URDANETA

CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428
urdanetacityuniversity@yahoo.com
(075) 568-7612 / (075) 568-2475 loc. 110
E-mail: ucu.reg@gmail.com

SCHOOL OF MIDWIFERY

Established in 1973
Level II Accreditation Status-ALCU-COA

MID 104-CLINICAL MANAGEMENT-OBSTETRICAL EMERGENCIES HIGH RISK

PREGNANCY MANAGEMENT
Name: FRIDALYN MOJICA
Date: September 30, 2016
LEARNING ACTIVITY 1
1. High risk factors are those that increase the chances for mortality and morbidity for both the mother and
fetus. The early recognition and management of problems can pave the way for improving maternal-fetal
well-being. *Identify/enumerate the essential risk factors
ANSWER: The factors that place a pregnancy at risk can be divided into four categories:
A. Existing Health Conditions- High blood pressure, Polycystic ovary syndrome, Diabetes, Kidney
disease, Autoimmune disease, Thyroid disease, Infertility, Obesity, HIV/AIDS.
B. Maternal Age- Teen pregnancy, First-time pregnancy after age 35.
C. Lifestyle Factors- alcohol use, cigarette smoking.
D. Medical Conditions that occur during Pregnancy- Multiple gestation, Gestational diabetes,
Preeclampsia and eclampsia. Placenta Previa, Preterm Labor.
2. The goal of antepartum fetal surveillance is to prevent fetal death.
*Discuss the Antepartum fetal testing and interpretation. Enumerate and explain the Midwifery
responsibilities for each.
ANSWER:
1. NONSTRESS_TEST- is a simple, non-invasive and painless procedure test its measures fetal heart
rate, fetal movement and uterine activity in the 3rd trimester to make sure theres no fetal distress. NST
generally ordered when there is factor of multiple pregnancy, preeclampsia, due date passes but your baby
stay puts, too much or too little amniotic fluid and if there is decrease fetal movement.
NST may be done any time after 28 weeks but its common later in 3rd trimester of pregnancy. The
test involves attaching one belt to the mothers abdomen to measure fetal heart rate and another belt to
measure contractions.
Movement, heart rate and reactivity of heart rate to movement is measured for 20-30 minutes. If
your baby's heart beats faster (at least 15 beats per minute over his resting rate) while he's moving for at
rd

Fridalyn Mojica 3 Year BSM

least 15 seconds on two separate occasions during a 20-minute span, the result is normal, or "reactive." A
normal result means that your baby is probably doing fine for now. NST has no risks to mother and her
baby.
Here are some reasons you might have a non-stress test:
You have diabetes that's treated with medication, high blood pressure, or some other medical condition
that could affect your pregnancy.
You have gestational hypertension.
Your baby appears to be small or not growing properly.
Your baby is less active than normal.
You have too much or too little amniotic fluid.
You've had a procedure such as an external cephalic version (to turn a breech baby) or third trimester
amniocentesis (to determine whether your baby's lungs are mature enough for birth or to rule out a
uterine infection). Afterward, your practitioner will order a non-tress test to make sure that your
baby's doing well.
You're past your due date and your practitioner wants to see how your baby is holding up during his
extended stay in the womb.
You've previously lost a baby in the second half of pregnancy, for an unknown reason or because of a
problem that might happen again in this pregnancy. In this case, non-stress testing may start as
early as 28 weeks.
You have a medical problem that may jeopardize your baby's health.
Your baby has been diagnosed with an abnormality or birth defect and needs to be monitored.
INTERPRETATION OF NON-STRESS TEST (NST)

rd

Fridalyn Mojica 3 Year BSM

TERMINOLOGY FOR Non Stress Test (RELEVANT)

I.

Accelerations Accels
*15 x 15 the acme of the acceleration is >15 beats/minute above the baseline, and
the acceleration lasts >15 seconds and <2 minutes from the onset to return to baseline.
*10 x 10 for preterm <32 weeks, having an acme >10 beats/min above the baseline with a duration
of >10 seconds from onset to the return to baseline.

II.

Baseline, Variability, Deceleration (decels)

*Same terminology, with knowledge of term vs. preterm physiology informing your Assessment.
*Some decel can only be defined with contractions, present, so know the physiology & the proper
use of the terms.

NON STRESS TEST ASSESSMENT TERMINOLOGY

I.
II.

Reactive - 2 accels within 20 min of each other (NORMAL RESULT)

Nonreactive - does not meet reactive criteria. (ABNORMAL RESULT)
A.
B.
C.
D.
E.

Other terms often used but are not standardized:

Equivocal
Unsatisfactory
Suspicious
Indeterminate
Abnormal

INTERPRETATION & MIDWIFE Responsibilities/ ACTION of Non Stress Test

* Reactive - Normal, Reassuring
MIDWIFE Action:
Fetal movement education in later half of pregnancy.
Inform when to return for next visit.
* Indeterminate- a temporary assessment, not a final assessment.
MIDWIFE Action:
Need more info before deciding. Time limit: 2 hours.
* Nonreactive &/or Other Non-Emergency Concerns- (fetus Compensating for some kind of stress)
MIDWIFE Actions:
Advice pt. to Consult with physician, probably refer for further assessment.
Position change, hydration?
Extended monitoring +/- US (BPP)
* Nonreactive &/or Emergent Concerns- (fetus Decompensating):
MIDWIFE Actions:
Immediate position change, hydration, O2
Immediate referral to L&D hospital

rd

Fridalyn Mojica 3 Year BSM

Non Stress Test MIDWIFERY RESPONSIBILITIES of Documentation

Inform pt. that she should sign a waiver of consent, document the results of NST, if recognize
abnormal result refer immediately to Doctor.

Maternal name, age, G/P, Gestational Age

Maternal risk factors relevant to fetal compromise
Fetal risk factors relevant to fetal compromise
Maternal vital signs (minimum: BP & Pulse rate)
Characteristics of the strip
o Contractions- regularity, maternal perception, strength
o FHR- baseline, variability, accels, decels, anything unusual
Interpretation/Assessment- Reactive or Nonreactive (urgency)
Actions & Plan- follows from assessment & risk factor evaluation
Health teaching

2. NONTRACTION_STRESS TEST- A Contraction Stress Test/ Oxytocin Challenge Test/

Nontraction Stress Test/ may be done during 32nd week of pregnancy or later to measure the baby's heart
rate during uterine contractions. It is usually done if you have an abnormal nonstress test or biophysical
profile are not in the normal range. It is performed near the end of pregnancy to determine how well the
fetus will cope with the contractions of childbirth or to make sure the baby can get the oxygen he needs
from the placenta during labor.
I.

Principle of NonTraction Stress Test

During uterine contractions, fetal oxygenation is worsened. Late decelerations in fetal heart rate
occurring during uterine contractions are associated with increased fetal death rate, growth retardation and
neonatal depression. This test assess fetal heart rate in response to uterine contractions via electronic fetal
monitoring. Uterine activity is monitored by tocodynamometer.
II.

Procedure and Midwife Responsibilities:

CST is performed weekly, as the fetus is assumed to be healthy after a negative test and should
remain so for another week. This test is done in hospital or clinic setting. External fetal monitors are put in
place and then either nipple stimulation or IV pitocin (oxytocin) is used to stimulate uterine contractions.
A. Nipple Stimulation- This is a procedure that relies on endogenous release of oxytocin following
nipple stimulation, and is conducted by the patient. The midwife instructs the patient on the
procedure, as follows. One nipple is massaged gently through clothing until a contraction begins,
or for a maximum of 2 minutes. If at least 3 contractions in 10 minutes is not achieved, then the
patient rests for 5 minutes and the other nipple is stimulated. Document the Result and Give health
education on the procedure
B. Oxytocin Challenge Test (OCT)- Patient is admitted to Labor and Delivery for an Oxytocin
Challenge/Contraction Stress test Initial Vital Signs are assessed and the external monitor is
applied. A continuous FHR tracing must be maintained for the duration of the test. The patient
shoulder rest in the lateral recumbent or Semi-Fowlers position. (Avoid the supine position). The
external monitor tracing should be assessed prior to the administration of Oxytocin.
Fetal heart rate baseline and current level of uterine activity must be established prior to
the initiation of the Oxytocin infusion.

rd

Fridalyn Mojica 3 Year BSM

If current uterine activity consists of three contractions of at least forty seconds duration
occurring within a ten minutes period, the fetal heart rate response to these contractions
will be evaluated. The administration of Oxytocin is not necessary and the test is complete.
If the level of uterine activity does not meet the above criteria Oxytocin will be given to
stimulate or increase uterine contractions.
The Oxytocin is always given as a piggyback infusion. The line with the Oxytocin should
be connected to the mainline at the most proximal port to the IV insertion site. The
Oxytocin infusion will always be regulated by using an infusion pump.
The Oxytocin infusion for the OCT will begin at 0.5 mU/min and the infusion rate may be
doubled every 20 minutes until uterine activity begins.
Once uterine activity is established smaller increments for Oxytocin increases may be used
until adequate uterine activity is achieved. Adequate uterine activity is defined, for the
purpose of this test, as 3 contractions of at least 40 seconds, duration within a 10 minutes
window.
Smaller increases may decrease the risk of uterine hyperstimulation
If the Oxytocin infusion is at a rate of 16 mU/min and uterine activity has not been
established notify the provider.
At a dose of 16mU/min the incremental increasing of Oxytocin will decrease to 0.5-1.0
mU/min every 15 minutes.

III. Contraindications
This "stress test" is usually not performed if there are any signs of premature birth, placenta Previa,
vasa Previa, cervical incompetence, multiple gestation, previous classic caesarian section. Other
contraindications include but are not limited to previous uterine incision with scarring, previous
myomectomy entering the uterine cavity, and PROM. Any contraindication to labor is contraindication to
CST.
IV. Interpretation of Result of NONTRACTION STRESS TEST
Result

Interpretation

Positive (Abnormal)

Presence of late decelerations w/ at least 50% of the contractions

Negative(Normal)

No late or significant variable decelerations, w/ at least 3 uterine contractions

(lasting 40 seconds) in 10 minute period.

Equivocal
Suspicious

Presence of late decelerations w/ fewer than 50% of contractions or

significant variable decelerations, Require repeat testing on following day.

Equivocal
Tachysystole

Presence of contractions that occur more frequently than every 2 minutes or

last longer than 90 seconds in the presence of late decelerations. Require
repeat testing on the following day.

Equivocal
Unsatisfactory

Fewer than three contractions occur within 10 minutes, or a tracing quality

that cannot be interpreted. Require repeat testing on following day

rd

Fridalyn Mojica 3 Year BSM

3. BIOPHYSICAL PROFILE (BPP) is prenatal ultrasound evaluation of current fetal well-being

involving a scoring system. It is performed over 30 minutes and assesses fetal behavior by observing fetal
breathing movement, body movement, tone and amniotic fluid volume.
A biophysical profile is a noninvasive test that doesn't pose any physical risks to you or your baby.
However, it's not always clear that a biophysical profile can help promote a baby's health.
The goal of a biophysical profile is to prevent pregnancy loss and detect fetal hypoxia when the
baby is deprived of an adequate oxygen supply early enough so that the baby can be delivered and not
sustain permanent damage.
The BPP has 5 components: 4 ultrasound assessments and an NST. The NST evaluates fetal heart
rate and response to fetal movement.
1.
2.
3.
4.
5.

Fetal Heart rate (NST)

Fetal Breathing
Fetal movement
Fetal Tone
Amniotic Fluid Volume

Midwife should Recommend a biophysical profile if you have:

A multiple pregnancy with certain complications

An underlying medical condition, such as diabetes or heart disease
A pregnancy that has extended two weeks past your due date (post term pregnancy)
A history of pregnancy loss or previous pregnancy complications
A baby who has decreased fetal movements or possible fetal growth problems
Preterm premature rupture of the membranes when the fluid-filled membrane that surrounds and
cushions the baby during pregnancy (amniotic sac) leaks or breaks before week 37 of pregnancy
Too much amniotic fluid (polyhydramnios) or low amniotic fluid volume (oligohydramnios)
Rh (rhesus) sensitization a potentially serious condition that can occur when your blood group is Rh
negative and your baby's blood group is Rh positive
Worrisome results from other prenatal tests
Parameter

Abnormal (0 points)

NST/ Reactive FHR

At least 2 accelerations in 20 minutes

Fetal Breathing
movements

At least 1 episode of >30s or >20s in 30 None or less than 30s or 20s

minutes

Fetal activity/ gross body

movements

At least 3 or 2 movements of the torso or Less than 3 or 2 movements

limbs

Fetal Muscle tone

At least 1 episode of active bending &

straightening of the limb or trunk

Qualitative AFV/AFI

At least 1 vertical pocket > 2 cm or more Largest vertical pocket </= 2 cm

in the vertical axis

rd

Fridalyn Mojica 3 Year BSM

Normal (2 points)

Less than 2 accelerations to satisfy

the test in 20 minutes

No movements of movements
slow & incomplete

Interpretation of BioPhysical Profile (BPP)

Each assessment is graded either 0 or 2 points, and then added up to yield a number between 0 and
10. A BPP of 8 or 10 is generally considered reassuring.
The presence of these biophysical variables implies absence of significant central nervous system
hypoxemia/acidemia at the time of testing.
By comparison, a compromised fetus typically exhibits loss of accelerations of the fetal heart rate
(FHR), decreased body movement and breathing, hypotonia, and, less acutely, decreased amniotic
fluid volume.

Recommended Management based on the BioPhysical Profile

BPP

Recommended Management

<2

Labor Induction

Labor induction if gestational age >32 weeks

Repeating test same day if <32 weeks, then delivery if BPP <6

Labor induction if >36 weeks if favorable cervix and normal AFI

Repeating test in 24 hours if <36 weeks & cervix unfavorable, then delivery if BPP<6 & follow
up if >6

Labor induction if presence of oligohydramnios

Midwife Responsibilities

Educate and explain to patient about the procedure, inform that ultrasound might need to be done
with a full bladder and she will likely have blood pressure taken before the test and at regular
intervals during the test.
When an abnormal biophysical profile is obtained, the responsibility of midwife should be
informed immediately the doctor and refer the patient if needed. Further management will be
determined by the overall clinical situation.
Document and explain the result of BPP, Advice pt. of health education of causes and extra
precautions of BPP

4. DOPPLER VELOCIMETRY - is a way to make sure that your baby is getting a healthy supply of
blood. It is to monitor the heartbeat and used to hear an unborn child's heartbeat. You may also need the
test if you have preeclampsia, have a low level of amniotic fluid or IUGR ( intrauterine growth retardation)
due to smoking, alcohol and drugs.
Doppler velocimetry uses ultrasound to check blood flow in the umbilical cord or between the uterus, aorta,
heart and placenta. If the blood supply is restricted, your baby can't get enough nutrients and oxygen.
Doppler velocimetry is painless and safe non-invasive procedure and assessment of circulation in many
clinical conditions. It's similar to a standard ultrasound. A technician will gently press an ultrasound probe
against the outside of your belly.

rd

Fridalyn Mojica 3 Year BSM

MODALITIES OF DOPPLER ULTRASOUND

Clinical implementations of Doppler ultrasound technology for assessing circulation include continuous
wave (CW), pulsed wave (PW), and color Doppler. CW and PW Doppler modes are also known as spectral
Doppler. These modalities can also be used to evaluate tissue movement and strain, and are known as tissue
Doppler imaging.
Continuous wave Continuous wave Doppler ultrasound is used extensively in obstetrics for determining
and monitoring the fetal heart rate, but cannot identify the exact location of the origin of the Doppler signals
in the ultrasound beam path. Free-standing CW devices with a spectral analyzer had been used for
insonating the umbilical arteries for velocimetric applications, but PW Doppler has replaced these devices.
Pulsed wave Pulsed wave Doppler ultrasound allows selection of the desired vascular location for
Doppler insonation. Simultaneous real-time two-dimensional dynamic imaging of the fetal anatomy
provides the necessary guidance for the targeted Doppler interrogation (figure 2). This Doppler mode is
essential for confident interrogation of deep vessels and is used extensively in clinical practice. Pulsed wave
Doppler is also referred to as duplex Doppler when it is combined with two-dimensional imaging.
Color flow mapping Color Doppler ultrasound flow mapping is based upon the estimation of mean
Doppler shifted frequency. It offers real-time depiction of two-dimensional flow patterns superimposed on
two-dimensional dynamic images of anatomic structures. Doppler color flow mapping provides qualitative
hemodynamic information, including the presence and direction of blood flow. This modality is used for
fetal echocardiography (picture 1) and to investigate other fetal and uterine circulations during pregnancy,
as well as pelvic vessels in non-pregnant women.
Tissue Doppler imaging Tissue Doppler imaging analyzes Doppler frequency shifts generated by tissue
movement or strain, as seen in myocardium during the cardiac cycle. In contrast to Doppler ultrasound for
assessing blood circulation, the Doppler signals generated by tissue movements and strain are substantially
higher in amplitude and lower in frequency. The method has been used to directly assess global and regional
myocardial function.
Midwife Responsibilities:
Explain the procedure and the benefits of test for you and for the baby.
Ask Patient OB history, Documents the Result and give health teaching
Discuss the results of Doppler velocimetry to fully understand what they might mean for the
pregnant and her baby.
If the midwife finds abnormal results and need further testing or closer monitoring. In some cases,
the midwife may refer in doctor and may recommend early delivery to help the baby.
Midwife may need regular Doppler velocimetry along with other tests to check on how your baby
is doing.

rd

Fridalyn Mojica 3 Year BSM

3. Discuss the biophysical profile which is a combination of five biophysical variables. Enumerate
and explain the Midwifery responsibilities for each.
ANSWER: A fetal biophysical profile is a prenatal test used to check on a baby's well-being. The test
combines fetal heart rate monitoring (non-stress test) and fetal ultrasound. During a biophysical profile, a
baby's heart rate, breathing, movements, muscle tone and amniotic fluid level are evaluated and given a
score.
Typically, a biophysical profile is recommended for women at risk of pregnancy loss. The test is
usually done after week 32 of pregnancy, but can be done when your pregnancy is far enough along for
delivery to be considered
BPP is done to Check on your baby's health if you have Hyperthyroidism, Bleeding problems,
Lupus, Type 1 diabetes or gestational diabetes, High blood pressure (hypertension), Preeclampsia, A small
amount of amniotic fluid (oligohydramnios) or too much amniotic fluid (polyhydramnios), A multiple
pregnancy (such as twins or triplets), A pregnancy that has gone past your due date, between 40 and 42
weeks.
The BPP has 5 components: 4 ultrasound assessments and an NST. The NST evaluates fetal heart
rate and response to fetal movement.
The 5 discrete Biophysical variables:
Component

Criteria

Fetal Heart Rate (NST)

At least 120 to 160 beats per minutes.

Fetal
Movement

Breathing At least one episode continuing more than 30 seconds.

Fetal Body Movement

At least three body or limb movements.

Fetal Muscle Tone

An episode of active extension with return to flexion of a limb or trunk

Amniotic Fluid Volume At least one cord and limb-free fluid pocket which is 2 cm by 2 cm in two
(AFV)
measurements at right angles.

Interpretation of Result of BPP

a. NST- A non-stress test (NST) measures fetal heart rate, fetal movement and uterine activity in the
third trimester to make sure there's no fetal distress. An NST may be done any time after 24 weeks
to 26 weeks but is most common later in the third trimester of pregnancy. It is often combined with
a biophysical profile (BPP).
b. Fetal movement- Fetal movement. If your baby moves his or her body or limbs three times or
more within 30 minutes, 2 points will be given. If your baby's movements don't meet the criteria, 0
points will be given.

rd

Fridalyn Mojica 3 Year BSM

c. Fetal breathing- Fetal breathing. If your baby displays at least one episode of rhythmic breathing
for 30 seconds or more within 30 minutes, 2 points will be given. If your baby's breathing doesn't
meet the criteria, 0 points will be given
d. Amniotic fluid volume- Amniotic fluid level. The ultrasound technician will look for the largest
visible pocket of amniotic fluid. To obtain a score of 2 points, the pocket must be a certain size. If
your amniotic fluid level doesn't meet the criteria, 0 points will be given.
Midwife Responsibilities:
Explain the procedure that pregnant may need a full bladder for the test. If so, pregnant will be
asked to drink water or other liquids just before the test and to avoid urinating before or during the
test. Usually women in the third trimester do not need to have a full bladder.
Inform pregnant if she smoke, she will be asked to stop smoking for 2 hours before the external
monitoring test because smoking decreases your baby's activity.
Midwife should inform about any concerns that have regarding the need for the test, its risks, how
it will be done, or what the results may mean. To help her understand the importance of this test,
fill out the medical test information form.
Give Health teaching in healthy lifestyle like proper diet, exercise.

Prepared by:
DR. AMELIA C. FERNANDO
University Physician

Noted by:
DR. CHRISTOPHER R. BAEZ
Dean
Submitted by:
FRIDALYN MOJICA
3rd Year BSM

rd

Fridalyn Mojica 3 Year BSM

10