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Antepartum Surveillance 6.

Contraction stress test
- Should be done in labor delivery unit
Techniques - Give oxytoxics to induce uterine contraction via IV
Obstetrics II fluids
Dr. de Castro - Do not do in a preterm pregnancy (below 26 weeks)
December 17, 2007 → might induce labor and eventual delivery
80% of perinatal morbidity and mortality lies in
Intrapartum prematurity
- During labor - Not contraindicated for gestational diabetes mellitus
- Assess for - Contraction at least 90mmHg → stress to the fetus
1. Fetal heart tone 60-80 → strong contractions
2. Character of amniotic fluid 40-60 → moderate contractions
- Assessed after rupture of bag of water 30-40 → mild contractions
- Clear: indicates fetal health < 30 → hypotonic
- Stained: evidence of fetal hypoxia 80-100 → tetanic contractions
3. Electronic fetal monitoring trace - Contractions induce hypoxia in baby → stress
- Will appreciate two things: - A fetal heart rate deceleration is a POSITIVE
- Fetal heart rate STRESS TEST → not good
- Fetal heart tone - What we want is a NEGATIVE STRESS TEST
- Note for decelerations Unlike NST where what we want is a REACTIVE test
- Late decelerations not a NON-REACTIVE test
- Variable decelerations
- Early decelerations Goal of Fetal Testing 
Tocodynamometer → measures force of uterine contraction - Detection of chronic & intermediate-term compromise to:
- Prevent stillbirth
Antepartum - Decrease neonatal mortality
- Before labor pain sets in (mother not in labor) - Minimize long-term morbidity
- Baby is still in utero Chronic compromise e.g. IUGR
- If something wrong is suspected
1. Biometry No technique devised so far to detect
- Measurement of the fetal age - Acute antenatal compromise
- Parameters are: - Chance events e.g. placental abruption or cord accident
- Biparietal diameter (BPD) - In twin pregnancy with only one gestational sac →
- Femur length compromise → cord entanglement
- Abdominal circumference - US cannot detect abruption placenta efficiently →
- Useful for mothers with irregular menstruation since waterloo of US; can only detect placenta previa
LMP will not be reliable - Unmonitored onset of labor
- Can give prediction when labor is due
2. Fetal movement counting Ideal Monitoring System
- Very practical - Gather wide range of information
- Monitor fetal movement in a 24 hour basis - Versatile for all maternal & fetal conditions
- To assess fetal behaviour - Flexible for all gestational ages
- 80% of fetal movement occurs during 11am to 6pm - Allows for varying degrees of onset, duration & severity of
3. Non-stress test intrauterine challenges
- Uses electronic fetal monitor Notes:
- 1 sensor to detect fetal movement ( or fetal kick) Biometry can be done at any age of gestation however biophysical
- 1 sensor for fetal heart rate profile can only be done >28 weeks of pregnancy because if there is
- No stress induced at all, you depend on fetal kick → complication due to test and baby is <28 weeks, baby will not survive
a good response is acceleration of fetal heart rate of due to lack of viability which is mainly due to respiratory distress
+15 beats per minute/kick from the baseline fetal syndrome → lack of lung surfactant
heart rate → 3 accelerations/ 10 minutes
- Can be done in doctors office Pitfalls of Fetal Monitoring
- A good response is labelled as: REACTIVE - Single parameter monitoring causes iatrogenic injury & demise
- No response: NON-REACTIVE → however does not from prematurity
mean that fetus is in definite distress or hypoxia → - Ensuring fetal safety while biding for maturation time is more
80% is still doing well demanding than simple delivery
How to differentiate the 20% → do contraction stress
test Lesson
Can also use vibroacoustic stimulator (VAS) placed - Only through a broad combination of variables can fetal status,
on the maternal abdomen where the perceived fetal ear normal or abnormal, be depicted accurately
should be to awaken fetus and evoke fetal movement
→ gives off vibration and sound Modalities
4. Biophysical profile - Ultrasonography
- 5 criteria - Biometry
- Amniotic fluid volume quantification - Anatomic survey → congenital scanning (optimum time:
- Fetal heart rate reactivity 18-22 weeks)
- Fetal breathing movement - Biophysical score
- Fetal movement - Doppler velocimetry
- Fetal tone → least important - Electronic fetal monitoring or CTG (cardiotocograph)
Each is given 2 points - Non stress test
Perfect score is then 10/10 - Contraction stress test
Acceptable is 8/10 – 10/10 - Examination of body fluids (invasive)
If 6/10 → equivocal (nonconlusive) → extend - Amniocentesis → sample of about 30cc
the test from 10 minutes to even about 30 minutes - Genetic amniocentesis → detect chromosomal
5. Fetal umbilical velocimetry aberration; 15-18 weeks; processing takes two weeks
- Measures amount of RBC that passes through and abortion is only allowed until 20 weeks
- Gives contraction rate: systole and diastole rate internationally (But not in UST!)
- Can also be done to determine lung maturity
- Done >28 weeks

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Term fetus: Preparation should be made for delivery . blood is shunted to priority areas: heart.Oligohydramnios requires further evaluation regardless of patient should contact their physician composite score .Single vertical pocket of amniotic fluid > 2 cm .What management decision/s must I make? .Presence of a vigorous fetus is reassuring .What information do I need? . malformations or stillbirth .Technique hands .6: Equivocal .Evidence lacking that it can be an independent test for of pregnancy predicting IUGR.Using CTG of EFM. fetal tone circumference.Assumption: Compromised fetus reduces its activity in brain.Abnormal: Nonreactive NST or AFI 5 cm or less .Absent or reversed end-diastolic flow reflects extreme placental .Reactive: At least 2 accelerations of at least 15 bpm for at .Is there adequate growth? .Graph for particular fetus that even brain is not spared . absent or insufficient) for a .Every time the mother feels fetal movement.Parameters demonstrable if respective brain center Fetal weight is estimated using abdominal circumference intact.Commonly associated with fetal sleep cycle Fetal Umbilical Artery Doppler Velocimetry .May result from any cause of CNS depression including . since the risk of fetal death is similar to the .e.Each fetus has its own degree of activity.Amniotic fluid volume .Procedure .Pregnant woman records length of time that fetus takes to . well-oxygenated Fetal dating: biparietal diameter. or opening or closing of . . limp .Differentiate from contraction stress test.Lung maturity is at >34 weeks when lung . the mother neonatal mortality rate resulting from prematurity.Which test will give this information? with return to flexion.In hypoxia.Physician must be able to check that the mother is able to .Interpretation .AF production reflects fetal urine production during the 2nd half .A screening test function .In hypoxia. response to decreased oxygenation.Test if big or small for fetal age (appropriate age for size) .Amniotic fluid volume Fetal Movement Counting .Continuous extension means a bad prognosis.Measure biparietal diameter.Amniotic fluid index: Sum of deepest cord-free fluid Fetal Biometry pockets .Lamellar bodies 20. i.000/cu.Value most established in pregnancies with IUGR .4 or less: Abnormal (possible hypoxia) kicks or the mother perceives activity that is less from the usual. . which makes a mark in the paper patients.Below 33 weeks.Composite score of: .Heart rate of the fetus that is not acidotic or neurologically depressed will accelerate with fetal movement Abnormal BPS .If parameter is not exhibited.To monitor circulation .“Kicks count” Oligohydramnios .Fetal tone (muscle tone) . autonomic function .What is the problem? limb movements within 30 minutes .Kidney is not a priority area: decreased GFR.AF volume can be used to assess long-term uteroplacental . .Results . there is initially brain-sparing. In these presses a button. fetal breathing movement. total of 10 .Fetus who is remote from term requires conservative not record uterine contractions management. patient in lateral recumbent or supine vascular resistance (ominous) position .Fetal gross body movement: 3 or more discrete body or . hypoxia may be so severe . femur length .Normal: reactive NST and AFI > 5 cm Non-Stress Test .Abnormal pattern of blood flow warrants 20 min to account for sleep period .Interpretation . proceed with surfactants are already formed. Tomultous movement → not good decreased urine formation .Most usually move 10x in < 60 minutes .Principle muscles .mm.Procedure: Each of the components is given a score of 2 make 10 movements (Book: 10 kicks in 40 minutes) (normal or present) or 0 (abnormal. non-stress test does .Vibro acoustic stimulator: Wakes up the fetus with sound . . femur length.Baseline not totally zero during diastole .Record for 20-60 minutes . ratio of 2 lecithin: 1 biophysical profile or contraction stress test sphingomyelin .Umbilical flow velocity waveform of normally growing fetus has fetal acidosis high-diastolic flow .Interpretation .Patients reporting reduced or cessation of movement must be evaluated further Modified Biophysical Profile .Select any period of day to count these. sonographical estimate of fetal weight .Principle . → sign of fetal .Heart rate reactivity is a good indicator of normal fetal .Simplest & least expensive .close surveillance (values beyond cut-off) or intervention (AEDV or ARED) 2 .Normally: < 3:1 ratio least 15 secs within 20 min-period .Evaluation or intervention depending on the circumstances.How does each test work? .Instruction: If fetus requires more than two (2) hours for 10 .During systole: there is more blood in the vessels passing .Placental dysfunction → diminished renal perfusion → . continue recording for another .Loss of Reactivity . adrenals.Cordocentesis (PUBS: percutaneous umbilical blood ultrasonography… sampling) → analyse pH → to detect hypoxia .Non Stress Test plus 4 variables observed by .Non-stress test. abdominal movement.3 or more episodes of extension of a fetal extremity .Nomograms for gestational ages .Clinical scenario .If non-reactive after 20 min. Gross body .Fetal breathing movements: 1 or more episodes of rhythmic fetal breathing movements of 30 seconds or Application more within 30 minutes .If non-reactive after 40 min of testing.Components lung development . .FHT range within normal 120-160 bpm under the Doppler (Upstroke) . daily testing often is performed .8 or 10: Normal distinguish between uterine contraction & fetal movement . ratio is 1 lecithin to 1 sphingomyelin Biophysical Profile . .

Post-term pregnancy .Fetal growth restriction . .Abnormal umbilical cord blood flow patterns occur first. non-intervention great.ARED: Absent reversed end diastolic (Resistance is . . AEDV.Oligohydramnios Timing .Likelihood of successful induction is high .Vaginal delivery is contraindicated for obstetric How Frequent? .AEDV: absent end diastolic volume Proven Intrauterine Growth Restriction .Decreased fetal movement .If with oxytocin stimulation.Heart rate pattern compared with contraction pattern .Varies according to the clinical variables in each patients .Deterioration of the fetal condition Notes from: Charlene Santos .Oxytocin . .MCA Doppler (If baseline diastole.When NST is nonreactive .General fetal movements & tone are the last parameters to Cecile Ong Chok Porciuncula demonstrate abnormal results Mitzel Mata Section C 2009! Regina Luz Contraction Stress Test .Followed by loss of breathing movements Emy Onishi Lala Nieto .BPS weekly: AFI 5 cm at 34 3 . oligohydramnios.Twice-weekly testing is the standard for pregnancies beyond 42 weeks & for patients with insulin-dependent diabetes Post-term Pregnancy .Functional signs abnormal (BPS < 4.Increases in direct proportion to the severity of the maternal or fetal condition .Testing usually begins when diagnosis is established (3rd trimester) . the purpose of the BPP is to avoid the maternal morbidity resulting from failed induction followed by cesarean delivery Pregnancy induced Hypertension .Prolonged rupture of membrane .FHR variation is reduced Fred Monteverde Mae Olivarez .Antepartum testing using the biophysical profile or other method should not be performed earlier than the gestational age at which extrauterine survival or active intervention for fetal compromise is possible . diastolic flow is poor) until fetal maturity ot favorable condition for delivery .No indications exist for testing in a fetus at term when .Umbilical artery: More commonly examined .Attempt to mimic labor by inducing uterine contractions by . there is compensatory state) ARED) → Deliver & Ductus venosus: used as back up or to stretch out the time for premature fetus Transcribed by: Fred Monteverde .Placenta previa . which stimulate release of oxytocin .Functional signs normal → Serial assessment. testing plans start with weekly testing .Nipple stimulation.32-34 weeks (If mother is diabetic or with chronic hypertension: 28 weeks) When not to do? .Maternal disease .For patients with a low probability of successful induction.Used if .In these patients. there are more decelerations with increased contraction: means that the fetus is easily compromised Indications for Testing . the BPP is a useful tool that can be used while waiting for cervical ripening.Contraindicated when labor is contraindicated .Previous classical CS: Scars are prone to ruptire . Lecture recorded by: Lala Nieto subsequently .Other tests results are suspicious .Doppler velocimetry: Increased S/D & RI at 28 weeks .Presence of late decelerations suggests placental insufficiency .in most high-risk pregnancies.