ASSESSMENT OF FETAL WELL-

BEING

Syed Abdullah monawwer

2017/092
 ASSESSMENT OF FWB

Clinical Monitoring

Biophysical Monitoring

Biochemical Monitoring

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FETAL MOVEMENT MONITORING
“KICK COUNTS”
 FETAL MOVEMENT
MONITORING
Simplest method of fetal assessment.
A study suggests that mothers perceive 88% of the fetal
movements detected by Doppler imaging.
The count should be performed daily starting at 28 weeks
of pregnancy.
Mother assesses fetal activity by counting the number of
times a baby kicks throughout the day.
Preferably done during periods of known activity (after
feeding, after maternal activity).
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 FETAL MOVEMENT
MONITORING
Since healthy babies have sleep cycles, baby may not kick,
or kick less than usual, or have less than 10 kicks in 2
hours. If so, wake up the baby by drinking fluid or by
walking for 5 minutes. Repeat the kick count.
No less than 3 movements in 30 minutes
Most healthy babies should take less than 2 hours for 10
kicks.
Fetal alarm signal if no movement in 12 hours

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ULTRASOUND
 ULTRASOUND
Production of images using high frequency sound waves emitted from a
transducer placed on the abdomen or inside the vagina
Purpose:
Confirmation of pregnancy
Fetal viability,
Gestational age,
Locating the placenta,
Amount of amniotic fluid,
Cervical length, fetal
Fetal anomalies,
Maternal abnormalities
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ULTRASOUND PROBES
Trans-vaginal:
Early pregnancy
Examining cervix in later pregnancy
Identifying lower edge of placenta
In women with increased abdominal adipose tissue

Abdominal:
Used after 12 weeks of
gestation
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 ULTRASONOGRAPHY: INDICATIONS FOR USE (1 ST
TRIMESTER)

Number, size, location of gestational sac

Fetal cardiac and body movement
Uterine abnormalities (bicornuate uterus, uterine
fibroid, IUD) or adnexal masses
Duration of pregnancy (crown-rump length)
Visualization during chorionic villus sampling

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ULTRASONOGRAPHY: INDICATION FOR USE (2 ND
AND 3 RD TRIMESTER)
Fetal viability, number and presentation,
Establishment of fetal age and growth by fetal biometry including:
⁃ BPD (biparietal diameter)
⁃ FL (femur length)
⁃ AC (abdominal circumference)
⁃ Biophysical profile

Evaluation of fetal anatomic structures:

⁃ Cerebral lateral ventricles
⁃ Spine
⁃ Four chamber view of the heart
⁃ Stomach-bowel, abdominal wall at the area of the umbilical cord insertion
⁃ Bladder and kidney
⁃ Limbs and umbilical cord

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ULTRASONOGRAPHY: INDICATION FOR USE (2 ND
AND 3 RD TRIMESTER)
Amount of amniotic fluid
Placental localization and maturity
Evaluation of the uterine, and adnexae for abnormalities
and masses
Cervical length
Visual assistance to invasive tests

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 ULTRASONIC ESTIMATION OF
GESTATIONAL AGE
Owing to normal biologic variability, accuracy of gestational age estimated by BPD
decreases with increasing gestational age.
Gestational age cannot be accurately calculated by ultrasound after 20 weeks’ gestation
because of the wider range of normal values of AC and HC around the mean.
For measurements made;
-at 14 to 20 weeks of gestation: variation up to 11 days
-at 20 to 28 weeks of gestation: variation up to 14 days
-at 29 to 37 weeks of gestation: variation can be up to 21 days

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 CARDIOTOCOGRAPHY (CTG)
OR
ELECTRONIC FETAL MONITORING (EFM)
 CTG
The cardiotocograph (CTG) is a continuous tracing of the fetal heart rate used to assess
fetal wellbeing, together with an assessment of uterine activity.
The CTG recording is obtained with the pregnant woman positioned comfortably in a
left lateral or semi-recumbent position to avoid compression of the maternal vena cava
Two external transducers are placed on the mother’s abdomen, each attached with a
belt.
One transducer is a pressure-sensitive contraction tocodynometer (stretch gauge) that
measures the pressure required to flatten a section of the abdominal wall. This
correlates with the internal uterine pressure and indicates if there is any uterine activity
(contractions).

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 CTG
The second transducer uses ultrasound and the Doppler effect to detect motion of the
fetal heart, and measures the interval between successive beats, thereby allowing a
continuous assessment of fetal heart rate
Recordings are then made for at least 30 minutes with the output from the CTG
machine producing two ‘lines’ traced onto a running piece of paper, one a tracing of
fetal heart rate and a second a tracing of uterine activity
The mother may be given a button to press to record any fetal movements that she has
felt

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 CTG
Features that are reported from a CTG to define normality and identify abnormality
and potential concern for fetal wellbeing include the:
Baseline rate.
Baseline variability.
Accelerations.
Decelerations.

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 CTG
Features that are reported from a CTG to define normality and identify abnormality
and potential concern for fetal wellbeing include the:
Baseline rate.
Baseline variability.
Accelerations.
Decelerations.

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 CTG: BASELINE FETAL HEART RATE
The normal fetal heart rate at term is 110–150 beats per minute (bpm). Higher rates are
defined as fetal tachycardia and lower rates as fetal bradycardia. The
Baseline fetal heart rate falls with advancing gestational age as a result of maturing
fetal parasympathetic tone and, prior to term, 160 bpm is taken as the upper limit of
normal.
The baseline rate is best determined over a period of 5–10 minutes.
Fetal tachycardias can be associated with maternal or fetal infection, acute fetal
hypoxia, fetal anaemia and drugs such as adrenoceptor agonists.

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 CTG: BASELINE VARIABILITY
Normal baseline variability reflects a normal fetal autonomic nervous system.
Baseline variability is considered abnormal when it is less than 10 bpm

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 CTG: FETAL HEART RATE
ACCELERATIONS
These are increases in the baseline fetal heart rate of at least 15 bpm, lasting for at least
15 seconds.
The presence of two or more accelerations on a 20–30-minute antepartum fetal CTG
defines a reactive trace and is indicative of a non-hypoxic fetus (i.e. they are a positive
sign of fetal health).

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 CTG: FETAL HEART RATE
DECELERATIONS
These are transient reductions in fetal heart rate of 15 bpm or more, lasting for more
than 15 seconds. Decelerations can be indicative of fetal hypoxia or umbilical cord
compression.
There is a higher chance of fetal hypoxia being present if there are additional abnormal
features such as reduced variability or baseline tachycardia

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 NORMAL CTG
A normal antepartum fetal CTG can therefore be defined as a
 baseline of 110–150 bpm,
 with baseline variability exceeding 10 bpm,
 with more than one acceleration being seen in a 20–30 minute tracing

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BASELINE OF 150 BPM BUT WITH
REDUCED VARIABILITY (RV).

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BASELINE FETAL HEART RATE IS NORMAL, THERE IS
REDUCED VARIABILITY, AN ABSENCE OF FETAL
HEART RATE ACCELERATIONS AND MULTIPLE
DECELERATIONS (D)

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NON STRESS TEST (NST)
 NST
The NST is the most common cardiotocographic method of antepartum fetal
assessment.
It is noninvasive and can be performed in any setting with an electronic fetal monitor.
There is no direct risk of maternal or fetal injury associated with non-stress testing.

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 NST
The NST is the most common cardiotocographic method of antepartum fetal
assessment.
It is non-invasive and can be performed in any setting with an electronic fetal monitor.
There is no direct risk of maternal or fetal injury associated with non-stress testing.
Heart rate accelerations, spontaneous or provoked (eg, by vibroacoustic stimulation),
have been shown to be a good indicator of normal fetal autonomic function and
absence of acidosis and neurologic depression.

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 NST
Vibroacoustic stimulation (VAS) (i.e., stimulating the fetus with a noxious vibration
and noise) is effective in producing a state change, fetal startle movements, and
increased FHR variability.

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 NST
Reactive NST :  The NST test is reactive from 33 weeks to term if there are two or
more fetal heart rate accelerations reaching a peak of at least 15 beats per minute (bpm)
above the baseline rate and lasting at least 15 seconds from onset to return to baseline
in a 20 minute period
Nonreactive NST — An NST is nonreactive if it does not meet acceleration criteria for
a reactive NST.
The fetal heart rate should be monitored for at least 40 minutes but no more than 120
minutes before interpreting the test as non-reactive.

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CONTRACTION STRESS TEST (CST)
 CST
The contraction stress test (CST) (oxytocin challenge test) is based on the fetal
response to a transient reduction in fetal oxygen delivery during uterine contractions.
If the fetus becomes hypoxemic (fetal arterial pO2 below 20 mm Hg) fetal
chemoreceptors and baroreceptors, as well as sympathetic and parasympathetic
influences, respond by reflex slowing of the fetal heart rate (FHR), which may
manifest clinically as late decelerations.
Done at 34+ weeks of pregnancy.

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CST

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BIOPHYSICAL PROFILE (BPP)
 BPP
A biophysical profile (BPP) includes four acute fetal variables:
⁃FBMs,
⁃Fetal gross body movement,
⁃Fetal tone
⁃CTG
⁃Amniotic fluid volume
A score of either 2 (normal) or 0 (suboptimal) is assigned to each of the variables, to
give an individual fetus a total score of between 0 and 10.

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 BPP
A score of 0, 2 or 4 is considered abnormal
A score of 8 or 10 normal
A score of 6 is equivocal and requires repeat within a
reasonable timescale (hours) to exclude a period of fetal sleep as a cause.

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BPP

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DOPPLER INVESTIGATION
 DOPPLER
The primary use of Doppler echo shifts in obstetrics have been to detect and measure
blood flow
Waveforms can be obtained from the umbilical and fetal vessels and the maternal
uterine artery
Data obtained from the umbilical artery provide indirect information about placenta
function, whereas data from the fetal vessels provide information on the fetal response
to hypoxia
Doppler insonation of the uterine artery can be used to assess the degree of placental
insufficiency

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MAGNETIC RESONANCE IMAGING (MRI)
 MRI
Noninvasive radiologic technique
Like CT provides pictures of soft tissue
Unlike CT is not use ionizing radiation

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 MRI
Fetal structure
Placenta (position, density, and presence of
gestational trophoblastic disease)
Quantity of amniotic fluid
Maternal structures (uterus, cervix, adnexa,
and pelvis)
Biochemical status of tissues and organs

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MRI

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3D & 4D ULTRASONOGRAPHY
 3D & 4D ULTRASONOGRAPHY
Mainly used as an adjunct to 2D ultrasound, either to
interrogate fetal structures that may be difficult to
visualize, such as the corpus callosum or fetal spine,
or to demonstrate fetal structural abnormalities to the
parents, for example cleft lip and palate.

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3D & 4D ULTRASONOGRAPHY

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 BIOCHEMICAL ASSESSMENT
Involves biological examination and chemical determination
Procedures used to obtain needed specimen
 Amniocentesis
 Percutaneous umbilical blood sampling
 Chorionic villus sampling
 Maternal sampling

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AMNIOCENTESIS
 AMNIOCENTESIS
Performed to obtain amniotic fluid, which contains fetal cells. Under direct
ultrasonographic visualization, a needle is inserted trans abdominally into the uterus,
amniotic fluid is withdraw into a syringe, and the various assessment are performed.
Genetic disorders:
 women more than 35 years old, with a previous child with a chromosomal abnormality, or with a family
history of chromosomal anomalies.
 Inherited errors of metabolism (such as Tay-Sachs disease, hemophilia, and thalassemia)

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 AMNIOCENTESIS
After 10-14 weeks gestation
Early – earlier than 15 weeks
Late – second trimester after 15 weeks
Only the amniotic (inner) sac should be aspirated

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AMNIOCENTESIS

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CORDOCENTESIS
 CORDOCENTESIS
Involves the insertion of the needle directly into fetal umbilical vessel under ultrasound
guidance and the removing 1-4 ml of blood
Indications for use:
 Prenatal diagnosis of inherited blood disorders
 Karyotyping of malformed fetuses
 Detection of fetal infection
 Determination of the acid-base status of fetuses with IUGR
 Assessment and treatment of isoimmunization and thrombocytopenia in the fetus

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CHORIONIC VILLUS SAMPLING (CVS)
 CHORIONIC VILLUS SAMPLING (CVS)
Removal of small tissue specimen from fetal portion of placenta
Earlier diagnosis and rapid results
Performed between 10 and 12 weeks of gestation

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CHORIONIC VILLUS SAMPLING (CVS)

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PERCUTANEOUS UMBILICAL CORD
BLOOD SAMPLING

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SERUM MARKERS
 SERUM MARKERS
Serum marker
 maternal serum alphafetoprotein MS-AFP
 maternal unconjugated estriol
 maternal serum beta-human chorionic gonadotropin (hCG)

• Pregnancy associated plasma protein - A (PAPP-A)

• Inhibin A

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 AFP
AFP is produced by the fetal liver, and increasing levels are detectable in the serum of
pregnant women from 14 to 34 weeks.
Approximately 80% to 85% of all open NTDs and open abdominal wall defects
If findings are abnormal, follow-up procedures include genetic counseling for families
with a history of NTD, repeat AFP, ultrasound examination, and possibly
amniocentesis.

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 SCREENING
Triple screening (16-18 weeks)
 Maternal serum alpha-fetoprotein (MS-AFP)
 Human chorionic gonadotropin (hCG)
 Unconjugated estriol (UE3)

Quadruple Screen (15-22 weeks most accurate 16-18 weeks)

 AFP
 hCG
 UE3
 Inhibin

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SCREENING

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 REFERENCES

Obstetrics by Ten Teachers 20th edition

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THANK YOU.

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