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BIOPHYSICAL-US IMAGING ,FOETAL MOVEMENT COUNT,ULTRA

SONOGRAPHY,CARDIOTOCOGRAPHY,CARDIOTOMOGRAPHY,N
ON STRESS TEST(NST),CONTRACTION STRESS
TEST(CST)AMNIOSCOPY,FOETOSCOPY.

AND

RADIOLOGYCAL EXAMINATION

INTRODUCTION

Biophysical refers to the combination of biological and physical factors. When discussing
biophysical aspects in pregnancy, it typically involves assessing the health and well-being of
both the mother and the developing fetus using various techniques and measurements. This can
include monitoring fetal heart rate, movement, muscle tone, breathing patterns, and amniotic
fluid volume. These assessments are crucial in ensuring a healthy pregnancy and identifying
any potential issues early on.

SCORE OF BIOPGYSICAL PROFILE

A biophysical profile combines five parameters (i.e., fe reactivity, fetal breathing movements,
fetal body move- ment, fetal tone, and amniotic fluid volume) into one as- sessment. The fetal
heart and breathing record measures short-term central nervous system function; the amniotic
fluid volume helps measure long-term adequacy of placental function. By this system, each
item has the potential for scoring a 2, so 10 would be the highest score possible. A biophysical
profile is more accurate in predicting fetal well- being than any single assessment (Oyelese &
Vintzileos, 2011). Because the scoring system is similar to an Apgar score determined at birth
on infants, it is often referred to as a fetal Apgar score.

Biophysical profiles may be done as often as daily during a high-risk pregnancy. The fetal
scores are as follows:

A score of 8 to 10 means the fetus is considered to be doing well.

• A score of 6 is considered suspicious.

• A score of 4 denotes a fetus potentially in jeopardy.

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For simplicity, some centers use only two assessments (amniotic fluid index [AFI] and a
nonstress test) for the analy- sis. Referred to as a modified biophysical profile, this predicts
short-term viability by the nonstress test and long-term vi- ability by the AFI. A healthy fetus
should show a reactive non- stress test and an AFI range between 5 and 25 cm (Bienstock et
al., 2015). Nurses play a large role in obtaining the infor mation for both a modified and a full
biophysical profile b obtaining either the nonstress test or the sonogram reading.

VARIOUS TYPE OF BIOPHYSICAL

1. Fetal movement count

2. Ultra sonography
3. Cardiotocography
4. Cardiotomograpgy
5. Non stress test(NST)
6. Contraction stress test
7. Amnioscopy
8. Foetoscopy

1.FETAL MOVEMENT COUNT

Daily Fetal Movement Count (Kick Counts)

Fetal movement that can be felt by the mother (quickening) occurs at approximately 18 to 20
weeks of pregnancy and peaks in intensity at 28 to 38 weeks. After that time, a healthy fetus
moves with a degree of consistency at about 10 times per hour. In contrast, a fetus who is not
receiving enough nutrients be- cause of poor maternal nutrition or placental insufficiency has
greatly decreased movements.

Kick counts are particularly useful in growth-restricted or postterm pregnancies to reveal

if a fetus is still receiving adequate nutrition. Make certain the woman knows fetal
movements do vary, especially in relation to sleep cycles, her activity, and the time since
she last ate. Otherwise, she can become unduly worried her fetus is in jeopardy when the
fetus is asleep or just having an inactive time

PURPOSE OF FETAL MOVEMENT COUNT

Fetal movement count, also known as fetal kick count or fetal movement monitoring, is
crucial during pregnancy for several reasons:
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❖ Monitoring Fetal Well-being:

Regular monitoring helps assess the health and well-being of the fetus. A decrease
in fetal movements could indicate potential issues that need medical attention.
❖ Indicator of Fetal Growth and Development:
Fetal movements provide insights into the growth and development of the baby.
Consistent movements signify a healthy, active fetus.
❖ Bonding Experience:
Counting fetal movements can be a bonding experience for parents. It allows them
to feel connected to the baby and understand its patterns of activity.
❖ Early Detection of Problems:
Changes in fetal movement patterns can sometimes be an early sign of fetal distress
or other complications. Prompt medical intervention can help address these issues.
❖ Reducing Anxiety:
Regular monitoring of fetal movements can reduce anxiety for expectant parents. It
provides reassurance that the baby is active and doing well.
❖ Guidance for Healthcare Providers:
Fetal movement counts provide valuable information to healthcare providers, aiding
them in making informed decisions about the pregnancy and potential interventions
if needed.

STEPS OF FETAL MOVEMENT COUNT

The steps for performing fetal movement count, also known as kick counting:

Choose a Time: Pick a time of day when your baby is typically active, such as after a meal or
when you're relaxed and lying down.

❖ Find a Comfortable Position:

Lie on your left side as this position can improve blood flow to the baby and make it
easier to feel movements.
❖ Focus on Counting Movements:
Pay attention to your baby's movements, including kicks, rolls, twists, and jabs. Each
movement counts as one kick.
❖ Count Movements:
Start counting movements and keep track of how long it takes to reach ten movements.
Most healthcare providers recommend counting movements until you reach ten, but
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you can continue counting if you're not feeling ten movements within a specific
timeframe.
❖ Note the Time:

Record the start time when you begin counting and note the time it takes to reach ten
movements or the total number of movements within a specific timeframe.

❖ Repeat Daily:
Perform kick counting at the same time each day for consistency. Some healthcare
providers suggest doing it after breakfast, lunch, and dinner.
❖ Report Any Changes:
If you notice a significant decrease in fetal movements or if your baby's movement
pattern changes significantly, contact your healthcare provider immediately for further
evaluation.

2.ULTRA SONOGRAPHY

Ultrasound is a painless procedure in which images of internal tissue and organs, such as
the appendix, are produced by the use of sound waves (RadiologyInfo.org, 2015). Because
it is non invasive, children accept ultrasound easily and may even enjoy watching the
oscilloscope screen during the procedure. Alert a child that the clear gel, which is applied
to the skin over the body part to be studied, may feel cool and sticky. Com- pare the
transducer that is used on the body surface to pick up internal images to a television camera
so it is not viewed as something strange .Explain that the ultrasound procedure is not an X-
ray, so they can remain in the room to comfort their child during the procedure. Because
ultrasound appears to have no long-term effects, it can be repeated over and over for serial
determinations.

USED OF ULTRASONOGRAPHY IN PREGANCY

Ultrasonography, which measures the response of sound waves against solid objects, is a much-
used tool for fetal health assessments. It can be used to:

• Diagnose pregnancy as early as 6 weeks gestation.

• Confirm the presence, size, and location of the placenta and amniotic fluid.
• Establish a fetus is growing and has no gross anoma- lies such as hydrocephalus;
anencephaly; or spinal cord, heart, kidney, and bladder concerns.
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• Establish the presentation and position of the fetus.

• Predict gestational age by measurement of the biparietal diameter of the head or
crown-to-rump measurement.
• Discover complications of pregnancy, such as the presence of an intrauterine
device, hydramnios (excessive amniotic fluid) or oligohydramnios (lessened
amniotic fluid), ectopic pregnancy, missed miscarriage, abdominal pregnancy,
placenta previa (a low-implanted placenta), premature separation of the
placenta, coexisting uterine tumors, or multiple pregnancy.
• Genetic disorders such as Down syndrome and fetal anomalies such as neural tube
disorders, diaphragmatic hernia, or urethral steno- sis also can be diagnosed. Fetal death
can be revealed by a lack of heartbeat and respiratory movement.
• After birth, a sonogram may be used to detect a retained placenta or poor uterine
involution in the new mother.

GUIDELINE FOR USG

Here's a general guideline for performing ultrasonography (USG) during pregnancy:

Timing:

USG can be done at various stages of pregnancy. Commonly, it's done in the first trimester
(around 6-10 weeks) for dating the pregnancy, checking for multiple pregnancies, and
assessing the viability of the fetus. It's also done in the second and third trimesters for growth
assessment, anomaly screening, and placental evaluation.

Purpose:

First Trimester: Confirm pregnancy, assess gestational age, check for multiple pregnancies,
evaluate the uterus and adnexa, assess for any early pregnancy complications like ectopic
pregnancy or miscarriage.

Second Trimester: Detailed anatomy scan to check fetal growth, organs, and detect any
anomalies. Assess placental location and function.

Third Trimester: Monitor fetal growth and well-being, assess amniotic fluid levels, placental
position, and umbilical cord blood flow.
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Preparation:

For abdominal scans, a full bladder may be required in the first trimester but not usually in later
trimesters. Wear comfortable clothing that allows easy access to the abdomen.

Follow any specific instructions given by the healthcare provider regarding fasting or bladder
filling.

Procedure:

• The procedure involves applying gel on the abdomen (for abdominal scans) or using a
transvaginal probe (for early pregnancies or detailed examinations).
• The probe is moved gently over the abdomen to obtain images of the fetus, placenta,
and amniotic fluid.
• The sonographer may take measurements of the fetus, assess organ development, and
check blood flow in umbilical vessels and other areas.

Safety:

• USG is generally considered safe during pregnancy when performed by trained

professionals.
• It uses non-ionizing radiation, unlike X-rays, making it safer for fetal imaging.
• However, excessive use should be avoided, and it's typically used when there is a
medical need.

Post-Procedure:

• After the scan, the images are interpreted by a radiologist or obstetrician.

• Results are discussed with the patient, including any findings or concerns.
• Follow-up scans may be recommended based on the initial findings.
• Always consult with your healthcare provider for specific instructions and guidance
tailored to your individual pregnancy and medical history.

3.CARDIOTOCOGRAPHY

Cardiotocography (CTG) records the fetal heart rate, fetal movements and uterine contractions
to assess signs of fetal hypoxia. A computerized analysis of the fetal heart rate has found the
variation to decrease with increasing gestational age, and reduced variability is a predictor of
intrapartum fetal distress and acidosis in postterm deliveries.
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Cardiotocography (CTG) is a common procedure used during pregnancy to monitor the fetal
heart rate (FHR) and uterine contractions. It's a valuable tool in obstetrics for assessing the
well-being of the fetus and detecting any potential issues that may require medical intervention.

Purpose:

• The primary purpose of CTG is to assess the fetal heart rate and its variability in
response to uterine contractions.
• It helps healthcare providers determine if the baby is getting enough oxygen and if there
are any signs of distress.

Procedure:

• CTG involves placing two sensors on the mother's abdomen.

• One sensor measures the fetal heart rate using Doppler ultrasound, while the other
sensor monitors uterine contractions.
• These sensors are connected to a monitoring device that records the heart rate and
contractions in real time.

Interpretation:

Healthcare providers interpret the CTG tracings to assess various parameters:

Baseline Fetal Heart Rate: The average heart rate over a 10-minute period.

Fetal Heart Rate Variability: Fluctuations in the heart rate, which indicate a healthy
autonomic nervous system.

Accelerations: Temporary increases in heart rate, often associated with fetal movement and a
sign of fetal well-being.

Decelerations: Temporary decreases in heart rate, which can be early, variable, or late,
indicating different levels of fetal distress.

Indications for CTG:

CTG may be performed in various situations, including routine antenatal monitoring,

assessment of fetal well-being in high-risk pregnancies (such as gestational diabetes or
hypertension), monitoring during labor, and assessing fetal response to contractions or
interventions.
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Types of CTG:

There are two main types of CTG:

Antepartum CTG: Done during pregnancy to monitor fetal well-being.

Intrapartum CTG: Done during labor to assess fetal response to contractions and detect any
signs of distress.

Limitations:

While CTG is a valuable tool, it has limitations. Interpretation requires training and experience,
as false positives (indicating distress when the baby is actually fine) and false negatives
(missing signs of distress) can occur. CTG should be used in conjunction with other
assessments and clinical judgment.

4.CARDIOTOMOGRAPGY

Computed tomography (CT) scans use X-rays and computer technology to create detailed
images of the inside of the body. While CT scans are generally safe for adults, their use during
pregnancy is limited and usually avoided unless absolutely necessary. Here are some key points
about CT scans during pregnancy:

Risk Considerations:

CT scans use ionizing radiation, which can potentially harm the developing fetus, especially
in the first trimester when organs are forming. The amount of radiation exposure from a CT
scan is generally low, but doctors weigh the benefits versus risks before proceeding.

Indications:

CT scans during pregnancy are typically reserved for situations where the benefits of the scan
outweigh the potential risks. For example, if there's a suspected life-threatening condition in
the mother that requires immediate diagnosis and intervention, a CT scan might be considered
after careful assessment.

Safety Measures:

If a CT scan is deemed necessary during pregnancy, radiologists and healthcare providers take
precautions to minimize radiation exposure to the fetus. This may include shielding the
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abdomen with lead aprons or using alternative imaging techniques that don't involve ionizing
radiation whenever possible.

Alternative Imaging:

In many cases, alternative imaging methods such as ultrasound or magnetic resonance imaging
(MRI) are preferred during pregnancy. These methods do not use ionizing radiation and are
considered safer for monitoring fetal development and assessing maternal conditions.

Timing:

If a CT scan is unavoidable during pregnancy, it's often recommended to perform it during the
second trimester when the risk to the fetus is slightly lower compared to the first trimester.

Consultation and Consent:

Before undergoing any imaging procedure during pregnancy, women are informed about the
risks, benefits, and alternatives. Informed consent is obtained, and discussions involve
weighing the necessity of the scan against potential risks to the fetus.

5.NON STRESS TEST(NST)

A nonstress test measures the response of the fetal heart to fetal movement. Position the woman
and attach both a a uterine the woman to push the button attached to the monitor (sim lar to a
call bell) whenever she feels the fetus move. This create a dark mark on the paper tracing at
these times.

➢ When the fetus moves, the fetal heart rate should increase approximately 15 beats/min
and remain elevated for 15 seconds.
➢ It should decrease to its average rate again as the fetus quiets If no increase in beats per
minutes noticeable on fetal movement, further testing may be necessary to rule out poor
oxygen perfusion of the fetus.
➢ A nonstress test usually is done for 20 minutes.
➢ The test is said to be reactive (healthy) if two accelerations of for heart rate (by 15 beats
or more) lasting for 15 seconds occur after movement within the time period.
➢ The test is nonreactive (fetal health may be affected) if no accelerations occur with the
fetal movements.
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➢ The results also can be interpreted as nonreactive if no fetal movement occurs or if there
is low short-term fetal heart rate variability (less than 6 beats/min) throughout the
testing period .
➢ If a 20-minute period passes without any fetal movement it may only mean that the
fetus is sleeping, although other reasons for lessened variability are maternal smoking,
drug use, or hypoglycemia.

Importance

Early Detection of Potential Issues:

NST can help detect potential problems with the fetus's oxygenation or nervous system
function early on. This early detection allows healthcare providers to take timely actions to
address any concerns and ensure the well-being of the fetus.

Monitoring High-Risk Pregnancies:

NST is often used in high-risk pregnancies, such as those involving maternal conditions like
hypertension, diabetes, or advanced maternal age, as well as pregnancies with suspected fetal
growth restriction. Regular NSTs can provide crucial information about the fetal response to
stressors in these cases.

Reducing Stillbirth Risk:

By assessing fetal well-being regularly through NST, healthcare providers can identify signs
of fetal distress or compromised oxygenation. This proactive approach can help reduce the risk
of stillbirth by enabling timely interventions when necessary.

Guiding Management Decisions:

The results of NST, whether reactive or nonreactive, guide healthcare providers in making
management decisions. For instance, a reactive NST generally indicates a healthy fetus, while
a nonreactive result may prompt further evaluation or interventions such as additional testing,
fetal monitoring, or delivery if deemed necessary.

Enhancing Maternal Confidence:

NST can also provide reassurance to expectant mothers by offering insights into their baby's
well-being. Knowing that regular monitoring is in place can reduce anxiety and stress during
pregnancy, promoting overall maternal well-being.
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Improved Pregnancy Outcomes:

The information gained from NST contributes to improved pregnancy outcomes by facilitating
appropriate management strategies. This can include optimizing timing for delivery if fetal
distress is detected or providing additional support and monitoring for pregnancies at higher
risk.

Method

Fetal Heart Rate Monitoring:

This is the central component of NST. It's done using a fetal heart rate monitor placed on the
mother's abdomen. The monitor records the baby's heart rate, which is then analyzed for
patterns and responses.

Maternal Positioning:

The mother is usually placed in a comfortable position, such as reclining on her left side, to
optimize fetal heart rate monitoring and to ensure her comfort during the test.

Observation of Fetal Movements:

During NST, healthcare providers also observe fetal movements. They note whether the baby
is active or not, as fetal movements can stimulate changes in the fetal heart rate, indicating a
healthy response.

Duration of Testing:

NST sessions typically last around 20-40 minutes. This duration allows sufficient time to
observe the fetal heart rate patterns and responses to movements.

Interpretation of Results:

After the NST session, the results are interpreted based on specific criteria. A "reactive" NST
indicates normal fetal well-being, where the baby's heart rate shows appropriate accelerations
in response to movements. A "nonreactive" NST may indicate a need for further evaluation.

Biophysical Profile (BPP):

In some cases, NST is combined with a biophysical profile. BPP includes additional
assessments such as fetal ultrasound (to check amniotic fluid levels, fetal movements, breathing
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movements, and muscle tone) along with NST. This comprehensive approach provides a more
detailed evaluation of fetal well-being.

Frequency of Testing:

The frequency of NST depends on various factors such as the mother's medical history,
gestational age, and any specific concerns. It may be performed weekly or more frequently in
high-risk pregnancies.

Documentation and Reporting:

The results of NST are documented in the mother's medical records, and healthcare providers
discuss the findings with the mother, explaining the implications and any further steps needed
based on the results.

Limitation of Nonstress testing

While nonstress testing (NST) is a valuable tool in monitoring fetal well-being during
pregnancy, it does have limitations that healthcare providers should be aware of:

False Positives and False Negatives:

NST results can sometimes be misleading. A "nonreactive" NST result may not always indicate
fetal distress or problems, as fetal sleep cycles or medications can affect fetal movements and
heart rate patterns. Conversely, a "reactive" NST result doesn't guarantee that everything is
normal, as certain conditions may not manifest in NST results.

Limited Predictive Value:

NST provides a snapshot of fetal well-being at the time of testing but doesn't predict future
outcomes with absolute certainty. A reactive NST doesn't guarantee that fetal distress won't
occur later, and a nonreactive NST doesn't always mean there's a serious problem.

Inability to Detect Structural Abnormalities:

NST primarily assesses fetal heart rate patterns and reactivity but doesn't evaluate structural
abnormalities or developmental issues. Additional tests such as ultrasound or genetic screening
may be needed to assess these aspects of fetal health.
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Dependence on Fetal Movements:

NST relies on fetal movements to stimulate changes in the fetal heart rate. In cases where the
baby is less active or in certain conditions such as fetal neuromuscular disorders, the test may
be less effective in eliciting the desired responses.

Interpretation Challenges:

Interpreting NST results requires expertise and understanding of fetal physiology. Variability
in interpretation among different healthcare providers or facilities can lead to inconsistencies
in management decisions.

Limited in Preterm Gestation:

NST is more reliable in the third trimester when fetal movements are more frequent and
predictable. In preterm gestation, fetal activity patterns may be less consistent, affecting the
reliability of NST results.

Resource Intensive:

NST requires dedicated monitoring equipment, trained personnel, and time for interpretation.
In busy healthcare settings, resource constraints may limit the availability or frequency of NST,
especially in low-resource or rural areas.

Patient Factors:

Maternal factors such as obesity, uterine contractions, or medications can sometimes interfere
with NST results, requiring careful consideration and interpretation by healthcare providers.

6.CONTRACTION STRESS TEST

The contraction stress test (CST) measures the ability of the placenta to provide enough oxygen
to the fetus while under pressure (contraction). Essentially, the same electronic monitoring
systems are used for CST and NST. The uterine contractions and FHR are recorded. If
contractions are not occurring spontaneously, either oxytocin will be given intravenously
(referred to as oxytocin challenge test) or nipple stimulation (referred to as nipple stimulation
test) will be used to induce contractions. The oxytocin challenge test involves IV oxytocin
administration until three uterine contractions are observed, lasting for 40-60 s, over a 10-min
period. The CST concludes when an adequate pattern of uterine activity (generally, three
contractions in 10 min) has been achieved.
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IMPORTANCE

contraction stress test (CST) is an important tool in pregnancy for assessing the fetal response
to uterine contractions. Here are some key points highlighting its importance:

Evaluation of Fetal Tolerance to Stress:

CST evaluates how the fetus responds to stress, specifically uterine contractions. This is crucial
as labor involves rhythmic uterine contractions, and knowing how the fetus responds to these
contractions helps assess its ability to tolerate the stress of labour.

Identification of Fetal Distress:

CST can help identify fetal distress during labor. If the fetus shows signs of distress (e.g.,
abnormal fetal heart rate patterns) during the CST, it may indicate that the fetus could
experience difficulties during actual labor and delivery.

Assessment in High-Risk Pregnancies:

CST is often used in high-risk pregnancies where there are concerns about fetal well-being.
This includes pregnancies with conditions such as preeclampsia, gestational diabetes,
intrauterine growth restriction (IUGR), or suspected placental insufficiency. CST provides
valuable information in these cases to guide management decisions.

Timing of Delivery:

CST results can assist healthcare providers in determining the optimal timing of delivery in
certain situations. For example, if CST indicates that the fetus is not tolerating contractions
well, healthcare providers may consider earlier delivery to prevent potential complications.

Comprehensive Fetal Assessment:

When combined with other tests such as nonstress testing (NST) and biophysical profile (BPP),
CST contributes to a comprehensive assessment of fetal well-being. This multi-faceted
approach helps healthcare providers make informed decisions regarding the management of
the pregnancy.
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Reduction of Adverse Outcomes:

By detecting fetal distress early, CST can help reduce the risk of adverse outcomes such as
fetal hypoxia, acidosis, or stillbirth. Timely interventions based on CST results can improve
pregnancy outcomes.

Confirmation of Fetal Maturity:

In cases where early delivery is being considered due to maternal or fetal concerns, CST can
help confirm fetal lung maturity. This is important for deciding if the fetus is ready for delivery
and may influence the approach to managing preterm labor.

Risk Reduction in Repeat Cesarean Deliveries:

In pregnancies with a history of previous cesarean deliveries, CST can be used to assess uterine
scar integrity and the risk of uterine rupture during labor. This information is crucial for
determining the mode of delivery and reducing complications.

STEPS CONTRACTION STRESS TEST

Here are the steps involved in conducting a contraction stress test (CST) in pregnancy:

Preparation:

• Obtain informed consent from the mother after explaining the purpose, procedure, risks,
and benefits of the CST.
• Review the mother's medical history, including gestational age, obstetric history, any
existing medical conditions, and medications.

Baseline Fetal Monitoring:

• Position the mother comfortably, usually lying on her left side.

• Apply fetal heart rate (FHR) monitors on the mother's abdomen to record the baseline
fetal heart rate. This baseline is established before any contractions occur.

Observation of Spontaneous Contractions:

• Allow the mother to have spontaneous contractions if they are occurring naturally.
• Monitor the frequency, duration, and intensity of these contractions using a
tocodynamometer or other contraction-monitoring device.
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Artificial Stimulation (if needed):

• If spontaneous contractions are not occurring or are insufficient for the test, administer
synthetic oxytocin (Pitocin) intravenously to induce contractions.
• Adjust the dosage of oxytocin carefully based on the mother's response and uterine
contractions, aiming for contractions that mimic those during labor but are not overly
intense or prolonged.

Continuous Fetal Heart Rate Monitoring:

• Throughout the contractions, continue monitoring the fetal heart rate using the fetal
heart rate monitor.
• Note any changes in the fetal heart rate patterns, such as accelerations, decelerations,
or variability.

Assessment of Fetal Response:

• Analyze the fetal heart rate patterns during contractions and compare them to the
baseline.
• Look for reassuring signs such as accelerations in fetal heart rate during contractions,
indicating a healthy response to stress.

Scoring the Test:

• Use a scoring system, such as the "Oxford Score," to evaluate the CST results based on
criteria such as the presence of late or variable decelerations, overall variability in fetal
heart rate, and the percentage of contractions with abnormal patterns.
• A "negative" CST result indicates a reassuring response with no significant
decelerations noted during contractions.
• A "positive" CST result indicates a concerning response, such as late decelerations,
suggesting fetal distress during contractions.

Post-Test Evaluation:

Remove the fetal monitoring equipment and assess the mother's condition for any immediate
post-test effects, such as uterine hyperstimulation if oxytocin was administered.Document the
CST results, including the fetal heart rate patterns, contractions, and interpretation of findings.
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Follow-Up and Management:

Discuss the CST results with the mother, explaining the implications and any recommended
further evaluation or management based on the findings.In cases of a positive CST indicating
fetal distress, consider additional monitoring, interventions, or discussions regarding the timing
and mode of delivery, especially in high-risk pregnancies.

LIMITATION CONTRACTION STRESS TEST

The contraction stress test (CST) is a valuable tool in assessing fetal well-being, but it does
have some limitations that healthcare providers should consider:

False Positives and False Negatives:

• CST results can sometimes be misleading. A "positive" CST result indicating fetal
distress may not always correspond to actual distress during labor.
• Conversely, a "negative" CST result may not guarantee a problem-free labor and
delivery.
• Dependence on Uterine Contractions: CST relies on the presence of uterine contractions
to assess fetal response. In cases where contractions are not occurring naturally and
synthetic oxytocin is used to induce contractions, the test may not accurately reflect the
natural labor process.

Interpretation Challenges:

Interpreting CST results requires expertise and may vary among healthcare providers.
Variability in interpretation can lead to inconsistencies in management decisions and
recommendations.

Resource Intensive:

CST requires dedicated monitoring equipment, trained personnel, and time for monitoring and
interpretation. This may limit its availability or frequency, especially in settings with limited
resources.

Inconclusive Results:

Some CST results may be inconclusive, making it challenging to definitively assess fetal well-
being. This can occur due to factors such as inadequate contractions or difficulty in interpreting
fetal heart rate patterns.
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Not Applicable to All Pregnancies:

CST is typically used in high-risk pregnancies or situations where there are concerns about
fetal well-being. It may not be routinely applicable or necessary in all pregnancies, leading to
selective use based on clinical indications.

Limited Predictive Value:

CST provides information about fetal response to stress during contractions but may not predict
future outcomes or complications during labor and delivery with absolute certainty.Maternal
Factors: Maternal factors such as medications, maternal heart rate variability, or uterine
anomalies can sometimes affect CST results, requiring careful consideration and interpretation.

7.AMNIOSCOPY

Amnioscopy, also known as transcervical amnioscopy or fetoscopy, is a diagnostic procedure

used in pregnancy to directly visualize the amniotic fluid, amniotic sac, and fetus within the
uterus.

Purpose:
Amnioscopy is primarily used to assess the amniotic fluid for various conditions such as
meconium staining (which can indicate fetal distress), blood, infection, or other abnormalities.

It allows direct visualization of the fetus, placenta, umbilical cord, and other structures within
the amniotic sac, providing detailed information about fetal well-being and development.

Indications:

• Amnioscopy is often performed in cases where there are concerns about fetal health,
such as suspected fetal abnormalities detected on ultrasound, abnormal levels of
amniotic fluid (polyhydramnios or oligohydramnios), or maternal conditions that may
affect the fetus.
• It can also be used to guide certain procedures such as fetal blood sampling
(cordocentesis) or fetal interventions like laser ablation for twin-to-twin transfusion
syndrome (TTTS).
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Procedure:

• Amnioscopy is typically performed in a hospital or clinic setting by a specialized

healthcare provider, such as a maternal-fetal medicine specialist or an obstetrician with
expertise in fetal procedures.
• The procedure may be done under local anesthesia or sedation, depending on the
patient's comfort and the complexity of the procedure.
• A thin, flexible endoscope or fetoscope is inserted through the cervix into the amniotic
sac under ultrasound guidance. This allows direct visualization of the amniotic fluid,
fetal membranes, and fetus.

Visualization and Assessment:

• Once the fetoscope is inserted, the healthcare provider can examine the amniotic fluid
for any abnormalities such as meconium staining, blood, or infection.
• The fetus, umbilical cord, placenta, and surrounding structures can be observed for any
structural abnormalities, growth issues, or signs of distress.

Benefits:

• Direct visualization through amnioscopy provides more detailed and accurate

information compared to indirect methods like ultrasound.
• It can aid in early detection of certain fetal conditions or abnormalities, allowing for
timely interventions or management decisions.
• Amnioscopy can also be used to confirm or rule out suspected findings from other
prenatal tests, providing additional diagnostic clarity.

Risks and Considerations:

• Although amnioscopy is generally considered safe, it carries risks similar to other

invasive procedures, including a small risk of infection, bleeding, or injury to the fetus
or membranes.
• Healthcare providers carefully weigh the benefits of the procedure against potential
risks and ensure that patients are well-informed and consented before proceeding.
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Overall, amnioscopy plays a valuable role in prenatal diagnosis and management, providing
direct visualization of the amniotic environment and fetal structures to assess fetal well-being,
detect abnormalities, and guide appropriate interventions when necessary.

8.FOETOSCOPY

Fetoscopy, also known as fetal endoscopy, is a medical procedure used during pregnancy to
directly visualize and examine the fetus within the uterus. It involves inserting a thin, flexible
instrument called a fetoscope through the mother's abdomen and into the amniotic sac, allowing
for direct visualization of the fetus, placenta, umbilical cord, and surrounding structures.
Fetoscopy is typically performed by specialized healthcare providers, such as maternal-fetal
medicine specialists or obstetricians with expertise in fetal procedures. This procedure provides
detailed information about fetal development, abnormalities, and well-being, allowing for
accurate diagnosis, monitoring, and in some cases, therapeutic interventions.

PURPOSE

The purpose of fetoscopy, also known as fetal endoscopy, in pregnancy is to directly visualize
and assess the fetus, placenta, umbilical cord, and surrounding structures within the uterus.
Here are the key purposes of fetoscopy:

Diagnostic Assessment:

Fetal Abnormalities:

• Fetoscopy allows healthcare providers to visually inspect the fetus for structural
abnormalities, developmental anomalies, or genetic conditions.
• This direct visualization can provide more detailed information compared to indirect
methods like ultrasound.

Placental Evaluation:

The placenta and its attachment to the uterine wall can be examined for abnormalities or
complications, such as placental abnormalities, placental tumors, or placental insufficiency.

Umbilical Cord Assessment:

The umbilical cord, including its blood vessels and insertion site, can be assessed for any
abnormalities that may affect fetal well-being, such as cord compression or cord entanglement
in multiple gestations.
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Fetal Well-being Monitoring:

Fetal Movements and Activity: Fetoscopy allows observation of fetal movements, muscle
tone, and general activity, providing insights into fetal neurological development and well-
being.

Fetal Heart Rate Monitoring:

In some cases, fetoscopy may include direct monitoring of the fetal heart rate, especially during
procedures or interventions that may impact fetal cardiac function.

Assessment of Fetal Growth and Development:

Fetoscopy can help evaluate fetal growth patterns, organ development, and overall fetal
maturity.

This information is crucial for assessing fetal well-being and determining the appropriate
management of the pregnancy.

Therapeutic Interventions:

Fetal Surgery: In certain cases of fetal abnormalities or conditions that require intervention
before birth, fetoscopy can be used to perform minimally invasive fetal surgeries.

This may include procedures such as fetal laser therapy for twin-to-twin transfusion syndrome
(TTTS), fetal shunt placement for hydrocephalus, or interventions for congenital diaphragmatic
hernia (CDH), among others.

Fetal Sampling and Treatment:

• Fetoscopy allows for procedures such as fetal blood sampling (cordocentesis) for
genetic testing or evaluation of fetal hematological conditions.
• It also facilitates targeted delivery of medications or treatments directly to the fetus
when indicated.

Research and Education:

• Fetoscopy serves as a valuable tool for research purposes, allowing for the study of fetal
development, responses to interventions, and the efficacy of new diagnostic or
therapeutic techniques.
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• It also plays a role in medical education and training for healthcare professionals
specializing in maternal-fetal medicine and fetal interventions.

STEPS FETOSCOPY:

Here are the general steps involved in performing a fetoscopy procedure:

Preparation:

• Obtain informed consent from the mother after explaining the purpose, risks, benefits,
and potential outcomes of the fetoscopy procedure.
• Review the mother's medical history, including gestational age, obstetric history, any
existing medical conditions, and medications.

Pre-procedure Assessment:

• Conduct a thorough prenatal evaluation, including ultrasound examinations, to assess

fetal anatomy, position, and any suspected abnormalities.
• Evaluate the amniotic fluid volume and overall uterine environment to ensure suitability
for fetoscopy.

Anesthesia and Sedation:

• Administer local anesthesia or regional anesthesia to the mother to minimize discomfort

during the procedure.
• Consider sedation or analgesia as needed to keep the mother relaxed and comfortable
during the procedure, especially if it is prolonged or involves discomfort.

Access and Insertion:

• Position the mother comfortably, usually lying on her back or slightly tilted to one
side.Cleanse and prepare the abdomen for aseptic insertion of the fetoscope.
• Make a small incision or create a port for inserting the fetoscope through the abdominal
wall and into the uterus.
• Use ultrasound guidance to guide the insertion of the fetoscope and ensure proper
positioning within the amniotic sac.
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Visualization and Examination:

• Once the fetoscope is inserted into the amniotic sac, slowly advance it towards the fetus
while continuously visualizing the procedure on a monitor.
• Direct the fetoscope towards the areas of interest, such as the fetus, placenta, umbilical
cord, or specific organs for examination.
• Carefully inspect and assess the structures within the uterus, observing for any
abnormalities, developmental issues, or signs of distress.

Diagnostic Procedures:

• If indicated, perform diagnostic procedures during fetoscopy, such as fetal blood

sampling (cordocentesis) for genetic testing, assessment of fetal hematological
conditions, or collection of samples for other analyses.
• Use specialized instruments or techniques as necessary for the intended diagnostic
procedures, ensuring safety and accuracy.

Therapeutic Interventions:

• If fetoscopy involves therapeutic interventions, such as fetal surgery or targeted

treatments, carefully perform the planned procedures under direct visualization.
• Monitor the fetal response and well-being throughout the interventions, adjusting as
needed to optimize outcomes and minimize risks.

Post-procedure Care:

• Remove the fetoscope carefully after completing the desired procedures or

examinations.
• Close the incision site or port and apply appropriate dressings.
• Monitor the mother and fetus post-procedure for any immediate complications, such as
bleeding, infection, or changes in fetal status.

Follow-Up and Evaluation:

• Evaluate the results of the fetoscopy procedure, including any diagnostic findings, test
results, or therapeutic outcomes.
• Discuss the findings with the mother, providing information, counseling, and
recommendations based on the fetoscopy results.
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Documentation and Follow-Up:

• Document all aspects of the fetoscopy procedure, including pre-procedure assessments,

intraoperative details, findings, interventions, and post-procedure care.
• Arrange for appropriate follow-up visits, monitoring, or additional interventions as
needed based on the fetoscopy results and clinical considerations.
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RADIOLOGYCAL EXAMINATION
Radiological examination in pregnancy refers to the use of imaging techniques, such as X-rays,
CT scans, and nuclear medicine studies, to diagnose or monitor medical conditions in a
pregnant woman. These procedures involve exposure to ionizing radiation, which can pose
risks to the developing fetus, especially during the early stages of pregnancy when the fetal
tissues are highly sensitive.

Key Points:

Types of Radiological Examinations: Common types include X-rays, CT scans, fluoroscopy,

and nuclear medicine procedures. Ultrasound and MRI are often preferred during pregnancy
as they do not involve ionizing radiation.

Risks to the Fetus:

Ionizing radiation can increase the risk of birth defects, growth restriction, and possibly cancer
later in life, depending on the dose and timing of exposure.

Risk Mitigation:

If a radiological examination is necessary, measures are taken to minimize fetal exposure. This
may include using the lowest possible radiation dose, shielding the abdomen, and optimizing
imaging protocols.

Clinical Justification:

Radiological examinations are only performed when the benefits to the mother outweigh the
potential risks to the fetus. Alternative imaging methods without radiation, like ultrasound or
MRI, are considered first.

Guidelines and Protocols:

Healthcare providers follow strict guidelines to ensure the safety of both mother and fetus. The
decision to proceed with radiological imaging is made collaboratively by the healthcare team,
considering all factors involved.

GUIDELINE OF DOING RADIOLOGYCAL EXAMINATION IN

PREGNANCY
 26

When conducting radiological examinations in pregnant women, specific guidelines and

protocols are followed to ensure the safety of both the mother and the fetus. These guidelines
aim to minimize fetal exposure to ionizing radiation while ensuring necessary diagnostic
information is obtained. Here are the key guidelines:

Justification of Examination:

Only perform radiological examinations if absolutely necessary and if the benefits outweigh
the risks.Consider alternative imaging modalities, such as ultrasound or MRI, that do not use
ionizing radiation.

Informed Consent:

Discuss the potential risks and benefits with the pregnant patient.Obtain informed consent,
ensuring the patient understands the reasons for the examination and the measures taken to
minimize risk.

Optimization of Radiation Dose:

Use the lowest possible radiation dose that still provides adequate diagnostic
information.Implement dose-reduction techniques, such as limiting the number of images,
adjusting exposure parameters, and using appropriate shielding.

Shielding:

Use lead shielding to protect the abdomen and pelvis whenever possible without compromising
the diagnostic quality of the image.Ensure proper placement of the shielding to maximize
protection.

Timing of Examination:

Consider the stage of pregnancy when planning the examination. The first trimester is the most
sensitive period, and extra caution is needed during this time.If possible, defer non-urgent
radiological examinations until after pregnancy or to a safer stage of pregnancy.

Documentation:

Record the justification for the examination, the informed consent process, and the steps taken
to minimize radiation exposure.Document the estimated fetal dose of radiation whenever
possible.
 27

Consultation with Specialists:

Involve a radiologist and, if necessary, a medical physicist to help plan and optimize the
examination.Consult with an obstetrician or maternal-fetal medicine specialist to ensure a
coordinated approach to the patient's care.

Post-Examination Care:

Monitor the patient for any immediate adverse reactions if contrast agents are used.Provide
appropriate follow-up care and support, addressing any concerns the patient may have about
the examination and its potential effects.

LIMITATION OF DOING RADIOLOGYCAL EXAMINATION IN

PREGNANCY

Radiological examinations during pregnancy come with certain limitations due to the potential
risks associated with exposing the developing fetus to ionizing radiation. These limitations are
essential to consider in order to protect both the mother and the fetus. Here are the primary
limitations:

Radiation Exposure Risks:

Teratogenic Effects:

Ionizing radiation can cause congenital malformations, especially if exposure occurs during
organogenesis (weeks 2-8 of gestation).Carcinogenic Effects: There is an increased risk of
childhood cancers with in-utero exposure to ionizing radiation.

Growth Restriction:

High doses of radiation can lead to intrauterine growth restriction (IUGR) and developmental
delays.

Dose Constraints:

Radiological examinations must use the lowest possible radiation dose, which may limit the
quality and diagnostic utility of the images obtained.Repeated imaging is often avoided, which
can restrict follow-up and monitoring of certain conditions.
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Timing and Urgency:

Examinations are preferably deferred until after the first trimester or until after delivery if they
are not urgently required, limiting immediate diagnostic capabilities.Urgent conditions
requiring immediate diagnosis and intervention may necessitate exposure, despite the potential
risks.

Modality Selection:

Preference for non-ionizing imaging modalities such as ultrasound and MRI can limit the
ability to diagnose conditions best visualized with X-ray or CT.Some conditions may not be
adequately assessed without the superior detail provided by radiological techniques involving
ionizing radiation.

Shielding and Positioning:

The need for abdominal shielding to protect the fetus can sometimes obscure important
diagnostic information.Positioning adjustments to minimize fetal exposure may be
uncomfortable for the pregnant patient and can complicate the imaging procedure.

Limited Use of Contrast Agents:

The use of certain contrast agents, particularly iodine-based contrast in CT and gadolinium in
MRI, is limited due to potential risks to the fetus, which can reduce the effectiveness of some
imaging studies.Potential adverse effects of contrast agents on the fetus must be carefully
weighed against the diagnostic benefits.

Ethical and Legal Considerations:

There are ethical considerations regarding the consent process and the potential for harm,
requiring thorough patient counseling and documentation.Legal implications may arise from
adverse outcomes associated with fetal radiation exposure, necessitating meticulous adherence
to guidelines and protocols.

Interdisciplinary Coordination:

Effective communication and coordination among radiologists, obstetricians, and other

healthcare providers are essential, which can complicate and prolong the decision-making and
diagnostic process.By understanding and addressing these limitations, healthcare providers.
 29

CONCLUSION
Biophysical and radiological examinations are vital components of prenatal care, providing
essential diagnostic information. The choice of examination modality is guided by the principle
of maximizing diagnostic benefits while minimizing risks, particularly to the developing fetus.
Ultrasound and MRI are preferred for their safety, with radiological examinations being used
judiciously. Careful planning, adherence to guidelines, and informed consent are key to
ensuring the health and safety of both mother and fetus.
 30

SUMMARY
Biophysical refers to the combination of biological and physical factors. When discussing
biophysical aspects in pregnancy, it typically involves assessing the health and well-being of
both the mother and the developing fetus using various techniques and measurements. This can
include monitoring fetal heart rate, movement, muscle tone, breathing patterns, and amniotic
fluid volume. These assessments are crucial in ensuring a healthy pregnancy and identifying
any potential issues early on.

Radiological examination in pregnancy refers to the use of imaging techniques, such as X-rays,
CT scans, and nuclear medicine studies, to diagnose or monitor medical conditions in a
pregnant woman. These procedures involve exposure to ionizing radiation, which can pose
risks to the developing fetus, especially during the early stages of pregnancy when the fetal
tissues are highly sensitive.
 31

JOURNAL

Electrohysterography in the diagnosis of preterm birth: a review

J Garcia-Casado et al.

2018.

Abstract

Preterm birth (PTB) is one of the most common and serious complications in pregnancy. About
15 million preterm neonates are born every year, with ratios of 10-15% of total births. In
industrialized countries, preterm delivery is responsible for 70% of mortality and 75% of
morbidity in the neonatal period. Diagnostic means for its timely risk assessment are lacking
and the underlying physiological mechanisms are unclear. Surface recording of the uterine
myoelectrical activity (electrohysterogram, EHG) has emerged as a better uterine dynamics
monitoring technique than traditional surface pressure recordings and provides information on
the condition of uterine muscle in different obstetrical scenarios with emphasis on predicting
preterm deliveries.

Objective:

A comprehensive review of the literature was performed on studies related to the use of the
electrohysterogram in the PTB context.

Approach:

This review presents and discusses the results according to the different types of parameter
(temporal and spectral, non-linear and bivariate) used for EHG characterization.

Main results:

Electrohysterogram analysis reveals that the uterine electrophysiological changes that precede
spontaneous preterm labor are associated with contractions of more intensity, higher frequency
content, faster and more organized propagated activity and stronger coupling of different
uterine areas. Temporal, spectral, non-linear and bivariate EHG analyses therefore provide
useful and complementary information. Classificatory techniques of different types and
varying complexity have been developed to diagnose PTB. The information derived from these
different types of EHG parameters, either individually or in combination, is able to provide
 32

more accurate predictions of PTB than current clinical methods. However, in order to extend
EHG to clinical applications, the recording set-up should be simplified, be less intrusive and
more robust-and signal analysis should be automated without requiring much supervision and
yield physiologically interpretable results.

Significance:

This review provides a general background to PTB and describes how EHG can be used to
better understand its underlying physiological mechanisms and improve its prediction. The
findings will help future research workers to decide the most appropriate EHG features to be
used in their analyses and facilitate future clinical EHG applications in order to improve PTB
prediction.
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BIBLIOGRAPHY

❖ Boback M Irene & Jenson Margaret" Maternity & Gynaecologic Care, mosby
company (5th edition) page no;964-971

❖ DC Dutta (2004)" text book of obstetrics" 9th th edition 2018, jaypee brothers
medical publication ,page no: 433-444.

❖ Myles (2003) text book for midwifes" 15th edition, Philadelphia: Churchill
livingstone publishers, page no:625-653

❖ Raman A V text book of maternity nursing ,19 th edition ,Wolters Kluwer,

page no :689-691

❖ Richi Susan Scoti Essentials Maternity ,New born ,and Womens Health
Nursing,4th edition Wolters Kluwer : page no 499-521