antenal fetal surveillance

1. SEMINARSEMINAR
ONON
ANTENATAL FETALANTENATAL FETAL
SURVEILLANACESURVEILLANACE
PRESENTED BYPRESENTED BY::
MS LISA CHADHAMS LISA CHADHA
MSC NURSING 1MSC NURSING 1STST
YEARYEAR
BVCON ,PUNEBVCON ,PUNE

2. DefinitionDefinition
Antenatal fetal surveillance is assessmentAntenatal fetal surveillance is assessment
of fetal wellbeing in antepartum period toof fetal wellbeing in antepartum period to
ensure delivery of healthy neonate.ensure delivery of healthy neonate.

3. IndicationsIndications
Maternal conditionsMaternal conditions
HypertensionHypertension
Diabetes mellitusDiabetes mellitus
Heart DiseaseHeart Disease
Chronic renal diseaseChronic renal disease
Acute febrile illnessAcute febrile illness
Pneumonia /asthmaPneumonia /asthma
EpilepsyEpilepsy
Drug AbuseDrug Abuse
Sickle cell diseaseSickle cell disease
Fetal conditionsFetal conditions
Fetal growthFetal growth
restrictionrestriction
Rh isoimmunisationRh isoimmunisation
Fetal CardiacFetal Cardiac
arrythmiasarrythmias
Fetal infectionsFetal infections

4. Pregnancy related condition
Preeclampsia
Multiple pregnancy
Post term pregnancy
Decreased fetal movements
Abnormal placentation
Placental abruption

5. Aims of Fetal MonitoringAims of Fetal Monitoring
Assuming satisfactory growth & wellbeing ofAssuming satisfactory growth & wellbeing of
fetus & mother throughout pregnancyfetus & mother throughout pregnancy
Screening high risk cases & adverse maternalScreening high risk cases & adverse maternal
and/or intrauterine factors which affect the fetusand/or intrauterine factors which affect the fetus
Detecting early congenital anomalies and inbornDetecting early congenital anomalies and inborn
metabolic disorders to decide early terminationmetabolic disorders to decide early termination

6. Objectives of Fetal SurveillanceObjectives of Fetal Surveillance
To determine gestational ageTo determine gestational age
To discover fetal congenital anomaliesTo discover fetal congenital anomalies
To detect abnormalities of fetal growthTo detect abnormalities of fetal growth
To detect & determine the severity of acute &To detect & determine the severity of acute &
chronic fetal hypoxiachronic fetal hypoxia

7. Initiation of antepartum fetalInitiation of antepartum fetal
surveillancesurveillance
EARLY PREGNANCYEARLY PREGNANCY
LATE PREGNANCYLATE PREGNANCY

8. EARLY PREGNANCYEARLY PREGNANCY

9. Early pregnancyEarly pregnancy

11. BiochemicalBiochemical
A. Material serum alpha foeto protein
It is the onco protein
It is produced by yolk sac & foetal liver.
The highest level of the AFP in foetal serum &
amniotic fluid .
Material serum level peak around 32 weeks .
MSAP screening can be done between 15 - 21
weeks gestation (17 weeks is ideal)

12. MSAFP elevated at
Wrong gestational age
Open neural tube defect of the foetus
Multiple pregnancy
IUF
Anterior abdominal wall defects
Renal anomalies
MSAFP is low at
Trisomies (Down syndrome)
Gestational trophoblastic diseases
neural tube defect

13. B. Triple test
It is combined biochemical test which includes
MSFP, HCG & UE3 (unconjugated oestriol) .
It is used for detection of down syndrome .
In an affected pregnancy level of MSAFP & UE3
tend to be low while that the HCG is high .
It is performed at 15-18 weeks .

14. C. Coomb’s test
Coomb’s test is used for Rh incompatibility.
if the coomb’ test is greater than 1:8 to 1:16 thann,
amniocentesis is done for diagnosis of need for
intrauterine transfusion.
It is used to detect presence or absence of the
material antibodies on fetal red cells .
if there are no antibodies , the blood is retested at
28 & 34 weeks of pregnancy.

15.  D. Acetyl choline esterase(AchE)
 It is elevated in most cases of open neural tube
defects , it has got better diagnostic value than
AFP.
E. Inhibin A
It is dimetric glycoprotein . it is produced by the
corus luteum & the placenta
.
serum level of the inhibin A is raised in the women
carrying a foetus with down syndrome

17. A. Florescence in Situ Hybridization(FISH)
FISH, or Fluorescence In Situ Hybridization, is a diagnostic
prenatal test which looks for a few common chromosomal
abnormalities mainly limited to Trisomy 13 (Patau syndrome),
Trisomy 18 (Edward’s syndrome) and Trisomy 21 (Down
syndrome) .
FISH does not have false positive results. If the fetal cells
contain certain chromosomal abnormalities, this will be apparent
with the FISH test.
The only exception might be if the parent has a chromosomal
abnormality and the fetal cells were contaminated with parental
cells.

18.
B. DNA amplification using the polymerace chain
reaction[PCR]
It provides the convenient & efficient means of
making millions of copies of a sort DNA sequence
heating cooling cycles are used to denature to DNA
& then build new widely used for assessing genetic
variation , for diagnosing genetic disease & for
forensic purpose.
It can be made directly from fetus by
amniocentesis
chorionic villi sampling
chrordiocentesis.

19. Amniocentesis
It is an invasive procedure, it is performed between
14-16 weeks of the pregnancy
By inserting a needle through the abdominal wall
into the amniotic sac . it is the procedure of the
collection or removal os amniotic fluid(appro. 10-15
ml)
colour of the amniotic fluid is usually in transparent
colour .
A yellowish tinge may suggest the blood
incapability & green may suggest meconium staining

20. Indications
Genetic testing- Genetic amniocentesis done to
detect certain conditions, such as Down syndrome.
Fetal lung testing- To determine whether the
baby's lungs are mature enough for birth.
Diagnosis of fetal infection- To evaluate a baby
for infection or other illness. The procedure also can
be done to evaluate the severity of anemia in babies
who have Rh sensitization — an uncommon
condition in which a mother's immune system
produces antibodies against a specific protein on the
surface of the baby's blood cells.

21. Treatment
To drain excess amniotic fluid from your
uterus in case of polyhydrominos

22. Risks
[1] Maternal :
Infection
Haemorrhage
 Premature rupture of the membrane and premature labour
Maternal iso- immunization in Rh mothers
[2] Foetal
Abortion
Trauma
Foeto maternal haemorrhage
 Oligohyromnios
fetal lung hypoplasia
Respiratory distress

23. Chorionic Villi Sampling
CVS is performed for prenatal diagnosis of genetic
disorders .
It is carried transcervically between 10-12 weeks
and transabdominally from 10th
week to term.
Diagnosis is obtained by 24 hours and as such
termination is required it can be done safely in the
first trimester itself .
The technique is used in CVS are direct vision
using a hysteroscope and transabdominal or
transvaginal aspiration guided by ultrasound .

24.  Transcervical: An ultrasound guides a thin
catheter through the cervix to your placenta. The
chorionic villi cells are gently suctioned into the
catheter. This is the most common method.
 Transabdominal: An ultrasound guides a long
thin needle through the abdomen to your
placenta. The needle draws a sample of tissue
and then is removed. This procedure is similar
to that of amniocentesis

25. Indication :
chromosomal analysis – down syndrome and other
chromosomal anomaly
DNA analysis – molecular genetic technique for the
thalassaemia,sickle cell Diseases
Enzyme analysis –in born error metabolism

26. Chorionic villus sampling does not detect:
Neural tube defects
Rh incompatibility
Complications:
foetal loss (1-2%) , oromandibular limb deformities ,
vaginal bleeding, limb reduction defects are high
when CVS are less then 10 week of the gestation
CVS when performed between 10-12 weeks are
safe and accurate as that of the of the aminocentesis

27. Fetoscopy
This is the technique where by direct visualization of the
fetus is undertaken via an endoscope
A cannula 2.4,3.0 mm in diameter with a selfoscope
1.7mm in diameter , attached to a microscope and with the
fine glass fibre light source is inserted transabdominally
under local anaesthesia .
An ultrasound scan is performed immediately prior to the
technique so that damage to placenta and fetus is kept to the
minimum.
It can be performed in 18-20 weeks and the following
samples can be obtained during the procedure
Fetal liver biopsy [metabolic disorders ]
Fetal skin biopsy [ skin disorders ]

28. Fetal Blood Sampling
Cordocentsis ( percutaneous umbilical blood
sampling )
Direct access to the fetal circulation during the
second and third trimesters is now possible through
PUBS . It is the most widely used method for fetal
blood sampling and transfusion
PUBS is now the route of choice for intrauterine
transfusion for severely anemic fetuses; it can start as
early as 19 weeks

29. Indication for fetal blood samling
 Fetal hemolytic disorder
 Fetal infection
 Acid-base balance - for fetal growth
restriction
 Karyotyping
 Suspected fetal thrombocytopenia
 Twin –twin transfusion syndrome
 Fetusl thyroid disorders
 Suspected fetal anaemia
 Abnormal Doppler flow
 Duodenal atresia
 Single umbilical artery
 Omphalocele

30. Risk:
This invasive procedure may lead to abortion,
preterm labour or preterm rupture of the
membrane,fetal bradycardia,chrorioamniotics.

32. BIOPHYSICAL
Ultrasonography
 Ultrasonography examination of the fetus in the early
[10-14 week] pregnancy can detect the foetal anomalies.
 Detection rate is about 70-80% with the false positive rate
of 5-6 %.
 The ultrasound is a sound wave beyond the audible
range of frequency greater than 2MHz(cycle per second).
SONAR stands for “sound,navigation,rating”. The clinical use
was introduced by lan Donald in Glascow in 1958.
It can be done
Transvaginal
Transabdominal

33. Magnetic resonance imaging(MRI)
 It is the non invasive procedure that can be used
for the fetal well being.
An MRI (or magnetic resource imaging ) scan is a
radiology technique that uses magnetism , radio
waves, & a computer to produce images of body
structures

34. Purpose
Fetal structure – CNS,thorax,
abdomen,genitourinary tract, musculoskeletal tract
& overall growth.
Placenta – it position , density & evalucation of
the trophoblastic diseases.
Amniotic fluid quantity
Biochemical , functional & metabolic malformation

36. Late pregnancyLate pregnancy

37. CLINICALCLINICAL

38. CLINICAL
The clinical assessment to done to assess the foetal
growth.
It can be done by following methods:-
Maternal weight gain
Blood pressure
Assessment of size of uterus & height of fundus
Clinical assessment of liquor
Edema of feet
Abdominal girth in last trimester

39. 1.Maternal weight gain:1.Maternal weight gain:
In second half of pregnancy: average weight
gain is 1 kg/fortnight.
Excess weight gain: Could be 1st
sign of pre-
eclampsia.
If weight gain less than normal, stationary or
falling: Look for IUGR

40. 2. Blood pressure:
Initial recording of BP prior to 12 weeks helps to
differentiate pre-existing chronic hypertension from
pregnancy induced hypertension.
Hypertension, pre-existing or pregnancy induced
may impair fetal growthh.

41. 3. Assessment of size of uterus & height of
fundus:
Top of fundus is measured from superior border of
symphysis pubis (bladder should be empty) using a
tape.
After 24 weeks of pregnancy, distance measured in
cm normally corresponds to period of gestation in
weeks

42. 4.Clininical4.Clininical assessment ofassessment of
liquorliquor
The normal range of aminioticThe normal range of aminiotic
fluid volume (AFI) is wide butfluid volume (AFI) is wide but
the approximate volumes are:the approximate volumes are:
- 500 ml at 18 weeks- 500 ml at 18 weeks
- 800 ml at 34 weeks.- 800 ml at 34 weeks.
- 600 ml at term.- 600 ml at term.
Clinical assessment is unreliable.Clinical assessment is unreliable.
Objective assessment depends on USGObjective assessment depends on USG
to measure:to measure:
- deepest vertical pool (DVP).- deepest vertical pool (DVP).
- Amniotic fluid- Amniotic fluid index (AFI).index (AFI).

43. BIOCHEMICALBIOCHEMICAL

44. BIOCHEMICAL
These test are mainly done for assessment of
pulmonary maturity.
1. Shake test or Bubble test (Clement’s):
Based on ability of pulmonary surfactant to form a
foam or bubble on shaking which remains stable for
at least 15 minutes.
Increasing dilutions of amniotic fluid are mixed with
96 % ethanol, shaken for 15 seconds and inspected
after 15 minutes for the presence of a complete ring
of bubbles at the meniscus. Indicates maturity of the
fetal lungs.

45. 2. Foam Stability Index (FSI) :
Based on surfactant detection by shake test.
Serial dilutions of amniotic fluid to quantitate amount of
surfactant present.
FSI >47 virtually excludes risk of RDS.
OTHER TEST
3. Presence of phosphatidyl glycerol[PG]
4. Saturated phosophatidly choline
5. Amniotic fluid optical density
6. Florescence polarization

46. BIOPHYSICALBIOPHYSICAL

47. BIOPHYSICAL
It is the screening test for the utero-placental insufficiency .
The fetal biophysical activities is initiated , modulated &
regulated by the fetal nervous system .
The fetal CNS is very much sensitive to diminished
oxygenation.

48. Fetal Movement CountFetal Movement Count
1. Fetal movement monitoring1. Fetal movement monitoring
Cardif ‘count 10’ formulaCardif ‘count 10’ formula::
Mother counts fetal movements starting at 9 am.Mother counts fetal movements starting at 9 am.
Counting ends when 10 movements are perceived.Counting ends when 10 movements are perceived.
Report to physician if:Report to physician if:
– (i) less than 10 movements occur during 12 hours on(i) less than 10 movements occur during 12 hours on
2 successive days or2 successive days or
– (ii) no movement is perceived even after 12 hours in a(ii) no movement is perceived even after 12 hours in a
single day.single day.

49. Daily fetal movement count (DFMC):Daily fetal movement count (DFMC):
One hour duration each in morning, noon andOne hour duration each in morning, noon and
evening. (Total 1+1+1 = 3 hours)evening. (Total 1+1+1 = 3 hours)
Total counts multiplied by four gives daily (12 hour)Total counts multiplied by four gives daily (12 hour)
fetal movement count (DFMC).fetal movement count (DFMC).
If there is diminution of number of ‘kicks’ to less thanIf there is diminution of number of ‘kicks’ to less than
10 in 12 hours (or less than 3 in each hour), it10 in 12 hours (or less than 3 in each hour), it
indicates fetal compromise.indicates fetal compromise.

50. Nonstress Testing(NST)
A test monitors the fetal heart rate in response to fetal
movements in order to assess the integrity of fetal central
nervous system & cardio vascular system.
The non – stress test(NST) involves application of the fetal
monitor to record the fetal heart rate.
The mother is instructed to push a marker button when she
feels the fetus move. The marker button when she feels the
fetus move.
The marker button indicates movement as it occurred in
relationship to the fetal heart rate.
With sufficient placental functioning ,the fetus should
demonstrate an acceleration in heart rate with movement, in
the same way that the adult experiences increased heart rate
with exercises.

51. Purpose
To assess the fetal ability to cope with
continuation of a high risk pregnancy.
To determine the project ability of a fetus to
withstand the stress of labour.
To assess the fetal status in women for whom
contraction stress test is contraindicated such
as previous caesarean section,or preterm
labour.


52. IndicationsIndications
Indications(Maternal)
Post dated Pregnancy
Rh Senstization
Material age 35 or more
Chronic renal disease
Hypertension
Collagen disease
Sickle cell disease
Diabetes
Premature rupture of
membrances
History of still birth
Trauma
Indications (Fetal)
Decreased fetal
movements
Intrauterine growth
retardation(IUGR)
Fetal evaluation after
amniocentesis
Oligohydramnios/polyhyd
ramnios

53. Result
Reactive non stress test(normal/negative)
Reactive indiacates a healthy fetus .
The result requires two or more FHR accelerations of at
least 15 beats per minutes , lasting at least 15 sec from the
beginning of the acceleration to the end , in association to
the end , in association with fetal movement during a 20 –
minute period.
Nonreactive nonstress test(abnormal)
No acceleration or accelerations of less than 15 beats per
min or lasting less than 15 sec in duration occur be
interpretated because of the poor quality of the FHR tracing.

54. 3. Contraction stress Tests
A contraction stress test is a test performed during
pregnancy to verify whether or not the unborn baby’s heart is
strong enough to withstand labour.
It uses drugs or nipple stimulation to make the uterus
temporarily contract in order to replicate labor contractions .
The test is typically only used if the unborn baby has has
abnormal results during other pregnancy health examinations
A contraction stress test(CST) can reveal whether your baby
has an abnormal heart rate during contractions- a distinct
pattern of slowing heartbeats during & immediately following a
contraction-that may indicate distress .

55. CSTCST
Oxytocin drip started at 0.5 mU/min, double inOxytocin drip started at 0.5 mU/min, double in
every 15-20 min interval till 3 contractions lastingevery 15-20 min interval till 3 contractions lasting
for 40-60 sec occur in 10 minfor 40-60 sec occur in 10 min
Time taken 1½ - 2 hrsTime taken 1½ - 2 hrs
No hypoxiaNo hypoxia →→ FHR pattern uncharged duringFHR pattern uncharged during
contractioncontraction
HypoxiaHypoxia →→ FHR slows down with decelerationFHR slows down with deceleration
– Late deceleration is significantLate deceleration is significant

56. Indications
IUGR
Postmaturity
Hypertensive disorders of pregnancy
Diabetes mellitus
Women with nonreactive NST
Contraindications
Third trimester bleeding
Incompetent cervix
Multiple gestation
Previous classical uterine incision
History of preterm labour
Premature rupture of membranes.

57. Result:
Negative contraction stress test (normal):
A negative result is represented by late or variabal
decelerations of the fetal rate.
Positive result : is represented by late or variable
declarations of the fetal heart with 50 % or more of the
contractions in the absence of hyperstimulation of the
uterus.
Equivocal: An equivocal result contain decelerations but
with less than 50% of the contractions ,or the uterine
activity shows the hyperstimulation of the uterus.
Unsatisfactory: An unsatisfactory result means that
adequate uterine contractions cannot be achieved or the
fetal heart rate tracing is not of sufficient quality for
adequate intervention

58. 5. FETAL CARDIOCOGRAPHY
It is a technical means of recording the fetal heartbeat & the uterine
contractions during pregnancy,typically in the third trimester .
The machine used to perform the monitoring is called a cardiotocography,
more commonly known as an electronic fetal monitor(EFM)
External measurement - means taping or strapping the two sensors to the
abdomen measures the tension of the maternal abdominal wall – an indirect
measure of the intrauterine pressure.
Internal measurement- requires a certain degree of cervical dilatation , as
it involves inserting a pressure catheter into the ulterine cavity , as well as
attaching a scalp electrode to the fetal head to adequately measure the
electric activity of the fetal heart to adequately measure the electric activity
of the fetal heart

59. Effect on management :
The use of cardiotography reduces the rate of
seizures in the newborn , but there is no clear
benefit in the prevention of cerebral palsy , perinatal
death and other complication of labour .
In contrast labour monitored by CTG is slightly more
likely to result in instrumenet delivery ( forceps or
vacuum extraction ) or caesarean section

60. 5.The biophysical profile ( BPP ) :
Has 5 components
1. Fetal movement
2 .Fetal tone
3 .Fetal breathing
4 .Amniotic fluid volume
5 .Fetal heart rate

61. VariableVariable Score – 2Score – 2 Score – 0Score – 0
Fetal reactivityFetal reactivity
> 2 FHR> 2 FHR
accelerationacceleration
No or < 2No or < 2
accelerationacceleration
Fetal breathingFetal breathing
movementmovement
At least 1 of > 30At least 1 of > 30
secsec
No FBM or < 30 secNo FBM or < 30 sec
Fetal movementFetal movement
(Gross body(Gross body
movement)movement)
> 3 discrete GBM> 3 discrete GBM < 2 or nil< 2 or nil
Fetal toneFetal tone
At least one episodeAt least one episode
of limb flexion toof limb flexion to
rapid extensionrapid extension
No limb movement orNo limb movement or
slow flexionslow flexion
Amniotic fluid volAmniotic fluid vol
> 1 pocket of > 1 cm> 1 pocket of > 1 cm
depth in twodepth in two
perpendicular planeperpendicular plane
Largest pocket < 1Largest pocket < 1
cm in twocm in two
perpendicular planesperpendicular planes

62. InterpretationInterpretation
Score – 10Score – 10 →→
– Conservative managementConservative management
– Repeat after 1 wk or after 3 days in IUGR, diabetes,Repeat after 1 wk or after 3 days in IUGR, diabetes,
postmaturitypostmaturity
Score – 8Score – 8 →→
– Liqour normal, manage as beforeLiqour normal, manage as before
– If less or postmaturityIf less or postmaturity →→ DeliverDeliver
Score – 6Score – 6 →→ EquivocalEquivocal
– Repeat test after 24 hrsRepeat test after 24 hrs
– If sameIf same →→ DeliverDeliver
Score – 4 or lessScore – 4 or less →→ AbnormalAbnormal
– Immediate delivery except when fetus is grossly immatureImmediate delivery except when fetus is grossly immature
Modified BPSModified BPS →→ Placental grading considerPlacental grading consider
– If premature agingIf premature aging →→ Fetal compromiseFetal compromise

63. 6.Fetal Monitering by Fetal Scalp Blood
Sampling
Fetal Scalp blood sampling is done when CTG shows
persistant abnormal trace.
It is used in the high risk cases of delivery.
Significance of fetal scalp blood PH
Normal 7.25-7.35
Border line 7.25-7.30
Abnormal below 7.20 delivery is done for fetal
asphyxia.

64. Doppler UltrasonographyDoppler Ultrasonography
UterineUterine
UmbilicalUmbilical
Internal carotid arteryInternal carotid artery
Cerebral vesselsCerebral vessels
Peak systolic & end diastolic blood flowPeak systolic & end diastolic blood flow
measuredmeasured
Systolic: Diastolic < 3 is normal in umbilical &Systolic: Diastolic < 3 is normal in umbilical &
uterine arteryuterine artery
Lack of diastolic component or reversal diastolicLack of diastolic component or reversal diastolic
blood flow is ominous sign.blood flow is ominous sign.

65. 7. Amniocentesis in Late Pregnancy7. Amniocentesis in Late Pregnancy
Pulmonary maturityPulmonary maturity
Assessment of severity of Rh-isoimmunisationAssessment of severity of Rh-isoimmunisation
Maturity of fetus by Nile blue testMaturity of fetus by Nile blue test
Orange cells > 50% mature fetusOrange cells > 50% mature fetus

66. 8.Other test8.Other test
Assessment of severity of Rh-
isoimmunisation:
It is done by amniocentesis for
estimation of bilirubin in the amniotic fluid
by spectophometric analysis.
Assesment of aminotic fluid leakage:
It can be done by fern test,nitrazine test,apt
test.