NCM 109: CARE OF MOTHER AND CHILD AT-RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)

GYNECOLOGIC NURSING

INTRODUCTION TO GYNECOLOGIC NURSING

I. DEFINITION OF TERMS AND TERMINOLOGIES

II. REVIEW OF THE ANATOMY AND PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM AND
NORMAL PREGNANCY

III. RISK FACTORS IN MATERNAL MORTALITY

IV. CHARACTERISTICS OF A HIGH-RISK CLIENT

V. ASSESSMENT OF A HIGH-RISK CLIENT

1) HEALTH HISTORY TAKING

a) Past Obstetrical ✓ Stillbirth – an infant born dead.

History
It may cause increased emotional or psychological
distress which could affect the health of the mother
leading to increased risk of IUGR and increased
risk of preterm delivery.

✓ Habitual Abortion – spontaneous termination of

three successive pregnancies before the 20th week
of gestation.

It may lead to emotional distress which could affect

the health of the pregnant woman; greater
possibility of happening it again.

✓ Cesarian Section Delivery – invasive surgical

procedure, thus considered more hazardous than
vaginal birth.

Possible Maternal Complications of CS:

1) Respiratory Tract Infection – secondary to

the effects of anesthesia, it suppresses the
cough reflex.
2) Wound Dehiscence
3) Thromboembolism
4) Hemorrhage
5) Bowel, bladder and uterine injury

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 ✓ Rh and Blood Group Sensitization – results from
antigen-antibody immunologic reaction within the
body.

It occurs when an Rh (-) woman carries Rh (+) fetus

either to term or terminated by spontaneous or
induced abortion; or if Rh (-) non-pregnant woman
receives an Rh (+) blood transfusion.

ABO Incompatibility – limited to type “O” mothers

with type “A” or “B” fetus. It may also occur when
the fetus has blood type AB.

Once the woman becomes pregnant, the maternal

serum anti-A and anti-B antibodies
cross the placenta and produce hemolysis of the
fetal RBCs. (The mother's immune system may
react and make antibodies against her baby's red
blood cells.)

Pathophysiology:

1) This disorder occurs when the fetus has a

blood group antigen that the mother does
not possess. The mother’s body forms an
antibody against that particular blood
group antigen, and hemolysis begins. The
process of antibody formation is called
maternal sensitization.

2) The fetus has resulting anemia from the

hemolysis of blood cells. The fetus
compensates by producing large numbers
of immature erythrocytes, a condition
known as erythroblastosis fetalis,
hemolytic disease of the newborn, or
hydrops fetalis. Hydrops refers to the
edema and fetalis refers to the lethal state
of the infant.

3) In Rh incompatibility, the hemolysis usually

begins in utero. It may not affect the first
pregnancy but all pregnancies that follow
will experience this problem. In ABO
incompatibility, the hemolysis does not
usually begin until the birth of the newborn.

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 Fetal Risks:

1) Infant death due to Rh hemolytic disease

2) Hydrops Fetalis – marked fetal edema
3) Erythroblastosis Fetalis
4) Neurologic Damage (kernicterus – high
levels of bilirubin in the blood)

b) Current Obstetrical ✓ Exposure to Infectious Diseases

History (Present
Health History) 1) Rubella – causes mild rash and mild
systemic illness to the mother; has
teratogenic effects of the fetus.

Maternal and Fetal Risks:

o 1st Trimester – abortion

o 2nd Trimester – single or multiple
birth defects
o 3rd Trimester – cataract, mental
retardation, deafness, LBW,
microcephaly

2) Cytomegalovirus – extensive damage to

fetus because virus crosses the placenta
and mild symptoms to mother

Fetal Risks:

o Neurologic Damage to Newborn –

hydrocephalus, microcephaly
o Eye Damage
o Deafness
o Chronic Liver Disease

3) Herpes Virus Type 2 – systemic affectation

and spreads into the bloodstream and
crosses the placenta to the fetus

Maternal and Fetal Risks:

o 1st Trimester – congenital

anomalies and spontaneous
miscarriage
o 2nd and 3rd Trimester – premature
birth, IUGR and continuous
infection at birth

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 4) Syphilis – microorganisms cannot cross
the placenta and damage the fetus until the
cytotrophoblast layer atrophies at about
16th to 18th weeks that causes extensive
damage.

c) Gynecologic History 1) Placenta Previa – improperly implanted placenta

in the lower uterine segment, on a portion of the
lower segment or over internal OS
– low implantation of the placenta and it is
the presenting part.
– as the lower uterine segment contracts and
the cervix dilates in the later weeks of
pregnancy, the placental villi are torn from
the uterine wall, thus exposing the uterine
sinuses at the placental site.

2) Abruptio Placenta – premature separation of the

placenta from the uterine wall after 20th week of
gestation and before fetus is delivered.
– Bleeding may appear in the vagina or
maybe concealed behind the placenta.

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 – Shock, fetal distress or death and DIC may
occur.

Disseminated Intravascular Coagulation (DIC) – a

pathologic syndrome in which clotting is
overstimulated throughout the circulatory system
by an underlying disease process.

– It is a rare and serious condition that can

disrupt the blood flow. It is a blood clotting
disorder that can turn into uncontrollable
bleeding.

Pathophysiology:

DIC creates many small blood clots that

might keep the blood from traveling
through the body. When this happens, the
blood might not be able to bring oxygen
and nutrients to the head, heart and other
organs. Then, having used up the proteins
and platelets that make the blood clot, DIC
might cause uncontrollable internal or
external bleeding.

systemic activation of blood

coagulation

generation and deposition of fibrin

microvascular thrombi in various

organs

multiple organ dysfunction syndrome

(MODS)

consumption of clotting factors and

platelets in DIC can result in life-
threatening hemorrhage

Derangement of the fibrinolytic system

further contributes to intravascular clot

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 formation, but in some cases, accelerated
fibrinolysis may cause severe bleeding.
Hence, a patient with DIC can present with
a simultaneously occurring thrombotic and
bleeding problem, which obviously
complicates the proper treatment.

3) Eclampsia – a major complication of pregnancy,

etiology is unknown often in primigravida and is
accompanied by elevated blood pressure,
albuminuria, oliguria, tonic and clonic convulsions
and coma. It may occur during pregnancy (12th
week AOG) or within 48 hours after delivery.

4) Multiple Gestation – can be by double ovulation

(fraternal or dizygotic) or a splitting of the fertilized
ovum (identical or monozygotic).

5) Elevated Hematocrit – it is a measure of the

percentage of packed RBC by volume in a sample
of whole blood.

Polycythemia – increase in the number of RBC due

to increased erythropoiesis; there will be plethora
(marked reddened appearance of the skin, beefy
red coloration of the newborn) (boiled lobster).

– It is the compensatory response to

insufficient oxygenation of the blood in
order to supply more oxygen to blood cells
which may be caused by congenital heart
disease and chronic pulmonary disease.

6) Spontaneous Rupture of Membrane – occurs

before onset of labor.

Primary Risk for the Mother: INFECTION

Potential Fetal and Neonatal Complications:

o Anoxia
o Cord Prolapse
o Preterm Delivery
o Respiratory Distress Syndrome
o Sepsis
o Traumatic Delivery

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 7) Pregnancy–Induced Hypertension – syndrome
involving hypertension, edema and proteinuria that
develops after the 20th week of gestation.

– generalized vasospasm which may lead to

abruptio placenta, DIC, thrombocytopenia,
placental insufficiency and intrauterine
fetal death.

2) PHYSICAL EXAMINATION

General Appearance and Vital Signs

Vital Signs Normal Alteration

Blood Pressure 90 – 140 / 60 – 90 elevated BP (which indicates
essential HPN, renal disease, pre-
gestational HPN).
Pulse 60 – 90 beats per minute; rate may increased pulse rate which may be
increase 10 beats per minute due to cardiac disorder or anxiety.
during pregnancy.
Respiration 16 – 24 breaths per minute; tachypnea or abnormal patterns
pregnancy may induce a degree of
hyperventilation; thoracic breathing
predominant
Temperature 36.2 – 37. 6 o C (36.5 – 37.5 o C) hyperthermia (infection)
Weight depends on body built less than 100 lbs. or more than 200
lbs.; rapid, sudden weight gain
(preeclampsia or eclampsia)

Head-to-Toe Assessment

Area Normal Alteration

Skin Color: consistent with racial pallor (anemia)
background; pinkish nail beds bronze yellow (hepatic disease)
Condition: absence of edema edema (preeclampsia)
(slight edema in lower extremities skin rashes, dermatitis (allergic
is normal during pregnancy) response)
Pigmentation: linea nigra, striae
gravidarum, chloasma
Nose: in pregnancy nasal mucosa olfactory loss (CN 1 deficit)
is redder than the oral mucosa and
is edematous in response to
increased estrogen, resulting in
nasal stuffiness and nosebleeds

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Mouth may note hypertrophy of gingival edema, inflammation (infection);
tissue because of estrogen pallor (anemia)
Neck small, mobile, non-tender nodes; enlargement or nodule tenderness
thyroid-small, smooth lateral lobes (hyperthyroidism)
palpable on either side of trachea
Chest and Chest: symmetrical, elliptical, increased AP diameter, funnel
Lungs smaller anteroposterior (AP) than chest, pigeon chest (emphysema,
transverse diameter asthma, COPD)
Ribs: slope downward from nipple more horizontal (COPD)
line angular bumps, rachitic rosary
(vitamin C deficiency)
Inspection and Palpation: no ICS retractions with inspiration,
retraction or bulging of intercostals bulging with expiration; unequal
spaces (ICS) during inspiration or expansion (respiratory disease);
expiration; symmetrical expansion, tachypnea, hyperpnea, Cheyne-
tactile fremitus Stokes respirations (respiratory
disease)
Percussion: bilateral symmetry in flatness of percussion (which may
tone; low-pitched resonance of be affected by chest wall
moderate intensity thickness); high-pitched diaphragm
(atelectasis or paralysis, pleural
effusion)
Auscultation of Upper Lobes: abnormal if heard over any other
bronchovesicular sounds above area of chest
sternum and scapula; equal
expiratory and inspiratory phases
Remainder of Chest: vesicular rales, rhonchi, wheezes; pleural
breath sounds heard; inspiratory friction rub; absence of breath
phase longer sounds; bronchophony; egophony;
whispered pectoriloquy
Breasts: (+) tenderness as one of
the earliest symptoms of
pregnancy; breasts may become
sore, heavy, or tingly as early as 1–
2 weeks after conception; nipples
may also feel sensitive or even
painful to touch.
Abdomen FHT: 120 – 160 beats per minute failure to hear fetal heartbeat after
which may be heard with Doppler 17-20 weeks (fetal demise,
at 10 – 12 weeks gestation; with hydatidiform mole)
fetoscope at 17 – 20 weeks
Fetal Movement: not felt prior to failure to feel fetal movements after
20 weeks gestation by examiner 20 weeks gestation (fetal demise,
hydatidiform mole)
Upper and skin warm, pulses palpable, full unpalpable or diminished pulses
Lower range of motion; may be some (arterial insufficiency); marked
Extremities edema of hands and ankles in late edema (pre-eclampsia)

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 pregnancy; varicose veins may
become more pronounced
Spine: normal spinal curves; abnormal spinal curves; flatness,
concave cervical, convex thoracic, kyphosis, lordosis; backache
concave lumbar; in pregnancy,
lumbar spinal curve may be
accentuated
Shoulders and Iliac Crests: uneven shoulders and iliac crests
should be even (scoliosis)
Reflexes: normal and symmetrical hyperactivity, clonus (PIH)
Genitalia (Pelvic External Female Genitals: lesions, hematomas, varicosities,
Area) normally formed with female hair inflammation of Bartholin’s glands;
distribution; in multiparas, labia clitoral hypertrophy
majora loose and pigmented; (masculinization)
urinary and vaginal orifices visible
and appropriately located
Vagina: pink or dark pink; vaginal abnormal discharge associated
discharge odorless, non-irritating; with vaginal infections
in multiparas, vaginal folds enough
smooth and flattened; may have
episiotomy scar
Cervix: pink color; OS closed eversion, reddish erosion,
except in multiparas, in whom OS Nabothian or retention cysts,
admits fingertip cervical polyp; granular area that
bleeds (carcinoma of cervix);
lesions (herpes, human papilloma
virus (HPV)

presence of string or plastic tip from

cervix (intrauterine device in
uterus)
Pregnancy Changes:
1 – 4 weeks AOG:
enlargement in anteroposterior
diameter

4 – 6 weeks AOG:
Goodell’s Sign (softening of absence of Goodell’s sign (which
cervix) suggests inflammatory conditions,
Hegar’s Sign (softening of isthmus and carcinoma)
of uterus)
Chadwick’s Sign (cervix takes on
bluish coloring)
8 – 12 weeks AOG:
Chadwick’s Sign (vagina and
cervix appear bluish-violet in color)

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 Uterus: pear-shaped, mobile, fixed (pelvic-inflammatory disease;
smooth surface nodular surface (fibromas)
Ovaries: small, walnut-shaped, pain on movement of cervix (PID);
non-tender (ovaries and fallopian enlarged or nodular ovaries (cysts,
tubes are located in the adnexal tumor, tubal pregnancy, corpus
areas) luteum of pregnancy)
Internal Pelvic Measurements:
Diagonal Conjugate: 12.5 cm measurement below normal
Obstetric Conjugate: estimated by disproportion of pubic arch
subtracting 1.5 cm – 2 cm from
diagonal conjugate
inclination of sacrum abnormal curvature of sacrum
motility of coccyx; external inter- fixed or malposition of coccyx
tuberosity diameter 8 cm
Anus and no lumps, rashes, excoriation, hemorrhoids, rectal prolapsed;
Rectum tenderness; cervix may be felt nodular lesion (carcinoma)
through rectal wall

3) LABORATORY PROCEDURES

Laboratory Procedure Purpose

Complete Blood Count (CBC) ▪ to determine the presence of anemia and estimate
the clotting ability
▪ done upon initial visit and repeated at 28 – 32
weeks AOG
o Hgb, Hct – anemia detection
o WBC – determines the presence of
infection
o Platelet – estimate clotting ability

ABO and Rh Typing ▪ to determine the woman’s blood type and the
presence or absence of Rh antigen
▪ blood may have to be available if the woman has
bleeding early in pregnancy
▪ for early detection and prompt treatment of Rh
incompatibility which occur when the mother is Rh
negative and the fetus is Rh positive

Syphilis Test ▪ to determine the presence of treponema pallidum

to confirm the presence of syphilis for early
treatment in pregnancy before fetal damage occurs

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 Gonorrhea Culture ▪ done for those women who are suspected of
having the disease

Urinalysis ▪ use for pregnancy test (determine the presence of

HCG in the urine)
✓ Heat and Acetic Test – to determine the
presence of albumin in the urine
(proteinuria) – this suggests pre –
eclampsia.
✓ Benedicts Test – to detect glycosuria –
may indicate DM.
✓ WBC – may indicate infection
✓ Ketonuria – may result from insufficient
food intake or vomiting

Rubella Titer ▪ part of the prenatal laboratory screen for the

woman using hemagglutination inhibition test.

Antibody Serum (HbSAg) ▪ to detect chance of developing hepatitis

Sickle Cell Screen (for black ▪ to screen for sickle cell trait or disease and
client – African-American) possibility of G6PD (glucose 6 phosphate
dehydrogenase)

Papanicolau’s Smear ▪ taken for early detection of cervical cancer and

diagnosis of pre-cancerous and cancerous
condition of the vulva and vagina.

▪ it also reveals inflammatory and infectious

disease.

▪ 3 separate specimens: (1) from the endocervix; (2)

from the cervical OS; (3) from the posterior vaginal
fornix.

4) FETAL DIAGNOSTIC PROCEDURES

Ultrasonography ▪ It uses high-frequency sound waves to visualize

structures within the body.
▪ It may use a transvaginal probe or an abdominal
transducer; abdominal UTZ during early

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 pregnancy requires a full bladder for proper
visualization (have the woman drink 1 to 2 quarts
of water before the examination).

Purposes:
1) Visualize a gestational sac in early pregnancy to
confirm the pregnancy.
2) Identify site of implantation (uterine or ectopic).
3) Verify fetal viability or death.
4) Identify multifetal pregnancy, such as twins or
triplets.
5) Diagnose some fetal structural abnormalities.

Three-Dimensional [3-D] Imaging – produces

clear detail and features.

6) Guide procedures, such as chorionic villus

sampling, amniocentesis, percutaneous umbilical
blood sampling.
7) Determine gestational age of the embryo or fetus.
8) Locate the placenta.
9) Determine the amount of amniotic fluid.

Amniotic Fluid Volume (AFV) – measures the

amniotic fluid pockets in all four quadrants
surrounding the mother’s umbilicus and produces
an amniotic fluid index (AFI).

5 – 19 cm: NORMAL
<5 cm: OLIGOHYDRAMNIOS (decreased AF) –
associated with growth restriction and fetal
distress during labor because of “kinking” of the
cord)

>30 cm: POLYHYDRAMNIOS (excess AF) –

associated with neural tube defects,
gastrointestinal obstruction, and fetal hydrops.

10) Observe fetal movements.

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Magnetic Resonance Imaging ▪ It provides a noninvasive radiological view of fetal
structures, including the placenta.
▪ It is being used when there is a high suspicion of
an anomaly.

Kick Count ▪ It is the maternal assessment of fetal movement.

▪ Fewer than 3 fetal kicks within an hour or
cessation of fetal movement for 12 hours
indicates the need for evaluation.
▪ A daily fetal movement record is kept at home
once a day, and the findings are evaluated during
prenatal visits to ensure fetal health. The sleep
cycle of the fetus should be considered when
selecting a time to evaluate fetal movement.

Doppler Ultrasound Blood ▪ It uses high-frequency sound waves to study the

Flow Assessment flow of blood through vessels.
▪ It determines adequacy of blood flow through the
placenta and umbilical cord vessels in women in
whom it is likely to be impaired (such as those with
PIH or DM).

Alpha-Fetoprotein Testing ▪ It determines the level of this fetal protein in the

(AFP) pregnant woman’s serum or in a sample of
amniotic fluid; correct interpretation requires an
accurate gestational age.
▪ High Levels: associated with open defects.
– Spina Bifida (open spine)
– Anencephaly (incomplete development
of the skull and brain)
– Gastroschisis (open abdominal cavity)
▪ Low Levels: associated with chromosome
abnormalities or gestational trophoblastic disease
(hydatidiform mole).

Chorionic Villus Sampling ▪ Obtaining a small part of the developing placenta

to analyze fetal cells at 10 -12 weeks of gestation.
▪ It is used to identify chromosome abnormalities or
other defects that can be determined by analysis
of cells. Results of chromosome studies are
available 24 to 48 hours later.

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 ▪ This cannot be used to determine spina bifida or
anencephaly.
▪ Higher rate of spontaneous abortion after
procedure that after amniocentesis.

Amniocentesis ▪ It involves insertion of a thin needle through the

abdominal and uterine walls to obtain a sample of
amniotic fluid, which contains cast-off fetal cells
and various other fetal products.
▪ It is the determination of overall fetal health and
maturity as well as developmental anomalies and
genetic make-up.

Standard Genetic Amniocentesis – done at 15

to 17 weeks AOG.

Early Genetic Amniocentesis – done at 11 to 14

weeks AOG

Purposes:
1) Early Pregnancy: to identify chromosome
abnormalities. biochemical disorders (such as
Tay-Sach’s Disease), and level of AFP

Primary Risk: spontaneous abortion following the

procedure

2) Late Pregnancy: to identify severity of maternal-

fetal blood incompatibility and assess fetal lung
maturity.

Detection of Fetal Maturity

1) Lung Maturity

Lecithin-Sphingomyelin Ratio (L/S)

Ratio (normally is 2:1 in the amniotic
fluid; 3:1 ratio desirable for diabetic
mother)
o Mature ratio decreases
occurrence of respiratory
disease syndrome (RDS) in 98%
of neonates.

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 Phosphatidyl Glycerol (PG) – the
presence of PG in the amniotic fluid
makes 0% incidence of RDS in infants.

Foam Stability Index (Foam and Shake

Test / Bubble Stability Test) – fresh
amniotic fluid diluted with equal part
normal saline solution (NSS) is mixed
with ethanol then vigorously shaken for
15-30 seconds; after 15 minutes, the
presence of bubbles is determined (ring
of foam at the meniscus or air-liquid
interface of the glass tube);
o (+) bubbles indicates that lungs
are mature (Clemens, et. al.,
1972).

2) Kidney Maturity

Creatinine level of 2mg/dl correlates with

gestational age of about 36 weeks.
As fetal kidneys mature, urine is added to
amniotic fluid.
An increasing amount of creatinine in the
amniotic fluid indicate that fetal kidneys
are mature.

3) Liver Maturity – detected by measuring the

optical density which is a reflection of the amount
of bilirubin present in the amniotic fluid.

4) Skin Maturity

Intrauterine, the fetus sheds cells and the

sebaceous glands produce cells
containing lipid globules. As fetus
matures, these fat cells increase.
Staining of fetal fat cells in the amniotic
fluid with Nile Blue Sulfate causes orange

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 stained. The amount of staining with Nile
blue sulfate should be more than 2%.
o If the number of stained
sebaceous cells is less than 2%
- prematurity rate of about 85%.
o If more than 20% - infant weighs
at least 2500 grams.

Detection of Fetal Abnormalities

1) Chromosomal
a) Pregnant women aged 35 and above
(incidence of Down Syndrome is 1:50)
b) Previous chromosomally abnormal
offspring
c) Chromosomal abnormality of both
parents
d) UTZ markers of chromosomal
abnormalities (duodenal atresia, hand
and feet anomalies)

2) Sex- Linked Disorders

3) Inborn Errors of Metabolism – hereditary

deficiency of a specific enzyme or CHON needed
for normal metabolism of specific chemicals
o detected through examination of
squamous and blood cells
o laboratory tests after birth are higher than
normal levels (galactosemia)

4) Neural Tube Defects – increase level of alpha-

feto protein (AFP) in the amniotic fluid because
fetal cerebrospinal fluid (CSF) leaks into the
amniotic fluid.

5) Rh Iso-immunization – determining the bilirubin

level in the amniotic fluid only if mother’s antibody
titer reaches 1:8 and is increasing.

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 Detection of Meconium

o through visual inspection of amniotic fluid (green-

meconium stained in non – breech presentation
indicates fetal distress)

Non – Stress Test (NST) ▪ It is the evaluation with an electronic fetal monitor
of the fetal heart rate (FHR) for accelerations of at
least 15 beats/minute lasting 15 seconds in a 20-
minute period.
▪ Fetal movements do not need to accompany the
accelerations.
▪ Adequate accelerations of the FHR are
reassuring that the placenta is functioning
properly and the fetus is well-oxygenated.

Purpose:
1) To identify fetal compromise in conditions
associated with poor placenta function, such as
HPN, DM, and post-term gestation.

Vibroacoustic Stimulation Test ▪ It is the procedure similar to the NST; in addition,

an artificial larynx device is used to stimulate the
fetus with sound; expected response is
acceleration of the FHR, as in the NST.

Purposes:
1) To clarify (if the NST is questionable) whether the
fetus is well oxygenated, thereby reducing the
need for more complex testing.
2) To clarify (during labor) questionable FHR
patterns.

Contraction Stress Test (CST) ▪ It is the evaluation of the FHR response to mild
uterine contractions by using an electronic fetal
monitor; contractions may be induced by self-
stimulation of the nipples which causes the
woman’s pituitary gland to release oxytocin, or by
intravenous oxytocin (Pitocin) infusion.
▪ The woman must have at least three contractions
at least 40 seconds in duration in a 10-minute
period for interpretation of the CST.

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 Purposes:
1) Same with NST; it may be done if the NST results
are non-reassuring (the fetal heart does not
accelerate) or if they are questionable.

Interpretation of Results:
Late Decelerations after a contraction can
indicate that fetus may not tolerate labor.
Negative CST results mean there are no late
decelerations and the fetus can probably tolerate
labor.

Non-Invasive ▪ Analysis of the range of fetal heart beats recorded

Electrocardiogram Recordings on a 10 – minute tracing that was obtained
(FHR Variability) between contractions.

▪ Normal Rate: 120 to160 beats per minute (rate

fluctuates slightly (5 to 15 beats per minute) when
a fetus moves or sleeps.

Abnormal Patterns in Baseline

1) Fetal Bradycardia – fetal heart tone is below 120

beats per minute for a 10-minute period.

Moderate Bradycardia – 100 – 119 beats

per minute; not considered serious and is
probably due to a vagal response elicited
by compression of the fetal head during
labor.

Marked Bradycardia – less than 100

beats per minute; a sign of possible
hypoxia and considered dangerous

2) Fetal Tachycardia – rate is 160 beats per minute

or faster for a 10-minute period.

Moderate Tachycardia – 161 – 180

beats per minute.

Marked Tachycardia – greater than 180

beats per minute; caused by fetal
hypoxia, maternal fever, drugs, fetal

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 arrhythmia or maternal anemia or
hyperthyroidism

Variability – fluctuations in the fetal heart rate overtime;

normal irregularity of cardiac rhythm.

Fetal Heart Rate Variability – one of the most reliable

indicators of fetal well-being.

o It is the variation or differing rhythmicity in the

heart rate overtime and is reflected on the fetal
heart rate tracing as a slight irregularity or “jitter”
to the wave.
o It may indicate fetal hypoxia or acidosis.

Factors Influencing FHR Variability:

1) Fetal Oxygenation Status

2) Cardiac Output Regulation
3) Fetal Behavior
4) Alcohol and Illicit drugs

o The degree of variability increases – when fetus

is stimulated.
o The degree of variability decreases – when fetus
sleeps.
o No variability present – the natural pacemaker
activity of the fetal heart (effects of the
sympathetic and parasympathetic NS) has been
affected.

o Baseline variability could be defined as either long

term or short term:

Short-Term
Long-Term
Variability (Beat to
Variability
Beat)
seen on the broad difference between
view of the recording successive
and result from heartbeats usually
fluctuations in the about 3 to 5 beats per
FHR of 6 to 10 beats minute
per minute that occur
3 to 10x / minute

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 o Decreasing Variability – indicates the
development of fetal distress.

o Absent Variability – a severe sign indicating

serious fetal compromise.

Periodic Changes – fluctuations in the FHR in response

to uterine contractions and fetal movement.

1) Accelerations – temporary normal increase in

the FHR caused by fetal movement or
compression of umbilical vein during a
contraction.

Causes:

o Repetitive Fetal Stimulation

o Direct Sympathetic Stimulation
Sympathetic nervous system stimulation
causes vasoconstriction of most blood
vessels. This occurs as a result of
activation of alpha-1 adrenergic
receptors by norepinephrine released by
post-ganglionic sympathetic neurons.
o Mild Umbilical Cord Compression
o Fetal Compensatory Mechanism
Stimulation

2) Deceleration – periodic decrease in the FHR

resulting from pressure on the fetal head during
contractions.

a) Early Deceleration normally occur late in

labor, when the head has descended fairly
low.
o If occurs early in labor, before the
head is fully descended, head
compression causing the waveform
change could be the result of
cephalo-pelvic disproportion (CPD)
and is a cause for concern.

School of Nursing | Gynecologic Nursing| Prof. A.J. Cabulagan| 20

 b) Late Deceleration – delayed until 30-40
seconds after the onset of a contraction and
continue beyond the end of contraction.
o It suggests uteroplacental
insufficiency or decreased blood flow
thru the intervillous spaces of the
uterus during uterine contraction.
o The lowest point of the deceleration
occurs near the end of the
contraction instead of it at its peak.

Cause: marked hypertonia or abnormal

uterine tone caused by administration of
oxytocin.

Nursing Management:

1) Stop or slow rate of oxytocin

administration.
2) Change woman’s position from supine to
lateral position (to relieve pressure on the
vena cava and supply more blood to the
uterus).
3) Administer IV fluid or oxygen as ordered.
4) Prepare for possible prompt birth if late
decelerations persist or if FHR variability
becomes abnormal (absent or
decreased).

c) Variable Decelerations – refers to

decelerations that occur at unpredictable time
in relation to contraction

Cause: cord compression due to prolapsed

cord or fetus lying on the cord.

Nursing Management: Change woman’s

position from supine to lateral or to
Trendelenburg position (to relieve pressure
on the cord).

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Biophysical Profile (BPP) ▪ It is a group of five fetal assessments, used to
evaluate the well-being of the fetus:
Fetal Heart Rate and Reactivity (NST)
Fetal Breathing Movements
Fetal Body Movements
Fetal Tone (closure of the hand)
Volume of Amniotic Fluid (AFI)
▪ It uses ultrasound and cardiotocography (CTG),
also known electronic fetal heart rate monitoring,
to examine the fetus.

Purpose:
1) Identify reduced fetal oxygenation in conditions
associated with poor placental function, but with
greater precision than the NST alone.

▪ As fetal hypoxia gradually increases, FHR

changes occur first, followed by cessation of fetal
breathing movement, gross body movements,
and finally loss of fetal tone.

▪ Amniotic fluid volume is reduced when placental

function is poor (shows pockets of low or absent
amniotic fluid).

Scoring:
A score of 2 points is given for each component that meets criteria. The test is continued until
all criteria are met or 30 minutes have elapsed. The points are then added for a possible
maximum score of 10.

Interpretation:

✓ 8 – 10: NORMAL
✓ 4 – 6: SUSPECTED CHRONIC ASPHYXIA
✓ 0 – 2: STRONG SUSPICION OF CHRONIC ASPHYXIA

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 Normal Abnormal
Component
(2 points) (0 point)
Fetal Breathing One or more episodes of No episodes of fetal
Movements fetal breathing lasting at lest
breathing movements
30 seconds within 30 lasting at least 30 seconds
minutes. during a 30-minute period of
observation.
Gross Body Movement 3 or more discrete body or Less than 3 body or limb
limb movements within 30 movements in 30 minutes
minutes
Fetal Tone One or more episodes of Slow extension with no
active extension and flexion return or slow return to
of a fetal extremity flexion of a fetal extremity

OR OR

opening and closing of the no fetal movement.

hand within 30 minutes
Amniotic Fluid Volume * A single deepest vertical A single deepest vertical
pocket of amniotic fluid pocket of amniotic fluid
measures greater than 2 measures 2 centimeters or
centimeters is present less
Non-Stress Test (NST) ** Reactive Non-reactive

Note:

*Amniotic Fluid Volume – measured as the vertical measurement, in centimeters, of the

single deepest pocket of amniotic fluid with a transverse measurement of 1 cm or more wide
without fetal small parts or umbilical cord.
** Reactive – Two or more fetal heart rate accelerations that peak (but do not necessarily
remain) at least 15 beats per minute above the baseline and last at least 15 seconds from
baseline to baseline during 20 minutes of observation.
**Non-Reactive: Less than two accelerations of fetal heart rate as described above after 40
minutes of observation.

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School of Nursing | Gynecologic Nursing| Prof. A.J. Cabulagan| 24
 Reactive NST

Non-Reactive NST

Percutaneous Umbilical Blood ▪ Obtaining a fetal blood sample from a placental

Sampling vessel or from the umbilical cord; may be used to
give a blood transfusion to an anemic fetus.
Purposes:
1) To identify fetal conditions that can be diagnosed
only with a blood sample.
2) Blood transfusion for fetal anemia caused by
maternal-fetal blood incompatibility, placenta
previa, or abruptio placenta.

VI. ROLES OF NURSES IN ASSESSING A HIGH-RISK CLIENT

*****
Prepared by:

ARIEL JAMES C. CABULAGAN, RN, MAN

Professor

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