3 Ultrasound Description Implementation Outlines and identifies fetal and maternal structures (uses high frequency sound-waves)Assists to confirm estimated date of deliveryImplementationPreviously, the test used to be done with a full bladder (drink 6-8 glasses of water pre-test), but with high-tech ultrasound, it is usually no longer necessarry.Inform the client that the test presents no known risks to client or fetus
6 DescriptionAspiration of amniotic fluid done from 14 weeks of pregnancy and onPerformed to determine genetic disorders (after AFP), the sex of the fetus, and fetal lung maturity (L/S ratio - this is later in pregnancy)RisksMaternal hemorrhageInfectionRh isoimmunizationAbruptio placentaeAmniotic fluid emboli
7 Implementation Instruct client to empty bladder before procedure Prepare client for ultrasound, which is performed to locate the placentaObtain baseline vital signs and FHR, and monitor every 15 minutesPosition client supineInstruct client that if chills, fever, leakage of fluid at the needle insertion site, decreased fetal movement, or uterine contractions occur, to notify the physician or health care provider
10 Chorionic Villus Sampling (CVS) DescriptionAspiration of a small sample of chorionic villus tissue at 8 to 12 weeks' gestationTest is performed for the purpose of detecting genetic abnormalitiesImplementationUsually, the client is instructed to drink water to fill the bladder before the procedure to aid in the position of the uterus for catheter insertionInstruct the client to report bleeding, infection, or leakage of fluid at insertion site after procedureRh-negative women may be given RhoGAM for risks related to the procedure
13 Endo-vaginal ultrasound used to locate area to insert catheter into uterus through the maternal abdomen for skin and blood samples:Percutaneous umbilical blood sampling (PUBS)Fetal blood is used to help diagnose conditions such as hemophilia, congenital rubella, toxoplasmosis, etc.
20 Non-stress test Description Performed to assess placental function and oxygenationDetermines fetal well-beingEvaluates fetal heart rate (FHR) in response to fetal movement
21 ImplementationExternal ultrasound transducer and the tocodynamometer (toco) are applied to the mother and a tracing of at least 20 minutes’ duration is obtained so that the FHR and the uterine activity can be observedObtain baseline blood pressure and monitor BP frequentlyPosition mother in the left lateral position to avoid vena cava compression (reality: SUPINE!!!!)Ask mother to press a button every time she feels fetal movementThe monitor records a mark at each point of fetal movement, which is used as a reference point to assess FHR response
22 Interpretation: Reactive Nonstress Test (Normal/Positive) Indicates a healthy fetusTwo or more fetal heart rate accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end in association with fetal movement, during a 20-minute periodNonreactive Nonstress Test (Abnormal/Negative)No accelerations or accelerations of less than 15 beats per minute or lasting less than 15 seconds in duration for a 40-minute observationUnsatisfactoryCannot be interpreted because of the poor quality of the FHR
25 Assesses placental oxygenation and function DescriptionAssesses placental oxygenation and functionDetermines fetal ability to tolerate labor and determines fetal well-beingFetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditionsPerformed if non-stress test is abnormal *** REALITY: VERY RARELY used anymore since it is so risky!
26 ImplementationThe external fetal monitor is applied to the mother and a 20 to 30-minute baseline strip is recordedThe uterus is stimulated to contract either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation (very rare!) until 3 palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achievedFrequent maternal BP readings are done and the client is monitored closely while increasing doses of oxytocin are given
27 Interpretation Negative Contraction Stress Test (Normal) Represented by no late or variable decelerations of the fetal heart ratePositive Contraction Stress Test (Abnormal)Represented by late or variable decelerations with 50% or more of the contractions in the absence of hyperstimulation of the uterusEquivocalContains decelerations, but with less than 50% of the contractions, or the uterine activity shows a hyperstimulated uterusUnsatisfactoryAdequate uterine contractions cannot be achieved, or the FHR tracing is not of sufficient quality for adequate interpretation
30 Fetal Biophysical Profile Overall, evaluates fetal statusAssesses 5 fetal variables:FHR with activity = reactive NSTAmniotic fluid volumeFetal tone (flexion and extension of extremities)Movements of body or limbsFetal breathing movements (oxygenation)
31 MATERNAL SERUM STUDIES MATERNAL SERUM STUDIES *** Some of these will be discussed in details throughout the courseTORCHALPHA-FETOPROTEIN (AFP)ESTRIOL LEVELHCGTRIPEL MARKER SCREENINGQUADRUPLE MARKER SCREEN
32 TORCHT= ToxoplasmosisO= Other (HIV, HIB, Variella, parovirus, syphillis, etc)R= RubellaC= Cytomegalovirus (CMV)H= Herpes Virus Type II
33 Alpha-Fetoprotein Screening (AFP) DescriptionAssesses the quantity of fetal serum proteins and if elevated is associated with open neural tube and abdominal wall defectsCan detect spina bifida (elevated) and Down’s syndrome (decreased)ImplementationExplain that the level is determined by a single maternal blood sample drawn at 15 to 18 weeks' gestationIf the level is elevated and the gestation is less than 18 weeks, a second sample is drawnAn ultrasound is performed when the level is elevated to rule out fetal abnormalities or multiple gestation
34 Estriol Level Primary estrogen secreted by the placenta Measurements are used to assess placental functioning and fetal viabilityNot a routine test28 weeks and Q week thereafterLow levels = fetoplacental deterioration
35 Triple-Marker Screening Includes:Human Chorionic Gonadotropin (HCG)Unconjugated estriolMSAFP (Maternal Serum AFP)Screen for chromosomal abnormalitiesIncreases detection of Trisomy 18 (Edward’s syndrome) and Trisomy 21 (Down’s syndrome)Test is positive if:Decreased Estriol and MSAFPIncreased HCGAmniocentesis is offered if positive
36 Now, also a Quadruple screen Fairly new!Combines the triple screen and a test for the hormone inhibin A, which is produced by the fetus and the placentaOne large study of over 23,000 women has reported that the quadruple screen detects almost 86% of all Down syndrome cases. Based on this study, the quadruple test is more likely to pick up Down syndrome and may be less likely to be false-positive than the triple screen
37 Summary findings:AFP: Increased = Neural Tube Deformity Decreased = Down’s syndromeHcG: Increased = Down’s syndromeEstriol: Decreased = Down’s syndromeInhibin A: Increased = Down’s syndromeAll findings, including type and amount of elevated or decreased levels, are evaluated to determine the risk for potential outcomes.
38 Other tests…… Kick Test (Fetal Movement Counting) Description Mother lies down on the left side for 1 hour after meals and counts fetal kicks for 30 minutesInstruct client to notify physician or health care provider if there are fewer than 5 kicks in 1 hour