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Antenatal Assessment and High Risk Delivery

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Title: Antenatal Assessment and High Risk Delivery


1
Chapter 3
Antenatal Assessment and High-Risk Delivery
(also equipment)
2
Introduction
  • During gestation period, the fetus undergoes
    various physiological development which requires
    medical attention to prevent complications at
    birth.
  • Cooperation among all members of the health care
    team is essential in identifying signs and
    symptoms of problems that might occur during
    pregnancy and thus find early solutions
  • Maternal history, antenatal assessment and
    intrapartum monitoring are all important in
    identifying early sign of risk in fetal
    development before perinatal period.

3
Maternal History and Risk Factors
  • Preterm delivery
  • Before 37 weeks of gestation
  • Cervical insufficiency
  • Toxic habits of pregnancy
  • Smoking
  • Illegal drugs
  • Alcohol

4
Maternal History
  • As a RT, you should review thoroughly the chart
    and assess the following
  • Hx of prenatal care, age of mother, is multiple
    gestation present
  • Para/Gravida
  • Current medications the mother is on
  • Approximate Gestational Age, note if water has
    broken, if birth is imminent, will it be a
    C-section or vaginal birth
  • Cervical insufficiency (Includes shortening or
    funneling due to weight of the uterus and
    developing fetus pushing down)
  • PROM (Premature rupture of fetal membrane...with
    hx of premature birth, risk of another premature
    birth goes up)
  • Toxic habits in pregnancy Alcohol, Smoking,
    Cocaine...all potent teratogens

5
Maternal History
  • As a RT, you should review thoroughly the chart
    and assess the following
  • Presence of Preclampsia (A triad of
    hypertension, proteinura and generalized edema),
    Severe Preclampsia (160/110.mmHg, gt5g/24hrs of
    protein, pulmonary edema, fetal growth
    restriction, oliguria, thrombocytopenia,
    headache, epigastric or RUQ pain, hepatocellular
    dysfunction, seizure)
  • Eclampsia, Placenta Previa, abruption
  • Genetic and cardiac abnormalities
  • Maternal HTN (2nd leading cause of maternal
    mortality, after embolism. Infant at risk for
    growth restriction, placental abruption and
    preterm delivery)

6
CERVICAL INSUFFICIENCY
  • Patients with risk factors for cervical
    insufficiency are recommended for evaluation by
    ultrasound examination of the cervix starting at
    16wks of gestation.
  • Cervical insufficiency is where the cervix dilate
    prematurely before the fetus develops fully.
  • Interventions such as cervical cerclage where
    sutures are placed around the cervical canal have
    been used in detection of such abnormality.
  • An elective cerclage should be considered for
    patients with history of 3 or more unexplained
    mid-trimester pregnancy losses or preterm
    delivery.

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Maternal History and Risk Factors (cont.)
  • Hypertension
  • Preeclampsia
  • Diabetes mellitus
  • Pregestational diabetes
  • Gestational diabetes
  • Infectious disease
  • Group B Streptococcus

10
Preclampsia
  • We may be familiar with pre-eclampsia,
    preeclampsia or often also called toxemia is a
    condition that can be experienced by any pregnant
    woman.
  • The disease is characterized by increased blood
    pressure which was followed by increased levels
    of protein in the urine. Pregnant women with
    preeclampsia also experience swelling in the feet
    and hands.
  • Preeclampsia generally appear in mid-gestation,
    although in some cases there were found in early
    pregnancy.
  • http//www.youtube.com/watch?v2t4BKI6NtTk

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Eclampsia
  • Eclampsia is a condition of continuation of
    preeclampsia are not resolved properly.
  • In addition to experiencing symptoms of
    preeclampsia, in women affected by eclampsia are
    also often suffer from seizures
  • Eclampsia can cause coma or even death of either
    before, during or after childbirth.
    http//www.youtube.com/watch?v97j0lJXMTlQ

13
Gestational Diabetes Mellitus GDM
  • Intrauterine growth restriction, preterm delivery
    and placental abruption has been found to cause
    an increase in perinatal morbidity and mortality.
  • Hypertensive disease states complicates 12-20 of
    pregnancies in the US and second only to
    embolism.
  • GDM caused by abnormal glucose tolerance that
    occurs during pregnancy. Mom has increased risk
    of getting type II diabetes after pregnancy.
    Increased risk of macrosomia (large baby 4000g),
    Traumatic vaginal delivery, and possible fetal
    death(small risk)

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Group B Streptococcus
  • type of bacterial infection that can be found in
    a pregnant womans vagina or rectum. This
    bacteria is normally found in the vagina and/or
    rectum of about 25 of all healthy, adult women.
  • Those women who test positive for GBS are said to
    be colonized. A mother can pass GBS to her baby
    during delivery. GBS is responsible for affecting
    about 1 in every 2,000 babies in the United
    States. Not every baby who is born to a mother
    who tests positive for GBS will become ill.
  • Although GBS is rare in pregnant women, the
    outcome can be severe, and therefore physicians
    include testing as a routine part of prenatal
    care.

17
Group B Streptococcus
  • The CDC has recommended routine screening for
    vaginal strep B for all pregnant women.
  • Performed between the 35th and 37th week of
    pregnancy (studies show that testing done within
    5 weeks of delivery is the most accurate at
    predicting the GBS status at time of birth.)
  • The test involves a swab of both the vagina and
    the rectum. The sample is then taken to a lab
    where a culture is analyzed for any presence of
    GBS. Test results are usually available within 24
    to 48 hours.
  • The American Academy of Pediatrics recommends
    that all women who have risk factors PRIOR to
    being screened for GBS (for example, women who
    have preterm labor beginning prior to 37
    completed weeks gestation) are treated with IV
    antibiotics until their GBS status is
    established.

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TOXIC HABITS IN PREGNANCY
  • Maternal habits should be assessed during early
    stages of gestation. Smoking, alcohol use and
    other illicit drugs use during pregnancy can have
    adverse effects on fetal development.
  • Alcohol is a potent teratogen, an agent or factor
    that causes malformation of the fetus. Alcohol
    abuse during pregnancy has been associated with
    mental retardation and prenatal and postnatal
    growth restriction. Brain, cardiac, spinal and
    craniofacial anomalies have also been associated
    with the abuse of alcohol during pregnancy. No
    safe range for drinking alcohol during pregnancy
    has been established.

20
TOXIC HABITS IN PREGNANCY
  • Smoking during gestation period equally has
    adverse effect on fetal development. Carbon
    monoxide and nicotine produce during smoking,
    reduces the amount of oxygen delivered to the
    fetus and the placenta during pregnancy. A strong
    correlation exist between small birth weight and
    cigarette smoking with mean weight of 200g or
    less recorded infants as compared to infants of
    non-smokers
  • Cocaine has strong sympathomimetic effects which
    causes vasoconstriction. It can cause various
    maternal complications such as myocardial
    infarction, stroke, seizures, bowel ischemia, and
    death if used during gestation period. Cocaine
    usage has also bee associated with placental
    abruption, preterm delivery and growth
    restriction. It also causes congenital
    malformation of the limbs, heart, brain and
    genitourinary tract. Children born to women who
    abuse opiates during pregnancy tend to have
    significant withdrawal symptoms after birth.

21
Maternal History and Risk Factors (cont.)
  • Fetal membranes
  • Premature rupture of membranes
  • Umbilical cord abnormalities
  • Number of vessels
  • Length of cord
  • Placenta
  • Placenta abruptio
  • Placenta previa

22
Fetal membranes
  • PROM
  • Risk factors for PROM can be a bacterial
    infection, smoking, or anatomic defect in the
    structure of the amniotic sac, uterus, or cervix.
    In some cases, the rupture can spontaneously
    heal, but in most cases of PROM, labor begins
    within 48 hours. When PROM occurs, it is
    necessary that the mother receives treatment to
    avoid possible infection in the newborn
  • Maternal risk factors for a premature rupture of
    membranes include chorioamnionitis or sepsis.
    Association has been found between emotional
    states of fear
  • Fetal factors include prematurity, infection,
    cord prolapse, malpresentation or genetic
    mutations

23
Umbilical cord abnormalities
  • The cord contains three blood vessels two
    arteries and one vein.
  • The vein carries oxygen and nutrients from the
    placenta (which connects to the mother's blood
    supply) to the baby.
  • The two arteries transport waste from the baby to
    the placenta (where waste is transferred to the
    mother's blood and disposed of by her kidneys).
  • A gelatin-like tissue called Wharton's jelly
    cushions and protects these blood vessels.
  • A number of abnormalities can affect the
    umbilical cord. The cord may be too long or too
    short. It may connect improperly to the placenta
    or become knotted or compressed

24
Umbilical cord abnormalities
  • They usually are not discovered until after
    delivery when the cord is examined directly.
  • Single umbilical arteryAbout 1 percent of
    singleton and about 5 percent of multiple
    pregnancies (twins, triplets or more) have an
    umbilical cord that contains only two blood
    vessels, instead of the normal three. In these
    cases, one artery is missing (2). The cause of
    this abnormality, called single umbilical artery,
    is unknown.

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Umbilical cord abnormalities
  • Single umbilical artery have an increased risk
    for birth defects, including heart, central
    nervous system and urinary-tract defects and
    chromosomal abnormalities
  • A woman whose baby is diagnosed with single
    umbilical artery during a routine ultrasound may
    be offered certain prenatal tests to diagnose or
    rule out birth defects
  • These tests may include a detailed ultrasound,
    amniocentesis (to check for chromosomal
    abnormalities) and in some cases,
    echocardiography (a special type of ultrasound to
    evaluate the fetal heart). The provider also may
    recommend that the baby have an ultrasound after
    birth.

27
Umbilical cord abnormalities
  • Umbilical cord prolapse occurs when the cord
    slips into the vagina after the membranes (bag of
    waters) have ruptured, before the baby descends
    into the birth canal. This complication affects
    about 1 in 300 births
  • The baby can put pressure on the cord as he
    passes through the cervix and vagina during labor
    and delivery. Pressure on the cord reduces or
    cuts off blood flow from the placenta to the
    baby, decreasing the baby's oxygen supply.
    Umbilical cord prolapse can result in stillbirth
    unless the baby is delivered promptly, usually by
    cesarean section

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Umbilical cord abnormalities
  • Vasa previa occurs when one or more blood
    vessels from the umbilical cord or placenta cross
    the cervix underneath the baby. The blood
    vessels, unprotected by the Wharton's jelly in
    the umbilical cord or the tissue in the placenta,
    sometimes tear when the cervix dilates or the
    membranes rupture. This can result in
    life-threatening bleeding in the baby.
  • Even if the blood vessels do not tear, the baby
    may suffer from lack of oxygen due to pressure on
    the blood vessels. Vasa previa occurs in 1 in
    2,500 births

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Umbilical cord abnormalities
  • About 25 percent of babies are born with a nuchal
    cord (the umbilical cord wrapped around the
    baby's neck)
  • A nuchal cord, also called nuchal loops, rarely
    causes any problems. Babies with a nuchal cord
    are generally healthy.
  • Sometimes fetal monitoring shows heart rate
    abnormalities during labor and delivery in babies
    with a nuchal cord. This may reflect pressure on
    the cord. However, the pressure is rarely serious
    enough to cause death or any lasting problems,
    although occasionally a cesarean delivery may be
    needed.
  • Less frequently, the umbilical cord becomes
    wrapped around other parts of the baby's body,
    such as a foot or hand. Generally, this doesn't
    harm the baby.

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HERPES SIMPLEX VIRUS
  • Babies born to women with primary or recurrent
    HSV outbreak during pregnancy, are at a risk of
    getting infested with HSV during membranes
    rupture or onset of labor.
  • The virus can ascend to infect the fetus and thus
    cesarean delivery is undertaken as soon as
    possible after membrane rupture or after the
    onset of labor.

35
HEPATITIS B VIRUS AND HUMAN IMMUNODEFICIENCY VIRUS
  • Both virus can cause death in the fetus therefore
    pregnant women should be screened for HBV and
    HIV.
  • The frequency of HIV infection is about 1 per
    1000 in the obstetric population in the United
    States with the prevalence high as 1-1.5 in
    inner-city populations. 30 of exposed fetuses
    will also acquire the infection. An
    antiretroviral drug, zidovidne used during
    pregnancy, labor and as a chemoprophylaxis for
    6wks in exposed newborns is associated with a
    decrease in perinatal HIV transmission to 8.3.
    Nursing should be discouraged in HIV positive
    women since the virus can be transferred in the
    breast milk.
  • Infants born to pregnanant women with HBV become
    infected at delivery. Anti-hepatitis B
    immunoglobulin treatments and vaccination within
    the first 12hrs of life has helped in preventing
    95 of neonatal infections. Cesarean delivery of
    these newborns has no advantage.
  • Cytomegalovirus, rubella, Toxoplasma, Listeria,
    mycobacteria and Treponema pallidum (syphilis)
    can all affect the mother, fetus and fetoplacenta
    unit significantly. Early diagnosis and
    treatments can help in avoiding complications.

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Maternal History and Risk Factors (cont.)
  • Amniotic fluid
  • Oligohydramnios
  • Polyhydramnios
  • Mode of delivery
  • Position of the fetus
  • Breech

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Cesarean Section
38
C-section
  • The first modern Caesarean section was performed
    by German gynecologist Ferdinand Adolf Kehrer in
    1881.
  • A Caesarean section is usually performed when a
    vaginal delivery would put the baby's or mother's
    life or health at risk, although in recent times
    it has also been performed upon request for
    childbirths that could otherwise have been
    natural.
  • In 2007, in the United States, the Caesarean
    section rate was 31.8.
  • Medical professional policy makers find that
    elective cesarean can be harmful to the fetus and
    neonate without benefit to the mother, and have
    established strict guidelines for non-medically
    indicated cesarean before 39 weeks.

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C-Section indications
  • Complications of labor and factors impeding
    vaginal delivery, such as
  • prolonged labor or a failure to progress
    (dystocia)
  • fetal distress
  • cord prolapse
  • uterine rupture
  • hypertension in the mother or baby after amniotic
    rupture
  • tachycardia in the mother or baby after amniotic
    rupture
  • placental problems (placenta previa, placental
    abruption or placenta accreta)
  • abnormal presentation (breech or transverse
    positions)
  • failed labor induction
  • failed instrumental delivery (by forceps or
    ventouse (Sometimes a trial of forceps/ventouse
    delivery is attempted, and if unsuccessful, it
    will be switched to a Caesarean section.)
  • large baby weighing gt4000g (macrosomia) large
    mother
  • umbilical cord abnormalities (vasa previa,
    multilobate including bilobate and
    succenturiate-lobed placentas, velamentous
    insertion)

41
C-Section indications
  • Other complications of pregnancy, pre-existing
    conditions and concomitant disease, such as
  • pre-eclampsia
  • hypertension
  • multiple births
  • previous (high risk) fetus
  • HIV infection of the mother
  • Sexually transmitted infections, such as genital
    herpes (which can be passed on to the baby if the
    baby is born vaginally, but can usually be
    treated in with medication and do not require a
    Caesarean section)
  • previous transverse Caesarean section
  • previous uterine rupture
  • prior problems with the healing of the perineum
    (from previous childbirth or Crohn's disease)
  • Bicornuate uterus
  • Rare cases of posthumous birth after the death of
    the mother
  • Lack of obstetric skill - obstetricians not being
    skilled in performing breech births, multiple
    births, etc. (In most situations, women can birth
    vaginally under these circumstances. However,
    obstetricians are not always trained in proper
    procedures)

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C-Section risks to baby
  • Non-medically indicated (elective) childbirth
    before 39 weeks gestation "carry significant
    risks for the baby with no known benefit to the
    mother."
  • TTN Retention of fluid in the lungs can occur if
    not expelled by the pressure of contractions
    during labor.
  • Potential for early delivery and complications
    Preterm delivery is possible if due-date
    calculation is inaccurate. One study found an
    increased risk of complications if a repeat
    elective Caesarean section is performed even a
    few days before the recommended 39 weeks.

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BREECH PRESENTATION
  • This mode of delivery creates a greater potential
    for complications during labor. Factors
    contributing to breech presentation includes
    multiparity, previous breech delivery, uterine
    anomalies, fetal anomalies, multiple gestation
    and polyhydramnios.
  • The term Breech Trial Collaborative Group
    conducted a multicenter randomized controlled
    trial of planned cesarean versus planned vaginal
    delivery for breech presentation at term. It
    concluded that planned cesarean delivery is
    preferred because of less risk for perinatal
    mortality or serious morbidity and no increase in
    serious maternal complications.
  • http//www.youtube.com/watch?vO6jddbdeFUo

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ASSISTED VAGINAL DELIVERY
  • Obstetric forceps is an instrument used to cradle
    and guide the fetal head while applying traction
    to expedite delivery. The vacuum extractor is a
    suction device that holds the head tightly and
    allows traction to be applied. Indications for
    forceps or vacuum usage include s maternal
    cardiac , pulmonary or neurologic disease which
    contraindicate s the pushing process maternal
    exhaustion in labor and nonreassuring fetal
    status.
  • Obstetrician forceps
  • VACUUM

45
Antenatal Assessment
46
Antenatal Assessment (cont.)
  • Amniocentesis
  • Diagnostics
  • Lung maturity
  • Abnormalities
  • Laboratory results
  • Chromosomal

47
Nonstress and Contractal Stress Test
  • Placental function
  • Fetal heart rate
  • Movement
  • Nonstress test
  • Contractions
  • Stress test

48
Contractal Stress Test
49
Contractal Stress Test (cont.)
50
Contractal Stress Test (cont.)
51
Contractal Stress Test (cont.)
52
Biophysical Profile
53
Intrapartum Monitoring
  • Fetal heart rate
  • Scalp blood gas
  • Cord blood gas
  • Fetal pulse oximetry

54
High-Risk Conditions
  • Preterm birth
  • Earlier than 37 weeks
  • Comorbidity
  • Risk factors
  • Tocolysis
  • Maternal steroids

55
High Risk Conditions (cont.)
  • Post term delivery
  • Causes
  • Associated maternal and fetal conditions
  • Meconium aspiration
  • Placental insufficiency
  • Inducing labor (Pitocin)

56
Equipment
  • During delivery (as discussed in NRP)
  • Flow inflating bag or Neo-Puff (T-piece)
  • Suction equipment (bulb, 5/6 F, 8F, 10F) set at
    -60-80 mmHg, Meconium aspirator
  • Intubation equipment ETT 2.5-3.5, cloth tape,
    scissors, blades 00-1 (straight blades) skin
    prep swabs, End Tidal CO2 detector
  • Pulse Ox probe
  • Blender
  • Temperature probe
  • Cord clamp
  • Capillary tube/lancet
  • OG feeding tube 8F
  • Warm blankets/Radient warmer
  • Medication box with Epinephrine, NS, UAC/UVC kit

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UVC placement
  • 1.Size 5 Fr umbilical catheter2. Vein larger
    but floppy wall3. Grasp the end of the umbilical
    stump with the curved hemostat to hold it
    upright and steady.4. Open and dilate the vein
    with forcep .5. Insert depth (a) the length
    from the xyphoid to the umbilicus and add
    0.51.0 cm. (b) 2/3 of shoulder-umbilicus
    distance (c) half of the UA line
    calculation6. Connect the catheter to the fluid
    and tubing7. Obtain an X-ray film8. Desired
    position catheter tip 0.51.0cm above the
    diaphragm9. Avoid the catheter entering the
    hepatic vein which may cause portal hypertension.

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UVC placement
  • 10. When to suspect catheter entering the hepatic
    vein If you meet resistance and cannot advance
    the catheter to the desired distance.(a) Try
    injecting flush as you advance the catheter (b)
    Withdraw catheter 2-3 cm, and gently rotate and
    reinsert in an attempt to get it through ductus
    venosus.

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UVC
  • Position
  • An umbilical venous catheter generally passes
    directly superiorly and remains relatively
    anterior in the abdomen. It passes through the
    umbilicus, umbilical vein, left portal vein,
    ductus venosus, middle or left hepatic vein, and
    into the inferior vena cava. 
  • The tip should lie at the junction of the
    inferior vena cava with the right atrium.

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  • Too long
  • If the umbilical venous catheter is advanced too
    far along its intended course, the tip may end up
    in a number of locations
  • left atrium and beyond (through a patent foramen
    ovale or an atrial septal defect)
  • pulmonary vein
  • left ventricle etc... 
  • right atrium and beyond
  • superior vena cava
  • right ventricle etc... 

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Most babies lt1250 grams (lt32 weeks) will need a
2.5 mm ID (internal diameter) ET tube. 1250 -
3000 grams (32-38 weeks) a 3.0 ID tube and gt3000
grams (gt38weeks) a 3.5 ID tube.
 Baby Weight(kg)  Tube Size(mm)  Oral Tube Length at Lip(cm)  Nasal Tube Length at Nose(cm)  Suction Tube Size(Fr)
 lt1.0 2.5 5.5 7.0  6 
1.0   2.5-3.0  6.0 7.5 6
2.0  3.0  7.0 9.0 6
3.0  3.0  8.5  10.5 6
3.5  3.0-3.5  9.0  11.0 8
4.0  3.5  9.0  11.0 8
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ETT Confirmation
  • The ET should be passed so that the tip lies
    approximately midway between the vocal cords and
    the carina. Tube position can be confirmed by
  • ensuring the ET tube tip is no more than between
    2.5 to 3.0cm beyond the vocal cords (to avoid
    intubation of the right main bronchus)
  • use of End Tidal CO2 detector
  • observing symmetrical chest-wall motion
  • hearing equal air entry on both sides of chest
    and not over stomach (may be an unreliable sign
    in tiny infants)
  • seeing moisture in the ET tube during exhalation
  • improvement of clinical condition
  • chest x-ray (ET tube tip is seen at the level of
    T2-T3)

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Taping
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NCPAP
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  • A Neonatal High Flow cannula up to 8L
  • B. Air/Oxygen Blender
  • C. Flowmeter for resuscitation bag
  • D. HFNC
  • E. Tubing
  • F. Heater
  • G. Water for concha

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