INTRODUCTION •

Majority of fetal deaths occur in the antepartum period. There is progressive decline in maternal
deaths all over the world. Currently more interest is focused to evaluate the fetal health. The primary
objective of antenatal assessment is to avoid fetal death.

AIMS OF ANTENATAL FETAL MONITORING :-

 To ensure satisfactory growth and well being of the fetus throughout pregnancy.
 To screen out the high risk factors that affect the growth of the fetus.
 To detect those congenital abnormalities or inborn metabolic disorders during early pregnancy.

INDICATIONS FOR ANTEPARTUM FETAL MONITORING

 Pregnancy with obstetric complications.
 Pregnancy with medical complications.
 Others Routine antenatal testing.

With use of this system, each item has the potential for scoring a 2, so 10 would be the highest score
possible. • It is popularly called a fetal Apgar. • Biophysical profiles may be done as often as daily
during a high-risk pregnancy. • If the fetus score on a complete profile is 8 –10, the fetus is considered to
be doing well. A score of 6 is considered suspicious; a score of 4 denotes a fetus probably in jeopardy
11/13/2014 7:44 AM 44

Biophysical •

Ultrasonographic examination of the fetus in the early (10-14 weeks) pregnancy can detect fetal
anomalies. • Crown-rump length (CRL) smaller than the gestational age is associated with the risk of
chromosomal anomalies (trisomy or triploidy).

• Increased nuchal translucency (soft tissue marker) at 10-14 weeks is associated with many
chromosomal abnormalities (trisomy, monosomy, triploidy).

26. Biophysical

• Biophysical profile is a screening test for uteroplacental insufficiency. • The following biophysical
tests are used:

1. Fetal movement count

2. Ultrasonography

3. Cardiotocography
4. Non stress test (NST)

5. Contraction stress test (CST)

1. FETAL MOVEMENT COUNT:-

 A healthy fetus moves with a degree of consistency, or at least 10 times a day.

 In contrast, a fetus not receiving enough nutrients because of placental insufficiency has greatly
decreased movements.

 Based on this, asking a woman to observe and record the number of movements the fetus is
making offers a gross assessment of fetal well-being.

 Cardif count 10 formula

 Daily fetal movement count (DFMC)

 Mothers perceive 88% of the fetal movements detected by Doppler imaging.

 Loss of fetal movements is commonly followed by disappearance of FHR within next 24 hours.

 In either of the above methods, if the results is ominous, the candidate is subjected to NST.

NONSTRESS TEST (NST)

In non-stress test, a continuous electronic monitoring of the fetal heart rate along with the recording of
fetal movements (cardiac tocography) is undertaken.

There is an observed association of FHR acceleration with fetal movements, which when present,
indicates a healthy fetus.

Results:-
Reactive (Reassuring)- when two or more accelerations of more than 15 beats per minute above the
baseline and longer than 15 seconds in duration are present in a 20 minutes observation in association
with movement of fetus

• Non-reactive (Nonreassuring) - Absence of any fetal reactivity.

Important features to note while interpreting a CTG

• Accelerations and normal base line variability (5-25 bpm) denote a healthy fetus.

• Absence of accelerations is the first feature to denote onset of gradual hypoxia.

• Absence of accelerations, reduced base line variability may be due to fetal sleep, infection, and hypoxia
or due to maternal medications.

CONTRACTION STRESS TESTING:-

  With contraction stress testing, the fetal heart rate is analyzed in conjunction with contractions.

 A source of oxytocin for contraction stress testing currently is achieved by nipple stimulation.

 Gentle stimulation of the nipples releases oxytocin in the same way as happens with
breastfeeding. With external uterine contraction and fetal heart rate monitors in place, the
baseline fetal heart rate is obtained.

 Next, the woman rolls a nipple between her finger and thumb until uterine contractions begin,
which are recorded by a uterine monitor.

 Three contractions with a duration of 40 seconds or longer must be present in a 10-minute

window before the test can be interpreted.

 The test is negative (normal) if no fetal heart rate decelerations are present with contractions.

 It is positive (abnormal) if 50% or more of contractions cause a late deceleration

OXYTOCIN CHALLENGE TEST

 To elicit an abnormal FHR response

 Performed by iv infusion of dilute oxytocin until three contractions occur in 10 minutes

RESULT:-
Positive test: Late deceleration after each of the three contractions; FHR baseline variability; no FHR
increase after FM

 Indicates decreased fetal reserve

Negative test: No decelerations

 Fetus is safe within one week

Suspicious: Repetitive variable decelerations

 Associated with abnormal FHR in labor, particularly in post-term gestation

 ULTRASONOGRAPHY:-
Sonography is a diagnostic medical test that uses high-frequency sound waves—also
called ultrasound waves—to bounce off of structures in the body and create an image. Fittingly,
the test is also referred to as an ultrasound or sonogram.

Sonography uses a device called a transducer on the surface of the skin to send ultrasound waves
and listen for an echo. A computer translates the ultrasound waves into an image.

• The production of high frequency sound waves which are reflected or echoed when beamed into the
body and an interface is encountered between different types of tissues or structures with different
densities.
• These echoes can be translated into visible images of the tissues or structures encountered.

METHOD:-
There are two main types of fetal ultrasound exams:

 Transvaginal ultrasound. With this type of fetal ultrasound, a wandlike device called a

transducer is placed in your vagina to send out sound waves and gather the reflections.
Transvaginal ultrasounds are used most often during early pregnancy. This type of
ultrasound also might be done if a transabdominal ultrasound didn't provide enough
information.

 Transabdominal ultrasound. A transabdominal fetal ultrasound is done by moving a

transducer over your abdomen.

Uses Of Ultrasonography:-
 Diagnose pregnancy as early as 6 weeks gestation.

 Confirm the presence, size, and location of the placenta and amniotic fluid
  Establish that a fetus is growing and has no gross anomalies, such as hydrocephalus, anencephaly,
or spinal cord, heart, kidney, and bladder defects

 Establish sex if a penis is revealed

 Establish the presentation and position of the fetus • Predict maturity by measurement of the
biparietal diameter of the head

 To discover complications of pregnancy.

 Fetal anomalies

 Fetal death

 After birth, an ultrasound may be used to detect a retained placenta or poor uterine involution in
the new mother.

Gestational age and fetal maturity:-

 At 5-10 weeks: gestational sac.

 At 8-14 weeks: the crown-rump length.

 At 14-20 weeks: length of the femur.

 At 18-26 weeks: the biparietal diameter.

 The fetal head is demonstrable by ultrasound by the 12th week of gestation.

PROCEDURE:-

During the procedure

 During a transabdominal fetal ultrasound, you'll recline on an exam table and expose
your abdomen. Your health care provider or technician will apply a special gel to your
abdomen. This will improve the conduction of sound waves and eliminate air between
your skin and the transducer.

 Your health care provider or technician will move or scan the transducer back and forth
over your abdomen. The sound waves reflected off your bones and other tissues will be
converted into images on a monitor

After the procedure

  You can wipe off any residual gel or lubricant. If you had a full bladder during the
ultrasound, you can urinate after the exam.

Results

Typically, a fetal ultrasound offers reassurance that a baby is growing and developing
normally. If your health care provider wants more details about your baby's health, he or
she might recommend additional tests

CARDIOTOCOGRAPHY:-
It is defined as the graphic recording of fetal heart rate and uterine contractions by the use of
electronic devices indicated for the assessment of fetal condition
Cardiotocography (CTG) is used during pregnancy to monitor fetal heart rate and uterine
contractions. It is most commonly used in the third trimester and its purpose is to monitor fetal
well-being and allow early detection of fetal distress

Objectives
To assess the effectiveness of antenatal CTG (both traditional and computerised assessments) in
improving outcomes for mothers and babies during and after pregnancy.

Indications for CTG:

 Alterations in fetal HR present during auscultation;

 High-risk delivery (Table 1);
 Induced or/and stimulated labor;
  Auscultation can not be performed due to maternal body composition or various other
reasons.

METHOD:-

External monitoring

CTG is most commonly carried out externally. This means that the equipment used to monitor
the baby's heart is placed on the tummy (abdomen) of the mother. An elastic belt is placed
around the mother's abdomen. It has two round, flat plates about the size of a tennis ball which
make contact with the skin. One of these plates measures the baby's heart rate. The other assesses
the pressure on the tummy. In this way it is able to show when each contraction happens and an
estimate of how strong it is.

The midwife may put some jelly on the skin to help get a strong signal.
The CTG belt is connected to a machine which interprets the signal coming from the plates. The
baby's heart rate can be heard as a beating or pulsing sound which the machine produces. Some
mothers can find this distracting or worrying but it is possible to turn the volume down if the
noise bothers you. The machine also provides a printout which shows the baby's heart rate over a
certain length of time. It also shows how the heart rate changes with your contractions.

If you have CTG before you are in labour you may be asked to press a button on the machine
every time the baby moves. At this time you will not be having any contractions so the CTG will
only monitor the baby's heart rate. 

Internal monitoring

Occasionally during labour, if a signal can't be found using the external monitor, or when
monitoring is more important, internal monitoring can be used. For internal monitoring, a small,
thin device called an electrode is used. This is inserted through the vagina and neck of the womb
(which will be opening during labour) and placed on the baby's scalp. This device records the
baby's heart rate.

If you have a twin (or higher multiples) pregnancy, internal monitoring can only be used on the
baby closest to the neck of the womb.

Additionally internal monitoring can only be used when the baby is going to be delivered head
first. Internal monitoring will not work on a breech (bottom or foot first) presentation

FHR pattern classification

Fetal heart rate was classified as either "reassuring" or "nonreassuring". The NICHD workgroup
proposed terminology for a three-tiered system to replace the older, undefined terms.[11]

 Category I (Normal): Tracings with all these findings present are strongly predictive of
normal fetal acid-base status at the time of observation and the fetus can be followed in a
standard manner:
o Baseline rate 110–160 bpm,

o Moderate variability,

o Absence of late or variable decelerations,

o Early decelerations and accelerations may or may not be present.

 Category II (Indeterminate): Tracing is not predictive of abnormal fetal acid-base status.

Evaluation and continued surveillance and reevaluations are indicated.
o Bradycardia with normal baseline variability

o Tachycardia

o Minimal or Marked baseline variability of FHR

o Accelerations: Absence of induced accelerations after fetal stimulation

o Periodic or Episodic decelerations: Longer than 2 minutes but shorter than 10 minutes;
recurrent late decelerations with moderate baseline variability
o Variable decelerations with other characteristics such as slow return to baseline,
overshoots of "shoulders" seen (humps on either side of deceleration)
 Category III (Abnormal): Tracing is predictive of abnormal fetal acid-base status at the
time of observation; this requires prompt evaluation and management.
o Absence of baseline variability, with recurrent late/variable decelerations or bradycardia;
or

o Sinusoidal fetal heart rate

FETOSCOPY:-

Definition
Fetoscopy is a procedure that utilizes an instrument called a fetoscope to evaluate or treat the
fetus during pregnancy.
There are two different types of fetoscopy: external and endoscopic.

External fetoscopy
An external fetoscope resembles a stethoscope, but with a headpiece. It is used externally on the
mother's abdomen to auscultate (listen to) the fetal heart tones after about 18 weeks gestation. It
also allows a birth attendant to monitor the fetus intermittently and ensure that the baby is
tolerating labor without the mother having to be attached to a continuous fetal monitor.

Endoscopic fetoscopy

The second type of fetoscope is a fiber-optic endoscope. It is inserted into the uterus either
transabdominally (through the abdomen) or transcervically (through the cervix) to visualize the
fetus, to obtain fetal tissue samples, or to perform fetal surgery.

Results
The normal fetal heart rate is 120 to 160 beats per minute, regardless of the method used for
auscultation (external fetoscopy or Doppler ultrasound). Some variability of fetal heart rate is
expected, as the heart rate increases with fetal activity and slows with fetal rest.
Results expected using endoscopic fetoscopy will vary depending on the procedure undertaken.
The goal is for the maximum benefit with the minimum of risk or complication to both the
mother and fetus
1. ULTRASONOGRAPHY (USG) • An ultrasonography is a diagnostic technique, which uses
high-frequency sound waves to create an image of the internal organs. • A screening
ultrasound is sometimes done during the course of a pregnancy to check normal fetal growth
and verify the due date. • It is a safe , non invasive, accurate and cost effective investigation
• Hard tissues such as bone appear white on the image and soft tissues appear grey.
2. 10. Indications: • In the first trimester: • To establish the dates of a pregnancy • To
determine the number of fetuses and identify placental structures • To diagnose an ectopic
 pregnancy or miscarriage • To examine the uterus and other pelvic anatomy • In some
cases to detect fetal abnormalities as anencephaly
3. 11. • Mid-trimester: (sometimes called the 18 to 20 week scan)to confirm pregnancy dates
or gestational age • To determine the number of fetuses and examine the placental
structures • To assist in prenatal tests such as an amniocentesis, Cordocenthesis . • To
examine the fetal anatomy for presence of abnormalities • To check the amount of amniotic
fluid by measuring AFI. • To examine blood flow patterns • To check on the location of
placenta; to see if its covering cervix • To observe fetal behavior and activity
4. 12. • Third trimester: • To monitor fetal growth, to check IUGR • Detailed anatomical
survey. • To check the amount of amniotic fluid • to determine the position of a fetus • To
assess the placenta
5. 13. types of ultrasounds performed during pregnancy Abdominal ultrasound Transvaginal
ultrasound
6. 14. Abdominal ultrasound • In an abdominal ultrasound, gel is applied to the abdomen and
the ultrasound transducer glides over the gel on the abdomen to create the image
7. 15. TRANSABDOMINAL USG
8. 16. TRANSVAGINAL ULTRASOUND • a smaller ultrasound transducer is inserted into the
vagina and rests against the back of the vagina to create an image. • A transvaginal
ultrasound produces a sharper image and is often used in early pregnancy.
9. 17. TRANSVAGINAL USG
10. 18. • Indication of transvaginal ultrasound:- • Early month of pregnancy • In this high
frequency of sound waves used so greater resolution is possible • Typical gynaecological
indication includes uterine size, evaluation of endometrium, myometrium, cervix •
Contraindication:- • Allergy to latex. • Vaginal infection
11. 19. Nursing responsibility before procedure • Explain the purpose of procedure and how it
will be done. • Advise for drink lots of water so that full bladder to capture clearer images •
Provide privacy. • Provide supine position . (dorsal position). • The abdominal wall is
prepared and draped. • Check USG
12. 20. Procedure : • TRANS ABDOMINAL USG:- • Explain the procedure to the patient. •
Provide privacy • Provide supine position to the patient. • Apply gel
13. 21. Transvaginal USG • A probe is placed into the vagina instead of over the abdomen. •
Provide dorsal lithotomy position with empty bladder. • Vaginal probe should be lubricated
with gel and the probe should be inserted in to an appropriate covering sheeth such as
condom • The sheath covered probe is gently advanced up the vaginal canal • If
ultrasound is done before the week 11, it would be transvaginal
14. 22. Safety of USG • Ultrasounds bring no long term or short-term harm to both mother and
baby. • In fact, it is a useful scanning tool. Because the waves are of very low intensity,
there is no danger in repeating the scans, if your condition merits it. • However if pregnancy
is normal, then 2 routine scans as part of antenatal care. • More scans are only necessary if
any medical condition
15. 23. Advantage of USG • Complex structure can be viewed in a single image. • Stored data
can be reviewed at any plane later on without needing the patient, this helps to get second
opinion if required. • Prenatal diagnosis of certain anomalies is improved. • Photo of 3-
Dimensional image improves antenatal parental bonding and important teaching tool.

1. CARDIOTCOGRAPHY • Cremer first demonstrates this method in 1904. In this test, Fetal
Heart Rate and uterine contraction are graphically recorded. It is generally performed in third
trimester. • The machine used to perform the monitoring FHR called a cardiotocograph or
electronic fetal monitor or external fetal monitor
2. 25. CARDIOTOCOGRAPH
3. 26. CARDIOTOCOGRAPH
4. 27. Procedure
5. 28. • INTERPRETATION • A typical CTG output for a woman not in labour. A: Fetal
heartbeat; B: Indicator showing movements felt by you (caused by pressing a button); C:
Fetal movement; D: Uterine contractions
6. 29. Advantages:- • Help to detect hypoxia in early stage. • Reduce fetal death • It is
important record for medico-legal purpose Drawback • Instrument is expensive and trained
person are required to interpret. • Mother has to confined in bed • Due to false prediction
caesarean section rate may be high

1. Non-stress Test ( NST) • Non-stress test is a simple, painless procedure in which a baby's
heartbeat is continuously monitored for 20 minutes or more along with recording fetal
movement. • The logic behind the test is, that like adults, a baby's heartbeat should
accelerate when it is active i.e. moving and kicking. • Principle : there is acceleration of fetal
heart rate with each fetal movement
2. 31. Performing time:- • The Non-stress test can be done whenever the need arises so there
is no specific time for it. around 30 weeks
3. 32. Indications of NST • Women with preexisting medical conditions such as diabetes. •
Women with pregnancy-induced medical conditions such as hypertension • Baby is less
active than normal • Baby is small for its age • Amniotic fluid is either too much or too little
• Women who have previously lost their babies in the second half of their pregnancies •
Women with pregnancies continuing after week 40 to basically check on the well- being of
baby
4. 33. Nursing responsibility • Explain procedure before performing test. • Informed consent
should be given prior to testing, and a woman has the right to refuse this test if she chooses
• Provide lateral position or semi fowler or sitting position to the women. • the recording is
obtained with the patient lie down on left side, or lateral recumbent position. ( to avoid supine
hypotension)
5. 34. Procedure
6. 35. Contd… • Two electronic devices will be strapped to mother abdominal. • The
transducer ultrasound will monitor baby's heartbeat. • The other device will record any
uterine contractions felt by the mother. • While fetal movement is recorded by mother by
pressing a button which makes the mark on the strip. • If there are no movements, the fetus
is stimulated manually or may be with a buzzer • The test takes about 20 minutes to an hour
7. 36. Interpretation • Reactive test (normal NST) :- NST is called reactive if there are at least
2 fetal movements in 20 minutes with acceleration of FHR by 15 beats/min for atleast 15
seconds • Non-reactive: absence of any fetal reactivity. It is associated with poor fetal and
neontatal outcome, but there is high incidence of false positive results also. This may be due
to fetal sleep, sedative or narcotic drugs, congenital anomalies and premature fetus
8. 37. Procedure :-
9. 38. • Advantages: - • It is a non-invasive test. • The test is simple, inexpensive and takes
less time. • There are no contradictions or complications • No special expertise required •
Provide immediate answer. • It can be repeated as many times as required without any risk.

1.  CONTRACTION STRESS TEST • Tests will be carried out to analyze the baby's well being
• CST is based on the observation that during contractions, blood flow to the placenta
lessens temporarily. An evaluation is done on how the fetus handles this stress. • Normally
fetal heart rate is not affected by contractions
2. 40. • In actual labor after contraction begins, if the fetal heartbeat slows down, it indicates
that the fetal is not able to tolerate the decreased blood flow resulting from the contraction. •
These decreases are called late decelerations. • If the placenta is not working to capacity or
the baby has some problem, Contraction can decrease the oxygen flow and cause the heart
rate to drop.
 3. 41. • Performing time: after 30 weeks gestation • Position:- • Semi recumbent position •
Lateral position
4. 42. Indication: • It is usually conducted if the pregnant woman has had problematic
pregnancies in the past or has medical problems in her current pregnancy. • CST is usually
performed if Non-stress test showed no change in fetal heart rate when the fetus moved. •
To check baby will remain healthy during the reduced oxygen levels that normally occur
during contraction
5. 43. Procedure Two fetal monitors will be strapped to the woman's abdomen to record fetal
heart rate. • One monitor will pick up uterine contractions and the other picks up fetal heart
beat. . Both will readings will record on graph paper. • Stimulate contraction by either nipple
stimulation or oxytocin. • Assess the maternal B.P every 10 to 15 min during the test.
6. 44. •The heartbeat will form a line at the top and the maternal contractions will form
wavelike lines at the bottom. Both lines will be matched to determine the significance of any
decelerations
7. 45. Result/ Interpretation • Negative- no late decelerations are present in the presence of
adequate contractions, the placenta is functioning properly and the fetus is doing well. It is
the desired result • Positive: late decelerations are present in the presence of adequate
contractions. Delivery of baby follows a positive result either by induction of labour or LSCS

1. FETOSCOPY • A fibreoptic instrument that can be passed through the abdomen of a

pregnant woman to enable examination of the fetus and withdrawal of blood for sampling in
prenatal diagnosis. • DEFINITION • Examination of the pregnant uterus by means of a
fiber-optic tube. • Time of performing:-18th week of pregnancy
2. 74. • Complication :- • Miscarriage, as high as 12%. • Excessive bleeding, infection, or
excessive leakage of the amniotic fluid. • Preterm rupture of the membranes which may
require early delivery of your baby . • Mixing your blood with babys blood

AMNIOSCOPY • Definition • Direct observation of the foetus and the colour and amount of the
amniotic fluid by means of a specially designed endoscope inserted through the uterine cervix. •
Contraindicated:- • Cervix is in insufficiently dilated • Complication:- • Sepsis • Rupture of
membrane

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57. References: 1. Dutta D.C. Textbook of obstetrics. Sixth edition. Calcutta, India; New Central Book
agency (P) Ltd: 2004. 2. Pillitteri A. Maternal and child health nursing. Care of the childbearing and
childrearing family. Sixth edition. Philadelphia; Lippincott Williams & wilkins: 2010. 3. Jacob A. A
comprehensive textbook of midwifery. Second edition. India; Jaypee Brothers Medical publishers (P) ltd.
11/13/2014 7:44 AM