1. Antepartum Fetal Surveillance ‘HELLO BABY, HOW ARE YOU?’
Presented By: Janet L. Smith, RNC, BSN
Author: Ruth Saathoff, RNC, BSN

2. OBJECTIVES: At the end of this class the learner will be able to:
Name 5 methods of monitoring the fetus for well-being
Describe the physiology of maternal and fetal circulation in the relationship to fetal reserve.
Identify the maternal and fetal conditions that indicate a need for fetal surveillance.

3. Indications for Fetal Evaluation
Maternal risk factors
Pre-existing maternal disease
Exposure to teratogens in 1st trimester
Substance abuse
Infertility or conception within 3 months of last delivery (cont.)
What risk factors can you identify that would require fetal surveillance?
Pre-existing maternal disease: diabetes, lupus, asthma, cardiac, renal, seizure disorder, psychiatric, chronic UTI’s or renal disease, blood or bleeding disorders, reproductive tract anomaly, ABO/Rh sensitivity, chronic hypertension, Maternal anemia (sickle cell, thalassemia),
Teratogens: from illness (rubella, Parvovirus, etc.) or dangerous drug or chemical exposure in 1st trimester.
Substance Abuse: any street drug, alcohol, smoking
Infertility: especially if prolonged
Conception within 3 months of last delivery
History of OB complication—previous or present: Incompetent cervix, Placenta previa, abruption, bleeding, PIH, HELLP, Polyhydramnios or oligohydramnios, Chorioamnionitis, PPROM, Preterm labor, multiple gestation. Isoimmunization (Rh sensitization),
Previous pregnancy loss: ectopic, mole, SAB, TAB, Stillbirth, or neonata
Prolonged PROM > 24 hours: at term or near term
Significant stressful event during pregnancy: Loss of loved one, MVA, etc.
Familial history of genetic abnormality: Downs Syndrome, Trisomy 13 or 18
Post dates: > 41 weeks
Can you think of others? Weight—too little gain or obesity, grandmultiparity; age--< 16 or > 35.

4. Indications for Fetal Evaluation
Maternal Factors (cont)
History of OB complication
Oligohydramnios, Gestational Hypertension, etc.
Previous pregnancy loss
PROM > 24 hours
Familial history of genetic abnormality
Post dates

5. Indications for Fetal Evaluation
Fetal risk factors
Prematurity
SGA or LGA
Intrauterine growth restriction (IUGR)
Known anomaly
History of IUFD
Fetal cardiac arrhythmias
Decreased fetal movement
Prematurity of less than 37 weeks with contractions present
SGA or LGA
IUGR
Known anomaly: cardiac; renal; structural
IUFD: suspected
Fetal cardiac arrhythmias as heard during office visit, seen on ultrasound,etc.
Decreased fetal movement: THE BIG ONE—the one most often present
Can you think of others: suspected breech presentation or shoulder presentation

6. Why and When
Why do we think of a well baby in terms of placental perfusion?
Oxygen & nutrients are needed for fetus
Risk factors may reduce delivery to fetus
Good oxygen & nutrient delivery results in movement and growth
When is surveillance started?
When risk is present
IDDM (type 1) - 32 weeks
Previous loss - 34 weeks
The fetus must obtain its oxygen through a number of structures and interfaces in the placenta. At various points oxygen reduction is present with the addition of risk factors.
We measure oxygen delivery by the response of the fetus. If the delivery is good, the fetus responds with movement and growth. If it is inadequate, the opposite is seen. A good response tells us the central nervous system is intact—no hypoxia.
When started:
When risk identified or as above for special situations.
Goal: to prevent an Intrauterine Fetal Demise—but 30-50% of IUFDs occur in women with no identifiable maternal or fetal risk factors.

8. Patient: Kay Sarah Doc: I. Ben Cursed M.D.
G 2 P
Previous 39 weeks
Present gestation is 37 weeks
Has been keeping a Fetal Activity Diary (FAD) since 36 weeks
Now to begin surveillance with weekly NST
FIRST: go to next slide and talk about FAD

9. Fetal Movement Counts
FM indicator of intact Central Nervous System function
First line defense to identify the fetus in trouble
30-50% of IUFD occur in women with no identifiable risk factors
FAD
Generally want 10 movements in 12 hours; most feel 10 in a few hours.
Rationale:fetal motor activity is reflective of functional changes in the central nervous system, which may signal deterioration of fetal health.
When adequate movements present, it indicates an intact nervous system and no hypoxia.

10. Methods for Fetal Movement Counts
Count-to-ten
Counting after meals
Evening monitoring
Also called KICK COUNTS
Count-to-ten: At. the same time of each day begin to count fetal movements. Document the time of day and the time when 10 movements have been noted. Usually less than 2 hours.
After meal counting--pt. evaluates fetal movement for min. periods each day. 4 or more fetal movements should be felt during each period. 4 movements/1 hour = reassuring.
Evening monitoring--maximum fetal activity period is from 7:00 p.m.-11:00 p.m. Pt. to monitor fetal movements until 10 are felt.
Pro’s: Patient has sense of responsibility, validity, control; noninvasive; can be done anywhere. Inexpensive, reassuring, easy to teach.
Con’s: It’s subjective; anxiety involved; not reliable as sole indicator of fetal well-being if fetal risk factors present
For most at-risk, initiate at weeks
Reasons for decreased fetal movement: fetal sleep, smoking, lack of eating, medications, time of day, gestational age (<37 weeks, less space), placental location.

11. Interpretation Report when criteria not met
Report no movement over 8 hours
Report sudden violent increase in fetal activity followed by cessation of movement
Report changes in normal pattern of fetal movement
National standard is that if a fetus has not moved in 12 hours, it is at serious risk for fast deterioration.
The 37 weeker who calls to say her baby doesn’t kick the same as before--less room.

13. Non-stress Test (NST)
Fetal movement typically accompanied by FHR accels when CNS intact and with adequate oxygenation
Procedure:
Position sitting, semi-Fowler’s with tilt to either side
Good quality EFM tracing for min
May monitor up to 60 min
Rationale: Fetal movement is typically accompanied by FHR accels in fetus with intact CNS and adequate oxygenation.
Procedure; Leopold’s maneuvers to identify back.
Test monitor for accuracy.
Inform patient of procedure
Document on monitor strip :NST begun”
If RNST: plan, teach, schedule, report, and document
if NRNST: reposition, stimulate baby, explore reasons (diet, recent nicotine, etc.), continue to monitor up to 60 minutes.
Multiple gestations: Careful assessment & documentation of method used to ascertain separate babies. Monitors that can do two external babies, have lights that flash. If flashing at the same time, same baby.

14. Interpretation What to look at (5 parameters) Assessment
What’s the baseline?
Is there variability present?
Any uterine activity present?
Any accels present?
Any decels present?
Assessment

15. Baseline Variability Accelerations Decelerations
Uterine Activity
Fetal Movement

16. Interpretation Reactive: 2 accels in 20 min. 15 bpm X 15 sec.
15 sec. from start of accel to end of accel
15 bpm at apex of accel
gestation < 32 weeks
10 bpm X 10 sec.
frequent decels of sec.
Might mention at frequent decels of sec. on a term baby usually means low amniotic fluid.
24-28 weeks—frequently nonreacive
28-32 weeks—50% may not be reactive

17. Interpretation Nonreactive: does not meet above criteria
if not reactive in 60 min. unlikely to become so; call HCP
isolated decels seen in as many as 33%
Causes of nonreactive tracing: Indicates a need for further testing
Sleep immature CNS
cigarettes fetal hypoxia and acidosis
meds
Spontaneous variable decels:
further assessment of amniotic fluid volume recommended
Assessment of cord placement/position/integrity
“In a reactive tracing with good baseline variability, isolated decelerations which are < 15 beats from the baseline rate lasting< sec. following an acceleration do not signify fetal compromise.” James, DK et al. High Risk Pregnancy Management Option. Saunders. 1995
Reassuring or non-reassuring: If reassuring, < 1% chance of fetal death within 1 week of test.

18. Example at term

19. Example 31 weeks

21. Back to Ms. Sarah Her NST is reactive Anything else?
Chart the 5 parameters on strip & chart
Call HCP and report
Schedule next appointment
Continue FAD
Review the 5 parameters:
baseline
variability present
uterine activity present
accels present
decels present

22. Retesting If no risk factors, unlikely to have FD in one week
With risk factors, repeat 2 times a week
If pregnancy status changes, repeat in hours
If no diagnosis of pregnancy risk factors: unlikely to have FD within one week of RNST
If DM or IUGR or postdates repeat q 2-4 days
If changes in pregnancy pattern, repeat in hours
Advantages: Non-invasive; established reliability and guidelines, very low false-reactive results (7:1000)
Disadvantages: Not definitive for stress/distress, Moderate false-nonreactive-- many are just ‘laid back babies or sleeping.

23. Patient: Ms. Hertzelot Doctor: I. Ben Cursed M.D.
37 weeks gestation
G1 P0
Has not felt baby move for 8 hours
Please do NST

24. Assessment NST: Non-reactive after 40 min Possible causes: fetal sleep
smoking before coming
Maternal medications
immature CNS
fetal hypoxia

25. Well, now what? Juice myth Do Fetal Acoustic Stimulation Test (FAST)
Usually elicited after 28 weeks
Can be done after 10 min of non-reactive pattern
Handheld device generates a low frequency (82 decibels) vibro-acoustic stimulus
Apply for 3-5 sec avoiding fetal head; may repeat X 2 at least 1 min apart
May cause some level of stress
Definition: A handheld device which generates a low frequency vibro-acoustic stimulus directed towards the fetus to improve the efficiency of the NST.
Rationale: Studies indicate it is probably at least as reliable as NST; provides some level of stress
It’s a startle response in utero if intact CNS (Nyman, Barr, & Westgren – 1992 “no adverse effects as of 4 years of age)
It’s “a useful way to reduce the number of non-reactive tracings and shorten testing time.” James
Procedure: Instruct patient

26. Results of FAST Causes ‘Moro’ or startle reflex if CNS intact
Increase in FHR
1 accel of 15 bpm over 2 minutes
2 accels of 15 bpm for at least 15 sec within 5 minutes of test
Useful way to reduce number of non-reactive NST's
Shortens testing time
Advantages:
Non-invasive
Quick
Low false-reactive
Disadvantages
same as for NST
Not as widely accepted as NST
Moderate false-nonreactive results

27. Vibroacoustic Stimulation

28. Back to Ms. Hertzelot Well, now what? NST reactive with FAST
Monitor until BL is restored
Home with FAD
Document on Strip and Chart
Reactive FAST can be a long return to baseline.

29. Patient: Ms. Shirley I. M. Late Doctor: I Ben Cursed M.D.
40 & 5/7 weeks gestation
Please do NST
Results:
NST: non-reactive
FAST (or VAS): still non-reactive
More monitoring: still non-reactive

30. Well, now what? Options: Contraction Stress Test (CST)
assumes uteroplacental insufficiency will show hypoxia with late decels with contractions
Biophysical Profile (BPP)
Ultrasound assessment of acute and chronic markers show good predictor of fetal well-being

31. CST Modes Nipple stimulation (BST) IV oxytocin (OCT)
may be poorly received by patient
noninvasive
IV oxytocin (OCT)
requires invasive procedure
Spontaneous contractions
Rationale: Based on assumption that fetus with uteroplacental insufficiency will show hypoxia with late decelerations in response to UC’s.

32. Interpretation FHR response to stress of contractions
3 contractions lasting sec. in 10 min.
‘Negative’ is absence of late decels (That’s good!)
‘Positive’ is presence of late decels (That’s bad!)
> 50% of contractions--need to deliver
‘Equivocal’ is presence of some lates
<50% of contractions
Hyperstimulation or Unsatisfactory Results
Considered testing failure and are not clinically useful
‘Suspicious’
Variable Decelerations
Advantages:
Tests fetal response tolerate stress
Familiar, accepted
Low false-negative
Disadvantages
Nipple stimulation. May be poorly received by patient
Oxytocin requires invasive procedure
Need setting with C?S capabilities
Uterine activity may be difficult to control or lead to uterine hyperstimulation or PTL
Replaceable by less potentially harmful tests, esp. FAST

33. Negative
Positive – Late Decelerations
Suspicious – Variable Decelerations
Test Failure - UterineTachysystole

34. BPP Parameters Need high tech equipment/skilled technician
Fetal Tone (FT) (7-8wks)
Fetal Movement (FM) (9wks)
Fetal Breathing Movements (FBM)) (20-21wks)
Amniotic Fluid Index (AFI) > 6 cms
NST (Accelerations wks)
Need high tech equipment/skilled technician
Non-invasive, highly predictive
Rationale: Ultrasound assessment of acute and chronic markers show good predictor of fetal well-being.
Procedure: prolonged ultrasound (20-30 min) plus NST
Advantages:
Non-invasive
Reliable and highly predictive in high-risk and prolonged pregnancy
Secondary findings of anomalies possible
Disadvantages
Need high-tech equipment
Need skilled technician
Time required
Modified BPP—NST and AFI (greater than 5 cms of fluid in 4 quadrant pockets)

35. Scoring Biophysical Variable Normal (Score = 2) Abnormal (Score = 0)
Fetal breathing movements
1 or more episodes of ≥ 20 s within 30 min
Absent or no episode of ≥ 20 s within 30 min
Gross body movements
2 or more discrete body/ limb movements within 30 min (episodes of active continuous movement considered as a single movement)
<2 episodes of body/limb movements within 30 min
Fetal tone
1 or more episodes of active extension with return to flexion of fetal limb(s) or trunk (opening and closing of hand considered normal tone)
Slow extension with return to partial flexion, movement of limb in full extension, absent fetal movement, or partially open fetal hand
Reactive FHR
2 or more episodes of acceleration of ≥ 15 bmp* and of >15 s associated with fetal movement within 20 min
1 or more episodes of acceleration of fetal heart rate or acceleration of <15 bmp within 20 min
Qualitative AFV
1 or more pockets of fluid measuring ≥ 2 cm in vertical axis
Either no pockets or largest pocket <2 cm in vertical axis

36. Interpretation Scoring 10 point scale (if performed with a NST)
8-10 indicates fetus in good condition
6 indicates need to repeat in 4-6 hours
<6 indicates need for delivery
AFI < 6 cms indicates delivery
See handout

37. Back to Ms. Late Well, now what? NST: non-reactive CST: negative
BPP: 6/10 (FT-2, FM-2, FBM-0, AFI-2, NST-0)
Report to HCP/document all findings
Home with FAD
Reschedule for repeat NST/BPP in 2-3 days

38. Other Surveillances Amniocentesis Ultrasound Examination
Fetal lung maturity
Testing- genetic, cultures, change in optical density
Ultrasound Examination
Uterine contents
Fetal biometry / dating
Fetal anatomic examination
Amniocentesis: Gives knowledge of maturity of fetal lung aids in optimizing delivery time in at-risk pregnancies. Done at weeks for genetic testing.
Done in HCP office most often.
Procedure & Nursing role: Pt. teaching, give Terbutaline as ordered to relax uterus, prepare sterile tray, etc., prepare specimens to block light and send to lab., give Rhogam if indicated, wedge hip to prevent supine hypotension.
Lung profile: L/S ratio (Lecithin/sphingomyelin) 2:1 at term--not reliable in diabetics, meconium or blood in fluid alters ratio
PG positive after 35 weeks. Not affected by diabetes, not affected by fluid contamination, can use vaginal pool specimen, but 25T of mature fetuses do not produce PG
Amniotic fluid creatinine level > 2mg/dl for maturity of renal system
Advantages: Reasonable reliability to lung maturity
Disadvantages: Invasive, Pt. anxiety, risks of ROM and /or infection, risk of placental perforation, risk of fetal puncture.
Ultrasound Level II: Complete review of systems, serially done for growth curve. Dating/EDD before 20 weeks, estimate fetal weight, look for symmetrical growth, anomalies,, Down’s syndrome. Non-invasive, but time consuming. Cost.

39. Other Surveillance Options
Doppler Flow Studies
Checks BP of uterine and placental vessels
Associated with fetal growth deficiency
Doppler flow Studies: movement of blood in vivo based on the change in frequency of reflected sound.
What checked: Abnormalities in UA blood velocity associated with fetal growth deficiency
fetal vessels, such as aorta and in brain, show fetal hemodynamic responses to physiologic and pathologic events
Maternal uterine artery blood flow, placenta implantation site, subplacental vessels.
Technique: transvaginal, or transabdominal
Used to assess or aid with screening in:
fetal growth deficiency fetal hypoxia
fetal anemia pre-eclampsia
These abnormal waveforms are associated with histological evidence of reduced numbers of small placental blood vessels and therefore reflect "placental insufficiency". In pregnancies with reduced, absent or reversed end-diastolic velocity, there is an increased risk of stillbirth, asphyxia, chromosomal and congenital abnormality. Abnormal umbilical Doppler waveforms can be present for weeks before there is evidence of fetal compromise and therefore are a marker of a high risk situation and should not normally be used in isolation as an indication for delivery. However, most obstetricians would consider delivering a fetus with absent end-diastolic velocity from about thirty two weeks gestation following administration of corticosteroids. In many instances, fetuses with absent end-diastolic velocity would present much earlier in pregnancy and may require extremely preterm delivery.

40. Other Surveillance Options (cont’d)
Chorionic Villus sampling
early prenatal genetic studies
Chorionic Villus Sampling
Rationale: Provides earlier prenatal diagnosis than amniocentesis
Available since 1983
The chorionic villus sample can be collected by putting a thin flexible tube (catheter) through the vagina and cervix into the placenta. The sample can also be collected through a long, thin needle put through the belly into the placenta. Ultrasound is used to guide the catheter or needle into the correct spot for collecting the sample

42. References:
American Academy of Pediatrics, American College of Obstetricians & Gynecologists, Guidelines for Perinatal Care (5th ed. 2002), Antepartum surveillance, pp
AWHONN Fetal Heart Rate Monitoring Principles and Practices 4th Ed.
Christensen FC, Olson K, Rayburn WF (2003). Cross-over trial comparing maternal acceptance of two fetal movement charts. Journal of Maternal-Fetal and Neonatal Medicine, 14(2), pp
Devoe, L, Glob. libr. women's med., (ISSN: ) 2008; DOI /GLOWM.10210
Martin, E.J., Intrapartum Management Modules (3rd ed. 2002), Performing fetal surveillance testing, pp
Mattson, S., Smith, J.E., Core Curriculum for Maternal-Newborn Nursing (3rd. ed.,2004), Clinical practice pp
Simpson, K. R., Creehan, P.A., Perinatal Nursing (2nd ed., 2001), Fetal surveillance, pp