FETAL ASSESSMENT

FETAL MOVEMENT
A. PHYSIOLOGY
 Passive unstimulated fetal activity commences as early as 7 weeks.
 Beyond 8 weeks AOG
 Fetal body mov’t are never absent for periods exceeding 13 mins.
 Between 20-30 weeks AOG
 Organized general body movements
 Fetus starts to show rest-activity cycle
 36 weeks AOG
 Established behavioral states
4 fetal behavioral state

 State 1F (quiescent state  State 3F

 Quiet sleep  Continuous eye movements in the absence of
eye movements
 Narrow oscillary bandwidth of the FHR
 No heart rate acceleration
 State 2F
 State 4F
 Frequent gross body movement
 Vigorous body movement with continuous eye
 Continous eye movement
movements & Heart rate accelerations.
 Wider oscillation of the FHR.
 Analogous to REM or active sleep in neonate
 Sleep wake cycles
 Impt determinant of fetal activity
 Independent from maternal ones
 Amniotic Fluid volume
 Another important determinant of fetal activity
 Decreased fetal activity with diminished amnionic volumes
 suggested that a restricted uterine space might physically limit fetal movement
Clinical application

 Diminished fetal activity may be a harbirger of impending fetal death

 Clinical methods to quantify fetal movement
 Uterine contraction tocodynomometer
 Visualization by sonography
 Maternal subjective perception
 FETAL BREATHING

 Fetal respiration  paradoxical chest wall movement

 2 identified types of respiratory movements
 1. gasps or sighs: occurred 1-4 per minute
 2. irregular burst of breathing: 240 cycles per minute; assoc. with rapid eye movement
 Fetal respiratory rate declined in conjunction with increased respiratory volume (33-36 weeks)
 Coincide with lung maturation
 Variables that could affect fetal respiratory movement
 Hypoxia
 Hypoglycemia
 Sound stimuli
 Cigarette smoking
 Amniocentesis
 Impending preterm labor
 Gestational age
 Labor- normal for respiration to cease
 CONTRACTION STRESS TEST
 Test of uteroplacental function
 Used to stimulate Uterine contraction
 Intravenous oxytocin
 Nipple stimulation
Criteria for interpretation of CST

 Negative: no late of significant variable decelerations

 Positive: late decelerations following 50% or more contractions
 Equivocal-suspicious: intermittent late decelerations or significant variable decelerations
 Equivocal-hyperstimulatory: fetal heart rate decelerations that occur in the presence of
contractions more frequent than every 2 minutes or lasting long than 90 seconds
 Unsatisfactory: fewer that 3 contractions in 10 minutes or an uninterpretable tracing
 NON STRESS TEST

 Test of fetal condition

 Fetal heart rate Acceleration
 Beat to beat acceleration
 Under the control of autonomic nervous system
 Causes of decreased beat to beat variability
 Sleep cycles
 Central depression ( from medication or cigarette smoking)
 Normal acceleration based on Gestational age
 32 weeks: 15bpm or more above baseline rate & acceleration last 15 seconds or longer but less than 2 minutes
 < 32 weeks: 10bpm or more above baseline for 10 seconds or longer.
Normal stress test

 2 or more accelerations peaking at 15bpm or more above baseline, each lasting for 15
seconds or more, and all occurring within 20 minutes of beginning the test.
 Abnormal NST

 Abnomal NST is not always ominous & can be seen with a sleeping fetus.
 Silent oscillary pattern
 FHR baseline that oscillated less than 5 bpm & presumably indicated absent acceleration and beat to beat variability.
 Terminal cardiotocogram
 1. baselince oscillation of less than 5 bpm
 2. absent acceleration
 3. late deceleration with spontaneous uterine contractions
Interval between testing

 More frequent testing is advocated for (2x per week testing)

 postterm pregnancy
 Multifetal gestation
 Pregestational diabetes
 Fetal growth restriction
 Pregnancy hypertension
 Daily NST or more
 Severe preeclampsia remote from term
Decelerations during NST

 Variable fetal heart rate deceleration during NST is not a sign of fetal compromise.
 ACOG
 Variable decelerations, if nonrepetitive and brief
 Less than 30 seconds
 Do not indicate fetal compromise or the need for obstetrical intervention.
 Repetitive variable deceleration
 At least 3 in 20 minutes
 Even if mild, have been associated with a greater risk of cesarean delivery for fetal distress.
 Decelerations lasting 1 minute or longer have been reported to have an even worse prognosis
 ACOUSTIC STIMULATION TESTS

 Loud external sound have been used to startle the fetus

 Provoke heart rate acceleration
 Commercially available acoustic stimulatior is positioned on the maternal abdomen & a
stimulus of 1to 2 second is applied.
 Repeated up to 3x for up to 3 seconds
 ACOG: positive response  rapid appearance of a qualifying acceleration following
stimulation.
 Fetal tachyarrythmia could be provoked with vibroacoustic stimulation.
 BIOPHYSICAL PROFILE
 5 fetal biophysical variables
 1. heart rate acceleration
 2. breathing
 3. movements
 4. tone
 5. amnionic fluid volume
 Test requires 30-60 minutes of examiners time
 Maternal medications (eg. Narcotics & sedatives)
 Can lower the score
 Ozkaya & Associates (2012)
 Found that biophysical test scores were higher if a test was performed in late evenings
 8pm to 10pm
Components & scores for the biophysical profile

COMPONENT SCORE 2 SCORE 0

NST 2 accelerations of 15 beats within 20-40 mins 0 or 1 acceleration within 20-40 min
Fetal breathing 1 episode of rhythmic breathing lasting for 30 sec < 30 sec of breathing within 30 min
within 30 min
Fetal movement discrete body or limb movements within 30 mins <3 discrete movements
Fetal tone 1 episode of extremity extension & subsequent 0 extension/flexion events
return to flexion
Amnionic fluid volume Pocket of amnionic fluid that measures at least Largest single vertical pocket 2cm
2cm in 2 planes perpendicular to each other
(2x2cm pocket)
 BPS interpretation
10 Normal, non asphyxiated fetus No fetal indication for intervention;
repeat test weaklyexcept in diabetic pt & postterm preg (2x/week)

8/10 Normal, non asphyxiated fetus No fetal indication for intervention; repeat testing per protocol
(Nomal AFV)

8/8 Normal, non asphyxiated fetus No fetal indication for intervention; repeat testing per protocol
(NST not done)

8/10 (decreased Chronic fetal asphyxia suspected deliver

AFV

6 Possible fetal asphyxia If amninic fluid volume abnormal: deliver

If Normal fluid at 36 weeks with favorable cervix: deliver
If repeat test 6: deliver
If repeat test > 6: observe & repeat per protocol
4 Probable fetal asphyxia Repeat testing same day: if BPS 6: deliver

0 to 2 Almost certain fetal asphyxia deliver

Modified biophysical profile

 NST + AFI determination

 Requires approximately 10 mins to perform
 ACOG
 Modified biophysical profile test is a predictive of fetal well being as other approaches to
biophysical fetal surveillance.
 AMNIONIC FLUID VOLUME

 Importance of amnionic fluid volume estimation

 Indicated by its inclusion into virtually all schemes in which fetal health is assessed.
 Based on rationale that diminished uteroplacental perfusion may lead to lower fetal renal blood
flow, decreased urine production  OLIGOHYDRAMNIOS
 ACOG
 The use of deepest vertical pocket measurement, as opposed to AFI, to diagnosed
oligohydramnios is associated with a reduction in unnecessary interventions without an increase
in adverse perinatal outcome.
 DOPPLER VELOCIMETRY

 Blood flow velocimetry measured by doppler ultrasound reflects downward impedance.

 Diagnostic tools for fetal well being
 Umbilical artery
 Middle cerebral artery
 Ductus venosus
 Maternal uterine artery doppler velocimetry
 Modality to predict placental dysfunction
 Goal: to balance stillbirth against the risk of preterm delivery.
 Doppler blood flow velocimetry

 Umbilical artery doppler waveform becomes abnormal

 If 60-70 % needs to be obliterated
 Such extensive placental vascular pathology has a major effect on fetal circulation.
 More than 40% of the combined fetal ventricular output is directed to the placenta, obliteration of placenta
vascular channel increases afterload
  fetal hypoxemia  ventricular dilation & redistribution of middle cerebral artery blood flow
  ultimately pressure rises in the ductus venosus due to afterload in the right side of the fetal heart
 Clinically:
 Abnormal waveforms in the ductus venosus are a late findings in the progression of fetal deterioration due to chronic
hypoxemia
 Umbilical artery velocimetry

 Abnormal Umbilical artery systolic-diastolic ratio

 > 95th percentile for gestational age or if diastolic flow is either absent or reversed.
 Absent or reversed end-diastolic flow
 Greater impedance to umbilical artery blood flow.
 Reported to result from poorly vascularized placental villi & is seen in extreme cases of fetal growth restriction.
 10% mortality rate for absent end diastic flow
 33% mortality rate for reversed end diastolic flow
 Of infants who had shown absent or reversed umbilical artery flow
 8% had evidence of cerebral palsy compared with 1% of those in whom doppler flow has been normal.
 ACOG
 No benefit has been demonstrated other than in pregnancies with suspected fetal-growth restriction.
 Velocimetry has not proved valuable as a screening test for fetal compromise in the general obstetrical population.
 Concluded that doppler investigations of other blood vessels beside the umbilical artery have not been shown to improve
perinatal outcome.
 Middle cerebral artery

 Doppler velocimetry interrogation of the MCA to detect fetal compromise is not recommended.
 Still technology has received particular attention because of observations that the hypoxic fetus attempts brain sparing by
reducing cerebrovascular impedance increasing blood flow
 Such brain sparring in growth restricted fetuses has been documented to undergo reversal.
 MCA doppler velocimetry has been proven valuable to detect severe fetal anemia in 165 fetuses with D-antigen
alloimmunization.
 Investigators concluded that doppler could safely replace amniocenteses in the management of alloimmunized pregnancies.
 Ductus venosus

 Ductus venosus velocimetry was the best predictor of perinatal outcome

 Negative or reversed flow in the ductus venosus was a late finding because these fetuses had already sustained
irreversible multiorgan damage due to hypoxemia.
 Gestational age at delivery was a major determinant of perinatal outcome independent of ductus venosus flow
 Uterine artery

 Vascular resistance in the uterine circulation normally decreases in the 1 st half of pregnancy due to invasion of
maternal uterine vessels by trophoblastic tissue.
 This process can be detected using doppler flow velocimetry & uterine artery doppler may be most helpful in assessing
pregnancies at high risk of development of high-resistance patterns has been linked to various pregnancy complications.