35 yrs. or older 2. Previous child with chromosomal abnormalities 3. Parent with chromosomal abnormalities 4. Familial history of neural tube defects 5. Fetal abnormalities per ultrasound 6. Assessment of fetal pulmonary maturity 7. Evaluate alpha-fetal protein (AFP) 8. Diagnosis of fetal hemolytic disease 15 COLOR OF AMNIOTIC FLUID:  NORMAL: clear, slightly yellow tinge during late pregnancy  ABNORMAL: strong yellow (blood incompatibility) green color (meconium staining) 16  Amniocentesis can provide the following informations: 1. L/S (Lecithin/sphingomyelin ratio)  These are the protein components of the lung enzyme surfactant that the alveoli begin to form at about 22nd – 24th wks. Pregnancy  Surfactant  A substance composed of lipoprotein that is secreted by the alveolar cells of the lung and serves to maintain the stability of pulmonary tissue by reducing the surface tension of fluids that coat the lung.  NORMAL: 2:1 (fetal lung maturity) 2. Phosphatidyl Glycerol (PG)  Precursor of surfactant; presence in amniotic fluid of the NB indicates lung maturity.  Helps confirm fetal maturity 17 3. Bilirubin level  Indicates blood incompatibility or the degree of destruction of fetal RBCs in an RH sensitized woman.  1 – 4 mg/100 ml  If elevated:  Reflects release of bilirubin as excessive RBC begin their breakdown  Bilirubin:  A byproduct of RBC breakdown 4. Creatinine  Level of < 1.8 mg/dl demonstrates maturing kidney function of fetus 5. Alpha-Fetoprotein indicates NEURAL TUBE DEFECT indicates DOWN’S SYNDROME 18 6. Chromosome analysis  Skin cells in the amniotic fluid may be cultured and stained for karyotyping. 7. Fetal Fibronectin  A glycoprotein that helps placenta attach to the uterine decidua.  Found abundantly in the amniotic fluid  Can be found in the woman’s cervical mucus early in pregnancy (fades after 20 wks. AOG)  Detection of this in the amniotic fluid or in the mother’s vagina indicates that preterm labor may begin 19 8. Inborn Errors of Metabolism  Examples:  Cystinosis = characterized by cystinuria (characterized by stone formation in the urinary tract)  Maple syrup urine disease (amino acid disorders) = characterized by :  Vomiting  Hypertonicity  Severe mental retardation  Seizures  Phenylketonuria  Enzyme deficiency resulting in accumulation of phenylalanine (an essential amino acid) & its metabolites in the blood causing severe mental retardation. 20 THERAPEUTIC NURSING MANAGEMENT 1. Assist with procedure, monitor for sterility 2. Determine whether the client is to empty her bladder prior to procedure (empty the bladder to prevent inadvertent puncture) 3. Position client in left lateral 4. Provide emotional support 5. Refer client for genetic counseling when indicated 6. Women who are Rh negative receive Rho (D) immune globulin (RhIG; RhoGAM) after the procedure to prevent fetal isoimmunization (development of antibodies in response to antigen from another individual of the same specie) 21 7. Secure an informed consent form, including a clear explanation of risks of the procedure before the procedure is done 8. Use universal precautions during the procedure. COMPLICATIONS: 1. Needle puncture of the fetus 2. Bleeding 3. Loss of amniotic fluid 4. Infection 5. Premature labor 6. Spontaneous abortion 7. Fetal distress 22 H. Percutaneous Umbilical Blood Sampling (PUBS/ Cordocentesis or Funicentesis)  Removal of blood from the fetal umbilical cord (vein) at about 17 wks.  Blood studies: 1) CBC 2) Direct Coomb’s test (agglutination test used to detect proteins esp. antibodies on the surface of RBC. 3) Blood gases 4) Karyotyping (chromosomal characteristics) 23 I. Amnioscopy  Visual inspection of the amniotic fluid through the cervix and membranes with an amnioscope.  PURPOSE:  To detect meconium staining  COMPLICATION:  Rupture of membrane 24 J. FETOSCOPY  Visual inspection of the fetus through a fetoscope that is inserted by amniocentesis technique in assessing fetal well-being.  PURPOSES: 1) To confirm intactness of the spinal column 2) Obtain biopsy sample of fetal tissue and fetal blood samples 3) Perform elemental surgery, such as: 1) inserting polyethylene shunt into the fetal ventricles to relieve hydrocephalus, or 2) into the bladder to relieve stenosed urethra  COMPLICATION: 1) Premature labor 2) Amnionitis 25 K. BIOPHYSICAL PROFILE  5 parameters: 1) Fetal heart reactivity  2 or more accelerations of at least 15 bpm for 15 sec. over a period of 20 min. 2) Fetal breathing movements  1 episode of 30 sec. of sustained fetal breathing movement within 30 min. of observation. 3) Fetal body movements  3 separate episodes of fetal limb or trunk movements within 30 min. 4) Fetal tone  Fetus extends then flexes extremities or spine of at least once in 30 min. 5) Amniotic volume  Pocket of amniotic fluid measuring 1 cm in vertical diameter. 26 K. BIOPHYSICAL PROFILE Score: 8 – 10 fetus is doing well; healthy fetus 6 - suspicious; requires determination of the need for immediate delivery of the fetus, considering maturity of the fetal lungs. 4 - fetus in jeopardy 27