The tests used to monitor fetal health include fetal movement counts, the nonstress test, biophysical profile, modified biophysical profile, contraction stress test, and Doppler ultrasound exam of the umbilical artery.

2. INTRODUCTION
Antenatal fetal surveillance is assessment of fetal well being in
antepartum period to ensure delivery of healthy neonate.
Two main objectives are:-
 Early detection of fetuses at risk to prevent perinatal mortality
and morbidity.
 Find out normal fetuses and avoid unwarranted interventions.
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3. INDICATIONS FOR ANTEPARTUM FETAL MONITORING
•IUGR
•Multiple pregnancy
•Polyhydramnios
•Oligohydramnios
•Rhesus alloimmunization
•Diabetes mellitus
•Hypertension
•Epilepsy
•Renal or Cardiac Disease
•Infection (Tuberculosis)
•SLE
•Advanced maternal age
(> 35 years)
• previous still birth or recurrent
abortion
•anencephaly, spina bifida
• autosomal trisomy
•Routine antenatal testing

4. 4

5. • Initial examination – assess size of uterus by bimanual
examination or by USG
• Thorough clinical examination of mother
• Investigations – Routine investigations ( blood, urine,
cervical cytology by PAP SMEAR)
• Special investigations – serological tests for rubella,
hepatitis B & HIV
CLINICAL MONITORING – AT FIRST VISIT

6. 6

7. Maternal weight gain
Excess weight gain-due to fluid retention or first
sign of pre-eclampsia
Weight gain is less than normal, stationary or even
falling suspect IUGR
Category BMI Weight in kgs
Low 19.8 12.5-18
Normal 19.8-26 11.5-16
High 26-29 7-11.5
Obese 29 7

8. Blood pressure
Initial record of blood pressure prior to 12 weeks helps
to differentiate a pre-existing chronic hypertension
from a pregnancy induced hypertension
Assessment of the size of the uterus and height
of the fundus
SFH is measured from superior border of pubis
symphysis to fundus
From 24th weeks of gestation corresponds to
periods of gestation
Difference of 3-4 cms acceptable
Below 10th percentile or difference of >4 cms
suggests IUGR

9. Clinical assessment of liquor
Any scanty or excess liquor is recorded in
the last trimester. Evidence of scanty
liquor may indicate placental insufficiency
Documentaion of the abdominal girth
Measured at lower border of umbilicus
Increases by 2.5 cm per week after 30weeks
95-100 cms at term.
Static or falling values alarming sign

10. ASSESSING SFH

11. GESTATIONAL AGE CHART ESTIMATED FROM
SYMPHYSIS FUNDAL HEIGHT

12. 2)BIOPHYSICAL TESTS
• Fetal movement count
• Cardiotocography
• Non-stress test (NST)
•Vibroacoustic stimulation test
• USG
•Amniotic fluid volume
•Doppler ultrasound
• Contraction stress test (CST)
• Nipple stimulation test
•Fetal biophysical profile (BPP)

13. FETAL MOVEMENT COUNT— TWO METHODS
1.Cardif ‘count 10’ formula
•patient counts fetal movements starting at 9 am.
• counting comes to an end as soon as 10 movements are
perceived.
•report the physician if—
i)Less than 10 movements occur during 12
hours on 2 successive days or
ii) no movement is perceived even after 12
hours in a single day.

14. 2) Daily fetal movement count (DFMC)
• Three counts each of one hour duration (morning,
noon and evening) is adviced
• The total counts multiplied by four gives daily (12
hour) fetal movement count
• If the number of ‘kicks’ is less than 10 in 12 hours (or
less than 3 in each hour), it indicates fetal compromise.
•The count should be performed daily starting at 28
weeks of pregnancy.

15. •Increased fetal movement is associated with maternal
hypoglycemia
•reduced with fetal sleep (quiet), fetal anomalies
(CNS), anterior placenta, hydramnios, obesity, drugs
(narcotics), chronic smoking
and hypoxia.

16. Cardiotocograph is a machine which is used to monitor the fetal heart
rate and uterine contractions
It can be used both externally and internally in the uterus
EQUIPMENT
It consists of the bedside monitor unit and transducers for FHR &
uterine activity which are secured on the mothers’ abdomen by elastic
straps.
CARDIOTOCOGRAPH /
ELECTRONIC FETAL MONITORING

18. The Ultrasound transducer is placed where FHS is heard.
The Toco transducer to monitor the uterine contraction is placed
on the uterine Fundus.
A hand held fetal activity monitor is given to mothers hand
which she presses at the time of perception of fetal movement
Paper strip : data about FHR & uterine activity is printed on a
paper strip. The FHR is recorded in the upper strip & uterine
activity in the lower grid.
Vertical lines on both upper & lower grids are time divisions.
Dark vertical lines are 1 min apart. Lighter lines subdivide the 1-
min divisions into six 10- second segments.

22. INDICATIONS OF EFM
ANTENATAL RISK FACTORS
• Prematurity
• Pre eclampsia/eclampsia
• Diabetes
• Multiple pregnancy
• Malpresentation
• Growth restriction
INTRAPARTUM RISK FACTORS
• Induction of labour with syntocinon or prostaglandin
• Meconeum stained liquor
• Epidural analgesia
• Previous LSCS
• Prolonged labour
• Suspicious fetal heart rate in auscultation

23. INTERPRETATION OF FHR in CTG
Four variables are considered when interpreting CTG; these are
1. Baseline FHR
2. Baseline Variability
3. Acceleration from the Baseline
4. Deceleration from the Baseline
1. Baseline FHR : it is the mean level of FHR excluding
accelerations & decelerations. it is expressed in beats per
minute.
• Normal : 110- 160 bpm
• Bradycardia : less than 110 bpm
• Tachycardia : more than 160 bpm

27. 2. Baseline variability : it is the oscillation or
fluctuation of baseline FHR .Normal variability is
between 10-25 bpm. Variability is a good indicator
of healthy fetus. Pathological if it is absent or
marked.
• Absent : undetectable
• Minimal : less than 5 bpm
• Moderate : 6- 25 bpm
• Marked : more than 25 bpm

33. 3. Accelerations
Accelerations are transient increase in FHR by 15
bpm or more lasting for atleast 15 seconds.
acceleration denotes an intact neurohormonal and
cardiovascular activity and therefore a healthy fetus.
• Prolonged acceleration lasts > 2 min but < 10 min.
• When acceleration lasts > 10 min it is a baseline
change

35. 4. Deccelerations
• Transient decrease in FHR below the baseline by 15 bpm or more
lasting > 15 sec
• Three basic types of deceleration ---- early, late and variable
a) Early deceleration
• they occur during contractions as fetal head is pressed against
woman’s pelvis or soft tissues causing the vagus nerve to slow
the heart rate
• They are uniform , repetitive , periodic slowing of FHR
• The onset, nadir (low point) and recovery of deceleration
coincides with the beginning, peak and ending of uterine
contraction respectively

38. b) Late deceleration
It is a non reassuring pattern that suggests
utero placental insufficiency and fetal hypoxia.
The onset of deceleration corresponds to the
mid to end of uterine contraction, nadir > 20
seconds after the peak of contraction and FHR
returns to normal after the contraction is over.

41. c) Variable Deceleration
This type of deceleration has an irregular pattern
with rapid onset and recovery ( within 30 sec).
Decelerations are variable in all respect of size,
shape, depth, duration and timing to the uterine
contractions. It is thought to indicate cord
compression and may disappear with change in
position of patient.

43. 3 categories of interpretation are
Category 1 - normal (reassuring)
Category 2 – indeterminate ( equivocal)
Category 3 – abnormal (nonreassuring)
SIGNIFICANCE OF FHR PATTERN

45. Uterine activity
Assessment of uterine activity involves four components:
1) Contraction frequency may be measured with the
electronic monitor as with palpation
2) Duration is calculated from the beginning to end of each
contraction.
3) Contraction intensity is described as mild, moderate or
strong.
4) Average Uterine resting tone is 5 to 15 mm Hg. During
labour it reaches about 50 to 75 mm Hg.

47. Continuous electronic monitoring of the fetal heart rate along with
recording of fetal movements (cardiotocography) is undertaken. It is
started after 30 weeks
PRINCIPLE
NST identifies whether an increase in the FHR occurs when the
fetus moves, indicating adequate oxygenation, a healthy neural
pathway from the central nervous system to the fetal heart and the
ability of the fetal heart to respond to stimuli.
If fetal heart does not accelerate with movement, fetal hypoxemia &
acidosis may be the reason.
NON-STRESS TEST (NST)

48. STEPS OF NST
•Explain procedure, empty bladder
• Give semi fowler’s / lateral tilt position
•record vitals & document time of start, name, reason
•Apply ultrasound transducer & toco transducer
•The mother is given a hand held fetal activity monitor to
press each time she senses movement.
•run 10 – 20 min FHR contraction strip
•if non reactive ,stimulate accoustically
•wait additional 20 min for reactive criteria 48

49. NON-STRESS TEST (NST)

50. 50

51. REACTIVE NST

52. NON REACTIVE

53. NST
ADVANTAGES
•Non invasive test requiring no initiation of contractions
•Quick to perform & can repeated 1- 2 times/wk or daily
•Painless & No known side effects to mother & fetus
•Low false – negative rate ( less than 1 %)
DISADVANTAGES
•Not as sensitive to fetal oxygen reserves as CST
•High false – positive rate, 80 % to 90%

54. VIBROACCOUSTICSTIMULATION
DEFINITION
It is a method of evaluating fetal status by
observing accelerations of the FHR following
vibroaccoustic stimulation
GOAL
•To alter the fetal behavioural state, wake a
sleeping fetus and provoke fetal accelerations
in the heart rate thus shorten the length of NST

56. VIBROACOUSTIC STIMULATION (VAS)
•Steps are same as NST
•a specifically designed accoustic stimulator is applied to the
mothers abdomen over the area of fetal head and stimulation
with vibration & sound of approximately 85 – 100 dB is given
for upto 3 seconds. vibroacoustic stimulation can be repeated
at 1- min interval upto 3 times.
Fetal response : Brain response to auditory stimulation
appear between 26 & 28 weeks of gestation. A reactive NST

57. Advantages of VAS
• Decreases NST length
• Decreases the incidence of nonreactive
NST
• Reduces need for fetal scalp pH during
labour as much as 50 %
• No known risks like hearing damage

58. Assessment of amniotic fluid volume is essential in pregnancies
complicated by IUGR & Pre eclampsia.
PRINCIPLE
It is based on the fact that decreased uteroplacental perfusion can result
in reduced renal blood flow, decreased urine production & conseuently
oligohydramnios.
Two Techniques are used
• Amniotic Fluid Index (AFI)
• Single Deepest Pocket (SDP)
AMNIOTIC FLUID VOLUME

59. Maternal abdomen is divided into quadrants taking the
umbilicus, symphysis pubis and the fundus as the
reference points.
• With USG, the largest vertical pocket in each quadrant
is measured.
• The sum of the four measurements (cm) is the AFI.
• Normal range : 5-24
• Oliohydramnios : < 5
• Polyhydramnios : > 24
AMNIOTIC FLUID INDEX

60. SINGLE DEEPEST POCKET
SDP is the depth of a single cord free pocket of amniotic fluid.
Normal Range : 2-8 cm
Polyhydramnios : > 8
Oligohydrmnios : < 2

61. CONTRACTION STRESS TEST / OXYTOCIN
CHALLENGE TEST
It is an invasive method to assess the fetal well being during
pregnancy.
PRINCIPLE
The test is based on the fact that the uteroplacental blood flow
decreases markedly during uterine contractions.
A normal fetus can withstand this hypoxic stress without difficulty.
But if the fetus has inadequate reserves & substantial hypoxia this
will result in fetal acidosis. The CST records the response of the
FHR to stress induced by uterine contractions

62. INDICATION
• IUGR
• Post maturity
• Hypertension
• Diabetes
CONTRAINDICATION
• Previous history of caesarean
• Compromised fetus
• Women who have high risk for preterm labour
• Preterm premature rupture of membrane
• Placenta previa
• APH
• Multiple pregnancy
• History of uterine surgery

63. Procedure
The oxytocin infusion is started with initial rate of infusion
1mU/min .it is escalated at an interval of 20 min until
effective contraction is achieved.( contraction last for 45 sec
and numbering 3 contractions in 10 min)
The alteration in FHR during contractions is recorded by
electronic fetal monitoring.
It takes at least 1 – 2 hours to perform the test.

65. Interpretation of CST
• Positive : persistent late deceleration with 50 % or more
of uterine contraction
• Negative : No late deceleration
• Suspicious : intermittent late deceleration donot persist with
most uterine contractions
• Unsatisfactory : Poor quality of recording or fewer than 3
contraction per 10 min
• Hyperstimulation : deceleration of FHR with uterine
contractions lasting > 90 seconds or occuring more frequently
than every 2 min

66. Positive CST- Nonreassuring FHR Pattern

67. Negative CST

68. Advantage
• Provides a minimally invasive follow-up of a nonreactive NST
• A negative test is associated with good fetal outcome
• A positive test allows obstetrician to plan for available options for
further testing & make plans for birth
Disadvantage
• More time consuming than NST
• Requires strict vigilance so that adequate contraction is attained
without causing hyper stimulation
• Cost is higher than NST

69. NIPPLE STIMULATION TEST
• It is an alternative to OCT
• Nipple stimulation in late pregnancy institutes a
neurohypophyseal reflex resulting in oxytocin release and
uterine contractions
• It is cheaper, less invasive, less harmful and less time
consuming
• The woman is asked to rub one nipple through her
clothing for 10 min which will induce contraction

70. Bio physical profile
Bio physical profile is an evaluation of fetal well being
through the use of various reflex activities that are CNS-
controlled and sensitive to hypoxia, as well as the fetal
environment that can affect fetal well being.
In 1980 Manning and colleagues introduced BPP
BPP is a noninvasive test that predicts the presence or
absence of fetal asphyxia

72. B.P.P- PARAMETERS
Fetal Heart Reactivity (NST)
Fetal Breathing Movement
Fetal Body Movement
Fetal Muscle Tone
Amniotic Fluid Volume

74. The fetal central nervous system that control each individual
parameter of the BPP react differently to hypoxemia. The control
centers that develop later require higher oxygen levels than those
developing earlier.
Therefore FHR reactivity disappears first. Fetal breathing
movements are affected next. and fetal movement & fetal tone are
the last areas affected. Because of this absence of fetal tone
indicates advanced asphyxia and acidosis.
The amount of amniotic fluid provides information about chronic
hypoxia & is a strong indication of fetal compromise.
PRINCIPLE

75. Variable Score 2
Observation for 30 min ( Normal score = 2 ) (Abnormal = 0)
Non Stress Test reactive
Fetal Breathing
Movements
1 or more episodes lasting >30 sec
Gross Body Movements
3 or more gross body or limb
movements
Fetal Muscle Tone
1 Or more episode of motion of a limb
(from extension to flexion) or trunk/
opening& closing of hand
Amniotic fluid volume
1 Or more pocket measuring 2 cm in
two perpendicular planes

77. Consists of NST and ultrasonographically
determined amniotic fluid index (AFI).
Modified BPP is considered abnormal
(nonreassuring) when the NST is non-reactive
and/or the AFI is < 5.
MODIFIED BIOPHYSICAL PROFILE

78. *Non invasive technique to assess placental blood flow to the fetus.
*Uses waveforms to describe Systolic (S) & Diastolic (D) blood
flow through vessels.
S
D

79. • Doppler wave forms are used to measure the velocity in several
vessels in the maternal – fetal unit, including the intra cerebral,
renal, internal iliac, femoral & umbilical arteries.
• Arterial doppler waveforms are helpful to assess the downstream
vascular resistance.
• The arterial Doppler waveform is used to measure the peak
systolic(s), peak diastolic (D) and mean (M) volumes.
ARTERIAL DOPPLER WAVEFORMS

81. • S/D ratio ( > 2 indicates reduced diastolic velocity &
increased placental vascular resistance )
• pulsatilityindex (PI) [PI = (S-D)/M] ( term = 1)
• Resistance Index (RI) [RI = (S-D)/S] ( > 0.72 is
greater than the normal limits from 26 weeks gestation
onwards)
In a normal pregnancy the S/D ratio, PI and RI
decreases as the gestational age advances.

83. Venous Doppler parameter provide
information about cardiac forward
function (cardiac compliance,
contractility and after load). Fetuses
with abnormal cardiac function show
pulsatile flow in the umbilical vein.
VENOUS DOPPLER