~ ~

Fetal SurveillanceTo test fetal well-beingFetal physical activitiesMovementBreathingAmniotic fluid productionHeart rateGoal: to prevent fetal death

Tools for fetal assessmentFetal movementsNon-stress testBiophysical profileContraction stress testAmniotic Fluid VolumeDoppler ultrasound

Fetal MovementsUnstimulated fetal activity commences at 7 weeksRest-activity (1F-2F) cycles

Fetal Movements75%20-75Perception of 10 fetal movements in up to 2 hours is considered normalSelf monitor, poor sensitivity and specificity

Fetal heart rates assessmentCardiotocography (CTG), Fetal monitorFetal activity acceleration determination (FAD) Non-stress test (NST) Fetal acoustic stimulation test (AST, FAST) Vibroacoustic stimulation test (VAST)Contraction stress test (CST) Oxytocin challenge test (OCT)

External / Internal devicehttp://www.hopkinsmedicine.org/healthlibrary/test_procedures/gynecology/external_and_internal_heart_rate_monitoring_of_the_fetus_92,P07776/

NomenclatureBaselineVariabilityAccelerationDecelerationUterine contraction

BaselineThe mean fetal heart rate rounded to increments of 5 bpm during a 10-min segment, excluding:Periodic or episodic changesPeriods of marked FHR variabilitySegments of baseline that differ >25bpmNormal FHR: 110~160bpm*

Beat-to-beat variabilityVariability is visually quantified as the amplitude of peak-to-trough in bpmAbsentamplitude range undetectableMinimalamplitude range detectable but5 bpmModerateamplitude range 6~25 bpmMarkedamplitude range >25 bpm*http://www.motherbabyuniversity.com/outreach/outreach/PeaPods/1835%20Fetal%20Monitoring/Pages/describing%20FHR%20patterns.html

Sinusoidal patternVisually apparent, smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 35 per minute which persists for 20 minutes or more.

AccelerationA visually apparent increase in the FHR from the most recently calculated baselineDuration: time from initial change in FHR from the baseline to the return of the FHR to baselineAcceleration32 weeks: 15 bpm, duration 15 sec

DecelerationEarly decelerationLate decelerationVariable decelerationProlonged deceleration: >2min, 10min*

Early Deceleration Symmetrically , gradual decrease and recovery Onset to nadir 30 secs Onset , peak and ending with contractionCaused by fetal head compression with vagus nerve response

*http://www.motherbabyuniversity.com/outreach/outreach/PeaPods/1835%20Fetal%20Monitoring/Pages/describing%20FHR%20patterns.html

Late deceleration Periodic, symmetrically , gradual decrease and recovery Onset to nadir 30 secs Related to ueroplacental insufficiency

*http://www.motherbabyuniversity.com/outreach/outreach/PeaPods/1835%20Fetal%20Monitoring/Pages/describing%20FHR%20patterns.html

Variable deceleration Nadir 15 bpm,

Variable deceleration - ComplicatedNadir < 70 bpm, duration > 60 secondsSlow return to baselineRepetitive deceleration 3 times in 20 minutesRecurrent deceleration with > 50% of uterine contractions in any 20 minute segment

*

Major Guideline for CTGACOG (2009)RCOG ( 2007)SOGC ( 2007 )RANZCOGAOFOG

AntepartumNST / AST ResultsReactive / Reassuring Normal baseline, Moderate variability Present of 2 accelerations in 20 minutes No variable or late decelerationNon-reactive / Non-reassuring 90%, PPV 50 - 70%.

If non-reactive.Further evaluationBiophysical profileContraction stress testPregnancy termination as indicated

Intrapartum interpretationCategory I, include all of following:Baseline 110-160 bpm, Moderate variability, No late or variable deceleration, Present or absent of accelerationCategory II, not categorize as I or IIICategory III, include either:Absent of baseline variability with recurrent late / variable deceleration or bradycardiaSinusoidal pattern

If not category ITreatment of maternal hypotension (IV)Provision of maternal oxygen (O2)Change in maternal position (Left decubitus position)Discontinuation of labor stimulationTreatment of tachysystoleDelivery if refractory

Medication affects results

Amniotic Fluid VolumeDecreased uteroplacental perfusion may lead to diminished fetal renal blood flow, decreased urine production, and ultimately, oligohydramnios.Amnionic fluid index < 5 cm or deepest pocket < 2 cm are acceptable criteria for oligohydramnios

Contraction Stress TestOxytocin challenge test / Nipple stimulationGoal: 3 contractions of 40-60 sec present in 10 minsResults:Negative: no late or significant variable decelerationsPositive: late decelerations in > 50% contractions

29late deceleration 100()

100()

24 G2P142 variable deceleration97()

98()contraction stress test nonstress test21 2021515 90non-reactive

Score 2Score 0Non stress testReactiveNon-reactiveFetal breathing 1 episode 30 sec in 30 minsAbsent / Less than 30 mins Fetal movement 3 body or limb movement in 30 mins2 or lessFetal tone 1 in 30 minsAbsent / Extension with no flexionAmniotic fluid volumeNormalOligohydramnios

~ Delivery ~

Modified biophysical profileNon-stress test + Amnionic fluid volumeEither one did not meet the criteria is considered abnormalLess time and labor consumingFalse-negative rate 0.08%, False positive rate of 1.5%

Fetal Death After Normal BPPFeto-maternal hemorrhageUmbilical cord accidentsPlacental abruption

Incidence: 1/1000

biophysical profile 102()

120fetal acidosis240 10pH

33G4P2A133biophysical profile, BPP4 101()

BPP6 BPP8 BPP8

Doppler Blood Flow VelocityFetal vessels for growth restriction evaluationUmbilical artery, Middle cerebral artery, Ductus venosusUterine artery for placental functionHowever, most perinatal outcome doesnt change while identification of abnormality, only umbilical artery Doppler is recommend by ACOG for fetal surveillance

Umbilical Artery DopplerS/D ratio: most commonly used indexAbout 4.0 at 20 weeks, 2.0 at 40 weeksGenerally < 3.0 after 30 weeksWave form: End diastolic flow Perinatal mortalityAbsent end-diastolic flow: 10%Reversed end-diastolic flow: 33%

Middle Cerebral ArteryHypoxic fetus attempts brain sparing by reducing cerebrovascular impedance and thus increasing blood flow, but no significant differences in pregnancy outcome compare to biophysical profileUseful for detection and management of fetal anemia of any causeIf PSV > 1.5 MoM Fetal blood sampling Transfusion if needed

Ductus VenosusThe best predictor of perinatal outcomeNegative or reversed flow in the ductus venosus was a late finding because these fetuses had already sustained irreversible multiorgan damage due to hypoxemiahttps://iame.com/online/multi_vessel_doppler/figure_3a.jpg

Uterine ArteriesMost helpful assessing pregnancies at high risk of uteroplacental insufficiencyPerinatal benefits of uterine artery Doppler screening have not yet been demonstratedNotch indicates increased resistance

In summaryAntepartum fetal surveillance telling more about the well-being of the babyAn abnormal result not always mean that the baby is in trouble. It simply mean that you need special care or test

23 G2P135 103()

23 G2P135 103()

103()Absence of end-diastolic flow velocityReversed end-diastolic velocityDecrease of middle cerebral arterial flowIncrease of middle cerebral arterial flow

Classification

ACOG RCOG SCOGCategory Category 1Category 2Category 3Classification Normal Suspicious Pathological Reassuring Non-reassuring Abnormal ClassificationNormal Atypical Abnormal

Baseline

ACOG RCOG SCOGDefinitionThe mean FHR rounded to increments of 5 beats per minute during a 10-minute segment, excludingPeriodic or episodic changesPeriods of marked FHR variabilitySegments of baseline that differ by more than 25 beats per minute FHR trace is stable excluding acceleration and deceleration in 5 to 10 mins Mean FHR rounded to increments of 5 beats in 10-minute segment, excluding Periodic or episodic changes or periods of marked FHR Variability(>25)Normal 110-160 bpm110-160 bpm110-160 bpm

Tachycardia>160 bpmModerate 161-180Abnormal 160 bpm > 10 minsBradycaridia

ACOG RCOG SCOGVariability is visually quantitated as the amplitude of peak-to-trough in beats per minute.Absentamplitude range undetectableMinimalamplitude range detectable but 5 beats per minute or fewerModerate (normal)amplitude range 625 beats per minuteMarkedamplitude range greater than 25 beats per minute3-5 cycles / mins

-Reassuring >=5-Non-reassuring< for 40-90 mins-Abnormal

Acceleration A visually apparent abrupt increase (onset to peak in less than 30 seconds) >= 32 weeks , > 15 bpm for > 15 secs- 2 mins < 32 weeks , > 10 bpm for 10 secs- 2mins

ACOG SCOG Prolonged acceleration lasts 2 minutes or more but less than 10 minutes in duration. If an acceleration lasts 10 minutes or longer, it is a baseline change.

Early Deceleration

ACOG SCOGVisually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction A gradual FHR decrease is defined as from the onset to the FHR nadir of 30 seconds or more. The decrease in FHR is calculated from the onset to the nadir of the deceleration. The nadir of the deceleration occurs at the same time as the peak of the contraction. In most cases the onset, nadir, and recovery of the deceleration are coincident with the beginning, peak, and ending of the contraction, respectively. They are associated with fetal head compression during labour and are generally considered benign and inconsequential. This FHR pattern is not Normally associated with fetal acidemia.

ACOG SCOG The decrease in FHR is calculated from the onset to the nadir of the deceleration. The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction. In most cases, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectivelyLate decelerations are found in association with Uteroplacental insufficiency and imply some degree of hypoxia.

Variable Deceleration Nadir 15 bpm , de > 2 mins

There are autonomic influences mediated by sympathetic or parasympathetic impulses from brainstem centers that normally increase or decrease the fetal heart rate*Loss of such reactivity, however, is most commonly associated with sleep cycleIt also may be caused by central depression from medications like magnesium or cigarette smoking*Fetal anemia, analgesic drugs such as morphine, meperidine, alphaprodine, and butorphanol, and chronic fetal distress should be considered.***Although a normal number and amplitude of accelerations seems to reflect fetal well-being, their absence does not invariably predict fetal compromise. Indeed, some investigators have reported 90-percent or higher false-positive rates (Devoe, 1986). Because healthy fetuses may not move for periods of up to 75 minutes, some have considered that a longer duration of nonstress testing might increase the positive-predictive value of an abnormal, that is, nonreactive, test (Brown, 1981). In this scheme, either the test became reactive during a period up to 80 minutes or the test remained nonreactive for 120 minutes, which indicated that the fetus was very ill.*A score of 8 or 10 is reassuring, and routine surveillance and expectant obstetric management may continue. A score of 6 raises concern, and the BPP should be repeated in 6 to 24 hr, especially in fetuses over 32 weeks' gestation. If the score does not improve, delivery should be considered, depending on gestational age and individual circumstances. Scores of 4 or below are worrisome, and delivery should be considered, again depending on gestational age and clinical context. It is important to consider that fetal breathing can be reduced in preterm fetuses