2.  Prolonged pregnancy  Decreased fetal movements  Hypertension in pregnancy  Diabetes in pregnancy  Fetal growth restriction  Multiple gestation  PPROM  Previous LSCS  Obstetric cholestasis  Sickle cell disease  ECV  Cord prolapse  Spinal cord injury – Autonomic dysreflexia

3.  In low risk pregnancy usually induction of labour is done at 41 weks of gestation.  When will you start your antepartum fetal surveillance?  No need of any antenatal fetal surveillance before 41 weeks of gestation provided she is feeling the fetal movements well and clinical assessment of liquor volume is adequate.

4.  Suppose she declines induction of labour at 41 weeks. When will you initiate fetal surveillance?  Fetal surveillance is initiated between 41 and 42 weeks because of evidence that perinatal morbidity and mortality increase as gestational age advances.  How often will you do it?  Twice weekly assessment of amniotic fluid and a NST should be adequate.  (ACOG and RCOG – Grade C recommendation)

5.  What will you do when the lady complains of decreased fetal movements?  After fetal viability has been confirmed and history confirms a decrease in fetal movements, arrangements should be made for the woman to have a CTG to exclude fetal compromise if the pregnancy is over 28+0 weeks of gestation.

6.  CTG for 20minutes  The presence of a normal fetal heart rate pattern (i.e. showing accelerations of fetal heart rate coinciding with fetal movements) is indicative of a healthy fetus with a properly functioning autonomic nervous system.  The fetal heart rate accelerates with 92–97% of all gross body movements felt by the mother

7.  If the term fetus does not experience a fetal heart rate acceleration for more than 80 minutes, fetal compromise is likely to be present  56% of women with a high-risk pregnancy who reported RFM had an abnormal CTG.This was associated with an unfavourable perinatal outcome.

8. Chronic hypertension Mild or moderate gestational hypertension, Women at high risk of pre-eclampsia :  Cardiotocography only if fetal activity is abnormal.

9. SEVERE GESTATIONAL HYPERTENSION OR PRE- ECLAMPSIA:  Cardiotocography at the time of diagnosis  Repeat CTG weekly unless the results of all fetal monitoring indicate more frequent CTG ◦ the woman reports a change in fetal movement ◦ vaginal bleeding ◦ abdominal pain ◦ deterioration in maternal condition.

10.  When to start fetal surveillance?  Initiate fetal surveillance at 38 weeks in pregnant women with diabetes provided there is no fetal growth restriction.  How often to repeat?  Repeat CTG weekly unless the results of all fetal monitoring indicate more frequent CTG until the time of termination of pregnancy

11.  CTG should not be used as the only form of surveillance in SGA fetuses.  Interpretation of the CTG should be based on short term fetal heart rate variation from computerised analysis  Use cCTG (computerised CTG) when DV Doppler is unavailable or results are inconsistent – recommend delivery if STV (short term variation) < 3 ms

12.  Ductus venosus Doppler has moderate predictive value for acidaemia and adverse outcome.  Ductus venosus Doppler should be used for surveillance in the preterm SGA fetus with abnormal umbilical artery Doppler and used to time delivery.

13. DICHORIONIC DIAMNIOTIC TWINS MONOCHORIONIC DIAMNIOTIC TWINS -CTG weekly from 36weeks MONOCHORIONIC MONOAMNIOTIC TWINS  If concerns about significant cord entanglement consider -CTGs 3 x weekly (Monday, Wednesday and Friday)  If no concerns about cord entanglement - weekly CTGs

14.  Women should be observed for signs of clinical chorioamnionitis.  It is not necessary to carry out weekly high vaginal swab, maternal full blood count or C- reactive protein because the sensitivity of these tests in the detection of intrauterine infection is low.  Cardiotogography is useful and indeed fetal tachycardia is used in the definition of clinical chorioamnionitis.

15.  No antepartum CTG is recommended unless fetal activity is abnormal or she experiences scar tenderness.

16.  Women should be informed that the case for intervention (after 37+0 weeks of gestation) may be stronger in those with more severe biochemical abnormality (transaminases and bile acids).  Women should be informed of the increased risk of maternal and perinatal morbidity from intervention at 37+0 weeks of gestation.  Women should be informed of the inability to predict stillbirth if the pregnancy continues.  No role for CTG

17.  When will you initiate and how often you will do fetal surveillance?  Offer fetal monitoring if the woman declines delivery by 40 weeks of gestation.  Twice weekly assessment of amniotic fluid and a NST from 40 weeks of gestation.

18.  When will you do CTG?  ECV should be performed where ultrasound to enable fetal heart rate visualisation, cardiotocography and theatre facilities are available.  Cardiotocography should be performed after the procedure.

19.  Suspicious or pathological fetal heart rate pattern - category 1 caesarean section should be performed with the aim of achieving birth within 30 minutes or less without compromising maternal safety.  Normal fetal heart rate pattern - category 2 caesarean birth can be considered with the aim of achieving birth within 75 minutes or less - but continuous assessment of the fetal heart trace is essential, if the cardiotocograph (CTG) becomes abnormal, re-categorisation to category 1 birth should immediately be considered.

20.  Why CTG?  Electronic fetal monitoring is advised to detect fetal distress secondary to AD.  Fetal bradycardia with AD in the mother  When will you do CTG?  Hospital care from 36+6 weeks of gestation onwards, for daily CTG and 4 hourly monitoring for uterine activity.