ASSESSMENT OF FETAL WELL-BEING
MATERNAL HISTORY AND EXAMINATION
- The woman's family medical history, the woman's personal medical history, and her reproductive health history
- Comprehensive physical examination, history of current pregnancy, and identified risk factors
- Health during previous pregnancies
- Outcome of previous pregnancies
- Routine prenatal labs
- Fetal assessment after first trimester and individualized fetal surveillance as indicated
FETAL HEART TONES
Description
FHTs are
representative of the fetal heart rate (FHR) and are an indicator of oxygen
perfusion to the fetal brain, heart, and adrenals. The evaluation of FHTs is
indicated in routine assessment of fetal well-being, in determining gestational
age, and in cases of threatened abortion or other abnormalities. FHTs can be
heard using techniques that amplify sound.
- Doppler at approximately 10 to 12 weeks' fetal gestation.
- Fetoscope (fetal stethoscope) at approximately 18 to 20 weeks' fetal gestation.
- Electronic fetal monitoring testing is usually done when the fetus is considered viable; around 24 weeks' gestation.
- Rate - between 110 and 160 bpm.
- In latter months of pregnancy, fetal heart sounds found:
- near the woman's midline in fetal occipitoanterior positions
- lateral to midline in fetal occipitotransverse positions
- in the woman's flank in fetal occipitoposterior positions
- below the woman's umbilicus in cephalic presentations
- at or above the woman's umbilicus in breech presentations.
- Failure to hear FHTs at the expected time may be due to maternal obesity, polyhydramnios, error in date calculation, or fetal death.
Nurse's Responsibility
- Explain equipment, purpose, and procedure to the woman.
- Assist the woman to a side-lying or semi-Fowler's position. Position may affect the ability to clearly hear the heart tones. Perform Leopold's maneuvers.
- Document findings on the woman's chart and monitor strip along with date, time, activity level, medications, and other information per your health care facility's guidelines.
- Discontinue electronic fetal monitoring as indicated according to guidelines.
- Communicate appropriate information to the woman and other personnel.
FETAL MOVEMENT
Description
Fetal movements
or €œkick counts may be evaluated daily by the pregnant woman
to provide reassurance of fetal well-being. Several methods proposed; however,
neither the ideal number of kicks nor the ideal interval for movement counting
has been defined. There are two methods defined in the literature.
- Cardiff Count-to-Ten:
- Assess fetal movement once per day at the same time each day.
- Less than 10 fetal movements in 10 hours for 2 consecutive days or no fetal movement in a 10-hour period must be reported to the primary care provider.
- Sadovsky:
- Assess fetal movement three times each day at the same time.
- Less than four fetal movements in 2 hours must be reported to the primary care provider.
Nurse's Responsibility
- Instruct the woman to lie on her side in a quiet place with no distractions. Have her place her hands on the largest part of her abdomen and concentrate on fetal movement.
- Instruct the woman to use a clock and record the movements felt.
- Instruct the woman that fetal movements are best assessed after meals, after or with light abdominal massage, and after short walks.
- Instruct the woman that the fetus can sleep for up to 40 minutes.
- Request the woman to explain the procedure so her understanding is ensured.
MATERNAL SERUM ALPHA-FETOPROTEIN
Description
MS-AFP levels
are analyzed at 15 to 20 weeks' gestation to identify certain birth defects and
chromosomal abnormalities during pregnancy. AFP is a major protein produced in
the fetal yolk sac during the first trimester and in the fetal liver during
late term.
- Elevated AFP levels are associated with birth defects and chromosomal abnormalities, such as open neural tube defects, open abdominal defects, and congenital nephrosis. Also associated with Rh isoimmunization, multiple gestation, maternal diabetes mellitus, and fetoplacental dysfunction.
- Decreased levels are associated with Down syndrome and other chromosome anomalies (eg, gestational trophoblastic disease).
- Follow-up for abnormal high or low levels includes ultrasound examination and amniocentesis.
Nurse's Responsibility
- Obtain health and pregnancy history, including the date of the woman's last menstrual period and risk factors. Accurate dating of the pregnancy is crucial to interpret the results of the serum levels.
- Explain the purpose and procedure for the test.
- Discuss the woman's concerns.
ULTRASOUND
Description
Ultrasound is a
noninvasive, safe technique that uses reflected sound waves as they travel in
tissue to produce a picture. In the abdominal approach, a clear gel is applied
to the woman's abdomen or to the transducer, and the transducer is moved along
the abdomen by the examiner. Images are produced onto a screen.
During the early weeks of gestation, when the uterus remains a pelvic organ, a
full bladder may be necessary to facilitate visualization. In the endovaginal
approach, a lubricated transducer probe is inserted (either by the woman or by
the examiner) into the vagina. No full bladder is necessary and this technique
is especially useful during the early weeks of pregnancy or when cervical
evaluation is important (ie, for assessment of preterm labor).
Three-dimensional ultrasound is a newer technology that is believed to offer
improved assessment of fetal growth and weight parameters.
- Uses in the first trimester of pregnancy include:
- Early confirmation of pregnancy and determination of the estimated date of confinement.
- Diagnosis of an ectopic pregnancy.
- Detection of an intrauterine device.
- Evaluation of placental location.
- Diagnosis of a multiple gestation.
- Guidance for chorionic villus sampling (CVS).
- Uses in the second and third trimester include:
- Evaluation of fetal growth, weight, and gestational age.
- Evaluation of the placenta for placenta previa or separation associated with vaginal bleeding.
- Evaluation of fetal presentation and position.
- Evaluation of fetal abnormalities.
- Evaluation of fetal viability.
- Determination of the Biophysical Profile (BPP) Score.
- Evaluation of amniotic fluid volume.
- Guidance for amniocentesis or fetal blood sampling.
Nurse's Responsibility
- Explain the purpose and procedure to the woman, emphasizing the need to remain still.
- Inform the woman of the need for a full bladder (if indicated) before the procedure.
- When indicated, instruct the woman to drink three to four glasses of water if the bladder is not full.
- Instruct the woman not to void until the procedure is over.
- Remove the lubricant from the woman's abdomen after the procedure or provide perineal cleaning products as needed.
AMNIOCENTESIS
Description
Amniocentesis is
a procedure needing informed consent, in which amniotic fluid is removed from
the uterine cavity by insertion of a needle through the abdominal and uterine
walls and into the amniotic sac. The procedure, when performed between 16 and
18 weeks gestation, is used in the prenatal diagnosis of genetic or metabolic
diseases. In later pregnancy, amniocentesis is performed for the assessment of
fetal lung maturity and to treat polyhydramnios. Risks associated with the
procedure are very low.
- In determination of genetic or metabolic diseases, the procedure is performed between 16 and 18 weeks' gestation. It is useful for women 35 years of age or older, for those with a family history of metabolic disease, a previous child with a chromosomal abnormality, a family history of chromosomal abnormality, a patient or husband with a chromosomal abnormality, or a possible female carrier of an X-linked disease.
- In determination of lung maturity, the lecithin/sphingomyelin (L/S) ratio of the amniotic fluid is analyzed.
- When the L/S ratio is 2:1 or greater, the fetal lung is considered mature and the incidence of respiratory distress syndrome in the newborn is low.
- Results may be less reliable with maternal diabetes or if the fluid is contaminated with blood or meconium.
- The presence of phosphatidylglycerol (PG), one of the last lung surfactants to develop, is the most reliable indicator of fetal lung maturity. PG is not present until 36 weeks' gestation and is measured as being present or absent. Unlike the L/S ratio, PG is not affected by hypoglycemia, hypoxia, or hypothermia.
- A Triple Marker Screening (TMS) can also be used for the evaluation of trisomy 18 and 21 and neural tube defects. This test is costly when compared to MS-AFP, thus it is limited in its use. The TMS evaluates unconjugated estriol and hCG: Down syndrome shows increased hCG and decreased estriol levels; trisomy 18 shows decreased hCG and decreased estriol levels. The quadruple screen, which includes a measurement of the substance Diameric Inhibin-A, provides a more sensitive and accurate detection of trisomy 21.
- In the treatment of polyhydramnios (2,000 mL amniotic fluid or > 25 cm amniotic fluid index [AFI]), amniocentesis may be performed to drain excess fluid and relieve pressure. Polyhydramnios can be associated with specific fetal abnormalities, such as trisomy 18, anencephaly, spina bifida, and esophageal atresia or tracheoesophageal fistula.
Nurse's Responsibility
- Reduce anxiety related to the procedure.
- Reduce the parents' anxiety by determining their understanding of the procedure and the meaning it holds for them.
- Reexplain the procedure before it begins, and answer any questions they have. Ensure informed consent is signed.
- Provide explanations during the procedure, correct misinformation they may have, and make sure they know when the results will be available and how they may obtain the results as soon as possible.
- Reduce pain and discomfort related to the procedure.
- Reduce discomfort by having the mother lie comfortably on her back with her hands and a pillow under her head. Relaxation breathing may help.
- Ensure adequate time between infiltration of local anesthetic and introduction of needle into the amniotic sac.
- Start I.V. fluids in accordance with institutional policy. Administer terbutaline subcutaneously or I.V. or ritodrine I.V. per your facility's policy.
- Reduce potential for traumatic injury to fetus, placenta, or maternal structures.
- Have the woman empty her bladder if the fetus is more than 20 weeks' gestation to avoid injury to the woman's bladder. If the fetus is less than 20 weeks' gestation, the woman's full bladder will hold the uterus steady and out of the pelvis. The placenta is localized with the use of ultrasound.
- Obtain maternal vital signs and a 20-minute fetal heart rate tracing to serve as a baseline to evaluate possible complications.
- Monitor the woman during and after the procedure for signs of premature labor or bleeding.
- Tell the woman to report signs of bleeding, unusual fetal activity or abdominal pain, cramping, or fever while at home after the procedure.
CHORIONIC VILLUS SAMPLING
Description
CVS involves
obtaining samples of chorionic villus (placental tissue [fetal origin]) to test
for genetic disorders of the fetus. CVS is performed between 8 and 12 weeks'
gestation.
- Using an ultrasound picture, a catheter is passed vaginally into the woman's uterus, where a sample of chorionic villus tissue is snipped off or obtained by suction.
- Results from CVS are available in 1 to 2 weeks.
- Complications include rupture of membranes, intrauterine infection, spontaneous abortion, hematoma, fetal trauma, or maternal tissue contamination.
- Incidence of fetal loss is about 2% to 5%.
Nurse's Responsibility
- Obtain maternal vital signs.
- Instruct the woman to void.
- Reduce woman's anxiety as related to the procedure.
- Inform the woman that a small amount of spotting is normal, but heavy bleeding or passing clots or tissue should be reported.
- Instruct the woman to rest at home for a few hours after the procedure.
PERCUTANEOUS UMBILICAL BLOOD SAMPLING
Description
PUBS, or
cordocentesis, involves a puncture of the umbilical cord for aspiration of
fetal blood under ultrasound guidance.
- It is used in the diagnosis of fetal blood disorders, infections, Rh isoimmunization, metabolic disorders, and karyotyping.
- Transfusion to the fetus may be conducted with this procedure.
- Using ultrasound picture, the provider inserts a needle (guided by ultrasound) for insertion into one of the umbilical vessels. A small amount of blood is withdrawn.
- Can also be used for fetal therapies, such as RBC and platelet transfusion.
Nurse's Responsibility
- Explain the procedure to the woman.
- Provide support to the woman during the procedure.
- Monitor the woman after the procedure for uterine contractions and the fetal heart rate for distress.
NONSTRESS TEST
Description
The nonstress
test (NST) is used to evaluate FHR accelerations that normally occur in
response to fetal activity in a fetus in good condition. Accelerations are
indicative of an intact central and autonomic nervous system and are a sign of
fetal well-being. Absence of FHR accelerations in response to fetal movements
may be associated with hypoxia, acidosis, drugs (analgesics, barbiturates),
fetal sleep, and some fetal anomalies.
- Maternal indications include postdates, Rh sensitization, maternal age 35 or older, chronic renal disease, hypertension, collagen disease, sickle cell disease, diabetes, premature rupture of membranes, history of stillbirth, trauma, vaginal bleeding in the second and third trimesters.
- There are no contraindications or known adverse effects associated with the NST.
- Fetal indications include decreased fetal movement, intrauterine growth restriction, fetal evaluation after an amniocentesis, oligohydramnios or polyhydramnios.
- Criteria for a reactive NST include two accelerations within 20 minutes, each lasting at least 15 seconds with a FHR increased by 15 bpm above baseline in response to fetal activity. The quality of the tracing is an important factor in the test interpretation.
- In a nonreactive or equivocal NST, the above criteria are not met.
Significance/Management
- Reactive NST - suggests < 1% chance of fetal death within 1 week of the NST.
- Nonreactive NST - suggests fetus may be compromised and there needs to be further follow-up with a BPP, Contraction Stress Test (CST), or Oxytocin Challenge Test (OCT).
- Equivocal NST - needs to be repeated in 2 to 3 hours or follow-up with CST, OCT, or BPP.
Nurse's Responsibility
- Explain the procedure and equipment to the woman. Make sure the woman has had adequate nutrition and fluid intake and, if a smoker, has not been smoking within the past 2 hours.
- Assist the woman to a semi-Fowler's position in bed. Perform Leopold's maneuvers, and apply the external fetal and uterine monitors.
- Event markers do not need to be used unless the fetal movement is not observed on the fetal monitor. If fetal movement not observed, instruct the woman to make a mark on the monitor strip each time fetal movement is felt. The nurse will do this if the woman cannot.
- Evaluate the response of the FHR immediately after fetal activity.
- Monitor the woman's blood pressure and uterine activity for deviations during the procedure.
FETAL ACOUSTIC STIMULATION TEST AND
VIBROACOUSTIC STIMULATION TEST
Description
Acoustic (sound)
and vibroacoustic stimulation (sound plus vibration), involve the use of
handheld battery-operated devices (usually a laryngeal stimulator) placed over
the mother's abdomen near the fetal head. This technique produces a
low-frequency vibration and a buzzing tone intended to induce fetal movement
along with associated FHR accelerations. The sound stimulus lasts for 2 to 5
seconds. The fetal acoustic stimulation test (FAST) and vibroacoustic
stimulation test (VST) are used as an adjunct following a nonreactive NST;
these tests may also be used with fetuses that exhibit decreased FHR
variability during labor. If no FHR accelerations occur in response to the
stimulus, it is repeated at 1-minute intervals up to three times. If the FHR
pattern remains nonreactive, further evaluation with BPP or CST is indicated.
- It is not known whether the fetus responds more to the sound or to the vibration.
- Both methods of testing are noninvasive, easy to perform, and yield rapid results.
- Interpretation depends on individualized institutional guidelines. Usually:
- Reactive - two accelerations meeting 15 × 15 criteria.
- Nonreactive - no accelerations.
- Equivocal - one acceleration or accelerations not meeting the 15 × 15 criteria or uninterpretable/unreadable fetal tracing.
- Tachycardic rate may result from stimulus and may last > 1 hour. If this occurs, observe FHR for normal baseline characteristics, other than the tachycardia, until the FHR returns to the prestimulus rate.
Nurse's Responsibility
- Explain procedure, equipment, and purpose to the woman.
- Assist the woman to a semi-Fowler's position in bed.
- Apply external fetal monitors to the woman.
- Demonstrate how the stimulus may feel on the woman's forearm or leg.
- Observe for reactivity.
OXYTOCIN CHALLENGE TEST OR CONTRACTION
STRESS TEST
Description
This test is
used to evaluate the ability of the fetus to withstand the stress of uterine
contractions as would occur during labor.
- The test is generally used when a woman has a nonreactive NST or equivocal FAST/VST, although in many areas, the CST has been replaced by the BPP.
- The test is contraindicated in women with third trimester bleeding, multiple gestation, incompetent cervix, placenta previa, previous classic uterine incision, hydramnios, history of PTL, or premature rupture of membranes.
- Contractions may occur spontaneously (unusual) or they may be induced.
- The CST utilizes endogenously produced oxytocin by way of nipple or breast stimulation.
- The OCT utilizes exogenous oxytocin (Pitocin), which is administered by way of I.V. infiltration.
Nurse's Responsibility
- Obtain maternal vital signs, especially blood pressure.
- Instruct the woman to void.
- Assist the woman to a semi-Fowler's or side-lying position in bed.
- Obtain a 20-minute strip of the FHR and uterine activity for baseline data.
- For CST:
- Apply warm packs to the breasts for 10 minutes before the CST.
- Instruct the mother on nipple stimulation (four cycles of 2 minutes on [stimulating] and 2 minutes off [not stimulating]).
- If no uterine contractions after four cycles, wait 10 minutes, then restimulate.
- If no uterine contractions after the second four cycles, stop the stimulation, notify physician, and prepare for OCT or BPP.
- Stop the stimulation if:
- Three or more contractions occur within 10 minutes which last > 60 seconds.
- Tetanic uterine contractions or hyperstimulation occurs.
- For OCT: follow 1 through 4 above. In addition:
- Administer diluted oxytocin through an I.V. infusion pump as indicated until three contractions occur within 10 minutes and last 40 to 60 seconds. Maintain mainline I.V. fluids in accordance with facility policy.
- Discontinue the infusion when:
- Criteria are met.
- Hyperstimulation occurs.
- Prolonged deceleration or bradycardia occurs.
- Persistent late decelerations are present.
Interpretation of CST/OCT
- Negative (normal) - three uterine contractions in 10 minutes without late decelerations.
- Positive (abnormal) - persistent late decelerations or late decelerations with > 50% of uterine contractions even if frequency is less than three contractions in 10 minutes; usually associated with hypoxia.
- Suspicious (equivocal) - late decelerations with < 50% of uterine contractions or significant variables.
- Unsatisfactory - quality of tracing inadequate to assess or less than three contractions in 10 minutes.
- Hyperstimulation:
Significance/Management of CST/OCT
- Negative - reassuring.
- Positive - nonreassuring.
- Suspicious - repeat in 24 hours.
- Unsatisfactory - repeat in 24 hours.
- Hyperstimulation - repeat in 2 hours.
BIOPHYSICAL PROFILE
Description
The BPP uses
ultrasonography and NST to assess five biophysical variables in determining
fetal well-being. A BPP is performed during a 30-minute time frame.
- Nonstress test - assessing for FHR acceleration in relation to fetal movements.
- Amniotic fluid index volume - assessing for one or more pockets of amniotic fluid measuring ¾ inch (2 cm) or more in two perpendicular planes.
- Fetal breathing movements - one or more episodes lasting at least 30 seconds.
- Gross fetal body movements - three or more body or limb movements, to include rolling, in 30 minutes.
- Fetal muscle tone - one or more episodes of active extension with return to flexion of spine, hand, or limbs.
For each
variable, if the criteria are met, a score of 2 is given. For an abnormal
observation, a score of 0 is given. A score of 8 to 10 is considered normal, 6
is equivocal, and 4 or less is abnormal.
Nurse's Responsibility
- Explain the purpose and procedure to the woman; provide emotional support.
- Instruct the woman to empty her bladder.
- Assist the woman onto the examination table and help her to assume a position of comfort.
- Remove the lubricant from the woman's abdomen after the procedure.
- Assist the woman in rising from the examination table.
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