Catanduanes State University

COLLEGE OF HEALTH SCIENCES

NURSING DEPARTMENT
Virac, Catanduanes

Jelibee T. Germina, RN, MAN

Instructor

Welcome, Future Nurses!

 DISCLAIMER
The information contained in the
presentation is for general information
and education purposes only.
Authors and publishers of the contents
are well acknowledged. As such the
college and its faculty do not claim
ownership of all source information.
 OBJECTIVES
 Describe/ Demonstrate the nursing assessments
designed to improve health of high-risk prenatal
client.
 Identify actual/ potential diagnostic tests in high-risk
prenatal client.
 TABLE OF CONTENTS
1. Identifying Clients at-risk
a. Demographic factors
b. Socioeconomic Status
c. Obstetric History
d. Current OB status
e. Maternal Medical History/Status
f. Habits
2. Diagnostic Tests in High-Risk Pregnancy
 INTRODUCTION
According to Dr. Maria Stephanie Fay Cagayan of
the Philippine Obstetrical and Gynecological
Society, the maternal mortality ratio declined to
104 per 100,000 live births in 2022.
She noted that maternal mortality ratio increased
during the start of the COVID-19 pandemic
from 100 per 100,000 live births in 2019 to 123
in 2020 and 212 in 2021.
01 Identifying Clients
at-Risk Factors
High-Risk pregnancies are defined as
those occurring in women with:

-Pre-existing medical illnesses

-Previous poor pregnancy outcome
-Evidence of maternal undernutrition/
external factors
 A. DEMOGRAPHIC FACTORS

 Age
 Poverty
 Non-white
 Multiparity
 B. SOCIAL-PERSONAL FACTORS

WEIGHT HEIGHT SMOKING/

ALCOHOL/
ILLEGAL
DRUG USE
8
 C. OBSTETRIC FACTORS

Birth of Previous
previous infant
Rh
Stillbirth
with weight Sensitizatio
>3.8 kg n

9
A 39 year old female is currently 18
weeks pregnant. She has two sets of
twin daughters that were born at 38
and 39 weeks gestation and an 11 year-
old son who was born at 32 weeks
gestation. She has no history of
miscarriage or abortion. What is her
GTPAL?
A 30 year old female is 25 weeks
pregnant with twins. She has 5 living
children. Four of the 5 children were
born at 39 weeks gestation and one
child was born at 27 weeks gestation.
Two years ago she had a miscarriage at
10 weeks gestation. What is her
GTPAL?
 D. EXISTING MEDICAL CONDITIONS

CARDIAC DISEASE DIABETES MELLITUS

HYPOTHYROIDISM
D. EXISTING MEDICAL CONDITIONS

RENAL DISEASE

CONCURRENT
INFECTIONS
 E. ENVIRONMENTAL AGENTS
MERCURY, LEAD,
PESTICIDES,
ANESTHETIC PASSIVE SMOKING
AGENTS
RADIATION
NAIL SALON
CHEMICALS,
PERSONAL HAIR IMPAIR
PRODUCTS FERTILITY
 F. HABITS

SMOKING ALCOHOL

METHAMPHETAMIN
ES, COCAINE,
HEROIN MARIJUANA
Active ingredient: delta-9-
tetrahydrocannibol (THC)
UNHEALTHY
DIET PATTERN,
PSYCHOSOCIAL/
SLEEP
MENTAL STRESS
DISTURBANCE
 02
DIAGNOSTIC TEST
In High-Risk Pregnancy
NON-INVASIVE: INVASIVE:

-Chorionic Villus Sampling

-Fetal Ultrasound
-Amniocentesis
-Cardiotocography -Embryoscopy
-Non-Stress Test -Fetoscopy
-Amniotic Fluid Index -Percutaneous Umbilical Blood
(AFI) Sampling (Cordocentesis)
-Contraction Stress Test (CST)
- Maternal Serum Alpha Feto
Protein (MSAFP)
 OBJECTIVES OF INVASIVE and NON-INVASIVE:
-Diagnosis
-to reduce maternal and fetal mortality rate.
-to check timely medical or surgical treatment of a
condition before or after birth.
-to give the parents the chance to abort a fetus with
the diagnosed condition.
-to give parents the chance to “prepare”
psychological, socially, financially, and medically for a
baby with a health problem or disability, or for the
likelihood of a stillbirth. 19
NON-INVASIVE DIAGNOSTIC TEST

1. Fetal Ultrasound
2. Non-Stress Test
3. Amniotic Fluid Index (AFI)
4. Cardiotocography
 1. ULTRASONOGRAPHY
 Is a diagnostic technique, which uses high-
frequency sound waves to create an image of the
internal organs.
 A screening is sometimes done during the course
of a pregnancy to check normal fetal growth and
verify the due date.
 It is a safe, non-invasive, accurate and cost
effective investigation.
 Hard tissues such as bone appear white on the
21
image and soft tissues appear grey.
 1. ULTRASONOGRAPHY
 INDICATIONS:
 In the First Trimester:
-to establish the dates of a pregnancy
-to determine the number of fetuses and identify
placental structures
- to diagnose an ectopic pregnancy or miscarriage
-to examine the uterus and other pelvic anatomy
-in some cases to detect fetal abnormalities such
as anencephaly.
22
 DIFFERENT TREATMENTS

MERCURY VENUS EARTH

It’s the smallest Venus has a Earth is the only
planet of them all beautiful name planet with life

NEPTUNE PLUTO JUPITER

It’s very far away It’s considered a It’s the biggest
from the Sun dwarf planet planet of them all

23
 1. ULTRASONOGRAPHY
 INDICATIONS:
 Mid Trimester:
-to determine the number of fetuses and examine the
placental structures
-to assist in prenatal tests such as AMNIOCENTESIS,
CORDOCENTESIS
-to examine the fetal anatomy for presence of abnormalities
-to check the amount of amniotic fluid by measuring AFI
-to examine blood flow patterns
-to check on the location of placenta; to see if its covering
cervix
-to observe fetal behavior and activity. 24
 1. ULTRASONOGRAPHY

 INDICATIONS:
 Third Trimester:
-to monitor fetal growth, to check IUGR
-detailed anatomical survey
-to check the amount of amniotic fluid
-to determine the position of a fetus
-to assess the placenta
25
TYPES of ultrasound performed during pregnancy
 1. ULTRASONOGRAPHY

 PROCEDURE (TRANS ABDOMINAL

USG):

 Explain the procedure to the patient.

 Provide privacy
 Provide a supine position to the patient
 Apply gel.
 1. ULTRASONOGRAPHY
 PREPARATION (TRANS ABDOMINAL USG):
1. Advise the mother to drink one quart of water 2
hours before the procedure.
2. Instruct not to void.
3. In AMNIOCENTESIS with UTZ to offer
visualization, the mother should void to prevent
injuring the distended bladder with the needle
insertion.
4. Transmission of gel is spread over the maternal
28
abdomen.
 1. ULTRASONOGRAPHY
 PREPARATION (TRANS ABDOMINAL USG):
5. Psychological support is given to the mother/father
Explain the reasons for the procedures together with its
benefits and the preparations
Explain that there is no known risk with infrequent and brief
exposure to high frequency of sound waves.
 Encourage verbalization of fears and concerns.
 Procedure is noninvasive and safe for mother and fetus
 Confinement is not needed
 No need for dye and there is no X-ray irradiation Procedure
takes a short time to accomplish
29
 1. ULTRASONOGRAPHY
 INDICATION (TRANS VAGINAL USG):

 Early month of pregnancy

 In this high frequency of sound waves used so
greater resolution is possible
 Typical gynaecological indication includes uterine
size, evaluation of endometrium, myometrium,
cervix.
30
 1. ULTRASONOGRAPHY
 PROCEDURE (TRANS VAGINAL USG):

 A probe is placed into the vagina instead of over the

abdomen.
 Provide dorsal lithotomy position with empty bladder.
 Vaginal probe should be lubricated with gel and the probe
should be inserted into an appropriate covering sheet such
as condom.
 The sheet covered probe is gently advanced up the vaginal
canal
 USG is done before week 11 31
 2. NON-STRESS TEST
 Measures the response of the fetal heart rate to
fetal movement.
 a test of fetal well being

 CONCEPT OF NST:
 Oxygen is required for fetal activity and heart rate
to be with in normal ranges.

32
TYPES of ultrasound performed during pregnancy
 2. NON-STRESS TEST

 INDICATIONS OF NST:

1. Post dated mothers.

2. GDM
3. IUGR
4. Placental and cord abnormalities
5. Absence of fetal movements
6. As a precaution 34
 2. NON-STRESS TEST
 Preparation:
 Position – semi Fowler’s or left lateral position slightly turned to
the left
 BP is checked first
 Explain:
 Procedure takes 30 – 60 minutes to finish
 Mother needs to activate “mark button” with each fetal
movement
 Does not need hospitalization – ambulatory basis
 Requires external electronic monitoring of FHT with ultrasound
transducer and tocodynamometer to trace fetal activity and/or
uterine activity 35
 2. NON-STRESS TEST
 Interpretation:
 Normal: Reactive
 Increased FHT (acceleration) greater than 15 bpm above
baseline –
lasting 15 seconds or more in a 10 – 20 minute period with
fetal movement
 Abnormal: Non Reactive
 No FHR acceleration with fetal movement
 Implications of Result:
 Abnormal result: mother needs another test, may be biophysical
profile 36
 2. NON-STRESS TEST
 ADVANTAGES:
 Non-invasive
 Painless
 Lack of risk to mother and fetus
 Immediate results
DISADVANTAGES:
 False positive results during fetal asleep
 40 min gives most sleeping fetus time to awaken
 Awaiting acceleration prolong
37
 3. AMNIOTIC FLUID INDEX
 AFI is a rough estimate of the amount of amniotic fluid and
is an index for the fetal well-being.
 AFI is the score (expressed in cm) given to the amount of
amniotic fluid seen on pregnant uterus and calculated by a
ultrasound.
 To determine the AFI, doctor may use a four-quadrant
technique, when the deepest, unobstructed, vertical length
of each pocket of fluid is measured in each quadrant and
then added up to the others, or the so called “Single
Deepest Pocket” technique.
38
3. AMNIOTIC FLUID INDEX

39
 3. AMNIOTIC FLUID INDEX
Method to evaluate Amniotic Fluid Volume:
 Most popular is four quadrant technique to calculate AFI.
 AFI is obtained by measuring the vertical diameter of largest
pocket of amniotic fluid in 4 quadrants of uterus by USG and
the sum of the result is AFI.
AFI:
 <5cm- Oligohydramnios
 5-10cm- decreased amniotic fluid volume
 10-19cm- Normal
 20-25cm- increased amniotic fluid volume
 >25cm- Polyhydromnios 40
 4. CARDIOTOCOGRAPHY (CTG)
CTG is a test used in
pregnancy to monitor both the
fetal heart pattern as well as
the uterine contractions.
It should only used in the 3rd
trimester when fetal neural
reflexes are present.
Its purpose is to monitor fetal
well-being and allow early
detection of fetal distress
antenatal or intrapartum. 41
 4. CARDIOTOCOGRAPHY (CTG)
 DIFFERENCE BETWEEN NST
and CTG:
 NST is a screening test used in
pregnancy to assess fetal status
by means of the fetal heart rate
and its responsiveness.
 CTG is used to monitor the fetal
heart rate and presence or
absence of uterine contractions.

42
 4. CARDIOTOCOGRAPHY (CTG)
 MATERNAL INDICATIONS:  FETAL INDICATIONS:
A. MATERNAL MEDICAL DISORDERS: 1. Reduced fetal movements
1. PIH 2. Suspected IUGR
2. DM 3. Abnormal FHR by
3. Anemia and other hematologic auscultation
disorders 4. Multiple pregnancy
4. Chronic hypertension 5. Rhesus iso-immunization
5. Cardiac disease 6. Before induction
6. Collagen disease
7. Renal disease
8. Thyroid disease
B. Bad OB Hx
43
C. Post-date pregnancy
 4. CARDIOTOCOGRAPHY (CTG)
 PARTS OF CTG:
 One transducer records the FHR
using an ultrasound beam,
 The other transducer records
uterine contractions.

44
 4. CARDIOTOCOGRAPHY (CTG)
 FINDINGS DEPENDS UPON
THE FOLLOWING
COMPONENTS:

1. Baseline FHR
2. Baseline variability
3. Accelerations
4. Decelerations

45
 4. CARDIOTOCOGRAPHY (CTG)
 BASELINE FHR:
 The mean level of the FHR when this is stable, excluding
accelerations and decelerations. It is determined over a
period of 5 or 10 minutes and expressed in bpm.

BASELINE VARIABILITY:
 The minor fluctuations in baseline FHR occurring at three to
five cycles per minute. It measures the highest peak and
lowest trough of fluctuation in a one-minute segment of the
trace.
46
 4. CARDIOTOCOGRAPHY (CTG)
 DECELERATIONS:

1. Early: Head
Compression
2. Late: Utero-placental
Insufficiency
3. Variable: Cord
compression and
Primary CNS
dysfunction.
47
 4. CARDIOTOCOGRAPHY (CTG)
 INTERPRETATION:
 Negative: No late deceleration with adequate contractions
 Positive: Late deceleration with adequate contractions
 Equivocal: no positive or negative window occurs
Hyperstimulation
 Excessive uterine activity is present in association with
deceleration of FHR
 Unsatisfactory: Inadequate FHR record or contractions. Test
should be repeated with in 24 hours.

48
 4. CARDIOTOCOGRAPHY (CTG)
 Tachycardia
 Hypoxia
 Chorioamnionitis
 Maternal fever
 B-mimetic drugs
 Fetal anemia
 Sepsis
 Heart failure
 Arrhythmias

49
 4. CARDIOTOCOGRAPHY (CTG)
 CATEGORIZATION OF FETAL HEART TRACES:

 NORMAL: All four reassuring

 Suspicious: 1 non-re-assuring; rest reassuring
 Pathological: 2 or more non-reassuring; 1 or more abnormal

50
 4. CARDIOTOCOGRAPHY (CTG)
SUSPICIOUS
CTG:

51
5. NIPPLE STIMULATION CONTRACTION TEST
Determines feto placental function/well-
being
Breast are stimulated with rolling of
nipples or warm towel application.
 Stimulation of the nipple causes stimulus
to be sent to the posterior pituitary gland
which in turn secretes oxytocin. This
oxytocin, in addition to causing
contraction of the breast tubules, also
has a direct effect on uterine
musculature causing it to contract. 52
5. NIPPLE STIMULATION CONTRACTION TEST
The baseline data are obtained through
monitoring as in OCT procedure.

Interpretations: same as OCT: the absence

of late decelerations in three contractions in
10 minutes is the desired result

53
 6. BIOPHYSICAL PROFILE
A scoring combining ultrasound
assessment of:
 Fetal breathing
 Amniotic fluid volume
 Fetal tone
 Fetal movement
 Reactivity of heart rate

54
6. BIOPHYSICAL PROFILE

55
 6. BIOPHYSICAL PROFILE

 Scores:

8 – 10 Normal, low risk for chronic

asphyxia
4 – 6 suspected chronic asphyxia
0 – 2 strong suspicion of chronic
asphyxia 56
 INVASIVE DIAGNOSTIC TEST
1. Maternal Alpha-Fetop Protein (MSAFP)
2. Amniocentesis
3. Contraction Stress Test (CST)
4. Chorionic Villi Sampling (CVS)
5. Percutaneous Umbilical Cord Blood
Sampling (PUBS)
6. Fetoscopy
7. Amnioscopy
 1. MATERNAL ALPHA-FETOPROTEIN SCREENING (MAFP):

 A blood test that measures the level of

alpha-fetoprotein in the mothers’ blood
during pregnancy.
 AFP is a fetal protein normally
produced by the fetal liver and is
present in the fluid surrounding the
fetus (amniotic fluid), and crosses the
placenta into the mother’s blood.

58
 1. MATERNAL ALPHA-FETOPROTEIN SCREENING (MAFP):

All pregnant women are usually offered the AFP test. But,
the doctor may recommend the test, especially if:
 Mother is 35 or older
 Have a family hx of birth defects
 Have diabetes
 Have taken certain drugs or medication during pregnancy

Time of performing the test: 15-18 weeks

60
 1. MATERNAL ALPHA-FETOPROTEIN SCREENING (MAFP):

MSAFP LEVEL HIGH INDICATES:

1. Open Neural Tube Defects (ONTD) such as spina

bifida
2. Other chromosomal abnormalities lead to IUFD
3. Defects in the abdominal wall of the fetus
4. Twins more than one fetus is making the protein
5. A miscalculated due date
6. Renal anomalies 61
 1. MATERNAL ALPHA-FETOPROTEIN SCREENING (MAFP):

MSAFP LEVEL LOW INDICATES:

1. Down’s syndrome
2. Gestational trophoblastic disease

62
 2. AMNIOCENTESIS
It is medical procedure used in prenatal diagnosis of
chromosomal abnormalities and fetal infections.
In which a small amount of amniotic fluid, which
contains fetal tissues, and the fetal DNA is
examined for genetic abnormalities.

63
C:\Users\BETH\Downloads\Amniocentesis (Amniotic Fluid Test).mp4
 2. AMNIOCENTESIS
INDICATION:
 Diagnostic Early and later therapeutic procedure
 Time of perform: between the 15th-20th weeks of pregnancy
 Mostly during the 18th week.

65
 2. AMNIOCENTESIS
CONTRAINDICATION:
 Acute skin infections near the site of needle placement
 Maternal fever
 Allergies to material used like skin preparation materials,
local anesthesia.
 May be difficulty in-patient with multiple pregnancies.

66
 2. AMNIOCENTESIS
Maternal Complication: Fetal Complication:
 Infection  Miscarriage
 Allo iimmunisation of the  Respiratory distress
mother  Postural deformities
 Preterm labor and delivery  Fetal trauma
 Hemorrhage  Oligohydramnions due to
leakage of amniotic fluid

67
 2. AMNIOCENTESIS
NURSING RESPONSIBILITY BEFORE PROCEDURE:
 Before procedure, take written consent.
 Explain the purpose of procedure
 Emptying the bladder and provide privacy
 Provide supine position with elevated head
 The abdominal wall is prepared aseptically and draped
 Check VS and FHR to obtain baseline data.
 Check USG
 Prophylactic administration of 100 mg of anti-D immunoglobulin in
Rh negative mother.
 The proposed site of puncture is unfiltered with 2ml of 1%
lignocaineE 68
 2. AMNIOCENTESIS
NURSING RESPONSIBILITY AFTER PROCEDURE:
 Fetus should be monitored for short period after procedure, check
FHR every 30 minutes.
 Tell patient, to report physician if uterine cramping, vaginal
bleeding or leakage of fluid or fever.
 Strenuous activities should be avoided for 24 hours following an
amniocentesis.

69
3. CONTRACTION STRESS TESTS/ OXYTOCIN CHALLENGE TEST

 CST is done to see whether fetus

remains healthy during reduced
oxygen levels (contraction).
 It is a test to evaluate FHR in the
presence of spontaneous or Oxytocin-
induced contractions.

70
 3. CONTRACTION STRESS TESTS/ OXYTOCIN CHALLENGE TEST

 Purpose:
 Observation of response of the fetus
to induced uterine contraction
 a test of feto-placental well being

 Preparation:
1. Semi-Fowler’s or left lateral position
2. BP is checked priorly and every 15
minutes during the test

71
 3. CONTRACTION STRESS TESTS/ OXYTOCIN CHALLENGE TEST

Preparation:
3. Explain:
 Procedure takes 1 – 3 hours to finish
 Mother receives oxytocin of increasing
dosage “piggybacked to the mainline
and aimed to cause 3 uterine
contractions in 10 minutes
 May be done on outpatient basis
4. Requires external electronic FHT
monitoring with ultrasound transducer and
tocodynometer to detect uterine activity 72
 3. CONTRACTION STRESS TESTS/ OXYTOCIN CHALLENGE TEST

Interpretation:
 Normal: Negative
 No late decelerations of FHR with each
of three contractions during a 10-
minute interval

Abnormal: Positive
 With late deceleration of FHR with
three contractions in 10 minutes

73
 3. CONTRACTION STRESS TESTS/ OXYTOCIN CHALLENGE TEST

Implication of Results
Normal
-pregnancy continues;
normal results of OCT may require
weekly tests

Abnormal results
-may indicate a need for
cesarean section or continued
observation 74
 3. CONTRACTION STRESS TESTS/ OXYTOCIN CHALLENGE TEST

ADVANTAGES:
 Follow up of non-reactive NST.
 More informative
DISADVANTAGES:
 Contra-indicated in placenta
previa, LSCS, PROM.
 Utero placental perfusion reduced
due to hyperstimulation.
 Time consuming.
75
 4. CHORIONIC VILLUS SAMPLING (CVS)

A form of prenatal diagnosis to determine chromosomal

or genetic disorders I the fetus.
It entails getting a sample of the chorionic villus
(placental tissue) and testing it.
It can can be performed in a transvaginally or
transabdominal manner.
Performing time: Before 15 weeks, usually performed
between the 10th and 12th weeks of pregnancy.

76
C:\Users\BETH\Downloads\Chorionic Villus Sampling (CVS).mp4
 4. CHORIONIC VILLUS SAMPLING (CVS)

 INDICATIONS:  CONTRAINDICATIONS:
 Abnormal first trimester  Active vaginal bleeding
screen results  Infection
 Increased AFP or other  Multiple gestation
abnormal USG findings  HIV infection
 Family Hx of a chromosomal
abnormality or other genetic
disorder
 Parents are known carries
for a genetic disorder
 Maternal age above 38 81
 5. PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBs)/
CORDOCENTESIS
 Cordocentesis, also sometimes called Percutaneous
Umbilical Cord Blood Sampling (PUBS), is a diagnostic test
that examines blood from the fetus to detect fetal
abnormalities.

82
 5. PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBs)/
CORDOCENTESIS

 An advanced imaging ultrasound determines the location

where the umbilical cord inserts into the placenta. The
ultrasound guides a thin needle through the abdomen and
uterine walls to the umbilical cord. The needle is inserted
into the umbilical cord to retrieve a small sample of fetal
blood. The sample is sent to the laboratory for analysis, and
results are usually available within 72 hours. The procedure
is similar to amniocentesis except the objective is to
retrieve blood from the fetus versus amniotic fluid.
83
 5. PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBs)/
CORDOCENTESIS
Cordocentesis is usually done when diagnostic information
can not be obtained through amniocentesis, CVS,
ultrasound or the results of these tests were inconclusive.
Cordocentesis is performed after 18 weeks of pregnancy.

Cordocentesis detects chromosome abnormalities (i.e.

Down syndrome) and blood disorders (i.e. fetal hemolytic
disease.).

84
 5. PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBs)/
CORDOCENTESIS
Cordocentesis may be performed to help diagnose any of
the following concerns:

 Malformations of the fetus

 Fetal infection (i.e. toxoplasmosis or rubella)
 Fetal platelet count
 Fetal anemia
 Isoimmunisation

85
 6. EMBRYSCOPY/ FETOSCOPY

 Embryoscopy is a relatively new and investigational

technique that permits direct visualization of the fetus as
early as the first trimester. Initially, a rigid fiberoptic
endoscope was passed trans cervically into the extra
coelomic cavity, permitting inspection of fetal anatomic
structures; fetal blood sampling was also feasible by this
method. However, improvements and advancements in
fiberoptic technology have led to the performance of thin-
gauge transabdominal and transcervical embryoscopy,
allowing visualization as early as 4 weeks after conception.
88
 6. EMBRYSCOPY/ FETOSCOPY

 Fetoscopy is an endoscopic procedure during pregnancy to

allow surgical access to the fetus, the amniotic cavity, the
umbilical cord, and the fetal side of the placenta. Fetoscopy
is a surgical procedure which may involve the use of a
fibreoptic device called a fetoscope.

 A small (3-4 mm) incision is made in the abdomen, and an

endoscope is inserted through the abdominal wall and
uterus into the amniotic cavity.

89
 6. EMBRYSCOPY/ FETOSCOPY

Fetoscopy allows for medical interventions such as a biopsy

(tissue sample) or a laser occlusion of abnormal blood
vessels (such as chorioangioma) or the treatment of spina
bifida.

90
 6. EMBRYSCOPY/ FETOSCOPY

Fetoscopy is usually performed in the second or third

trimester of pregnancy. The procedure can place the fetus at
increased risk of adverse outcomes, including fetal loss or
preterm delivery, so the risks and benefits must be carefully
weighed in order to protect the health of the mother and
fetus(es).The procedure is typically performed in an
operating room by an obstetrician- gynecologist. It is
associated with a 3-5 % risk of miscarriage.

91
C:\Users\BETH\Downloads\FETOSCOPY
EMBRYOSCOPY.mp4
 MEDICATION
F. S
..\DRUGS in PREGNANCY.pptx
 PATIENT CLASSIFICATION

VITAL PATIENT
SIGNS PROFILE
Mercury is a small Mars is made of
planet basalt

WEIGHT & MEDICAL

HEIGHT RECORD
Venus has a Jupiter is the
beautiful name biggest planet

94
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