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.

1. Antenatal Assessment of
fetal wellbeing
Shrooti Shah
M.Sc. Nursing
CON, BPKIHS
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2. contents
• Introduction
• Aims of antenatal fetal monitoring
• Indications
• Assessment in early pregnancy
• Assessment in late pregnancy
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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.
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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.
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5. Indications for antepartum fetal
monitoring
Pregnancy with obstetric
complications.
Pregnancy with medical
complications.
Others
Routine antenatal testing.
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6. Assessment in early pregnancy
Biochemical
Cytogenetic Biophysical
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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.
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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
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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.
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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.
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11. Prenatal genetic diagnosis
Amniocentesis
Chorion villous
sampling (CVS)
Cordocentesis.
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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.
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13. Amniocentesis
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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.
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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.
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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.
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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.
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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.
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19. Chorionic villus sampling
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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.
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21. Fetal blood sampling (cordocentesis)
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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
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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).
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24. Assessment of fetal wellbeing in
late pregnancy
Clinical
Biophysical Biochemical
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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
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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)
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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.
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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.
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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.
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30. Nonstress test
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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.
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32. Reactive Non stress test
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33. Non reactive non stress test
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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.
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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
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36. Deceleration pattern
Early decelerations (type I dips)
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37. Late deceleration (Type II Dips)
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38. Variable decelerations
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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.
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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
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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
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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.
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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
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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
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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
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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.
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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.
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49. Ultrasonography
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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
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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.
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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.
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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.
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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
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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).
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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
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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.
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