ASSESSMENT

OF THE FETAL
WELL-BEING
Introduction
■ Majority of fetal deaths occur in the antepartum period
■ The goal of antepartum fetal assessment is to both identify fetuses at risk of
intrauterine death or other complications of intrauterine asphyxia and
intervene to prevent these adverse outcomes, if possible
■ The primary objective of antenatal assessment is to avoid fetal death.
■ First and Second trimester antenatal assessment is directed primarily at the
diagnosis of fetal anomalies
■ The goal of third-trimester testing is to determine whether the intrauterine
environment continues to be supportive to the fetus
SCREENING
■ A process of identifying apparently healthy people who may be
at increased risk of a disease or condition

ASSESSMENT
■ Process for defining the nature of that problem, determining a
diagnosis and developing specific treatment recommendations

DIAGNOSTIC TEST
■ A test to establish the presence (or absence) of disease as a basis for
treatment decisions in symptomatic or screen positive individuals
(confirmatory test)
Aims of Antenatal Fetal
Monitoring / Diagnosis
■ 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 congenital abnormalities or inborn metabolic disorders
during early pregnancy
■ Risk assessment approach be used in the management of maternal,
fetal health care
■ Suggestive arrangement for delivery – Tertiary care center for high
risk obstetric patients
Components of Fetal
Assessment
 CLINICAL
PARAMETE
RS
PHYSICAL ASSESSMENT
- includes evaluation of maternal and fetal well being.
a. rounding the baseline – height, weight, VS
b. scheduled surveillance-monthly
c. regular pre-natal visit

Head -to -Toe Assessment

1. General appearance
2. Head and scalp 7. neck
11. back
3. eyes 8. breast
12. rectum
4. nose 9. heart
5. ears 13. pelvic examination
10. lungs
6. mouth
Four Types of Pelvic
1. Gynecoid
2. Anthropoid
3. Android
4. Platypelloid
Measuring Fundal Height

McDonald’s Rule:
-Method of determining during mid
pregnancy that the fetus is growing
in utero by measuring fundal
(uterine) height.

Months: Measure cm x 2/7

Weeks: Measure cm x 8/7

Milestones:
12 weeks over symphysis pubis
20 weeks at umbilicus
36 weeks xiphoid process
FETAL LIE
Refers to the relationship between the long axis of the fetus with
respect to the long axis of the mother. 
FETAL HEART RATE
■ measures the heart rate and rhythm of the baby (fetus)
■ Normal FHR: 120-160 beats/minute
■ Can be heard and counted as early as the 10th to 11th week of
pregnancy
■ Two methods for fetal heart rate monitoring
External fetal heart rate monitoring uses a device to listen to or
record the fetal heartbeat through the mother's abdomen. A
fetoscope (a type of stethoscope) is the most basic type of external
monitor. Another type of monitor is a hand-held electronic Doppler
ultrasound device. 
Internal fetal heart rate monitoring uses an electronic transducer
connected directly to the fetal skin. 
BIOPHYSIC
AL
METHOD
BIOPHYSICAL MONITORING /
TEST
The biophysical profile is a noninvasive prenatal diagnostic test that
■
usually is performed after the 28th week of pregnancy to evaluate
the well-being of the fetus
■  It combines an ultrasound examination with a nonstress test. 
■ The nonstress test is performed to assess fetal heart rate
acceleration in response to movement. 
■ The ultrasound test is designed to assess four components:
• Fetal gross body movement: Separate movements of the body or
limbs, including fine motor movements
• Fetal muscle tone: Opening or closing of the hands and mouth,
extension and flexing of the limbs, or repositioning or rotation of the
trunk of the body
• Fetal breathing movements: Continuous, rhythmic breathing
episodes
• Amniotic fluid volume: A single pocket of amniotic fluid that
measures at least one centimeter across and two centimeters
Physiological Basis for Fetal
testing
■ Antepartum testing is based on the premise that the fetus responds to
hypoxemia
■ Fetal biophysical activities (eg. Heart rate, ,movement) are sensitive to fetal
oxygenation and pH levels
■ Changes in fetal biophysical activities occur in response to hypoxemia and
acidemia
■ Biophysical parameters can also be affected by factors unrelated to hypoxemia
such as:
a. Gestational age
b. Maternal medication, smoking
c. Fetal sleep-wake cycles
c. Fetal disease/anomalies
Why is the biophysical profile
performed?
• Long-term maternal diseases, such as hypertension, lupus, renal disease,
or thrombocytopenia
• Decrease in fetal movement
• Previous stillbirth or other negative outcome
• Multiple gestation (more than one fetus)
• Pregnancy-related hypertension (high blood pressure) or preeclampsia
• Possible intrauterine growth restriction
• Diabetes before pregnancy or diabetes associated with pregnancy (gestational
diabetes)
• Late term pregnancy (at or beyond 41 weeks)
• Moderate or severe asthma
How are components scored during
the biophysical profile?
■ The biophysical profile will yield a maximum score of 10 points, if all criteria
are satisfied. Each of the components receives a score of two points,
unless the results are abnormal. The criteria for each component are listed
below.
• Nonstress test: At least two episodes of fetal heart rate acceleration
during a 20-minute period
• Fetal gross body movement: Three or more separate movements of the
fetal body or limbs over 30 minutes
• Fetal muscle tone: One or more episodes of active extension and flexion
of an arm or leg, or the opening and closing of a hand, during the 30-
minute test
• Fetal breathing movements: At least one episode of continuous fetal
breathing that lasts at least 30 seconds during the 30-minute test
• Amniotic fluid volume: A single pocket of amniotic fluid that measures at
least one centimeter across and two centimeters vertically
■ Any component that does not meet the criteria shown is considered
abnormal and receives a score of zero points.
How is the biophysical profile
performed?
■ Fetal movements and muscle tone are monitored over a period of at
least 30 minutes.
■ Nonstress test: An electronic fetal monitor is used to measure the
unborn baby’s heart rate while the pregnant woman is reclining or
lying down. A belt with an electronic sensor is placed around her
abdomen. During that time, the fetal heart rate is measured and
recorded. The test usually takes about 20 minutes.
■ There should be two or more accelerations of the fetal heart rate. If
there are fewer than two, it may indicate that the fetus is asleep. In
that case, the baby may be “awakened” with a buzzer or a loud noise
to stimulate movement. The nonstress test may be done in a doctor’s
office or a hospital.
What does the biophysical profile test
score indicate?
■ A total score of 10 points or eight out of 10 points with normal amniotic fluid volume is
regarded as normal. A score of six indicates that there may be problems that require
further evaluation or monitoring. If the pregnancy is at or beyond 37 weeks, delivery of
the baby may be considered. The biophysical profile should be repeated within 24 hours
if the pregnancy is less than 37 weeks.
■ A score of less than eight may suggest that the fetus is not receiving enough oxygen (fetal
asphyxia). However, it can also be lower when certain drugs such as corticosteroids are
administered during pregnancy.
■ If the biophysical profile yields a score of four or less, delivery should be induced. If the
period of gestation is less than 32 weeks and the score is four, further evaluation and
monitoring of the pregnancy may be necessary.
■ Overall, a low score indicates a greater risk of stillbirths and fetal asphyxia.
■ For the modified biophysical profile, results are considered normal if the nonstress test is
reactive (normal) and the pocket of amniotic fluid measures more than two centimeters.
■ Ultrasonography: through
the use of sound waves off of internal
structures, UTZ allows visualization of the
fetus without hazards of X-rays. It allows
patient to see her baby and even produces
image (called sonogram) that she can show to
friends and family.
■ The ultrasound exam is also performed when the
woman is reclining or lying down. A device called a
transducer is gently applied over the abdomen to
produce sound waves that echo off the internal
structures of the body. It takes about 30 minutes to
complete the examination.
■ To prepare patient for abdominal UT, have
her drink 1 qt (1L) of fluid 1-2 hours before the
test.
Midwives Responsibility
1. Obtain consent and explain procedure to patient
2. Provide privacy for the patient and asked to patient to undress and put on a hospital gown.
3. Place patient on the desired position.
4. The nonstress test is often done first. The provider puts a belt with a device (sensor) attached
around patient’s belly. The sensor will check baby’s heart rate. This will be displayed on a screen.
5. The provider puts a second belt and sensor around patient right next to the first. This sensor
measures contractions. Even though labor may still be a few weeks off, contractions are normal at
this point in pregnancy. This part of the test often lasts 20 to 30 minutes.
6. If baby doesn’t move during the test, don’t panic. The baby might be asleep. If this happens, a
nurse/midwife may try to wake the baby with a buzzer.
7. The belts and devices are then taken off. This part of the test is over.
8. The ultrasound part of the test may take up to 1 hour. Provide warmed ultrasound gel on patient’s
bare belly.
9. The provider will press a small, handheld wand (transducer) into the gel and against patient’s belly.
Images of the baby in the uterus will be shown on a screen.
10. The provider will look at your baby’s breathing movements, body movement, and muscle tone. He
or she will also measure the amniotic fluid around the baby.
11. When this part of the exam is complete, the provider will wipe the ultrasound gel off your belly.
Contraction Stress Test
■ Performed near the end of the pregnancy to determine how well the fetus
will cope with the contractions of childbirth.
■ Aim is to induce contractions and monitor the fetus to check for heart rate
abnormalities using a CARDIOTOCOGRAPH
Contraindication
This "stress test" is usually not performed if
there are any signs of
1. Premature birth  
2. placenta previa, vasaprevia  
3. Cervical incompetence  
4. Multiple gestation.  
5. previous classic cesarean section  
6.  Other contraindications include but are not
limited to previous uterine incision with scarring,
previous myomectomy   entering the uterine
cavity, and PROM. Any contraindication to labor
is contraindication to CST.
Oxytocin challenge test (OCT)
▪ If adequate contractions (at least 3 in 10 minutes) cannot be
achieved with nipple stimulation, an oxytocin challenge test
may be performed.

▪ It involves the  intravenous  administration of

exogenous oxytocin  to the pregnant woman. The target is to
achieve around three contractions every ten minutes

▪ An abnormal response (+ Test) seen as late decelerations in

the fetal heart rate, indicates fetal hypoxia and may warrant
immediate Cesarean Delivery.
Doppler ultrasound exam of the umbilical
artery
Doppler fetal monitor is a hand-
held ultrasound transducer used to detect the fetal
heartbeat for prenatal care. It uses the Doppler
effect to provide an audible simulation of the heartbeat.

Use of this monitor is sometimes known

as Doppler auscultation. The Doppler fetal monitor is
commonly referred to simply as a Doppler or fetal
Doppler. It may be classified as a form of Doppler
ultrasonography (although usually not
Cardiotocography
■ A technical means of recording (graph) the fetal heartbeat (cardio) and the
uterine contractions (toco) during pregnancy, typically in the third trimester.
■ The machine used to perform the monitoring is called
CARDIOTOCOGRAPH, commonly known as an Electronic Fetal Monitor
(EFM)
■ How long does CTG monitoring take? Antepartum and on admission to the
labor room (admission CTG) the usual (minimum) duration of recording is 30
minutes. Particularly in the third trimester of pregnancy the CTG should be
obtained with the mother placed in a left lateral position to prevent vena
cava syndrome.
■ to detect fetal hypoxia.
■What is a normal CTG?
■ Normal antenatal CTG trace: The normal antenatal CTG is associated
with a low probability of fetal compromise and has the following
features:
• Baseline fetal heart rate (FHR) is between 110-160 bpm
• Variability of FHR is between 5-25 bpm
• Decelerations are absent or early
• Accelerations x2 within 20 minutes
How to read a CTG (DR C
BRaVADO)
• DR: Define risk
• C: Contractions
• BRa: Baseline rate
• V: Variability
• A: Accelerations
• D: Decelerations
• O: Overall impression
Nipple Stimulation Test
■ the process of rolling or rubbing your nipples in a circular motion. It is 
considered a natural induction method and its effectiveness does have scientific 
evidence
■ How to perform: The patient stimulate one breast, through their clothes  for 2 
minutes an then rest for 5 minutes. This cycle is repeated as necessary, but it is 
interrupted whenever contractions begin.
■ Advantages: hyperstimulation is not more frequent than previously reported with 
CST
■ Average time: 45 Minutes
■ Easy and quick method
Biochemical
Monitoring
Maternal Serum Alpha fetoprotein
(MSAFP) Screening
■ 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
■ Normal Value: 2.5 MOM (Multiples of the median)
■ Time of performing test: 15-18 weeks
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
Who takes the AFP Test
■ Have a family history of birth defects
■ Age 35 year or older
■ Have Diabetes
■ Have taken certain drugs or medication during pregnancy

Midwives Responsibility
❑Explain procedure before performing test
❑Informed consent should be given prior to
testing
Amniocentesis
■ a test done during pregnancy to diagnose certain genetic disorders, birth
defects, and other conditions in an unborn baby. The test is usually done
between weeks 15 and 20 of pregnancy.
■ It onvolves taking a sample of amniotic fluid in order to examine fetal cells found
in this fluid
■ Indication: Early in pregnancy, used for diagnosis of chromosomal and other
fetal problems such as:
a. Down syndrome (Trisomy 21)
b. Trisomy 18
c. Fragile X
d. Rare, inherited metabolic disorders
■ e. Neural tube defectsLater on, it can be used to detect problems such as:
infection, prediction of lung maturity, meconium stain
■ Therapeutic: Induction of abortion, repeated decompression of the uterus in
acute hydramnios
Midwives Responsibility
■ Take written consent. Explain purpose of procedure and how it will be done.
■ If patient is in early pregnancy, patient may need avoid urinating (peeing)
before the test to make sure that you have a full bladder. This helps move
the uterus into a better position for the test. In later pregnancy, the test
requires an empty bladder
■ Provide privacy
■ Place patient on supine position with elevated head 20-30 degree (dorsal
position)
■ The abdominal wall is prepared aseptically and draped
■ Check the vital sign and FHR to obtain baseline data
■ Prophylactic administration of 100mg of anti-D immunoglobulin in Rh
negative mother
■ The proposed site of puncture is infiltered with 2 ml of 1% lidocaine
■ The procedure usually takes about 15 minutes. Afterwards, patient may be
told to avoid any hard exercise or physical activity for the next 24 hours.
Acetyl Choline Esterage (AchE)
■ Amniotic fluid AchE level is elevated in most cases of open neural tube
defects (e.g. Spina Bifida, Anencephaly)
■ Time of performing test: Between 15th and 18th week of gestation
■ Consist of sequence of tests: Maternal Serum and amniotic fluid
■ Elevated AFP Level: fetal pathology
■ Low level AFP: Downs Syndrome
■ Normal AFP concentration at 16th week is about 20mg/L
 Triple Test
■ It is combined biochemical test which includes MSAFP, HCG, and UE3
(unconjugated estriol)
■ Estriol and HCG are two hormones that are present in the mothers blood
during pregnancy
■ 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
■ Performing Time: 15-18 weeks.
■ The triple screen Test involves drawing blood from the mother. The blood
sample is then sent sent to laboratory for testing
Contraindication
■ Acute skin infections
■ Maternal fever
■ Allergies to material used (local anesthesia)
■ Mulitple pregnancy

Indications
• Previously affected child or a family history of a genetic disease, 
chromosomal abnormalities, or metabolic disorder
• Maternal age over 35 years by the pregnancy due date
• Risk of a sex-linked genetic disease
• Previous ultrasound with questionable or abnormal findings
• Abnormal cell-free DNA test
Chorionic Villus Sampling
■ chorionic villus biopsy, is a prenatal test that involves taking a sample of tissue 
from the placenta  to test for chromosomal abnormalities and certain other 
genetic problems
■ Performing time: done between the 10th and 12th weeks of pregnancy
■ There are two types of CVS procedures:
• Transcervical. In this procedure, a catheter is inserted through the cervix into the 
placenta to obtain the tissue sample
• Transabdominal. In this procedure, a needle is inserted through the abdomen 
and uterus into the placenta to obtain the tissue sample
Complications
• Cramping, bleeding, or leaking of amniotic fluid (water breaking)
• Infection
• Miscarriage
• Preterm labor
• Limb defects in infants, especially in CVS procedures done before 9 weeks 
(rare)
Midwives Responsibility
■ Explain procedure, Secure consent and provide privacy.
■ Assess patient for any sensitivity, allergic reactions, bleeding
disorder
■ Patient may or may not be asked to have a full bladder right before 
the procedure. Depending on the position of the uterus and 
placenta, a full or empty bladder may help move the uterus into a 
better position for the procedure.
■ Place patient on a supine position and place her hands behind her 
head
■ Monitor vital signs for baseline data
■ An UTZ will be performed to check the FHR, position of placenta, 
fetus and umblical cord
Contraindication
■ Active vaginal bleeding
■ Infection
■ Multiple Gestation
■ HIV Infection
■ In transcervical CVS
Cervical Stenosis, cervical myomas
■ In transbdominal CVS
Fetal position that block acess to placenta
Cordocenthesis or Percutaneous
Umbilical Cord Blood Sampling (PUBS)
/ Fetal Blood Sampling
■ PUBS provides a means of rapid chromosome analysis and is useful when
information cannot be obtained through amniocentesis, CVS, or ultrasound
(or if the results of these tests were inconclusive)
■ Time of performance: 18 weeks of gestation
Indication
■ Malformations of the fetus
■ Fetal infection (toxoplasmosis or rubella)
■ Fetal platetlet count in the maternal circylation
■ Fetal anemia
■ Isoimmunisation

■ Blood loss from the puncture site

■ Infection
■ Drop in FHR
■ POM
■ Fever
■ Chills
■ Leaking Amniotic fluid
Fetoscopy
■ Fetoscopy is an endoscopic procedure during pregnancy to allow
surgical access to the fetus, the amniotic cavity, the umbilical cord,
and the fetal side of the placenta. A small incision is made in the
abdomen, and an endoscope is inserted through the abdominal
wall and uterus into the amniotic cavity
■ Doctors also use this procedure to perform fetal surgery and
collect tissue samples to biopsy. 
■ To facilitate diagnosis and treatment of the fetus, evaluate for
disorders such as neural tube defects and congenital blood
disorders, and assist with fetal karyotyping.
Midwives Responsibility
■ Obtain consent and explain procedure to the patient
■ Instruct the patient to withhold food and fluid for 8 hours prior to the
endoscopic procedure.
■ Explain that a local anesthetic will be applied to the abdomen to ease with
insertion of the fetoscope.
■ Explain that the procedure takes approximately 60 min and is performed in
an ultrasound department.
■ Positioning for this procedure is in the supine position.
■ During the procedure. Lower abdomen is cleaned and a local  is
administered in the area where the incision will be made.
■ If samples are obtained, label specimen appropriately
■ Advise patient to breathe normally during the examination. If necessary for
better fetal visualization, the patient will be asked to inhale deeply and hold
her breath.
■ Instruct the patient in the care of the incision and to contact her HCP
immediately if she is experiencing chills, fever, dizziness, moderate or
severe abdominal cramping, or fluid or blood loss from the vagina or
incision.
QUESTIONS OR
CLARIFICATION
S?