1. Perinatology. Risk factors in perinatal period.
By Korda I.

2. Anatomy of a normal placenta:
The placenta provides the fetus with oxygen and nutrients and takes away waste such as carbon dioxide via the umbilical cord.

3. Indicators of High Risk Pregnancy
Maternal age <16 or >35
Chronic disease – hypertension, diabetes, cardiovascular or renal disease, thyroid disorder
Preeclampsia- abn hypertension during pregnancy
Rh isoimmunization- neg and pos in blood  coagulation
History of stillbirth
IUGR- baby is smaller than needs to be; Growth Retardation
Postterm pregnancy – 2wks past the due date
Multiple gestation
History of preterm labor
Previous cervical incompetence

4. Maternal Assessment of Fetal Activity
Fetal movement
Vigorous activity reassuring
Decreased activity requires immediate follow-up
Factors affecting activity
Sound
Drugs
Sleep
Smoking
Blood glucose level

5. Ultrasound High frequency sound waves (Real time scanning)
Advantages - early detection of fetal anomalies, accurate determination of gestation, noninvasive and painless, no known harmful effects, use at any time during pregnancy
Types
Transabdominal US- need full bladder, if not full drink 3-4 8oz glasses and rescan
Endovaginal US- probe is inserted into vagina (closer to structures) same preparation. Lithotomy position.

6. Clinical Applications 1st trimester
Early identification of pregnancy
Observation of FHR and breathing movements
Measurements – biparietal “side bones of head” diameter of fetal head, crown to rump, fetal femur length, birth weight
Detection of anomalies
Identification of amniotic fluid index
Location of placenta and grading; to check whether there’s proper profusion. Lower the number the better.
Detection of fetal death
Determination of fetal position and presentation
Accompanying procedures (ex: Amniocentesis

7. Doppler Blood Flow Studies Not same as Doppler fetal hrt tones
Evaluates blood flow in fetus and mother
Assesses placental function
Helpful in managing pregnancies with maternal diabetes, IUGR “term for slowed growth of the fetus during pregnancy”, preterm labor, prolonged pregnancies, and multiple gestation

8. Nonstress Test Evaluate fetal heart rate with fetal activity
Reassuring if accelerations occur with fetal movement
Interpretation
Reactive – 2 or more FHR accelerations of at least 15 bpm with a duration of at least 15 seconds in a 20 minute interval (desired)
Nonreactive – reactive criteria not met within 30 minutes
If decelerations are noted- phys notified- for further evalutaion

9. incr of about 15 bmp lasting 15 sec desired
Fetal Movement
Figure 14–5 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement (FM). Top of strip shows FHR; bottom of strip shows uterine activity tracing. Note that FHR increases (above the baseline) at least 15 beats and remains at that rate for at least 15 seconds before returning to the former baseline.

10. Ex: Nonreactive NST. Poss sleep or hypoglycemic. Poss treat w/ juice.
Figure 14–6 Example of a nonreactive NST. There are no accelerations of FHR with FM. Baseline FHR is 130 bpm. The tracing of uterine activity is on the bottom of the strip.

11. Biophysical Profile Assessment of 5 biophysical variables
Fetal breathing movement (US to determine)
Fetal movement of body or limbs
Fetal tone (extension and flexion of extremities)
Amniotic fluid volume
Reactive NST with activity
Scoring (2 or 0, no in-between) Between 8-10 is good/desired
2 is given for normal
0 is given for an abnormal finding

12. Contraction Stress Test
Evaluates the Respiratory function of the placenta
Does it get O2 to the baby? Test to check if the placenta has the reserves needed during contractions.
Records FHR response to stress of uterine contractions
Compress arteries to placenta
Uterine Contractions induced by nipple stimulation or Oxytocin (Caution: may cause pt to go into labor!)
Interpretation
Negative – 3 good contractions lasting 40 seconds in 10 minute interval with no late decelerations
Positive – persistent late decelerations with more than 50% of the contractions (NOT THE DESIRED RESULTS)

13. CST “Contraction Stress Test”

14. Postive CST- baseline about 150, HR drops w/ contractions

15. Another example of positive CST.
Figure 14–8 Example of a positive contraction stress test (CST). Repetitive late decelerations occur with each contraction. Note that there are no accelerations of FHR with three fetal movements (FM). The baseline FHR is 120 bpm. Uterine contractions (bottom half of strip) occurred four times in 12 minutes.

16. Amniocentesis
Amniotic fluid obtained by inserting a needle through the abdominal and uterine walls
Purpose
Genetics - Abnormal AFP
Fetal lung maturity
Risks
Infection (Sterile tech req’d)
Pregnancy loss
Tests
Triple tests – AFP, hCG, and UE3 (unconjugated estriol/estrogen)
L/S ratio- “Lecithin/Sphingomyelin” test for fetal lung maturation; 2:1
Fetal maturity index
Phosphatidylglycerol- another phospholipid surfactant

17. Amniocentesis
Figure 14–9 Amniocentesis. The woman is scanned by ultrasound to determine the placental site and to locate a pocket of amniotic fluid. Then the needle is inserted into the uterine cavity to withdraw amniotic fluid.

18. Other Fetal Diagnostic Tests
Chorionic Villus Sampling – performed at 10 – 12 weeks, off the placenta
Percutaneous Umbilical Blood Sampling-
Computed Tomography- obtain maternal pelvic and fetal diameters
Magnetic Resonance Imaging- confirm anamolies, placental assessment for location and size
Fetal Echocardiography- identify cardiac anomalies- during 2nd and 3rd trimester

19. Changes in Fundal Height

20. Fetal Monitoring Fetal heart sounds Benefits of fetal monitoring
Auscultate between 16 and 40 wks by stethoscope, fetoscope, or Doppler
Benefits of fetal monitoring
Procedure
Normal fetal heart rate: bpm

21. Fetoscope

22. Doppler

23. Sites for Auscultation of Fetal Heart Tones

24. Placental insufficiency
It is the failure of the placenta to supply nutrients to the fetus and remove toxic wastes.
When the placenta fails to develop or function properly, the fetus cannot grow and develop normally. The earlier in the pregnancy that this occurs, the more severe the problems. If placental insufficiency occurs for a long time during the pregnancy, it may lead to intrauterine growth retardation (IUGR).

25. Fetal distress
Fetal distress is defined as depletion of oxygen and accumulation of carbon dioxide,leading to a state of “hypoxia and acidosis ” during intra-uterine life.
Decreased movement felt by the mother or Fetal hyperactivity
Meconium in the amniotic fluid
Cardiotocography signs
increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction
Fetal heart rate less than 120 or greater than 170 beats per minute
Progressive decrease in baseline variability
Late deceleration
Severe variable decelerations

26. Fetal distress
Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp prick through the open cervix in labour
fetal acidosis
elevated fetal blood lactate levels indicating the baby has a lactic acidosis

29. Causes Abnormal position and presentation of the fetus Multiple births
Shoulder dystocia
Umbilical cord prolapse
Nuchal cord
Placental abruption
Premature closure of the fetal ductus arteriosus

30. Treatment
In many situations fetal distress will lead the obstetrician to recommend steps to urgently deliver the baby. This can be done by labor induction, or in more urgent cases, a caesarean section may be performed.

32. Intrauterine growth restriction (Intrauterine growth retardation; IUGR)
(IUGR) refers to a condition in which a fetus is unable to achieve its genetically determined potential size.

33. Screening the fetus for growth restriction
symphysis–fundal height measurements
Biometry and amniotic fluid volumes
Uterine artery Doppler measurement
Umbilical artery Doppler measurement
Three-dimensional ultrasonography

34. Resuscitation Algorithm:

35. Why we need to resuscitate:
pH 7.00
pH 6.80
pH 7.30

36. How often do we use our resuscitation skills?

37. Suction Equipment
Warmer & Blankets
Bag, Mask, & Oxygen
Laryngoscope and ETT Tube

38. Universal Precautions

39. Assessment: Then
Appearance
Pulse
Grimace
Activity
Respirations

40. Apgar score

42. Assessment: Now Physiologic Parameters (Apgar’s best)
Questions to ask yourself
Physiologic Parameters (Apgar’s best)
Breathing
Heart Rate
Color
Clear of Meconium?
Breathing or Crying?
Good Muscle tone?
Color Pink?
Term Gestation?

43. Initial Management: For all deliveries
Provide warmth
Position and Clear Airway
Dry
Give Oxygen (as necessary)

44. Providing Warmth: The cycle of hypothermia
Acidosis
Pulmonary Vasoconstriction
Anaerobic metabolism
Pulmonary Hypertension
Tissue hypoxia
Right to left shunting
Hypoxemia

45. Positioning: Sniffing

46. The “Trusty” Bulb Syringe

47. Clear of Meconium?

48. Color pink?

49. Pulse Oximetry: Resuscitation monitor
Not affected by acrocyanosis
Be patient and get a reading
If baby in shock, get central IV access

50. Breathing or Crying?
Indications for PPV (Positive pressure ventilation)
Apnea or gasping
Heart rate <100 even if breathing
Persistent central cyanosis (saturation <90%) despite 100% free-flow oxygen

51. Self-Inflating Bag O2 Reservoir Pressure manometer attaches
PEEP valve port
ml Bag size

52. Neopuff CPAP(continuous positive airway pressure (with mask)
Pressure limited ventilation with PEEP
Blended oxygen
Eliminates variability associated with bag ventilation

53. Masks
Smallest sizes are for preterm infants

54. Make sure the airway is clear Lift the baby’s jaw into the mask
Keep the mouth slightly open
Rate 40-60

55. Indications for Intubation
Meconium and baby is not vigorous
PPV by bag-mask does not result in good chest rise
PPV needed beyond a few minutes
Chest compressions necessary
Route to administer epinephrine
Special indications: Prematurity, CDH

56. Miller 0
Miller 1

57. >2000 gm
3.5 gm
3.0
2.5
<1000 gm
Stylet

58. Intubation Technique

59. Indications for Compressions
Heart rate <60 bpm after 30sec of PPV
Coordinate with ventilation
4 events in 2 seconds
90 compressions and 30 breaths per minute
One and Two and Three and Breathe
2 seconds

60. 2 thumb technique preferred
Compressions
2 thumb technique preferred

61. Medications: Epinephrine
Indication: Heart rate <60 after 30 sec of coordinated ventilation and compressions
1:10,000 (0.1mg/ml)
Route: ETT or IV
ml/kg
1ml Term
0.5ml Preterm
0.25ml Extreme preterm

62. Extended Algorithm
Endotracheal Intubation if not already accomplished
Establish IV access with UVC
Stat CXR
Discontinue efforts if no heart rate after 15 minutes
Indication: Heart rate <60 after 30 sec of coordinated ventilation and compressions
1:10,000 (0.1mg/ml)
Route: ETT or IV
ml/kg
1ml Term
0.5ml Preterm
0.25ml Extreme preterm

63. IV Access: “Low” UVC

64. Volume
Indication: No response to resuscitation and evidence of blood loss
Normal Saline
Ringers or Blood as alternatives
10 ml/kg, may repeat
Route: IV (Umbilical vein)

65. Sodium Bicarbonate
Indication: Documented or assumed metabolic acidosis
Concentration: 4.2% NaHCO3 (0.5meq/ml)
Dose: 2meq/kg
Route: IV (Umbilical vein)

66. Naloxone (Narcan)
Indication: Severe respiratory depression after PPV has restored a normal HR and color and…
History of maternal narcotic administration within the past 4 hours
Dose: 0.1mg/kg of 1mg/ml solution
Route: ETT, IV, IM, SQ

69. Thanks for attention!!!