1. ASSESSMENT OF Fetal
Well-being
Lectures 3

2. Assessment of fetal well-being
The major expected outcome is the detection of potential fetal compromise
Used before intrauterine asphyxia of the fetus and health care provider can take measures to prevent or minimize adverse perinatal outcomes
First- and second-trimester antepartal assessment is directed primarily at the diagnosis of fetal anomalies.
The goal of third-trimester testing is to determine whether the intrauterine environment continues to be supportive to the fetus.

3. Daily Fetal Movement Counts3

4. Daily Fetal Movement Counts Kick Counts
Assessment of fetal activity by the mother
Non-invasive, inexpensive, simple to understand, and does not interfere with routine at home
once a day, roughly at the same time every day in a comfortable sitting or lying position
when baby is usually active (after meals, after activity, and in the evening).
Since healthy babies have sleep cycles, baby may not kick, or kick less than usual, or have less than 10 kicks in 2 hours. If so, wake up the baby by drinking fluid or by walking for 5 minutes. Repeat the kick count.

5. Daily Fetal Movement Counts Kick Counts
No less than3 movements in 30 minutes
Most healthy babies should take less than 2 hours for 10 kicks.
not moved 10 times in 2 hours or the baby has sustained significant changes.
Fetal alarm signal if no movement in 12 hours
The evaluation may include:
Ultrasound - taking pictures from sound waves to evaluate the growth of the baby, amniotic fluid quantity, placenta, blood flow pattern etc.
Non stress test (NST) -Baby's heart rate monitoring in response to its own movements
Biophysical profile (BPP) -using an ultrasound exam with a non stress test (NST) to evaluate baby's heart rate, breathing, body movement, muscle tone, and amniotic fluid quantity
Contraction stress test (CST) -Baby's heart rate monitoring in response to uterine contractions

6. OBSTETRIC ULTRASOUND 6

7. Ultrasound in obstetrics can provide good information about the fetus and its environment
With ultrasound, can be determined an early intervention or conservative management in pregnancy
Latest developments in ultrasound examination is a transvaginal ultrasound discovery - the observation of "FLOW DOPLLER" and the most sophisticated ultrasound 3 D and 4D which has a high ability to determine fetal condition 7 7

8. Ultrasonography Indications for use Fetal heart rate activity
Gestational age
Fetal growth
Fetal anatomy
Fetal genetic disorders and physical anomalies
Placental position and function
visual assistance to other invasive tests
Fetal well-being

9. Ultrasonography Abdominal Vaginal After 1 trimester Full blader
Early diagnostic of uterine pregnancy
Empty blader
Obese woman

10. Ultrasonography Levels of ultrasonography:
An important and safe technique in antepartum fetal surveillance
Levels of ultrasonography:
Standard examination
Used for specific indications, i.e., fetal viability, fetal presentation, gestational age, locate the placenta, fetal anatomy and malformation
Specialized or targeted examination
Suspicion of an abnormal fetus (abnormal finding on clinical examination, poly- or oligohydramnionios, elevated AFP)

11. Ultrasonography: Indication for use 1 trimester
Number, size, location of gestational sac
Fetal cardiac and body movement
Uterine abnormalities (bicornuate uterus, uterine fibroid, IUD) or adnexal masses
Duration of pregnancy (crown-rump length)
Visualization during chorionic villus sampling

12. Ultrasonography: Indication for use ( 2nd and 3rd trimester )
Fetal viability, number and presentation,
Establishment of fetal age and growth by fetal biometry including:
BPD ~ biparietal diameter
FL ~ femur length
AC ~ Abdominal circumference
Biophysical profile
Evaluation of fetal anatomic structures:
Cerebral lateral ventricles
Spine
Four chamber view of the heart
Stomach-bowel, abdominal wall at the area of the umbilical cord insertion
Bladder and kidney
Limbs and umbilical cord
Amount of amniotic fluid
Placental localization and maturity
Evaluation of the uterine, and adnexae for abnormalities and masses
Cervical length
Visual assistance to invasive tests 12 12

13. Fetal heart activity Fetal viability 6-7 weeks by echo scaner
10-12 weeks by Doopler
Fetal viability
Fetal cardiac activity
Fetal movement
Breathing movement

14. Gestational age Gestational sac dimensions (about 8 weeks)
Crown-rump length (7-12 weeks)
Biparietal diameter (after 12 weeks)
Femur length (after 12 weeks)
BPD, FL and AC the most important parameters for determination of gestational age
Determination of gestational age should be performed prior to 26 weeks gestational age
3rd trimester determination of gestational age does not acurately reflect gestational age

15. Fetal growth BPD ~ biparietal diameter FL ~ femur length
AC ~ Abdominal circumference
Discrepancy resulting from inaccurate dates
True intrauterine growth restriction (IUGR)
Symmetric - the fetus being small in all parameters, reflects a chronic or long-standing insult and may be caused by low genetic growth potential, intrauterine infection, undernutrition, heavy smoking, or chromosomal aberration.
Asymmetric - head and body growth varying, suggests an acute or late-occurring deprivation, such as placental insufficiency resulting from hypertension, renal disease, or cardiovascular disease.
Macrosomia - weighing more than 4000 g, associated with maternal glucose intolerance, carries an increased risk of intrauterine fetal death, and at increased risk for trauma during birth.

16. Ultrasonography: gestational age
Week’s Gestation
7 – 10 29
Crown-rump length (CRL)
Crown-rump length
Biparietal Diameter (BPD)
Femur Length (FL)
Humerus Length (HL)
Biparietal Diameter
Femur Length
Humerus Length
Head Circumference (HC)
Binocular distance
Binocular distance Biparietal Diameter
Other long bones
Head Circumference
a In decreasing order
b Only if cephalic index ( BPD divided by occipital-frontal diameter ) is normal ( 76-84%) ; otherwise , the fetal head may be dolichocephalic or brachycephalic 16 16

17. 1st trimester fetus CRL 17
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18. 28 mm CRL in 10 weeks
twin pregnancy 18
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19. Biparietal Diameter
a cross section through the fetal head at the level of the thalamus. The skull is represented by the thick white lines which surround the brain. This view is used to measure the biparietal diameter (line) and the circumference of the head (dots). 19
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20. Fetal Femur 20
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21. Pregnant uterus - longitudinal21
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22. Fetal : intracranial structure and extremity22
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23. Fetal anatomy Head (ventricles, blood vessels) Small bowel Neck Liver
Spine
Heart
Stomach
Small bowel
Liver
Kidney
Blader
Limb

24. Fetal Cardiac Structure24
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25. Fetal Liver and
Lung interface 25
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26. Fetal Liver
3rd Trimester 26
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27. Fetal Spine 27
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28. Spine 3 D 28
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29. Neural tube defects
NTD’s result from failure of tube closure by the 6th weeks gestational age (embryonic age 26 – 28 days )
Various NTD’s anomalies :
Anencephaly
Encephalocele
Spina Bifida 29 29

30. Gross malformation may be detected in 1st trimester sonogram 1:
Anencephalus (absence of a major portion of the brain, skull, and scalp)
Acrania (partial or complete absence of the cranium). 30 30

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32. Spina Bifida
Consist of a hiatus, usually in the lumbosacral vertebrae, through which a meningeal sac may protruded → meningocele
90% of cases, the sac contains neural elements → meningomyelocele
The fetal spine should be examined by sonography with: sagittal, tranverse and coronal views 32
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33. Spina
Bifida 33
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34. NEURAL TUBE DEFECTS 34
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35. NEURAL TUBE DEFECTS 35
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36. Fetal anatomy Gross malformation may be detected in 1st trimester sonogram 2:
Hydrancephaly (the cerebral hemispheres are absent and replaced by sacs filled with cerebrospinal fluid
Cystic Hygroma (is a congenital multiloculated lymphatic lesion that can arise anywhere, but is classically found in the left posterior triangle of the neck. 36 36

37. Abdominal Wall Defects
The two most common are :
Omphalocele
Gastroschisis
Can be ascertained early in pregnancy by maternal serum alphafetoprotein screening programs 37
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38. Gross malformation may be detected in 1st trimester sonogram 3:
Omphalocele (abdominal wall defect in which the intestines, liver, and occasionally other organs remain outside of the abdomen in a sac)
Gastroschisis (paraomphalocele congenital abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall) 38 38

39. OMPHALOCELE 39

40. GASTROSCHISIS 40
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41. Duodenal atresia
Diagnosed prenatally by the demonstration of the double bubble sign ( distension of the stomach and first part of the duodenum )
Must be differentiated from other cystic structures in the upper abdomen
Diagnosis generally is not possible before 24 weeks
30% of cases has been associated with trisomy 21 41
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42. Gross malformation may be detected in 1st trimester sonogram 4:
Fused twins (Siamese twins) are identical twins whose bodies are joined in utero 42 42

43. Fetal genetic Disorders Nuchal Translucency
The maximum thickness of the subcutaneus translucent area between the skin and the soft tissues overlying the posterior aspect of the cervical spine in sagital scane plane. (10-14 weeks)
A thickness > 3 mm ( sagital plane):
90% trisomy 18 and 13
80% trisomy 21
5% normal 43 43

44. Placenta position and function
Location
Relationship between cervical os
Maturation

45. Uterus and Adnexa Uterine fibroid Cervical incompetence :
Tunneling of the internal ( dilatation )
Cervical length < 3 cm
Bulging membranes ( with or without prolaps of the cord or fetal parts )
30 weeks of gestational age: length of cervix more than 3 cm
Adnexal mass :
Physiological: Diameter corpus luteum at pregnancy about 2 cm
Uterine fibroid 45 45

46. Sonographic assesment of the amniotic fluid
Normal : at 2nd and 3rd trimester vertical pocket about 2 cm
AFI ( amniotic fluid index ): sum of the depth of the largest pocket of fluid in the four quadrants of abdomen
AFI < 5 cm : strongly asociated with oligohidramnions postmaturity 46 46

47. Amniotic Fluid
Index 47
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48. Interpretation of the AFl
10.1 to cm Normal
5.1 to cm Borderline
Less than or equal 5.0 cm Abnormal (Oligohydramnios)
Greater than cm Abnormal (Polyhydramnios)
Oligohydramnios is associated with congenital abnomalies (ex. renal agenesis) growth restriction fetal distress
Polyhydramnios is associated with neural tube defects obstruction of the fetal gastrointestinal tract, multiple fetuses and fetal hydrops

49. DOPPLER VELOCIMETRY
The primary use of Doppler echo shifts in obstetrics have been to detect and measured blood flow
Basis of Doppler Velocimetry : The sound of moving blood cells within vasculature generates an effective Doppler Shift
There are 2 methods of estimating circulatory hemodynamics :
Direct measurement of the volume of blood flow
Indirect estimation of flow velocity using wave form analysis 49 49

50. DOPPLER VELOCIMETRY
The shifted frequencies can be displayed as a plot of velocity versus time, and the shape of these waveform can be analyzed to give information about blood flow and resistance in a given circulation
Velocity waveforms from umbilical and uterine arteries, reported as systolic/diastolic (S/D) ratio achieve

51. DOPPLER VELOCIMETRY
Most fetuses will achieve an S/D ratios of 3 or less by 30 weeks
Persistent elevation of S/D ratios after 30 weeks is associated with IUGR resulting from uteroplacental insuficiency
In postterm pregnancies an elevated S/D ratio indicates a poorly perfused placenta
Abnormal result are seen with chromosome abnomalities in the fetus 51 51

52. Fetal Umbilical Cord Doppler52
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53. DOPPLER VELOCIMETRY

54. Fetal Breathing Movement54
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55. Fetal Umbilical artery and Bladder55
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56. Biophysical profile (BPP)
Real-time ultrasound permits detailed assessment of the physical and physiologic characteristics of the developing fetus and cataloging of normal and abnormal biophysical responses to stimuli.
The biophysical profile (BPP) is a noninvasive dynamic assessment of a fetus and its environment by ultrasonography and external fetal monitoring. BPP scoring is a method of fetal risk surveillance based on the assessment of both acute and chronic markers of nonreassuring fetal status.
The BPP includes:
fetal breathing movements,
fetal movements,
fetal tone,
fetal heart rate patterns by means of a nonstress test,
AFV;
The fetal response to central hypoxia is alteration in movement, muscle tone, breathing, and heart rate patterns. The presence of normal fetal biophysical activities indicates that the central nervous system (CNS) is functional and the fetus therefore is not hypoxemic

57. Biophysical profile (BPP)

58. Biophysical profile (BPP)
The BPP is an accurate indicator of impending fetal death.
Fetal acidosis can be diagnosed early with a nonreactive nonstress test and absent fetal breathing movements.
An abnormal BPP score and oligohydramnios are indications that labor should be induced.
Fetal infection in women whose membranes rupture prematurely (at less than 37 weeks of gestation) can be diagnosed early by changes in biophysical activity that precede the clinical signs of infection and indicate the necessity for immediate birth.
When the BPP score is normal and the risk of fetal death low, intervention is indicated only for obstetric or maternal factors.

59. Magnetic resonance imaging59

60. Magnetic resonance imaging (MRI)
Noninvasive radiologic technique
Like CT provides pictures of soft tissue
Unlike CT is not use ionizing radiation

61. Magnetic resonance imaging (MRI)
Fetal structure
Placenta (position, density, and presence of gestational trophoblastic disease)
Quantity of amniotic fluid
Maternal structures (uterus, cervix, adnexa, and pelvis)
Biochemical status of tissues and organs
Soft tissue, metabolic, or functional anomalies

62. BIOCHEMICAL ASSESSMENT62

63. BIOCHEMICAL ASSESSMENT
Involves biological examination and chemical determination
Procedures used to obtain needed speciment
Amniocentesis
Percutaneous umbilical blood sampling
Chorionic villus sampling
Maternal sampling

64. BIOCHEMICAL ASSESSMENT. Amniocentesis64

65. Amniocentesis
First introduced by Serr and Fuchs and Riis in the 1950s for fetal sex determination
Only at the late 70th a static ultrasound was used to locate the placenta and amniotic fluid pocket
Only In 1983, Jeanty reported a technique of amniocentesis ’’under ultrasound vision’’

66. Amniocentesis is perform to obtain amniotic fluid, which contains fetal cells. Under direct ultrasonographic visualization, a needle is inserted transabdominally into the uterus, amniotic fluid is withdraw into a syringe, and the various assessment are performed

67. Amniocentesis: Indications
Genetic disorders
women more than 35 years old, with a previous child with a chromosomal abnormality, or with a family history of chromosomal anomalies.
Inherited errors of metabolism (such as Tay-Sachs disease, hemophilia, and thalassemia) and other disorders for which marker genes are known may also be detected.
Cells are cultured for karyotyping of chromosomes. Karyotyping also permits determination of fetal sex, which is important if a sexlmked disorder is suspected.
Alpha-fetoprotein (AFP) levels are assessed as a followup for elevated levels in maternal serum. High AFP levels in amniotic fluid help confirm the diagnosis of a neural tube defect such as spina bifida or anencephaly or an abdominal wall defect such as omphalocele. AFP levels may also be elevated in a normal multifetal pregnancy and with intestinal atresia, presumably caused by lack of fetal swallowing.
Assessment of pulmonary maturity
L/S > 2:1
Diagnosis of fetal hemolytic disesase
bilirubin level < 0.015

68. Amniocentesis After 10-14 weeks gestation
Early – earlier than 15 weeks
Late – second trimester after 15 weeks
Only the amniotic (inner) sac should be aspirated
Approximately 1 cc for gestational age
laboratory failure op to 20%

69. Complications
Leakage of amniotic fluid (better prognosis than spontaneous leakage)
Amnionitis
Vaginal bleeding
Needle puncture of the fetus
Long term complications:
Respiratory distress??
Isoimmunization??

70. Amniocentesis Maternal complications Fetal complications Hemorrhage
Fetomaternal hemorrhage with possible maternal Rh isoimmunization
Infection
Labor
Abruptio placentae
Damage to intestines or bladder
Amniotic fluid embolism
Fetal complications
Death
Hemorrhage
Infection (amnionitis)
Direct injury from the needle
Miscarriage or preterm labor
Leakage of amniotic fluid

71. Amniocentesis and HIV positive women
Increased rate of vertical transmission
Chemoprophylaxis previous to amniocentesis appears to be beneficial in preventing vertical transmission

72. Multiple Gestation Three methods:
Indigo carmine injection to the first sac
A single needle puncture sampling technique (Jeanty 1990)
Simultaneous visualization of two needles on each side of the separating membrane (Bahado-Singh 1992)
Abortion risk – probably higher
Detailed description of fetus position and placental location

73. BIOCHEMICAL ASSESSMENT Percutaneous umbilical blood sampling (CORDOCENTESIS)73

74. CORDOCENTESIS
Involves the insertion of the needle directly into fetal umbilical vessel under ultrasound guidance and the removing 1-4 ml of blood

75. CORDOCENTESIS Indications for use
Prenatal diagnosis of inherited blood disorders
Karyotyping of malformed fetuses
Detection of fetal infection
Determination of the acid-base status of fetuses with IUGR
Assessment and treatment of isoimmunization and trombocytopenia in the fetus

76. CORDOCENTESIS. Complications
Blood leaking from puncture site
Cord laceration
Thromboembolism
Preterm labour
Premature rupture of membranes
Infections

77. BIOCHEMICAL ASSESSMENT Chorionic villus sampling77

78. Chorionic villus sampling (CVS)
Earlier diagnosis and rapid results
Performed between 10 and 12 weeks of gestation
Removal of small tissue specimen from fetal portion of placenta
Chorionic villi originate in zygote and reflects genetic makeup of fetus

79. Chorionic villus sampling
Was developed in the 80th
percutaneous transabdominal
transvaginal
transcervical

80. Chorionic villus sampling (CVS)
Complications:
vaginal spotting or bleeding immediately afterward,
Miscarriage
Rupture of membranes,
chorioamnionitis.
Because of the possibility of fetomaternal hemorrhage, women who are Rh negative should receive immune globulin (RhoGAM) to avoid isoimmunization.

81. Chemical determination81

82. SERUM MARKER Serum marker
maternal serum alphafetoprotein MS-AFP
maternal unconjugated estriol
maternal serum beta-human chorionic gonadotropin (hCG)
Others
• Pregnancy associated plasma protein - A (PAPP-A)
• Inhibin A

83. SERUM MARKER Positive test indicates increased risk
Negative test indicates no increased risk but not mean normal fetus
Multiple fetuses cannot be assessed

84. AFP
AFP is produced by the fetal liver, and increasing levels are detectable in the serum of pregnant women from 14 to 34 weeks.
Approximately 80% to 85% of all open NTDs and open abdominal wall defects
Screening is recommended for all pregnant women.
If findings are abnormal, follow-up procedures include genetic counseling for families with a history of NTD, repeat AFP, ultrasound examination, and possibly amniocentesis.

85. (15-22 weeks most accurate 16-18 weeks)
Triple screening
(16-18 weeks)
Maternal serum alpha-fetoprotein (MS-AFP)
Human chorionic gonadotropin (hCG)
Unconjugated estriol (UE3)
Quadruple Screen
(15-22 weeks most accurate weeks)
AFP
hCG
UE3
Inhibin

86. Neural or abdominal wall defects
Quadruple Screen
hCG
Estradiol
Inhibin
AFP
Down Syndrome
High
Low
Neural or abdominal wall defects
Nml
Trisomy 18
Down Syndrome
PAPP-A is low
Inhibin A is elevated

87. Electronic fetal monitoring87

88. Indications for Electronic Fetal Monitoring Assessment Using NST and CST
Maternal diabetes mellitus
Chronic hypertension
Hypertensive disorders in pregnancy
IUGR
Sickle cell disease
Maternal cyanotic heart disease
Postmaturity
History of previous stillbirth
Decreased fetal movement
Isoimmunization
Meconium-stained amniotic fluid at third-trimester amniocentesis
Hyperthyroidism
Collagen disease
Older pregnant woman
Chronic renal disease

89. Contraindications for Electronic Fetal Monitoring Assessment
NST No
but results may not be conclusive if
gestation is 26 weeks or less.
CST :
rupture of membranes,
previous classic incision for cesarean birth,
preterm labor,
placenta previa,
placenta abruptio
multifetal pregnancy,
previous preterm labor,
hydramnios,
more than 36 weeks of gestation,
incompetent cervix

90. Fetal Responses to Hypoxia or Asphyxia
Hypoxia or asphyxia elicits a number of responses in the fetus. There is a redistribution of blood flow to certain vital organs. This series of responses (redistribution of blood flow favoring vital organs, decrease in total oxygen consumption, and switch to anaerobic glycolysis) is a temporary mechanism that enables the fetus to survive up to 30 minutes of limited oxygen supply without decompensation of vital organs.
However, during more severe asphyxia or sustained hypoxemia, these compensatory responses are no longer maintained, and a decrease in the cardiac output, arterial blood pressure, and blood flow to the brain and heart occurs, with characteristic FHR patterns reflecting these changes.

91. Fetal heart rate terminology
Baseline rate
Bradycardia&Tachicardia
Variability
-Longterm & Short term
Acceleration
Deceleration
-Early
-Late -
Varible

92. NST
is the most widely applied technique for antepartum evaluation of the fetus.
Basis: the normal fetus will produce characteristic heart rate patterns in response to fetal movement.
can be performed easily in an outpatient setting because it is noninvasive.
relatively inexpensive and has no known contraindications.
Disadvantages center around the high rate of false-positive results for nonreactivity as a result of fetal sleep cycles, medications, and fetal immaturity.
The test is also slightly less sensitive in detecting fetal compromise than are the CST and BPP.

93. NST Interpretation
Two or more accelerations of 15 beats per minute lasting for 15 seconds over a 20-minute period
Normal baseline rate
Long-term variability amplitude of 10 or more beats per minute
If the test does not meet the criteria after 40 minutes, it is considered nonreactive, in which case further assessments are needed with a CST or BPP.
twice weekly (after 28 weeks of gestation) with patients who are diabetic or at risk for fetal death.

94. NST Reactive Nonreactive
2 or more accelerations of FHR of 15 beats/min lasting ≥15 sec, associated with each fetal movement in 20-min period
Allow to continue
Nonreactive
Any tracing with either no FHR accelerations or accelerations <15 beats/min or lasting <15 sec throught any fetal movement during testing period
CST, BBP
Unsatisfectory quality of FHR recording not adequate for interpretation
Repeated in 24 hours or
CST

95. CST
Uterine contractions decrease uterine blood flow and placental perfusion. If this decrease is sufficient to produce hypoxia in the fetus, a deceleration in FHR will result, beginning at the peak of the contraction and persisting after its conclusion (late deceleration).
Nipple-Stimulated
10 min massage
2 min massage 5 min break
Oxitocin-Stimulated
10 U in 1000 ml fluid IV

96. CST NEGATIVE POSITIVE SUSPICIOUS HYPERSTIMULATION UNSATISFACTORY
No late decelerations, with minimum of three uterine contractions lasting 40 to 60 sec within 10-min period
Reassurance that the fetus is likely to survive labor should it occur within 1 wk; more frequent testing may be indicated by clinical situation
POSITIVE
Persistent and consistent late decelerations occurring with more than half of contractions
Management lies between use of other tools of fetal assessment such as BPP and termination of pregnancy; a positive test result indicates that fetus is at increased risk for perinatal morbidity and mortality; physician may perform expeditious vaginal birth after successful induction or may proceed directly to cesarean birth; decision to intervene is determined by fetal monitoring and presence of FHR reactivity
SUSPICIOUS
Late decelerations occurring in less than half of uterine contractions once adequate contraction pattern established
NST and CST should be repeated within 24 hr; if interpretable data cannot be achieved, other methods of fetal assessment must be used*
HYPERSTIMULATION
Late decelerations occurring with excessive uterine activity (contractions more often than every 2 min or lasting longer than 90 sec) or persistent increase in uterine tone
UNSATISFACTORY
Inadequate uterine contraction pattern or tracing too poor

97. CST

98. Дякую за увагу!