3. .
INTRODUCTION
Majority (80%) of fetal deaths occur in the ante partum
period.
The important causes of death are – (1) chronic maternal
hypoxia (IUGR). (2) Maternal complications, e.g. diabetes,
hypertension, infection. (3) Fetal congenital malformations
and (4) unexplained cause
There is a progressive decline in maternal deaths all over the
world. Currently more interest is focused to evaluate the fetal
health. The primary objective of antenatal fetal assessment is
to avoid fetal death. As such simultaneously with good
maternal care during pregnancy & labor, the fetal health in
uteri should be supervised with equal vigilance
4. aims of antenatal
fetal monitoring
To ensure satisfactory
growth & wellbeing of the
fetus throughout pregnancy.
To screen out the high risk
factors that affects the
growth of fetus.
To prevent prenatal
morbidity and mortality.
5. When to start fetal Assessment
Fetal assessment is done once or twice
weekly
Risk assessed individually
For any patient with decrease fetal movement
start immediately
Post dated delivery
DM
6. Common indications for fetal
monitoring
Pregnancy with obstetric complications: IUGR,
multiple pregnancies, polyhydramnios or
oligohydramnios, rhesus alloimmunization.
Pregnancy with medical complications: Diabetes
mellitus, hypertension, epilepsy, renal or cardiac
diseases, infections (tuberculosis), SLE
Others: Advanced maternal age (>35yrs), previous
still birth or recurrent abortion, previous birth of
baby with structural or chromosomal abnormalities.
Routine antenatal testing
8. Clinical evaluation of fetal
well being:
First visit: initial antenatal examination should
be carried out, record is kept of the size of the
uterus.
Subsequent visit: following clinical parameters
are taken into account-
Maternal wt. gain and Blood pressure
Assessment of the size of the uterus and height of
the fundus
Clinical assessment of excess liquor
Documentation of the girth of the abdomen.
9. Fundal examination
Fundal height, or McDonald's rule, is a measure of the size of
the uterus used to assess fetal growth and development
during pregnancy.
10. Fundal examination
It is measured from the top of the mother's uterus to the top of the
mother's pubic bone in centimeters.
Fundal height roughly corresponds to gestational age in weeks between 16
to 36 weeks for a vertex fetus. When a tape measure is unavailable, finger
widths are used to estimate centimeter (week) . However, landmark distances
from the pubic symphysis are highly variable depending on body type.
Recording the actual fundal height measurement from the palpable top of
the uterus to the superior edge of the pubic symphysis is standard practice
beginning around 20 week’s gestation.
11.
12. fundal height at various points during
pregnancy
Gestational age
Fundal height
landmark
12 weeks Pubic Symphysis
16 weeks Halfway between
pubic & umbilicus
20 weeks at Umbilicus
22-24 weeks 1-2 fingerbreadth above
umbilicus
28-30 weeks 3 fingerbreadths above
umbilicus
32 weeks 3-4 fingerbreadth below
xiphoid process
36-38 weeks Xiphoid Process of
Sternum
40 weeks 2-3 finger below xiphoid
process if lightening occurs
13.
14. Shorter measures
Fetus descent into the pelvis, seen
normally two to four weeks before
delivery
Error in estimated date of pregnancy
based on first day of last menstrual
period
Fetus is healthy but physically small
Oligohydramnios
Fetus positioned sideways
Small for gestational age
15. Longer measures
Twins, or other types of multiple birth
Error in estimated date of conception
Fetus is healthy but physically large
Gestational diabetes causing a larger
baby
Polyhydramnios
Large for gestational age
Hydatidiform Mole
Breech birth
17. ABDOMINALPALPATION&
LEOPOLDSMENEUVERS
Leopold's Maneuvers are a common and
systematic way to determine the position
of a fetus inside the woman's uterus; they
are named after the gynecologist Christian
Gerhard Leopold.
They are also used to estimate term fetal
weight.
The maneuvers consist of four distinct
actions, each helping to determine the
position of the fetus. The maneuvers are
important because they help determine the
position and presentation of the fetus,
which in conjunction with
correct assessment of the shape of
the maternal pelvis can indicate whether
the delivery is going to be complicated, or
whether a Cesarean section is necessary.
18. Leopold's Maneuvers are difficult to
perform on obese women and women
who have polyhydramnios.
The palpation can sometime
be uncomfortable for the woman if care
is not taken to ensure she is relaxed and
adequately positioned. To aid in this,
the health care provider should first
ensure that the woman has recently
emptied her bladder. If she has not, she
may need to have a straight
urinary catheter inserted to empty it if
she is unable to micturate herself.
The woman should lie on her back with
her shoulders raised slightly on a pillow
and her knees drawn up a little.
Her abdomen should be uncovered, and
most women appreciate it if the
individual performing the maneuver
warms their hands prior to palpation.
19. fundalPalpation / Fundal Grip
Determines lie & presentation of
fetus
Face the woman, palpate the
woman's upper abdomen with both
hands.
professional can often determine
the size, consistency, shape, and
mobility of the form that is felt.
The fetal head is hard, firm,
round, and moves independently of
the trunk while the buttocks feel
softer, are symmetric, and the
shoulders and limbs have small
bony processes; unlike the head,
they move with the trunk
20. Lateral Palpation / Lateral Grip
Determine the location of the fetal back.
facing the woman, the health care
provider palpates the abdomen with gentle
but also deep pressure using the palm of
the hands. First the right hand remains
steady on one side of the abdomen while the
left hand explores the right side of the
woman's uterus. This is then repeated using
the opposite side and hands.
The fetal back will feel firm and smooth
while fetal extremities (arms, legs, etc.)
should feel like small irregularities and
protrusions.
21. First PelvicGrip / Superficial PelvicGrip
Determine what fetal part is lying above
the inlet, or lower abdomen? The
individual performing the maneuver first
grasps the lower portion of the abdomen
just above the pubic symphysis
with the thumb and fingers of the right
hand. This maneuver should yield the
opposite information and validate the
findings of the first maneuver. If the
woman enters labor, this is the part which
will most likely come first in a vaginal
birth.
The Paw lick's Grip, although still used
by some obstetricians, is not
recommended as it is more uncomfortable
for the woman.
22. SecondPelvicGrip / DeepPelvic Grip
Face the woman's feet, as he or she will
attempt to locate the fetus' brow. The
fingers of both hands are moved gently
down the sides of the uterus toward
the pubis.
The side where there is resistance to the
descent of the fingers toward the pubis is
greatest is where the brow is located. If
the head of the fetus is well-flexed, it
should be on the opposite side from the
fetal back. If the fetal head is extended
though, the occiput is instead felt and is
located on the same side as the back.
24. MATERNAL SERUMALPHA
FETOPROTEIN(MSAFP) AFP is an oncofetal protein produced
by the yolk sac & fetal liver.
Highest levels of AFP in fetal serum
& amniotic fluid are reached around
13 weeks & thereafter it decreases.
Maternal serum levels reach a peak
around 32 weeks.
MSAFP level is elevated in a number
of conditions: (a)Wrong gestational
age (b) Open neural tube
defects(NTDS) (c) multiple
pregnancy, Rh isoimmunization (d)
IUFD
Nurse will use a small needle to
withdraw blood from a vein (usually
in arm or hand), & a laboratory
specialist will analyze the sample. The
procedure takes only a few minutes
& is relatively painless.
25.
26. TRIPLE TEST
Triple test, also called triple screen, the Kettering test
or the Bart’s test.
It is a combined test which includes MSAFP, HCG &
UE3 (unconjugated estriol). Maternal age in relation
to confirmed gestation age is also taken into account.
In an affected pregnancy, level of MSAFP & UE,
tend to be low while that of HCG is high.
It is performed at 15-18 weeks. It gives a risk ratio &
for confirmation amniocentesis has to be done. The
result is considered to be screen positive if the risk
ratio is 1:250 or greater. The levels may indicate
increased risk for certain conditions or may be
benign:
27. Cont…
AFP UE3 HCG Associated conditions
Low low high Down’s syndrome
Low low n/a Trisomy 18
( Edwards syndrome)
High low n/a Neural tube defects (like
spina bifida that may have associated increased levels of
acetyl cholinesterase in the ammonic fluid), omphalocele,
multiple twins, or an underestimation of gestational age
28. HUMAN ESTRIOL
Normal estriol production is dependent on a
physiologically normal fetus & placenta since the fetal
adrenal gland provides the precursor for the production
of estrogens by the placenta
Measurement of estriol in blood or urine & comparison
of the findings with the established normal values for the
time in gestation, therefore, gives an indication of the
fetoplacental unit.
The levels of estriol increases throughout pregnancy,
especially in the last trimester, to a peak at term.
Compromise is determined by a decrease in estriol.
29. A value above 12mg indicates fetal wellbeing. Values between 4
& 12 mg may indicate fetal jeopardy if late in pregnancy, with
the probability of jeopardy being higher than closer the value is
to 4mg. Value below 4 mg indicates severe fetal jeopardy or even
impending death of fetus.
Estriol series may be ordered when there is a potential concern
such as in the following conditions.
Post maturity by dates
Unsure dates & possibility of post maturity
Elderly primigravida
Toxemia/hypertensive disorders of pregnancy
Diabetes
Intra uterine growth retardation
Suspected fetal death
Suspected fetal abnormality such as anencephaly
30. ACETYLCHOLINE ESTERASE
Amniotic fluid AChE level is elevated in most cases of open
neural tube defects .It has got better diagnostic value than
AFP.
Inhibin A: It is produced by the corpus luteum & the
placenta. Serum level of inhibin A is raised in women carrying
a fetus with Down’s syndrome.
First trimester screening (increased HCG, decreased MSAFP,
decreased PAPP) can detect Trisomy 21 in 85%with a false
positive rate of 5%.
Second trimester screening (15-18 weeks): Triple test
(decreased MSAFP, decreased UE, and increased Total hCG)
and quadruple test (decreased MSAFP, decreased UE, Total
HCG, increased inhibin A) can detect Trisomy 21 in 70% &
80% of affected pregnancies respectively
33. Amniocentesis
Obtaining a sample of amniotic fluid surrounding
the fetus during pregnancy.”
Indications:
Diagnostic (at 11- 20 weeks)
Chromosomal analysis (Down syndrome),Spina bifida
Inherited diseases (muscular dystrophy)
Fetal lung maturation (L/S ratio
Therapeutic( at any time):
Reduce maternal stress in polyhydramnios
Mainly in twin-twin transfusion or if abnormality
associated
34. AMNIOCENTeSIS(GENETIC)
It is an invasive procedure, performed between
14 &16 weeks under ultrasonographic guidance.
It is the deliberate puncture of the amniotic fluid
sac per abdomen.
Procedure:-
After emptying the bladder, the patient remains
in dorsal position.
The abdominal wall is prepared aseptically &
draped
The proposed site of puncture is infiltrated with
2ml of 1% lignocaine.
A 20-22 gauze needle about 4” in length is
inserted into the amniotic cavity under real time
sonographic control, with the stiletto in. Injury to
the placenta, umbilical cord & fetus is to be
avoided.
The stiletto is withdrawn & few drops of liquor
are discarded. Initial 1-2ml of fluid is either used
for AFP or is discarded as it is contaminated with
maternal cells. Rest is used for fetal karyotyping.
About 30ml of fluid is collected in a test tube for
diagnostic purposes. Fetal cardiac motion is to be
seen after the procedure. The fetal cells obtained
in this procedure are subjected for cytogenic
analysis.
35. Cytogenic analysis- The desquamated fetal cells
in the amniotic fluid, obtained by amniocentesis
are cultured, G banded & examined to make a
diagnosis of chromosomal anomalies, e.g. Trisomy
21 (Down’s syndrome, monosomy X(Turners
syndrome) & others.
DNA analysis – Single gene disorders (cystic
fibrosis, Tay-Sachs disease) can be diagnosed
using specific DNA probes. DNA amplification is
done by polymerase chain reaction (PCR). The
specific chromosomes region containing the
mutated gene can be identified.
Biochemical- Amniotic fluid AFP level is high
when the fetus suffers from open neural tube
defects. This is also confirmed by ultrasound
scanning. The normal AFP concentration in liquor
amnii at the 16th week is about 20mg/liter.
Amniotic fluid level of 17 hydroxy progesterone is
raised in congenital adrenal hyperplasia
36. PRECAUTIONS
Sonographic localization
of placenta is desirable to
prevent bloody tap & feta
maternal bleeding.
Prophylactic
administration of 100mg of
anti-D immunoglobulin in
Rh-negative non immunized
mother.
37. HAZARDS
Maternal complications are
infection, hemorrhage,
premature rupture of membranes
& premature labor, maternal
isoimmunization in Rh-negative
cases.
Fetal hazards are fetal loss
(0.06-0.5%), trauma,
fetomaternal hemorrhage, and
oligohydramnios due to leakage
of amniotic fluid & may lead to
fetal lung hypoplasia, respiratory
distress, and talipes
40. CHORIONIC VILLUS
SAMPLING (CVS) It is carried out transcervically between 10-
12 weeks & transabdominally from 10
weeks to term.
Few villi are collected from the chorion
under ultrasonic guidance with the help of
long malleable polyethylene catheter
introduced transcervically .
complications like fetal loss (1-2%), oro
mandibular limb deformities or vaginal
bleeding are higher. False positive results (2-
3%) are there due to placental mosaics &
maternal cell contamination. In such
situation, amniocentesis should be
performed to confirm the diagnosis. Limb
reduction defects (LRD) are high when
CVS was performed at less than 10 weeks of
gestation. CVS when performed between 10
& 12 weeks of gestation are safe & accurate
as that of amniocentesis. Anti-D
immunoglobulin 50micro grams IM should
be administrated following the procedure to
a Rh negative women.
41.
42. CORDOCENTESIS (PERCUTANEOUS UMBLICAL BLOOD SAMPLING)
A 22 gauze spinal needle 13cm in length is
inserted through the maternal abdominal &
uterine wall under real time ultrasound
guidance using a curvilinear probe.
The needle tip is progressed carefully & it
punctures the umbilical vein approximately
1-2cm. from placental insertion. Generally,
0.5 to 2 ml of fetal blood is collected. It is
performed under local anesthesia usually
from 18 weeks gestation.
Risks: - The invasive procedure may lead to
abortion, preterm labor & intrauterine fetal
death. These may be due to bleeding, cord
hematoma formation, infection (amnionitis),
fetomaternal hemorrhage or preterm rupture
of membranes. Overall fetal loss is 1-4%.
Anti D immunoglobulin 100 microgram IM
should be given to Rh negative, yet
unimmunized women.
43. All the information obtained in
amniocentesis or chorion villus
sampling could be gathered.
Additional values are
Hematological ____________
for fetal anemia, bleeding
disorders, rhesus diseases &
heamoglobinopathies
Fetal infections___________
Toxoplasmosis, viral infections
Fetal blood gas & _________
in fetal growth restriction
Acid base status
Fetal therapy _____________
Blood transfusion, drug therapy
44. BIOPHYSIAL (early pregnancy):
Crown- Rump Length
Nuchal translucency at 10 – 14 weeks-
skin fold thickness behind the fetal
cervical spine.
Absence of nasal bone on USG at 10-12
weeks
47. Fetal movement counting
Cardiff technique:
Done in the morning,
patient should calculate how long it
takes to have 10 fetal movement.
10 movements should be appreciated in
12 hours
48. Fetal movement counting
Sadovsky technique:
For one hour after meal the woman
should lie down and concentrate on fetal
movement
4 movement should be felt in one hour
If not , she should count for another
hour
If after 2 hours four movements are not
felt, she should have fetal monitoring
49. Non stress test
Done using the cardiotocometry
with the patient in left lateral
position. Record for 20 minutes
50. Non stress test
The base line 120-160 beats/minute
Reactive:
At least two accelerations from base line
of 15 bpm for at least 15 sec within 20
minutes
Non reactive:
No acceleration after 20 minutes- proceed
for another 20 minutes
If non reactive in 40 minutes---proceed for contraction
stress test or biophysical profile
53. Contraction stress test
Fetal response to induced stress of
uterine contraction and relative placental
Insufficiency.
Should not be used in patients at risk of
preterm labor or placenta previa.
Should be proceeded by NST
72. Fetal Biophysical profile
Abnormal (score=
0)
Normal (score=2)Biophysical
Variable
Absent FBM or no
episode >30 s in 30
min
1 episode FBM of at least 30 s duration in
30 min
Fetal breathing
movements
2 or fewer body/limb
movements in 30 min
3 discrete body/limb movements in 30 minFetal movements
Either slow extension
with return to partial
flexion or movement
of limb in full
extension Absent fetal
movement
1 episode of active extension with return to
flexion of fetal limb(s) or trunk. Opening
and closing of the hand considered normal
tone
Fetal tone
Either no AF pockets
or a pocket<2 cm in 2
perpendicular planes
1 pocket of AF that measures at least 2 cm
in 2 perpendicular planes
Amniotic fluid
volume
73. ManagementInterpretationTest Score Result
Intervention for obstetric and maternal factorsRisk of fetal asphyxia
extremely rare
10 of 10
8 of 10 (normal fluid)
8 of 8 (NST not done)
Determine that there is functioning renal
tissue and intact membranes. If so, delivery of
the term fetus is indicated. In the preterm
fetus less than 34 weeks, intensive
surveillance may be
preferred to maximize fetal maturity.
Probable chronic fetal
compromise
8 of 10 (abnormal fluid)
Repeat test within 24 hrEquivocal test, possible
fetal asphyxia
6 of 10 (normal fluid)
Delivery of the term fetus. In the preterm fetus
less than 34 weeks, intensive surveillance
may be preferred to maximize fetal maturity
Probable fetal asphyxia6 of 10 (abnormal fluid)
Deliver for fetal indicationsHigh probability of fetal
asphyxia
4 of 10
Deliver for fetal indicationsFetal asphyxia almost
certain
2 of 10
Deliver for fetal indicationsFetal asphyxia certain0 of 10
81. Management of abnormal Doppler
Depends on:
fetal maturity
gestational age
Obstetric history
82. Management of Doppler results
Reverse flow or absent end diastolic flow---
Immediate delivery
High resistance index---- repeat in few days
or delivery
Normal flow---- repeat in 2 week if indicated
