Antepartum Fetal Well Being Assessment

Asheber Gaym M.D.

January 2009
 Outline

• Discuss fetal well being and its determinants

• List possible causes of fetal distress
• Discuss fetal response to asphyxia
• List available methods of fetal well being
assessment
• Outline antepartum plan for fetal well being
assessment

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 Determinants of fetal well being

• Healthy genetic make-up in terms of chromosome number,

structure and genetic composition
• Healthy structural formation- no anomalies
• Adequate anatomical and physiological function to deliver
essential gases and nutrients and eliminate biologic waste
– Entails healthy maternal cardiopulmonary function; adequate
hemoglobin concentration; adequate uterine perfusion; normal
placental function; healthy fetal circulation and adequate fetal
hemoglobin content
– Any abnormality in this process from whatever cause will result in
fetal hypoxia and eventual asphyxia
– Extent of insult depends on severity and speed of insult

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 Etiology of Fetal Distress or Asphyxial Insult
Origin of insult Possible causes of insult
Maternal cardiovascular function Cardiac and pulmonary disease
Hypovolemia from any cause
Maternal hemoglobin level/function Anemia; Carbon monoxide poisoning
Uterine perfusion Maternal hypertensive disease
Placental function Placental abruption; Placental infarction;
Placental tumors; Chronic villitis; Placental
ageing in post term pregnancy; Placental
infection
Cord related problems True knot; Cord compression (oligohydramnios)
Cord prolapse; Cord entanglement; Short cord
Fetal cardiovascular function Congenital cardiac anomalies; neural tube
defects ; non-immune hydrops
Fetal hemoglobin concentration Fetal anemia due to hemolysis ( RH Disease)
Maternal drugs administration Sedative drugs; general anesthesia
Fetal sleep state Long fetal sleep state

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 Fetal Response to Asphyxia
Organ system Response Detectable Effect
Central nervous •Increased sympathetic output – •Fetal tachycardia; reduced
system – mediated early response renal perfusion
via the
chemoreceptor •Increased parasympathetic output •Fetal bradycardia- variable
and later by the and late decelerations
baroreceptor
reflexes •CNS depression and loss of control •Loss of fetal beat-to- beat
of heart rate as asphyxia worsens variability

Cardiovascular •Peripheral vasoconstriction •Reduced renal perfusion-

system oligohydramnios; asymetric
growth restriction
•Increased after load due to •Reduced aortic
vasoconstriction and hypertension velocimetry
•Myocardial ischemia in late stages •Bradycardia

Renal system Reduced renal perfusion Oligohydramnios

Hematologic Hemoconcentration and increased Polycythemia
system hemoglobin production
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 Antepartum tests of fetal wellbeing
Test Conduct of test Normal Test Result

Daily maternal fetal 1. Count to ten method- 1. More than 10

movement count- three Mother instructed to movements in a 12
different ways of counting count fetal movement hour period.
recommended by different and report if less than Movement alarm
authors 10 counts in a 12 hour signal- less than 10 in a
period 12 hour period
2. Count for 30 minutes, 2. More than four
three times per day movements

3. Count for an hour 3. More than four

between 7 and 11 PM movements
after dinner

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 Antepartum tests of fetal well being

Test Conduct of test Possible test results

Contraction In a labor suit. Oxytocin drip Negative – no late or variable

stress test started and escalated until decelerations
(CST)- can three contractions in ten Positive – late decelerations following >
be either minutes lasting 35 seconds. 50% of contractions
the Continuous electronic fetal Equivocal-suspicious – intermittent late
oxytocin heart rate monitoring decelerations or significant variable
challenge conducted and patter decelerations
test or the analyzed. Equivocal hyperstimulatory-
nipple decelerations with contractions more
stimulation Contraindications- scarred frequent than 5/10mins or lasting longer
test uterus; multiple pregnancy; than 90 secs.
PROM; Past history of Unsatisfactory – fewer than three
preterm labor contractions in 10 minutes or an
uninterpretable tracing.

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 Antepartum fetal well being tests
Test Conduct of test
Non stress test (NST) Mother in left lateral
position and continuous
electronic fetal heart
monitoring conducted for
40 minutes. Mother
provided with indicator to
press whenever she feels
fetal movements. Tracing
of fetal heart pattern made
throughout and checked
for alterations associated
with fetal movement.
Asheber Gaym,2009
Normal test result
Reactive NST- At least two
fetal heart rate
accelerations of at least 15
beats per minute lasting at
least 15 seconds associated
with fetal movements.
Indicates a healthy fetus.
Non-reactive NST- if less
than the above during the
40 minutes in terms of fetal
movement and fetal heart
rate changes.
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 Antepartum fetal well being tests
Test Conduct of test
Fetal biophysical profile Real time ultrasonography
score conducted to measure
several fetal biophysical
parameters including fetal
tone; fetal breathing
movement; gross body
movement and amniotic
fluid volume. A NST is also
conducted at the same
time and taken as the fifth
parameter of the fetal
biophysical profile score.
Each parameter scored
either 0,1 or 2. Total score
is out of 10. Test conducted
for 30 minutes; can be
prolonged upto 2 hours.
Asheber Gaym,2009
Test results
10- Normal fetus ; repeat
after a week. Twice weekly
in a diabetic or post term
pregnancy.
8 – Normal if no
oligohydramnios
6- Possible fetal asphyxia;
repeat test in 6 hrs.
4- Probable fetal asphyxia
Repeat after 6 hours,
deliver if the results are the
same
0-2- Almost certain fetal
asphyxia- Deliver
immediately
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 Antepartum fetal well being tests
Test Conduct of test Normal test results
Doppler velocimetry Doppler velocimetry S:D ratios within the
studies studies are conducted on normal range for
major fetal vessels, mainly gestational age.
the fetal aorta. Systolic and
diastolic flow and Reduction of diastolic
velocimetry studies are blood flow or reversal of
conducted and S:D ratios diastolic flow regarded as
computed. As asphyxia abnormal.
progresses and
sympathetic discharge
increases, fetal
hypertension issues
progressively reducing
diastolic blood flow.

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 Predictive value of tests of fetal well being

• A normal fetal well being test result indicates that the risk of fetal
death in utero within the next seven days is less than one per
thousand.
• This indicates the need to repeat the test at least once every
week.
• All of the fetal well being tests have satisfactory sensitivity
( ability to detect all distressed fetuses correctly and not to
diagnose a distressed fetus as healthy)
• The major weakness of all tests is poor specificity ( diagnosing
many healthy fetuses as being asphyxiated leading to many
unnecessary interventions incurring costs to the health system
and premature deliveries as a result)

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 Predictive value of fetal well being tests

• The reason for the poor specificity is the state of fetal sleep in
which most fetal biophysical parameters have results similar to
the asphyxiated fetus. The fetal sleep periods can sometimes
last upto two hours.

• Many strategies are in place to reduce the impact of this poor

specificity including:
– Performing two tests concurrently
– Performing the tests postprandial to avoid the effect of hypoglycemia
– Awakening the fetus with an artificial larynx before the test conduct
– Repeating the test after some time to confirm the results
– Prolonging the duration of the test period

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 Antepartum plans for fetal well being
assessment
• The intensity of fetal well being assessment is individualized to
a particular mother and her fetus’ risk to intrauterine asphyxial
insult based on the presence or absence of complications
• “Low risk” pregnancies ( pregnancies in which there are no
complications diagnosed as yet) can be followed by daily
maternal movement counts beginning from the period of fetal
viability ( 28 weeks). Mother is instructed on the importance
of daily fetal movement count and the need to report
significant changes to her provider as soon as possible. Any
reduction reported by the mother is followed up by the more
rigorous fetal well being tests.

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 Antepartum plans for fetal well being
assessment
• “High risk” pregnancies- in which a significant complication
has been diagnosed, need to be followed up by one of the
antepartum fetal well being tests in addition to the daily
fetal movement count. In most cases once per week testing
is sufficient. In growth retarded, post term and diabetic
pregnancies twice weekly testing is recommended.
• An institution usually chooses one of the fetal well being
tests to be its preferred method of fetal well being testing
for the unit. Most obstetric units utilize either the non-
stress test or the fetal biophysical profile as the mainstay of
their fetal well being testing strategy.

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