1. Assessment of High Risk Pregnancy
Chapter 26
Assessment of
High Risk Pregnancy
Copyright © 2016 by Elsevier Inc. All rights reserved.

2. Learning Objectives
Explore biophysical, psychosocial, sociodemographic, and environmental influences on high-risk pregnancy.
Examine risk factors identified through history, physical examination, and diagnostic techniques.
Differentiate among screening and diagnostic techniques, including when they are used in pregnancy and for what purposes.

3. Learning Objectives (Cont.)
Discuss psychologic considerations for the woman and her family experiencing a high-risk pregnancy.
Develop a teaching plan to explain screening and diagnostic techniques and implications of findings to women and their families.

4. Assessment of Risk Factors
A comprehensive approach to high risk pregnancy is used now.
The factors associated with high risk childbearing are grouped into broad categories based on threats to health and pregnancy outcomes.

5. Assessment of Risk Factors (Cont.)
Biophysical
Originates with the mother or the fetus
May affect development and functioning of both
Genetic disorders, nutritional and general health status, and medical or obstetric-related illnesses

6. Assessment of Risk Factors (Cont.)
Psychosocial
Maternal behaviors and adverse lifestyles that have a negative effect on health of mother or fetus
May include emotional distress and disturbed interpersonal relationships
Inadequate social support
Unsafe cultural practices

7. Assessment of Risk Factors (Cont.)
Sociodemographic
Arise from mother and her family
Lack of prenatal care, low income, marital status, and ethnicity
Environmental
Hazards in workplace and woman’s general environment
May include chemicals, anesthetic gases, and radiation

8. Antepartum Testing: Biophysical Assessment
Daily fetal movement count (DFMC)
Used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation
Also called kick counts
Several different protocols are used for counting
A count of fewer than three kicks in 1 hour warrants further evaluation by a nonstress test (NST).
Fetal alarm signal

9. Antepartum Testing: Biophysical Assessment (Cont.)

10. Antepartum Testing: Biophysical Assessment (Cont.)
Ultrasonography
Levels of ultrasonography
Abdominal
Transvaginal
Indications for use
Fetal heart activity
Gestational age
Fetal growth
Fetal anatomy

11. Antepartum Testing: Biophysical Assessment (Cont.)
Ultrasonography (Cont.)
Indications for use
Fetal genetic disorders and physical anomalies
Placental position and function
Adjunct to other invasive tests
Fetal well-being
Doppler blood flow analysis
Amniotic fluid volume
Biophysical profile (BPP)
Modified biophysical profile

12. Antepartum Testing: Biophysical Assessment (Cont.)

13. Antepartum Testing: Biophysical Assessment (Cont.)
Ultrasonography (Cont.)
Nursing role
Nonmedical ultrasounds
3-D and 4-D increasingly popular with pregnant women and their families
American Institute of Ultrasound in Medicine (AIUM) and the American College of Obstetricians and Gynecologists (ACOG) have published statements that strongly discourage this practice
Exposure of the fetus to high-frequency sound waves without a clear medical indication
Performed by people who are not qualified health care professionals

14. Antepartum Testing: Biophysical Assessment (Cont.)

15. Antepartum Testing: Biophysical Assessment (Cont.)
Magnetic resonance imaging (MRI)
Noninvasive radiologic technique
Examiner can evaluate the following:
Fetal structure, overall growth
Placenta
Quantity of amniotic fluid
Maternal structures
Biochemical status of tissues and organs
Soft-tissue, metabolic, or functional anomalies

16. Antepartum Testing: Biochemical Assessment (Cont.)
Biochemical assessment involves biologic examination and chemical determinations
Procedures used to obtain the needed specimens include amniocentesis, percutaneous umbilical blood sampling, chorionic villus sampling, and maternal sampling
Amniocentesis: obtains amniotic fluid
Potential complications
Indications for use
Genetic concerns
Fetal maturity
Fetal hemolytic disease

17. Antepartum Testing: Biochemical Assessment (Cont.)

18. Antepartum Testing: Biochemical Assessment (Cont.)
Chorionic villus sampling (CVS)
Technique for genetic studies
Earlier diagnosis, rapid results
Performed between 10 and 13 weeks of gestation
Involves removal of small tissue specimen from fetal portion of placenta
Transcervically or transabdominally

19. Antepartum Testing: Biochemical Assessment (Cont.)

20. Antepartum Testing: Biochemical Assessment (Cont.)
Percutaneous umbilical blood sampling (PUBS) (also called cordocentesis)
Direct access to the fetal circulation during the second and third trimesters
Most widely used method for fetal blood sampling and transfusion
Insertion of needle directly into fetal umbilical vessel under ultrasound guidance

21. Antepartum Testing: Biochemical Assessment (Cont.)

22. Antepartum Testing: Biochemical Assessment (Cont.)
Maternal assays
Maternal serum alpha-fetoprotein (MSAFP)
Maternal serum levels used as screening tool for neural tube defects (NTDs) in pregnancy
Detects 80% to 85% of all open NTDs and open abdominal wall defects early in pregnancy
Screening recommended for all pregnant women
Triple- and quad-screening to detect autosomal trisomies

23. Antepartum Testing: Biochemical Assessment (Cont.)
Maternal assays (Cont.)
Multiple marker screens
Coombs’ test
Screening tool for Rh incompatibility
Detects other antibodies that may place fetus at risk for incompatibility with maternal antigens

24. Antepartum Testing: Biochemical Assessment (Cont.)
Maternal assays (Cont.)
Cell-free DNA screening in maternal blood
Noninvasive prenatal genetic testing
Provides definitive diagnosis noninvasively for fetal Rh status, fetal gender, and certain paternally transmitted single gene disorders
Performed as early as 10 weeks of gestation
Results are usually available in about 10 business days

25. Fetal Care Centers
Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as support services for families with a fetal anomaly diagnosis.
Access to support services such as genetic counseling, social work, chaplain services, a palliative care team, and ethics consultation because of the complex emotional stressors they face

26. Antepartum Assessment Using Electronic Fetal Monitoring
Indications
Does the intrauterine environment continue to support the fetus?
Nonstress test
Procedure
Interpretation: reactive or nonreactive
Vibroacoustic stimulation
Contraction stress test
Nipple-stimulated contraction test
Oxytocin-stimulated contraction test
Interpretation

27. Non-Stress Test (NST)
Non-stress test (NST)-is the most widely applied technique for antepartum evaluation of the fetus
Basis for the NST is that the normal fetus will produce characteristic heart rate (HR) patterns in response to fetal movement
FHR is recorded with a Doppler transducer, and a tocodynamometer is applied to detect uterine contractions or fetal movements

28. Vibroacoustic Stimulation (fetal acoustic stimulation
Another method of testing antepartum FHR response and is sometimes used in conjunction with the NST
Test takes approximately 15 minutes to complete, with the fetus monitored for 5 to 10 minutes before stimulation to obtain a baseline FHR
Fetal baseline pattern is nonreactive, the sound source is then activated for 3 seconds
Monitoring continues for 5 more minutes

29. Contraction Stress Test (CST)
provides an earlier warning of fetal compromise than the NST with fewer false-positive results
Monitored electronically with the fetal ultrasound transducer and uterine tocodynamometer
Tracing is observed 10 to 20 minutes for baseline rate, long-term variability, and the possible occurrence of spontaneous contractions
Two methods of CST

30. Nipple-Stimulating Contraction Test
Woman applies warm moist washcloths to both breast for several minutes
Woman massages one nipple for 10 minutes
Massaging the nipples causes a release of oxytocin from the posterior pituitary
Woman massages the nipple for 2 minutes, rest for 5 minutes, and repeats the cycle as necessary to achieve adequate uterine activity

31. Oxytocin-Stimulated Contraction Test
Exogenous oxytocin also can be used to stimulate uterine contractions
Given IV
30 units of Pitocin in 500 ml fluid
Method of oxytocin infusion is to begin at 0.5 mU/min double the dose every 20 minutes
Until three uterine contractions of lasting 40 to 60 seconds are observed within a 10-minute period

32. Antepartum Assessment Using Electronic Fetal Monitoring (Cont.)

33. Antepartum Assessment Using Electronic Fetal Monitoring (Cont.)

34. Antepartum Assessment Using Electronic Fetal Monitoring (Cont.)

35. Psychologic Considerations Related to High-Risk Pregnancy
Label of high risk often increases the patient’s sense of vulnerability
May exhibit anxiety, low self-esteem, guilt, frustration, and inability to function
May affect parental attachment, accomplishment of the tasks of pregnancy, and family adaptation to the pregnancy

36. Nursing Role in Antepartal Assessment for Risk
Provide education
Anticipatory planning
Counseling for family adaptation
Support person
In many settings nurses perform the following:
NSTs
CSTs
BPPs

37. Key Points
A high-risk pregnancy is one in which the life or well- being of the mother or infant is jeopardized by a biophysical or psychosocial disorder coincidental with or unique to pregnancy.
Biophysical, sociodemographic, psychosocial, and environmental factors place the pregnancy and fetus or neonate at risk.

38. Key Points (Cont.)
Biophysical assessment techniques include DFMCs, ultrasonography, and MRI.
Biochemical monitoring techniques include amniocentesis, PUBS, CVS, MSAFP, multiple marker screens, and cell-free DNA screening in maternal blood.

39. Key Points (Cont.)
Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as care coordination and other support services for families with a fetal anomaly diagnosis.
Reactive NSTs and negative CSTs suggest fetal well-being.

40. Key Points (Cont.)
Most assessment tests have some degree of risk for the mother and fetus and usually cause some anxiety for the woman and her family.
The nurse’s roles in assessment and management of the high-risk pregnancy are primarily those of educator and support person.

41. Question
A prenatal screening technique called nuchal translucency (NT) uses ultrasound measurement of fluid at the nape of the neck between 14 and 16 weeks to identify possible fetal abnormalities. An elevated NT of greater than 3 mm indicates an increased risk of which of the following?
Trisomy 13
Fetal cardiac disease
Trisomy 18
Trisomy 21
ANS: B
Feedback
A Incorrect: When combined with low maternal serum marker levels, elevated NT indicates a possible increased risk of certain chromosomal abnormalities in the fetus, including trisomy 13.
B Correct: An elevated NT alone indicates an increased risk for fetal cardiac disease.
C Incorrect: When combined with low maternal serum marker levels, elevated NT indicates a possible increased risk of certain chromosomal abnormalities in the fetus, including trisomy 18.
D Incorrect: When combined with low maternal serum marker levels, elevated NT indicates a possible increased risk of certain chromosomal abnormalities in the fetus, including trisomy 21.