MODALITIES OF DIAGNOSIS - NURSING ASSIGNMENT
INTRODUCTION
Advances in technology mean that assessment of the fetus
during pregnancy has become increasingly sophisticated and more widespread. For
example, biochemical tests on maternal sternum are commonly perbaned in order
to identify which pregnancies carry a high risk of down syndrome. Also
ultrasound scanning is continually being refined. More potential abnormalities
are identified in the antenatal period.
ASSESSMENT
OF FETAL WELL BEING IN EARLY PREGNANCY
Antenatal assessment of fetal well being in early pregnancy
is primarily designed to detect fetal congenital abnormality, chromosomal
disorder, sex linked genetic disorders or inborn errors of metabolism it can be
done in two ways.
·
Biochemical
·
Biophysical
BIOCHEMICAL
Maternal Serum Alpha Fetoprotein (MSAFP)
Description:
MS-AFP levels are analysed at 15-20 weeks gestation to
identify certain birth detects and chromosomal abnormally during pregnancy. AFP
us a major protein produced in the fetal yoksac during the first trimestes and
in the fetal lives during rare term.
·
Elevated AFP levels
are associated with birth defects and chromosomal abnormalities, such as open
neural tube defects, open abdominal defects and congenital nephrosis.
·
Also associated with
pH 150 immunization, multiple gestation, maternal DM, and Fetoplacental
dysfunction.
·
Decreased level are
associated with down syndrome and other chromosome anomalies.
Procedure:
·
Obtain health and
pregnancy history including the LMP and risk factors. Accurate dating of
pregnancy is crucial to interpret the result of the serum levels.
·
Explain the purpose
and procedure for the test.
·
Discuss the woman’s
concerns, and make ensure that informed consent is signed.
·
Assemble equipments
·
Provide privacy
·
Assist the patient to
lie in supine position
·
Check the maternal
vital signs
·
Wash hands and put on
gloves
·
Select the and examine
the vein, visualize the vein and palpate the vein
·
Instruct the patient
to extent his arm, cleanse the skin with swap in circular motion.
·
Insert the needle and
withdraw adequate amount of blood
·
Apply a gauze piece to
the puncture site without applying pressure and withdraw the needle slowly.
·
Eject the blood sample
into appropriate container and label the specimen and sent to laboratory.
·
Purpose the needle and
syringe and clean the hands.
Triple Test
Description
·
It is a combined
biochemical test which includes MSAFP, HCG and UE3 conconjugated estriol
·
It is mainly used for
the detection of downs syndrome
·
In an a flected
pregnancy the level of AFP and UE3 tend to be low while hcg is high
·
It is performed at
15-18 weeks
·
It gives a risk
ration, if this risk is greater than a specific limit (250) then the mother is
consider to be a high risk group and offered for further diagnostic test
INVASIVE
DIAGNOSTIC TESTS
AMNIOCENTESIS
Definition
Amniocentesis is a deliberate puncture of the amniotic sac
per abdomen for diagnostic and therapeutic purposes.
Description
Amniocentesis is a procedure needing informed consent in
which amniotic fluid is removed from the uterine cavity by inserting a needle
through the abdomen and uterine walls into the amniotic sac. The normal time
for the procedure is 16 to 18 weeks gestation when approximately 20 ml of
amniotic fluid is removed and sent for analysis.
Indications
A. Dianostic
·
Early months
For dianosis of chromosomal and genetic disorders
o Sex linked disorder
o Karyotyping
o Inborn errors of metabolism
o Neural tube defects
·
Later months
o Fetal maturity
o Degree of fetal hemolyis in Rh sentized mother
o Mechnium staining of liquor
o Amniography or
tetography
B. Therapuetic
·
Fast half of pregnancy
o Induction of abortion by instillation of chemicals such as
hypertonic saline, urea or prostaglandin
o Decompression of uterus in acute hydramnious
·
Second half of
pregnancy
o Decompression of uterus in unresponsive care of chronic
hydramnious
o To give intrauterine fetal transfusion in severe hemolysis
following Rh isoimmunization
o Amnioinfusion –infusion of warm normal saline into the
amniotic cavity, transabdominally or transvertically to increase the volume
amniotic fluid.
Preprocedural Preparations
1.
Obtain informed
consent
2.
ensure that
ultrasonogram is done for sonographic localization of placenta to prevent
bloody tap and fetomaternal bleeding
3.
Prophylactic
administration of 100 mg of antiimmuno globalin in Rh negative non-immunized
mother
4.
Ask the patient to
empty her bladder
5.
skin preparation
6.
Obtain maternal vital
signs and a 20 minutes fetal heait rate tracing to serve as baseline
Articles and Equipments Needed
·
TPR Tray
·
Stethoscope
·
Sterile gloves
·
Dressing tray
·
Sterile towels
·
1% rignocaine
·
Disposable syringes
5ml, 2ml
·
Cotton swabs
·
Antiseptic solutions
·
Sterile bottles – to
collect the specimen
·
20-22 gauze spinal
needle of 4 inch length with stillette
·
Adhesive plaster
Procedure
·
Explain to the patient
the need purpose of procedure and how it will be done
·
Ensure that informed
consent is signed
·
Have the woman empty
her bladder
·
Assemble equipment
·
Provide privacy
·
Assist patient to lie
in dorsal position
·
Check the maternal
vital signs and fetal heat rate
·
Wash hands and don
sterile gloves
·
Start IV fluids in
accordance with institutional policy
·
Administer terbataline
scor IV or ritodrin IV per institutional policy
·
An ultrasound
examination is performed and the placenta localized and a pool of liquor found
·
Drape the area with
sterile towels
·
Prepare abdominal wall
aseptically
·
Assist the physician
in infiltrating the proposed site of puncture with 2 ml of 1% lignocaine
·
Ensure adequate time
between infiltration of local anesthetic and introduction of needle into the
amniotic sac
·
Assist physician while
inserting the needle and stellette (A 20 to 22 gauze spinal needle) through the
abdominal wall into uterus, under direct ultrasound guidance the stillet is the
withdrawn and a few drops of liquor are discussed.
·
Physician withdraw
10-20 ml of amniotic fluid for analysis alter that keep a dressing gauze and
place an adhesive bandage over the puncture site
·
Monitor the woman
during the procedure for signs of premature labor, bleeding or fetal distress
·
Discard the used
material
·
Remove the used
material
·
Remove and discard the
glove
·
Wash hands
·
Option maternal vital
signs and a 20 minute fetal heart tracing
·
Instruct the woman to
report signs of bleeding, unusual fetal activity, abdominal pain, cramping or
leves while at home after the procedure
·
Label the specimen
contained adequately including the estimates week of gestation and EDP and sent
to laboratory
·
Record the procedure
done date time
Complications
|
Maternal
|
Fetal
|
|
Infection
|
Haemorrage
|
|
Antipartum hemorrhage
|
Trauma to umbilical cord
and vessels
|
|
Rh-isoimmunization
|
Fetal trauma from needle
puncture
|
|
Fetal loss
|
Death
|
|
Abortion
|
|
|
Preterm labour
|
|
|
Amniotic fluid leakage
|
|
CHRIONIC VILLUS SAMPLING
Definition
It is the acquisition of chrionic villi placental tissue
under continous ultrasound guidance
Description
CVS involved obtaining samples of chorionic villus tissue to
test for genetic disorder of fetus. It is performed between 8 and 12 weeks of
gestation.
Articles and Equipments Needed
·
TPR Trady
·
Stethoscope
·
Sterile gloves
·
Pressing tray
·
Sterile towel
·
1% of lignocaine
·
Sterile bottles
·
Disposable syringe
·
Polyethylene catheter
·
Sterile bottles
·
Adhesive plaster
·
Cotton swaps
·
Antiseptic selations
Procedure:
·
Explain the procedure
to the patient
·
Ensure that informed
consent is signed
·
Advice to empty the
bladder
·
Arrange equipment
·
Provide privacy and
place the mother in dorsal position
·
Check the maternal
vital signs and fetal heart rate
·
Wash hands and sere
sterile gloves
·
Start influids,
administer terbutaline sc or w
·
An ultrasound
examination is performed and a cathetes is passed vaginally into the woman’s
uterus where a sample of chorianic villus tissue is shipped off or obtained by
suction or
·
The transabdominal
approach involves the insertion of a needle into maternal abdomen under
ultrasound guidance, the needle is pushed through the uterine wall and into
placental tissue, tissue is aspirated via an attached syringe
·
After that keep a
dressing gauze and place an adhesive bandage over the puncture site
·
Monitos the woman
during the procedure for signs of premature labour, bleeding of fetal distress
·
Discard the used
material, wash hands
·
Optain maternal vital
signs and a 20 minutes fetal health tracing
·
Instruct the woman to
report signs of bleeding, parsing dots or tissue should be reported
·
Label the specimen and
send to laboratory
·
Record the procedure,
date done, time etc
·
Instruct the woman to
rest at home for a few hours after the procedure
·
If pain is there mean
reduce the pain by having the mother lie comfortably on her back with her hands
and a pillow under her head. Relaxation breathing may also help to reduce pain
and discomfort related to procedure
Complications
·
Rupture membrances
·
Intrauterine infection
·
Spontaneous abortion
·
Hematoma
·
Fetal trauma
·
Maternal tissue
contamination
·
Incidence of fetal
loss is about 2% to 5%
Percutaneous Umblical Blood Sampling
Description
PUBs or cordocentesis, involves a puncture of umbilical cord
for aspiration of fetal blood under ultrasound guidance.
Indication
·
It is used in the
diagnosis of fetal blood disorders infections, Rh isoimmunization, metabolic
disorders and karyotyping
·
Transfusion to the
fetus may be conducted with this procedure
Articles and Equipment Needed
·
TPR Tray
·
Stethoscope
·
Sterile gloves
·
Dressing tray
·
Disposable syringes
·
Cotton swabs
·
Antiseptic solutions
·
Sterile bottles
·
Adhesive plaster
·
25 gauze spinal needle
13 cm in length
Procedure
·
Explain the procedure
to the patient and ensure that informed consent is signed
·
Advice the mother to
empty her bladder and assist her to lie in dorsal position and provide privacy
·
Check the maternal
vital signs and fetal heart rate
·
Wash hands and wear
sterile gloves
·
Start influids and
administer ritoderin IV
·
Under ultrasound
picture, the physician insects a needle into one of the umbilical vessels
through maternal abdominal and uterine wall. The needle tip puncturer the
umbilical vein approximately 1-2 inch from placental insertion 0.5 ml of blood is collected. It is performed
after 18 weeks of pregnancy
·
After that keep a
dressing gauze and place and adhesive bandage over the puncture site
·
Monitor women during
the procedure for signs of bleeding or fetal distress
·
Remove and discard the
gloves, wash hands
·
Option maternal vital
signs and 20 minutes fetal heart training
·
Instruct the woman to
report signs of bleeding, abdominal pain cramping or fever etc
·
Label the specimen and
sent to laboratory and record the procedure
Complications
·
Abortion
·
Preterm Labour
·
Intrauterine death
·
Fetal 1085 2-5%
BIOPHYSICAL
ULTRASOUND IMAGING
Description
Ultrasound is a noninvasive, safe technique that uses
reflected sound waves as they travel in tissue to produce a picture. In
abdominal approach, a clear gel is applied to the womans abdomen or to the
transduces and the transduces as moved along the abdomen and images are
produced into a screen.
Purposes
·
To diagnose pregnancy
as early as 6 weeks of gestation
·
To confirm the size
and location of placenta and amount of amniotic fluid
·
To identify the growth
of the fetus and to detect any gross abnormality
·
To diagnose presentation
and position of the tests
·
To predict maturity of
feters
·
To confirm suspected
ectopic pregnancy
·
To confirm suspected
multiple of gestation, placenta pravia and cord presentation
·
To estimate fetal
growth and normally
·
To estimate
gestational age
·
To optaine biophysical
profile for determining fetal well being
Articles
·
Ultrasound machine
with transducer
·
Ultrasound
gel/coupling gel
·
A gown for the patient
Procedure
Explain to the woman the
nature of examination
·
Instruct the women to
drink 8 glasses of water 2 hrs prior to the examination if in the first
trimester
·
Assist the patient to
wear hospital gown
·
The patient is
assisted to wear supine position on the examining table and expose her abdomen
from costal margin to symphysis pubis
·
Apply the ultrasound
gel or coupling gel generously to the abdomen
·
After completion of
procedure removal gel from the women abdomen and assist her to dress back into
her clothes
·
Forward the finds of
scan to the unit
·
Wash hands and record
the procedure and findings
ASSESSMENT OF FEATAL
WELL-BEING IN LATE PREGANNCY
By three ways
·
Clinical
·
Biochemical
·
Biophysical
Clinical
The clinical assessment of fetal growth can be evaluated by
parameters. They may be useful as screening test for further investigation.
Biochemical
Two biochemical tests, performed in the past for assessment
of antenatal fetal well being were estimation of a) urinary or plasma oertriol
b) plasma human plauntal lactogen (HPL) level.
Value of urinary oestriol 12 mg or less in 24 hours urine was
considered critical for the fetus. Similarly value of plasma HPL 4mg/ml or less
after 30 weeks of gestation was considered critical. Due to peer predictive
value, both these tests have been abdonded.
FETAL
MOVEMENT COUNT
Description
Fetal movement or kick counts may be evaluated daily by the
pregnant woman to provide reassurance of fetal well being. There are two
methods
1) Credit Count To-Ten
a) Assess fetal movement once
per day at the same time each day.
b) Less than 10 fetal
movement in 10hrs for 2 consecutive days 8 no fetal movement in a 10 hour
period must be reported.
2) Sadovsky
a) Assess fetal movement
three times each day at the same time
b) Less than 4 fetal
movements in 2 hrs must be reported
Procedure
·
Instruct the women to
lie on her side in a quiet place with no disturbance and place her hands on the
largest part of abdomen and concentrate on fetal movement
·
Instruct the women to
use a clock and record the movements felt
·
Instruct women’s the
fetal movements all best assessed after meals, after light abdominal massage
and after short walks
DOPPLER ULTRASOUND
Description
Doppler ultrasound techniques are for the study of maternal
and fetal circulation, through Doppler ultrasound we can evaluate the fetal
heart rate an assessment of fetal well being and placental blood flow also can
be assessed during Doppler shift.
Procedure
1.
Explain the equipment,
purpose and procedure to the woman
2.
assist the woman to a
sick lying or semi lowless position
3.
perform leopold’s
maneuvers
4.
Document finding on the
woman’s chart and monitor strip along with date, time, activity level,
medications and other informations
5.
Discontinue electronic
fetal monitoring as indicated according to guidelines
6.
Communicate
appropriate information to the woman and other personal.
NON-STRESS TEST
Definition
A test that monitors the fetal heart rate in response to
fetal movement in order to assess the integrity of fetal central nervous system
and cardio-vascular system.
Purpose
1.
To assess the fetal
ability to cope with continuation of high risk pregnancy
2.
To determine the
projected ability of a fetus to withstand the stress of labour
3.
To assess the fetal
status in women for whom contraction stress test is contraindicated such as
previous cesarean section, placenta previa or preterm labour
Indications
|
Maternal
|
Fetal
|
|
Post dated pregnancy
|
Decreased fetal movement
|
|
Rh sensitization
|
IDGR
|
|
Maternal age 35 or more
|
Fetal evaluation after
amniocedntesis
|
|
Chronic renal disease
|
Oligohydramnious /
polyhydramnious
|
|
Hypertension
|
|
|
Sickle cell disease
|
|
|
Premature rupture membranes
|
|
|
Vaginal bleeding in 2nd
and 3rd trimester
|
|
Articles
1.
Electronic fetal heart
monitor
2.
Ultrasound transduces
3.
Tocotransducer
4.
Monitor strip
5.
Ultrasound gel
6.
Belts to hold the
transducer in place
Procedure
Explain to mother about the
procedure and its purpose and how she has to cooperate
·
Make sure that woman
had eaten food and ask her to empty her urinary bladder
·
Turn on the monitor
and press the test button to see that is working and adjust the paper seed
·
Perform abdominal
palpation
·
Confirm the presence
of fetal heart tones with fetoscope or stethoscope and not the area of maximum
intensity.
·
Position the woman in
semi powlers or lateral tilt position and place the monitor belts under her
back so that they are flat against her skin.
·
Connect the ultrasound
tranducer and the tochotraducer to the fetal monitor. Apply ultrasound gel to
the ultrasound tranducer
·
Place the ultrasound
transducers on the fetal back, move the tranducer unit clear audible fetal
heart tones are heard and the signal light flashing steadily secure the device
in place with belt
·
Place the
tocotranducer on the fundis of the uterus and secure in place with the belt
·
Run the monitor and
evaluate the quality of the tracing to determine if it is adequate for
interpretation, if it is not reposition the transducer until interpretable data
is obtained.
·
Give the hand button
to the woman and ask her to press the button every time shee feels fetal
movement
·
Run the monitor and
obtain a tracing for at least 20 min
·
On completion, part of
the monitor and take out the strip of paper
·
Remove the abdominal
straps and wipe off the gel from the abdomen and transducer
·
Make the woman
comfortable and give relevant instructions
Interpretation
Reactive or negative test: At least 2 or more acceleration of fetal heart rate with
an amplitude of at least 15 beats per minute and duration of at least 15
seconds. It suggest that the fetus is
healthy.
Non reactive test: No
acceleration less than 15 beats per min or les than 15 seconds for a 40 minute period. It suggested that
fetus may be compromised and there needs to be further follow up with
bio-physical profile, CST and OCT
OXYTOCIN
CHALLENGE TEST
Description
A test in which the fetus is exposed to the stress of
contractions to determine whether there is adequate placental perfusion under
stimulated labor conditions
Purpose
·
To assess the fetal
ability to cope with the continuation of a high risk pregnancy
·
To determine the
projected ability of the fetus to withstand the stress of labour
Indications
1.
IVGR
2.
Postmaturity
3.
Hypertensive disorder
of pregnancy
4.
Diabets mellitus
5.
Women with nonreactive
NST
Contraindications
1.
Third firmest bleeding
2.
Incomplent cervix
3.
Multiple gestation
4.
History of
pretermlabour
5.
Premature rupture of membranes
Articles
1.
All the articles for
NST
2.
An IV line to
administer a dilute dose of oxytocin
3.
An IV infusion pump to
monitor the flow rate
4.
Medication and IV
fluids
Procedure
·
Explain the mother the
procedure and its purpose
·
Make sure that woman
had eaten food and ask her to empty her urinary bladder
·
Turn on the monitor
and press the test button to see that it is working and adjust the paper seed
·
Perform abdominal
palpation
·
Position the woman in
semifowler’s position and place the monitor belts under her back so that they
are flat against her skin
·
Connect the ultrasound
transduces and the tocotranducer to fetal monitor apply ultrasound gel to the
ultrasound transducer
·
Confirm the presence
of fetal heart tones with a fetoscope or stethoscope
·
Place the ultrasound
transducer on the maternal abdomen over the fetal back. Move the transducer
until clear, audible fetal heart tones are heard and the signal light us
flashing steadily. Secure the device in place with belt
·
Place the
tocotransduces on the fundus of the uterus and secure in place with the belt
·
Run the monitor and evaluate
the quality of tracing to determine if it is adequate for interpretation. If
its not reposition the tranducer
·
Start the oxytocin
infousion at a rate of imulmin
·
Start up the infusion
rate every 15 min at the prescribed rate until effective uterine contractions
are established
·
Monitor the uterine
contractions using hands to palpate the hardening of the uterus
·
Continue the infusion
until the contractions are occurring at a frequency of a least one in a 10
minute period and lasting at least 30 seconds.
·
The recorded strip is
then taken out for interpretation and infusion of oxytocin is discontinued
·
Monitoring and
infusion without oxytocin are continued until contractions have diminished to their
baseline activity
Interpretation
Negative: No
deceluation occur with contractions or frequent as three m a ten minute period.
Indicates fetal well being and predicts that the fetus will continue to be
alright for another week without complications
Positive:
Repeated rate deceluation of fetal heart patterns occur during the test further
assessment is done to decide on the need to immediate termination of pregnancy.
Biophysical Profiling
·
It is an another
measure of fetal well being
·
This is used to determine
whether there are signs of fetal hypoxia or compromised placental function or
both
·
A score is calculated
on the basis of 5 criteria
They are;
o Fetal breathing movements: In healthy fetus breathing
movements can be visualized in 3rd trimester of pregnancy. There
should be at least 30 seconds of sustained fetal breathing movement in 30
minute of observation
o Fetal Movements: Movement is often compromised in hypoxic
fetuses. There should be 30 or more gross body movements in 30 minutes of
observation.
o Fetal Tone: There should be at least one episode of motion
of a limb from a position of flexion to extension and rapid return to flexion
o Fetal Reactivity: There should be two or more fetal heart
accelerations of at least 15 beats per minutes within 40 minutes of observation
o Qualitative amniotic fluid volume: There should be a
packet of amniotic fluid that measures at least 1 centimeter in two
perpendicular plans
Urinanalysis
This is done to exclude certain abnormalities. Pyelonephritis
can readily develop because of changes in the renal tract during pregnancy
·
Ketones due to
increased maternal metabolism of vomiting
·
Glucose caused by
higher, circulating blood levels, reduced renal threshold or disease
·
Protein due to
contamination by vaginal leucorrboea, disease such as UTI or PIH
BLOOD
TEST
ABO BLOOD GROUP AND RH FACTORS
Blood tests are done as part of the initial assessment to
determine. ABO blood group and Rh factor. Antibody screening is done followed
by titration, if present, follow up of a woman, whose blood group is
Rh-negative, will include further blood test and 28th, 32nd,
36th, 40th week for Rh. Antibody titre to ensure that the
pregnancy is not stimulating antibody activity. If the titration demonstrates a
rising antibody response, more frequent assessment will be done in order to
plan the management
Haemoglobin and Haematocrit
These are performed in order to assess the adequancy of iron
stores. Hb estimation is repeater at 28th week, when physiological
effects of hemodilution become more apparent and at 36th week to
ensure that any anemia is treated prior to delivery. The decision to use
supplements is made on an individual basis. However, most women in the rural
population are given iron and folic acid supplements, health education about
inducing iron-rich foods in diet should also be given.
Venereal Disease Research Laboratory
This test is done for all pregnant woman. Early testing will
allow the women to be treated adequately in order to prevent infection of
fetus. It is to be remember that all positive results do not indicate active
syphilis
Human Immunodeficiency Virus (HIV) Test
Routine screening to detect HIV infection is done in many
centers. It is important to gain informed consent prior to the blood test and
to after appropriate counseling
Rubella Immune Status
This is done by measuring the rubella antibody litre. Women
who are not immunized must be advised to avoid contact with anyone suffering
from the disease.
CONCLUSION
Apart from clinical evaluation, biochemical and biophysical
methods have also been used for the diagnosis. Some of these methods carry risk
to the mother and or the fetus and are also expensive. Therefore, this
application should provide definite benefits that clearly out weights the
potential risk and the costs.
BIBLIOGRAPHY
1.
A comprehensive Text
Book of Midwifery
Annamma Jacob, Second
Edition,
Jaypee Publishers,
Page No.144-148
2.
A Text Book of
Obstetrics, D.C. Dutta
Sixth Edition, New
Central Book Agency (P) Limited
Page No.105-111,
642-643
3.
Myles Textbook for
Midwives, Diane M. Fraser
And Margaret A Cooper,
14th Edition
Page No. 414-427
4.
Clinical Nursing
Procedures, The Art of Nursing
Practice, Annamma
Jacob, Rekha R. Jaypee Publications Page No.523-538
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