July 29, 2022

Antepartum Fetal
Assessment
Marian Luisa A. Roque, 2nd year resident
 Outline
(Primary Source: Ch 20 Williams Obstetrics, 26th ed)

FETAL MOVEMENT
FETAL BREATHING
CONTRACTION STRESS TESTING
NONSTRESS TESTS
BIOPHYSICAL PROFILE
AMNIONIC FLUID VOLUME
DOPPLER VELOCIMETRY
1.
Fetal Movement
 Fetal Movement

• Fetal activity commences as early as 7 weeks AOG

• Between 20 and 30 weeks’ gestation:

• General body movements become organized, and the fetus starts to
show rest-activity cycles

• By approximately 36 weeks AOG, rest-activity cycles give way to

behavioral states in most normal fetuses
 Fetal Movement: Behavioral States

STATE 1F Quiescent state – quiet sleep with narrow oscillatory

Quiet Sleep bandwidth of the fetal heart rates

Includes frequent gross body movements, continuous

STATE 2F eye movements, wider oscillation of fetal heart rate
Active Sleep Analogous to REM (rapid eye movmeent) or active sleep
in the neonate

STATE 3F Continuous eye movmeents in the absence of body

REM without body movements and no heart rate accelerations
movement

STATE 4F Vigorous body movement with continuous eye

Awake state movements and heart rate accelerations
 Fetal Movement

• At 28 to 30 weeks AOG, fetuses

transition to spend most of their time
in states 1F and 2F
● Sometimes when monitoring for an
hour, there are no fetal movements
because the baby is sleeping.
● This should be emphasized to
mothers, especially to those with
high-risk pregnancies, when they
are being educated on counting fetal
movements
 Determinants of Fetal Activity

Sleep-wake cycles Patient habit and

● Mean duration of a complete medications
cycle, which included active and ● MATERNAL SMOKING decreases
quiet states , is 60 minutes fetal activity
● Longest period of inactivity: 75 ● Treatment of substance abuse
minutes
disorders (use of methadone and
buprenorphine) also decreases
Amnionic Fluid Volume fetal movement
● Fetal activity declines in patients ● BETAMETHASONE
with diminishing amnionic fluid ADMINISTRATION decreases fetal
volumes movement for up to 24-72 hours
● Restricted uterine space = ● Glucose loading promotes
physical limitation of fetal activity.
movement
 Fetal Movement

Protocols:
● Use of tocodynamometer, visualization with sonography, maternal
subjective perceptions

● MATERNAL SUBJECTIVE PERCEPTIONS - most popular method

● ACOG (2002): Daily fetal movement count after 28 weeks AOG.
● 10 movements in 2 hours is considered reassuring.
● Once 10 movements are perceived, count may be discontinued
for the day
● Best predictor is still the maternal sense that fetal activity is
reduced. Any such report warrants further evaluation.
 Protocols in Fetal Movement Monitoring:

Methods: Patient habit and

● Mean duration of a complete medications
cycle, which included active and ● MATERNAL SMOKING decreases
quiet states , is 60 minutes fetal activity
● Longest period of inactivity: 75 ● Treatment of substance abuse
minutes
disorders (use of methadone and
buprenorphine) also decreases
Amnionic Fluid Volume fetal movement
● Fetal activity declines in patients ● BETAMETHASONE
with diminishing amnionic fluid ADMINISTRATION decreases fetal
volumes movement for up to 24-72 hours
● Restricted uterine space = ● Glucose loading promotes
physical limitation of fetal activity.
movement
2.
Fetal Breathing
 Fetal Breathing

Fetal respiration:
● Fetal respirations shows paradoxical
chest wall movement
● This happens due to expulsion
of clear amniotic fluid debris:
contraction on inspiration,
expansion on expiration
● In the newborn or adult, the
opposite happens
 Fetal Breathing

Fetal respiration:
● 2 types:
● Gasps or sighs
● Frequency: 1 to 4 per
minute
● Irregular bursts of breathing
● Up to 240 cycles per
minute
● Rapid respiratory
movements associated
with rapid eye movement
 Fetal Breathing

Factors affecting respiratory rate:

● Maternal hypoglycemia
● sound stimuli
● cigarette smoking
● Amniocentesis Since many factors affect fetal
● impending preterm labor breathing, it must be used in
● gestational age conjunction with other
parameters.
● Fetal respiratory rate declines in
conjunction with increased respiratory
volume at 33 to 36 weeks AOG,
coinciding with lung maturation
● Fetal heart rate
● labor
3.
Contraction
Stress Test
 Contraction Stress Test

Rationale
● During a uterine contraction, pressures
generated by the myometrium exceed the
collapsing pressure of vessels that run
through it
● Blood flow is lowered into the
placenta’s intervillous space, hence
resulting in brief periods of impaired
oxygen exchange
● Hypoxia must be brief, or
uteroplacental pathology is suspected,
and is made evident by LATE FETAL
HEART RATE DECELERATIONS
 Contraction Stress Test

How to perform the test:

● We induce oxygen impairment by uterine contractions. Place patient in Semi-
Fowler’s or left lateral decubitus position to relieve vena caval occlusion
● Nipple stimulation is used to induce uterine contractions
● Nipples are rubbed through her clothing for 2 minutes or until a
contraction begins
● 2-minute nipple stimulation will ideally induce a patern of 3
contractions for 10 minutes If not, after a 5 minute rest she is
instructed to retry to achieve desired pattern. If unsuccessful, dilute
oxytocin is used.
● Oxytocin use in the CST:
● Dilute oxytocin: 20 units oxytocin in 1 liter PLR (6 mU/min initially,
uptitrate by 6 mU every 40 minutes)
Contraction Stress Test

INTERPRETATION:

A positive CST =
fetus must be
delivered
immediately
POSITIVE CST:
Equivocal-suspicious CST:
Equivocal - hyperstimulatory CST:
 Contraction Stress Test

Contraindications:
• Premature rupture of membranes (bag of water)
• Previous classical casesarian section (can trigger uterine
rupture)
• Placenta previa (can induce bleeding)
• Cervical incompetence
• History of premature labor in pregnancy
• Multiple gestation (can possibly trigger premature labor)
Review of decelerations:
4. Prolonged Deceleration
4.
Nonstress Test
 Nonstress Test

• Fetal heart rate acceleration in response to fetal movement

• Rationale: The FHT of a non-acidemic fetus (by hypoxia or
neurological depression) will temporarily accelerate in response
to fetal movement
• Fetal movements during testing are identified by maternal
perception and are self-recorded
• Primarily a test of fetal condition
• CST: test of uteroplacental sufficiency and function
 Nonstress Test

REVIEW: 32 weeks’ gestation or more, accelerations are increases ≥ 15 beats per minute
(bpm) above the baselinerate, and the acceleration lasts ≥15 seconds but <2 minutes.
Before 32 weeks, accelerations are defined as having a rise ≥10 bpm above baseline For ≥10
seconds
 Nonstress Test: Reactive

At least 2 accelerations
within a 20 min window
• Negative predictive
value against fetal
demise within 7 days:
99.5 to 100%
• False positive
reassurance against
acidosis as high as 15%
in growth restriction
 Vibroacoustic stimulation

In the event you have a normal baby (or a baby you do not
expect to be hypoxic) with a non-reactive stress-test, a
vibroacoustic test may be performed
• Loud external sound to startle the fetus and provoke heart
rate acceleration
• VAS is positioned on the maternal abdomen and a stimulus of
1-2 sec is applied. This may be repeated up to 3 times for up to
3 seconds.
• Positive response: rapid appearance of an acceleration
following stimulation
 Nonstress Test: Non-reactive

• Do not meet all of the criteria for a

reactive test
• May occur in 10% of fetuses at term
and up to 50% of fetus 24-28 weeks
• Have a 55% false positive rate (in
which case, a back-up test is normal)

● Before concluding that a test is

nonreactive, a 40-minute or longer
tracing should be performed.
● This threshold accounts for fetal
sleep cycles
 Nonstress Test

Interval between NST: previously set arbitrarily at 7 days.

(Stable maternal medical condition)

High risk conditions (i.e. preeclampsia) require daily NST

5.
Biophysical
Profile
 Biophysical Profile

• Assessing 5 specific biophysical variables more accurately

predicts fetal health

• FHT acceleration
• Breathing
• Movement
• Tone
• Amniotic fluid volume

• Each normal value is assigned a score of 2, and any other

abnormal manifestation 0. 30 minutes are allotted before a
score of 0 is assigned to any component.
Biophysical Profile
Biophysical Profile: INTERPRETATION
Biophysical Profile: INTERPRETATION
 The Modified Biophysical Profile:

• Nonstress test + Assessment of Amniotic Fluid volume

• Benefits: shorter time to perform (Approx: 10 minutes)
• Study of 17,429 modifed BPPs in 277 women, investigators
concluded that such testing was a excellent fetal
surveillance tool (Nageotte, 1994).
• Miller and associates (1996) reported results of more than
54,000 modified BPPs performed in 15,400 high-risk
pregnancies. They described a False-negative rate oF 0.8
per 1000 and a False positive rate of 1.5 percent.

Bottom line: BPP and modifed BPP are comparable to other biophysical fetal
surveillance approaches in predicting fetal well-being.
6.
Amnionic Fluid
Volume
 Amniotic Fluid Volume

• Rationale: diminished uteroplacental perfusion may lead to

lower fetal renal blood flow, decreased urine production,
and ultimately, oligohydramnios
• Amnionic fluid volume is measured either by the AFI or by the
single deepest vertical pocket (DVP).

The American College of Obstetricians and Gynecologists (2021a)

concludes that DVP measurement, as opposed to AFI, is
associated with fewer unnecessary interventions but comparable
perinatal outcomes (Nabhan, 2008; Reddy, 2014).

An AFI ≤5 cm and a DVP ≤2 cm is considered abnormal.

7.
Doppler
Velocimetry
 Doppler Velocimetry Evaluation:

Middle Cerebral
1. Umbilical Artery* 2. Artery
Primary method of
detecting fetal anemia

3. Ductus Venosus
 Umbilical Artery

The umbilical arteries arise from the common iliac arteries and represent the dominant
outflow of the distal aortic circulation.

Because there are no branches after their origin, the umbilical arteries purely mirror
the downstream resistance of the placental circulation.

Normal umbilical artery resistance falls progressively through pregnancy, reflecting

the increased numbers of tertiary stem villous vessels
• The amount of flow during diastole increases as gestation advances due to decreasing
placental impedance. The S/D ratio normally decreases from approximately 4.0 at 20 weeks
to 2.0 at term, and it is generally less than 3.0 after 30 weeks.

Increased resistance in the umbilical arteries represents pruning of the placental

arterial tree (seen in several pathologic conditions, including preeclampsia and
chronic hypertension)
Umbilical Artery
 Umbilical Artery

As umbilical artery resistance RISES, diastolic velocities FALL and ultimately

become ABSENT (i.e., absent end-diastolic velocity [AEDV]).

As resistance rises even further, an elastic component is added, which

induces reversed end-diastolic velocity (REDV) as the insufficient,
rigid placental circulation recoils after being distended by pulse pressure
 Middle Cerebral Artery

With fetal anemia, the peak

systolic velocity is enhanced
due to greater cardiac output
and decreased blood viscosity.

However, to detect fetal

compromise, Doppler
velocimetry of the MCA is not
recommended (Morris, 2012).
 Ductus Venosus

• Doppler ultrasound can also assess the fetal venous circulation, an

abnormal ductus venosus Doppler waveform indicates cardiac
dysfunction. However, its routine use in surveillance of fetal-growth
restriction is not recommended
7.
Doppler
Velocimetry
Thank you for listening J