Fetal Assement Methods

12/3/2020

up to 9% of exam 5 to 9 questions

13.00 Adjunct Fetal Surveillance Methods 10%) 13.01 Auscultation (Intermittent Auscultation- IA) 13.02 Fetal movement counting 13.03 Nonstress testing 13.04 Fetal acid base interpretation – will be covered in a separate section 13.05 Biophysical profile 13.06 Fetal Acoustic Stimulation

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HERE IS ONE FOR YOU!!

AWW… Skin to Skin in the OR ☺

Auscultation

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Benefits of Auscultation • Based on Random Control Trials, neonatal outcomes are comparable to those monitored with EFM • Lower CS rates • Technique is non-invasive • Widespread application is possible • Freedom of movement • Lower cost • Hands on Time and one to one support are facilitated

Limitation of Auscultation • Use of the Fetoscope may limit the ability to hear FHR ( obesity, amniotic fluid, pt. movement and uterine contractions) • Certain FHR patterns cannot be detected – variability and some decelerations • Some women may think IA is intrusive • Documentation is not automatic • Potential to increase staff for 1:1 monitoring • Education, practice and skill assessment of staff

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Auscultation • Non-electronic devices such as a Fetoscope or Stethoscope • No longer common practice in the United States though may be increasing due to patient demand • Allows listening to sounds associated with the opening and closing of ventricular valves via bone conduction • Can hear actual heart sounds

Auscultation Fetoscope • A Fetoscope can detect: • FHR baseline • FHR Rhythm • Detect accelerations and decelerations from the baseline • Verify an FHR irregular rhythm • Can clarify double or half counting of EFM • AWHONN, (2015), pp. 88 • AWHONN, (2018), pp. e4

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Examples of Fetoscopes

Pinard Horn Leff Fetoscope Fetoscope

Auscultation – Doppler

• Electronic devices such as a hand held Doppler: • Detects FHR baseline • Detects FHR rhythm • Detects increases and decreases from the baseline • An electronic Doppler device uses ultrasound technology to detect the motion of the heart walls or valves and then converts it to sound • AWHONN, (2015) pp. 87-88

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Auscultation – Doppler

• When an irregular heartrate is audible by Doppler, assessment with a Fetoscope is warranted to rule out artifact. • A Doppler can not be used reliably to verify the presence of an irregular rhythm due to its technical limitations • It may half an SVT rate (Supraventricular Tachycardia)

Addressing the Elephant in the Room

Using the EFM ultrasound device versus a hand held Doppler

http://ab.pkimgs.com/pkimgs/ab/images/dp/wcm/201615/0007/baby-elephant-costume-c.jpg

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Auscultation – Using a Fetal Monitor • The external US may be used to listen to the FHR intermittently, however……. • Some systems archive data even when the paper tracing is turned off. Segments of the EFM may be retrievable but the data generated would be of too short a duration to be reliably interpreted. Using a hand held device would minimize these issues and the decision to use a certain device should be handled by institutional policies and procedures. • AWHONN (2015) p. 88

Auscultation

• Both Fetoscope and a Hand Held Doppler without a recording device can not verify: • Variability • Sinusoidal Pattern • These are visual assessments and an EFM device is required

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REMEMBER Auscultation is an Auditory Assessment

EFM is based on Visual Interpretation and includes the component of variability and decelerations!

DON’T Forget About the Uterine Activity

Comparison Model for Palpation of Uterine Activity Palpation of Uterus Feels Like….. Contraction Intensity Easily indented Tip of the nose Mild

Slightly indented Chin Moderate

Cannot indent Forehead Strong

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Documentation • Using Categories with IA (Intermittent Auscultation) • Category I is considered NORMAL. By auscultation, a Category I tracing includes all of the following: • Normal FHR baseline – 110-160 • Regular rhythm • Presence or absence of FHR increases/accelerations from the baseline rate • Absence of FHR decreases/decelerations from the baseline • AWHONN (2015) p. 91

Documentation

• Using Categories with IA • Category II is considered indeterminate and requires further investigation. By auscultation, a Category II tracing includes all of the following: • Irregular rhythm • Presence of FHR decreases/decelerations from the baseline • Tachycardia - baseline >160 bpm >10 minutes in duration • Bradycardia - baseline <110 bpm <10 minutes in duration • AWHONN (2015) p. 91

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Intermittent Auscultation (IA) Versus Continuous EFM

• AWHONN (2015) Fetal Heart Monitoring Position Statement • Current research indicates that FHR auscultation, when provided with a 1:1 nurse-patient ratio, is comparable to EFM for fetal assessment of the laboring woman. • Woman’s preference should be taken into account when possible

(IA) versus Continuous EFM

• ACOG • IA versus continuous EFM should be based upon risk factors, patient and obtetric preference, and departmental policy • ACOG & AAP (2017) P. 240

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Intermittent Auscultation

• Studies showing no difference in outcome

were based upon one-to-one nursing care

• Allows for more mobility for the patient

• Studies show good results done by trained personnel

Intermittent Auscultation

• Inconsistency in guidelines from ACOG, AWHONN, SOGC and ACNM regarding frequency of auscultation • No clinical trials have examined methods of fetal assessment during the latent phase of labor – frequency is at the discretion of the midwife or physician • AWHONN (2018) p. e8 • Feinstein et al (2008, p. 22) citing SOGC, 2007

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Frequency of Auscultation

• AWHONN • Insufficient evidence to make a recommendation. Frequency at the discretion of the midwife or physician – < 4cm • Every 15-30 minutes in Active phase of labor Latent phase (4-5 cm) • Every 15-30 minutes in Active phase of labor > 6 cm • Every 15 minutes Second Stage (passive decent) • Every 5 - 15 minutes in the Second stage (active pushing) • AWHONN (2018) p. e8

AWHONN PRACTICE BULLETIN – IA - 2018

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Frequency of Auscultation

• ACOG – No Risk Factors • Active phase of labor – 6cm should be the considered the threshold for the active phase of most women in labor • Determined, evaluated and recorded at a minimum of 30 minutes; preferably before, during and after a uterine contraction • Second stage - should be determined, evaluated and recorded at a minimum of 15 minutes • ACOG & AAP (2017) P. 240

Frequency of Auscultation

• ACOG – if Risk Factors are identified….. • First stage - Active phase of labor – should be determined, evaluated and recorded at a minimum of 15 minutes; preferably before, during and after a uterine contraction • Second stage - should be determined, evaluated and recorded at a minimum of 5 minutes • ACOG & AAP (2017) P. 240

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Auscultation Procedure

• Review • Miller, Miller, and Tucker (2013) text regarding procedure • Page 30 • Miller, Miller, and Cypher (2017) text regarding procedure • Page 29

Screening Devices for Fetal Well-Being For the exam read Miller, Miller & Tucker (2013) or the latest version is Miller, Miller and Cypher (2017) or one of the medical texts on the exam resource list….

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Goals of Antenatal Fetal Assessment

• To identify fetuses that are well oxygenated or those who may be at risk for hypoxia • To enable appropriate interventions to prevent or reduce perinatal morbidity and mortality

Antenatal Fetal Testing

• Any fetal testing is a screening tool to rule out fetal hypoxemia and acidosis • Creasy and Resnik (2019) pg. 549

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For the test to show value it must: • Have a wide range and be flexible • Detect fetal peril in enough time to allow intervention • Have a low false positive rate due to the consequences of delivering a preterm infant • High sensitivity for modest degrees of compromise to facilitate early interventions • Have a high negative value to prevent stillbirth and fetal injury • Incorporate multiple variables • Detect fetal compromise from a variety of sources • Be applicable in the inpatient and outpatient settings • Have measurable benefits for the high risk populations • Creasy and Resnik (2019) pg. 549

A few facts to keep in mind:

Fetal Assessment Methods are best when combined • A change in fetal behavior implies a change in fetal status • Maternal kick counts, NST and BPP • Doppler and Ultrasound are more useful to track both short- and long-term growth/development

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A few facts to keep in mind: • *As the fetus grows the parasympathetic nervous system dominates which decreases the fetal heart rate and is responsible for an increase in variability • *The response to acute change in fetal status is more immediate as the fetus matures • The presence of normal fetal tone and gross body movements and breathing reliably predict the absence of fetal hypoxemia and academia at the time it is observed

Key Measures of Effectiveness of Screening • False-negative • Fetal death that occurs within one week of a normal antepartum test • Rates range from 0.4 to 6 per 1000 with current testing methods • False-positive • Abnormal test that prompts delivery but is not associated with acute or chronic disruption of fetal oxygenation • Rates range from 30 to 90% with current testing methods Miller, Miller & Cypher (2017), pp.210-211

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Antepartal Screening

• Primarily used for patients considered to be at increased risk for disrupted fetal oxygenation (Miller et al, 2017, p.180) • Optimal gestational age to begin is not known • Initiated at 32 to 34 weeks for most medical indications

Indications for Antepartum Screening…

• There are a variety of conditions • Examples: • Decreased fetal movement • Previous history of unexplained stillbirth • Diabetes • Preeclampsia • Chronic hypertension • IUGR • Miller, Miller & Cypher, (2017) text on pps. 212-213 lists more…

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Antepartal Assessments On Exam

• Auscultation  • Fetal movement and stimulation • NST • Nonstress testing • Fetal acid-base interpretation • Umbilical cord blood analysis • BPP • Biophysical profile • Fetal Acoustic Stimulation

Fetal Movement Kick Counts and Stimulation

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Fetal Movement Counting (Kick Counts)

• Inexpensive and simple

• Cessation of movement may be a response to hypoxia

• Maternal perception of normal fetal movement is a reliable indicator of fetal wellbeing

Effects of fetal hypoxemia Fetal activity Effect of worsening hypoxia Fetal heart rate Affected first

Breathing Affected next

Movement Third to be affected

Fetal tone Last to be affected

AWHONN, (2015), p. 300 40

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Who needs FM counting?

Some recommend routine fetal movement counting, particularly in women who are high risk • Miller, Miller & Cypher, (2017), p. 224

Fetal Movement Counting

• Several counting protocols • The optimal number of movements and the ideal duration for counting movements have not been identified • There are several protocols….

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Fetal Movement Counting

• One approach is to start counting daily • 10 distinct movements in a period of up to 2 hours is reassuring • ACOG (2014) p. 2

Methods

• ACOG (2014) describes the following: • Woman lies on her side and counts FM • Perception of 10 distinct movements in a period of up to 2 hours is considered reassuring • Once 10 movements have been perceived, count may be discontinued

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Other Methods • Cardiff “Count-To-Ten” Method • Every morning at 9 a.m. lie quietly and count baby’s movements • See how long it takes for you to count 10 baby movements • When the baby has moved 10 times, mark that time on the graph • If your baby has not moved 10 times by 9 p.m., you should come to the hospital and ask to see a physician/nurse midwife

Freda, M. C., Mikhail, M., Mazloom, E., Polizzotto, R., Damus, K., & Merkatz, I. (1993) Fetal movement counting: Which method? Maternal Child Nursing, 18, 314-321.

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Methods

• ACOG (2014) also describes • Count fetal movements for 1 hour three times a week • The count is reassuring if it equals or exceeds the woman’s previously established baseline count

Other Methods • Sadovsky method • Count FM three times a day, morning, noon, and night preferably one hour after a meal • Count for one hour during each session • Lie down, if possible • During each session, stop counting after you have felt 4 movements • If you feel less than 4 movements during any one-hour time period, continue to count for one more hour • At the end of the second hour, if FM still less than 4, come to L&D and ask to see a physician/midwife

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Fetal Movement Counting • Mother’s perception of fetal activity in comparison to previously perceived fetal movement levels is MOST Valuable Information • Number of movements per week changes as pregnancy progresses: • Total weekly movements increase reaching a maximum between the 26th to 32nd week • Then movements gradually decrease until the 38th week and then should remain constant • AWHONN, (2016), p. 288

Factors Influencing Fetal Movement • Time of day • Maternal activity • Tobacco • Caffeine use • Glucose Load • Gross fetal body movements are unaffected by glucose levels which dispels a common belief that juice, or a meal is necessary prior to Fetal Movement Counting • AWHONN (2016) p. 289 • Maternal perception

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Newer Information

http://www.countthekicks.org/medical-community/educational-materials/

Non Stress Test

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Nonstress Test

• Based upon premise that FHR will temporarily accelerate if the fetus is not acidotic or neurologically depressed • Reactivity (accelerations) thought to be a good indicator of autonomic function • ACOG, (2014), pp. 2-3

Non-stress Testing (NST)

NST evaluates:

• Fetal oxygenation

• Neurological function

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Nonstress Test

• Considered reactive if there are 2 or more accelerations within 20 minutes with or without fetal movement discernable by the woman that • Increase > 15 bpm from baseline to peak of acceleration • Last > 15 seconds from beginning of rise to return to baseline

Nonstress Test

• Before 32 weeks, an acceleration is defined as a rise of at least 10 bpm lasting at least 10 seconds. • Miller, Miller &Cypher, (2017) • Some resources may say state; once a fetus < 32 weeks has achieved accelerations of 15 X 15 this is the criteria you should use in future testing • Currently there is insufficient evidence to support this premise

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Nonstress Test • Must consider gestational age • NST of a non-compromised preterm fetus is often nonreactive • Gestational age % Nonreactive 24-28 weeks 50% 28-32 weeks 15% • Fetal heart rate decelerations during an NST that persist for 1 minute or longer are associated with a ↑ cesarean sections for non-reassuring fetal heart rate and fetal demise

ACOG, 2014, p.3

Nonstress Test

May need to extend testing to 40 minutes or longer to account for fetal sleep-wake cycles If criteria not met within 40 minutes: test is non-reactive

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Nonstress Test

• A reactive NST is considered a normal test • In most institutions the test is repeated 1-2 x weekly • Miller, Miller & Cypher (2017), p. 218

ReactiveReactive NST NST 60

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Nonreactive NST

• Requires further evaluation • CST or BPP

Fetal behavioral states affect Nonstress testing startle, stretch, flex, rotate, regular and irregular breathing, suck, swallow, REM, hiccup, yawn

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Rest and Activity Cycles • 1F (quiet sleep) • Decreased FHR variability; rare accels • 2F (active sleep) • Minimal to moderate variability; accelerations • 3F (quiet awake) • Absent body movements, no FHR accelerations • 4F (active awake) • Vigorous body movements moderate to marked variability; FHR accelerations

What About Fetal Stimulation?

• Oral (orange juice) or IV glucose administration did not decrease incidence of nonreactive NST’s in 2 trials with fewer than 1000 subjects • No benefit found from fetal manipulation such as abdominal rocking • Tan & Sabapathy, (2010) • AWHONN (2015)

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Potential Exam Questions

• Interpret a NST as reactive or nonreactive • What to do for nonreactive NST • Orange juice is not the correct answer • Notify care provider and obtain an order for VAS (Vibroacoustic Stimulation)

Vibroacoustic Stimulation

• AKA: VAS or FAST • Evaluates acid base balance • acidosis prevents the fetus from reacting • lack of accels tells nothing! • presence of accels eliminates acidosis • May decrease the time needed for NST

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Method • Artificial larynx placed over fetal vertex 1-2 second stimulus applied • May be repeated 3 times for progressively longer durations of up to 3 seconds • ACOG, 2014, p. 3 • 1-2 second stimulus – Only One Application • Miller, Miller & Cypher 2017, p. 218 • Other recommendations in varying sources • Study the table in your handout regarding duration of stimulus, number of repeats, and interpretation…. • NEVER DURING A DECEL or BRADYCARDIA

1734: Acoustic stimulation

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• Another example of acoustic stim…..

FAS

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FAS

Scalp Stimulation

• Neither scalp stimulation nor vibroacoustic stimulation is appropriate during FHR decelerations or bradycardia • This is an assessment only to be used during the FHR BASELINE!!!!! • Miller, Miller & Cypher (2017) p. 159

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Menihan and Kopel-Puretz 2019 • Has eliminated the use of fetal scalp blood sampling • Clark, Gimovsky and Miller(1982 &1984): • 36/100 – Acceleration with digital pressure • pH 7.19-7.40 • 15/100 No response to digital pressure, acceleration with Allis clamp • pH 7.23-7.33 • 49/100 No response to either stimulus (digital or Allis clamp) • pH less than 7.20- (19) pH less than 7.23 (30)

Menihan and Kopel-Puretz 2019 Continued • Induced accelerations reflect a fetus with an intact ANS (autonomic nervous system) • A fetus with the ability to demonstrate spontaneous or induced accelerations is not acidotic • Again – only done during the baseline – if performed during a deceleration or bradycardia event – may have misleading results

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1249

arrived, nurse left room for supplies for room nurse left arrived, Anesthesia Anesthesia

1254 1300

Do not perform scalp stimulation during a deceleration or fetal bradycardia

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Accelerations with Stimulation

• High correlation between fetal heart rate acceleration in response to scalp or vibroacoustic stimulation and a normal scalp pH • Miller, Miller and Cypher, (2017), p. 158

WHAT IF THERE IS NOT AN ACCELERATION??????

• If no acceleration from stimulation • Fetus may or may not be acidemic • Freeman , (2012), p. 139 • AWHONN, (2015), p. 197 • May be due to drugs/medications or CNS injury • Tucker, (2004), p. 173-174

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Biophysical Profile (BPP)

Parameters

• Evaluates fetus with both EFM and real- time ultrasound • Measures five parameters • Fetal breathing movements • Gross body movements • Fetal tone • Fetal heart rate reactivity • Amniotic fluid volume

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Biophysical Profile

• Physiology • Asphyxia changes CNS function • Acute hypoxia results in loss of FHR reactivity, breathing, movement, and tone

• Chronic changes in O2 levels lead to a • Decrease in amniotic fluid (Oligohydramnios) and • Resultant variables

Biophysical Profile

• Physiology • Both quiet sleep and asphyxia can have same effects on some parameters • Fluid volume unchanged • Prematurity can change interpretation

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Biophysical Profile (Miller et al, 2017) Don’t need to memorize for the exam….

Component Normal (Score = 2) Nonstress test Reactive

Fetal breathing movements At least one episode of fetal breathing movements of at least 30 seconds duration in a 30 minute observation Fetal movement At least three trunk / limb movements in 30 minutes

Fetal tone At least one episode of active extension with return to flexion of fetal limb or trunk; opening and closing of hand considered normal tone

Amniotic fluid volume (AFV) Deepest vertical pocket > 2cm

Scoring

• Each of assigned components is assigned a score of either • 2 if normal or present • 0 if abnormal, absent, or insufficient

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Scoring • A total score or 8 or 10 with normal AFV is normal • A score of 6 is equivocal or suspicious and is usually repeated in 24 hours • Score of less than 6 is associated with an  in perinatal morbidity and mortality abnormal and require hospitalization for further evaluation • Regardless of composite score, if the largest vertical pocket of amniotic fluid volume is ≤ 2 cm, further evaluation is warranted • ACOG, (2014), pp. 3-4; Miller, Miller & Cypher (2017), pp. 221-223

For The Exam

• You may be given a biophysical profile score and be asked to interpret it as • Normal • Equivocal or suspicious • Abnormal • Or they may ask what you would do based upon the score

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For the Exam

• As fetal hypoxemia worsens • Fetal activities decrease or cease • In order to reduce energy and oxygen consumption • Occurs in the reverse order of normal neurologic development • Breathing (20-21 weeks) and FHR reactivity are the last to develop and are usually the first to be suppressed • Tone and movement developed between 7.5 to 9 weeks gestation are the last to be affected • AWHONN, (2015), p. 300

Effects of fetal hypoxemia Fetal activity Effect of worsening hypoxia

Fetal heart rate Affected first

Breathing Affected next

Movement Third to be affected

Fetal tone Last to be affected

AWHONN, (2015), p. 300 88

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Modified BPP • Is as predictive of fetal status as other types of biophysical surveillance • Combines NST with AFI • NST is a short-term indicator of fetal acid-base status • AFI is an indicator of long-term placental function • Normal if NST is reactive with no significant decelerations and AFI is greater than or equal to 2 cm • (must meet both criteria) • Regardless of the NST, if the AFI is < 2cm or less • ACOG, (2014), pp.3- 4; Miller, Miller & Cypher, (2017) , pp. 222-223

Management

Regardless of reactivity, oligohydramnios constitutes an abnormal test that requires further evaluation • Back up tests: BPP or CST

Miller, Miller & Cypher, (2017) p. 222

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AFI: Amniotic fluid index

2014 ACOG changed the requirement for evaluation of amniotic fluid volume in a Modified Biophysical Profile from the 4-quadrant amniotic fluid index to a single deepest vertical pocket of greater than 2cm

Miller, Miller and Cypher, (2017), pps. 222

Amniotic Fluid Volume

Low-normal Amniotic Fluid Volume Single deepest pocket of greater than 2cm

Low or Oligohydramnios is single deepest pocket is less than 2cm

Miller, Miller and Cypher, (2017), pps. 222-223

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VAS Vibroacoustic Stimulation

Addendum 1

Additional Information Not on the Test

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CST

Contraction Stress Test Information has been removed from the content outline

An interesting case study Shows a spontaneous CST

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G3 P2 @ 40 weeks with FM. No complications until now. 2 prior vag deliveries. Spontaneous CST 97

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Positive CST

100

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Outcome • The care provider thought the strip was “reassuring” • discharged patient home • Patient returned next morning • Delivered 7#1oz with thick mec • Apgars 5/7 • Transferred to NICU • Questionable hyaline membrane disease or meconium aspiration

101

ST Segment Analysis

• Further research is needed • Requires internal monitoring and a special machine • Evaluates the fetal ECG • Looks at the changes in the ST segment • Myocardial hypoxia can lead to elevation of ST segment and T wave

102

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Doppler Velocimetry

• Assessment of the placenta status • Assist in determining the relative risk of sudden fetal deterioration IMPORTANT – Doppler US is not used in isolation. Usually paired with BPP

103

Umbilical Artery Doppler

• Reflects placental vascular resistance • May be most useful in the pre-term infant • Mirrors the downstream resistance of the placental circulation • Normally in pregnancy umbilical artery resistance falls throughout pregnancy because of the increasing number of tertiary stem villous vessels • In pre-eclampsia and in chronic hypertensive pregnancies there is pruning of the placental arterial trees

104

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https://sonoworld.com/Client/Fetus/html/doppler/capitulos- html/chapter_03.htm

105

Umbilical Artery Doppler Continued.

• Clinical significance of this test is it is beneficial in high risk patients to track fetal growth and in cases of placental abnormalities • Most important prognostic feature of the umbilical artery waveform is the end diastolic flow • Absent flow and reversed flow represent progressively ominous finds necessitating close monitoring or consideration of delivery based upon gestational age.

106

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MCA – Middle Cerebral Artery

• Most useful with anemias, twin to twin transfusions and cardiac function (AWHONN pg. 304) measures speed of fetal blood flow • As the fetal Hct decreases and oxygen carrying capacity decreases, cardiac output increases as does transaortic velocities • An increase in diastolic velocities reflect an increase in brain flow • As IUGR worsens MCA diastolic velocities rise possibly due to shunting

107

Doppler Velocimetry and Biochemical Assessment for Fetal Lung Maturity • Additional information may be found in the Miller, Miller & Cypher book. Information is not on the content outline. See handout from Creasy and Resnik and AWHONN.

108

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The END…….

•Any Questions??????

http://www.aliexpress.com/item/6pcs-lot-high-quality-interest-creative-silicone-baby-pacifier-funny-nipple-pacifier-buck-teeth-and-rabbit/964186150.html

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References

• American College of Obstetricians and Gynecologists (2014, Reaffirmed 2019). (Replaces Practice Bulletin Number 9, October 1999). Antepartum Fetal Surveillance. ACOG Practice Bulletin Number 145, July. ACOG: Washington, DC. • American Academy of Pediatrics and American College of Obstetricians and Gynecologists (2017). Guidelines for Perinatal Care, 8th ed. Elk Grove Village, IL: AAP.

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References

• American College of Obstetricians and Gynecologists (2009, reaffirmed 2017) Replaces Practice Bulletin #70 (2005). Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. ACOG Practice Bulletin Number 106, July. ACOG: Washington, DC.

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References

• Association of Women’s Health, Obstetric, and Neonatal Nurses (2015). Fetal Heart Monitoring Principles & Practices, 5th ed. Kendall/Hunt Publishing. Washington, DC: AWHONN. • Association of Women’s Health, Obstetric, and Neonatal Nurses (2018). Fetal Heart Monitoring Position Statement. Washington, DC: AWHONN.

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References

• Devoe, L. D. (2008). Antenatal fetal assessment: Contraction stress test, nonstress test, vibroacoustic stimulation, amniotic fluid volume, biophysical profile, and modified biophysical profile—an overview. Seminars in Perinatology, 32, 247-252. • Creasy, R.K. et al. CREASY & RESNIK’S MATERNAL-FETAL MEDICINE Principles and Practice, 8th Ed. (2019). Chapter 34 Assessment of Fetal Health, Anjali J. Kaimal, MD, MAS

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References

• Freeman, R. K., Garite, T. J., & Nageotte, M. P. & Miller, L.A. (2012). Fetal Heart Rate Monitoring, 4th ed. Philadelphia: Lippincott Williams & Wilkins. • Miller, L. A., Miller, D. A., & Cypher, R.L. (2017). Fetal Monitoring: A Multidisciplinary Approach, 8th ed. St. Louis: Elsevier/Mosby.

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References

• Parer, J. T. , King, T.L. & Ikeda, T. (2018). Electronic Fetal Heart Rate Monitoring – The 5 Tier System , 3rd ed. Burlington;MA: Jones & Bartlett Learning • Simpson, K.R., Creehan, P.A. (2021) Association of Women’s Health, Obstetric, and Neonatal Nurses Perinatal Nursing 5th ed. Wolters/Lippincott. Philadelphia, PA.

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References

• Tan, K. H., & Sabapathy, A. (2001a). Maternal glucose administration for facilitating tests of fetal wellbeing. Cochrane Database of Systematic Reviews, 2001, Issue 4. Art. No.: CD003397. • Tan, K. H., & Sabapathy, A. (2001b). Fetal manipulation for facilitating tests of fetal wellbeing. Cochrane Database of Systematic Reviews, 2001, Issue 4. Art. No.: CD003396.

• Tucker, S. M., Miller, L. A., & Miller, D. A. (2009). Fetal Monitoring A Multidisciplinary Approach, 6th ed. St. Louis: Mosby/Elsevier. • Tucker, S. M. (2004). Fetal Monitoring and Assessment, 5th ed. St. Louis: Mosby.

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