______________________________________________ OBSTETRICS 2

2.03B FETAL ASSESSMENT (PART 2)

DR. CANDELARIO - September 25, 2017
MIDTERMS: QUIZ 1
or bold, red letters = Emphasized during lecture
Italic, blue letters = Audio
Green = OT
FETAL CTG
Qualitative and Quantitative Description
1. Baseline FHR
2. Baseline variability (STV/LTV) jaggedness and
wiggleness of trace
3. Periodic/episodic changes
(Accelerations/Decelerations)
4. Changes or trends of FHR patterns over time
5. Frequency and intensity of uterine contractions

PERIODIC/EPISODIC CHANGES

1. Acceleration (fetal movement)

- Increase of 15 beats from the baseline FHR lasting
for 15 seconds or more from the beginning to end b. Late: begins at peak of contraction, poor variability
(decreasing of heart rate for a period of less than 2 mins - Pathologic
cannot be higher than 2 mins, otherwise it will be - Uteroplacental insufficiency
prolonged acceleration, >10mins: there is change in
o True sign of hypoxia
baseline, whether bradycardia or tachycardia)
- Deceleration starts at the acme of contraction
- A sign of good fetal movement

2. Deceleration: with regards to occurrence of uterine

contraction
a. Early: suggestive of head compression
- Consistently coincidental with uterine contraction (peak
nadir or drop of the contraction is coincidental with the
peak/acme contraction)
- Mirror image of the contraction (gradual in appearance
with reference to uterine contractions)
- During descent of fetal head
- Breech presentation
- Most of the time non-pathologic

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c. Variable METHODS TO MONITOR FETAL HEALTH/
- Independent of contractions/based on shape and degree FETAL SURVEILLANCE
- V, U, W shape  Fetal Movements
- Mild moderate or severe  Fetal Breathing
 Non-stress Tests
 Contraction Stress Testing
 Acoustic Stimulation Tests/ VAS (Vibroacoustic stimulation)
 Biophysical Profile
 Amniotic Fluid Volume
 Doppler Velocimetry

We have to remember that in reading a CTG:
Identify baseline FHR, the baseline variability, periodic changes
(whether acceleration or deceleration present then identify if
early/late/variable). Identify any changes in the trends of fetal heart
rate patterns over time. Also check intensity and frequency of
uterine contractions
Ex: Basal FHR report: 130/min, variability is normal,
moderate variability 15 beats difference, 10 accelerations present,
no decelerations
NON-STRESS TEST
 No uterine contraction
 Test of fetal condition to assess fetal well being
 Rationale:
o FETAL HEART REACTIVITY: presence of FHR
accelerations associated with fetal movement
o Indicator: Good Fetal Health
 If you see acceleration, in your mind you know that the
baby is moving. If the baby is moving even in the
presence of stress to the mother which are contractions
during labor, you know that there is enough fetal
reserve. Kahit na squeeze na yung uterine blood flow,
still the baby is moving then the output in the CTG is
acceleration
o Absence / more than 40 mins; some books: >80 mins:
 May suggest fetal distress/fetal hypoxia
 Loss of fetal reactivity may mean hypoxia and
neurologic depression and acidosis
 For fetal surveillance: test to know how is the baby inside the
uterus. Is the baby at risk for hypoxia? Basis: presence of
acceleration. If intact/normal: (+) acceleration; if absent: no
fetal reactivity: means neurologic depression
 Physiology: Intact cortical function where fetal movement is
elicited will result to FHR acceleration
o Fetal movement means intact cortical function: because
movement is developed in the cerebral cortex
 Normally initiated at 32 weeks (for severe cases we can start
even at 26 weeks)
 Interval/Frequency of NST tests
o 7 days
o Biweekly (DM, gestational diabetes, postterm, post dated,
preeclampsia, IUGR)
 National Institute of Child Health and Human Development
Fetal Monitoring Workshop's definition of acceleration
depending on AOG
o >32 weeks (baseline rate 15 beats and duration
of 15 seconds or more)
o <32 weeks (10bpm/10seconds)
 Advantage: done as outpatient

Steps in doing NST

1. Position (semi-recumbent position) - not on supine it will
lead to fetal bradycardia due to compression of the IVC and
aorta
2. History (assess for risks)/PE (auscultate FHT)
3. Doppler Transducer (area of FHT, where heart is auscultated)
4. Tocodynamometer (fundus of uterus)
5. Mother: push event marker (when there is fetal movement)
6. Vital signs every 5 mins
7. Run paper (test would last for 20 mins)

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NST interpretation VIBROACOUSTIC STIMULATION TEST (VAST)
 Reactive: 2 or more accelerations in 20 mins  Decrease time spent in doing NST
o Baby will do well within 1 week  Use of artificial larynx (by Gagnon) applied over abdominal
o Sign of good fetal condition wall over fetal head for 1-3 seconds produce vibratory
sound stimulus of 100-110 db
 Sounds of 100-105 db provoke fetal movement
 Response: fetal startle as seen by a reactive NST or palpable
fetal movement or visible in the ultrasound called “fetal
recoil test”
 Gestational age related
o <24 weeks: no response
 The auditory system is not yet developed/mature
o 23-27 weeks: 30% will respond
o 27-30 weeks: 80% will respond
o >30 weeks: 96% will respond
 Non-reactive: no acceleration/ 1 acceleration
o If non-reactive: Extend test (20 mins)/ Provoke fetal
movement via meal/manipulation of uterus/sound
o Not immediately suggestive of hypoxia (ask last meal of
mother or apply stimulation to awaken the baby and
provoke fetal movement)
o Absence of accelerations - does not mean fetal
compromise (healthy fetus may not move up to 75 mins)
o Nonreactive in 80-120 mins imposes a problem,
increase in neonatal morbidity (do additional tests like
BPP)
This reactive NST also shows a transition from the on reactive state (first half of
tracing) in which there are no movements and low FHR variability. The onset of
normal FHR variability accelerations, and fetal activity (spikes on lower channel)
correspond to VAS. The initial quiet state of the fetus does not signify fetal
compromise

CONTRACTION STRESS TEST (CST)

 A test of uteroplacental function
 Experiment: Uteroplacental blood flow decreases markedly
or ceases during contractions. Thus, this tests if the fetus will
be able to tolerate well the hypoxic stress. If the baby can’t
tolerate the contraction: sign that the baby is not doing well
 CST: Uterine contractions cause hypoxic stress that a normal
 Normal NST: normal baseline FHR, normal variability (6-25 healthy fetus can tolerate without difficulty; while in a
beats), deceleration none or less than 30 sec, more than 2 stressed fetus → positive outcome: decelerations following a
acceleration contraction called late decelerations (which is a sign of
 Atypical: baseline FHR 100-110 in less than 30 mins, variability uteroplacental insufficiency. This is what we look for in
minimal in 40-80mins, deceleration 30-60 sec, and it will not contraction stress test. In contrast to non-stress test: what we
reach two accelerations look for is the acceleration)
 Two ways:
Parameter Normal NST Atypical NST Abnormal NST o Oxytocin challenge test (IV oxytocin 1L of D5LRS + 10
(Previously (Previously (Previously
“Reactive”) “Non-Reactive”) “Non-Reactive”) units oxytocin starts at 0.5-1mU/mins) to achieve 3
Baseline 110-150bpm 100-110 bpm Bradycardia contractions in 10 minutes each lasting for 40 sec or
>160bpm <30min <1100bpm more (unsuccessful if 3 contractions in 10 minutes is not
Rising baseline Tachycardia >160
for >30min reached). Record simultaneous FHR and uterine activity
Erratic baseline o Nipple Stimulation Test (OPD): instruct patient to
Variability 6-25 bpm < (absent or < 5 for > 80min rub one nipple under clothes for 2 mins. Rest for 5mins,
(moderate) minimal) for > 25 bpm >10min then rub again until 3 contractions in 10 mins is
< 5 (absent or 40-80min Sinusoidal
minimal) for achieved
<40 min  Done: as early as 28 weeks
Decelerations None or occasional Variable Variable
variable <30 sec decelerations 30- decelerations >60
60 sec duration sec duration
Late decelerations
Accelerations > 2 accelerations < 2 accelerations < 2 accelerations
with acme of > 15 with acme of > 15 with acme of > 15
bpm lasting 15 sec bpm, lasting 15 bpm lasting 15 sec
<40min testing sec in 40-80 min in > 80min

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Indications Contraindications Three-Tier Fetal Heart Rate Interpretation System
 DM  PROM National Institute of Health Workshops
 Post-maturity  Placenta Previa: may bleed A. Category I trace
 HPN disorder  3rd trimester bleeding  Baseline rate of 110-160bpm
 IUGR  Previous CS: uterine rupture  Baseline FHR variability: Moderate
 Previous stillbirth  Multifetal Pregnancy  Late or Variable decelerations: absent
 Collagen disease  Incompetent Cervix: may dilate  Accelerations: present or absent
Cervix
B. Category II trace
 PolyHydramnios: may lead to
 Accelerations
premature delivery
o Absence of induced accelerations after fetal stimulation
 Periodic/episodic Decelerations
Interpretation of CST o Recurrent variable with minimal-moderate variability
Positive Persistent >50% of contractions has late o Prolonged deceleration >2mins but <10mins
deceleration o Recurrent late with moderate variability
Negative No late decelerations – GOOD o Variable deceleration with slow return to baseline,
Suspicious Inconsistent-intermittent overshoots, “shoulders”
Equivocal- Contraction every 2mins lasting for 90secs  Baseline FHR
Hyperstimulatory or more. Can induce fetal hypoxia o Bradycardia not accompanied by absent variability
(iatrogenic). Stop the test! Not good for the o Tachycardia
baby  Baseline FHR variability
Unsatisfactory No good contractions (no 3 contractions in o Minimal baseline variability
10 mins, stop the test) o Absent variability not accompanied by recurrent
decelerations
A healthy result: Reactive non-stress test and a o Marked baseline variability
negative contraction stress test C. Category III trace
 Absent variability and any of the following:
o Recurrent late decelerations
o Recurrent variable decelerations
o Bradycardia
o Sinusoidal pattern
 Should terminate pregnancy

BIOPHYSICAL PROFILE (BPP)

 Evaluates fetal wellbeing that observes 4 parameters (fetal
breathing movement, fetal movement, fetal tone, AFV) by
ultrasound and 1 parameter by EFM (electronic fetal
monitoring)
 Done whenever in doubt of the CTG result
 Score of 0 or 2 per parameter
A positive CST with three late decelerations following each of three oxytocin-induced
o If the full definition is not achieved, give a score of 0
uterine contractions. The mother noted decreased fetal movement during the o If the full definition is achieved, give a score of 2
preceeding day and had a nonreactive NST. Her prenatal course was normal except
for mild labile hypertension not requiring treatment. She was delivered by cesarean 1. Fetal Breathing Movement (2)
section, and the 2545g normal-appearing newborn had Apgar scores of 3 (1 minute),
6 (5 minutes) and 7 (10 minutes). Umbilical arterial pH was 6.95, carbon dioxide  30 seconds of sustained breathing movement in a
tension was 90mmHg, and base excess was 14mEq. No reason was evident for fetal 30 min period, paradoxical movement of chest wall
academia, but the newborn did well
 Hiccups for breathing are also considered and given a
score of 2
CATEGORIZATION OF FHR FEATURES
Feature Baseline Variability Decelerations Accelerations
2. Fetal Movement (2)
Reassuring 110-160 >/= 5 None Present  3 or > gross body movements in a 30min period
Non- 100-109 <5 Early The absence of observation
reassuring 161-180 (>/=40min deceleration of  Ex: 4 movements in 5 mins, give 2 already; no
) but less Variable movement in 25 mins, wait until 30 mins
accelerations
than deceleration 3. Fetal Tone (2)
90mins Single with an
deceleration otherwise  1 or more episodes of limb motion from flexion to
up to 3mins normal CTG extension and rapid return to flexion (fisting of the
Abnormal <100 <5 for Atypical is of hand, hiccups are also considered, give a score of 2)
>180 >/=90min variable, uncertain 4. Amniotic Fluid Volume (2)
Sinusoida Late  SVP (single volume pocket)= 2x2cm or
l pattern deceleration, significance
 AFI (amniotic fluid index) = 5-20cm
>10mins Single  Polyhydramnios: 25 cm, the score is still 2
prolonged
deceleration
 Only give a score of 0 if oligohydramnios
>3mins 5. Fetal Heart Reactivity (NST) (2)
 Reactive NST (2 accelerations 20-40mins)

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PHYSIOLOGIC CRITERIA OF FETAL BPP Modified (BPP NST/AFV)
(HYPOXIC CASCADE)  Normal (NST/AFV): Repeat weekly
BPP CNS center AOG of development  >36 weeks (Abnormal NST/AFV): Deliver
Tone center Cortex-subcortical area 7.5-8.5 weeks  <36 weeks (individualized test) further testing
Movement Cortex 9 weeks  NST (reactive) but is oligohydramnios: look for cause and
Breathing 4th ventricle 20-21 weeks biweekly testing
FHR Medulla, Posterior 24-26 weeks  AFV (Normal) NST (Nonreactive): do CST or full BPP
reactivity hypothalamus
This is why Non-Stress Test (NST) cannot be performed at less than Amniotic Fluid Volume
26 weeks, because FHR reactivity is still under development  AFI of <5
o Increased CS rate for fetal distress
BPP Cascade o Low 5min APGAR score
 The most recently developed center is the earliest to be  Causes:
affected by hypoxia (Theory of cascade of hypoxia) o Decreased uteroplacental perfusion
o Decreased renal blood flow
 FHR reactivity (as seen in NST) is the first to be affected by
o Decreased urine production
hypoxia, then breathing, movement and tone
o Oligohydramnios - chances of CS is very high
 Tone: Last to be affected (earliest to develop, so it should be o Ex: HTN → vasoconstriction → decreased uteroplacental
more established) perfusion → baby tends to shunt blood to the more
 Chronic Marker of hypoxia : amniotic fluid volume (AFV) important organ (brain and adrenals) → decrease blood
 Acute: movement, FHR reactivity flow to the kidneys → decrease renal blood flow →
 Hindi naman agad mawawala yung fluid unless there is decrease urine prod → Oligohydramnios
ruptured BOW and the only anomaly that can lead to
oligohydramnios is Renal agenesis
 Formation of AF volume is a function of the fetal kidney Fetal breathing is affected by infection. So if there is ruptured BOW
 Decreased uteroplacental perfusion → decreased blood (noted from BPP) → if there is early sign of intra amniotic infection
flow to the kidney → blood is needed more in the brain → → check on the absence fetal breathing
less blood goes to the kidneys → lesser urine formation →
oligohydramnios (occurs within months → chronic) DOPPLER VELOCIMETRY
 Other parameters: Acute Hypoxia  Detects and measures blood flow (Doppler principle)
 It measures the motion or velocity of the RBCs as it passes
Interpretation through the dilated blood vessels
 Total Score: 10/10 if all 5 parameters fulfilled (w/ NST)  Ex: problems in blood flow like vasoconstriction, HTN
 w/o NST total score is: 8/8  3 fetal vascular circuits (fetal health to intervene for IUGR
 If score is 8/8 or 10/10: Reassuring fetuses)
 If score is 6/10: Equivocal (needs close monitoring) 1. Umbilical artery
 If score is <4/10: Non-reassuring (Terminate/ 2. Middle Cerebral Artery
Deliver) 3. Ductus Venosus
 Note: breathing is sometimes affected by meal. If 0: probably  Assess fetus at risk for IUGR and hypoxia or acidosis
the mother did not take her meal so let her eat or drink a glass (called ARED flow)
of juice, then let her come back  Assess risk for preeclampsia (diastolic notch: notching of
uterine arteries)
BPP Interpretation/Management
BPP Interpretation Management
Measurement
10/10 Normal Repeat test weekly (for
8/8 DM/Post term: twice weekly)  S/D ratio (systolic/diastolic ratio)
8/10 Normal AFV Repeat weekly  Pulsatility index
If oligohydramnios Deliver o S-D/mean
6/10 Possible asphyxia, Deliver  Resistance index (Pourcelot’s index)
Abnormal AFV o S-D/S
Normal AFV and term  Normal flow: good uteroplacental perfusion
Oligohydramnios and Deliver o Increased diastolic flow
close to term  S/D ratio normally decreases from
Oligohydramnios and If L:S (lecithin- 4 at 20 weeks to 2 at term, it decreases as AOG advances
preterm sphingomyelin) ratio <2:  S/D ratio is less than 3 after 30 weeks (beyond 3, it
repeat test in 24h becomes abnormal, Normally, ratio should be decreasing)
In 24h, if <6: deliver  Abnormal S/D (above 95th percentile for AOG)
In 24h, if >6: repeat/observe  ISUOG (International Society of Ultrasound in Obstetrics and
4/8 or Probable asphyxia Repeat test same day (repeat Gynecology): free loop of cord
4/10 <4: deliver)  More diastolic flow (placental cord insertion) less at fetal cord
0 or 2 Fetal asphyxia Deliver insertion

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Maternal Uterine Artery
 Predicts placental dysfunction
 DIASTOLIC NOTCH: predictive of IUGR and risk of
preeclampsia; Doppler done at 24 weeks, give Aspirin to
prevent pre-eclampsia
 Vascular resistance in uterine circulation normally decreases
in the first half of pregnancy (trophoblastic invasion)
 High risk of uteroplacental insufficiency shows high
resistance patterns
 22-24 weeks
 Abruption, preeclampsia, FGR
1. Umbilical Artery
 About 60-70% of small placental vessels need to be
obliterated before umbilical artery becomes abnormal
Umbilical artery (hypoxia)
 A – Normal
 B/C – ARED (Absent-Reversed Diastolic Blood Flow); poor
outcome for the baby
 S/D ratio above 95th % - Abnormal
 AEDBF (absent RDBF): Perinatal mortality of 10%
 REDBF (reduced RDBF): Perinatal mortality of 33%
 American College of OB-GYN: Umbilical artery Doppler
velocimetry is beneficial for suspected fetal growth
restriction
 No benefit for Post-term, DM, SLE, APAS
2. Middle cerebral artery
 In babies with growth restriction, there is increased blood flow
to the brain, increased flow to the MCA
 HYPOXIC FETUS attempts “Brain Sparing” by reducing
cerebrovascular impedance and increasing blood flow
 If decreased blood flow to umbilical artery → decrease blood
flow to brain → baby is in trouble → there is no compensatory
mechanism → hypoxia
 If there is compensatory (we call it brain sparing): decrease
blood flow to umbilical artery → increase blood flow to the
brain → brain sparing → good outcome
 Such brain sparing growth restricted fetuses will undergo the
reversal
 Risk of fetal death
 Sensitive tool for assessing fetal anemia
 Peak systolic velocity (increased-increased cardiac
output/blood viscosity)
 MCA value of >1.5 multiple of median (MOM): Anemia
(alloimmunized pregnancy, erythroblastosis fetalis)
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OBSTETRICS 2
3. Ductus venosus
 Imaged as it branches from umbilical vein approximately at
the level of diaphragm
 Waveform is biphasic (first peak: systolic flow while second
peak: diastolic flow) followed by a nadir; the a wave
 a wave: atrial contraction
o Decreased, absent, or reversed in preterm IUGR fetus
(sustained irreversible multi-organ damage due to
HYPOXIA)
 Worst scenario would be an abnormality in the ductus
venosus
Antenatal fetal testing
 Which is the best test? Every test has an end point so it’s more
of a common sense. Each test should be supplementary to each
other. No best test.
o Good history taking
o Inform mother the risks of hypoxia
o Important: is to detect early problems and close
monitoring of the mother
o For NST: acceleration
o For Contraction Stress Test: no late deceleration
o Vibroacoustic Test: acceleration. What if acceleration is
absent? It’s okay. Maybe the baby is sleeping
 When is it done earliest?
o At 32 weeks. If high risk: 26weeks
o As early as 26-28 weeks, but usually most of the test is done
at 32 weeks. Why? Because prematurity can have different
results. Ex: tachycardia at very premature AOG. This can
be seen in fetuses below 32 weeks which is physiologic.
Because the sympathetic nervous system matures earlier
than parasympathetic system. That is why tachycardia
is physiologic in premature fetuses. So it will depend
on the time that you will do the test
 What is the significance of these tests?
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Fetal Tachycardia
 Baseline rate above 160 bpm

Good ba ung variability? Minimal lang. Parang suspicious

Normal/non-reassuring/pathologic/abnormal? Normal siya. Kita

niyo may acceleration. This is a normal test actually. Baseline FHR:
130

Is that bradycardia or deceleration? (Tachycardia di ba? Baseline

FHR: 160.) It’s a deceleration kasi hindi sya 10 mins. Hindi na
umabot ng > 10. So that is a prolonged deceleration. After a very
long contraction. This is a 3cm/min for a 2 minute- contraction –
that’s very bad for the baby. Usually iatrogenic. Because they gave
oxytocin. There’s a change in baseline rate of 180. You can see the
variability becoming less because of tachycardia. What is your
interpretation in this tracing? Probably abnormal test, right? You
agree that the variability is not good. It’s not normal. So ako ilalabas Fetal Bradycardia
ko na yung baby diyan  Periods with baseline rate less than 110

These are just from Web sources, for us to have more

examples on CTG tracings

Baseline Fetal HR: 110-160 bpm (based on the lecture)

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