biophysial and biochemical examination for fetal well being

2. AASSSSEESSSSMMEENNTT
OOFF
MMAATTEERRNNAALL AANNDD FFEETTAALL
WWEELLLL BBEEIINNGG
DDUURRIINNGG PPRREEGGNNAANNCCYY
PPrreesseenntteedd bbyy::
SShhaalliinnii jjoosshhii
MM..SSCC..((NN)) 11sstt yyrr..

3. DDeeffiinniittiioonn ::
‘‘ Assessment’ means is ‘to evaluate’ i.e.
here we gather the information of client
status and it identifies the specific needs
of a client by which better care can be
given to the client and her developing
fetus.That means,it is the systematic
supervision(examination & advice)of a
woman during pregnancy.So,it is the
foundation stone for antenatal care.

5. OOBBJJEECCTTIIVVEESS::
To screen the ‘high risk’ cases.
To prevent or to detect and treat at the earilest
any complications.
To ensure continued medical surveillence and
prophylaxis.
To educate mother about the physiology of
pregnancy and labour by demonstration,charts
and diagrams so that fear is removed and
psychology is improved.

6. CCoonnttdd……
To discuss with the couple about the
place,time and mode of delivery and care
of newborn.
To motivate the couple about to the need
of family planning.
To give appropiate advice to couple
seeking MTP.

8. AASSSSEESSSSMMEENNTT
MMaatteerrnnaall
MMeeaassuurreess
FFeettaall
MMeeaassuurreess

9. MMAATTEERRNNAALL MMEEAASSUURREESS ::
History Taking
Examination
• General
• Physical
• Obstetrical
Radiological Examination

11. History Taking
Vital Statistics
 Name: …………………………..
 Date of first examination: ……..
 Address:…………………………
 Age:………………………………
 Gravida:Parity…………………..
 Duration of marriage: ………….
 Religion:…………………………

12. CCoonnttdd……
• Occupation: ……………………………
• Period of Gestation: …………………..
Chief Complaints: …………………….
History Of present illness:……...........
History of present pregnancy: ……….
Obstetrics History:……………………..
Menstrual history: ……………………..
Past medical history: ………………….
Past surgical history: …………………..

13. CCoonnttdd……
Family History
Personal History
Investigations
Hb
ABO/Rh
HIV/HbsAg/VDRL
USG
PAP smear
Blood sugar
Urine analysis

14. AANNTTEENNAATTAALL EEXXAAMMIINNAATTIIOONN

15. EExxaammiinnaattiioonn ::
General and Physical Examination:
• Build:Obese/Avgerage/Thin
OBESE

16. CCoonnttdd……
 Nutrition:Good/Average/Poor

17. CCoonnttdd……
• Height:Short stature is likely to be
associated with small pelvis.

18. CCoonnttdd……
Weight:The total weight gain during the
course of singleton pregnancy for a
healthy women averges 11 kg(24 Ib)
BMI(20-26) is 11 to 16 kg
BMI >29 not gain more than 7 kg
BMI <19 allowed to gain upto 18 kg

19. CCoonnttdd……
• Pallor:The sites to be noted are lower
conjunctiva,dorsum of tongue and nail
beds.
EYES TONGUE NAIL BED

20. CCoonnttdd……
• Jaundice:The sites to be noted are
conjunctiva,tongue,skin.

21. CCoonnttdd……
• Tongue,teeth,gums and tonsils:
GLOSSITIS STOMATITIS

22. CCoonnttdd……
• Neck:Neck veins,thyroid gland or lymph
nodes should be inspected.
NECK VEINS GOITRE

23. CCoonnttdd……
• Oedma of legs:The site of oedma are over the
medial malleolus and anterior surface of the
lower 1/3rd of the Tibia.Pitting oedma and
varicosity also should be inspected.
Oedma Varicosity

24. CCoonnttdd……
• Breast Examination:It should be inspected
for pregnancy changes.

25. OObbsstteettrriiccaall EExxaammiinnaattiioonn ::
ABDOMINAL
EXAMINATION
VAGINAL
EXAMINATION

26. AAbbddoommiinnaall EExxaammiinnaattiioonn::
Fundal grip Lateral grip
Pelvic grip Pawlik’s grip(3rd
Leopold)

27. CCoonnttdd……
F.H.S.
Fundal
height

28. VVaaggiinnaall EExxaammiinnaattiioonn::
It should be done by using the left fingers(thumb &
index),the character of vaginal discharge,cervix
consistency,cystocele,uterine prolapse,rectocele is to be
elicited.
Prolapse

29. CCoonnttdd……
Can be done for taking vaginal swabs for
investigations:

30. RRaaddiioollooggiiccaall EExxaammiinnaattiioonn::
INDICATIONS:(5 Rads)
 Diagnosis of
pregnancy
 Fetal maturity
 X-ray Pelvimetry
 X-ray chest
 Congenital
malformation

31. Absorbed radiation by the fetus in different
diagnostic radiation procedures:
PPRROOCCEEDDUURREE DDOOSSEE((RRAADDSS))
Abdominal X-Ray
0.263
Pelvic X-Ray
0.5-1.1
Chest X-ray
<0.001
Abdominal CT
0.50-1.10
Ventilation lung scan 133 Xe
0.004-0.019

32. FFEETTAALL MMEEAASSUURREESS

34. FFEETTAALL MMEEAASSUURREESS::
Clinical(Maneuvers)
Biochemical(MSAFP,Triple test,AChE,)
Cytogenetic
• Amniocentesis
• Chorion Villus Sampling(CVS)
• Cordocentesis
• Fluorescence In Situ Hybridisation(FISH)

35. CCoonnttdd……
Biophysical
• Fetal movement count(DFMC)
• Non Stress Test(NST)
• Fetal biophysical profile(BPP)
• Cardiotocography
• Contraction stress test(CST)
• Doppler Ultrasound
• Vibroacoustic stimulation(VAS)

43. BBiioopphhyyssiiccaall PPrrooffiillee::
It is the screening test for utero-placental
insufficiency.The fetal biophysical
activities are initiated,modulated and
regulated through fetal nervous
system.The fetal CNS is very much
sensitive to diminished oxygenation.

44. CCoonnttdd……
HHyyppooxxiiaa
CChhaannggeess iinn ffeettaall
BBiioopphhyyssiiccaall pprrooffiillee
CCNNSS ddeepprreessssiioonn MMeettaabboolliicc AAcciiddoossiiss

47. CCoonnttdd……
 It is the continuous electronic
monitoring of the fetal heart rate
along with recording of fetal
movements (cardiotocography) is
undertaken.
 FHR acceleration with fetal
movements,which when
present,indicates a healthy fetus.
 It is used as screening test.
 The test is valuable to identify the
fetal wellness rather than illness.
 Test should be started after 30
weeks and frequency should be
twice weekly.

48. CCoonnttdd……
• Reactive(Reassuring): When two or more
acceleration of more than 15 beats per
minute above the base line and longer
than 15 sec in duration are present in a 20
min observation.
• Non-Reactive(Non-Reassuring):Absence
of any fetal reactivity.

49. FFeettaall CCaarrddiioottooccooggrraapphhyy

51. Fetal movement count(DFMC)
• The patient counts the fetal movements every
morning,noon and evening.
• Three counts each of one hour duration are
recommended.
• If the no. of kicks are less than 10 in 12 hrs. or 3
in each hour it indicates fetal compromise.
• Increased fetal movements associated with
maternal hypoglycemia.
• Decreased FM cause obesity,smoking,hypoxia,
anterior placenta,hydramnios,narcotic drugs.

53. IInnddiiccaattiioonnss ::
• Diagnosis of pregnancy.
• Assessment of gestational age.
• Diagnosis of multiple pregnancy.
• Assessment of IUGR or BPP.
• Uterine size either > dates or < dates.
• Asessment of liquor volume.
• Diagnosis of any abnormality e.g. placenta
praevia etc.

54. CCoonnttdd……

56. The Nuchal translucency is
used to provide a risk
assessment for
chromosomal
abnormality, specifically
Trisomies 13, 18 and
21(Downs Syndrome).
This is a risk assessment
based on age, heritage,
history, and a specific
ultrasound measurement.
The accuracy of this is
increased by factoring in
the levels of bHCG and
PaPP-A in the maternal
blood. Nuchal
Translucency (11-14
weeks : CRL 45-84mm)

60. Associated with spina
bifida (secondary to
cord tethering)
“Banana sign”.
BANANA SIGN

61. “Lemon Sign" is inward
scalloping of the
frontal bones and is
associated with
"open" spina bifida
and the Chiari II
malformation

62. Wks of gestation BPD mm FL mm HC mm AC mm
12 21 8 70 56
13 25 11 84 69
14 28 15 98 81
15 32 18 111 93
16 35 21 124 105
17 39 24 137 117
18 42 27 150 129
19 46 30 162 141
20 49 33 175 152
21 52 36 187 164
22 55 39 198 175

63. WKS in
gestation BPD mm FL mm HC mm AC mm
23 58 42 210 197
25 64 47 232 208
26 67 49 242 219
27 69 52 252 229
28 72 54 262 240
29 74 56 271 250
30 77 59 280 260
31 79 61 288 270
32 82 63 296 280
33 84 65 304 290
34 86 67 311 299

64. Wks in
gestation BPD mm FL mm HC mm AC mm
35 88 68 318 309
36 90 70 324 318
37 92 72 330 327
38 94 73 335 336
39 95 75 340 345
40 97 76 344 354
41 98 78 348 362
42 100 79 351 371

68. CCoonnttdd……
• IUGR cab be diagnosed accurately with serial measurement of
BPD,AC,HC and amniotic fluid volume.
• AC is the single measurement which best reflects fetal nutrition.
• The avg. increase of BPD beyond 34 wks is 1.7 mm/wk.
• When HC/AC ratio is elevated(>1.0) after 34 wks,IUGR is
suspected.
• A measurement of BPD of 9.8 cm indicates maturity.
• Increased fetal nuchal skin thickness(in first trimester)>3 mm by
TVS is a strong marker for chromosomal anomalies(trisomy
21,18,13)
• CRL(in mm)+6.5=Gestational age in wks.After 12 wks it get
decreased.
• GS should increase by 1.1 mm in diameter/d.

69. DDoopppplleerr UUllttrraassoouunndd

70. CCoonnttdd……
• Doppler velocimetry of umbilical artery is
studied in pregnancy with complications.
• Used to measure the Peak
systolic(S),peak diastolic(D) and mean
values.
• Pulsatility index(P.I.)=(S-D)/M
• S/D & PI decreases with gestational age if
it increases shows IUGR,HTN.

71. MMooddiiffiieedd BBiioopphhyyssiiccaall PPrrooffiillee::
It consists of NST and ultrasonography
determined amniotic fluid index(AFI).
Modified BPP is considered abnormal
(nonreassuring) when the NST is non
reactive and/ or the AFI is <5.

72. Fetal BBiioopphhyyssiiccaall PPrrooffiillee:: ((BBPPPP))
Observation for 30 mins.Normal score =2. Abnormal=0
PPaarraammeetteerrss MMiinniimmaall nnoorrmmaall ccrriitteerriiaa SSccoorree
Non Stress
Reactive pattern 2
Test(NST)
Fetal
1 episode lasting>30 sec 2
Breathing
movements
Gross body
3 discrete body/limb movements 2
movements
Fetal muscle
tone
Amniotic fluid
1 episode of extension with return 2
flexion
1 pocket measuring 2 cm in 2 2
perpendicular planes

73. CCoonnttrraaccttiioonn ssttrreessss tteesstt::
• It is based to observe the response of the
fetus at risk for uteroplacental insufficiency
in relation to uterine contractions.
• Test is +ve when late decelerations are
present with onset of contractions.
• It has high false +ve rate.
• NST & BPP should be done when CST is
+ve before doing any intervention.

74. INDICATIONS:
Intrauterine growth restriction
Postmaturity
Hypertensive disorders of pregnancy
Diabetes

75. CCOONNTTRRAAIINNDDIICCAATTIIOONNSS::
Compromised fetus
Previous history of Caesarean section
Complications likely to produce preterm
labour
APH

76. SSUUMMMMAARRIIZZAATTIIOONN::
• Assessment
• Maternal measures(H/T,OBS. Grips)
• Fetal measures(NST,CST,DFMC,USG)

77. RREECCAAPPTTUULLIISSAATTIIOONN::
• Assessment of mother
History Taking
Examination
• General
• Physical
• Obstetrical
Radiological Examination

78. • FFEETTAALL MMEEAASSUURREESS::
Clinical(Maneuvers)
Biophysical
• Fetal movement count(DFMC)
• Non Stress Test(NST)
• Fetal biophysical profile(BPP)
• Cardiotocography & USG.

79. BBIIBBLLIIOOGGRRAAPPHHYY::
• Dutta D.C. “TEXTBOOK OF
OBSTETRICS” New Central Book Agency
(P) LTD 2009 Pp 95-113
• Myles “TEXTBOOK FOR MIDWIVES”
Churchill Livingstone 14 edition Pp 251-
272:417-422
• BNS-103 Maternal health Nursing IGNOU
Pp 67-70

80. CCoonnttdd ......
• http:www.hps.org/physiccians/radiology-pregnant-
patient-qa.html
• http://www.scribd.com/doc/6624348/Bioph
ysical-Assessment
• http://www.brooksidepress.org/Products/M
ilitary_OBYGN/Ultrasound/2ndand3rdTrim
esterUltrasoundScanning.html
• http://www.ultrasoundpaedia.com/USP2nd
trimesterpathologywinner.html

81. TTHHAANNKK YYOOUU !!!!!!