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Flashcards in Pregnancy Deck (22):
1

The Apgar Scoring System

Evaluation of the general condition of a newborn is done by adding the numerical values for each of the five different physiologic parameters (see table below)

Range of the Apgar score: from 0 to 10
[A score is given for each sign at one minute and five minutes after birth
(If there are problems with the baby, an additional score is given at 10 minutes)]

Apgar scoring totals and interventions total score
8 - 10 =normal
5 - 7 =mild depression
(the neonate may require some stimulation, i.e., gently but firmly
slapping the soles of the feet or rubbing the spine or the back oxygen may be necessary)
3 - 4 =moderate depression (the baby will need oxygen
the baby may need insertion of a feeding tube to decompress the stomach)
0 - 2 =severe depression, (requiring immediate life support)
Physiological Parameter

Activity (Muscle Tone)
extend elbows, thigh, knees and baby flexes promptly
extension yields slower responses; some flexion
flaccid

Pulse
above 100
slow; below 100
absent

Grimace (Reflex Irritability)
stimulate and baby cries vigorously and moves
weak cry and/or weak movement
no response

Appearance (Skin Color)
completely pink
acrocyanosis (pink body, blue extremities)
pale or cyanotic (blue)

Respiration
vigorous crying or regular breathing
irregular, shallow, or gasping
Absent

2

First Trimester Assessments:

Chorionic villi sampling (CVS)
Basic ultrasound screening

3

Basic ultrasound screening

Performed transvaginally (a lubricated transducer probe is placed in the vagina) or abdominally (after application of a transmission gel) depending on gestation

Can be performed in the outpatient or inpatient setting in all three trimesters

A full bladder enhances visualization when abdominal ultrasound is performed

Confirms
viability
age of the pregnancy

Determines
the number of gestational sacs the size of the gestational sac
location of gestational sac

Identifies uterine abnormalities
rule out an ectopic pregnancy
locate the presence of an intrauterine contraceptive device

Indicates fetal presentation
Measurements can be taken to confirm/estimate gestational age Identifies morphologic anomalies

4

Chorionic villi sampling (CVS)

Typically performed between 10 and 12 weeks gestation Used to obtain a fetal karyotype
Involves obtaining a sample of chorionic villi from the placenta via a syringe/needle
Allows a woman earlier/safer timing for pregnancy termination as results are obtained quickly

5

Second Trimester Assessments

Quad marker screening
Amniocentesis
Ultrasonography

6

Quad marker screening

(also called maternal serum expanded alpha-fetoprotein [AFP] screening)

A screening test performed at 16 weeks gestation to assess risk for chromosomal anomalies and neural tube defects

Maternal blood sample is drawn and sent out for analysis
Measure blood serum levels of: maternal serum alpha fetoprotein (MSAFP), human chorionic gonadotropin (HcG), unconjugated estriol (UE), and inhibin A.

MSAFP = a protein produced by the baby's liver
HcG = a hormone produced by the placenta
UE = a protein produced in both the placenta and the baby's liver
inhibin A = a hormone produced in the placenta

Does not indicate absolutely that abnormalities are detected, only the further investigation is recommended

7

Amniocentesis

May be performed as early as 12 weeks gestation
A procedure performed to obtain a sample of amniotic fluid for direct analysis of fetal chromosomes, development, viability and lung maturity

Performed under ultrasound guidance

Rh negative mother must receive RhoGAM® immediately after the procedure to prevent isoimmunization

Risks include:
amnionitis spontaneous abortion
preterm labor/delivery
premature rupture of membranes

Recommended for women 35 years of age or older and any pregnant woman with an abnormal quad marker screening

Frequently performed late in pregnancy to provide information about fetal lung maturity

lecithin and sphingomyelin are protein components of surfactant, a lung enzyme that is formed by the the alveoli beginning around the 22nd week

evaluation of amniotic fluid for lecithin/sphingomyelin (L/S) ratio is used to determine fetal lung maturity
a ratio of 2:1 (which typically occurs by 35 weeks gestation) is traditionally accepted as lung maturity

8

Third Trimester Assessments:

"Kick counts" (or counting fetal movements)
Non-stress test (NST)
Biophysical profile (BPP)
Percutaneous umbilical blood sampling
Contraction stress test (CST) - also called oxytocin challenge test (OCT)
Ultrasonography
Amniocentesis

9

"Kick counts" (or counting fetal movements)

Many variations have been developed, but there are two major methods

Method 1:
the woman lies on her side
she counts and records 10 distinct movements in a period of up to 2 hours
once 10 movements have been perceived, the count can be discontinued

Method 2:
the woman counts and records fetal movements for 1 hour, three times a week
the count should equal or exceed the woman's previously established baseline

An active fetus reflects adequate oxygenation by the uteroplacental unit

If fetus is quiet, mother is encouraged to drink some juice, lie down on her left side and repeat the count of movements

If at least three movements are not noted within an hour's time, the mother is encouraged to call her physician immediately

10

Non-stress test (NST)

The fetus should be at least 32-34 weeks in order for the test results to be accurate

The electronic fetal monitor is placed on the maternal abdomen for 20-30 minutes

Records fetal heart rate (FHR) fluctuations continuously

The mother is given a button to press each time she feels the baby move

Each time the fetus moves, FHR should accelerate 15 beats/min above the baseline for 15 seconds

A reactive (good) outcome is one in which two or more such accelerations in FHR occur with associated fetal movement

Women with risk factors, e.g., diabetes, undergo frequent testing, often twice weekly

11

Biophysical profile (BPP)

A comprehensive fetal assessment of five variables:

fetal breathing movement
fetal movement of the body or limbs
fetal tone (extension or flexion of the limbs)
amniotic fluid volume index (AFI) visualized as pockets of fluid around the fetus
reactive non-stress test

First four components observed and measured under ultrasound; the non- stress test on an external fetal monitor

Allows for identification of a compromised fetus
a score of 0-2 points is awarded for each of the five components of the test
a score of 8-10 points with normal fluid volume is the desired result; less than that indicates need for intervention

12

Percutaneous umbilical blood sampling

An ultrasound-guided procedure used to obtain a sample of fetal blood drawn from the fetal umbilical cord

A needle is introduced through the maternal abdomen, much like amniocentesis, but is then introduced into the fetal umbilical cord

Risks and treatment same as for amniocentesis

Fetal blood sample provides information about chromosomal anomalies, fetal karyotyping, and blood disorders

13

Contraction stress test (CST)

also called oxytocin challenge test (OCT)

Evaluates the oxygen and carbon dioxide exchange within the fetoplacental unit

Allows for identification of the fetus at risk for intrauterine asphyxiation

Contraindications include: placenta abruption, placenta previa, undiagnosed third trimester bleeding, previous cesarean delivery, premature rupture of membranes (PROM), incompetent cervix, and/or multiple gestation

Procedure
performed in a labor and deliver unit under electronic fetal monitoring mother should have IV access and OR team available

to initiate contractions, IV oxytocin is administered or the client is instructed in nipple stimulation procedure
the desired result is a "negative" test which consists of three contractions of moderate intensity in a 10 minute period without evidence of late decelerations

a positive result = repetitive, persistent late decelerations with >50% of the contractions; an equivocal result = nonpersistent late decelerations
treatment of a positive CST is expeditious delivery, via cesarean section

14

Postpartum Assessment

Postpartum care begins immediately after childbirth.
Maternal Postpartum Assessment: BUBBLE-HE

Letter Assessment includes
B
Breasts
Inspection of nipples - everted, flat, inverted?
Breast tissue - soft, filling, firm?
Temperature and color - warm, pink, cool, red streaked
U
Uterus
Location - midline or deviated to either the right or the left side? Tone - firm, firm with massage or boggy?
B
Bladder
Last time the client emptied her bladder - spontaneous or via catheter?
Palpable or nonpalpable?
Color, odor, and amount of urine?
B
Bowels
Date and time of the last bowel movement? Presence of flatus and hunger?
Note: unless the colon was manipulated, there is no need to auscultate for bowel sounds
L
Lochia
Color, amount, presence of clots? Free flow of lochia?
E(I)
Episiotomy(Incision)
Type and other tissue trauma (lacerations, etc.)?
Assess using REEDA (R=redness, E=edema, E-ecchymosis, D=discharge, A=approximation)
L/H
Legs (Homans' sign)
Pain, varicosities, warmth or discoloration in calves? Presence of pedal pulses?
Sensation and movement (after cesarean birth)

E
Emotions
Affect
Client-family interaction Effects of exhaustion
(B)
Bonding
Interaction with infant, e.g., "taking in" phase, with presence of finger tipping, gazing, enfolding, calling infant by name, identifying unique characteristics

*Homans' sign (sometimes spelled as Homans sign) or the dorsiflexion sign is considered a sign of deep vein thrombosis (DVT)

* episiotomy is an incision made in the perineum — the tissue between the vaginal opening and the anus — during childbirth

*lochia is the vaginal discharge after giving birth (puerperium) containing blood, mucus, and uterine tissue

15

Postpartum assessments that would require notifying the health care provider:

Maternal
Temperature greater than 100.4 F (38 C) Increased lochia, clots or foul odor Perineal pain or swelling
Calf tenderness
Appetite loss
Sleep disturbances
Continued mood swings or depression
Elimination problems (burning, frequency or urgency of urination, or persistent constipation)

Newborn
Temperature greater than 100.4 F (38 C) Poor feeding effort
Vomiting or diarrhea
Inconsolable crying
Inability to arouse; exceedingly sleepy Yellowing of the skin
No wet diaper in eight hours

16

Fetal heart rate (FHR)

Baseline heart rate = 120 - 160 bpm (for full term fetus) Bradycardia = less than 120 bpm
Tachycardia = more than 160 bpm
During contractions:
FHR may increase or decrease by 30 bpm

FHR should return to the baseline immediately after end of contraction

*Changes in fetal heart rate may signal hypoxia, maternal infection or other factors - notify physician and/or certified nurse midwife

17

Fetal Monitoring
variable decelerations

an irregular pattern of fetal heart rate deceleration that occurs when a deep sudden drop in the fetal heart rate is noted that can often be eliminated by repositioning the client, at which time the FHR returns to its baseline pattern
caused by umbilical cord compression nursing interventions
position the woman onto her side or a different position apply oxygen
notify the physician and/or certified nurse midwife

18

Methods of fetal monitoring

Doppler - utilized for intermittent monitoring
fetal heart rate is located by Leopold's maneuvers monitored for 1 to 2 minutes for beat regularity and rate

External monitoring
Tocodynamometer (toco) attached via an elasticized strap to the woman's abdomen to assess uterine activity
External fetal monitor (EFM) attached via an elasticized strap to the woman's abdomen to ultrasonically monitor fetal heart rate patterns

Internal monitoring
Intrauterine pressure catheter (IUPC) inserted by the provider for a more accurate assessment of contraction strength and duration
Spiral electrode (SE) applied by the provider for a direct assessment of the fetal heart
requires rupture of membranes
client remains on bedrest during monitoring

19

Timing of FHR

Intermittent
For 30 minute periods
Continuous
When membranes rupture, to rule out fetal distress or prolapsed cord

20

Fetal Monitoring
late decelerations

a pattern of FHR deceleration when the FHR slows after the peak of a contraction and returns to the baseline well after the contraction has ended.
a cardinal sign of a stressed neonate and possible hypoxia indicates an inadequate feto-placental unit
interventions

immediately turn the woman onto her side
apply oxygen
discontinue oxytocin, if it is running
notify the physician and/or certified nurse midwife

21

Fetal Monitoring
early decelerations

FHR decelerations that mirror the contraction and return quickly to baseline by the end of the contraction
very common
caused by head compression
no intervention is needed; they are not a sign of distress

22

Monitor strip assessment for variability

Beat to beat rhythm fluctuations that indicate adequate acclimation to the internal environment

Variability is affected by medications or by hypoxia.

If the fetal heart rhythm does not vary with contractions
assist woman to change positions
notify physician and/or certified nurse midwife

Accelerations: heart rate increases during fetal movements and contractions
Decelerations: heart rate slows
early decelerations:
late decelerations:
variable decelerations:

*Labor contractions are the periodic tightening and relaxing of the uterine muscle, the largest muscle in a woman's body. Something triggers the pituitary gland to release a hormone called oxytocin that stimulates the uterine tightening.