Assessment

of
Fetal wellbeing

Presenter: Allia Madden

What is the purpose?
Fetal surveillance has become essential to modern-day obstetrics
in order to reduce perinatal and postpartum morbidity and
mortality.
A variety of monitoring techniques are employed during both
the antepartum and intrapartum periods to detect mothers at
high-risk for fatal fetal complications such as stillbirths and
allow for timely application of appropriate intervention.
 While factors such as drugs and infections may
contributed to adverse perinatal complications, fetal
hypoxia is the leading source, accounting for 70% of all
fetal morbidity and mortality.

Antepartum It is important to note that a growth restricted fetus is

particularly at risk of fetal hypoxia and hence most
Monitoring monitor modalities are aimed at identifying fetal hypoxia
as well as abnormal fetal growth.

The American College of Obstetricians and

Gynecologists (ACOG) states that the goal of Antepartum
Fetal Surveillance is to reduce the risk of stillbirth.
 Indications for Antepartum Surveillance

Surveillance is required for all pregnancies deemed high risk.

These include:
• Previous unexplained stillbirth
• Decreased or abnormal patterns of fetal movement
• Postdate pregnancies
• Intrauterine growth restriction
• Abnormalities in liquor volume (polyhydramnios and oligohydramnios)
• Hypertensive disorders in pregnancy
• Diabetes in pregnancy (pregestational and gestational)
• Rhesus isoimmunization
• Multiple gestions (especially monochorionic and those greater than two)
• Maternal medical conditions such as hyperthyroidism, heart disease, haemoglobinopathies etc.
• Smoking and drug abuse
Methods of Antepartum Surveillance

Biophysical Testing
• Assessment of fetal movement
Note:
• Assessment of symphysiofundal height No testing modality is entirely reliable on its own.
• Cardiotocography Multimodality testing improves the overall
• Biophysical profile reliability of the testing process
• Fetal Biometry
• Assessment of Liquor volume
• Doppler Ultrasound

Biochemical testing
• Alpha fetoprotein (AFP)
• Human Chorionic Gonadotropin (hCG)
• Human Placental Lactogen (HPL)
 Fetal movement (quickening) and unique
patterns movement are recognized by
mothers at 18 – 20 weeks for
primigravida mothers and as early as 13
Assessment weeks in the multigravida. Most activity
noted in the evening.
of
Fatal Movement Fetal hypoxia reduces movement and
causes changes in movement patterns
due the shunting of blood to vital organs
such as the brain, heart and adrenal
glands.
 Methods of fetal movement counting

Daily fetal movement chart (DFMC) or Pearson – Weaver Chart is used to chart fetal movement over a predetermined time period.
Normal: 10 or more movement in 12 hours

There are two main strategies of counting: Fixed number of movements (Cardiff) and Fixed period (Sadovsky)

 Cardiff “Count-to-Ten” Method: Count over a 12 hour period e.g. 9am – 9pm

until 10 fetal movements are appreciated. Attainment of any less requires cardiotocography and/or ultrasonography.

 Sadovsky Method: Count movements over a 30 – 60 minute period, three times daily (morning, afternoon and evening) usually after meals
or four times daily including at bedtime. <3 fetal movements is alarming and requires future testing.

Studies showed higher compliance achieved with the “Count-to-Ten” Method however no difference in perinatal morbidity was noted.
Assessment of Symphysiofundal Height

The symphysioundal height is the distance, in centimeters, from the superior boarder of the symphysis pubis to the uterine
fundus.
This may be influenced by factors such as size and number of fetuses, liquor volume and presence of uterine tumors such
as fibroids.

Serial measurements are done and plotted on a growth chart allowing for the detection of growth abnormalities. Detection
of abnormalities would then require further investigations such liquor volume assessment.
Cardiotocography [Non-
stress Test]
Cardiotocography allows for the assessment of
the fetal heart rate (cardio), strength (toco) and
frequency of uterine contractions.

In the antepartum with a quiescent uterus (the

absence of coordinated contraction) fetal heart
rate is recorded in response to fetal movement.
Physiology of Cardiotocography

• In a developing fetus, the sympathetic nervous system develops before the parasympathetic
nervous system and equilibrium not being achieved until week 32-34. Hence baseline heart rate
varies with gestation and tends to decline with progression to term
• Regardless of this Antenatal CTG monitoring begins as early as Week 28
Baseline fetal heart rate is 110 – 160 bpm
• Baseline variability is affected by the autonomic nervous system which has chemoreceptors
sensitive to pH, pO2 and pCO2 and is therefore vital in assessing fetal adaptation to hypoxia
Normal baseline variability is 5 – 25 bpm
Physiology of Cardiotocography

• The mother is placed in the left lateral position (eliminate aorto-

caval compression offering optimal placental perfusion). Fetal heart
is located using a transducer and the mother must indicate fetal
movement.

• Duration - at least 20 minutes.

 Interpretation of CTG readings
• Baseline Fetal Heart Rate: 110 – 160 bpm
➢ < 110 bpm – Fetal bradycardia
Indicative of fetal hypoxia, maternal medication (Beta Blockers), fetal heart block
or compression of the umbilical cord
➢ > 160 bpm – Fetal Tachycardia
Indicative of fetal hypoxia, maternal fever (infection), anaemia (fetal or maternal) or
chorioamnionitis
• Baseline Variability: 5 – 25 bpm
➢ Fetal hypoxia
➢ Physiological (fetal) - fetal sleep wake cycle or prematurity
➢ Maternal Factors- Sedative or Corticosteroid use
Interpretation of CTG results

Accelerations – increase in heart rate of ≥ 15 beats above the baseline lasting for at least 15 seconds
Accelerations in response to movement are a reassuring feature and indicative of fetal
well-being
Decelerations – decrease in heart rate of ≥ 15 beats below the baseline lasting for at least 15 seconds
All decelerations during the antepartum period are abnormal.

Decelerations suggest fetal hypoxia and when unprovoked, suggests that all coping mechanisms have
been exhausted in dealing with the hypoxic stimuli and indicate that the fetus may not be able to
tolerate the stresses of labour. An abdominal delivery may be required.
 Interpretation of CTG
readings

• Reactive NST – ≥ 2 accelerations

over the 20 minute period.

• Absent accelerations may be due to

the fetal sleep-wake cycle.
Continue for 20 more minutes. If
still absent this should be taken as
abnormal and requires further
testing and clinical action.
Contraction Stress Test

What is it? Contraindications

This test is based on the response of the fetal
heart to uterine contractions (induced by
endogenously nipple stimulation or
exogenously by oxytocin) with the knowledge
that uterine contractions decrease placental
perfusion leading to transient hypoxia.
• Mothers at risk of preterm labour
• Presence of C – section scar as risk of uterine
rupture
• Major placenta previa which may lead to
haemorrhage

Once the fetus is already in a hypoxic state and

is unable to compensate and this is revealed as
decelerations on the recorded tracing.
 Possible results:
• Positive- Late decelerations following more than 50% of the contractions
Contraction Stress • Suspicious- Intermittent presence of late decelerations or significant

Test Results variable decelerations

• Negative- No late decelerations following contractions
• Unsatisfactory- Less than 3 contractions in 10 minutes
Biophysical Profile

Biophysical Profile (BPP) utilizes cardiotocography and ultrasound in its assessment of fetal
hypoxia.

The five (5) components of BPP include:

• Non-stress Test (NST)
• Fetal Breathing movement
• Gross fetal body movement
• Fetal tone
Note: Though time consuming, this method has a very
• Quantification of liquor volume high negative predictive value and normal results can
be considered valid for up to a week.
Modified Biophysical Profile

Modified BPP allows for a quick assessment of fetal hypoxia using these two
components:
• a) Non-Stress Test (NST)
• b) Amniotic Fluid Index/ Maximum Vertical Pocket (Amoniotic Fluid Vol.)

This method is much quicker and is no dependent on the fetal sleep-wake cycle.

Note: NST – acute hypoxia

AFI – chronic hypoxia
Fetal Biometry

Fetal Biometry allows for the identification of a growth restricted fetus with the use of ultrasound technology.
Measurements of:
o Head Circumference
o Biparietal Diameter
o Abdominal Circumference
o Femur Length

Percentiles allow for the comparison of each component and then collectively help to estimate fetal weight
(especially AC). This estimated weight can then be compared according to the gestational age of the fetus.
Some component may be compared to each other and indicate disparities in anatomical growth
e.g. Head Circumference vs Abdominal Circumference
Serial measurements can also be done to track growth
Liquor Volume Assessment

Liquor volume is a measure of both placental function and renal perfusion of the fetus. It can be assessed using
both physical examination and Ultrasonography.

Physically: Symphysiofundal height reveal a uterus that is small for dates and easily palpated fetal parts.

Ultrasound:
Maximum Vertical Pocket- Single largest pocket of amniotic fluid free of fetal parts.
(Normal: 2-8 cm)

Amniotic Fluid Index- Maternal abdomen divided into quadrants and the largest vertical
measurement in each quadrant is added (Normal: 5-25 cm)
Liquor Volume Assessment
 Doppler Ultrasound

A Doppler Ultrasound demonstrates blood flow pattern in maternal and fetal blood vessels.
Commonly performed Doppler Studies are:

Umbilical Artery Doppler

In the normal fetus there is blood flow from
the fetus to the placenta throughout systole and diastole.
In growth restriction, there may be increased
placental vascular resistance which may result in
abnormalities in flow
Results: Normal, Absent End Diastolic Flow and
Reversed End Diastolic Flow.
Doppler Ultrasound

Uterine Artery Doppler

Performed at 20- 24 weeks and is a good predictor of possible fetal
growth restriction.
Results: Reduced End Diastolic Flow or Notching of the wave form
Middle Cerebral Artery Doppler
This relies on the fact that in IUGR, there is stunning of blood to vital
organs such as the brain. Increased blood flow in the Middle Cerebral Artery may
suggest fetal hypoxia.
Biochemical Testing

Used less frequently due to advancements in biophysical technologies.

Maternal serological markers:

• Alpha fetoprotein (AFP) (birth defects and genetic abnormalities)
• Human chorionic gonadotropin (hCG) (estimate gestion)
• Human placental lactogen (HPL) (related to diet)
• Estriol (low.. Down syndrome or fetal demise)
• Diamine oxidase (metabolic barrier against excess histamine)
Intrapartum Fetal Monitoring

The primary objective of Intrapartum Fetal Monitoring is to identify fetal hypoxia during the intrapartum
period (labour) and therefore allow for timely intervention.

Common techniques utilized in intrapartum monitoring:

 Intermittent Auscultation of Fetal Heart Rate
 Continuous Fetal Heart Rate monitoring with Cardiotocography
Intermittent Auscultation
of the Fetal Heart Rate
Instruments involved: Pinard’s Stethoscope or Doppler.
Auscultate the fetal heart for one minute through a uterine contraction for:
➢ First Stage- every 15 minutes
➢ Second Stage- every 5 minutes
Any abnormalities in baseline heart rate or presents of decelerations require
continuous fetal heart rate monitoring
Limitations

 Requires one to one midwife care.

 Requires experienced practitioners with experience in palpating
contractions and recognition of fetal heart rate changes.
 No printed recording to allow for future review.
 Difficult to auscultate the fetal heart rate in the obese patients.
 Not suitable for monitoring multiple pregnancies.
 Baseline variability, reactivity and some decelerations are not
detectable.
 Continuous Fetal Monitoring
with Cardiotocography
Indications:
Antepartum Intrapartum
• Previous C-section • Oxytocin augmentation
• Maternal diseases e.g. Pre-eclampsia or Diabetes • Epidural Analgesia
• Post term (> 42 weeks) • Maternal pyrexia
• Prolong membrane rupture (>24 hours) • Fresh meconium-stained liquor
• Induction of labour
• Antepartum Haemorrhage

Fetal
• Intrauterine Growth Restriction (IUGR)
• Prematurity
• Breech presentation
• Oligohydramnios
• Meconium-stained liquor
Cardiotocography

Components of Intrapartum Cardiotocography:

 Baseline Fetal Heart Rate: 110-160 bpm

 Baseline Variability: 5-25 bpm

 Accelerations

 Decelerations:

➢ Early Decelerations- Peak of contraction matches deceleration peak; may indicate fetal head compression

➢ Late Decelerations- Deceleration occurs after the onset of the contraction; may indicate fetal hypoxia or any
condition causing uteroplacental insufficiency

➢ Variable Decelerations- Decelerations at random time amount and lengths. May indicate cord compression
or seen in malpresentation, oligohydramnios and post term pregnancies.
 Sinusoidal Fetal Heart Rate Pattern: Associated with sudden fetal anaemia due to Rhesus incompatibility, fetal
Intracranial Haemorrhage, Twin to Twin transfusion syndrome (TTTS),
severe fetal hypoxia and asphyxia
Cardiotocography Classification
Cardiotocography Categorization
Intermittent Auscultation vs CTG

Studies show:
There was an increase in the chance of C-Section with Intermittent
Auscultation.
No reduction in the risk of neonatal seizures or Cerebral Palsy
No observed reduction in perinatal mortality when compared
No difference in APGAR scores or neonatal ICU admission
Fetal Scalp
and Umbilical Cord Blood Sampling

In the presence of abnormal fetal heart rate patterns on CTG, fetal blood sampling can be conducted to
assess fetal wellbeing. This influence decision to continue labour or convert to abdominal delivery.

Fetal Scalp pH Umbilical Blood pH

Normal: > 7.25 Normal umbilical artery: 7.18 – 7.38

Acidosis : < 7.20 (immediate delivery) Normal umbilical vein: 7.25 – 7.45
References

Roopnarinesingh’s Textbook of Obstetrics

https://americanpregnancy.org/healthy-pregnancy/pregnancy-health-wellness/first-fetal-movement/
https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2021/06/antepartum-fetal-surveillance
https://pubmed.ncbi.nlm.nih.gov/26467769/
https://www.glowm.com/article/heading/vol-5--surveillance-of-fetal-wellbeing--fetal-movement-counting/id/411783#.Yz
QxL3bMLIU

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6510058/#:~:text=Antenatal%20CTG%20is%20most%20commonly,preg
nancy%20(after%2028%20weeks)
.
https://www.aafp.org/pubs/afp/issues/1998/0801/p453.html#:~:text=Symmetric%20growth%20restriction%20implies
%20a,the%20liver%2C%20muscle%20and%20fat.