Ante Part Um Assessment Final

8/8/2019 Ante Part Um Assessment Final

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Antepar tum

Assessment


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Antepartum Fetal Surveillance

Fetal Movement counting

Non stress test Contraction stress test

Biophysical Profile Scoring

Doppler Velocity


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Fetal Movements

7 weeks -onset of passive unstimulated fetal

activity commences and becomes more

sophisticated and coordinated by the end of

pregnancy

8 weeks-beyond 8 menstrual weeks, fetal

body movements are never absent for time

periods exceeding 13 minutes


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Between 20 and 30 weeks, general body

movements become organized and the fetus

starts to show rest-activity cycles

third trimester, fetal movement maturation

continues until about 36 weeks, when

behavioral states are established in 80 percent

of normal fetuses


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Fetal heart rate patterns, general body movements, and eye

movements and described four fetal behavioral states:

State 1F is a quiescent state (quiet sleep),

with a narrow oscillatory bandwidth of the

fetal heart rate.

State 2F includes frequent gross body

movements, continuous eye movements, and

wider oscillation of the fetal heart rate. This

state is analogous to rapid eye movement

(REM) or active sleep in the neonate.


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State 3F includes continuous eye movements

in the absence of body movements and no

accelerations of the heart rate. The existence

of this state is disputed (Pillai and James,

1990a). State 4F is one of vigorous body movement

with continuous eye movements and fetal

heart rate accelerations. This statecorresponds to the awake state in infants.


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fetal urine production in normal pregnancies

in states 1F or 2F.

bladder volumes increased during quiet sleep

(state 1F).

During state 2F, the fetal heart rate baseline

bandwidth increased appreciably, and bladder

volume was significantly diminished.


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Factors Affecting Fetal Activity

Fetal sleep Awake cycle

Amniotic Volume


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Fetal Sleep-Awake cycle

An important determinant of fetal activity

appears to be sleep-awake cycles, which are

independent of the maternal sleep-awake

state

Sleep cyclicityhas been described as varying

from about 20 minutes to as much as 75

minutes.


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Timor-Tritsch and associates (1978)

reported that the mean length of the quiet

or inactive state for term fetuses was 23minutes


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Patrick and associates (1982)

-measured gross fetal body movements

with real-time ultrasound for 24-hour periods

in 31 normal pregnancies and found the

longest period of inactivity to be 75 minutes.


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Amniotic Fluid Volume

Sherer and colleagues (1996) assessed the number of fetal movements in 465 pregnancies during

biophysical profile testing in relation to amnionic fluid volume

estimated using ultrasound.

They observed decreased fetal activity with

diminished amnionic volumes and suggested that

a restricted intrauterine space might physicallylimit fetal movements.


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Types of Fetal Movements

classified the movements into three categories

according to both maternal perceptions and

independent recordings using piezoelectric

sensors.

1.Weak

2. Strong

3. Rolling


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Fetal Movement Counting

Maternal perception

Doppler device

Real-time UTZ


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Maternal Perception

Most investigators have reported excellentcorrelation between maternally perceivedfetal motion and movements documented by

instrumentation.

For example, Rayburn (1980) found that 80

percent of all movements observed duringultrasonic monitoring were perceived by themother


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. In contrast, Johnson and colleagues (1992)

reported that :

beyond 36 weeks, mothers perceived only 16

percent of fetal body movements recorded by a

Doppler device. Fetal motions lasting more than

20 seconds were identified more accurately by the

mother than shorter episodes.


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Fetal Movement Counting

Count of Ten

4 Fetal movements in 1 hour after meal The count is accepted as reassuring if it ewquals

or exceeds a previously established baseline count


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Non Stress Test

Nonstress test:

describe fetal heart rate acceleration in

response to fetal movement as a sign of fetalhealth.

This test involved the use of Doppler-detected

fetal heart rate acceleration coincident with

fetal movements perceived by the mother


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Non-Stress Test


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Non Stress Test

By the end of the 1970s, the nonstress test

had become the primary method of testing

fetal health.

The nonstress test was much easier to

perform, and normal results were used to

further discriminate false-positive contraction

stress tests


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Non Stress Test

the nonstress test is primarily a test offetal

condition

it differs from the contraction stress test,which is a test ofuteroplacental function.


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Evaluates alertness of fetal CNS by observing

FHR characteristics of the non stressed fetus-

FHR response

(acceleration=reactivity) to fetal movements


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FHR acceleration

Increase baseline fetal heart rate of 15

beats/ min for at least 15 secs

Acceleration is the hallmark of Fetal Health


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NST interpretation

Reactive NST- 2 or more acceleration within 20

min.

Nonreactive NST- reactive criteria not met.

Unsatisfactory trace tracing quality cannotbe met.


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Contraction Stress Test

Evaluates the status of basal fetal O2 reserves

by observing FHR response to uterine

contraction.

Ways to perform CST:

1. Oxytocin stress test2. Nipple stimulation Test


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Contraction Stress Test


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Oxytocin Challenge Test

Contractions were induced using intravenous

oxytocin, and the fetal heart rate response

was recorded using standard monitoring. The

criterion for a positive (abnormal) test was

uniform repetitive fetal heart rate

decelerations.


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Contractions are induced with either oxytocin

or nipple stimulation if there are fewer than

three in 10 minutes.

If oxytocin is preferred, a dilute intravenous

infusion is initiated at a rate of 0.5 mU/min

and doubled every 20 minutes until a

satisfactory contraction pattern is established.


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Nipple Stimulation

induce uterine contractions is usually

successful for contraction stress testing

(Huddleston and associates, 1984).

involves the woman rubbing one nipple

through her clothing for 2 minutes or until a

contraction begins.


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She is instructed to restart after 5 minutes if

the first nipple stimulation did not induce

three contractions in 10 minutes.

Advantages include reduced cost and

shortened testing times.


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CST Interpretation

(-) no late deceleration

(+)- presence of late decelerations in 50% of

uterince contraction Suspicious CST- presence of late decelerations

but < 50% of UC

Hyperstimulation

Unsatisfactory


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FHR Deceleration

Decrease in baseline FHR of 15bpm for 15

secs

If in relation with uterine contractions -Early deceleration

-Variable deceleration

-Late deceleration


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Indications for CST

Vaginal delivery is contemplated

Prior to induction of labor

-Postdated pregnancy

-DM

-Severe HPN

-Oligohydramnios


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Biophysical Profile

Variables:

1. Determined through real time

ultrasonography -Fetal tone

-Fetal body movement

-Fetal Breathing -Amniotic fluid volume


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2. Determined through electronic fetal heart

rate monitoring

-

FHR reactivity


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Factors affecting Biophysical

Activities

1. Maturity of CNS

2. Sensitivity to hypoxia

3. Extent, duration, chronicity and frequencyof insult

4. Drugs that depress CNS

5. Sleep-wake cycle of fetus


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Fetal Breathing Paradoxical chest wall movement

During inspiration the chest wall paradoxically

collapses and the abdomen protrudes

(Johnson and co-authors, 1988).

In the newborn or adult, the opposite occurs.

One interpretation of the paradoxical

respiratory motion might be coughing to clear

amnionic fluid debris.


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Umbilical Artery Doppler Velocimetry Doppler ultrasonography is a noninvasive

technique to assess blood flow by

characterizing downstream impedance.


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The umbilical artery systolicdiastolic (S/D)

ratio, the most commonly used index, is

considered abnormal if it is above the 95th

percentile for gestational age or if diastolic

flow is either absent or reversed.


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Absent or reversed end-diastolic flow signifies

increased impedance to umbilical artery blood

flow.

It is reported to result from poorly

vascularized placental villi and is seen in the

most extreme cases of fetal growth restriction


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Current Antenatal Testing Recommendations

According to the American College ofObstetricians and Gynecologists (1999), there

is no "best test" to evaluate fetal well-being.

Three testing systemscontraction stress

test, nonstress test, and biophysical profile

have different end points that are considered,depending on the clinical situation.


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The most important consideration in decidingwhen to begin antepartum testing is the

prognosis for neonatal survival.

The severity of maternal disease is another

important consideration. In general, with the

majority of high-risk pregnancies, most

authorities recommend that testing begin by32 to 34 weeks.


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Pregnancies with severe complications might

require testing as early as 26 to 28 weeks.

The frequency for repeating tests has been

arbitrarily set at 7 days, but more frequent

testing is often done.


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Thank you!

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