Professional Documents
Culture Documents
and wellbeing
assessment.
Dr. Clayon Kelly
Clinical assessment
Naegeles Rule
Most common means of pregnancy
dating
EDD is calculated by counting back 3
months and adding 7 days,
LMP = Feb 20/ EDD = Nov 27
Naegeles Rule
Limitations
Many women do not have a 28 day cycle
(follicular phase is variable)
Fertile window is more than 1 day (which is
not necessarily on day 14)
There are variations in time from fertilization
to implantation
Many women are uncertain of LMP
Early pregnancy bleeding or recent OCP usage
can lead to incorrect assumption of date of
ovulation
Clinical asssessment
Uterine size
Uterus remains a pelvic organ until 12
weeks gestation, where it is just above
the symphysis pubis
At 16 weeks- midway between
symphysis and umbilicus
At 20 weeks at umbilicus
After 20 weeks the SFH in cm should
correlate with week of gestation
Uterine size
Limitations
Pelvic mass (leiomyoma)
Obesity
Retroverted uterus
Fetal maturity
Two types of tests are used to
determine pulmonary maturity: (1)
biochemical tests measure the
concentration of particular
components of pulmonary surfactant
and (2) biophysical tests evaluate the
surface-active effects of these
phospholipids.
Biochemical Tests
Lecithin/sphingomyelin ratio The
lecithin/sphingomyelin (L/S) ratio for assessment of fetal
pulmonary maturity is based upon the observation that
there is outward flow of pulmonary secretions from the
lungs into the amniotic fluid.
This process changes the phospholipid composition of
amniotic fluid, thereby enabling indirect assessment of
fetal lung maturity through evaluation of this fluid. The
concentrations of lecithin and sphingomyelin in amniotic
fluid are approximately equal until 32 to 33 weeks of
gestation, at which time the concentration of lecithin
begins to increase significantly while the sphingomyelin
concentration remains about the same.
Phosphatidylglycerol Phosphatidylglycerol
(PG) is a minor constituent of surfactant. It begins
to increase appreciably in amniotic fluid several
weeks after the rise in lecithin.
Because PG enhances the spread of phospholipids
on the alveoli, its presence indicates an advanced
state of fetal lung development and function. It may
be reported qualitatively as positive or negative,
where positive represents an exceedingly low risk
of RDS, or in a quantitative fashion, in which a
value 0.3 is associated with a minimal rate of
respiratory distress.
Biophysical test
The foam stability index (FSI) is a rapid predictor of
fetal lung maturity based upon the ability of
surfactant to generate stable foam in the presence of
ethanol.
Ethanol is added to a sample of amniotic fluid to
eliminate the effects of non-surfactant factors on
foam formation. The mixture is then shaken and will
demonstrate generation of a stable ring of foam if
surfactant is present.
The foam stability index (FSI) is calculated by utilizing
serial dilutions of ethanol to quantitate the amount of
surfactant present.
Fetal wellbeing
WHAT ARE WE
ASSESSING FOR?
As levels of oxygen in the brain fall,
various areas of the brain and spinal
cord are increasingly inhibited
This results in progressive loss of
fetal breathing movements, gross
fetal movements and fetal tone
Persistent Hypoxia fetal demise
ADVERSE EFFECTS
OF HYPOXIA
Fetal Outcomes
Neonatal Outcomes
Stillbirth
Mortality
Metabolic acidosis
at birth
Metabolic acidosis
Hypoxic renal damage
Necrotizing
enterocolitis
Intracranial
haemorrhage
Seizures
Cerebral palsy
WHICH TO ASSESS?
Small for gestational age fetus
Decreased fetal movement
Postdates pregnancy
Pre-eclampsia/chronic hypertension
Pre-pregnancy diabetes
Insulin requiring gestational diabetes
Preterm premature rupture of membranes
Chronic (stable) abruption
Rhesus isoimmunization
HOW TO ASSESS
Assessment of fetal condition can be performed by
various means
Easy to perform
Inexpensive
Convenient
Keeps the patient aware of her fetus's
usual behavioral pattern
2 types
Sadovsky technique
Mother rest after eating for 1 hour and
fetal activity checked (5- 10)
Fetal heart
auscultation
This may be done sonographically from anytime
after six weeks; via hand help Doppler from
early in the second trimester; and by
auscultation after 26 to 28 weeks.
The normal fetal heart range is 110-160 beats
per minute; the baseline rate tends to fall as
pregnancy progresses. Regular auscultation
which reveals a regular, normal rate and
rhythm is encouraging. Abnormal heart rhythms
may include tachycardias, bradycardias, or
irregularity in the heart rate.
NST
Ultrasound
Sonographic evaluation using the biophysical
profile or Doppler velocimetry are widely used for
antepartum evaluation. However, neither test is
useful for intrapartum fetal monitoring
Doppler waveform analysis of the umbilical artery
is used extensively for assessing downstream
resistance to flow. The value of this technique is
primarily for monitoring growth restricted fetuses.
It is not recommended for general fetal
surveillance
Result
SONOGRAPHIC
ASESSMENT
Asphyxia Asphyxia Risk of
Treatment
Risk
Death
(per
1000/wk)
10/10
None
0.565
None
8/10
None
0.565
None
8/8
None
0.565
None
8/10 (AFI)
Chronic
5-10
20-30
>37, deliver
<37, serial
testing
6/10
? Acute
50
>37, deliver
<37, rpt. In 24
hrs: deliver if
persistent
Result
SONOGRAPHIC
ASESSMENT
Asphyxia Asphyxia Risk of
Treatment
Risk
Death (per
1000/wk)
6/10 (AFI)
Chronic +
acute
>10
>50
>34, deliver
<34, test od
4/10
Acute
36
115
>34, deliver
<34, test od
4/10 (AFI)
Acute +
chronic
>36
>115
>28, deliver
2/10
Acute
73
220
>28, deliver
0/10
Severe
100
1000
>28, deliver
SONOGRAPHIC
ASESSMENT
Score of 8 or 10 good outcome, predictive for one
week
Score of 6 equivocal; repeat and reassess within
24 hrs.
Score of 4 or less needs delivery; timing according
to gestational age and/or severity of score
DOPPLER STUDIES
The Doppler effect is a change in the
frequency of a wave, resulting from
motion of the wave source or receiver,
or in the case of a reflected wave,
motion of the reflector
DOPPLER STUDIES
Umbilical artery Doppler studies should
not be used as a screening tool in the
general population
DOPPLER STUDIES
Other high risk pregnancies may also
benefit
DOPPLER STUDIES
Intervention based on the identification
of abnormal umbilical artery waveform
patterns has reduced the incidence of
perinatal death by 38% in pregnancies
at risk
DOPPLER STUDIES
ADVANTAGES
Relatively low cost
Equipment generally available
DOPPLER STUDIES
DISADVANTAGES
Assessment requires some skill
Assessment is sometimes highly user
dependent
Not appropriate in labour
Limited application
Biochemical
Capillary blood collected from the fetal
scalp usually correlates well with
arterial values. However, scalp edema
can result in erroneous results. A scalp
pH value of <7.20 has traditionally
been used to represent the critical
value for identifying fetal acidosis.
BIOCHEMICAL MONITORING
THANK YOU