Antenatal Assessment and High Risk Delivery

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Chapter 3
Antenatal Assessment and High-Risk Delivery
(also equipment)
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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.

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Maternal History and Risk Factors

• Preterm delivery
• Before 37 weeks of gestation
• Cervical insufficiency
• Toxic habits of pregnancy
• Smoking
• Illegal drugs
• Alcohol

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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

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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)

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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

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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

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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.

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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.

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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.

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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

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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

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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

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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.

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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.

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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
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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)

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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

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Antenatal Assessment
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Antenatal Assessment (cont.)

• Amniocentesis
• Diagnostics
• Lung maturity
• Abnormalities
• Laboratory results
• Chromosomal

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Nonstress and Contractal Stress Test

• Placental function
• Fetal heart rate
• Movement
• Nonstress test
• Contractions
• Stress test

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Contractal Stress Test
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Contractal Stress Test (cont.)
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Contractal Stress Test (cont.)
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Contractal Stress Test (cont.)
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Biophysical Profile
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Intrapartum Monitoring

• Fetal heart rate
• Scalp blood gas
• Cord blood gas
• Fetal pulse oximetry

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High-Risk Conditions

• Preterm birth
• Earlier than 37 weeks
• Comorbidity
• Risk factors
• Tocolysis
• Maternal steroids

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High Risk Conditions (cont.)

• Post term delivery
• Causes
• Associated maternal and fetal conditions
• Meconium aspiration
• Placental insufficiency
• Inducing labor (Pitocin)

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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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