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ASSESSMENT OF FETAL

WELL BEING
Assessment of fetal wellbeing is
either:

 Antepartum: assessment late in


pregnancy, before onset of labor.

 Intrapartum: assessment during


labor.
ANTEPARTUM
ASSESSMENT OF FETAL
WELL- BEING
AIM:
AIM:
To detect fetuses at risk of hypoxia
during 3rd trimester of
pregnancy, so that it can be
delivered before IUFD, or hypoxic
injury. Fetal hypoxia is mostly caused
by uteroplacental insufficiency.
PLACENTAL
INSUFFICIENCY
DEFINTION
Failure of the placental functions to
deliver adequate oxygenation and
nutrition to the fetus.

TYPES
 Acute: Suddenly occurring associated with
otherwise normal fetus. (E.g. Placental separation).
 Chronic: Associated usually with
intrauterine growth restriction (IUGR - small
for date fetus).
:AETIOLOGY
Impairment of the placental circulation
due to thrombosis of the vessels or
placental infarcts.
 Hypertensive states of pregnancy (PE,
eclampsia, and chronic hypertension).
 Accidental hemorrhage or placenta
praevia.
 Postmaturity syndrome.
 Diabetic pregnancy when associated with
vasculopathy.
 Placental infarctions.
 Idiopathic.
PATHOLOGY
Fetal response to placental insufficiency:
 Redistribution of blood flow preferentially

to the brain and fetal heart.


 Asymmetric IUGR.

 Oligohydramnios due to reduced renal

perfusion.
 Decreased fetal movement to conserve

energy.
 Disturbance of fetal heart rate due to

defective autonomic regulation.


DIAGNOSIS OF PLACENTAL
:INSUFFICIENCY
HISTORY:
 Careful history taking may reveal the cause of
placental insufficiency, e.g. PE, post maturity,
etc.

CLINICAL SIGNS suggestive of SGA fetus or


Oligohydramnios:

 Poor maternal weight gain during regular ANC


follow up (normal = 0.5 kg/wk > 20 wks).
 fundal level < Gestational age "GA".

ANTEPARTUM FETAL SURVEILLANCE AFS


(Placental Function Tests)
Placental Function Tests
 Daily fetal movement count (DFMC).

 Non-Stress Test (NST).

 Fetal Biophysical Profile (BPP).

 Doppler color flow studies.

 Oxytocin challenge test (OCT).


( The Non Stress Test(NST
Idea: To test FHR changes in
response to fetal movements.
Procedure: external
cardiotocography (CTG)
 Basal FHR is recorded and its changes in
response to fetal movements are
detected.
 Duration of the test: FHR recordings over
20 min observation period. The test may
be extended for another 20 minutes if
fetal movements are insufficient.
:Response to NST

Reactive:
Normally a rise in FHR of at
least 15 bpm, for at least 15
sec. will occur at least twice
within a period of 15-20 min.
testing.
Non reactive:
No FHR changes or changes
less than normal
Management according to
:NST
 Reactive NST: repeat every week.
 Non reactive NST: Further fetal
evaluation:
 Ultrasound Biophysical Profile Score
(BPPS)
 Colour Doppler velocimetry studies
(fetal umbilical and cerebral arteries)
 Oxytocin Challenge Test (OCT).
Ultrasound Biophysical
:(Profile Score (BPPS
 The BPP is one of the most popular and
informative tests for antepartum fetal
surveillance (AFS). It is a simple test
based on clear ultrasound parameters that
can pick up those fetuses at risk of
hypoxia. Each tested parameter is given a
score (either 0 or 2).

 Timing of BPP: The test is done any time


during the third trimester and can be
repeated freely whenever AFS is indicated.
Parameters studied:
observation of the following parameters over a
period of 30 minutes:

 Fetal tone (flexion attitude of fetal limbs,


head and body).
 Fetal body movements (flexion / extension
limb and body movements).
 Fetal breathing movements (expansion
movements of the fetal abdomen).
 Amniotic fluid volume (or amniotic fluid
index - AFI).
 NST ( normal when FHR accelerations show
rise of 15 bpm, for 15 secs, twice in 15-20
min. duration.
Interpretation of the test
Each item is scored either 0 or 2, with a maximum 10/10.
 Scores of 10 to 10 denote a normal fetal
well being, with normal fetal PH.
 Scores of 8/10 may need repeating the

test and /or adding Doppler US evaluation.


 Scores < 8 suggest severe hypoxia.

Termination of pregnancy should be


considered.
 Scores < 6 denote severe fetal acidaemia,
with severely compromised fetal outcome.
Modified BPP
 It combines non - stress test (NST)
and Amniotic fluid index (AFI).

 It is less complicated and less time


consuming.

 If the non – stress test is non-


reactive, a complete BPP should be
done.
COLOR DOPPLER STUDIES
OF FETAL BLOOD FLOW
 Measurement of the resistance to fetal blood flow
within the umbilical artery and the middle
cerebral artery yields excellent information
about the state of fetal organ perfusion.

 HIGH resistance in the umbilical artery is


concomitant with placental insufficiency, while
LOW resistance in the fetal middle cerebral
artery points to vascular shift and brain sparing,
suggestive of hypoxia.

 Absent or reversed end-diastolic flow in the


umbilical arteries Doppler velocimetry flow
studies denotes a severely compromised fetus
that needs urgent delivery.
OXYTOCIN CHALLENGE
.:(TEST (OCT
 Monitoring FHR changes on CTG, in
response to I.V. oxytocin induced mild
uterine contractions.
 Positive OCT: FHR decelerations obtained after
each uterine contraction (fetal distress).
 Negative OCT: No FHR changes occur in response
to contractions (good fetal well being).

 The test has formerly been indicated if


the NST was non reactive, however OCT
is rarely used nowadays being outdated
by the safer and easier Doppler US
velocimetry studies.
MANAGEMENT OF PLACENTAL
INSUFFICIENCY
 Cases suffering chronic placental
insufficiency with IUGR are carefully
monitored and delivered nearest to 37
weeks gestation. If Doppler studies
revealed very high umbilical artery
resistance index with poor BPP score,
immediate termination of pregnancy is
indicated.
 Cases with acute placental
insufficiency from the start, or those who
developed acute on top of chronic
insufficiency, with Oligohydramnios, poor
BPP scores, abnormal Doppler studies, are
for immediate termination of pregnancy
Delivery by CS
 offers the best chance for fetal
survival in cases with placental
insufficiency when pregnancy
termination is indicated. In some
selected cases induction of labour
may be chosen with continuous
electronic FHR monitoring by the
CTG. If fetal bradycardia occurs, or if
ROM revealed presence of
meconium, vaginal delivery is
KEY POINTS IN
ANTEPARTUM FETAL
:)SURVEILLANCE )AFS
 AFS detects fetuses at risk secondary to utero-placental
insufficiency, but cannot predict sudden events.
 All pregnant women at high risk for placental insufficiency
should do a DFMC.
 The NST should be offered to cases with decreased DFMC or to
high risk cases in general.
 The BPP includes a NST with evaluation of specific US
parameters. It should be performed and repeated whenever
fetal compromise is suspected.
 Doppler umbilical artery studies are indicated whenever an
abnormal BPP is encountered. Abnormal findings reflect serious
fetal condition.
 Normal AFS tests may be repeated on weekly or biweekly
intervals.
 Abnormal AFS tests necessitate termination of pregnancy.
 In most cases CS delivery will offer best chances for fetal
neonatal survival.
INTRAPARTUM
ASSESSMENT OF
FETAL WELL BEING
 Aim: To detect fetuses at risk for hypoxia
during labour )fetal distress), thus
minimizing the risks of intrapartum and
neonatal fetal death, or severe fetal
hypoxic injury (e.g.; cerebral palsy).

 Pathophysiology of hypoxia:
Decreased Oxygen supply to the fetus
during labour is associated with decreased
elimination of CO2, with resultant fetal
respiratory acidosis and decreased fetal
blood PH.
CAUSES OF INTRAUTERINE
FETAL HYPOXIA (FETAL
(DISTRESS
1. Acute fetal hypoxia:
 Cord accidents (cord prolapse, cord compression, true
knots, coils around fetal neck, and rupture vasa praevia).
 Placental separation (accidental Haemorrhage, placenta
praevia).
 Placental compression (prolonged ROM, uterine
hypertonicity, obstructed labour).
 Some congenital and or chromosomal fetal anomalies.

2. Chronic fetal hypoxia:


 Placental insufficiency.
 Maternal hypoxia: (Severe anemia or excessive
haemorrhage, congestive heart failure, severe pulmonary
disease, during eclamptic fits, during anaesthesia with
improper oxygenation).
Diagnosis of Fetal Distress
:during Labor
A- CLINICAL DIAGNOSIS:
 Abnormal FHR recordings by the sonicaid (severe
bradycardia, severe tachycardia).
 Passage of meconium after ROM in (cephalic presentation
not breech).
N.B.: Intrauterine asphyxia results in relaxation of the fetal
anal sphincter & increased intestinal peristalsis.
Meconium, (the thick intestinal particulate secretion in
the neonate), will then escape into the amniotic fluid
giving it yellowish or greenish colour that appears after
rupture of membranes.

B- INTRAPARTUM FETAL SURVEILLANCE tests: - IFS


 The aim of IFS tests is to detect fetal distress occurring
during labour. The best available method for such IFS is
the use of continuous external electronic FHR
monitoring.
ELECTRONIC FHR
MONITORING:
( Cardiotocography –
(CTG
 The CTG entails Continuous electronic
FHR monitoring during labour in relation
to uterine activity. An external US
transducer is placed on the maternal
abdomen at a site selected to give the
best FHR recordings. Another transducer
is placed to record the onset, duration and
intensity of uterine contractions and
associated increased intrauterine pressure
Interpretation of FHR Monitoring
:by CTG
Normal FHR tracings:
 Normal FHR values: 120-140
beat per minute (b/m).
 Normal FHR Pattern: beat to
beat variability (fluctuations
by ± 5 to 10 b/m.
periodically).
Interpretation of FHR
:(.Monitoring by CTG (cont
Abnormal FHR tracings:
 Baseline bradycardia: < 100 b/m.
 Baseline tachycardia: > 160 b/m.
 Absence of beat to beat variability: FHR variation
within 1 min is < 5 b/m.
 Late Decelerations: Slowing of FHR at the peak of
the uterine contraction that returns to normal a
short period after the contraction ends. Late
deceleration is the most dangerous pattern, as it
indicates severe utero-placental insufficiency.
 Variable Decelerations: Slowing of FHR which is not
related to uterine contractions. It mostly indicates
cord compression especially in cases with ROM or
Oligohydramnios.
N.B.: Early Decelerations refer to slowing of
FHR that starts at the onset of the
uterine contraction and returns to normal
with its end. It is mostly associated with
head compression within the bony pelvis
with reflex stimulation of vagus nerve.
Early decelerations are usually harmless.

N.B.: Sinusoidal FHR pattern is a smooth


wave like pattern of regular frequency (3-
5 cycles/min), and amplitude (5-20 bpm).
Short episodes of sinusoidal FHR patterns
are considered a variant of normal.
Longer episodes may reflect fetal
anaemia and severe hypoxia (e.g.
accidental haemorrhage).
Fetal Blood sampling During
labour
 Abnormal FHR patterns on CTG during labour are
sometimes misleading, with a resultant increase
in the rate of unnecessary CS deliveries. In cases
where FHR tracings on the CTG are abnormal,
fetal blood sampling (FBS) will be the most
accurate .

 The blood sample is taken via a small needle


probe applied to fetal scalp after ROM , which is
known as fetal scalp PH. Normal fetal pH ranges
from 7.25 - 7.35.

 In cases of fetal hypoxia: Accumulation of Co2.


(Anaerobic pathway for energy & lactic acid).

 This leads to fetal acidosis. If < 7.25 =Mild


acidosis.
Management of fetal distress
:during labour
 High risk cases should be offered a
continuous CTG monitoring throughout
labour.
 Whenever abnormal CTG findings are
recorded
 Stop oxytocin, if it has been infused
 Change position of the mother to Left
lateral position .
 O2 mask to the mother )to avoid maternal
hypoxia).
 I.V. Fluids )to avoid maternal dehydration).
If the above measures are successful):
Labour is allowed to proceed under
strict observation.
Management of fetal
distress during labour
:(.(cont
If The above measures were
unsuccessful i.e.;
 FHR patterns showed persistent
abnormality.
 Abnormal FHR patterns recurred after a
period of normality.
 A difficult and prolonged vaginal
delivery is anticipated.
An immediate delivery by CS will be
the best and safest option
available.
N.B.: If fetal distress occurs when the
cervix is fully dilated, the
membranes ruptured, the presenting
part engaged, and the maternal
pelvis is adequate, immediate
vaginal delivery may be
encouraged by:
 Instrumental delivery by the low

forceps procedure.
 Breech extraction in cases of

complete or frank breech


presentations.
Key points in intrapartum
:)fetal surveillance )IFS
 Cases at high risk for fetal hypoxia should be
selected and carefully monitored throughout
labour.

 Intrapartum fetal monitoring will detect early


fetal hypoxia.

 IFS, has decreased the number of intrapartum


fetal deaths, but it has increased the number of
CS deliveries.

 FHR accelerations signify normal fetal PH and


intact CNS.
Key points in intrapartum
:).fetal surveillance )cont
 Decelerations are characterized based on
the timing with contractions:

• Early decelerations: head compression


vagal response (no hazards).
• Late decelerations: uteroplacental
insufficiency (serious hypoxia anticipated).
• Variable decelerations: cord compression
(especially with ROM or oligohydramnios).
Whenever IFS points to fetal distress,
measures should be taken for
immediate delivery:

Most cases will benefit from immediate


CS.

Some selected cases may continue a


carefully
monitored trial for a rapid vaginal
delivery.