Antepartum Fetal Surveillance

Chandani Pandey
History

• Mayor of Geneva described the method of auscultating fetal heart sounds by

placing the ear next to the maternal abdomen in 1818.
• In 1821, Kergaradec - by Laennec's stethoscope
INTRODUCTION
• ANTENATAL FETAL SURVEILLANCE IS ASSESSMENT OF FETAL WELL
BEING IN ANTEPARTUM PERIOD TO ENSURE DELIVERY OF HEALTHY
NEONATE.
• Two main objectives are:-
 Early detection of fetuses at risk to prevent perinatal mortality and morbidity.
 Find out normal fetuses and avoid unwarranted interventions
INTRODUCTION

• Majority of fetal deaths occur in the antenatal period.

• Causes of deaths:
1)Chronic fetal hypoxia(IUGR)
2)Fetal congenital malformation
3)Maternal complications
4)Unexplained cause
Indication
• MATERNAL
• FETAL
• PREGNANCY RELATED
Indication
Maternal Fetal
• Hypertension
• Fetal growth restriction
• Diabetes
• Rh isoimmunization
• Heart disease
• Fetal cardiac arrhythmias
• Chronic renal disease
• Fetal infections
• Sever anemia
• APLA
• Acute illnesses
• Epilepsy
• Substance abuse
Pregnancy related/ obstretrics
• Multiple pregnancy
• Gestational hypertension
• Preeclampsia
• Decreased fetal movement
• Abnormal placentation
• Placental abruption
• Amniotic fluid disorders
• PROM
• GDM
• Previous unexplained still birth
• Cholestasis of pregnancy
• Post term pregnancy
When to start ??
• Depends up on factors like:-
Past history of adverse outcome
Severity of maternal and fetal conditions
• Generally Monitoring is recommended when estimated fetal maturity is sufficient
to expect a reasonable chance of survival
When result of tests can be followed up with action
Usually initiated around 32 weeks or 1-2 weeks before stillbirth in previous
pregnancy
Decision is individualized
components

Clinical

biochemistry biophysical
Clinical monitoring
1. Maternal weight gain
2. Blood pressure
3. Assessment of size of uterus & height of fundus
4. Edema of feet
5. Abdominal girth in last trimester
PROCEDURES OF ANTENATAL
EXAMINATION
• AT FIRST VISIT:
1) Size of the uterus following bimanual examination
2) If h/o recurrent abortion or premature labour then look for cervical
incompetence.
 Maternal weight gain
• In second half of pregnancy: average weight gain is1 kg/fortnight.
• Excess weight gain: Could be 1st sign of preeclampsia.
• If weight gain less than normal, stationary or falling: Look for IUGR
• Recommended Ranges of Weight Gain during Singleton Gestations Stratified by
Pre- pregnancy Body Mass Index
Category BMI Wt. in kgs
Low 19.8 12.5–18
Normal 19.8–26 11.5–16
High 26–29 7–11.5
Obese > 29 7
Blood pressure
• Initial recording of BP prior to 12 weeks helps to differentiate pre-existing chronic
hypertension from pregnancy induced hypertension.
• Hypertension, pre-existing or pregnancy induced may impair fetal growth.
Abdominal girth
• Measured at lower border of umbilicus.
• Increases by 2.5cm per week after 30wks.
• 95-100cms at term.
• Static or falling values alarming sign
 Assessment of uterine height
• Top of fundus is measured from superior border of
symphysis pubis (bladder should be empty) using
a tape.
• After 24 weeks of pregnancy, distance measured
in cm normally corresponds to period of gestation
weeks.
• Difference of 3-4 cms acceptable
• Below 10th percentile or difference of >4cms
suggests IUGR
• Positive predictive value of60%
• Negative predictive value of 76.8%
BIOCHEMICAL plus USG marker in early
pregnancy
Detection and false positive rates of screening tests for Trisomy 21
Screening test Detection rate False –positive rate

NT+ PAPP-A+ serum ßhCG 79-87% 5%

Maternal age(MA) 30% 5%
MA+ serum ßhCG+ PAPP-A at 11-14 wk 60% 5%
MA+ fetal NT at 11-14 wk 75% 5%
MA+ fetal NT+ NB at 11-14 wk 90% 5%
MA+ fetal NT+ serum ßhCG+ PAPP-A at 11-14 wk 90% 5%

MA+ fetal NT+ NB+ serum ßhCG+ PAPP-A at 11-14 wk 97% 5%

biochemical- Triple test
• Used for Down Syndrome screening.
• It comprises:
. Maternal serum AFP
. ß-hCG
. uE3 (unconjugated oestriol )
• Best carried at 15-18 weeks
• In Trisomy 21: AFP & uE3 are low while ß-hCG is raised
• Detection rate: 60% (false positive rate 5%)
• In trisomy 18 all above components are low
Biochemical – quadruple test

• Improves the detection rate of Down Syndrome compared to the Triple

test

• Triple test+ Inhibin A estimation

• Detection rate: 67%-76%

Invasive tests
Basis of antepartum test

Changes in fetal
Metabolic
Hypoxia CNS depression biophysical
acidosis
activity.
Antepartum tests
1. Fetal movement monitoring
2. The non stress test (NST)
3. vibroacoustic stimulation (VAS)
4. The contraction stress test (CST)
5. The biophysical profile
6. Doppler USG
Fetal movement
• Simple, inexpensive method of fetal monitoring
• Passive unstimulated movement – 7 weeks
• Nijhuis and colleagues (1982)- four fetal behavioral states
State 1F – quite sleep
State 2F- Gross body movement, continuous eye movements, and wider
oscillation of fetal heart rate
analogues to REM or active sleep in neonate
State 3F- continuous eye movement with no body movement and heart rate
acceleration
State 4F- vigorous body movement with continuous eye movement and heart
rate acceleration
Analogue to awake state in newborn
Fetal movement

• Fetal sleep cycle- 20 to 75 mins ( mean 23 mins)

• Sadovsky and collegue- fetal movement – 3 types
• Weak, strong and rolling
Fetal movement

• Cochrane review of four trials in 2007 concluded that there is insufficient

evidence to recommend routine fetal movement counting to prevent fetal death.
• positive predictive value of the maternal perception of reduced FM for fetal
compromise 2% to 7%
• Despite these results, there may be some advantages to this type of fetal
assessment.
Factors affecting maternal perception of fetal
movement
• Fetal and placental factors :-
Placental location
The length and type of fetal movements
Amniotic fluid volume (AFV)
• Maternal factors :-
Parity, obesity.
Psychological factors anxiety.
Cardif ‘count 10’ formula:
• Moore and Piacquadio, 1989
• Mother is instructed to count fetal movements at any convenient time
• Counting ends when 10 movements are perceived.
• Mean interval – 21+/-18 mins
• Report to physician if:
– less than 10 movements occur during 12 hours on 2 successive days or
– no movement is perceived even after 12 hours in a single day.
Daily fetal movement count (DFMC):

• One hour duration each in morning, noon and evening. (Total 1+1+1 = 3 hours)
• Total counts multiplied by four gives daily (12 hour) fetal movement count
(DFMC).
• If there is diminution of number of ‘kicks’ to less than 10 in 12 hours (or less than
3 in each hour), it indicates fetal compromise.
Fetal movement
• RCT in Denmark: Fetal movement counting  73% reduction in avoidable
stillbirths (RR 0.27, 95% CI 0.08- 0.93).
• In contrast, a Large (N = 68,654) international trial  no significant difference in
potentially avoidable late fetal deaths between women who were instructed to
count routinely and controls.
• Cochrane review: Though more number of babies at risk of death were identified,
NO REDUCTION IN PERINATAL MORTALITY.
Nonstress test
• Freeman first described the NST in 1975.
• Describe fetal heart rate acceleration in response to fetal movement as a sign of
fetal health i.e. test of fetal condition
• Indicates normally functioning autonomic nervous system and exclude cellular
hypoxia
• Advantages:
Simple to perform,
Relatively quick, and
Noninvasive.
When to start NST ??
• NST is not routinely started until 32-weeks gestation.
• Up to 50% of NSTs reactive from 24- to 28-weeks gestation.
• 85% from 28 to 32 weeks of gestation
• In up to 50% of NSTs variable decelerations may be observed.
• If last for <30 seconds and <2 during a 20-minute period

NO fetal compromise
Nonstress test

• Simultaneous recording of:

1.Fetal heart rate (FHR)
– Doppler ultrasonographic device, or
– Skin-surface electrodes on the maternal abdomen.
2.Uterine activity
– Tocodynamometer,
– Palpation by trained test personnel, or
– Patient's report.
Method
Non stress test – interpretation

• The test result may be reactive, nonreactive, or inadequate.

• The criteria for a Reactive test (Reassuring) are:
(i) heart rate between 110 and 160,
(ii) normal beat-to-beat variability (5 beats/minute [bpm]), and
(iii) TWO accelerations of at least 15 bpm above baseline lasting for not less than
15seconds, within a 20-minute period.
• Nonreactive test (Non reassuring):
– Fails to meet the three criteria.
– Absence of any fetal reactivity.
• Inadequate test: Adequate fetal heart tracing cannot be obtained.
Non stress test – interpretation

• If test is nonreactive:
– Test is repeated later the same day (or)
– Perform another test of fetal well-being.
(Contraction stress test (CST) may be used as a confirmatory test when the NST is
nonreactive or inadequate.).
• Before 32 weeks, accelerations are defined as having an 10 bpm or more above
baseline for 10 seconds or longer.
• Although a normal number and amplitude of accelerations seems to reflect fetal
well-being, "insufficient acceleration" does not invariably predict fetal
compromise.
Nonstress test

• Studies show that risk of fetal demise within the week following a reactive test is
approximately 3 in 1,000.
• But when the NST is nonreactive, perinatal death is about 40 per 1000 .
Vibroacoustic stimulation (VAS)
• As adjunct to nonstress test
• After non reactive NST
• An artificial larynx delivers sound stimuli at 80- 100 decibels ,placed
on maternal abdomen and 2-3 second stimuli are given
• Acceleration after stimuli have same validity as unprovoked reactive
NST
• Reduces number of false positive NST result
Contraction stress test
Also known as oxytocin challenge test
Principle:
• Based on the idea that uterine contractions can compromise an unhealthy fetus.
• Pressure generated during contractions can briefly reduce or eliminate perfusion
of intervillous space.
• Healthy fetoplacental unit has sufficient reserve to tolerate this short reduction in
oxygen supply.
• Under pathologic conditions, respiratory reserve may be so compromised that
reduction in oxygen results in fetal hypoxia.
Contraction stress test

• Similar to NST, CST monitors FHR

and uterine contractions
• Method-
• Alternative method is nipple
stimulation-ACOG Recommends
stimulation through light clothing for
two minutes at a time with rest
interval of five minutes.
Adequate uterine contractions obtained
with in four minutes of stimulation
Contraction stress test

• A CST is considered completed if

– uterine contractions have
spontaneously occurred within 30
minutes,
– lasted 40 to 60 seconds each, and
– occurred at a frequency of three
within a 10-minute interval.
Contraction stress test

• Negative CST is more reassuring than a reactive NST, with the chance of fetal
demise within a week of a negative CST being approximately 0.4 per 1,000.
• However, if a positive CST follows a nonreactive NST, the risk of stillbirth is 88
per 1,000, and the risk of neonatal mortality is also 88 per 1,000.
Contraindication of CST
• Placenta previa
• Previous CS
• Multiple gestation
• Polyhydramnios
• History of preterm
• Incompetent cervix
• PROM
Biophysical profile
• Also known as Manning score, 1980
• Provides detailed assessment of behavioral state of fetus in -utero
• Combines NST with other 4 parameters by real-time ultrasonic examination.
• Other 4 parameters-
-Fetal breathing movements
-Fetal movements
-Fetal tone
-Amniotic fluid
• A score of 0 or 2 is assigned for each.
• The total score determines the course of action
Biophysical profile

• NST- acceleration on CTG /NST – good cardiovascular reserve

• Fetal breathing - well oxygenated brain stem
• Fetal tone and movement - well oxygenated midbrain and cerebral
cortex
• Normal amniotic fluid - well perfused kidney
Biophysical profile

• The likelihood of in-utero fetal demise within 1 week of a reassuring test is

approximately 0.6 to 0.7 per 1,000.

Modified Biophysical profile –

• In 1989
• Attempt to simplify and reduce the time.
• Focusing on the components of the BPP most predictive of perinatal outcome.
• Two parameters:-
1. NST indicator of present fetal condition.
2. AFI /AFP a marker of long-term status.
 Doppler velocimetry
• Noninvasive technique to assess blood flow by characterizing downstream impedance
• Three fetal AND one maternal vascular circuits :-
Umbilical artery,
Middle cerebral artery
Uterine artery
Ductus venosus
• S/D ratio= systolic peak velocity/diastolic peak velocity
• Resistance index (RI)=systolic- end diastolic peak velocity/systolic peak velocity
• Pulsatility index (PI)=systolic-end diastolic peak velocity/time averaged maximum
−velocity
Doppler – umblical artery
Principle:
• Poorly functioning placentas with extensive vasospasm or infarction have an
increased resistance to flow.
• The two commonly used indices of flow are:
-Systolic : diastolic ratio (S/D) and
-Resistance index (S-D/S).
Doppler – umblical artery
• RI had the best discriminatory ability when compared with the S/D ratio
(P<.05), the PI (P<.001).
• S/D ratio, however, remains the most popular index.
• S/D ratio less than or equal to 3.0, Resistance index less than or equal to 0.6 is
considered normal after 30 completed weeks of pregnancy.
• Umbilical artery Doppler velocimetry measurements - only in IUGR.
• Absent or reversed end-diastolic flow is seen in the most extreme cases of IUGR
and is associated with a high mortality rate.
• Umbilical artery Doppler velocimetry measurements, in conjunction with other
tests of fetal well-being, can reduce the perinatal mortality in IUGR by almost
40%.
• Benefits of this technique before 28 weeks of gestation are uncertain.
 Doppler – umblical artery

• Diagnostic feature of umbilical artery Doppler waveform is the end diastolic flow.
• Absent or reverse end diastolic flow ominous finding.
• frequency of absent end diastolic flow is approximately 2% in high-risk
pregnancies and 0.3% in a general obstetric population.
• In pregnancies complicated with FGR, fetal surveillance should consist of weekly
umbilical Doppler.
• BPP or NST should be used either as a backup test or simultaneously with the
umbilical artery Doppler.
Umbilical Doppler index is high or increasing

weekly umbilical Doppler ultrasound + Twice weekly NST/ BPP

Doppler waveforms
MANAGEMENT WITH ABSENT END DIASTOLIC FLOW

• Guided by the gestational age.

>34 completed weeks -Delivery
Between 28 to 34 completed -conservative
• Daily umbilical artery Doppler, NST, and BPP (or modified BPP)+ Ductus
venosus
• Reverse flow at any gestational age beyond 28 weeks- Delivery
Doppler – uterine artery
• Indication –
1) History of Preeclampsia
2) Previous child with IUGR
3) Unexplained high maternal serum alpha-fetoprotein level
4) High human chorionic gonadotropin level.
5) Thrombophilias

.
Doppler – uterine artery

• Uterine Doppler screening is commonly performed around 20 weeks.

• Increased uterine artery impedance to flow at 20–24 weeks follow-up at 26–
28 weeks.
• Cut-off values at 23 weeks' gestation are:-
a mean PI above 1.5–1.61.
mean RI above 0.57–0.58.
• Bilateral notches are found in about 25–30% of pregnancies at 12 weeks, 10–
15% at 20 weeks and 5% at 24 weeks.
• Sensitivity is up to 85% when performed between 22 and 23 weeks’ gestation.
• High risk patients given low-dose aspirin because of bilateral uterine artery
notching at 12 to 14 weeks have an 80% reduction of placental disease
Doppler – uterine artery

• An early diastolic notch in the uterine arteries at 12 to 14 weeks suggest delayed

trophoblast invasion.
• Persistence “notching” beyond 24 weeks

confirmatory evidence.

• For both preeclampsia and IUGR uterine artery Doppler more accurate in the second
than the first trimester.
• Increased PI with notching in the second trimester best predictor of preeclampsia.
• Persistence of bilateral notching with high RI after 24 weeks in high risk women –
sensitivity of 81.4%, PPV 71% and NPV 93% for adverse pregnancy outcome
Doppler – middle cerebral artery
Hypoxia-induced
cerebrovascular

dilation

• Impedance
decreases

• Increases end-
diastolic blood flow
Doppler – middle cerebral artery
MCA doppler in fetal anemia
• RH isoimmunization
• Parvovirus infection
• fetomaternal hemorrhage
Venous doppler

• Ductus venosus connects the intra-abdominal portion of the umbilical vein with
the inferior vena cava at its inlet to the right atrium.
• Shunt plays a critical role in the delivery of well-oxygenated blood to the left side
of fetal heart.
• In normal fetus venous flow is non pulsatile.
• Appearance of pulsatile flow in venous system is associated with increased
morbidity and mortality.
• Perinatal mortality increases to 38.8% when venous Doppler indices become
abnormal.
Other assessment by USG
• Viability of the fetus
• Pregnancy dating
• Detection of multiple pregnancy
• Detection of congenital anomalies
• Placental localization
• Monitoring of high risk pregnancy (biophysical scoring)
• Adjunct to any procedure, e.g. amniocentesis, cordocentesis, cervical circlage,
external cephalic version
Intrapartum tests
1. Fetal heart rate monitoring:
a. Intermittent auscultation
b. Continuous electronic monitoring
c. Computerized CTG
2. Fetal scalp blood gas
3. Fetal blood lactate
4.Fetal pulse oximetry
5. Fetal electrocardiogram
6.Fetal scalp stimulation
Intrapartum tests -
• Fetal heart rate monitoring:
Noninvasive:
1. Ultrasonic monitoring
2. Surface-electrode monitoring from maternal abdomen.
Invasive: (Most accurate)
Placing electrode into skin of fetal presenting part to record fetal
electrocardiogram.
 Fetal heart rate monitoring

• Intermittent auscultation –
Auscultation for 60 sec immediately after contraction
Every 15-30 mins in first stage of labor
Every 5 mins in second stage of labor

• Continuous electronic monitoring – in increased risk of intrapartum hypoxia and

cerebral palsy
-Induction or augmentation of labor
Fetal heart rate monitoring

• Computerized CTG • Parameters of the fetal monitoring

- Reduce testing time record:
- Reduces need for additional test 1. Baseline heart rate
2. Beat-to-beat variability
3. Accelerations
4. Decelerations
– Early
– Late
– Variable
Fetal heart rate monitoring

• Baseline heart rate: Normally between 110 and 160 bpm.

• Baseline fetal bradycardia (FHR < 110 bpm), may result from congenital heart
block , drugs like beta blockers
• Baseline tachycardia (FHR >160 bpm), may result from maternal fever, infection,
stimulant medications or drugs, and hyperthyroidism and fetal cause like
prematurity, anemia arrythmia and hypoxia
• Fetal dysrhythmias are typically associated with FHR > 200 bpm.
Baseline heart rate
Beat to Beat variability
• Recorded from calculation of each RR interval.
• Autonomic nervous system of healthy, awake term fetus constantly varies the
heart rate from beat to beat by approximately 5 to 25 bpm.
• Reduced beat-to-beat variability may result from:
depression of the fetal central nervous system due to
– fetal immaturity,
– hypoxia,
– maternal medications such as narcotics, sedatives, Betablockers, and
intravenous magnesium sulfate.
Average variability Absent variability
Fetal heart rate monitoring

• Accelerations :
-Reassuring
Decelerations: (Should note the
Shape & Timing)
a. Early
b. Late
c. Variable
Early deceleration
-Symmetric in shape
-Closely mirror uterine contractions in
time of onset, duration, and termination.
-Benign
-More commonly seen in active labor
when fetal head is compressed in the
pelvis, resulting in a parasympathetic
effect.
Early deceleration
Late deceleration

• The onset, nadir, and recovery of the deceleration occur after the beginning, peak,
and end of the contraction, respectively.
• A fall in heart rate of only 10 to 20 bpm below baseline (even if still within the
range of 110-160) is significant.
• Late decelerations are the result of uteroplacental insufficiency and possible fetal
hypoxia.
 Late deceleration
• As the uteroplacental • Associated with decreased uterine
insufficiency/hypoxia worsens, blood flow and can occur as a result
(i) beat-to-beat variability will be of:
reduced and then lost, - Hypoxia
(ii) decelerations will last longer, -Placental abruption
(iii) they will begin sooner following the - Cord compression / prolapse
onset of a contraction,
- Excessive uterine activity
(iv) they will take longer to return to
baseline, and - Maternal hypotension / hypovolaemia
(v) the rate to which the fetal heart
slows will be lower.
• Repetitive late decelerations demand
action.
Late deceleration
Variable deceleration
• Vary in shape and timing relative to contractions.
• Result from fetal umbilical cord compression.
• Variable decelerations are a cause for concern if:
-severe (60 bpm or last for 60 seconds, or both),
-associated with poor beat-to-beat variability, or
-mixed with late decelerations
Variable deceleration
Fetal heart monitoring
Atypical variable deceleration
• Deceleration to less than 70bpm lasting for > 60 sec
• Loss of variability in baseline FHR
• Biphasic deceleration
• Prolonged secondary acceleration ( post deceleration overshoot of
>20bpm and/ or lasting for > 20 sec
• continuation of baseline at lower level after deceleration
• Associated fetal tachycardia
Sinusoidal FHR
• Smooth sine wave line undulating pattern in fetal heart rate baseline with
cycle frequency of 3-5 per mins , persisting for 20 mins or more.
• Causes-
• Fetal anemia
• ICH
• Severe fetal Rh alloimmunization
• Fetomaternal hemorrhage
• Bleeding in vasa previa
• Twin-twin transfusion syndrome
• Severe fetal asphyxia
• Administration of drugs like meperidine , morphine ,butanorphanol
Intermittent auscultation vs electronic
monitoring
Auscultation Electronic monitoring
Fetal heart rate monitoring

• A 2006 systematic review of 12 randomized trials including >37,000 women (both

low and high risk)comparing continuous electronic FHR monitoring and
intermittent auscultation showed:
1. Intrapartum fetal death rate approximately 0.5/1000 births with either approach.
2. Use of electronic FHR monitoring instead of intermittent auscultation did not
result in a significant reduction in overall risk of perinatal death (RR 0.85, 95% CI
0.59-1.23).
3.Apgar scores & NICU admission rates were similar for both modalities.
4. Electronic FHR monitoring instead of intermittent auscultation did not reduce the
risk of hypoxic ischemic encephalopathy, long-term neurologic impairment, or
cerebral palsy.
Fetal heart rate monitoring

• Frequency of neonatal seizures was reduced in the electronically monitored group

(RR 0.50, 95% CI 0.31- 0.80)
• Use of electronic FHR monitoring instead of intermittent auscultation increased
the frequency of operative delivery (cesarean delivery RR 1.66, 95% CI 1.30-
2.13; instrumental vaginal delivery RR 1.16, 95% CI 1.01-1.32)
• US Department of health and human services 2011:
EFM during labour significantly lowered early neonatal and infant mortality (RR
0.50, p < .001)
Fetal blood sampling
• For fetal assessment in labor – 1962, Saling
• Normal - Intrapartum scalp pH above 7.20
Base deficit < 8 mmol/L.
• The scalp PH level drops as the amplitude and duration of deceleration increase
• LIMITATION: Do not give continuous information on fetal acid base status
Need to repea often I.e every 30 mins
Requires operative skills and special instruments
Uncomfortable to the patients
Fetal blood sampling

Fetal scalp PH Recommended action

> 7.25 • Repeat FBS if abnormal FHS pattern persist

7.21- 7.24 • Repeat FBS in 30 mins or consider delivery if rapid

fall since last sample

<7.20 • Delivery indicated

Fetal Scalp lactate
• Alternative to blood gas analysis
• required only 5ul of blood ( 35ul in FBS)
• With Lactate pro machine normal 2.9-3.08mmol/L
• Pathological CTG and lactate > 3.08 – immediate delivery
• Failure rate 5%
Fetal pulse oximetry
• Measure fetal oxygen saturation during labor
• Smooth pliable head with emitting light diodes , photodetector and non invasive
contact electrodes
• Placed over fetal cheek or temple
• Animal studies have shown – fall in fetal arterial pH base occurred when oxygen
saturation dropped below 30%
• RCT trails – 50% reduction in caesarean rate done for non-reassuring FHR pattern
• Did NOT reduce cesarean delivery rates for ‘nonreassuring’’ FHR patterns in
NICHD trial
Fetal electrocardiogram analysis
• To target End organ- i.e heart
• In combination with standard
cardiotocography
• Fetal ECG obtained from scalp
fetal electrode that is used for
internal FHR monitoring
• Changes in T wave and ST
segment of fetal ECG identified
Fetal electrocardiogram analysis

• An increase in T wave height ,

increase in T/ QRS ratio- hypoxic
stress
• ST depression with negative T
wave (biphasic ST events )
between contraction- severe
fetal decompensation
 STAN
• The fetal ST interval changes in the
fetus suffering from oxygen deficiency.
• ST Analysis (STAN) consists of
highlighting theses changes.
• STAN is the basis of treadmill test in
adult
• For a fetus, the birth is the treadmill.
• Rosen et al showed that hypoxia was
associated with a significant elevation
of the T wave in the f ECG.
Fetal scalp stimulation
• Simple clinical test
• Indirectly estimates fetal acid base status
• Fetal scalp is stimulated while doing vaginal examination and FHR
response is observed
• An acceleration of 15 bpm lasting >15 sec = fetal scalp pH >7.25
• Sensitivity – 80-100% to exclude fetal acidosis
Assessment of fetal pulmonary maturity

1.Amniotic fluid Lecithin/Sphingomyelin (L/S) ratio.

-L/S ratio at 31–32 weeks = 1
-L/S ratio at 35 weeks = 2.
• L/S ratio > 2 indicates pulmonary maturity.

2. Shake test or Bubble test (Clement’s):

• Based on ability of pulmonary surfactant to form a foam or bubble on shaking
which remains stable for at least 15 minutes.
• Increasing dilutions of amniotic fluid are mixed with 96 % ethanol, shaken for 15
seconds and inspected after 15 minutes for the presence of a complete ring of
bubbles at the meniscus.
• Indicates maturity of the fetal lungs.
Assessment of fetal pulmonary maturity

3. Foam Stability Index (FSI) :

Based on surfactant detection by shake test.
Serial dilutions of amniotic fluid to quantitate amount of surfactant present.
FSI >47 virtually excludes risk of RDS.

4. Presence of phosphatidyl glycerol (PG) in amniotic fluid :

Indicates lung maturation.
Thin layer chromatography.
Assessment of fetal pulmonary maturity

5. Saturated phosphatidyl choline:

> 500 ng/mL indicates pulmonary maturity.

6. Fluorescence polarization:
Polarized light to quantitate surfactant.
Ratio of surfactant to albumin measured by automatic analyzer.
Presence of 55 mg of surfactant per gram of albumin indicates fetal lung
maturity.
Assessment of fetal pulmonary maturity
7. Amniotic fluid optical density:
> 0.15 at 650 mμ indicates lung maturity.

8. Lamellar body:
Storage form of surfactant in amniotic fluid.
Can be counted as size is same as that of platelets.
Lamellar body count > 30,000/μL indicates pulmonary maturity.
Assessment of fetal pulmonary maturity

9. Orange colored cells:

Desquamated fetal cells obtained from centrifuged amniotic fluid are stained
with 0.1% Nile blue sulfate.
Presence of orange colored cells > 50% suggests pulmonary maturity.

10. Amniotic fluid turbidity:

At term, amniotic fluid is turbid due to vernix.
References:

1. Williams obstetrics 25th edition

2. Ian Donald’s obstetrics problems
3. Aria’s practical guide to high risk pregnancy and delivery
4.High risk in pregnancy by D.K. James
5. Management of labor by Arulkumaran
6. DC Dutta text book of obstetrics
INTRA UTERINE FETAL RESUSCITATION:
• Steps to improve fetal oxygenation before delivery.
SPOILT:
1. Syntocinon off
2. Position: Full Left Lateral
3. Oxygen
4. I.V infusion of Crystalloid fluids
5. Low BP if present : IV Vasopressor
6. Tocolysis: