B.

Sc DEGREE COURSE IN
NURSING (BASIC)
Midwifery and Obstetrical Nursing

Unit: VII- High-risk pregnancy

ASSESSMENT OF FETAL WELLBEING

DR.LATHA VENKATESAN,
PRINCIPAL
 Overview
• Introduction
• Purpose
• Biochemical Assessment
• Non Invasive Procedures
• Invasive Procedures
• Bio Physical Assessment
• Biophysical Profile
• CTG
• USG
• NST
 INDIA’s WORLD RECORD

• UNICEF reported that India celebrated the birth of more than

67,000 children on New Year's eve, with China being a distant
second at 46,000.
• The government has made its goal to test pregnant women for Hb
levels at least 4 times during the pregnancy. As of Dec 2019, we are
already covering 92% of the registered pregnant women for Hb
testing.

• Economic Times Health World (February 25, 2020)

 PIH & GDM

• Pregnancy induced Hypertension treated at medical institutions has

increased from 49% to 59% during Jan 2018 and Dec 2019.

• Whereas Just 16% of our pregnant mothers were Diagnosed to

have GDM as of Dec 2019. While the incidence of GDM is
relatively low but can cause severe adverse effects such as
preterm deliveries, respiratory distress and hypoglycemia in the
new-born.
 INTRODUCTION

• Approximately 3 % of live born infants have a major birth

defect.

• Majority (80%) of foetal deaths occur in antenatal Period

• Foetal well being depends on satisfactory maternal health

throughout pregnancy. After a thorough clinical examination of
the mother, the investigations are initiated.
 Aims of Antenatal foetal monitoring:

To ensure To screen
satisfactor out the
y growth high risk
and well factors
being of that affect
the fetus the growth
throughout of the
pregnancy. fetus.
 PURPOSES

Decide
Triage
Prevent the time
mothers
Maternal and
to High Screen the fetus for
Complica mode of
Risk &
tions safe
Low Risk
delivery

Chromos Growth
Structura
omal abnormal
l Defects
errors ities
INVESTIGATIONS IN EACH
TRIMESTER
 FIRST TRIMESTER SCREENING
RECOMMENDED PREFERABLE
Height, Weight, BP, Hb BMI
Blood Group & Rh for both partners CBC

Midstream Urine Urine Culture

VDRL, HIV, HbSAg Rubella IgG
Thyroid Stimulating Hormone Thyroid function test
DIPSI –OGCT HbA1C, GTT
(Diabetes in pregnancy study Group
India)
Dating Scan+ Nuchal Translucency + Uterine Artery Doppler +
Dual Marker+ Cervical Length Placental Growth Factor
 SECOND TRIMESTER SCREENING

RECOMMENDED PREFERABLE
Repeat Blood Investigations
Hb, Blood Sugar, TSH
Quadruple or Triple Marker Non Invasive Pregnancy test

Anomaly scan 3D/ 4D Scan/ Fetal Echo,

Uterine artery Doppler
Cervical Length

DIPSI Screen – 75gm glucose- GTT, HbA1C

2hr blood sugar
 THIRD TRIMESTER SCREENING

RECOMMENDED PREFERABLE

Repeat Blood Investigations

Hb, Blood Sugar, TSH
DIPSI Screen – 75gm HbA1C,GTT
glucose- 2hr blood sugar
Growth Scan with Liquor Foetal Doppler Velocimetry
Volume and Placental
Location

F0etal Movement Count (6 in CTG, Modified Biophysical

2 hours) Profile,
Types of Antenatal Assessment

Biochemical

Biophysical
BIOCHEMICAL ASSESSMENT
Maternal Serum Alpha fetoprotein

• AFP is a oncofetal protein.

• It is produced by yolk sac and fetal liver.

• Highest level of AFP in fetal serum and amniotic fluid is

reached around 13 weeks and thereafter it decreases.

• Maternal serum level reaches a peak around 32 weeks.

 Maternal Serum Alpha fetoprotein

Elevated Levels in • Low levels are

1. Wrong gestational age found in
2. Open neural tube defects • trisomies (Down’s
(NTDs) syndrome) and
gestational
3. Multiple pregnancy
trophoblastic
4. IUFD disease
5. Anterior abdominal wall
defects
6. Renal anomalies
 Beta-hCG

• Human chorionic gonadotrophin (hCG) is released from

placental trophoblasts and is involved in establishing pregnancy
by maintaining progesterone secretion from the corpus
luteum. ...

• In Down's syndrome (DS) pregnancies, serum hCG remains

significantly high compared to gestation age
 PAPP-A & Estriol

• PAPP-A: Pregnancy Associated Plasma Protein–A (PAPP-A ) is

secreted by placenta and levels elevate with gestational age.
• Low PAPPA may be commonly seen in prenatal screening for
Down syndrome.

• Estriol is a hormone produced by the placenta, using ingredients

made by the fetal liver and adrenal gland.
• Estriol is decreased in the Down syndrome
 TRIPLE TEST

• It is a combined biochemical test which includes MSAFP, HCG

and UE3(unconjugated oestriol).

• It is used for detection of Down’s syndrome.

• In an affected pregnancy level of MSAFP and UE3 tend to be

low while that of hCG is high.

• It is performed at 15-18 weeks.

BIOCHEMICAL- NON INVASIVE
 AChE & Inhibin A

• Acetylcholine esterase : (AChE) Amniotic fluid Ache level is

elevated in most cases of open neural tube defects. It has got
better diagnostic value than AFP.

• Inhibin A is a dimeric glycoprotein. It is produced by the corpus

luteum and the placenta. Serum level of inhibin A is raised in
women carrying a fetus with Down syndrome.
 QUADRUPLE TEST

MSAFP

Beta HCG
Estriol

Inhibin- A
 BIOCHEMICAL-INVASIVE

Chorionic
villous Cordocentesi
Amniocentesis
sampling s
(CVS)
 AMNIOCENTESIS

• Aspiration of amniotic fluid from the pregnant uterus for

examination.

• Time-between the 14th and 16th weeks of pregnancy.

• An ultrasound is done to determine the position of the

fetus and the location of a pocket of amniotic fluid and the
placenta.
AMNIOCENTESIS
 PARAMETERS TESTED IN AMNIOCENTESIS

Alpha-fetoprotein

Bilirubin Determination

Chromosomal Anamoly

Colour of Amniotic fluid

Inborn errors of metabolism

L/S Ratio after 24 weeks

 COMPLICATIONS

• Miscarriage is common

• Infection

• Leaking of amniotic fluid

 CHORIONIC VILLUS SAMPLING

• CVS is performed for prenatal diagnosis of genetic disorders.

• It is carried out transcervically between 10-12 weeks and

transabdominally from 10 weeks to term.

• A few villi are collected from the chorion frondosum under

ultrasonic guidance.
 INDICATIONS

• Possible reasons for having a CVS can include:

• Maternal age of 35 years or greater

• Abnormal first trimester screen results

• Increased nuchal translucency or other abnormal ultrasound findings

• Family history of a chromosomal abnormality or other genetic

disorder

• Parents are known carriers for a genetic disorder

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 COMPLICATIONS

• While it provides earlier diagnosis than amniotic fluid studies,

• complications like
• fetal loss(1-2%),
• Oligohydramnios
• Infections
• oromandibular limb deformities or
• vaginal bleeding are higher.
PER CUTANEOUS UMBILICAL CORD SAMPLING

33
FETAL BLOOD SAMPLING (CORDOCENTESIS)

• This technique is used to take a sample of fetal blood during

pregnancy in order to screen for chromosomal abnormalities,
hemoglobinopathies and other disorders affecting blood or cells.

• It is performed under local anaesthestic usually after 18 weeks

gestation.
Fetal blood sampling cont…

• All the information obtained in chorion villus sampling,

could be gathered.

• Hematological- for fetal anaemia, bleeding disorders

(autoimmine thrombocytopenia), rhesus disease.

• Fetal infections- toxoplasmosis, viral infections • Fetal

blood gas and acid base status- in fetal growth restricition

• Fetal therapy- blood transfusion

 COMPLICATIONS

• Abortion,

• preterm labour and

• intrauterine fetal death.

• These may be due to bleeding,

• cord haematoma formation,

• infection or preterm rupture of membranes.

 SCREENING FOR GDM

•HbA1C

•DIPSI one step screen 75 gms 2 hour

•Cut off of 140 mg/dl

•At 24 to 28 weeks

•Repeat at 32 weeks in high risk women i.e Polyhydramnios /

previous GDM / Parents & siblings diabetic
 SCREENING FOR PIH
•Blood Pressure

• Glycosylated Fibronectin

•Water Retention – edema / rapid weight gain

• Micro albuminuria

•Spot test – Urine Protein /Creatinine ratio

• Ratio of PlGF / sFlt

• LDH raised in HELLP Syndrome

• Renal artery doppler

BIOPHYSICAL ASSESSMENT
 BIO PHYSICAL TEST
Fetal
movement
count
NST
CTG

Vibroacoustic
stimulation
USG test

CST BPP
 FETAL MOVEMENT COUNT

• 10 movements in 12
hours
Cardiff count 10

• Three counts each of

one hour duration
DFMC
 FETAL MOVEMENT COUNT

• The count should be performed daily starting at 28 weeks of

pregnancy.

• Loss of fetal movements is commonly followed by

disappearance of FHR within next 24 hours.

• In either of the above methods, if the results is ominous, the

candidate is subjected to NST.
NON – STRESS TEST
 DEFINITION

NST consists of detecting the fetal heart rate,

fetal movement and uterine activity externally

 PURPOSE:

 to assess the fetal wellbeing

 to measure the heart rate in response to its own movements

CONCEPT OF NST:

Oxygen is required for fetal activity and heart

rate to be with in normal ranges.

TIME TO PERFORM NST:

1. after 28 weeks of gestation.

2. between 38-42 weeks.
3. as early as beginning of third trimester.
 INDICATIONS

• Post dated mothers

• GDM

• IUGR
• Placental and cord abnormalities

• Absence of fetal movements

• As a precaution
 INTERPRETATION

• Atleast 2 fetal movements in 20 min

REACTIVE with acceleration of FHR reacting a
peak of atleast 15 Bpm

NON- • No fetal movements or no acceleration

of heart rate
REACTIVE

• fewer fetal movements or acceleration

UNCERTAIN less than 15 Bpm
 NST Cont

ADVANTAGES: DISADVANTAGES:
 Non invasive.  False positive results during
 Painless.
fetal sleep.
 Lack of risk to mother and
fetus.  40 min gives most sleeping
 immediate results
fetus time to awaken.

Awaiting acceleration
prolong NST
ULTRASOUND
 USG

I trimester II trimester III Trimester

• Dating Scan • Viability of the • Estimated Fetal
• Location of fetus Weight
Gestational Sac • Pregnancy dating • Liquor- AFI
• Nuchal • Detection of • Presentation
Transulency multiple pregnancy
• FHR • Detection of
congenital
anomalies
Ultrasound screening for chromosomal abnormality

• Nuchal translucency(N.T)
• Skin fold thickness behind the fetal cervical spine

• Timing: 11-13 +6days weeks of pregnancy

• 75-80% of trisomy 21

• 5-10% normal karyotype ( but could be associated with cardiac

defects, diaphragmatic hernia, Exomphalos)
Nuchal translucency
BIOPHYSICAL PROFILE
 FOETAL BPP

Foetal Gross Foetal

Amniotic
NST breathing body muscle
fluid index
movement movement tone
 Fetal Biophysical profile
Abnormal (score= 0) Normal (score=2) Biophysical
Variable
Absent FBM or no episode >30 s episode FBM of at least 30 s duration in 1 Fetal breathing
in 30 min 30 min movements

or fewer body/limb movements 2 discrete body/limb movements in 30 min 3 Fetal movements

in 30 min

Either slow extension with return episode of active extension with return to 1 Fetal tone
to partial flexion or movement of flexion of fetal limb(s) or trunk. Opening
limb in full extension Absent fetal and closing of the hand considered normal
movement tone

Either no AF pockets or a pocket of AF that measures at least 2 cm 1 Amniotic fluid volume

pocket<2 cm in 2 perpendicular in 2 perpendicular planes
planes
Management Interpretation Test Score Result
of 10 10
Intervention for obstetric and maternal Risk of fetal asphyxia
of 10 (normal fluid) 8
factors extremely rare
of 8 (NST not done) 8
Determine that there is functioning renal
tissue and intact membranes. If so,
delivery of the term fetus is indicated. In Probable chronic fetal of 10 (abnormal 8
the preterm fetus less than 34 weeks, compromise fluid)
intensive surveillance may be
.preferred to maximize fetal maturity
Equivocal test,
Repeat test within 24 hr possible of 10 (normal fluid) 6
fetal asphyxia
Delivery of the term fetus. In the preterm
fetus less than 34 weeks, intensive Probable fetal of 10 (abnormal 6
surveillance may be preferred to maximize asphyxia fluid)
fetal maturity
High probability of fetal
Deliver for fetal indications of 10 4
asphyxia
Fetal asphyxia almost
Deliver for fetal indications of 10 2
certain
Deliver for fetal indications Fetal asphyxia certain of 10 0
 MODIFIED BPP

NST AFI
 MODIFIED BIOPHYSICAL PROFILE (BPP)

• A standard NST is combined with an amniotic fluid index

(AFI)
• Negative: Reactive NST / AFI > 5.0 cm
• If NST is nonreactive or has decelerations, or if the AFI is <
5.0 cm, then a BPP is performed.
• Negative results are repeated every 3 to 4 days.
• If the AFI > 5.0 cm, a repeat AFI may be done in one week.
CONTRACTION STRESS TEST
Introduction

CST is done to see whether fetus remains

healthy during reduced oxygen levels (contraction).

 DEFINITION:

CST or oxytocin challenge test evaluates FHR in the

presence of spontaneous or oxytocin-induced Contractions.

 PURPOSES:

• to assess fetal placental functioning.

• fetus ability to cope up with continuation of high

risk pregnancy and stress of labor

 INDICATIONS:

a) In abnormal biophysical profile.

b) Gives better picture of your baby than NST

c) Contractions , fetal breathing movements, fetal muscle

tone, and AFI can be checked.
 False
positive
results

RISKS

Labor
Prolonged
starts contraction
before s
EDD
 STEPS RATIONALE

1. Take client to prenatal Ensures that qualified

testing unit. personnel conducts test.
2. Explain the client the
procedure. Gain co-operation.
3. Position the client in
semi-fowlers position.
4. place client on an Eliminates supine
external monitor. An USG hypotension.
to record FHR and CTG
for contractions
 STEPS RATIONALE

5. Record client BP initially To determine supine

and at 5-10 min intervals. hypotension.

6. Obtain atleast 10 min base

line recording (FHR AND To test fetal well being.
contractions)

7. Prepare and begin oxytocin Can discontinue the infusion in

infusion. hyperstimulation.
a)start oxytocin infusion.
b)client is evaluated by To test adequate uterine
physician when dose is 10 contractions and FHR
mu/mt
 INTERPRETATIONS
• No late deceleration with adequate
NEGATIVE contractions

• late deceleration with adequate contractions

Positive
• No positive or negative window occurs
Equivocal
• Excessive uterine activity is present in
Hyper stimulation association with deceleration of FHR.

• Inadequate FHR record or contractions. Test

Unsatisfactory • should be repeated with in 24 hours
 CST contd

DISADVANTAGES:
ADVANTAGES:
 Follow up of non reactive  Contra-indicated in placenta
NST.
praevia,LSCS,PROM.
 More informative.
 Utero placental perfusion
reduced due to
hyperstimulation.
 Time consuming.
CARDIOTOCOGRAPHY
 INTRODUCTION

• Cardiotocography (CTG) is a test used in pregnancy to

monitor both the fetal heart pattern as well as the uterine
contractions.

• It should only used in the 3rd trimester when fetal neural

reflexes are present.

• Its purpose is to monitor fetal well-being & allows early

detection of fetal distress antenatal or intra-partum.
INDICATIONS FOR CTG

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 PARTS OF CTG

• It involves the placement of 2 transducers on the

abdomen of a pregnant woman:

• one transducer records the fetal heart rate using

ultrasound beam ,

• the other transducer records uterine contractions

 FHR Ranges

– NormalBaseline FHR 110–160 bpm

– Moderate bradycardia 100–109 bpm
– Moderate tachycardia 161–180 bpm
– Abnormal bradycardia < 100 bpm
– Abnormal tachycardia > 180 bpm

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 BASELINE FETAL HEART RATE

The mean level of the FHR when this is stable, excluding

accelerations and decelerations. It is determined over a time
period of 5 or 10 minutes and expressed in bpm.

76
 BASELINE VARIABILITY

• The minor fluctuations in baseline FHR occuring at three to five

• cycles per minute. It is measured by estimating the difference in

beats per minute between the highest peak and lowest trough
of fluctuation in a one-minute segment of the trace

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BASELINE VARIABILITY

78
ACCELERATIONS

79
 DECELERATIONS

EARLY • Head compression

LATE • Utero-Placental
Insufficiency

VARIABLE • Cord compression

• Primary CNS dysfunction

80
EARLY DECELERATION

81
LATE DECELERATION

82
VARIABLE DECELERATION

83
 TACHYCARDIA
Hypoxia Chorioamnionitis
Maternal fever B-Mimetic drugs
Fetal anaemia,sepsis,ht failure,arrhythmias

84
85
 Categorization of fetal heart rate traces

Category Definition

Normal All four reassuring

Suspicious 1 non-reassuring
Rest reassuring
Pathological 2 or more non-reassuring
1 or more abnormal

86
 SUSPICIOUS CTG

CTG CAUSE CLINICAL MANAGEMENT

PATTERN
EARLY 2nd Stage NONE
LATE Uterine Stop oxytocin
hypercontractily Consider terbutaline sc
Oxygen @ 8-10 l/min
Left lateral decubitus
VARIABLE Cord compression Consider amnioinfusion
(mild/mod v.d.)
TACHYCARDIA Maternal Infection screen
fever,tachycardia,dehy Hydrate - crystalloids
dration Stop tocolysis if pulse>120
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WIRELESS CTG
SUMMARY
 REFERENCE
• Annamma Jacob’s.(2004).A Comprehensive textbook of
Midwifery. Jaypee Brothers and Publishers:New Delhi.

• D. C. Dutta’s.(2004).Textbook of Obstetrics.New Central Book

Agency: Calcutta.

• Emily slone McKinney.(2009).Maternal – Child

Nursing.Saunders Elsevier: Missouri.