DIAGNOSTIC TESTS TO ASSESS FETAL WELL-BEING WORKBOOK

Ultrasound:
A G 3 P 1 patient is in her 23rd week of pregnancy. Her last normal menstrual period
began 5 months ago, but she had some bleeding 4 months ago. Your physical
assessment provides the following data: The fundus is palpable at 2 finger-breaths
below the umbilicus; the FHR is 140. The patient states that she has not felt
quickening. Based on this information, why do you think this patient will have an
ultrasound?
Based on the information given above, I would think that the indications
for an ultrasound would be to evaluate fetal growth and well-being,
evaluate vaginal bleeding, and to determine the significant discrepancy
between uterine size and clinical date. The patients FHR is appropriate
for gestational age but the vaginal bleeding and small fundal height need
to be further investigated.

1. How will you teach/prepare this patient for an ultrasound?

I would explain the procedure to the patient and answer any questions she
had. I would then explain that she needs to drink 1-1.5 quarts of water
approximately two hours prior to examination and I would advise her to
not void because her bladder needs to be full during the procedure in
order for best accuracy. If a transvaginal ultrasound were performed, then
I would prepare as if a pelvic examination was about to be performed.

2. Describe the US procedure and purposes during the First trimester.

During the first trimester, transabdominal US can detect a gestational sac
as early as four to five weeks after LMP, FHR by 6 to 7 weeks, and fetal
breathing by 10-11 weeks. If EDB is unknown an US can be ordered. The
procedure includes the patient lying in lithotomy position, with
appropriate drapes and making sure the patients buttocks are at the end
of the table.

3. Describe the US procedure and purposes during the Second and Third Trimesters.
During the second and third trimester a standard ultrasound exam is
performed to evaluate fetal presentation, fetal number, amniotic fluid

volume, placental position, cardiac activity, fetal biometry, and anatomic

survey. The patient undergoes the same procedure as explained in the
previous question.

4. Discuss the Advantages and Disadvantages of an US.

There is no evidence of physical harm to the fetus. In large studies,
researchers compared several outcomes between a group of women who
had US exams performed and a group of women who did not. The group
the had an US exam showed higher rates of detections of abnormalities
and multiple gestations. There were no significant differences in
outcomes.

MATERNAL ASSESSMENT OF FETAL MOVEMENT/ASSESSING FETAL ACTIVITY:

Your patient is pregnant for the first time. She asks you how to monitor her babys
movements.
1. What is the purpose of monitoring kick counts?
The purpose of monitoring kick counts is to regularly assess fetal wellbeing. Marked decrease in activity or cessation of movement may indicate
possible fetal compromise requiring immediate evaluation. The
coordination of whole body movement in the fetus requires complex
neurological control, so fetal movement is very important.

2. Discuss the various protocols for this procedure (Include the Cardiff Count-to Ten
Scoring).
There are a variety of methods when assessing fetal movement. One of
which is inexpensive, noninvasive, and easily done. This method is called
Cardiff Count-to Ten. In this method the woman will place an X for each
fetal movement until she has recorded ten. The woman is supposed to
count 3 times a day for 20-30 minutes each session. If fewer than 3
movements in a session, have the woman count for an hour.

3. What are the advantages and disadvantages for this procedure?

Some advantages are that the woman may not understand that certain
things could affect the movements of the fetus such as caffeine, exercise,
or even time of day. She can also have false feelings of movements. It also
reduces maternal anxiety.

BIOPHYSICAL PROFILE:

The physician has ordered a BPP for your patient.

1. Explain this procedure to her.
Tell her it uses a realtime noninvasive ultrasound to visualize physical and
physiological characteristics of the fetus and observe for fetal biophysical
responses to stimuli. It will identify a compromised fetus or confirm a
healthy fetus. It will feel just like any other ultrasound and usually takes
less than 8 minutes, but can take 30 minutes.

2. Where will this procedure be performed?

Most often, a biophysical profile (BPP) is performed by an obstetrician, but
can be performed by ultrasound technologist, radiologist, or a specialized
nurse. A BPP is usually performed in your doctors office, hospital, or
clinic.

3. What are the 5 parameters of BPP? Discuss each parameter.

ATI : BPP assesses fetal wellbeing by measuring the following five
variables with a score of 2 for each normal finding, and 0 for each
abnormal finding for each variable.
I

FHR acceleration/Reactive FHR (reactive nonstress test) = 2;

nonreactive = 0.

Fetal breathing movements (at least 1 episode of greater than 30

seconds duration in 30 min) = 2; absent or less than 30 seconds duration

= 0.
I

Fetal movements/Gross body movements (at least 3 body or limb

extensions with return to flexion in 30 min) = 2; less than 3 episodes = 0.

Fetal tone (at least 1 episode of extension with return to flexion)

= 2; slow extension and flexion, lack of flexion, or absent movement = 0.

Qualitative amniotic fluid volume (at least 1 pocket of fluid that

measures at least 2 cm in 2 perpendicular planes) = 2; pockets absent or
less than 2 cm = 0.

Test
FHR
Acceleration/Reacti
ve FHR by reactive
nonstress test (NST)

Fetal breathing
movements by
ultrasound scanning

Gross body
movements by
ultrasound scanning

BPP Scoring:
Normal (2)
Greater than or equal to 2
accelerations of greater than or
equal to 15 beats/min for greater
than or equal to 15 seconds in 2040 minutes

Greater than or equal to 1 episode

of rhythmic breathing lasting
greater than or equal to 30 sec
within 30 min
Greater than or equal to 3 discrete
body or limb movements in 30
min (episodes of active
continuous movement considered
as single movement)

Fetal tone by
ultrasound scanning

Greater than or equal to 1 episode

of extension of a fetal extremity
with return to flexion, or opening
or closing of hand

Amniotic fluid

At least one pocket of at least 2

Abnormal (0)
0 or 1 acceleration in 2040
minutes

Less than 30 sec of breathing

in 30 min

Less than or equal to 2

movements in 30 min

No movements of
extention/flexion

Less than 1 pocket of

amniotic fluid measuring less

volume by amniotic
fluid index

than 2 cm

cm AFI>5

4. How is BPP interpreted and what are the indications for the scores?
ATI : Interpretation of findings:
B

Total score of 8 to 10 is normal; low risk of chronic fetal asphyxia

4 to 6 is abnormal; suspect chronic fetal asphyxia

< 4 is abnormal; strongly suspect chronic fetal asphyxia

Perinatal
Mortality
Within 1 Week
Without
Intervention

Test Score

Interpretation

Management

10/10

No fetal indication for intervention; repeat

Normal
test weekly except in patient with DM and
nonasphyixiated Less than 1/1000
pregnancies that are postterm (twice
fetus
weekly)

8/10 (normal Risk of fetal

fluid)8/8 (if no asphyxia
NST done)
extremely rare

Less than 1/1000 Same as above

8/10
(abnormal
fluid)

89/1000

Induce birth

Chronic fetal
asphyxia
suspected

6/10

Possible fetal
asphyxia

89/1000

If amniotic fluid volume abnormal, induce

birthIf normal fluid at greater than 36
weeks with favorable cervix, induce birthIf
repeat test less than or equal to 6, induce
birthIf repeat test greater than 6, observe
and repeat per protocol

4/10

Probable fetal
asphyxia

91/1000

Repeat testing same day; if BPP score less

than or equal to 6, induce birth

2/10

Almost certain
fetal asphyxia

125/1000

Induce birth

0/10

Certain fetal
asphyxia

600/1000

Induce birth

NONSTRESS TEST:
Betty is an insulin-dependent diabetic in her 32 nd week of pregnancy. She is
scheduled for a NST.
1. Why is she having the test?
NST test are performed at 28 weeks and are increased to twice a week at
32 weeks because pregnancies complicated by DM are at increased risk
for neural tube defects. Used to rule out the risk for fetal death.
2. How would you explain the procedure for performing an NST to the patient?
A nonstress test is used to evaluate your baby's wellbeing. It is a
noninvasive procedure that monitors the response of the baby's heart rate
to fetal movement. A doppler is used to monitor the baby and a
tocotransducer is used to monitor uterine contractions. You will push a
button every time you feel your baby move.

3. What findings suggest that the fetus if healthy?

A reactive NST determines that the FHR is a normal baseline rate with
moderate variability and accelerates to 15 bpm for at least 15 secnds and
occurs two or more times during a 20 minute period.

4. How often is this test likely to be performed?

NST might be started at 28 weeks but may begin at 26 weeks. NST are
increased to twice a week at 32 weeks gestation. If a NST is nonreactive
then a contraction stress test will be performed. If the woman requires
hospitalizations NSTs may be done daily.

5. Describe what a fetal monitoring strip would show in each case. What further
testing may be indicated?

a. Reactive
A reactive NST determines that the FHR is a normal baseline rate with
moderate variability and accelerates to 15 bpm for at least 15 seconds
and occurs two or more times during a 20 minute period.

b. Nonreactive
A reactive NST determines that the FHR is a normal baseline rate with
moderate variability and accelerates to 15 bpm for at least 15 seconds
and occurs two or more times during a 20 minute period.

6. Discuss the advantages and disadvantages of the NST.

Disadvantages include a high rate of false nonreactive results with the
fetal movement response blunted by sleep cycles if the fetus, fetal
immaturity, maternal medication, and chronic smoking. Both fetal
movement and the amplitude of FHR accelerations increase with
gestational age.

7. Discuss the interpretation of the findings for reporting to the HCP.

The nurse performs the NST and has to report findings to the HCP. Variable
decelerations do not indicate fetal compromise if they are brief and
nonrepetitive (less than 30 seconds). Repetitive variable decelerations (at
least 3 in 20 minutes) are at increased risk of c/s, if they last 1 minute or
longer the likelihood of having a c/s birth is high. Nurses may or may not
interpret the results and they will report the findings to the HCP and

possibly the family and provide teaching.

CONTRACTION STRESS TEST:

After performing a NST for 1 hour in the womens clinic, your patient had a
Nonreactive NST finding.
The physician has now ordered a CST.

1. How would you explain this new procedure to the patient?

The contraction stress test is a way to see the respiratory function of the
placenta. It can identify the fetus at risk for intrauterine asphyxia by
looking at the response of the FHR to the stress of uterine contractions.
You will lay in a semi-Fowlers position or side-lying position to avoid
supine hypotension. The ultrasonic transducer is placed on your abdomen
over the area of the fetal back or chest so the FHR can be monitored. For
the first 15-20 minutes. You will record a baseline measurement and then
the breast stimulation or Pitocin will be released.

2. Where would the CST be performed?

The CST would be performed in an outpatient setting. In a hospital or
office

3. Distinguish between the two ways to perform CST.

There are two different ways to perform CSTs. One way is to administer
oxytocin IV just like whats done in an induction. The other way is to
mechanically stimulate the breast, nipples, so that oxytocin will be
released and cause contractions.

1. Discuss the advantages and disadvantages of a CST.

If youre having a high-risk pregnancy, your healthcare practitioner might
recommend it as you get closer to your due date. The contraction stress

test is more cumbersome, expensive, and risky than other similar tests, so
its not done very often anymore

2. Discuss the interpretation of the findings for reporting to the HCP.

If the result is negative then there are no late or significant variable
decelerations. If the result is positive, then there are late decelerations
following 50% or more of contractions. If there are intermittent late
decelerations or significant variable decelerations, a follow-up test should
be conducted.

MSAFP/QUADRUPLE MARKER SCREENING:

1. Explain the difference between MSAFP and AFP.

An AFP is a fetal protein that is excreted from the fetal yolk sac during the
first 6 weeks. It can detect anecephally and spina bifida as well as trisomy
21 and trisomy 18.

2. Why is MSAFP considered a screening test?

It is a screening for Downs Syndrome, which is the most common
chromosomal abnormality found in live births.

3. What are the possible causes of elevated AFP?

If the fetus has a neural tube defect, AFP will be elevated.

4. What are the possible causes of low levels of AFP?

There is a greater chance of Downs Syndrome or trisomy 18

5. Discuss the timing of the AFP and the procedure.

It is conducted in the second trimester by amniocentesis ( 16-17 weeks)

6. What are the advantages and limitations of MSAFP?

If the woman is over 35, it can skew the results. It is only a screen and not
a diagnostic as well. If the screen is positive, then it can help the monitor
prepare emotionally.

7. What is multiple marker screening and why is this performed?

hCG (human chorionic gonadotropin) ~ which is made by the placenta
estriol ~ made by the placenta
fetus alpha-fetoprotein (AFP) ~ made by the fetus

AMNIOCENTESIS:

Joann is a primigravida with Pregnancy induced hypertension in her 35 th week of

pregnancy. She is scheduled for an amniocentesis today.

1. What is the purpose of an amniocentesis, consider time performed?

The purpose is to check for genetic abnormalities, respiratory problems,
Rh problems, possible infection as well as inborn errors.

2. Why do you think this patient is having this procedure performed?

This patient could be genetically inclined for chromosomal errors, they
might need to know the fetus respiratory status as well as diagnose an
Rh problem.

3. How is fetal lung maturity confirmed? Discuss L/S ratio.

Lecithin and sphongomyelin are found in the amniotic fluid. The ratio 0.5:1
at 20 wks, 1:1 at 30-32 wks, and 2:1 at 35 wks.

4. Why is bilirubin in amniotic fluid evaluated?

Testing bilirubin from the amniotic fluid can detect Rh incompatibility or if
the fetus is losing too many RBCs.

5. What pre-procedure and post-procedure care is indicated?

Vitals obtained from mother, FHR, clean abdomen, ultrasound, reassess
blood type and obtain consent. Prior to test, blood may be taken to
determine blood type and Rh factor.

6. What are the advantages of this procedure?

It is 99% accurate and the test can be used for many types of diagnostic
tests.

7. Why is early amniocentesis sometimes chosen over standard amniocentesis for

prenatal diagnosis of genetic disorders?
It may be necessary to further investigate possible problems or concerns.

8. What are risks associated with amniocentesis?

The risks are low but include transient vaginal spotting, cramping, or
amniotic fluid leakage. Chorioamnionitis is very rare but possible.

CHORIONIC VILLUS SAMPLING:

1. What is the purpose of Chorionic villus sampling and why would it be ordered?
The purpose of this is to detect genetic, metabolic, and DNA
abnormalities.

2. What is the major advantage of CVS compared to the amniocentesis?

The greatest advantage is the earlier diagnosis/detection due to the fact
that amniocentesis isnt performed until at least 16 weeks.

3. What major risks are associated with CVS?

There is a risk for a spontaneous abortion, failure to obtain tissue, rupture
of membranes, leakage of amniotic fluid, vaginal spotting/bleeding,
chorioamnionitis, interactive infection, mandibular defects or Rh
immunization.

CORDOCENTESIS/PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS):

1. What is the purpose of Cordocentesis/ PUBS and why would it be used?

This procedure is used for diagnosis of hemophilia, fetal infections,
chromosome abnormalities, nonimmune hydrops, and isoimmune
hemolytic disorders, as well as assessment of fetal hemoglobin/hct for
calculation of transfusion requirements in 2nd and 3rd trimester.

2. Describe the procedure and post procedure follow-up.

The bladder needs to be full for the ultrasound. An ultrasound is done and
a 25 gauge spinal needle is inserted along the fetal umbilical cord. Fetal
blood is drawn from needle. Follow up if testing is positive.

3. What are the risks associated with this procedure?

Complications include failure to obtain a bleeding sample, bleeding from
the site, fetal bradycardia, premature rupture of membranes, and
chorioamnionitis.