Fetal Assessment

Presented by:Ann Hearn RNC, MSN

2010

Ultrasound

Definition -- an instrument which uses reflective sound waves as they travel in tissue to visualize structures in the body

Purposes of an Ultrasound

Placental location Assessment of gestational age Determining structural

abnormalities of the fetus Confirming an ectopic pregnancy or

hydatiform mole Determining multiple gestations

Ultrasound

It is a non-invasive and painless procedure

Results are immediate

Allows the mother and family to “see” the baby

Ultrasound -- Nursing Care

Make sure that the patient has a full bladder

Place patient on back with a towel roll under one hip -- allowing better perfusion of the placenta

The test requires about 20 - 30 minutes

Amniocentesis

Removal of amniotic fluid by insertion of a needle through the abdominal and uterine wall into the amniotic sac

Amniocentesis

An invasive procedure Requires a consent form to be signed Performed about 14 - 16 weeks

gestation Patient must be informed of possible

complications– Trauma– Infection – Hemorrhage– Preterm labor

Amniocentesis

Purporses:– Genetic disorders– Fetal health – Triple test

alpha-fetoprotein (AFP) human chorionic gonadotrophin (hCG) unconjugated estriol (UE3) Diameric Inhibin-A (soon to be added)

– Fetal lung maturity L/S ratio

Amniocentesis

Preparation– Vital Signs and FHT’s– Empty bladder– Abdominal prep and scrub– Ultrasound

Area of insertion is anesthesized and a needle inserted into the amniotic cavity

15 - 20 cc of fluid withdrawn for analysis

Amniocentesis

Amniocentesis

Post care / Discharge Teaching– Monitor V/S, FHT’s and UC’s – Observe for leakage of fluid from site– Teach patient to report –

Fetal hyperactivity or lack of fetal movement

Vaginal discharge: clear or bleeding Uterine contractions or abdominal

pain Fever or chills

L/S Ratio Lecithin /Sphingomyelin

Ratio

Lecithin and Sphingomyelin are two components of Surfactant.

Assesses Fetal Lung Maturity

L/S Ratio Lecithin /Sphingomyelin Ratio

As surfactant increases in the lungs, the levels of lecithin should also increase.

Lecithin become 2 - 3 times > spingomyelin by about 35 weeks

Fetal maturity = L/S ratio 2 : 1

Karyotyping

Determine sex of the fetus

Normalcy ofChromosomes

Karyotyping

Indications:– Maternal age 35 or > at time of birth (AMA)– Pervious child born with a chromosomal

abnormality– Mother carrying an X-linked disease– Parents carrying and inborn error of

metabolism– Both parents carrying an autosomal

recessive disease– Family history of neural tube defects

Karyotyping

Trisomy Monosomy

Alpha - Fetoprotein AFP

Measurement of a protein produced by the yolk sac and fetal liver

Elevated levels of AFP may be indicative of open neural tube defects because the AFP leaks out of the fetal circulation into the amniotic fluid

Low level associated with Down syndrome

Chorionic Villus Sampling

CVS Removal of small tissue specimen

from the fetal portion of the placenta

Tissue obtained about 8 - 12 weeks gestation

Chromosomal studies performed

Trans-cervical Chorionic Villus Sampling

Chorionic Villus SamplingCVS

Risks:– Failure to obtain tissue– Rupture of amniotic membranes– Leakage of amniotic fluid– Vaginal bleeding – Intraurterine infection– Rh Alloimmunization– Maternal tissue contamination of the

specimen– Increased risk of spontaneous abortion

Chorionic Villus SamplingCVS

Nursing interventions– Monitor :

vital signs FHR uterine contractions/cramping vaginal discharge

– Administer Rhogam if indicated– Teach patient to report:

Change in fetal movement Uterine contractions Vaginal discharge

Non-Stress Test (NST)

Assessment of fetal status Observation of fetal heart rate

associated with fetal movement. The FHR should increase or

accelerate with fetal movement FHR accelerations indicate an

intact CNS and adequate oxygenation

Procedure for an NST

Electronic fetal monitor is applied Fetal movements are documented Compare the FHR with the fetal

movements Results:

– Reactive -- at least two accelerations of FHR with fetal movement of 15 BPM, lasting 15 seconds or more, over 20 minutes.

– Nonreactive -- the reactive criteria are not met. Indication of need for further assessment

Non-Stress Test - Reactive

Contraction Stress Test - CST

A means of identifying the fetus that is at risk for intrauterine asphyxia. Usually shows if there is utero-placental insufficiency.

Procedure for an CST

Electronic fetal monitor attached IV oxytocin stimulation started Goal -- 3 contractions of good quality,

lasting 40-60 seconds over a 10 minute period

Results:– Negative -- 3 contractions in 10 minutes with

NO signs of late decelerations– Positive -- repetitive persistent late

decelerations occurring with more than half the contractions

Positive CST

Contraction Stress Test

Post OST Monitoring– FHR– Labor– SROM

Discharge instructions– Notify HCP for the following:

Regular painful contractions Leakage of amniotic fluid Decrease or increase in fetal movement Vaginal bleeding

Fetal AssessmentNon - Stress Test

Reactive Non - Reactive

Repeat in 1 - 2 weeks Reactive Stimulate

Non- ReactiveContraction Stress Test

Negative Positive

Repeat in 24 hours Further Evaluation

Negative Possible Delivery

NST in 1 week

Try This!

Which of the following is NOT an indication of fetal distress?A. A reactive NSTB. Non-reactive NSTC. A positive CSTD. A negative CST

Biophysical Profile

Comprehensive assessment of five biophysical variables:1. Fetal breathing movement2. Fetal movements of body or limbs3. Fetal tone (extension and flexion of

extremities)4. Amniotic fluid volume – visualized as

pockets around the fetus5. Reactive FHR with activitity (reactive

NST)

Biophysical Profile

By combining these five assessments, the BPP helps to

identify the compromised fetus and to confirm the

healthy fetus

Since it combines several assessments, it is a better

indicator of fetal well-being

Biophysical Profile

A score of 2 is assigned to each normal finding for a maximum score of 10.

Scores of 8-10 are considered normal

Lower scores are associated with a compromised fetus and warrant further assessment and possible delivery of the fetus.

BiophysicalVariable

Normal(Score = 2)

Abnormal(Score = 0)

Fetal breathing movements

1 or more episodes of >20 s within 30 min

Absent or no episode of >20 s within 30 min

Gross body movements

2 or more discrete body/ limb movements within 30 min (episodes of active continuous movement considered as a single movement)

<2 episodes of body/limb movements within 30 min

Fetal tone 1 or more episodes of active extension with return to flexion of fetal limb(s) or trunk (opening and closing of hand considered normal tone)

Slow extension with return to partial flexion, movement of limb in full extension, absent fetal movement, or partially open fetal hand

Reactive FHR

2 or more episodes of acceleration of >15 bmp* and of >15 s associated with fetal movement within 20 min

1 or more episodes of acceleration of fetal heart rate or acceleration of <15 bmp within 20 min

Qualitative AFV

1 or more pockets of fluid measuring >2 cm in vertical axis

Either no pockets or largest pocket <2 cm in vertical axis

Kick Counts

Non-invasive Goal: 10 kicks in < 2 hours

The End

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