BY

Ms. Sutapa Paul

Professor
TCN

ANTENATAL ASSESSMENT
OF FETAL WELLBEING
Aims of fetal monitoring

 Assuring satisfactory growth & well being of

fetus as well as the mother throughout the
pregnancy
 Screening out the high risk cases & the
adverse maternal or intrauterine factors
which may affect the healthy growth of fetus
 Detecting congenital abnormalities or in
born metabolic disorders in early in
pregnancy
Types of fetal well being assessment

Clinical method
Biophysical method
Biochemical method
Clinical method

 Clinical parameters taken in every antenatal

visits are as follows:
 1. maternal weight gain
 2.Blood pressure
 3. Assessment of the size of uterus (in early
wks for calculating duration of gestation) &
height of fundus ( if uterus is
disproportionally enlarges it may suggest
multiple pregnancy & hydramnios)
 4. Documentation of the girth of abdomen (girth
gradually diminishes beyond term or earlier May
be due to placental insufficiency)
 5. Hemoglobin estimation
 6. Routine examination of urine culture when
indicated
 7. Serological test for syphilis
 8. ABO grouping & RH typing
 9. Estimation of post prandial blood sugar(PP) &
glucose tolerance test (GTT)
 10. Test of toxoplasmosin
Biophysical method

Principal:
 Biophysical profile is a screening test for
utero-placental insufficiency. The fetal
biophysical activities are initiated, modulated
& regulated through nervous system. The
fetal CNS is very much sensitive to dimished
fetal oxygenation
 Hypoxia

 Metabolic acidosis

 CNS depression
Changes in the
biophysical activities
Following tests are used:

A)Fetal movement count

B)Electronic fetal monitoring:
a)Non stress test(NST)
b)Cardiotocography
c)Ultrasonography
A) Fetal movement count

 That can felt by mother named quickening

from 18 to 20 wks of pregnancy. Any of the 2
following method can be applied:
 1. Cardif count 10 formula: patient count
fetal movement staring at 9 am. The counting
comes to an end as soon as 10 movements
are perceived. She is instructed to report the
physician if _
 i) less than 10 movements occurs during 12 hrs on
2 successive day
 ii) no movement perceived even after 12 hrs in a
day
 2. Daily fetal movement count (DFMC):
3 counts each of 1 hr duration. Morning, noon &
evening are recommended. The total counts
multiplied by 4 gives daily (12 hrs) fetal
movement count. Diminished no of kick
indicating failing placental function.
3. Fetal heart rate: FHR should be
120 to 160 beats /mins through the
pregnancy.
FH sound can be heard & counted
as early as the 10th to 11th wk of
pregnancy by the use of an
ultrasonic Doppler technique
 Rhythm strip testing: Assessment of the
fetal heart rate in terms of baseline long &
short term variability.
 For the test women is placed in a semi-
fowler’s position to prevent supine
hypotension syndrome during the test.
External fetal heart rate & uterine contraction
monitors are attached abdominally & allowed
to record the fetal heart rate for 20 mins.
 Base line reading: refers to the average rate
of the fetal heart per min
 Short term variability: denotes the small
changes in rate that occur from second to
second. For eg. The baseline (average) of the
fetal heart beat would be 130 beats per mins.
Beat to beat variability is prevented by this.
 Long term variability: denotes the
differences in heart rate that occur over the
20 mins time period. As the average fetus
moves about 2 times every 10 mins &
movement causes the heart rate to increase.
There will typically be 2 or more instances of
fetal heart rate acceleration in a 20 min
rhythm strip. It reflects the state of fetal
sympathetic nervous system.
B) Electronic fetal monitoring

 Antepartum monitoring: testing is not begun

until the fetus in thought to be viable, at
about 25 wks of gestation.
 Non-stress test(NST)
 Acoustic stimulation test(AST)
 Contraction stress test(CST)
 Mammary stimulation test(MST)
Non-stress test(NST)

 Definition: It is continuous electronic

monitoring of fetal heart rate along with
recording of fetal movements is undertaken.
 Purpose: to identify the fetus who may not
be adapting well to the intrauterine
environment.
 There is an observed association of FHR
acceleration with fetal movements which
when present indicates a healthy fetus.
Indication

Maternal:
 Diabetes
 Maternal HTN, PIH
 Maternal collagen or vascular diseases
 Drug use
 Poor uterine growth conditions
 Hemoglobinopathic conditions
 Isoimmunization
 Maternal heart disease
 Maternal renal disease
 Previous still birth
 Vaginal bleeding in 2nd & 3rd trimester
 PROM
 Post term pregnancy
 Premature labor indication
 Maternal age over 35 years.
Fetal:
 IUGR
 Multiple gestation
 Oligohydramnios or polyhydramnios
 Assessment of fetus after amniocentesis
 Decreased fetal movement
 Placental perfusion or function problems
 procedure

NST consist of the following tests:

 1.The women is asked to empty her bladder
bcoz confinement to bed or chair for at least 1
hr is probable. Fasting is not necessary, as
hypoglycemia may adversely affect the fetal
activity
 2. Semi fowler’s position with a lateral tilt or
left lateral position to ensure adequate
uterine blood flow
 3. Vitals obtained & reassure regularly
 4. The tocodynamometer is placed over the
fundus of the uterus. The ultrasound
transducer is positioned over the point of
maximum impulse(PMI).
 5. Women is asked pushes the button
attached to the monitor whenever she feels
the fetus move. The proper tracking is
marked by a dark line at these points.
Reactive non-stress test

The test is consider reactive if over 20 mins

there are 2 FHR acceleration each of at
least 15 beats/mins lasting atleast 15 secs&
occurring simultaneously with fetal
movement.
A reactive NST is consider a good predictor
of fetal well being for 1 wk. women with
multiple risk factors may tested 2 or 3 times
a wk.
Non-Reactive non-stress test
 Absence of 2 acceleration in the 2 observation periods.
 Failure indicates:
1.Lack of fetal movement during the test may indicate
fetal sleep. The nurse should attempt to awake the
fetus by gently manipulation of maternal abdomen.
The test period may be extended for an additional 20
mins or Acoustic stimulation may be added. Healthy
fetus who is not compromised by utero-placental
insufficiency will respond to these measures.
 2. failure
to elicit any FHR
acceleration during the test may
result from maternal drug use or
fetal age less than 32 weeks. failed
acceleration bcoz of immaturity of
CNS.
Acoustic Stimulation Test (AST)

 By means of an artificial larynx sound has been

used to stimulate the fetus who appears to be
sleeping when NST is performed. The sound is
transmitted through the maternal abdomen &
wake up the fetus.
 According to monitor record within 5 mins after
the stimulus fetus will show reactivity of 2 fetal
heart accelerations of at least 15 beats/min,
lasting 15 or more secs. The test may take only 10
mins whereas NST may take 30 to 60 mins.
Contraction stress Test (CST)

The FHR is analyzed in

conjunction with contractions.
Contraction are initiated by IV
infusion of oxytocin. But the
procedure may led to preterm
delivery. So current CST is
achieved by nipple stimulation.
Mammary stimulation test (MST)

 Mother rolls the nipple between her fingers &

thumb until uterine contraction begin, which is
recorded by a uterine monitor.
 3 contractions with a duration of 40 secs or more
is recorded.
 The test is negative (normal) when no FHR
decelerations are present with contractions
 IS positive (abnormal) when 50% or more
contractions causes late deceleration( FHR at the
end of a contraction).
 Cardiotocography

A normal tracing after 32 wks would

show base line heart rate of 110-150
beats/min with an amplitude of base line
variability 5-25bpm. There should be no
deceleration or there may be early
deceleration of very short duration.
 Importantly there should be 2 or more
acceleration during a 20 mins period
 Ultrasound

 With ultrasound intermittent sound waves of

high frequency are projected towards the
uterus by a transducer placed on the
abdomen. The sound frequencies that
bounce back can be displayed on an screen of
various thickness & properties present
distinct appearance.
Ultrasound done for:

 Diagnose pregnancy as early as 6 wks of

gestation.
 Confirm the presence, size & location of the
placenta & amniotic fluid.
 Establishes that the fetus is increasing in size &
has no gross defect.
 Establishes the presentation & position of the
fetus.
 Predict maturity by measurement of Biparietal
diameter (BPD).
 Biparietal diameter

 In 90% of pregnancies, when the Biparietal

diameter of the fetal head is 8.5 cm or more
the infant will weight more than 250 gm.
 A Biparietal diameter of 9.5 cm indicates a
fetus of 40 wks.
 3 other measurements commonly made by
sonogram are HC, AC & FL.
Doppler umbilicus velocimetry

 Measures RBCs in the uterine & fetal vessels

are traveling.
 It determine vascular resistance present in
women with diabetes or HTN of pregnancy &
the resultant placental insufficiency .
 Decrease velocity is an important predictor of
poor neonatal outcome.
 Placental grading

 Based on changes, particularly the amount of

calcium deposits present in the base of the
placenta, placenta can be graded by ultrasound as
 0 ( a placenta 12 to 24 wks)
 1 ( 30 to 32 wks)
 2 ( 36 wks)
 3 ( 38wks) , bcoz fetal lungs to be mature at 38
wks, a grade 3 placenta suggests that fetus is
mature
Amniotic fluid volume assessment

 The portion of fluidformed by fetal kidney

output. Fetus stressed in utero indicate
circulatory & kidney function are failed, so
volume of amniotic fluid also depressed.
 4 quadrant values added to produce amniotic
fluid index ( AFI).
 20 wks, 15 cm, more than 20 to 24 cm poly
hydramnios & less than 5 to 6 cm is
oligohydramnios.
 Biochemical

 MSAFP
 MSAFP + HCG + UE3( CONJUGATED
ESTRIOL)
 Acetyl choline esterase (AchE)
 Estriol & HPL
 CVS
 Cordocentesis( Percutenious umbilical blood
sampling)
 Amniocentesis
 Lecithin/ Sphingomyelin ratio
 Phosphatidyl glycerol
 Bilirubin determination
 Chromosomal analysis
 Inborn errors of metabolism
 Alpha feto protein
Maternal Serum Alpha Fetoprotein

 It produced by the fetal yolk sac & liver,

enters the maternal circulation through the
placenta & the amniotic fluid through fetal
urine.
 Normally AFP is detectable in maternal
serum at about 7 wks of gestation & rises
steadily to pick in the 3rd trimester.
 All women should have serum testing
performed at 16 to 18 wks.
 Elevated AFP indicate:

 Open neural tube defect

 Fetal distress & death
 Multiple gestation
 Maternal DM
 Rh isoimmunization
 Abdominal wall defect
 Renal anomalies
 Wrong gestational age
Decreased AFP indicate:

 Down syndrome
 Maternal HTN states
Tripple test

 It is a combined biochemical test which

includes MSAFP, HCG & UE3
( unconjugated oestriol)
 It is used for detection of down
syndrome
 In affected pregnancy level of MSAFP &
UE3 tend to be low while HCG is high.
Acetyle choline esterase ( AchE)

Amniotic fluid AchE level is

elevated in most cases of
open neural tube defect. It has
got better diagnostic value
than AFP.
Estriol & HpL

Matenal estriol measurement

indicates fetoplacental function. It
rises during normal pregnancy.
HpL is a product of placenta,
increasing level during pregnancy,
corelate with increasing fetal
weight.
Chorionic villus sampling (CVS)

 Perform to diagnose genetic disorders. It is

carried out transcervically between 10 to 12
wks & trans abdominally from 10 wks to
terms.
 A few villi are collected from the chorionic
frondosum under ultrasonic guidance with
the help of long malleable plastic catheter
introduced transcervically along the extra
ovular space.
 The cells removed by CVS are submitted to DNA
analysis to detect any genetic disorder. Bcoz
chorionic villi cells are rapidly dividing, results
are available quickly.
 Chromosomal diseases are :
 1)Down syndrome
 2) Trisomy 18 & Trisomy 13
 3) Turner syndrome (XO)
 4) Klinefelter’s Syndrome ( XXY)
 5) cri- du- chat syndrome (Detection of short
arm of chomosome)
Cordocentasis ( percutenious umbilical
blood sampling)
 It has currently replaced fetoscopy. A 25 gauze
spinal needle of 13 cm in length inserted to the
maternal abdominal & uterine wall under real
time ultrasound guidance. The needle tip is
progressed carefully & it punctures the
umbilical vein appropriately 1-2 cm from the
placental insertion. Generally 0.5- 2ml of fetal
blood is collected. It performed under local
anesthesia usually after 18 wks of gestation.
CVS detect:

Fetal anemia
Bleeding disorder

Blood may be transfused using the

same technique
The fetus is monitored by NST
after the test
 AMNIOCENTESIS

 Is aspiration of amniotic fluid from the

pregnant uterus for examination. It is an
invasive procedure & is performed only when
the necessary information can not be
obtained by other non-invasive procedure
like ultrasound scanning.
 It is performed between 14-16 wks under
continuous ultrasonographic guidance.
 Procedure

 A 18 to 20 gauze spinal needle about 4’’ in length

is introduced. Do not suggest that she take a
deep breath & hold it bcoz it lowers the
diaphragm against the uterus & shifts
intrauterine contents. After needle insertion into
amniotic cavity over a pool of amniotic fluid,
carefully avoiding the fetus & placenta a syringe
is attached & a chosen amount of amniotic fluid
is withdrawn. The needle is than removed.
 Aftercare

 The women rest quietly at about 30 mins.

 During the procedure & 30 mins afterward,
assess the fetal heart rate monitor & uterine
contraction monitor to be certain the FHR
remains normal & no uterine contractions are
occurring.
 If the women has Rh-negative blood, anti D
immunoglobulin may be administered after the
procedure to prevent fetal issoimmunization.
Informations by amniocentesis

Colour:
 1) In late pregnancy slightly yellow. A strong
yellow colour suggest a blood incompatibility
(the yellow results from the presence of
bilirubin released with the haemolysis of red
blood cells)
 2) A green colour suggests meconium
staining, a phenomenon associated with fetal
distress.
Hazards of amniocentesis

Maternal:
 Infection
 Haemorrhage
 PROM
 Premature labor
 Maternal issoimmunization in RH-negative
cases
Fetal:
 Abortion
 Trauma
 Feto-maternal haemorrhage
 Fetal respiratory distress
Lecithin / sphingomyelin ratio

 These are the protein components in the lung

enzyme surfactant that the alveoli begin to
form about the 22nd to 24th wks of pregnancy.
 A ratio of L to S of 2 to1 traditionally
accepted a slung maturity.
 Infant of mothers with severe diabetes may
have false mature readings of lecithin of
stress to infant.
Phosphatidyl glycerol & desaturated
Phosphatidyl choline
 These are the compound in addition to L & S
found in surfactant. Pathway for these
compounds mature at 35 to 36 wks. When
they are present in the sample of amniotic
fluid obtained by amniocentesis, it can be
predicted that respiratory distress syndrome
will not occur.
Bilirubin determination

The presence of
Bilirubin may be
analyzed if a blood
compatibility is
suspected
Chromosomal analysis

A few fetal skin cells are always

present in amniotic fluid. These cells
may be cultured & stained for
karyotyping. The chromosomal
disease that can be detected by
prenatal amniocentesis.
Inborn error of metabolism

If enzyme defect

present in
amniocentesis indicate
metabolic error.
Alpha-feto protein

 Increse level of AFP indicate

anencephaly, omphocele,
myelomeningocele present may present
in the fetus
 Decreased level indicate chromosomal
defect such as down syndrome
Amnioscopy

 Transvaginal Amnioscopy to identify

meconium staining of amniotic fluid, value of
late pregnancy complicated by maternal
HTN, prolong pregnancy, suspected IUGR or
previous unexpected still birth
 Risk is membrane rupture.
Fetoscopy

Visualization of fetus by
inspection through a fetoscope,
an extremely narrow , hollow
tube inserted by amniocentesis
technique to assess fetal
wellbeing.
Biophysical profile

 Fetal breathing
 Fetal movement
 Fetal tone
 Amniotic fluid volume
 Placental grade
 Fetal heart reactivity
Assessment Instrument used Criteria for a score( each point carries
marks)

Fetal Sonogram At least 1 episode of 30 sec of sustained fetal

breathing breathing movements within 30 min of obser

Fetal Sonogram At least 3 separate episodes of fetal limb or tr

movement movement within a 30 min observation

Fetal tone Sonogram The fetus must extend & then flex the extrem
or spine at least once in 30 min

Amniotic fluid Sonogram A pocket of amniotic fluid measuring more th

volume cm in vertical diameter must be present

Placental Sonogram Placenta grade 3. grading is based on structu

grade amount of calcium present

Fetal heart NST 2 or more FHR acceleration of at least 15 b/m

reactivity baseline & 15 secs duration occur with fetal
movement over 20 mins.
The fetus score on a complete
profile of 8 to12 is normal range.
The fetus considered to be do
well. A score of 4 to 6 denotes a
fetus abnormality.
Nurses responsibility

Assessment:
 Manage NST &CST preparation & testing &
may assist the physician with several other
tests.
 In some setting, USG & BPS may managed by
nurses.
 The nurse must recognize reassuring borderline
results & report accurately to the physician.
Nursing diagnosis:
 High risk for ineffective coping related to
adverse findings
 Fear related to fetal health or illness
 Anxiety related to fear of unknown &
discomfort as a result of the procedure
 Risk for fetal injury related to hypoxia or
specific invasive procedure
Expected outcome:
Client will demonstrate
understanding of purpose &
procedure of relevant assessment
technique.
Thank you