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Antenatal Assessment of 
fetal wellbeing 
Shrooti Shah 
M.Sc. Nursing 
CON, BPKIHS 
11/13/2014 7:44 AM 1
contents 
• Introduction 
• Aims of antenatal fetal monitoring 
• Indications 
• Assessment in early pregnancy 
• Assessment in late pregnancy 
11/13/2014 7:44 AM 2
Introduction 
• Majority of fetal deaths occur in the 
antepartum period. 
• There is progressive decline in maternal 
deaths all over the world. Currently more 
interest is focused to evaluate the fetal 
health. 
• The primary objective of antenatal 
assessment is to avoid fetal death. 
11/13/2014 7:44 AM 3
Aims of antenatal fetal monitoring 
• To ensure satisfactory growth and well being 
of the fetus throughout pregnancy. 
• To screen out the high risk factors that affect 
the growth of the fetus. 
• To detect those congenital abnormalities or 
inborn metabolic disorders during early 
pregnancy. 
11/13/2014 7:44 AM 4
Indications for antepartum fetal 
monitoring 
Pregnancy with obstetric 
complications. 
Pregnancy with medical 
complications. 
Others 
Routine antenatal testing. 
11/13/2014 7:44 AM 5
Assessment in early pregnancy 
Biochemical 
Cytogenetic Biophysical 
11/13/2014 7:44 AM 6
Biochemical 
Maternal serum alpha fetoprotein (MSAFP) 
• AFP is a oncofetal protein. 
• It is produced by yolk sac and fetal liver. 
• Highest level of AFP in fetal serum and amniotic 
fluid is reached around 13 weeks and thereafter it 
decreases. 
• Maternal serum level reaches a peak around 32 
weeks. 
11/13/2014 7:44 AM 7
Maternal serum alpha fetoprotein 
(MSAFP) 
MSAFP level is elevated in a number of conditions: 
1. Wrong gestational age 
2. Open neural tube defects (NTDs) 
3. Multiple pregnancy 
4. IUFD 
5. Anterior abdominal wall defects 
6. Renal anomalies 
Low levels are found in trisomies (Down’s 
syndrome) and gestational trophoblastic 
disease 
11/13/2014 7:44 AM 8
Triple test 
• It is a combined biochemical test which includes 
MSAFP, HCG and UE3(unconjugated oestriol). 
• It is used for detection of Down’s syndrome. 
• In an affected pregnancy level of MSAFP and 
UE3 tend to be low while that of hCG is high. 
• It is performed at 15-18 weeks. 
11/13/2014 7:44 AM 9
• Acetylcholine esterase : (AChE) Amniotic 
fluid Ache level is elevated in most cases of 
open neural tube defects. It has got better 
diagnostic value than AFP. 
• Inhibin A is a dimeric glycoprotein. It is 
produced by the corpus luteum and the 
placenta. Serum level of inhibin A is raised in 
women carrying a fetus with Down syndrome. 
11/13/2014 7:44 AM 10
Prenatal genetic diagnosis 
Amniocentesis 
Chorion villous 
sampling (CVS) 
Cordocentesis. 
11/13/2014 7:44 AM 11
Amniocentesis 
• Aspiration of amniotic fluid from the pregnant uterus 
for examination. 
• Typically scheduled between the 14th and 16th 
weeks of pregnancy. 
• An ultrasound is done to determine the position of 
the fetus and the location of a pocket of amniotic 
fluid and the placenta. 
11/13/2014 7:44 AM 12
Amniocentesis 
11/13/2014 7:44 AM 13
Amniocentesis 
• Alpha-fetoprotein: 
Increased levels of AFP: open body defect, 
such as anencephaly, myelomeningocele, or 
omphalocele. 
Decreased level of AFP: chromosomal 
defects such as Down syndrome 
• Bilirubin Determination: 
if a blood incompatibility is suspected. 
11/13/2014 7:44 AM 14
Amniocentesis cont… 
• Chromosome analysis: few fetal skin cells 
are always present in amniotic fluid. These 
cells may be cultured and stained for 
karyotyping for genetic analysis. 
• Color: . A strong yellow color suggests a 
blood incompatibility. A green color suggests 
meconium staining, a phenomenon 
associated with fetal distress. 
11/13/2014 7:44 AM 15
Amniocentesis cont… 
• Fetal fibronectin 
Fibronectin is a glycoprotein that plays a part 
in helping the placenta attach to the uterine 
decidua. 
Detection of fibronectin in either the amniotic 
fluid or in the mother’s vagina can serve as 
an announcement that preterm labor may be 
beginning. 
11/13/2014 7:44 AM 16
Amniocentesis cont… 
• Inborn errors of metabolism: can be detected by 
amniocentesis, for example: cystinosis and maple syrup 
urine disease (amino acid disorders). 
• Lecithin/Sphingomyelin Ratio: 
 Lecithin and sphingomyelin are the protein components 
of the lung enzyme surfactant that the alveoli begin to 
form at the 22nd to 24th weeks of pregnancy. 
 After amniocentesis, the L/S ratio may be determined 
quickly by a shake test. 
 An L/S ratio of 2:1 is traditionally accepted as lung 
maturity. 
11/13/2014 7:44 AM 17
Chorionic villus sampling 
• CVS is performed for prenatal diagnosis of genetic 
disorders. 
• It is carried out transcervically between 10-12 weeks and 
transabdominally from 10 weeks to term. 
• A few villi are collected from the chorion frondosum under 
ultrasonic guidance. 
• While it provides earlier diagnosis than amniotic fluid studies, 
complications like fetal loss(1-2%), oromandibular limb 
deformities or vaginal bleeding are higher. 
11/13/2014 7:44 AM 18
Chorionic villus sampling 
11/13/2014 7:44 AM 19
Fetal blood sampling (cordocentesis) 
• This technique is used to take a sample of fetal blood 
during pregnancy in order to screen for chromosomal 
abnormalities, hemoglobinopathies and other disorders 
affecting blood or cells. 
• It is performed under local anaesthestic usually after 18 
weeks gestation. 
• Risks: the invasive procedure may lead to abortion, 
preterm labour and intrauterine fetal death. These may be 
due to bleeding, cord haematoma formation, infection or 
preterm rupture of membranes. 
11/13/2014 7:44 AM 20
Fetal blood sampling (cordocentesis) 
11/13/2014 7:44 AM 21
Fetal blood sampling cont… 
All the information as obtained in amniocentesis or 
chorion villus sampling, could be gathered. 
Additional values are mentioned below: 
• Hematological- for fetal anaemia, bleeding 
disorders (autoimmine thrombocytopenia), rhesus 
disease. 
• Fetal infections- toxoplasmosis, viral infections 
• Fetal blood gas and acid base status- in fetal 
growth restricition 
• Fetal therapy- blood transfusion 
11/13/2014 7:44 AM 22
Biophysical 
• Ultrasonographic examination of the fetus in the 
early (10-14 weeks) pregnancy can detect fetal 
anomalies. 
• Crown-rump length (CRL) smaller than the 
gestational age is associated with the risk of 
chromosomal anomalies (trisomy or triploidy). 
• Increased nuchal translucency (soft tissue marker) 
at 10-14 weeks is associated with many 
chromosomal abnormalities (trisomy, monosomy, 
triploidy). 
11/13/2014 7:44 AM 23
Assessment of fetal wellbeing in 
late pregnancy 
Clinical 
Biophysical Biochemical 
11/13/2014 7:44 AM 24
Clinical 
The clinical assessment of fetal growth can 
be evaluated by the following parameters: 
• Maternal weight gain 
• Blood pressure 
• Assessment of the size of the uterus and 
height of the fundus 
• Clinical assessment of excess liquor 
11/13/2014 7:44 AM 25
Biophysical 
• Biophysical profile is a screening test for 
uteroplacental insufficieny. 
• The following biophysical tests are used: 
1. Fetal movement count 
2. Cardiotocography 
3. Non stress test (NST) 
4. Fetal biophysical profile (BPP) 
5. Doppler ultrasound 
6. Vibroacoustic stimulation test 
7. Contraction stress test (CST) 
11/13/2014 7:44 AM 26
Fetal movement count 
• A healthy fetus moves with a degree of consistency, 
or at least 10 times a day. 
• In contrast, a fetus not receiving enough nutrients 
because of placental insufficiency has greatly 
decreased movements. 
• Based on this, asking a woman to observe and 
record the number of movements the fetus is 
making offers a gross assessment of fetal well-being. 
11/13/2014 7:44 AM 27
Fetal movement count cont… 
• Cardif count 10 formula 
• Daily fetal movement count (DFMC) 
• Mothers perceive 88% of the fetal movements detected 
by Doppler imaging. 
• Loss of fetal movements is commonly followed by 
disappearance of FHR within next 24 hours. 
• In either of the above methods, if the results is ominous, 
the candidate is subjected to NST. 
11/13/2014 7:44 AM 28
Nonstress test (NST) 
• In non-stress test, a continuous electronic 
monitoring of the fetal heart rate along with 
the recording of fetal movements (cardiac 
tocography) is undertaken. 
• There is an observed association of FHR 
acceleration with fetal movements, which 
when present, indicates a healthy fetus. 
11/13/2014 7:44 AM 29
Nonstress test 
11/13/2014 7:44 AM 30
Non stress test 
• Reactive (Reassuring)- when two or more 
accelerations of more than 15 beats per 
minute above the baseline and longer than 15 
seconds in duration are present in a 20 
minutes observation in association with 
movement of fetus 
• Non-reactive (Nonreassuring)- Absence of 
any fetal reactivity. 
11/13/2014 7:44 AM 31
Reactive Non stress test 
11/13/2014 7:44 AM 32
Non reactive non stress test 
11/13/2014 7:44 AM 33
Important features to note while 
interpreting a CTG 
• Accelerations and normal base line variability (5-25 
bpm) denote a healthy fetus. 
• Absence of accelerations is the first feature to denote 
onset of gradual hypoxia. 
• Absence of accelerations, reduced base line 
variability may be due to fetal sleep, infection, hypoxia 
or due to maternal medications. 
• Interpretation of the CTG should always be made in 
the context of clinical situation. 
11/13/2014 7:44 AM 34
Non stress test cont… 
• Baseline FHR is the mean level of FHR between the 
peaks and the depressions in beats per minute 
(bpm). 
• Accelerations are increase in FHR by 15 bpm or 
more lasting for at least 15 seconds. 
• Deceleration is decrease in FHR below the baseline 
by 15 bpm or more. 
• Baseline variability is the oscillation of baseline FHR 
excluding the accelerations and decelerations. A 
baseline variability of 5-25 bpm is a sign of fetal 
wellbeing 
11/13/2014 7:44 AM 35
Deceleration pattern 
Early decelerations (type I dips) 
11/13/2014 7:44 AM 36
Late deceleration (Type II Dips) 
11/13/2014 7:44 AM 37
Variable decelerations 
11/13/2014 7:44 AM 38
Contraction stress testing 
• With contraction stress testing, the fetal heart rate is 
analyzed in conjunction with contractions. 
• A source of oxytocin for contraction stress testing 
currently is achieved by nipple stimulation. 
• Gentle stimulation of the nipples releases oxytocin 
in the same way as happens with breastfeeding. 
With external uterine contraction and fetal heart rate 
monitors in place, the baseline fetal heart rate is 
obtained. 
11/13/2014 7:44 AM 39
Contraction stress test cont… 
• Next, the woman rolls a nipple between her finger and thumb 
until uterine contractions begin, which are recorded by a 
uterine monitor. 
• Three contractions with a duration of 40 seconds or longer 
must be present in a 10-minute window before the test can 
be interpreted. 
• The test is negative (normal) if no fetal heart rate 
decelerations are present with contractions. 
• It is positive (abnormal) if 50% or more of contractions 
cause a late deceleration 
11/13/2014 7:44 AM 40
Oxytocin challenge test 
• To elicit an abnormal FHR response 
• Performed by iv infusion of dilute oxytocin until 
three contractions occur in 10 minutes 
• Positive test: Late deceleration after each of the 
three contractions; FHR baseline variability; no FHR 
increase after FM 
• Indicates decreased fetal reserve 
• Negative test: No decelerations 
• Fetus is safe within one week 
• Suspicious: Repetitive variable decelerations 
• Associated with abnormal FHR in labor, particularly in 
post-term gestation 
11/13/2014 7:44 AM 41
Vibroacoustic stimulation 
• A specially designed acoustic stimulator is applied to the 
mother’s abdomen to produce a sharp sound of 
approximately 80 decibels at a frequency of 80 Hz, startling 
and waking the fetus. 
• During a standard nonstress test, if a spontaneous 
acceleration has not occurred within 5 minutes, apply a 
single 1- to 2-second sound stimulation to the lower 
abdomen. 
• This can be repeated again at the end of 10 minutes if no 
further spontaneous movement occurs, so that two 
movements within the 20-minute window can be evaluated. 
11/13/2014 7:44 AM 42
Biophysical profile 
• A biophysical profile combines five 
parameters 
1. fetal reactivity 
2. fetal breathing movements 
3. fetal body movement 
4. fetal tone 
5. amniotic fluid volume 
11/13/2014 7:44 AM 43
Biophysical profile 
• With use of this system, each item has the potential for 
scoring a 2, so 10 would be the highest score possible. 
• It is popularly called a fetal Apgar. 
• Biophysical profiles may be done as often as daily 
during a high-risk pregnancy. 
• If the fetus score on a complete profile is 8–10, the fetus 
is considered to be doing well. A score of 6 is 
considered suspicious; a score of 4 denotes a fetus 
probably in jeopardy 
11/13/2014 7:44 AM 44
Biophysical profile 
S.no. Parameters Minimal normal criteria Score 
1. Non stress test 
(NST) 
Reactive pattern 2 
2. Fetal breathing 
movement 
1 episode lasting >30 sec 2 
3. Gross body 
movement 
3 discrete body/ limb 
movements 
2 
4. Fetal muscle tone 1 episode of extension (limb 
or trunk) with return of 
flexion 
2 
5. Amniotic fluid 1 pocket measuring 2cm in 
two perpendicular planes 
2 
11/13/2014 7:44 AM 45
Biophysical profile 
BPP score Interpretation Management 
8-10 No fetal asphyxia Repeat testing at weekly interval 
6 Chronic asphyxia If >36weeks- deliver 
4 Chronic asphyxia If ≥36 weeks deliver, if ,32 weeks 
repeat testing in 4-6 hours. 
0-2 Certain asphyxia Test for 120 min—Persistent 
score≤4---deliver regardless of 
gestational age. 11/13/2014 7:44 AM 46
Modified biophysical profile 
• Use only two assessments (amniotic fluid 
index and a nonstress test). 
• A healthy fetus should show a reactive 
nonstress test and an AFI range between 5 
and 25 cm. 
• Modified BPP is considered abnormal 
(nonreassuring) when the NST is non-reactive 
and/or the AFI is <5. 
11/13/2014 7:44 AM 47
Ultrasonography 
• The production of high frequency sound 
waves which are reflected or echoed when 
beamed into the body and an interface is 
encountered between different types of 
tissues or structures with different densities. 
• These echoes can be translated into visible 
images of the tissues or structures 
encountered. 
11/13/2014 7:44 AM 48
Ultrasonography 
11/13/2014 7:44 AM 49
Uses of ultrasonography 
• Diagnose pregnancy as early as 6 weeks gestation. 
• Confirm the presence, size, and location of the 
placenta and amniotic fluid 
• Establish that a fetus is growing and has no gross 
anomalies, such as hydrocephalus, anencephaly, or 
spinal cord, heart, kidney, and bladder defects 
• Establish sex if a penis is revealed 
• Establish the presentation and position of the fetus 
• Predict maturity by measurement of the biparietal 
diameter of the head 
11/13/2014 7:44 AM 50
Uses of ultrasonography cont… 
• To discover complications of pregnancy. 
• Fetal anomalies 
• Fetal death 
• After birth, an ultrasound may be used to 
detect a retained placenta or poor uterine 
involution in the new mother. 
11/13/2014 7:44 AM 51
Gestational age and fetal maturity 
• At 5-10 weeks: gestational sac. 
• At 8-14 weeks: the crown-rump length. 
• At 14-20 weeks: length of the femur. 
• At 18-26 weeks: the biparietal diameter. 
• The fetal head is demonstrable by ultrasound by the 
12th week of gestation. 
11/13/2014 7:44 AM 52
Biparietal diameter 
• Ultrasonography may be used to predict fetal 
maturity by measuring the biparietal diameter (side-to- 
side measurement) of the fetal head. 
• BPD is 8.5 cm or greater, it can be predicted that 
the infant will weigh more than 2500 g (5.5 lb) or is 
at a fetal age of 40 weeks. 
• Two other measurements commonly made by 
ultrasound to predict maturity are head 
circumference (34.5 cm indicates a 40-week fetus) 
and femoral length. 
11/13/2014 7:44 AM 53
Doppler Umbilical Velocimetry 
• Doppler ultrasonography measures the velocity at 
which red blood cells in the uterine and fetal vessels 
travel. 
• Assessment of the blood flow through uterine blood 
vessels is helpful to determine the vascular 
resistance present in women with diabetes or 
hypertension of pregnancy and whether resultant 
placental insufficiency is occurring 
11/13/2014 7:44 AM 54
Placental grading 
• Based particularly on the amount of calcium 
deposits in the base of the placenta. 
• Placentas can be graded by ultrasound as 
1. 0 (a placenta 12–24 weeks) 
2. 1 (30–32 weeks) 
3. 2 (36 weeks) 
4. 3 (38 weeks). 
11/13/2014 7:44 AM 55
Determination of fetal maturity by 
the rapid surfactant test 
1. Shake test or bubble test (clement’s) 
2. Foam stabililty index( FSI) 
3. Phosphatidyl Glycerol and Desaturated 
Phosphatidylcholine 
4. Others 
• Creatinine (Cr) – assess fetal renal maturity 
• ΔOD450 – assess fetal liver maturity 
• Lipocyte—assess fetal skin maturity 
11/13/2014 7:44 AM 56
References: 
1. Dutta D.C. Textbook of obstetrics. Sixth 
edition. Calcutta, India; New Central Book 
agency (P) Ltd: 2004. 
2. Pillitteri A. Maternal and child health nursing. 
Care of the childbearing and childrearing 
family. Sixth edition. Philadelphia; Lippincott 
Williams & wilkins: 2010. 
3. Jacob A. A comprehensive textbook of 
midwifery. Second edition. India; Jaypee 
Brothers Medical publishers (P) ltd. 
11/13/2014 7:44 AM 57
11/13/2014 7:44 AM 58

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Assessment of fetal wellbeing

  • 1. Antenatal Assessment of fetal wellbeing Shrooti Shah M.Sc. Nursing CON, BPKIHS 11/13/2014 7:44 AM 1
  • 2. contents • Introduction • Aims of antenatal fetal monitoring • Indications • Assessment in early pregnancy • Assessment in late pregnancy 11/13/2014 7:44 AM 2
  • 3. Introduction • Majority of fetal deaths occur in the antepartum period. • There is progressive decline in maternal deaths all over the world. Currently more interest is focused to evaluate the fetal health. • The primary objective of antenatal assessment is to avoid fetal death. 11/13/2014 7:44 AM 3
  • 4. Aims of antenatal fetal monitoring • To ensure satisfactory growth and well being of the fetus throughout pregnancy. • To screen out the high risk factors that affect the growth of the fetus. • To detect those congenital abnormalities or inborn metabolic disorders during early pregnancy. 11/13/2014 7:44 AM 4
  • 5. Indications for antepartum fetal monitoring Pregnancy with obstetric complications. Pregnancy with medical complications. Others Routine antenatal testing. 11/13/2014 7:44 AM 5
  • 6. Assessment in early pregnancy Biochemical Cytogenetic Biophysical 11/13/2014 7:44 AM 6
  • 7. Biochemical Maternal serum alpha fetoprotein (MSAFP) • AFP is a oncofetal protein. • It is produced by yolk sac and fetal liver. • Highest level of AFP in fetal serum and amniotic fluid is reached around 13 weeks and thereafter it decreases. • Maternal serum level reaches a peak around 32 weeks. 11/13/2014 7:44 AM 7
  • 8. Maternal serum alpha fetoprotein (MSAFP) MSAFP level is elevated in a number of conditions: 1. Wrong gestational age 2. Open neural tube defects (NTDs) 3. Multiple pregnancy 4. IUFD 5. Anterior abdominal wall defects 6. Renal anomalies Low levels are found in trisomies (Down’s syndrome) and gestational trophoblastic disease 11/13/2014 7:44 AM 8
  • 9. Triple test • It is a combined biochemical test which includes MSAFP, HCG and UE3(unconjugated oestriol). • It is used for detection of Down’s syndrome. • In an affected pregnancy level of MSAFP and UE3 tend to be low while that of hCG is high. • It is performed at 15-18 weeks. 11/13/2014 7:44 AM 9
  • 10. • Acetylcholine esterase : (AChE) Amniotic fluid Ache level is elevated in most cases of open neural tube defects. It has got better diagnostic value than AFP. • Inhibin A is a dimeric glycoprotein. It is produced by the corpus luteum and the placenta. Serum level of inhibin A is raised in women carrying a fetus with Down syndrome. 11/13/2014 7:44 AM 10
  • 11. Prenatal genetic diagnosis Amniocentesis Chorion villous sampling (CVS) Cordocentesis. 11/13/2014 7:44 AM 11
  • 12. Amniocentesis • Aspiration of amniotic fluid from the pregnant uterus for examination. • Typically scheduled between the 14th and 16th weeks of pregnancy. • An ultrasound is done to determine the position of the fetus and the location of a pocket of amniotic fluid and the placenta. 11/13/2014 7:44 AM 12
  • 14. Amniocentesis • Alpha-fetoprotein: Increased levels of AFP: open body defect, such as anencephaly, myelomeningocele, or omphalocele. Decreased level of AFP: chromosomal defects such as Down syndrome • Bilirubin Determination: if a blood incompatibility is suspected. 11/13/2014 7:44 AM 14
  • 15. Amniocentesis cont… • Chromosome analysis: few fetal skin cells are always present in amniotic fluid. These cells may be cultured and stained for karyotyping for genetic analysis. • Color: . A strong yellow color suggests a blood incompatibility. A green color suggests meconium staining, a phenomenon associated with fetal distress. 11/13/2014 7:44 AM 15
  • 16. Amniocentesis cont… • Fetal fibronectin Fibronectin is a glycoprotein that plays a part in helping the placenta attach to the uterine decidua. Detection of fibronectin in either the amniotic fluid or in the mother’s vagina can serve as an announcement that preterm labor may be beginning. 11/13/2014 7:44 AM 16
  • 17. Amniocentesis cont… • Inborn errors of metabolism: can be detected by amniocentesis, for example: cystinosis and maple syrup urine disease (amino acid disorders). • Lecithin/Sphingomyelin Ratio:  Lecithin and sphingomyelin are the protein components of the lung enzyme surfactant that the alveoli begin to form at the 22nd to 24th weeks of pregnancy.  After amniocentesis, the L/S ratio may be determined quickly by a shake test.  An L/S ratio of 2:1 is traditionally accepted as lung maturity. 11/13/2014 7:44 AM 17
  • 18. Chorionic villus sampling • CVS is performed for prenatal diagnosis of genetic disorders. • It is carried out transcervically between 10-12 weeks and transabdominally from 10 weeks to term. • A few villi are collected from the chorion frondosum under ultrasonic guidance. • While it provides earlier diagnosis than amniotic fluid studies, complications like fetal loss(1-2%), oromandibular limb deformities or vaginal bleeding are higher. 11/13/2014 7:44 AM 18
  • 19. Chorionic villus sampling 11/13/2014 7:44 AM 19
  • 20. Fetal blood sampling (cordocentesis) • This technique is used to take a sample of fetal blood during pregnancy in order to screen for chromosomal abnormalities, hemoglobinopathies and other disorders affecting blood or cells. • It is performed under local anaesthestic usually after 18 weeks gestation. • Risks: the invasive procedure may lead to abortion, preterm labour and intrauterine fetal death. These may be due to bleeding, cord haematoma formation, infection or preterm rupture of membranes. 11/13/2014 7:44 AM 20
  • 21. Fetal blood sampling (cordocentesis) 11/13/2014 7:44 AM 21
  • 22. Fetal blood sampling cont… All the information as obtained in amniocentesis or chorion villus sampling, could be gathered. Additional values are mentioned below: • Hematological- for fetal anaemia, bleeding disorders (autoimmine thrombocytopenia), rhesus disease. • Fetal infections- toxoplasmosis, viral infections • Fetal blood gas and acid base status- in fetal growth restricition • Fetal therapy- blood transfusion 11/13/2014 7:44 AM 22
  • 23. Biophysical • Ultrasonographic examination of the fetus in the early (10-14 weeks) pregnancy can detect fetal anomalies. • Crown-rump length (CRL) smaller than the gestational age is associated with the risk of chromosomal anomalies (trisomy or triploidy). • Increased nuchal translucency (soft tissue marker) at 10-14 weeks is associated with many chromosomal abnormalities (trisomy, monosomy, triploidy). 11/13/2014 7:44 AM 23
  • 24. Assessment of fetal wellbeing in late pregnancy Clinical Biophysical Biochemical 11/13/2014 7:44 AM 24
  • 25. Clinical The clinical assessment of fetal growth can be evaluated by the following parameters: • Maternal weight gain • Blood pressure • Assessment of the size of the uterus and height of the fundus • Clinical assessment of excess liquor 11/13/2014 7:44 AM 25
  • 26. Biophysical • Biophysical profile is a screening test for uteroplacental insufficieny. • The following biophysical tests are used: 1. Fetal movement count 2. Cardiotocography 3. Non stress test (NST) 4. Fetal biophysical profile (BPP) 5. Doppler ultrasound 6. Vibroacoustic stimulation test 7. Contraction stress test (CST) 11/13/2014 7:44 AM 26
  • 27. Fetal movement count • A healthy fetus moves with a degree of consistency, or at least 10 times a day. • In contrast, a fetus not receiving enough nutrients because of placental insufficiency has greatly decreased movements. • Based on this, asking a woman to observe and record the number of movements the fetus is making offers a gross assessment of fetal well-being. 11/13/2014 7:44 AM 27
  • 28. Fetal movement count cont… • Cardif count 10 formula • Daily fetal movement count (DFMC) • Mothers perceive 88% of the fetal movements detected by Doppler imaging. • Loss of fetal movements is commonly followed by disappearance of FHR within next 24 hours. • In either of the above methods, if the results is ominous, the candidate is subjected to NST. 11/13/2014 7:44 AM 28
  • 29. Nonstress test (NST) • In non-stress test, a continuous electronic monitoring of the fetal heart rate along with the recording of fetal movements (cardiac tocography) is undertaken. • There is an observed association of FHR acceleration with fetal movements, which when present, indicates a healthy fetus. 11/13/2014 7:44 AM 29
  • 31. Non stress test • Reactive (Reassuring)- when two or more accelerations of more than 15 beats per minute above the baseline and longer than 15 seconds in duration are present in a 20 minutes observation in association with movement of fetus • Non-reactive (Nonreassuring)- Absence of any fetal reactivity. 11/13/2014 7:44 AM 31
  • 32. Reactive Non stress test 11/13/2014 7:44 AM 32
  • 33. Non reactive non stress test 11/13/2014 7:44 AM 33
  • 34. Important features to note while interpreting a CTG • Accelerations and normal base line variability (5-25 bpm) denote a healthy fetus. • Absence of accelerations is the first feature to denote onset of gradual hypoxia. • Absence of accelerations, reduced base line variability may be due to fetal sleep, infection, hypoxia or due to maternal medications. • Interpretation of the CTG should always be made in the context of clinical situation. 11/13/2014 7:44 AM 34
  • 35. Non stress test cont… • Baseline FHR is the mean level of FHR between the peaks and the depressions in beats per minute (bpm). • Accelerations are increase in FHR by 15 bpm or more lasting for at least 15 seconds. • Deceleration is decrease in FHR below the baseline by 15 bpm or more. • Baseline variability is the oscillation of baseline FHR excluding the accelerations and decelerations. A baseline variability of 5-25 bpm is a sign of fetal wellbeing 11/13/2014 7:44 AM 35
  • 36. Deceleration pattern Early decelerations (type I dips) 11/13/2014 7:44 AM 36
  • 37. Late deceleration (Type II Dips) 11/13/2014 7:44 AM 37
  • 39. Contraction stress testing • With contraction stress testing, the fetal heart rate is analyzed in conjunction with contractions. • A source of oxytocin for contraction stress testing currently is achieved by nipple stimulation. • Gentle stimulation of the nipples releases oxytocin in the same way as happens with breastfeeding. With external uterine contraction and fetal heart rate monitors in place, the baseline fetal heart rate is obtained. 11/13/2014 7:44 AM 39
  • 40. Contraction stress test cont… • Next, the woman rolls a nipple between her finger and thumb until uterine contractions begin, which are recorded by a uterine monitor. • Three contractions with a duration of 40 seconds or longer must be present in a 10-minute window before the test can be interpreted. • The test is negative (normal) if no fetal heart rate decelerations are present with contractions. • It is positive (abnormal) if 50% or more of contractions cause a late deceleration 11/13/2014 7:44 AM 40
  • 41. Oxytocin challenge test • To elicit an abnormal FHR response • Performed by iv infusion of dilute oxytocin until three contractions occur in 10 minutes • Positive test: Late deceleration after each of the three contractions; FHR baseline variability; no FHR increase after FM • Indicates decreased fetal reserve • Negative test: No decelerations • Fetus is safe within one week • Suspicious: Repetitive variable decelerations • Associated with abnormal FHR in labor, particularly in post-term gestation 11/13/2014 7:44 AM 41
  • 42. Vibroacoustic stimulation • A specially designed acoustic stimulator is applied to the mother’s abdomen to produce a sharp sound of approximately 80 decibels at a frequency of 80 Hz, startling and waking the fetus. • During a standard nonstress test, if a spontaneous acceleration has not occurred within 5 minutes, apply a single 1- to 2-second sound stimulation to the lower abdomen. • This can be repeated again at the end of 10 minutes if no further spontaneous movement occurs, so that two movements within the 20-minute window can be evaluated. 11/13/2014 7:44 AM 42
  • 43. Biophysical profile • A biophysical profile combines five parameters 1. fetal reactivity 2. fetal breathing movements 3. fetal body movement 4. fetal tone 5. amniotic fluid volume 11/13/2014 7:44 AM 43
  • 44. Biophysical profile • With use of this system, each item has the potential for scoring a 2, so 10 would be the highest score possible. • It is popularly called a fetal Apgar. • Biophysical profiles may be done as often as daily during a high-risk pregnancy. • If the fetus score on a complete profile is 8–10, the fetus is considered to be doing well. A score of 6 is considered suspicious; a score of 4 denotes a fetus probably in jeopardy 11/13/2014 7:44 AM 44
  • 45. Biophysical profile S.no. Parameters Minimal normal criteria Score 1. Non stress test (NST) Reactive pattern 2 2. Fetal breathing movement 1 episode lasting >30 sec 2 3. Gross body movement 3 discrete body/ limb movements 2 4. Fetal muscle tone 1 episode of extension (limb or trunk) with return of flexion 2 5. Amniotic fluid 1 pocket measuring 2cm in two perpendicular planes 2 11/13/2014 7:44 AM 45
  • 46. Biophysical profile BPP score Interpretation Management 8-10 No fetal asphyxia Repeat testing at weekly interval 6 Chronic asphyxia If >36weeks- deliver 4 Chronic asphyxia If ≥36 weeks deliver, if ,32 weeks repeat testing in 4-6 hours. 0-2 Certain asphyxia Test for 120 min—Persistent score≤4---deliver regardless of gestational age. 11/13/2014 7:44 AM 46
  • 47. Modified biophysical profile • Use only two assessments (amniotic fluid index and a nonstress test). • A healthy fetus should show a reactive nonstress test and an AFI range between 5 and 25 cm. • Modified BPP is considered abnormal (nonreassuring) when the NST is non-reactive and/or the AFI is <5. 11/13/2014 7:44 AM 47
  • 48. Ultrasonography • The production of high frequency sound waves which are reflected or echoed when beamed into the body and an interface is encountered between different types of tissues or structures with different densities. • These echoes can be translated into visible images of the tissues or structures encountered. 11/13/2014 7:44 AM 48
  • 50. Uses of ultrasonography • Diagnose pregnancy as early as 6 weeks gestation. • Confirm the presence, size, and location of the placenta and amniotic fluid • Establish that a fetus is growing and has no gross anomalies, such as hydrocephalus, anencephaly, or spinal cord, heart, kidney, and bladder defects • Establish sex if a penis is revealed • Establish the presentation and position of the fetus • Predict maturity by measurement of the biparietal diameter of the head 11/13/2014 7:44 AM 50
  • 51. Uses of ultrasonography cont… • To discover complications of pregnancy. • Fetal anomalies • Fetal death • After birth, an ultrasound may be used to detect a retained placenta or poor uterine involution in the new mother. 11/13/2014 7:44 AM 51
  • 52. Gestational age and fetal maturity • At 5-10 weeks: gestational sac. • At 8-14 weeks: the crown-rump length. • At 14-20 weeks: length of the femur. • At 18-26 weeks: the biparietal diameter. • The fetal head is demonstrable by ultrasound by the 12th week of gestation. 11/13/2014 7:44 AM 52
  • 53. Biparietal diameter • Ultrasonography may be used to predict fetal maturity by measuring the biparietal diameter (side-to- side measurement) of the fetal head. • BPD is 8.5 cm or greater, it can be predicted that the infant will weigh more than 2500 g (5.5 lb) or is at a fetal age of 40 weeks. • Two other measurements commonly made by ultrasound to predict maturity are head circumference (34.5 cm indicates a 40-week fetus) and femoral length. 11/13/2014 7:44 AM 53
  • 54. Doppler Umbilical Velocimetry • Doppler ultrasonography measures the velocity at which red blood cells in the uterine and fetal vessels travel. • Assessment of the blood flow through uterine blood vessels is helpful to determine the vascular resistance present in women with diabetes or hypertension of pregnancy and whether resultant placental insufficiency is occurring 11/13/2014 7:44 AM 54
  • 55. Placental grading • Based particularly on the amount of calcium deposits in the base of the placenta. • Placentas can be graded by ultrasound as 1. 0 (a placenta 12–24 weeks) 2. 1 (30–32 weeks) 3. 2 (36 weeks) 4. 3 (38 weeks). 11/13/2014 7:44 AM 55
  • 56. Determination of fetal maturity by the rapid surfactant test 1. Shake test or bubble test (clement’s) 2. Foam stabililty index( FSI) 3. Phosphatidyl Glycerol and Desaturated Phosphatidylcholine 4. Others • Creatinine (Cr) – assess fetal renal maturity • ΔOD450 – assess fetal liver maturity • Lipocyte—assess fetal skin maturity 11/13/2014 7:44 AM 56
  • 57. References: 1. Dutta D.C. Textbook of obstetrics. Sixth edition. Calcutta, India; New Central Book agency (P) Ltd: 2004. 2. Pillitteri A. Maternal and child health nursing. Care of the childbearing and childrearing family. Sixth edition. Philadelphia; Lippincott Williams & wilkins: 2010. 3. Jacob A. A comprehensive textbook of midwifery. Second edition. India; Jaypee Brothers Medical publishers (P) ltd. 11/13/2014 7:44 AM 57