1. ASSESSING FETAL WELL-BEING Biophysical Profile Daily fetal Movement Counting (DFMC)

2. – Done starting 27 th week – fetal sleep wake pattern – maternal food intake – drug-nicotine use – environmental stimuli

3. Daily fetal Movement Counting (DFMC) Cardiff count to 10 method – one method currently available – begin at the same time each day (usually in the morning after breakfast ) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) – expected findings – 10 movements in 1hrs or less – warning signs – 10-12 movements in 1hr or less more than 1hr to reach 10 movements less than 10 movements in 12hrs longer time to reach 10 FMs than on previous days. movements are becoming weaker, less vigorous movement alarm signal <3 FMs in 12hrs – warning signs should be reported to healthcare provider immediately; often require further testing. Eg. Non stress test (NST), biophysical profile (BPP)

4. Daily fetal Movement Counting (DFMC) Because of variations in movements among normal healthy fetuses as well as variations in different health care providers’ level of confidence in the technique, a variety of protocols have been developed by different institutions. There also is great variety in what is accepted as normal in different areas of the country. Another way to approach this assessment is … Sandovsky Method ask the mother to lie in a left recumbent position after a meal and record how many fetal movements she feels over the next hour. A fetus normally moves a minimum of twice every 10 minutes or an average of 10 to 12 times an hour. The mother is instructed to telephone her health care provider if she has felt fewer than five ( half the normal number) during the chosen hour.

5. Biophysical Profile 1.is a test measures the health of the fetus during the third trimester of pregnancy. It is a simple and painless test that combines an ultrasound evaluation with a non-stress test (NST). The biophysical profile assesses five parameters of fetal status which are the following: 2.Fetal heart rate (FHR) 3.Fetal breathing movements 4.Gross fetal movements 5.Fetal muscle tone 6.Amniotic fluid volume 7.Through a biophysical profile (BPP) the condition of the fetus can be most accurately predicted as it involves several parameters to be evaluated.

6. Purpose of Performing Biophysical Profile 1.To assess acute and chronic markers of fetal well-being. The components of examination in BPP are acute and chronic markers of fetal well-being. The short-term (acute) markers are the FHR reactivity, fetal breathing movements, gross fetal movements and fetal muscle tone. A major chronic or long-term marker is the amount of amniotic fluid. 2.Check the health status of the fetus if the mother has the following condition: 3.Bleeding problems 4.Lupus 5.Hyperthyroidism 6.Chronic kidney disease 7.Gestational diabetes 8.OligohydramniosOligohydramnios 9.PolyhydramniosPolyhydramnios 10.Multiple pregnancy 11.Preeclampsia 12.Pregnancy past the due date

7. Procedure Biophysical profile procedure involves two parts, the Non-stress Test (NST) and the ultrasound evaluation. Fetal heart rate reactivity is interpreted from a non-stress test (NST). The other four parameters are measured by real-time Ultrasonography. With the NST procedure the mother is asked to lie on her left side. Two devices are strapped to her belly – the first is used to record the fetal heart beat and the other to measure contractions of the uterus. Fetal movements, heart rate and its reactivity to fetal activity are measured for about 20 to 30 minutes while the technician listens and watches on the electronic screen. In real-time ultrasonography procedure, fetal body movements, muscle tone and breathing movements are noted and evaluated. Also, the amount of amniotic fluid surrounding the fetus is assessed and recorded. This procedure may take about an hour and the technician will note signs that are important in measuring the health of the fetus.

8. Interpretation A scoring technique is used to interpret the data, with each parameter contributing either 0 or 2 points. These scores are added for a total score range of 0 to 10. A score of 10 is perfect while the score of zero is the worst score. A total score of 8 to 10 is considered normal unless oligohydramnios is present. A score of 6 is considered borderline and a score below it requires further assessment and evaluation

9. Fetal Nonstress Test to determine the response of the fetal heart rate to the stress to activity. Indications – pregnancies at risk for – placental insufficiency – Postmaturity pregnancy induced hypertension (PIH), diabetes warning signs noted during DFMC maternal history of smoking, inadequate nutrition

10. Fetal Nonstress Test The Fetal Non-Stress test is a simple, non-invasive test performed in pregnancies over 28 weeks gestation. The test is named “non-stress” because no stress is placed on the fetus during the test. to determine the response of the fetal heart rate to the stress to activity. Indications – pregnancies at risk for – placental insufficiency – Postmaturity pregnancy induced hypertension (PIH), diabetes warning signs noted during DFMC maternal history of smoking, inadequate nutrition

11. How is a NST Performed? The test involves attaching one belt to the mother’s abdomen to measure fetal heart rate and another belt to measure contractions. Movement, heart rate and “reactivity” of heart rate to movement is measured for 20-30 minutes. If the baby does not move, it does not necessarily indicate that there is a problem; the baby could just be asleep. A nurse may use a small “buzzer” to wake the baby for the remainder of the test.

12. Procedure Done within 30mins wherein the mother is in semifowlers position; external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels fetal movement. Attach external noninvasive fetal monitors tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected monitor until at least 2 FMs are detected in 20mins. if no FM after 40mins provide women with a light snack or gently stimulate fetus through abdomen If no FM after 1hr further testing may be indicated, such as a CST Result : Non reative Nonstress Not Good Reactive Response is Real Good

13. Interpretation of results Reactive result – real good baseline FHR between traction beteen 120 and 160 beats per min. at least two accelerations of the FHR of at least 15 beats per min., lasting at least 15secs in a 10 to 20 min period as a result of FM good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (↓ FHR) and sympathetic (↑ FHR) nervous system; noted as an uneven line on the rhythm strip result indicates a healthy fetus with an intact nervous system Nonreactive result – not good stated criteria for a reative result are not met could be indicative of a compromised fetus requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)

14. Contraction Stress Test(CST)/ Oxytocin Challenge Test (OCT) The Contraction Stress Test (CST) is a screening tool used to establish fetal well-being and reserve. It identifies a fetus at risk for uteroplacental insufficiency by observing the response of the fetal heart rate to the stress of uterine contractions (spontaneous or induced). The prepartum CST evaluates respiratory function of the placenta and indicates whether the fetus will be able to withstand the stress of labor. Contraction Stress Test (CST/OCT-oxytocin challenge test) Assess ability of fetus to withstand the stress of uterine contractions Assesses placental oxygenation and function Determines fetal well being Performed if NST is abnormal

15. Contraction Stress Test(CST)/ Oxytocin Challenge Test (OCT), Nipple stimulation, Antepartum testing Indications: The CST may be indicated for evaluation of pregnancies at risk for placental insufficiency which may include, but are not limited to the following: 1. Hypertensive Disorders 2. Decreased fetal movement 3. Oligohydramnios or polyhydramnios 4. Intrauterine growth restriction 5. Post term pregnancy 6. Isoimmunization 7. Previous fetal demise 8. Multiple gestation 9. Antiphospholipid syndrome 10. Hyperthyroidism 11. Hemoglobinopathies 12. Cyanotic heart disease 13. Chronic renal disease 14. Diabetes mellitus 15. Non-reactive Non-Stress Test (NST)

16. Contraction Stress Test(CST)/ Oxytocin Challenge Test (OCT), Nipple stimulation, Antepartum testing Contraindications: The CST is contraindicated with conditions associated with an increased risk of preterm labor and delivery, uterine rupture or uterine bleeding. These may include but are not limited to the following: 1.Preterm labor or patients at high risk for preterm labor 2.History of extensive uterine surgery or classical cesarean delivery. 3.Preterm rupture of membranes 4.Known placenta previa 5.Multiple gestation If the test must be performed despite the presence of one of these conditions, prepare for emergency delivery.

17. CST may be performed by a RN who has been certified in fetal monitoring. It is done in the labor and delivery setting as an outpatient or inpatient. A physician order must be obtained and informed consent performed and signed by the patient. Interpretation of CST: 1.Negative: no late variable decelerations. 2.Positive: late decelerations associated with 50% or more of contractions (even if the contraction frequency is fewer than three in ten minutes). 3.Equivocal/Suspicious: Intermittent late decelerations or severe variable decelerations. 4.Equivocal/Hyperstimulation: Fetal heart rate decelerations that occur in the presence of contractions more frequent than every two minutes or lasting longer than 90 seconds. 5.Unsatisfactory: Fewer than three contractions in ten minutes or an uninterpretable tracing.

18. Procedure Prerequisites: 1.Fetal monitor 2.Ultrasonic gel 3.Intravenous solution 4.Oxytocin (if using Oxytocin) Procedure: 1.Orient patient 2.Review order and obtain consent 3.Position patient in the lateral recumbent or semi-fowler’s position 4.Obtain vital signs 5.Attach external fetal monitor. 6.Monitor uterine activity and the fetal heart rate for 10-20 minutes 7.Obtain and document baseline fetal heart rate and variability

19. Procedure 8.If three or more spontaneous contractions that last at least 40 seconds occur in a ten minute period, additional uterine stimulation is not necessary. If there are no contractions or fewer than three in ten minutes, contractions can be induced by either nipple stimulation or intravenous administration of low-dose Pitocin. a.Nipple Stimulation: instruct the patient to rub one nipple with her fingers or a warm cloth either directly or through her clothing for two minutes or until a contraction begins. Once the contraction begins, the patient is instructed to stop the stimulation and wait to restart if another contraction has not followed within five minutes. KEYPOINT: It is important to monitor frequency of contractions to avoid uterine hyperstimulation. b.Oxytocin: if nipple stimulation is unsuccessful or if Oxytocin is preferred, an intravenous infusion of Oxytocin may be initiated at a rate of 0.5 millunits/minutes – 1millunits/minute and doubled every 20 minutes until an adequate contraction pattern is achieved. KEYPOINT: An electrolyte solution such as lactated ringers is started as a primary Infusion and Oxytocin is infused as a piggyback.

20. Procedure 9.Assess blood pressure and pulse with each increase of Oxytocin. 10.Notify health care provider of findings prior to discharge. KEYPOINTS: a.Equivocal or unsatisfactory result should be repeated in 24 hours. b.A positive CST indicates that delivery is warranted. c.A negative CST usually correlates with good fetal outcomes. 11.When external fetal monitor is removed, clean with approved chemical disinfectant.

21. Procedure A tocotransducer and an ultrasound transducer are placed on the abdomen for 20 minutes to record baseline vital signs and baseline measurements of uterine contractions fetal movements, and FHR. The contractions cause a temporary decrease in blood and oxygen flow to the fetus, which most fetuses are able to tolerate. Three contractions, each lasting 40 seconds, must occur within a 10 minute period. If the fetus’s heart rate stays constant, the test is considered normal. KEYPOINTS: a.Equivocal or unsatisfactory result should be repeated in 24 hours. b.A positive CST indicates that delivery is warranted. c.A negative CST usually correlates with good fetal outcomes.

22. Procedure The fetus may experience a decelerated heart rate during the test. If 50% or more of the contractions cause FHR to decrease, the test is stopped and results are considered abnormal. If test results are abnormal, the patient should observed for 30 minutes after the test to make sure that contractions don’t continue. FHR shouldn’t drop below baseline at the end of the contraction or after the contraction. This is termed late deceleration and can be indicative of fetal hypoxia. KEYPOINTS: a.Equivocal or unsatisfactory result should be repeated in 24 hours. b.A positive CST indicates that delivery is warranted. c.A negative CST usually correlates with good fetal outcomes.

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