ASSESSMENT OF FETAL GROWTH AND DEVELOPMENT

PRENATAL VISIT - Include both diagnosis, verification of pregnancy and

establishment of the data base for ongoing prenatal care Less than 28 weeks=once/month . I Between 28-32 weeks=2x/month Greater than 32 weeks = 1 x/week There should be at least 3 prenatal visits during pregnancy following the prescribe timing: (DOH)
1. 1st prenatal visits should be made early in pregnancy as possible during the 1st trimester 2. 2nd visit during the 2nd trimester 3. 3rd and subsequent visits during the 3rd trimester

More frequent visits should be done for those at risk or with complications.
I.INTERVIEW a. Probability of pregnancy with symptoms noted b. Menstrual history 1. Menarche 2. Duration and flow/amount 3. LMP c. OB History 1. OB Scoring G- represents gravid T represents full term deliveries, 37 completed weeks or more P- represents pre-term deliveries, 20 or less than 37 completed weeks L represents the # of children living M represents the multiple gestations and birth ( not the number of neonates delivered)

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2. Estimation of AOG based on: a. Last Menstrual Period (LMP) ex.. LMP=Feb. 11,2006 AOG=?
y

Add the days of gestation from the day of LMP up to the date of the visit. Divide the score with 7 ( 7 days in a week).

b. Fundic Height (FH)= Using Mc Donalds Rule FH x 2= AOG in 7 months FH x8 = AOG in 7 weeks
c. y y y y UTZ 6-8th weeks - Fetus in gestational sac 9-10th weeks- Fetal heart activity 11th weeks- Fetal movements 12th weeks - Biparietal diameter (BPD)

3. Computation of EDC/EDD base on:

a. LMP (Naegeles Rule)

Jan-March
* April- December =

= +9
-3

+7
+7 +1

ex: (1) LMP= Feb 11,200 Computing for EDC/EDD : 2 +9 11 11 +7 18 06 +0 06 *28?-28 days in Feb,2005 EDD = Nov. 18,2006

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(2) LMP= May 28,2006

5 -13

28 +7

06 +1

35 -28

2 +1

35

06 -28

EDD = March 7,2007 b. Quickening ( when LMP is not known)

Primigravida (quickening at 18-20 weeks) Formula: +4 +20

Ex. Quickening: April 1, 2006

06

EDD:Aug.21,2006 .

+4 +20 8 21 06

Multigravida ( quickening at 16-18 weeks) Formula: +5 +4

4 +5 9

1 +4 5

06

EDD: Sept. 05,2006 _

06

d. Outcomes of previous pregnancy/ies

6. . Contraceptive History 7. Previous major illness
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8. Current health problems and all medicines being used 9. Reaction- to pregnancy- psychological changes of pregnancy B. PHYSICAL EXAMINATION

1. Vital Signs 2. Height and weight 3. Breast Examination 4. Abdominal Examination a. Contour of uterus- fundic height b. Leopolds maneuver ( If applicable) c. FHR (if applicable) 5. Vaginal or bimanual exam (internal examination) a. Note changes consistent with pregnancy b. Determine cervical readiness and fetal position
C. LABORATORY TEST

1. Pregnancy test 2. CBC: Hgb & Hct 3. Urine Exam: Pus, Glucose and CHON

* Leopoldss Maneuver systemic method of observation and palpation to determine fetal presentation and position

1. First Maneuver determines whether fetal head or breech is in the fundus 2. Second Maneuver locates the back of the fetus ; determines location of FHT/FHB 3. Third Maneuver determines the part of the fetus at the inlet and its mobility or the degree of engagement 4. Fourth Maneuver determined fetal attitude and degree of fetal extension into the pelvis

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* Papanicolaou Smear/ Cytologic Exam/ Pap smear Purpose: To detect abnormalities of cell growth by exam The cells and secretions from cervix and vagina Frequency: 20 y/o over 1x in 3 years 40 y/o over- 1x in a year WHO: 35 y/o above = 1x/annually Preparations: 1. Patient on lithotomy position 2. Prepare equipments (speculum and slide) * 3 Separate specimens from: endocervix , cervical os, vaginal pool
Results:

Class I= Normal typical cells ; (-) for entraepithilial lesion or malignancy Class II= Inflammation ; atypical squamous cells of undetermined significance (ASCUS) Class III- Mild to moderate dysplasia ; low grade spuamous intraepithelial lesion (LSIL) Class IV- Probability malignant ; high grade squamous epithelial lesion (HGIL) Class V- malignant ; Squamous cell carcinoma
C.LABORATORY EXAMINATIONS 1. CBC

Hgb= 11.5 gms/100ml or 115 gm/L Less= Anemia Hct= 30 cells/vol. % or 30% Less= Anemia
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2. U/A

PUS- Pyuria Albumin- Albuminuria Glucose-Glucosuria

3. FBS/HEMOGLUCOTEST

- NPO for 8 hours - Normal Valve: 80-120 mg/dl less= Hypoglycemia

4. OGTT- Oral Glucose Tolerance Test

High- Diabetes

- FBS Sample - Intake of 100 gm glucose in solution ingested w/in 5 min after FBS blood extraction - Blood extraction of 1hour glucose intake - Done in 3x/hr
* OGCT- Oral Glucose Challenge Test

- intake of 50gms of glucose - extraction of blood of 1hour * if result is greater than 130 mg/dL- OGTT ******done at 24-28th weeks of pregnancy
5. Venereal Disease Research Lab. (VDRL)

- Detect Syphilis- Congenital syphilis

6. Antibody Titer for Rubella

- To determine susceptibility (+) rubella Titer= greater than 1:8- No Rubella Antibody Mother needs gammaglobulinn
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(Passive immunity)
7. Benedicts Test/Clinitest

- Detects glucose (DM) - Done before breakfast Blue-green= no precipitate== 0 Yellow green- +1 Green yellow- +2 Brownish orange= +3 Brick red = +4 Abnormal results; Diabetes Mellitus

8. Heat ad Acetic acid test (5-10% acid used)

(+) CHON= White Turbidity- Albuminuria/froteinuria

9. ABO Typing

Antigen=Rh

Rh (+)- Dominant ( Both parents) Prob. If: Father Rh(+) Mother Rh (-) * Childs Rh(+) antigen passes thru the cord to the placenta and maternal serum * Mothers serum sensed an antigen and creates an antibody against it * Disruption of the bloods equilibrium Rh(+) Child

Clumping & Hemolysis

Problem: Newborn: Hemolytic Anemia Erythroblastosis Fetaliss

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Maternal-Child incompatibility Treatment: Rhogam

ASK  Diet  Personal habits ( cigarette, smoking, recreational drug use) influences insulin/ glucose balance and fetal growth
 Exercise Accidents or experienced intimate partner abuse

1. ESTIMATING FETAL GROWTH

a. Mc Donalds Rule y Symphysis fundal height measurement

 Method of determining fetal growth in utero by measuring fundic height during mid-pregnancy (20-31 1st week)  Measures distance from the fundus to the symphysis in cm is equal to the week of gestation  Measures from the notch of the symphysis pubis to the fundus y Becomes inaccurate during the 3rd trimester of pregnancy because the fetus is growing more in weight than in height y Greater fundal ht indicates  multiple pregnancy  miscalculated due date  LGA  Hydramnios  Hydatidiform mole y Smaller fundal height  Failing to thrive ( intrauterine growth restriction)  Pregnancy length was miscalculated  Anomaly such as anencephaly y Symphysis pubis = 12 weeks y Umbilicus = 20 weeks y Xiphoid process = 36 weeks
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FORMULA: FH X 2 = AOG in months 7 FH X 8 = AOG in weeks 7

b. Bartholomews Rule - Ways of estimating AOG by Fundic Height Symphisis pubis = 10 -12 weeks Navel/Umbilicus = 20 -22 weeks

Fundus/Xiphoid = 36 weeks Between symphysis and umbilicus = 16-18 weeks Between umbilicus to fundus = 28 - 32 weeks Below the fundus = 40 weeks

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2. ASSESSING FETAL WELL-BEING a. FETAL MOVEMENT y Fetal movement can be felt by the mother ( quickening) y Occurs at 18-20 weeks of pregnancy y Peaks in intensity at 28-38 weeks y Moves 10 x a day y SADOVSKY METHOD  ask the woman to lie in a left recumbent position after a meal and record how many fetal movements she feels over the next hour  fetus normally moves a minimum of twice every 10 minutes or an average of 10-12 times an hour  if less than 10 movements= repeat for the next hour. y CARDIFF METHOD  Count to-ten  Woman records the time interval it takes for her to feel 10 fetal movements.  Usually occurs within 60 minutes.  Fetal vary bec of sleep cycles of the fetus, her activity. And thr time since she last ate. b. FETAL HEART RATE y 120-160 beats /minute y Fetal heart sounds can be heard and counted as early as the 10th-11th week of pregnancy by using a Doppler. Rhythm Strip Testing y y y y y

Means assessment of the fetal heart rate for whether a good baseline rate and a degree of variability are present. Woman in semi fowlers position to prevent her uterus from compressing the vena cava causing supine hypotension. Attach a an external fetal heart rate monitor abdominally Record the FHR for 20 minutes BASELINE refers to the average rate of the fetal heartbeat /minute

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VARIABILITY refers to small changes in rate that occur if the fetal parasympathetic nervous system are receiving adequate oxygen and nutrients Categorize as  Absent ( none apparent)  Minimal ( extremely small fluctuations  Moderate ( amplitude range of 6-25 beats /minute  Marked ) amplitude range over 25 beats/minute y Requires a woman to remain in a fairly fixed position for 20 minutes.

Nonstress testing

Measures the response of the fetal heart rate to fetal movements y Position a woman and attach both a fetal heart rate and a uterine contraction monitor. y Done 10-20 minutes y Reactive = if 2 accelerations of fetal heart rate ( by 15 beats or more) last 15 seconds after movement y Non reactive = if no accelerations occur with fetal movement. Or = if no fetal movement occurs = low short term fetal heart rate variability ( less than 6 beats/minute) throughout the resting period. y After 20 minutes with no fetal movements= fetus is sleeping y Give the woman oral carbohydrate snack such as orange juice= increase blood glucose= increase fetal movement y Use loud sound to stimulate the fetus to move.
y y

Instruct the woman to push a button attached to the monitor whenever she feels the fetus move.= create a dark mark on the paper tracing at these times. When the fetus moves= the fetal heart rate should increase about 15 beats /minute and remain elevated for 15 seconds.
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y y

Decrease to it average rate again = fetus quiets No increase in beats /minute = poor oxygen perfusion of the fetus

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