WELCOME

SCREENING OF High-risk pregnancy

DEFINITION
High

risk pregnancy is defined as one which is complicated by factor or factors that adversely affects the pregnancy outcome- maternal or perinatal or both.

General consideration

Mother ,fetus,or newborn increased risk of morbidity or mortality during,or after delivery

At

Before,

 Obstetric

disorders can impose a higher toll on the mother and/or fetus:

Abruptio placenta

Prematurity

Postterm pregnancy

Preeclampsia-eclampsia

Polyhydramnios

Oligohydramnios

Growth restriction

Chromosomal abnormalities

Leading

cause of maternal death

Thromboembolic disease

Hypertensive disease
Hemorrhage Infection Ectopic pregnancy

Risk factors related to specific pregnancy problems

Preterm labor
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

Polyhydramnios
Diabetes mellitus Mutiple gestation Fetal congenital abnormalities Isoimmunization(Rh or ABO) Nonimmune hydrops Abnormal fetal presentation

Oligohydramnios
Renal agenesis Prolonged rupture of membranes

Intrauterine growth
restriction Intrauterine fetal

demise

PRECONCEPTIONAL EVALUATION
Preconceptional

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

Initial

screening
oMaternal age oModality of conception oEthic background oPast obstetric history

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

oParental karyotype
oCervical and uterine anomalies oConnective tissue disease

oHormonal abnormalities
oAcquired and inherited thrombophilias

oInfectious disease of the genital

tract Previous stillbirth or neonatal death

o drugs
oInfectious agents oradiation

Reproductive history
Grand

multiparity

Third

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

Previous surgery
Myomectomy Repair

of complete perineal tear Repair of vesico- vaginal fistula Repair of stress incontinence Previous Caesarian section or hysterectomy

Family history
Socio-economic

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.

RISK APPROACH
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.

During labour
PROM Prolonged

labour Hand, feet or cord prolapsed Placenta retained more than half an hour PPH Puerperal fever and sepsis

Antepartum course
Prenatal

visits
o Fever(>100.4,even >)
o Urinary ,pulmonary ,hematological

Vital signs
A

sources; chorioamnionitis o Preterm labor;adverse effect on fetus and mother o Amniocentesis for microscopy and culture o Antipyretics, antibiotics

Pulse B
oTachycardia(>100bpm) oInfection, anemia, heart disease,et. oMild:follow-up; Severe: ECG , hemogram

Blood pressue C
o >140/90mmHg >30/15mmHg oPIH, chronic hypertention,

urinalysis

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

EXAMINATION
General

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

PRENATAL SCREENING
Maternal Serum Alpha Fetoprotein
AFP-

is a fetal protein- yolk sac and fetal liver in fetal serum & amniotic fluid by 6 weeks

Present Peak

is in 13 weeks and then decreases tube does not close it escapes

Neural Blood

sample in 15-18 weeks

0.5 to 2.5 MoM - normal range

Elevated in
Wrong NTD

gestational age

Multiple
IUFD

pregnancy

Abdominal
Renal IUGR

wall defects

anomalies

Pre-eclampsia

Low in
Trisomy GTN

Triple test
Triple

screen, the Kettering test or the Bart's test multiple-marker screening test MSAFP, hCG, UE3

hCG
Maximum:

100-200 IU between 60-70

days
Fall

to 10 -20 IU in 100-130 days constant

Remains Peaks

at 32 week onwards

Oestriol

Detectable

at 9 weeks (0.09 ng/ml)

30

ng/ml at term

Triple test
Detect

downs syndrome
nad UE3 is low

MSAFP hCG

is high 15-18 weeks

Performed Confirm

by amniocentesis

 AcetylCholine

esterase (AChE)elevated in neural tube defects.

A- produced by corpus luteum and placenta. It is raised in down syndrome.

Inhibin

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

Three
Total

counts of 1 hour duration

counts multiplied by 4 gives

DFMC
Less

than 10 in 12 hrs or less than 3 in

one hour denotes fetal compromise

Ultrasonography

Fetal indications
Diagnosis

of pregnancy of gestational age, presentation

Assessment Diagnosis

of multiple pregnancy, ectopic of IUFD, anomaly

pregnancy
Diagnosis

Assess

IUGR

Utero placental
Localization Diagnosis

of placenta

of abruptio placenta, molar

pregnancy, uterine malformations,

cervical incompetence
Assessment
Uterine

of liquor amnii

size

Maternal
Pelvic

mass diagnosis

Amniocentesis CVS Cordocentesis Fetoscopy Intrauterine

fetal therapy

Basic:

fetal numbers, pesentation,fetal viability, placental location, gestational age

Limited: for suspected problem

Comprehensive:

fetal anomalies , growth, physiologic complication

Procedure
Explain Ensure Supine Gel

the procedure

full bladder position and drape

is applied to improve the contact is applied to the abdomen and moved

Transducer

vertically and horizontally until the whole uterus

and contents are scanned

Transvaginal ultrasound

 Lie

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

Amnioscopy
Visual

inspection of amniotic fluid

throught he cervix and membranes with

amnioscope.
The

main use is to detect meconium

staining
Carries

risk of membrane rupture

Amniotic fluid assessment

Less

than 20 weeks: uterus dived

along linea nigra.

The

vertical diameter of the largest

pocket is measured.
AFI

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

Fetoscopy
Fetoscope-

a extremely narrow, hollow

tube inserted by amniocentesis technique

Uses

Intactness of spinal cord can be confirmed Biopsies of fetal tissue and fetal blood

samples

Surgeries: inserting a polythene stunt to the fetal ventricles to relieve hydrocephalus

 Performed

at 16th or 17th week

Prepared
Local Minor

as for amniocentesis

anesthesia scalpel incision fetoscope

inserted

Risks
Premature
Amnionitis Leakage Injury

labour

of fluid

to the fetus

Chorionic villus sampling

form

of prenatal diagnosis to

determine chromosomal or genetic

disorders in the fetus.

CVS

was tested for the first time by

Italian biologist Giuseppe Simoni in 1983

Indications

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.

 Transcervically:

10-12 weeks
10 weeks to term

Transabdominally:

Few villi are collected from the chorionic

frondosum

Ultrasonic guidance Long malleable polythene catheter Safe between 10-12 weeks Anti D immunoglobulin 50 mcg IM

Risks
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

Oromandibular Vaginal

deformities

bleeding

Amniocentesis

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.

Diagnostic
Early

months (14-16wks): sex- linked

disorders, karyotyping, inborn errors of

metabolism, NTD
Later

months: fetal maturity, degree

of fetal hemolysis, meconium staining

of liquor, amniography or fetography

Therapeutic
First

half: induction of abortion repeated,

decompression of the uterus

Second

half: decompression of uterus,

intrauterine fetal transfusion,

amnioinfusion

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.

Site
Early

months: 1/3rd of the way up the

uterus from symphysis pubis

Later

months: suprapubic after lifting the

presenting part

Precautions
Prior

sonographic localization
of 100 mcg of anti D

Administration

immunoglobulin

Hazards
Maternal:

infection, hemorrhage,

premature rupture of membranes,

premature labour, maternal

isoimmunization
Fetal:

abortion, trauma, feto-maternal

hemorrhage, oligohydramnios

USE
Cytogenetic

analysis: trisomy 21,

turners syndrome
DNA

analysis: cystic fibrosis, Tay

sachs disease

Percutaneous umbilical

cord blood sampling

(cordocentesis)

25 gauze spinal needle 13 cm in length

Inserted through abdomen

Ultrasound guidance
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

INDICATION
Hematological:

anemia, bleeding

disorders
Infection:

toxoplasmosis, viral infection

Fetal
Fetal

blood gas and acid base status

therapy: blood transfusion, drug

therapy

Risks
Abortion
Preterm

labour

IUD-

bleeding, cord hematoma formation,

infection, rupture of membranes

Anti

D immunoglobulin 100 mcg IM

Cardio Toco-graph/ Electronic Fetal Monitoring (EFM)

Definition
Cardiotocograph

is an electronic fetal

monitor which records graphically the fetal heart activity (cardio) and uterine contractions (toco).Both can be recorded simultaneously and continuously.

Indications

High risk pregnancies

IOL and Augmentation of Labour. Reduced FM. Premature labour. APH/IPH

Oligo hydramnios

Hypertension.
Abnormal FHR detected

Mal presentation
GDM

Multiple Gestation.
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 buttonto monitor fetal

movement

Display unitdisplays fetal heart rate and

intensity of contractions

Beltsto secure the transducer Graph paper

Accelerations
Accelerations

are temporary normal

increases in FHR due to fetal movement or compression of the umbilical vein during contraction.

Deceleration
They

are the periodic decreases in FHR

resulting from pressure on the fetal

head during contraction.

Early Decelerations

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.

 The

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

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.

 The

lowest point of deceleration occurs

at the end of contraction instead of at the

peak.

Changing the womans position from supine to lateral may help in relieving the pressure on the aorta & vena cava & to supply more blood to the uterus.

Variable decelerations:
It

occurs during unpredictable times during the contractions & indicates compression of the cord. Changing the womans 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

Is

the FHR pattern in the interval

between uterine contraction lasting

10 minutes or more

Baseline Bradycardia
Baseline

FHR <110 beats/minute

causes Heart block occiput posterior position serious fetal compromise.

Baseline Tachycardia
It

means baaseline FHR>160 beats per minute Causes: Maternal fever dehydration drugs(beta sympatho mimetics)

Beat to beat variability

Variability

between one beat to another Classification

Absent variability=amplitude change undetectable

Minimal =<5BPM Moderate =6-25 BPM Marked =>25BPM

Baseline acceleration
These

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
1.
2.

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)

This

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

NST-meaning

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:
Easy

to conduct the test

Non

invasive procedure

Procedure:

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 womens back . position the women in semi fowlers 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

Interpretation
Reactive

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

 Non-reactive

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

This

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

Procedure

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 to 2hrs

Negative CST
No

late decelerations with a minimum of three uterine contractions lasting 40 to 60 seconds within a10 minute period. This indicates fetal well being
Positive

CST Persistent and consistent late decelerations indicate a positive CST.

Contraindication
Threatened

preterm labour Placenta previa Hydramnios Multifetal pregnancy Rupture of membrane Previous preterm labour Previous classical c.birth

Contraindication
Threatened

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

Findings

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

This

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

The

Fetal

hypoxia Maternal hypotension Prolonged cord compression Fetal congenital heart blocks

Baseline variability
Electrical

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.

 Loss

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.

but

Period of fetal sleep "also causes a reduction in variability and commonly last for 20-30 minute even in advanced labour.

Nursing management
Notify

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

Fetal Assessment
1. Vibroacoustic stimulation o burst of sound to stimulate fetus o when NST is nonreactive

C Ancillary tests

o anoxia
2.fetal scalp stimulation o stimulate fetal vertex

o anoxia

Fetal Maturity Tests

Indications for assessing fetal lung maturity:
<37 weeks
according following criteria: oLecithin:Sphingomyelin Ratio(L/S) oPhosphatidylglycerol(PG) oFoam Stability Index(FSI) risk of respiratory distress syndrome

Intrapartum Fetal Surveillance

Continuous

electronic fetal monitoring and intermittent palpation and auscultation

Foetal

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%

CONCLUSION

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

BIBLIOGRAPHY

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 Womens 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 ???..........

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