SCREENING OF High-risk pregnancy
risk pregnancy is defined as one which is complicated by factor or factors that adversely affects the pregnancy outcome- maternal or perinatal or both.
Mother ,fetus,or newborn increased risk of morbidity or mortality during,or after delivery
disorders can impose a higher toll on the mother and/or fetus:
cause of maternal death
Hemorrhage Infection Ectopic pregnancy
Risk factors related to specific pregnancy problems
age below 16 or over 35 years Low socioecomonic status Maternal weight below 50Kg Poor nutrition Previous preterm birth Incomplete cervix Uterine anomalies Smoking Drug addiction and alcohol abuse Pyelonephritis, pneumonia Multiple gestation Anemia Abnormal fetal presentation Preterm rupture of membranes Placental abnormalities infection
Risk factors related to specific pregnancy problems
Diabetes mellitus Mutiple gestation Fetal congenital abnormalities Isoimmunization(Rh or ABO) Nonimmune hydrops Abnormal fetal presentation
Renal agenesis Prolonged rupture of membranes
restriction Intrauterine fetal
evaluation and counseling of women of reproductive age Issues of potential consequence to a pregnancy such as medical problems, lifestyle, or genetic issues should be investigated and interventions devised prior to pregnancy.
Maternal assessment for potential fetal or perinatal risk
oMaternal age oModality of conception oEthic background oPast obstetric history
Past obstetric history
Habitual abortion oKaryotype of abortus Previous preterm delivery birth of a IUGR or macrosomic baby Rh isoimmunization or ABO incompatibility Previous preeclampsia-eclampsia Previous infant with genetic disorder or congenital aomaly Teratogen exposure
oCervical and uterine anomalies oConnective tissue disease
oAcquired and inherited thrombophilias
oInfectious disease of the genital
tract Previous stillbirth or neonatal death
oInfectious agents oradiation
stage abnormalities(PPH)- this has a particular tendency to recur
Past medical history
Chronic hypertension Renal disease Diabetes mellitus Heart disease Previous endocrine ablation (eg.thyroidectomy) Maternal cancer pulmonary disease (eg.tuberculosis, sarciodosis, asthma)
Gastrointestinal and liver disease
(Viral hepatitis) Epilepsy
Blood disorders (eg,anemia,
coagulopathy) Psychiatric illness Pre-eclampsia Infections in pregnancy (malaria, HIV)
Sickle cell trait and disease
Substance use or abuse Thyroid disorders
of complete perineal tear Repair of vesico- vaginal fistula Repair of stress incontinence Previous Caesarian section or hysterectomy
status- patients belonging to low socio- economic status have a higher incidence of anaemia, preterm labour, growth retarded babies. Family history of diabetes, hypertension or multiple pregnancy and congenital malformation.
During pregnancy Elderly primi (≥ 30 years) Short statured primi (≤ 140 cm) Threatened abortion and APH Malpresentations Pre-eclampsia and eclampsia Anaemia Elderly grand multiparas Twins and hydroamnios Previous still birth, IUD, manual removal of placenta Prolonged pregnancy History of previous Caesarean section and instrumental delivery Pregnancy associated with medical diseases.
labour Hand, feet or cord prolapsed Placenta retained more than half an hour PPH Puerperal fever and sepsis
o Fever(>100.4℉,even >)
o Urinary ,pulmonary ,hematological
sources; chorioamnionitis o Preterm labor;adverse effect on fetus and mother o Amniocentesis for microscopy and culture o Antipyretics, antibiotics
oTachycardia(>100bpm) oInfection, anemia, heart disease,et. oMild:follow-up; Severe: ECG , hemogram
Blood pressue C
o >140/90mmHg ↑>30/15mmHg oPIH, chronic hypertention,
o Protein, glucose, leukocyte,blood, ketonuria o anbiotics
Blood test Haemoglobin Blood type and Rh grouping with antibody screening Rubella titres Syphillis screen Hepetitis B screen HIVscreen Pap Smear Gonorrhea and Chlamydia culture Test for toxoplasmosis and antiphospholipid antibodies Post prandial blood glucose and glucose tolerance test
physical examination Height: Below 150 cm particularly, Below 145 cm in our country. Weight: Overweight or underweight, Body Mass Index (BMI): Weight/( height)2 BMI: 20- 24 is accepted as normal
Pelvic Examination Uterine size and fundal heightdisproportionately smaller or bigger Abdominal girth Genital prolapse Lacerations or dilatations of the cervix Associated tumors Pelvic inadequacy
Maternal Serum Alpha Fetoprotein
is a fetal protein- yolk sac and fetal liver in fetal serum & amniotic fluid by 6 weeks
is in 13 weeks and then decreases tube does not close it escapes
sample in 15-18 weeks
0.5 to 2.5 MoM - normal range
screen, the Kettering test or the Bart's test multiple-marker screening test MSAFP, hCG, UE3
100-200 IU between 60-70
to 10 -20 IU in 100-130 days constant
at 32 week onwards
at 9 weeks (0.09 ng/ml)
ng/ml at term
nad UE3 is low
is high 15-18 weeks
esterase (AChE)elevated in neural tube defects.
A- produced by corpus luteum and placenta. It is raised in down syndrome.
Assessment of fetal wellbeing
Fetal movement count
Cardif ‘count 10’ formula
Mother counts the fetal movements from 9 am Stops as soon as 10 movements are perceived Report if:
– <10 movement in 12 hrs on 2 successive days
– No movements even after 12 hrs in a single day
Daily fetal movement count
counts of 1 hour duration
counts multiplied by 4 gives
than 10 in 12 hrs or less than 3 in
one hour denotes fetal compromise
of pregnancy of gestational age, presentation
of multiple pregnancy, ectopic of IUFD, anomaly
of abruptio placenta, molar
pregnancy, uterine malformations,
of liquor amnii
Amniocentesis CVS Cordocentesis Fetoscopy Intrauterine
fetal numbers, pesentation,fetal viability, placental location, gestational age
Limited: for suspected problem
fetal anomalies , growth, physiologic complication
Explain Ensure Supine Gel
full bladder position and drape
is applied to improve the contact is applied to the abdomen and moved
vertically and horizontally until the whole uterus
and contents are scanned
down on a table with knees bent Place transducer, into the vagina The probe is covered with a condom and a gel. The probe sends out sound waves, which reflect off body structures. A computer receives these waves and uses them to create a picture. See the picture on a nearby TV monitor.
Transvaginal ultrasound may be done for the following problems:
Abnormal findings on a physical exam, such as cysts, fibroid tumors, or other growths Abnormal vaginal bleeding and menstrual problems Ectopic pregnancy Pelvic pain
Transvaginal ultrasound is also used during pregnancy to: Evaluate cases of threatened miscarriage Listen to the unborn baby's heartbeat Look at the placenta Look for the cause of bleeding Monitor the growth of the embryo or fetus early in the prgnancy See if the cervix is changing or opening up when labor is starting early
inspection of amniotic fluid
throught he cervix and membranes with
main use is to detect meconium
risk of membrane rupture
Amniotic fluid assessment
than 20 weeks: uterus dived
along linea nigra.
vertical diameter of the largest
pocket is measured.
is the sum of 2 measurements
20 weeks and more: divide into 4 quadrants Vertical diameter of the largest pocket of fluid in each quadrant is checked
4 values are added Between 28-40 weeks- average AFI is 15cm 20-24 cms indicate hydramnios 5-6 cm indicates oligohydramnios
a extremely narrow, hollow
tube inserted by amniocentesis technique
Intactness of spinal cord can be confirmed Biopsies of fetal tissue and fetal blood
Surgeries: inserting a polythene stunt to the fetal ventricles to relieve hydrocephalus
at 16th or 17th week
as for amniocentesis
anesthesia scalpel incision –fetoscope
Amnionitis Leakage Injury
to the fetus
Chorionic villus sampling
of prenatal diagnosis to
determine chromosomal or genetic
disorders in the fetus.
was tested for the first time by
Italian biologist Giuseppe Simoni in 1983
Abnormal first trimester screen results Increased nuchal translucency Family history of a chromosomal abnormality or other genetic disorder
Parents are known carriers for a genetic disorder
Previously, maternal age above 35 has been an
indication for CVS.
10 weeks to term
Few villi are collected from the chorionic
Ultrasonic guidance Long malleable polythene catheter Safe between 10-12 weeks Anti D immunoglobulin 50 mcg IM
Risk Risk Risk
of miscarriage in CVS in about 0.5 – 1
of infection and amniotic fluid leakage
of Limb Reduction Defects, specially if
carried out before 10th week of pregnancy
Amniocentesis is a procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections, in which a small amount of amniotic fluid, which contains fetal tissues, is extracted from the amnion or amniotic sac surrounding a
developing fetus, and the fetal DNA is
examined for genetic abnormalities.
months (14-16wks): sex- linked
disorders, karyotyping, inborn errors of
months: fetal maturity, degree
of fetal hemolysis, meconium staining
of liquor, amniography or fetography
half: induction of abortion repeated,
decompression of the uterus
half: decompression of uterus,
intrauterine fetal transfusion,
Empty bladder- dorsal position Ultrasonic guidance- local anesthetic a 18-20 gauze needle (4‖) is inserted through the mother's abdominal wall into the amniotic sac. puncture the sac & extract approximately 30 ml of amniotic fluid.
After the amniotic fluid is extracted, the fetal cells are separated from the sample.
The cells are grown in a culture medium, then fixed and stained.
months: 1/3rd of the way up the
uterus from symphysis pubis
months: suprapubic after lifting the
of 100 mcg of anti D
premature rupture of membranes,
premature labour, maternal
abortion, trauma, feto-maternal
analysis: trisomy 21,
analysis: cystic fibrosis, Tay –
cord blood sampling
25 gauze spinal needle 13 cm in length
Inserted through abdomen
Punctures the umbilical vein app. From 1-2 cm
from placental insertion
0.5-2 ml of fetal blood is collected
After 18 weeks of gestation
toxoplasmosis, viral infection
blood gas and acid base status
therapy: blood transfusion, drug
bleeding, cord hematoma formation,
infection, rupture of membranes
D immunoglobulin 100 mcg IM
Cardio Toco-graph/ Electronic Fetal Monitoring (EFM)
is an electronic fetal
monitor which records graphically the fetal heart activity (cardio) and uterine contractions (toco).Both can be recorded simultaneously and continuously.
High risk pregnancies
IOL and Augmentation of Labour. Reduced FM. Premature labour. APH/IPH
Abnormal FHR detected
Previous CS. Abdominal Trauma. Prolonged ROM. Meconium Liquor
Parts of tocograph
Fetal heart rate monitor
Ultrasound transducer— to monitor uterine
fetal heart rate and pattern
Toco transducer-- to monitor uterine activity
Calibration button—to monitor fetal
Display unit—displays fetal heart rate and
intensity of contractions
Belts—to secure the transducer Graph paper
are temporary normal
increases in FHR due to fetal movement or compression of the umbilical vein during contraction.
are the periodic decreases in FHR
resulting from pressure on the fetal
head during contraction.
Early deceleration follows the pattern of contractions, beginning when the contraction begins & ending when the contraction ends.
The waveform of FHR is inverse to the contraction wave form.
rate rarely falls below 100 BPM & returns quickly between 120-160 BPM.
It occurs late in labour. If they occur early in labour before the head has descended, it could be the result of cephalo pelvic disproportion.
Late decelerations are those that are delayed until 30-40 seconds after the onset of contraction and continue beyond the end of contraction.
It suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces during contractions.
lowest point of deceleration occurs
at the end of contraction instead of at the
Changing the woman’s position from supine to lateral may help in relieving the pressure on the aorta & vena cava & to supply more blood to the uterus.
occurs during unpredictable times during the contractions & indicates compression of the cord. Changing the woman’s position from supine to lateral or to a trendelenburg position may help in relieving the pressure on the cord. Administering oxygen to the mother is also helpful.
Baseline heart rate
the FHR pattern in the interval
between uterine contraction lasting
10 minutes or more
FHR <110 beats/minute
causes Heart block occiput posterior position serious fetal compromise.
means baaseline FHR>160 beats per minute Causes: Maternal fever dehydration drugs(beta sympatho mimetics)
Beat to beat variability
between one beat to another Classification
Absent variability=amplitude change undetectable
Minimal =<5BPM Moderate =6-25 BPM Marked =>25BPM
are abrupt increase in FHR above baseline, their onset to peak is <30 seconds. If the increase lasts for 2-10 minutes it is called prolonged acceleration
Types of cardiotocograph
External fetal monitoring Internal fetal monitoring
The external fetal monitoring has two tests
a. Non stress test (NST) b. Contraction stress Test (CST)
Non stress test (NST)
is also called fetal activity test (FAT).
non stress test is used to assess the integrity of the fetal central nervous system.
This test is based on the theory that an intact nervous system and responsive cardiovascular system results in transient acceleration of fetal heart rate in response to fetal activity
When the electronic fetal monitoring is done in
the antenatal period, in the absence of uterine activity ,it is called non stress test
When it is done in labour it is called intra partum fetal monitoring or contraction stress test
Advantage of NST:
to conduct the test
Explain the purpose and function of external electronic fetal monitoring to the women Turn on the monitor and press the test button . confirm the paper speed, switch on the back of the monitor is set i.e. 1cm /mts, 3cm/mts Record complete patient identification , information at the beginning of the strip. Record the date and time
perform Leopold maneuver to determine fetal position and the location of the fetal back Place monitor belts under the women’s back . position the women in semi fowler’s or lateral tilt position. The supine position is avoided to prevent the compression of maternal blood vessels supine hypertension
Connect ultra sound transducer and toco transducer to the fetal monitor. Apply gel to the transducers. Gel is needed to improve conduction
Confirm the presence of fetal heart tones with a feto scope
Place the ultra sound transducer on the maternal abdomen over the fetal back. Move the transducer until clear audible fetal heart tones are heard. Secure the ultra sound device in place with the belt
Place the toco transducer on the fundus of the uterus. since normal uterine contraction are dominant in fundal region Evaluate the tracing for baseline rate ; long term variability, acceleration and deceleration and uterine contraction frequency, duration and return to resting tonus between contraction
NST:- it is defined as two or more accelerations of fetal heart rate with amplitude at least 15beats /mts and duration of at least 15seconds during a 20mts period
NST:- this test result shows no acceleration or acceleration less than 15beats/mts or less than 15 seconds in duration for a 40 mts observation
Contraction stress test
test is also called oxytocin challenge test ( OCT ). This test is based on experimental evidence showing that utero placental blood flow decreases markedly or ceases during uterine contraction . Therefore uterine contraction cause a hypoxic stress that a normal healthy fetus can tolerate without difficulty.
A fetus with a chronic or acute problem will not be able to tolerate such a decrease in oxygen supply and will demonstrate this by late deceleration of fetal heart rate following the contraction
It is same as that of NST except start intravenous oxytocin administration using pump at 0.5-1 mu/mts . Double the rate every 15 to 20 mts until the mother gets 3 contraction lasting for 40 to 60 seconds with in
10 mts period. If late deceleration appears before this
duration , the administration of oxytocin must be interrupted.
Test requires 1 ½ to 2hrs
late decelerations with a minimum of three uterine contractions lasting 40 to 60 seconds within a10 minute period. This indicates fetal well being
CST Persistent and consistent late decelerations indicate a positive CST.
preterm labour Placenta previa Hydramnios Multifetal pregnancy Rupture of membrane Previous preterm labour Previous classical c.birth
preterm labour Placenta previa Hydramnios Multifetal pregnancy Rupture of membrane Previous preterm labour Previous classical c.birth
INTERNAL FETAL MONITORING
This technique provides an accurate appraisal of fetal wellbeing during labour. For this method, membranes must be ruptured and the cervix must be sufficiently dilated. A small electrode attached to the presenting part yields a continuous fetal heart rate monitoring. A solid or fluid filled catheter is introduced in to the uterine cavity to monitor uterine activity. This technique carries much complications, so it is clinically not so significant in Indian setup
Baseline fetal heart rate is the fetal heart rate between the uterine contraction. A rate more rapid than 160 beats per minute is termed as baseline tachycardia
The causes of baseline tachycardia are: Prematurirty Mild fetal hypoxia Maternal fever Parasympatholytic drugs(atropine) Beta –sympathomimetics(ritrodrine, isoxupirine) Amnionitis Maternal anemia Fetal infection Fetal cardiac problems
rate slower than 110 beats per minute is baseline bradicardia. causes are
hypoxia Maternal hypotension Prolonged cord compression Fetal congenital heart blocks
activity in the fetal heart results in minute variations in the length of each beat.
This causes the tracing to appear as a jagged rather than a smooth line.
The baseline rate should vary by at least 5 beats over a period of one minute.
of this variability may indicate fetal hypoxia
may also be noted for a short period after the administration of maternal pethidine, which depresses as the cardiac reflex centre in the fetal brain.
Period of ―fetal sleep "also causes a reduction in variability and commonly last for 20-30 minute even in advanced labour.
the physian Late deceleration: change the position Stop the oxytocin in case of hyper stimulation Oxygen administration start IV fluids Tachy cardia-maternal pyrexia: antipyretics
1. Vibroacoustic stimulation o burst of sound to stimulate fetus o when NST is nonreactive
C Ancillary tests
2.fetal scalp stimulation o stimulate fetal vertex
Fetal Maturity Tests
Indications for assessing fetal lung maturity:
according following criteria: oLecithin:Sphingomyelin Ratio(L/S) oPhosphatidylglycerol(PG) oFoam Stability Index(FSI) risk of respiratory distress syndrome
Intrapartum Fetal Surveillance
electronic fetal monitoring and intermittent palpation and auscultation
scalp stimulation Ancillary tests
A:fetal scalp blood sampling
o PH- 7.25 to 7.35. o Serious fetal distress;low Apgar scores
B:Fetal lactate levels
A higher value Marker of neurologic disability D: Cord blood gases and pH C: Foetal oxygen saturation monitor: 30-70%
Aim at: Recognize the risk beginning as early as possible. Just by: Preconceptual counseling. Early and frequent prenatal care And try to: Optimize outcome both of fetus and mother Maximize therapeutic treatment
Dutta DC, Text Book of Obstetric, 6th edi. New Central Company,Calcutta, 2004. Pillitteri A. Maternal and Child Health Nursing .4th ed 2010. Perry L. Maternity and Women’s Health Care.9th edi. Mosby publications 2009. Boback J. Maternity and Gynecological Care, the nurse and the family.4th ed. Mosby company publication. USA.1989. Jenson.D.M., Benson.C.R, Bobak.M.I. Maternity care of nurse and family, First edition, St LouiseC.V. MosbyCompany, 1977 Elizabeth.M. Midwifery for Nurses, First edition , New Delhi: CBI Publishers, 2010. Cooper.A.M, Diane.M.F, Myles textbook for Nidwifes, 14th edi, Churchill livingstone Edinburgh 2003 American college of obstetricians and gynacologists; Ante partum fetal surveillance. ACOG practice Bulletin no 9, 1999
Any doubts ???..........