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• Introduction
• Antepartum Testing
• Antepartum Fetal Risk
• Assessment
• Handouts

Pregnancy

Antepartum Care (Review "Common Problems of Pregnancy" in N814.  Prepared by Diane Hill ARNP-C, EdD, Associate Professor, School of Nursing)

• Danger signs during pregnancy
• Emotional Changes
• Psychosocial assessment
• Nutritional considerations (What is another weight gain recommendation?)

Recommendations for Weight Gain During Pregnancy

* Institute of Medicine (1990). Nutrition During Pregnancy, Washington, DC, National Academy Press

• Management of weight problems
• Nausea and vomiting
• Pica
• Constipation
• Hemorrhoids
• Leg cramps
• Backache
• Abdominal/pelvic pain
• 1st trimester danger signs
• 2nd trimester danger signs( Do you know how to do fetal kick counts?)
• 3rd trimester danger signs
• Skin changes
• Headaches
• Urinary problems
• Edema
• Vaginal discharge
• Infectious diseases
• Uterine size inconsistent with EDC.(What is SGA, LGA, IUGR)
• PIH
• Abruptio placentae
• postpartum problems
• Ectopic pregnancy
• Preterm labor
• Gestational diabetes
• Domestic violence
• Lactation Management
• Infection (Group B Streptococci)

Bibliography

Text:  Johnson, et al. 

Von Der Pool, B. A. (1998).  Preterm labor:  diagnosis and treatment.  American Family Physician. 57(10), pp 2457-2464.

Antepartum Testing

• Ultrasound
• Chorionic Villus Sampling
• Amniocentesis
• Fetal Movement Counts
• Biophysical Profile
• Non Stress Test
• Usual prenatal tests
  • Every visit:  vital signs, urine dipstick for glucose, albumin and ketones; weight; fundal height; FHR; fetal movement, Leopold's maneuvers for fetal lie and presentation
  • First trimester or beginning prenatal care:  CBC, UA, Type and Rh and antibody screen, screen for chlamydia, gc, syphilis, HBsAG, rubella, Pap smear,   group B streptococcus, bacterial vaginosis sickle cell screen. HIV.
  • 15-20 weeks:  Triple screen (maternal serum alpha fetoprotein, estriol, HCG)
  • 20-24 weeks:  Preterm birth prevention education.  This continues throughout pregnancy.
  • 24-28 weeks:  1 hr glucose measurement after 50 gm glucose load.
  • 28-36 weeks:  CBC at 28 weeks;  antibody screen at 28 weeks for Rh neg woman; RhoGAM, if indicated; parenting education; labor and delivery education
  • 36-40 weeks: 
  • 28-36 weeks; 

Antepartum Fetal Risk Assessment

Prior to 20 weeks gestation

Ultrasound

Sound is used to measure and identify structures.

Types

Transabdominal. Women must have a full bladder

Vaginal. Uses a small light-weight endovaginal transducer. Useful for assessment of early embryonic development, fetal heartbeat, and enhanced visualization of intrapelvic structures

Uses

Confirms pregnancy, confirms viability, rules out ectopic, determines gestational age (the earlier the ultrasound, the more accurate). Rule out pregnancy abnormalities such as molar pregnancy, fibroids, multiple gestation, bicornate uterus, assess for IUGR and monitor infant growth (symmetrical and asymmetrical), detect congenital anomalies.

Amniocentesis

Done at 16-18 weeks to sample fluid for cells to grow for chromosomal abnormality determination, biochemical determination (over 60 types can be detected).

Chronionic Villi Sampling

Performed either transabdominally or transvaginally. A small sample of villi are retrieved. Can be done at 8-14 weeks. Villi in the chorion frondosm are believed to reflect fetal chromosome, enzyme, and DNA content, thereby permitting early diagnosis of abnormalities. Quicker determination of anomalies is possible because the sample is direct fetal tissue. Risks include failure to obtain tissue, ROM, bleeding, infection, spontaneous AB, Rh isoimmunization (Rh neg women must get Rho Gam)

Second 20 weeks

Ultrasound

Used to date pregnancy (serial tests necessary because accuracy decreases with increasing pregnancy), monitor IUGR, determine fetal position, monitor bleeding (abruptio or previa), part of the Biophysical Profile, used for special procedures (fetoscopy, PUBS, external version)

Percutaneous Umbilical Blood Sampling (PUBS)

Can be used to draw fetal blood for sampling (hemoglobinopathies, coagulopathies, acid base determination, and intrauterine infection. Can be used for intrauterine transfusion. Infant is given O negative blood.

Risks include transient fetal bradycardia, bleeding, infection. A paralytic agent, such as pancuranium bromide (Pavulon) is usually used to control fetal movement.

Maternal Blood Assessment

Coombs test. Titer of 1:8 to 1:16 detects sensitizations and need for amniocentesis.

Amniocentesis

Lecithin/shpingomyelin ratio. Can be measures at 35 weeks.

Phostatidylglycerol. Present at 36 weeks.

Delta Optical Density. Examines bilirubinoid pigments in amniotic fluid. Used to determine gestational age and for indication and follow-up of fetal hemolytic disease.

Fetal fat cells. Over 10% indicates maturity.

Alpha-fetal protein (MSAFP) Elevated in NTD, abdominal wall defects, teratomas, fetal distress,

Congenital anomaly determination.

Non Stress Test (Rice and Simpson (1996), AWHONN Perinatal Nursing)

Indications: maternal diabetes, hypertension, IUGR, Sickle cell disease, maternal cyanotic heart disease, suspected postmaturity, history of previous stillbirth, Rh sensitization, meconium stained fluid at amniocenteses, 40 weeks or over.

Contraindications: none

Performed: Usually every 3-4 days

Results:

Reactive. Indicates fetal well being for 3-4 days. Criteria: ACOG Minimum of two fetal heart rate accelerations of 15 bpm above the baseline and lasting at least l1 seconds within a 20 minute time frame.

Based on the premise that a normal fetus moves at various intervals and that the cns and myocardium respond to movement with acceleration of the FHR. It is a sign of fetal well being.

Nonreactive. Does not meet criteria. Continue monitoring, due a biophysical profile and/or OCT.

Oxytocin Challenge Test (OCT)

Evaluates the FHR response to stress during. uterine contractions.

Run a baseline FHR for 20 minutes

If spontaneous uterine contractions do not occur, stimulate contractions via IV oxytocin or breast stimulation

Must have three contractions (40 seconds) in 10 minutes

Results:

Negative (Reassuring for 1 week) No late decelerations

Positive (Abnormal, fetus unable to tolerate decreased blood flow and decreased O2) Late decelerations following >50% of contractions. Need to deliver infant.

Suspicious Intermittent late or significant variable decelerations. Need other tests of fetal status such as BPP.

Biophysical Profile (BPP)

5 item test of fetal well being. Includes NST and ultrasound.

Parameters. fetal muscle tone, fetal movement, fetal breathing movements, amniotic fluid volume.

Each item is scored as either 2 (criteria met) or 0 (criteria not met). 8-10 indicates fetal well being. 0 - 4 suspected chronic asphyxia.

Placental grading for maturity

Doppler blood flow studies (Umbilical velocimetry.

Ultrasound noninvasive study of blood flow in maternal and fetal circulations to assess placental function. Can provide information about total blood flow in the umbilical vessels. Information assists in the management of multiple gestation, diabetes, prolonged pregnancy, IUGR, Sickle cell disease, twin-to-twin transfusion. Compliments NST, CST, BPP.

Fetoscopy

MRI

Fetal Kick Counts

Accoustic stimulation

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