An te par tu m

As s es s me nt
 Antepartum Fetal Surveillance

• Fetal Movement counting

• Non stress test
• Contraction stress test
• Biophysical Profile Scoring
• Doppler Velocity
 Fetal Movements
• 7 weeks -onset of passive unstimulated fetal
activity commences and becomes more
sophisticated and coordinated by the end of
pregnancy

• 8 weeks-beyond 8 menstrual weeks, fetal

body movements are never absent for time
periods exceeding 13 minutes
• Between 20 and 30 weeks, general body
movements become organized and the fetus
starts to show rest-activity cycles

• third trimester, fetal movement maturation

continues until about 36 weeks, when
behavioral states are established in 80 percent
of normal fetuses
Fetal heart rate patterns, general body movements, and eye
movements and described four fetal behavioral states:

•  State 1F is a quiescent state (quiet sleep),

with a narrow oscillatory bandwidth of the
fetal heart rate.   
•  State 2F includes frequent gross body
movements, continuous eye movements, and
wider oscillation of the fetal heart rate. This
state is analogous to rapid eye movement
(REM) or active sleep in the neonate.    
• State 3F includes continuous eye movements
in the absence of body movements and no
accelerations of the heart rate. The existence
of this state is disputed (Pillai and James,
1990a).  
•   State 4F is one of vigorous body movement
with continuous eye movements and fetal
heart rate accelerations. This state
corresponds to the awake state in infants.
• fetal urine production in normal pregnancies
in states 1F or 2F.

• bladder volumes increased during quiet sleep

(state 1F).

• During state 2F, the fetal heart rate baseline

bandwidth increased appreciably, and bladder
volume was significantly diminished.
 Factors Affecting Fetal Activity
• Fetal sleep –Awake cycle

• Amniotic Volume
 Fetal Sleep-Awake cycle
• An important determinant of fetal activity
appears to be sleep-awake cycles, which are
independent of the maternal sleep-awake
state

• Sleep cyclicity has been described as varying

from about 20 minutes to as much as 75
minutes.
• Timor-Tritsch and associates (1978)
– reported that the mean length of the quiet
or inactive state for term fetuses was 23
minutes
• Patrick and associates (1982)

-measured gross fetal body movements

with real-time ultrasound for 24-hour periods
in 31 normal pregnancies and found the
longest period of inactivity to be 75 minutes.
 Amniotic Fluid Volume
• Sherer and colleagues (1996)
– assessed the number of fetal movements in 465 pregnancies during
biophysical profile testing in relation to amnionic fluid volume
estimated using ultrasound.

– They observed decreased fetal activity with

diminished amnionic volumes and suggested that
a restricted intrauterine space might physically
limit fetal movements.
 Types of Fetal Movements
• classified the movements into three categories
according to both maternal perceptions and
independent recordings using piezoelectric
sensors.

1.Weak
2. Strong
3. Rolling
 Fetal Movement Counting
• Maternal perception

• Doppler device

• Real-time UTZ
 Maternal Perception
• Most investigators have reported excellent
correlation between maternally perceived fetal
motion and movements documented by
instrumentation.

• For example, Rayburn (1980) found that 80

percent of all movements observed during
ultrasonic monitoring were perceived by the
mother
• . In contrast, Johnson and colleagues (1992)
reported that :
– beyond 36 weeks, mothers perceived only 16
percent of fetal body movements recorded by a
Doppler device. Fetal motions lasting more than
20 seconds were identified more accurately by the
mother than shorter episodes.
 Fetal Movement Counting
• “Count of Ten”

– 4 Fetal movements in 1 hour after meal

– The count is accepted as reassuring if it ewquals or
exceeds a previously established baseline count
 Non Stress Test
• Nonstress test :
• describe fetal heart rate acceleration in
response to fetal movement as a sign of fetal
health.
• This test involved the use of Doppler-detected
fetal heart rate acceleration coincident with
fetal movements perceived by the mother
Non-Stress Test
 Non Stress Test
• By the end of the 1970s, the nonstress test
had become the primary method of testing
fetal health.

• The nonstress test was much easier to

perform, and normal results were used to
further discriminate false-positive contraction
stress tests
 Non Stress Test
• the nonstress test is primarily a test of fetal
condition

• it differs from the contraction stress test,

which is a test of uteroplacental function.
• Evaluates alertness of fetal CNS by observing
FHR characteristics of the non stressed fetus-
FHR response

• (acceleration=reactivity) to fetal movements

 FHR acceleration
• Increase baseline fetal heart rate of ≥ 15
beats/ min for at least 15 secs

• “ Acceleration is the hallmark of Fetal Health”

 NST interpretation
• Reactive NST- 2 or more acceleration within 20
min.

• Nonreactive NST- reactive criteria not met.

• Unsatisfactory trace – tracing quality cannot

be met.
 Contraction Stress Test
• Evaluates the status of basal fetal O2 reserves
by observing FHR response to uterine
contraction.

Ways to perform CST:

1. Oxytocin stress test
2. Nipple stimulation Test
Contraction Stress Test
 Oxytocin Challenge Test
• Contractions were induced using intravenous
oxytocin, and the fetal heart rate response
was recorded using standard monitoring. The
criterion for a positive (abnormal) test was
uniform repetitive fetal heart rate
decelerations.
• Contractions are induced with either oxytocin
or nipple stimulation if there are fewer than
three in 10 minutes.

• If oxytocin is preferred, a dilute intravenous

infusion is initiated at a rate of 0.5 mU/min
and doubled every 20 minutes until a
satisfactory contraction pattern is established.
 Nipple Stimulation
• induce uterine contractions is usually
successful for contraction stress testing
(Huddleston and associates, 1984).

• involves the woman rubbing one nipple

through her clothing for 2 minutes or until a
contraction begins.
• She is instructed to restart after 5 minutes if
the first nipple stimulation did not induce
three contractions in 10 minutes.

• Advantages include reduced cost and

shortened testing times.
 CST Interpretation
• (-) –no late deceleration
• (+)- presence of late decelerations in 50% of
uterince contraction
• Suspicious CST- presence of late decelerations
but < 50% of UC
• Hyperstimulation
• Unsatisfactory
 FHR Deceleration
• Decrease in baseline FHR of ≥15bpm for≥ 15
secs
• If in relation with uterine contractions
• -Early deceleration
• -Variable deceleration
• -Late deceleration
 Indications for CST
• Vaginal delivery is contemplated
• Prior to induction of labor
• -Postdated pregnancy
• -DM
• -Severe HPN
• -Oligohydramnios
 Biophysical Profile
• Variables:
• 1. Determined through real time
ultrasonography
• -Fetal tone
• -Fetal body movement
• -Fetal Breathing
• -Amniotic fluid volume
• 2. Determined through electronic fetal heart
rate monitoring
• -FHR reactivity
 Factors affecting Biophysical
Activities
• 1. Maturity of CNS
• 2. Sensitivity to hypoxia
• 3. Extent, duration, chronicity and frequency
of insult
• 4. Drugs that depress CNS
• 5. Sleep-wake cycle of fetus
 Fetal Breathing
• Paradoxical chest wall movement
• During inspiration the chest wall paradoxically
collapses and the abdomen protrudes
(Johnson and co-authors, 1988).

• In the newborn or adult, the opposite occurs.

• One interpretation of the paradoxical
respiratory motion might be coughing to clear
amnionic fluid debris.
• The physiological basis for the breathing reflex
is not completely understood, such exchange
of amnionic fluid appears to be essential for
normal lung development.
Umbilical Artery Doppler Velocimetry
• Doppler ultrasonography is a noninvasive
technique to assess blood flow by
characterizing downstream impedance.
• The umbilical artery systolic–diastolic (S/D)
ratio, the most commonly used index, is
considered abnormal if it is above the 95th
percentile for gestational age or if diastolic
flow is either absent or reversed.
• Absent or reversed end-diastolic flow signifies
increased impedance to umbilical artery blood
flow.

• It is reported to result from poorly

vascularized placental villi and is seen in the
most extreme cases of fetal growth restriction
 Current Antenatal Testing Recommendations

• According to the American College of

Obstetricians and Gynecologists (1999), there
is no "best test" to evaluate fetal well-being.

• Three testing systems—contraction stress

test, nonstress test, and biophysical profile—
have different end points that are considered,
depending on the clinical situation.
• The most important consideration in deciding
when to begin antepartum testing is the
prognosis for neonatal survival.

• The severity of maternal disease is another

important consideration. In general, with the
majority of high-risk pregnancies, most
authorities recommend that testing begin by
32 to 34 weeks.
• Pregnancies with severe complications might
require testing as early as 26 to 28 weeks.

• The frequency for repeating tests has been

arbitrarily set at 7 days, but more frequent
testing is often done.
Thank you!