COLLEGE OF NURSING

MADURAI MEDICAL COLLEGE, MADURAI-20

OBSTETRICS AND GYNAECOLOGICAL NURSING

SEMINAR

ON

MATERNAL AND FOETAL MEASURES

SUBMITTED TO SUBMITTED BY

MRS.S.AUYISHA SITHIK, M.Sc (N), MBA M.JEYAMANI

MRS.N. RAJA LAKSHMI, M.Sc(N), I YEAR M.Sc (N)

NURSING TUTOR GRADE II CON, MMC,

CON,MMC,MADURAI . MADURAI.
INTRODUCTION
The maternal and foetal assessment during pregnancy and labour are important aspects of
obstetric management. The main reasons identified for this assessment are: for early
diagnosis of abnormal features of pregnancy and foetal development and to refer the maternal
and foetal assessment and monitoring that is essentially done during antenatal and intranatal
period. There are at least four reasons to regularly assess the foetal health.

ANTENATAL FOETAL MONITORING — EARLY

PREGNANCY
Antenatal foetal monitoring is generally done in three ways:
 Clinical
 Biochemical
 Biophysical
CLINICAL
The clinical assessment of foetal growth can be evaluated by the various parameters.
At every antenatal visit, you must keep in mind the following clinical parameters for
assessment of satisfactory progress of gestation.

1) Maternal Weight Gain: During the second half of pregnancy the average
weight gain is 1 kg a fortnight. Any excess weight gain may be due to excess
of fluid retention and could be first sign of pre eclampsia, if the weight is less
than normal, or even falling, one should look out for I.U.G.R.

2) Blood Pressure: Hypertension pre existing or pregnancy induced may affect

satisfactory growth of the foetus. Unless proper analysis is made and special
care is taken, these cases are associated with high perinatal mortality.

3) Assessment of the Size of the Uterus and Height of the Fundus: In early
weeks, the size of the uterus is of great value in confirming the calculated
duration of gestation. The height of the fundus should be documented at each
visit and compared with the calculated duration of gestation.
Provided the woman is sure about her date of last menstrual period and the
examination recorded at 10th week of gestation is available, a measurement of
symphysis-fundal height in later months of pregnancy may be useful as a screening
test for further investigation. The measurement is compared to the expected
distance plotted on a chart. If the measurement falls below the 10th centile, foetal
growth retardation is suspected and a more precise investigation should be made.

4) Clinical Assessment of Excess Liquor: Clinical assessment of excess liquor should

be recorded, as well as scanty liquor in the last trimester. Presence of scanty liquor
may indicate a failing placental function and the need for undertaking placental
function test. If the uterus is disproportionately enlarged, it may suggest multiple
pregnancy or polyhydramnios. If the fundus is not rising normally as it should, it
may suggest growth retardation or intra uterine foetal death.

5) Measurement and Documentation: Measurement and documentation of the

abdominal girth in the last trimester of pregnancy should form a routine part of
abdominal examination. This is measured at the lower border of the umbilicus.
Normally the abdominal girth increases steadily upto term. If the girth
gradually diminishes beyond term or earlier, it indicates placental insufficiency.
This is of particular value in suspecting a failing placental function in high risk
group of cases such as pre eclampsia, chronic hypertension, chronic nephritis,
bad obstetric history and suspected cases of growth retardation.
The other two methods biochemical and biophysical carry some risk to the mother and/or
the foetus and are also expensive. Therefore, their application should provide definite
benefits that clearly outweighs the potential risk and the cost. In early pregnancy
Biochemical and Biophysical assessment is done where cogenital inborn abnormalities,
chromosomal disorders, sex linked genetic disorders, or inborn error of metabolism are
suspected, the following investigation are carried out in early months of pregnancy.

BIOCHEMICAL
Maternal Serum Alpha Feto Protein (MSAFP)
AFP is a oncofoetal protein (molecular weight 70,000) it is produced by yolk sac and foetal
liver. Highest level of AFP in foetal serum and amniotic fluid is reached around 13 weeks
and thereafter it decreases. Maternal serum level reaches a peak around 32 weeks.
MSAFP level is raised in number of conditions:
a) Wrong gestational age
b) Open neural tube defects
c) Multiple pregnancy
d) IUFD
e) Anterior abdominal wall defects
f) Renal anomalies

Low levels are found in Down’s syndrome test is done between 15-18 weeks of
pregnancy. MSAFP value of 2.5 multiples of the median (MOM) when adjusted with
maternal weight, is taken as the cut off point. Cases with such high values are
considered for high resolution ultrasound imaging and/or amoniocentesis.

Triple Test
It is a combined biochemical test which includes MSAFP, HCG, and unconjugated
estriol (UES).
Monitoring of Maternal and Foetal Well-being
MATERNAL SYMPHYSIS - FUNDUS GROWTH CHART

GESTATIONAL AGE (Weeks)

SYMPHYSIS - FUNDUS HEIGHT (cms)

AMNIOCENTESIS
It is an invasive procedure and should be performed only when the necessary information
cannot be obtained by other non-invasive procedure like ultrasound scanning. It is performed
between 14-16 weeks under continuous ultrasound guidance. The following test are
performed according to the needs: To estimate alpha fetoprotein concentration (AFP) in
liquor amni in those cases where open neural tube defect is suspected. AFP concentration is
raised if the foetus has open neural tube defects. This is also confirmed by ultrasound
scanning. The normal AFP concentration in liquor amounts at the 16th wk is about 20 mg/lt.
Culture and chromosomal studies of the desquamated foetal cells in the aminiotic fluid are
carried out under the following conditions:
a) Pregnancy above the age of 35 years;
b) Previous child born with chromosomal abnormalities particularly autosomal trisomy in a
woman with X linked recessive disorders.
c) To determine the sex, ordinarily, only the males have a 50% risk of being affected by such
disorders. In case of male foetus, cordocentesis is further done. If the particular foetus is
affected, pregnancy may be terminated.
d) To detect inborn error of metabolism by enzyme studies. If the previous child is affected,
subsequent sibling face a risk of 1 in 4. In these cases when no treatment is available after
birth, antenatal diagnosis offers the parents the option to determine the pregnancy.
e) Direct DNA studies within the chromosomes for genetic disorders.

CHORIONIC VILLUS SAMPLING (CVS)

Chorionic villus sampling is performed in specialized centers, for prenatal diagnosis of
genetic disorders. It is carried out transcervically between 10-12 weeks and transabdominally
from 10 wks to term. Diagnosis can be obtained within 24 hours and such if termination is
required, it can be done safely in first trimester. A few villus are obtained for the chorionic
frondosum under the ultrasound guidance with the help of long malleable plastic catheter
introduced transcervically along the extraocular space, while it provides earlier than aminiotic
fluid studies, complications like foetal loss (2- 4%), limb deformities or vaginal bleeding are
higher. Anti-D immunoglobins 50 mg should be administered following the procedure to a
Rh-negative woman.
CORDOCENTESIS (PERCUTANEOUS UMBILICAL BLOOD SAMPLING)
A 25 gauze spinal needle 13 cm in length is inserted through the maternal abdominal and
uterine wall under the real time ultrasound guidance using a curvilinear probe. The needle tip
is progressed carefully and it punctures the umbilical vein approximately 1-2 cm from the
placental insertion. Generally, 0.5 to 2 ml of foetal blood is collected, it is performed under
local anaesthesia after 18 weeks gestation. This invasive procedure may lead to abortion,
preterm labour and intrauterine death. This may be due to bleeding, haematoma formation,
infection or preterm rupture of membranes. Overall foetal loss is 2-5% Anti-D immunoglobin
injection 100 mg should be given to Rh negative, yet unimmunized women.

BIOPHYSICAL
It is becoming more and more popular replacing the other tests. Standard morphometer
measurement are foetal crown-rumplength (CRL in first trimester); 31 biparietal diameter
(BPD), head circumference (HC), abdominal circumference, femur length (FL) and total
intrauterine volume (TIUV), routine anomaly scan is done at 18- 20 weeks. High resolution
ultrasonography is used to detect the markers of chromosomal anomaly. CLR at 7 wks
menstrual age is 10 mm BPD is helpful to assess foetal growth when measured serially, its
value is less reliable after 28 weeks.

Head/Abdomen Ratio
It is useful in suspected IUGR when sparing head growth is observed (asymmetrical
IUGR) and the ratio is increased. Head circumference is measured at the level of third
ventricle and the abdominal circumference at the level of umbilical vein. Femur length
when combined with BPD, is useful up to 32 weeks.
ANTENATAL MONITORING–LATE PREGNANCY
· Clinical
· Biochemical
· Biophysical

CLINICAL
The clinical assessment of foetal growth can be evaluated by the parameters mentioned
for early pregnancy. They may be useful as screening test for further investigation.

BIOCHEMICAL
The two biochemical tests performed in the past for assessment of antenatal foetalwell being
were estimation of' a) Urinary or plasma oestriol b) Plasma Human Placental Lactogen (HPL)
level, Value of urinary oestriol 12 mg or less in 24 hours urine and plasma value of 4 mg/ml
or less after 30 weeks of gestation was considered critical for the foetus. Due to poor
predictive value, both these tests have been abandoned.
Amniocentesis for pulmonary maturity and assessment of severity of Rh iso-immunisation.
The assessment of lung maturation in high risk cases where preterm termination of pregnancy
is anticipated. The confirmation of lung maturation minimizes the incidence of respiration
distress syndrome in the newborns.
The following criteria are used:
· Lecithine/syphingomyline ratio (L:S) greater than 2
· Identification of Phosphatidyl glycerol (PG)
· Optical density difference at 650 mu greater than 0.15 by spectrophotometric analysis.

SHAKE TEST OR BUBBLE TEST

This is a useful bed side test, rapidly performed with a fair degree of accuracy. The test is
based on the ability of pulmonary surfactant to form a foam or bubble, on shaking which
remains stable for at least 15 minutes. Increasing dilution of aminiotic fluid are mixed with
96% ethanol, shaken for 15 seconds and inspected after 15 minutes for the presence of a
complete ring of bubbles at the meniscus. If it is present, the test is positive and indicates
maturity of foetal lungs.
ASSESSMENT OF SEVERITY OF RH-ISOIMMUNIZATION
Amniocentesis for estimation of bilirubin in the aminotic fluid by spectrophotometry is
indicated if; i) Antibody titre rises to more than 1:8; ii) Previous history of severely
affected baby that was either stillborn or required exchange transfusion; iii) Father is
heterozygous, to determine whether the particular baby will be affected or not.
The amniocentesis is generally started at 30-32 weeks of gestation. The optical density
of the liquor containing the bilirubin pigment is observed at 250-700 mu wave length.
The optical density difference at 450 mu wave length indicates the severity of foetal
haemolysis.
Oxytocis Challenge Test (OCT)
This test is invasive, and the availability of non invasive tests has made its use limited.
It assess the foetal well being in utero during pregnancy as suggested by alterations in
FHR in response to the uterine contractions. The test is based on the determination of the
respiratory function of the fetoplacental unit during induced contractions when the blood flow
through the unit is curtailed. The objective is to detect the degree of foetal compromise so
that a suitable time can be selected to terminate the pregnancy. A persistent late deceleration
of the FHR indicates an anoxic foetus. Its use is very much selective.

BIOPHYSICAL
Biochemical assessment has largely been replaced by biophysical evaluation.

PRINCIPLE
Biophysical profile is a screening test for uteroplacental insufficiency. The foetal
biophysical activities are initiated, modulated and regulated through foetal nervous
system. The foetal CNS is very much sensitive to diminished foetal oxygenation.
Hypoxia ® metabolic acidosis ® CNS depression ® Changes in biophysical
activity.
The following tests are used:
i) Foetal Movement Count
ii) Cardiotocography
iii) Non-stress Test
iv) Ultrasonography
v) Radiological
i) Foetal Movement Count: Any of two methods can be applied:
— Cardiff count 10 formula – one popular technique described by the work of Pearson and
Weaver (1976) is the Cardiff count to ten chart. The woman starts counting the foetal
movements in the morning and stops as soon as 10 movements are perceived, She is
instructed to report to doctor/nurse if; i) less than 10 movements occur during 12 hours on
two successive days, or ii) no movements is perceived even after 12 hours in a single day.
— Daily foetal movement count (DFMC) – Three counts, each of one hour duration
(morning, noon and evening) are recommended. The total count 33
multiplied by four gives daily (12 hours) foetal movement count (DFMC). If there is
diminution of the number of ‘kicks’ to less than 10 in 12 hours, it indicates failing placental
function.
— The count is performed 3 or 4 times a week. Loss of foetal movements is commonly
followed by disappearance of FHR within next 24 hours. In either of the methods if the result
is ominous, the candidate is subjected to NST.
ii) Non-stress Test (NST): In non stress test, a continuous electronic monitoring of the foetal
heart rate along with recording of foetal movement is undertaken. There is an observed
association of FHR acceleration with foetal movements, which when present, indicates a
healthy foetus. It can reliably be used as a screening test. Foetal movement count is quite
reliable screening method specially where the sophisticated gadgets are not available. NST is
used primarily as a screening procedure. It requires less time and is less inconvenient to the
patient. Manning later on modified the scoring profile by using 4 parameter observed by
ultrasonography and only when these are found abnormal, then the patient is subjected to
NST.
iii) Ultrasonography (Biophysical Profile): The foetal compromise in utero demonstrates
one or both of the following changes:
· A decrease or cessation of biophysical activity
· A significant reduction in the volume of amniotic fluid.
The basic concept is that a multiple variable assessment of foetal biophysical activities is a
more sensitive and reliable test for foetal well being than the examination of a single
parameter. One such widely used biophysical profile is named after Manning. The profile is
made up of 5 components apart from the standard NST, the other 4 parameters are observed
by using real time ultrasonography. The normal observation is given a score of 2 and an
abnormal one is given a score of 0. The features of a normal score are:
· A reactive non stress tests (NST)
· Presence of atleast one episode of foetal breathing movement within 30 minutes and lasting
for 30 seconds or more. · Presence of at least 3 discrete gross foetal movements within a 3
minutes period. · Presence of foetal tone which is defined as one or more episodes of limb
extension with return to flexion within 30 minutes. · Adequate aminiotic fluid volume
evidenced by one or more larger pockets of fluid greater than 1 cm in vertical diameter.
· In the absence of oligohydraminos a score of 8 or 10 is normal; a score of 6 is equivocal and
a score of 4 or less is abnormal. It is less expensive and can be repeated or continued if
desired.
iv) Ultrasonography: IUGR can be diagnosed accurately with serial measurement
of BPD, AC and HC and the amniotic fluid volume. AC is the single measurement which
reflects foetal nutrition. The average increase of biparietal diameter beyond 34 weeks is 1.7
mm per week. When the average thoracic diameter/biparietal diameter ratio is less than 0.9,
IUGR is suspected. A measurement of biparietal diameter of 9.8 cm indicates maturity and
one of 10.1cm suggests post-maturity.

v) Doppler Ultrasound: The use of Doppler velocimetry through umbilical arteries, aorta,
cerebral, renal and uterine arteries carried out in an attempt to detect foetal compromise. The
shape of Doppler flow velocity waveform (FVW) is determined by ventricular contraction in
systolic, constitutents of blood and peripheral vascular resistance. When the resistance is
increased in the down stream as in hypertension, blood velocity is decreased in diastole.
Generally blood velocity increases with advancing gestation as the placental bed resistance
decreases. When the placental resistance is high, as in IUGR, the diastolic component is
reduced or may be absent. In a severe case it may even be reversed (high value for
systolic/diastolic ratio). In such a case the foetus is found to be hypoxic and academic,
resulting in increased perinatal mortality. Absent or reversed end diastolic velocity mandates
close foetal surveillance.
vi) Foetal Cardiotocography (CTG): A normal tracing after 32 wks, would show base line
heart rate of 110-150 beats per minute (bpm) with an amplitude of baseline variability 5-25
bpm. There should be no deceleration or there may be early deceleration of very short
duration. Importantly there should be two or more acceleration during a 20 minutes period.

vii) Radiological: This is rarely performed in pregnancy. But when sonar is not available for
diagnosis of gross congenital abnormalities of the foetus or for confirmation of intrauterine
death of the foetus, radiological examination may be done. This may also be used to
determine foetal maturity by noting the presence or absence of lower femoral or upper tibial
epiphysis, though often, there are individual variations.
INTRANATAL FOETAL MONITORING
DEFINITION
Intranatal foetal monitoring is the process of foetal surveillance to identify signs associated
with well being and with compromise. In simple terms, it means to watch the foetal
behaviour during labour.

PURPOSE
a) To evaluate how the foetus tolerates labour and to identify hypoxic insult to the
foetus during labour.
b) To detect at the earliest any evidence of foetal jeopardy, so that prompt measures can be
taken before any adverse effect of anoxia occur. Even in normal labour, the baby is subjected
to stress due to :
1) Uterine contractions temporarily curtailing the uteroplacental circulation.
2) Head compression affecting the functions of the vital centers of the brain. A previously un-
compromised foetus and/or in pathologic state of labour, the foetal distress may appear
abruptly. Herein lies the importance of continuous foetal monitoring.

METHODS OF FOETAL MONITORING

· Clinical
· Biophysical
· Biochemical
Clinical
Periodic auscultation of the foetal heart rate using ordinary stethoscope or fetoscope to note
its rate, rhythm and intensity is traditional and valuable and FHR should be recorded at every
30 minutes interval initially followed by 15 minutes interval in the first stage and at about 5
minute interval in the second stage. The auscultation should be made for 30 seconds
immediately following an uterine contraction. Normal foetal heart rate should be at an
average rate of 140 beats per minutes (bpm) in between contraction with a variation between
120-160 per minutes. There may be bradycardia during a contraction, which however comes
back to normal before the contraction passes off; the slowing is probably caused by vagal
stimulation.
Limitations
i) As it is periodic observation, any transient significant abnormality in between
observation is likely to be overlooked.
ii) Human error
iii) Difficult at times to count the FHR during uterine contractions or in case of obesity
or hydraminos.
Evidence of Distress
i) An increase in FHR to over 160/min or a decrease in rate to less than 120/min.
ii) FHR takes a long time to come back to its normal rate after the contraction
passes off.
iii) Irregularity
Causes of Foetal Tachycardia
a) Drugs to mother, e.g. beta-adrenergic agents.
b) Infection – both maternal and foetal
c) Anaemia – both maternal and foetal
d) Foetal distress
Causes of Foetal Bradycardia
a) Foetal distress, acidosis
b) Use of local anaesthetic drugs, epidural analgesia
c) Foetal heart conduction defect
d) Drugs to mother e.g. narcotics and anti-hypertensives
Meconium Stained Liquor
Meconium staining of the liquor as observed following rupture of membranes indicates foetal
distress. Its presence in breech presentation is of no value. Thin meconium suggests that the
baby at one time was distressed, while thick (Pea soup) meconium suggests chronic foetal
distress. Presence of abnormalities in FHR along with meconium stained liquor necessitates
interference in the absence of continuous electronic foetal monitoring system.
Tocotransducer

(uterine contractions)
Ultrasound transducer
(FHR)

Ultrasound transducer
Excessive Foetal Movements
Experienced by the patient or by the palpating hands of the observer may be a
manifestation of foetal distress.
The tocotransducer (tocodynamometer) measures uterine activity transabdominally. The
device is placed over the fundus over the umbilicus. The tocotransducer can measure
and record the frequency, regularity and duration of uterine contractions, but not their
intensity.
BIOPHYSICAL
Ultrasound : Doppler effect is used to detect foetal pulse rate from major foetal vessels.
This observation has to be rechecked when an abnormality is detected.
Electronic Foetal Monitoring
Electronic foetal monitoring may be continuous or intermittent with a short strip taken at
regular intervals during labour. Electronic monitoring allows one nurse to observe two
labouring women and supporting the labouring women with breathing and relaxation
technique, if the nurse maintains the primary focus on the woman not on the machine.

There are two modes of electronic foetal monitoring (EFM). The external mode
employs the use of external transducer placed on the woman’s abdomen to assess heart
rate and uterine activity. The internal mode uses a spiral electrode applied to the foetal
scalp after rupturing the membranes and the intrauterine pressure catheter (IUPC) to
assess the uterine activity and pressure simultaneously.
External Monitoring
Separate transducers are used to monitor the FHR and the uterine contractions. The
ultrasound transducer acts though the reflection of high frequency sound waves from a
moving interface, in this case the foetal heart and valves. Therefore short term variability
and beat to beat changes in the FHR cannot be assessed by this method. Once the nurse
locates the area of maximum intensity of FHR, conducive gel is applied to the surface of
the ultrasound transducer and transducer to be positioned over this area. The tocotransducer
(tocodynamometer) measures uterine activity transabdominally. The devices are placed over
the fundus over the umbilicus. The tocotransducer can measure and record the frequency,
regularity and duration of uterine contraction but not their intensity.

Internal Monitoring
The technique of continuous internal monitoring provides an accurate appraisal of foetal
Well being during labour. For this type of monitoring the membranes must be ruptured.
The cervix sufficiently dilated and presenting part low enough for placement of the
Electrode. A small spiral electrode attached to the presenting part yields a common
FHR on the foetal monitoring strip.
To monitor the uterine activity a solid or fluid filled intrauterine pressure catheter
(IUPC) is introduced into the uterine cavity. A solid catheter has a pressure sensitive
Tip that measures changes in intrauterine pressure. A catheter filled with sterile water
Can also be used. As the uterus contracts it compresses the catheter, placing pressure on
The monitor strain gauze or pressure transducer. The pressure sensed by both types of
Catheter are then converted into a pressure reading in millimeters of mercury. The
Normal ranges during a contraction is 50-75 mmhg. The display of FHR and uterine
Activity on the chart paper differs for the two modes of electronic monitoring. Each
Small square represents 10 seconds, each larger box of 6 square equals 1 minute when
The monitor is set to run at 3 cm/min.
Advantages over Clinical Monitoring
· It provides precise information of FHR in relation to the uterine contraction.
· Early detection of foetal jeopardy
· Pattern of FHR, prior to particular change can be studied from the graphic record.
· It is an important record for medico legal purpose.
Disadvantages
· Instruments are expensive and trained personnel required to interpret it.
· Mother has to be confined to bed.
· Due to false prediction caesarean rate may be high.

INTERNAL INVASIVE FOETAL MONITORING

Interpretations
Normal Pattern
· Baseline heart rate between 120-160 bpm
· Baseline variability between 5-25 bpm
· Two accelerations in 20 minutes observation
· No deceleration
Abnormal Pattern
· Baseline heart rate < 120 bpm (Bradycardia) or > 160 bpm (Tachycardia)
· Baseline variability < 5 bpm for 40 minutes or more
· Repetitive early or variable decelerations without any accelerations.
· Repetitive late deceleration
· Sinusoidal pattern
Baseline FHR is the mean level of FHR between the peaks and depression.
Accelerations are increase in FHR by 15 bpm or more lasting for at least 15 seconds.
Accelerations denotes a healthy foetus.
Deceleration is the decrease in FHR below the baseline by 15 bpm or more.
Baseline variability is the oscillations of baseline FHR excluding the accelerations and
decelerations. A baseline variability of 5-25 bpm is a sign of foetal well being.
Reduced baseline variability is observed in foetal hypoxia, sleep and congenital
malformations, mother given drugs (like sedatives and antihypertensives)
Deceleration pattern – Three basic types of deceleration are observed which are called
as early, late and variable deceleration.
i) Early decelerations: Foetal head compression briefly increases intra- cranial pressure,
causing the vagus nerve to slow the heart rate. Early decelerations are not associated
with foetal compromise and require no intervention. They occur during contractions
as the foetal head is pressed against the woman’s pelvis or soft tissues, such as the
cervix. The rate at the lowest point of the deceleration usually remains above 100 bpm.

Early deceleration
Uteroplacental insufficiency (maternal disease – hypertension etc.) may result in a
pattern of late deceleration. This non reassuring pattern suggest that the foetus has
reduced reserve to tolerate the recurrent reductions in oxygen supply that occur with
contractions.
ii) Late deceleration: Late deceleration are gradual decelerations that look similar to
early decelerations, but are shifted to the right in relation to the contraction.
They often begin after the peak of the contraction. The FHR returns to the
baseline after the contraction ends. They have consistent appearance. The FHR
may remain in the normal range and may not fall much below its baseline level.
The amount of rate of decrease from the baseline is not related to the
amount of uteroplacental insufficiency.

iii) Variable decelerations: Condition that restrict flow through the umbilical cord may
result in variable decelerations. These decelerations do not have the uniform
appearance of early and late deceleration. Their shape, duration and degree of fall
below baseline rate are variable. They fall and rise abruptly with the onset and
relief of cord compression, unlike the gradual fall and rise of early and late
deceleration. Variable deceleration also may be non periodic, occurring at times
unrelated to contraction. Several methods are used to classify variable decelerations
according to depth and duration, but no uniform agreement exists. One guideline suggests
that variable deceleration are significant when the FHR repeatedly decreases to less than 70
bpm and persists at that level for at least 60 seconds before returning to the baseline. Baseline
rate and variability are also considered when evaluating variable decelerations.

Lag time
It is the time taken for the FHR to reach the lowest point of the FHR dip from the
apex of the preceding uterine contractions.

Sinusoidal Pattern
It is a stable baseline FHR with fixed base line variability without any acceleration. It
is often associated with foetal anaemia, feto-maternal haemorrhage, foetal hypoxia, and
when narcotic are given to the mother.
Uterine Activity
Assessment of uterine activity has four components: frequency, duration, intensity and
uterine resting zone (contraction frequency may be measured with the electronic
monitor the same may as with palpation beginning of one contraction to beginning of
the next) or from peak to peak. Duration is calculated from the beginning to end of
each contraction. Contraction intensity is described as mild, moderate or strong.
Average resting zone is 5 to 15 mm of Hg.
Vibroacoustic Stimulation
Vibroacoustic stimulator is applied to the mother’s lower abdomen, and it is turned on
upto 3 seconds. A reassuring response is an acceleration that peaks at 15 bpm for 15
seconds or more. An absent response, however, does not necessarily mean that the
foetus is suffering from hypoxia or acidosis.
Foetal Scalp Stimulation
Scalp stimulation evaluates the foetus response to tactile stimulation. The examiner
applies pressure to the scalp with a gloved finger or fingers and scrap the fingers in a
circular motion. An acceleration in FHR, is reassuring response that suggests the
foetus is in normal oxygen and acid base balance. The acceleration may be delayed as
much as 10 minutes rather than immediate. This is contraindicated in few conditions –
· Preterm foetus
· Prolonged rupture of membrane
· Chorioaminionitis
· Placenta Praevia
· Maternal fever of unknown origin
BIOCHEMICAL
To corroborate the significance of foetal ECG abnormality due to hypoxia, Sailing in
1962 demonstrated a simple and quick method of obtaining foetal blood sample from
the scalp to detect the foetal blood pH. The normal foetal scalp blood pH ranges from
7.25 to 7.35. A pH less than 7.2 is an indication for urgent interference. This is less
common because it is invasive and the results are not available immediately.In labour, a
rapid evaluation of the general condition of the woman including vital signs (Pulse, BP, Resp,
temp), observation of the uterine contractions and listening to the FHS, immediately after the
contraction is very important.
THE PARTOGRAPH
In recent years the Partograph has been widely accepted as an effective means of
recording the progress of labour. It is a chart on which the salient features of labour
are entered in a graphic form and therefore provides the opportunity for early
identification of deviations from normal. In some centres they use partograph for all
labouring women. W.H.O. has modified the partograph and has hence made it simpler
and easy to use. The latent phase is removed and the plotting on the partograph begins
in the active phase when the cervix is 4 cms dilated.
Patient information: Full name, gravida, para, hospital, number, date and time of
admission and time of ruptured membranes.
Foetal heart rate: Record every half hour.
Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination
I : Membranes intact
C : Membranes ruptured, clear fluid
M : Meconium stained fluid
B : Blood stained fluid
Moulding
1) Sutures opposed 2) Sutures over lapped but reducible 3) Sutures over lapped and not
reducible.
Cervical dilatation: Assessed at every vaginal examination and marked with a cross (´)
begin plotting on the partograph at 4 cm.
Name Mrs. B........................................ Gravida .............. Para ........... Hospital No. ...........
Date of admission ........... Time of admission ............ Ruptured membrances ...... hrs.
Alert line: A line starts at 4 cms of cervical dilatation to the point of expected full
dilatation at the rate of 1 cm per hour.
Action line: Parallel and 4 cm to the right of the alert line.
Descent Assessed by Abdominal Palpation
It refers to the part of the head (divided into 5 parts) palpable above the symphysis
pubis, recorded as a circle (O) at every vaginal examination. At 0/5 the sinciput (S) is
at the level of the symphysis pubis.
Hours : Refers to the time elapsed since onset of active phase of labour
Time : Record actual time.
Contraction : Chart every half hour, palpate the number of contraction in 10 minutes and
their duration in seconds.
· Less than 20 seconds
· Between 20 and 40 seconds
· More than 40 seconds
Oxytocin : Record the amount of oxytocin per volume i/v fluid in drops per minute every
30 minutes when used.
Drugs given : Record any additional drugs given.
Pulse : Record every 30 minutes and mark with a dot.
Blood pressure : Record every 4 hours and mark with arrows.
Temperature : Record every 2 hours
Proteins, acetone and volume : Record every time urine is passed.
CONCLUSION:

In this seminar we have learnt about monitoring of maternal and foetal well being in antenatal
and intranatal period. Monitoring procedures basically are of the types, which are clinical,
biophysical and biochemical. The unit gave clear picture about monitoring procedures carried
on separately in early and late pregnancy. The intranatal foetal monitoring is evaluated with
different types of techniques. Many times proper assessment of the woman in antenatal
period can prevent problems during intranatal period and hence prevent short term or long
term morbidity or even death. The nurses are expected to have knowledge about these
procedures in order to assist the obstetrician as well as to identify abnormal signs and
symptoms of complications occuring in mothers and the foetal well being.
BIBLIOGRAPHY:

1. Adelle Pillitery. (2006). Maternal and Child Health Nursing. (2nd edition) .New delhi:
Lippincott and Williams Publishers.
2. Annamma Jacob. comprehensive text book of midwifery.( 2nd edition).New
Delhi:published by Jaypee brothers.
3. Dutta,D.C. (2004). Text book of Obstetrics. (6th edition). NewDelhi: Published by
New central Book Agency (P) Ltd.
4. Gloria Leifer. (Maternity nursing). (10th edition).New Delhi: published by
Saunderelesevier.
5. Kinney,M.C. Maternal-Child Nursing.( 2nd edition).New Delhi:Elsevier Philadelphia
publishers.
6. Lowdermilk. Maternity and Women’s Health Care( 9th edition). Missouri: Mosby
publications.
7. Neelam Kumari. (2011). A Textbook of midwifery and gynanecological nursing.New
Delhi:Published By S.Vilcas publishers.
8. Reeder .(1972). Maternity Nursing.( 18th edition). Philadelphia: Lippincott publishers.
9. Ruth Bennet,V. (2005). Myles Text Book for Midwives, (12th edition), New
Delhi:Published by English Language Book Society.
NET REFERENCE:
http://www.researchgate.com
http://egyankosh.ac.in
http://www.bmus.org
http://www.fetalmedicine.org
http://www.radiopedia.org

JOURNAL REFERENCE
Fetal movement Measurement and technology :Anarrative review.

Journal on Ultrasound Obstetric and Gynaecology :Standardization of Fetal Ultrasound

biometry measureme nts.