Fetal surveillance

Antepartum assessment of fetal wellbeing

Regulator of fetal heart rate:
as in adult, FHR is primarily controlled by autonomic nervous system,
sympathetic( accelerator) and parasympathetic (decelerator). It is
generally accepted that progressive vagal dominance occurs as the
fetus approaches term.
The basic fetal heart pattern
• The baseline fetal heart rate(FHR): range from 120 to 160
bpm.
• Beat to beat variability: the normal range is 5-15 bpm.
• Acceleration: they are abrupt in onset and generally are
elevated to 15-25 bpm above the base line. They are occur in
response to fetal movements or contractions and partial cord
compression.
• No deccelaration: they are abrupt in onset and generally are
reduced by 15-25 bpm below the base line.
Abnormal FHR pattern ( baseline) 
• Tachycardia: baseline rate > 160 bpm. Known etiological
factors include fetal hypoxia, maternal fever, and
thyrotoxicosis, drugs ……..etc.
• Bradycardia: baseline rate <120 bpm. It is benign if it is
associated with normal beat to beat variability. Congenital
heart block may produce bradycardia (70 bpm) with abscent
variability.
Abnormal FHR pattern (periodic)
• Early deceleration: the occur coincidentally with uterine
contractions with slow onset and slow return. They are seen
with fetal head compression and are not associated with fetal
distress.
• Late deceleration: their appearance is like the early type with
a latency period between the onset of uterine contraction and
the beginning of the deceleration. They are caused by fetal
hypoxia.
• Variable deceleration: they are variable in duration, intensity
and timing but often coincide with uterine contractions.
 They are abrupt in onset and return, and are caused by
umbilical cord compression.
• Prolonged deceleration: isolated deceleration of >2min.

Techniques to assess well being

• Fetal movement.
• Nonstress test.
• Contraction stress test.
• Biophysical profile.
• Doppler ultrasound.
Fetal movement
This can be assessed by CTG, ultrasound and by subjective
perception by the mother. About 80% of movements seen by
uss are perceived by the mother. The count to ten chart is a
simple method where the mother is instructed to record the
number of fetal movements for 12 hours daily. Less than 10
movements indicates performance of non stress test.

Non stress test

Non stress test is the most widely used primary testing.
Advantages:
• Easy to perform.
• It is valid when antenatal risk demands an earlier assessment
of fetal well being.
• The rate of perinatal death following normal (reactive) test is
quite low.
• It has no contraindications.

Contraction stress test

Normal uterine contractions will decrease intervillous space blood flow.
This will exert some hypoxic stresses to the fetus through
impairment of uterine blood flow. If uteroplacental function and
thus feta oxygenation has been normal, these temporary changes
will not disturb fetal oxygenation. However, if fetal oxygenation is
 low, uterine contractions will cause deceleration. So CST will test
fetal reserve prior to development of fetal compromise.

Biophysical profile (BPP)

 This was first described by Manning in 1980, it includes non stress
test and four parameters assessed by ultrasound.

Biophysical profile
Variable Normal (score 2) Abnormal (score 0)

Fetal breathing At least 30 sec of sustained Less than 30 sec of

movements breathing in 30 min of breathing in 30 min
observation
 Fetal movements in 30 min . Simultaneous 3 ≥ ≥ 2 movements in 30
.limb and trunk movements min

Fetal tone episode of motion of limb 1 Fetus in semi or full

from flexion to extension and limb extension with
rapid return to flexion no return or slow
.return to flexion

Amniotic fluid Pocket of at least 1 cm in 2 Largest pocket less

volume perpendicular planes 1cm in 2 perpendicular
planes

Fetal reactivity accelerations of at least 15 2≥ No accelerations or≤2

beats/ min lasting at least 15 in 20 min of
seconds and associated with observation
fetal movements

Interpretation of BPP
 Score 10- normal fetus.
 Score 8 with normal amniotic fluid means normal fetus and repeat
after few days.
 Score 8 with decreased liquor means chronic fetal asphyxia and
delivery is advised.
 Score 6 with decreased liquor indicates delivery to be performed
immediately.
 Score 4 or less indicate fetal asphyxia.

Doppler ultrasound
To evaluate the rate of blood flow in maternal and fetal blood vessels.
• Determination of blood flow volume. Ml/min by measuring
the blood vessel diameter.
• Flow waveform analysis: indirect indices of flow have been
developed that provide useful information about distal
resistance to the blood flow.
 Systolic diastolic ratio: the maximal systolic shift is divided by
the end diastolic shift.
 Resistance index : the difference in systolic and diastolic shift
is divided by systolic value.
 Pulsatility index: the difference in systolic and diastolic shift
is divided bymean value.

• Blood flow velocity: automatically performed.

Clinical applications of Doppler

• Preeclampsia and intrauterine growth restriction.
• Screening for placental insufficiency by uterine artery
Doppler.
• Diagnosis and screening for anemia in cases of red cell
isoimmunisation.
• Diagnosis of fetal cardiac abnormalities.