Antepartum fetal assessment

Antepartum fetal assessment

Definition:

Antepartum fetal assessments are methods that now routinely used

to get accurate measures of how well pregnancy is proceeding for mother
and the child. Also, antepartum fetal assessments give the ability to
evaluate and assess the fetal growth, maturity and well-being.

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Importance:

1. Decrease the incidence of intrauterine fetal asphyxia.

2. Decrease adverse perinatal outcome.
3. Identify the risk of intrauterine fetal death

Initiation of antepartum fetal surveillance

For most of the patients initiation of antepartum fetal surveillance at

32-34 weeks of gestation is appropriate. However, in pregnancies with
multiple or particularly worrisome high-risk conditions (eg, chronic
hypertension with suspected intrauterine growth restriction), testing might
begin as early as 26-28 weeks of gestation.

Frequency of testing

If the maternal medical condition is stable, tests of fetal well-being

(NST, BPP, or modified BPP) are repeated at weekly intervals, but in the
presence of certain high-risk conditions, such as postterm pregnancy,
gestational diabetes, intrauterine growth restriction, or pregnancy-induced
hypertension, testing are performed two-three times a week or daily.

Antepartum fetal assessment techniques:

 Clinical assessment & Daily fetal movement count.

 Biophysical tests.
 Ultrasonography.
 Amniotic fluid study.
 Hormonal studies.
 Vaginal smear.

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 Amnioscopy.
 Foetoscopy.

I. Clinical assessment
1. Clinical examination in each antenatal visit is the primary
and main assessment of fetal wellbeing. This includes
detection of:

 fetal heart sound

 fetal size and growth
 fundal level

2. Daily fetal movement count (DFMC)

Decreased placental perfusion and fetal acidemia and acidosis are

associated with decreased fetal movements. This is the basis for maternal
monitoring of fetal movements or “the fetal movement count test.” The
concept of counting fetal movements is attractive, since it requires no
technology and is available to all women.

Procedure

 The test is valid after 30 weeks of pregnancy.

 The mother counts the fetal movements she feels in 3 hours during
the period of 12 hours e.g. from 9 am to 9 pm, one hour at the
beginning, one hour at the middle and one hour at the end of this
period. The count is multiplied by 4 to get the fetal movements in
12 hours. If it is less than 10 movements, this indicates that the
fetus may be at risk and non-stress test is indicated.

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 Count-to-ten Cardiff system: The mother counts the fetal

movements from 9 am till she reaches 10 movements. No further
count is needed unless she did not count 10 movements in up to 12
hours. It was found that there is a reduction or cessation of the fetal
movement 12-24 hours before stoppage of the fetal heart rate
"alarm signal".

Advantages

 Informative and non-invasive.

 Pregnant woman can monitor herself.
 No cost.

Disadvantage:

 Awareness of the fetal movement is differ from a mother to

another.
 Cessation of fetal movement may occur due to intrauterine sleep.
 Sedation of the fetus occurs if the mother is taking sedatives.
 Sudden death of the fetus may occur without preceding slowing of
the fetal movement as in abruptio placentae or it may be preceded
by increased flurry movements.
II. Biophysical tests:
o Non-stress Test

The Fetal Non-Stress test is a simple, non-invasive test performed in

pregnancies from 30 weeks of gestation. Before 30 weeks, the fetus is not
developed enough to respond to the test protocol. The test is named “non-
stress” because no stress is placed on the fetus during the test. This test
used to detect acceleration of FHR in response to fetal movement.

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Healthy babies will respond with an increased heart rate during times of
movement, and the heart rate will decrease at rest. The concept behind a
non-stress test is that adequate oxygen is required for fetal activity and
heart rate to be within normal ranges. When oxygen levels are low, the
fetus may not respond normally. Low oxygen levels can often be caused
by problems with the placenta or umbilical cord.

Indications

 Decrease fetal movement (<10/12 hours) or its cessation.

 Intrauterine growth retardation especially with a major cause as
pre-eclampsia.
 Fetal danger as in antepartum haemorrhage.
 Biochemical evidence of placental insufficiency.

Procedure

 It is done starting from the 30 weeks of pregnancy.

 The electronic fetal monitor is used during pregnancy to record the
pattern of fetal heart rate (FHR) and its response to the fetal
movements reported by the mother by pressing a button in her
hand.
 The test is carried out for 20 minutes. If fetal movement did not
occur the test is extended for another 20 minutes during which the
fetus is stimulated mechanically by the 1st pelvic grip or by
acoustic stimulation using an artificial larynx placed against the
maternal abdomen to "awaken the fetus".

Results

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 Reactive test: 2 or more fetal movements are accompanied by

acceleration of FHR of 15 beats/ minute for at least 15 seconds’
duration. Reactive test means that the fetus can survive for one
week, so the test should be repeated weekly. Reactive non-stress
result indicates that blood flow (and oxygen) to the fetus is
adequate.
 Non -reactive test: no FHR acceleration in response to fetal
movements so contraction stress test is indicated.

o Contraction Stress Test (Oxytocin Challenge Test)

Definition:

A contraction stress test (CST) is performed near the end of pregnancy to

determine how well the fetus will cope with the contractions of childbirth.
The aim is to induce contractions and monitor the fetus to check for heart
rate abnormalities using a cardiotocograph.

Procedure

 It is done after 32 weeks of pregnancy.

 Two transducers are applied to the mother’s abdomen; one to
record the FHR pattern and the other to record the uterine activity.
 Three uterine contractions per 10 minutes are induced by one of the
following:
o IV oxytocin drip starting with 0.5mU/ minute and doubled gradually
or
o tactile stimulation of the nipple: This is a procedure that relies
on endogenous release of oxytocin following nipple stimulation, and
is conducted by the patient. The nurse instructs the patient on the

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procedure, as follows. One nipple is massaged gently through clothing

until a contraction begins, or for a maximum of 2 minutes. If at least 3
contractions in 10 minutes is not achieved, then the patient rests for 5
minutes and the other nipple is stimulated.

Results

 Positive test: consistent and persistent late deceleration of FHR, so

placental insufficiency is diagnosed and delivery by caesarean
section is indicated.
 Negative test: late deceleration does not occur with uterine
contractions. It denotes that the fetus can survive safely for one
week when it should be repeated.

Contraindications

 Threatened preterm labor.

 Placenta praevia.
 Rupture of membranes.        
 Previous classical C.S.     
 Multiple pregnancies.

o Biophysical profile:

Definition:

A fetal biophysical profile is a prenatal test used to check on a baby's

well-being. The test combines fetal heart rate monitoring (non stress test)
and fetal ultrasound. During a biophysical profile, a baby's heart rate,
breathing, movements, muscle tone and amniotic fluid level are evaluated
and given a score.

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Variable Score 2 Score 0

Fetal breathing Last for 30 seconds in Less than 30 seconds
movements 30 minutes of in 30 minutes of
observation. observation.
Fetal movements 3 or more discrete body Less than 3
or limb movements movements.
within 30 minutes.
Fetal tone One or more episodes Not observed.
of limb extension with
return to flexion within
30 minutes.
Non-stress test Reactive. Non-reactive.
Amniotic fluid One or more amniotic Largest pocket
volume fluid pockets measures measures less than 1
1 cm or larger in 2 cm in 2 perpendicular
perpendicular planes. planes.
Maximum score 10 Minimum score 0

 A score of 8-10 is normal.

 A score of 4-6 → deliver if lung is mature otherwise
corticosteroids are given for 48 hours before delivery.
 A score of < 4 is abnormal → evaluate for immediate delivery.

III. Ultrasonography
Real-time sonography

It can be used for detection of:

 Gestational age: by measurement of gestational sac, crown rump

length, biparietal diameter or femur length.
 Viability of the fetus: by fetal heart movement or fetal movement.

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 Fetal weight.   
 Amniotic fluid volume.   
 Placenta: location, size and maturity.
 Congenital anomalies.
Doppler ultrasound

Definition:

It is non-invasive test that be used to estimate the blood flow through the
blood vessels by reflection of the ultrasound waves on the RBCs inside
the blood vessels.

Usage of the Doppler ultrasound:

 Detection of fetal heart rate as early as 10-12 weeks.

 Assessment of fetal cardiac function.
 Detection of uteroplacental blood flow, because of impairment of
uteroplacental blood flow indicates fetal hypoxia.

IV. Amniotic fluid study

is a medical procedure used for prenatal diagnosis of chromosomal

abnormalities and fetal infections in which a small amount of amniotic
fluid, which contains fetal tissues, is sampled from the amniotic
sac surrounding a developing fetus, than the fetal DNA is examined for
genetic abnormalities. The most common reason to have an "amnio" is to
determine whether a baby has certain genetic disorders or a chromosomal
abnormality, such as Down syndrome. Amniocentesis (or another
procedure, called chorionic villus sampling (CVS)) can diagnose these
problems in the womb. Amniocentesis is usually done when a woman is
between 14 and 16 weeks pregnant. 

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Benefits of amniotic fluid study:

1-Detection of Fetal Maturity

o Lung maturity

o Lecithin/ sphingomyelin (L /S) ratio:

o Before 34 weeks of gestation, lecithin and sphingomyelin
are present in the amniotic fluid in equal concentrations (1/1)
. At about 35 weeks, the lecithin concentration rises so the
ratio of L/S is 2/1 or more with this ratio the risk of
respiratory distress is minimal.
o Phosphatidyl glycerol:
o Its detection in the amniotic fluid indicates lung maturity. It
is more reliable than L/S ratio as it is not detected in blood,
meconium or vaginal discharge so the contamination of the
sample with any of these does not confuse the
interpretation .
o Foam stability (shake) test:
o It is a rapid test for detection of fetal lung maturity.
o The test depends upon the ability of the surfactant in the
amniotic fluid, when mixed with 95% ethanol in a glass tube
and shacked well, to generate a ring of foam at the air-liquid
interface that persists for at least 15 minutes.
o Kidney maturity

Amniotic fluid creatinine level of 2 mg/ dl or more indicates fetal kidney

maturity providing that maternal serum creatinine is normal.

o Liver maturity

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In absence of abnormal haemolysis, it is 0.01 -0.06 D OD at 34-36 weeks

and continue to decrease up to term.

o Skin maturity

The sebaceous glands of the fetus produce cells containing lipid so

stained orange with Nile blue sulphate . If 50% or more of the cells in the
amniotic fluid are of these type the foetus is mature.

2-Detection of Fetal Abnormalities

o Chromosomal abnormalities:

Such as Down’s syndrome (trisomy 21) can be diagnosed by examination

of the desquamated fetal cells in the amniotic fluid.

Chromosomal study is indicated in the following conditions:

 Pregnant women of 35 years old or more as the incidence of

Down's syndrome is increased to reach 1:50 when the mother is 40
years old or more.
 A previous chromosomally abnormal offspring.
 Chromosomal abnormality in either parents.
 Ultrasonographic markers of chromosomal anomalies as: cardiac
defects, duodenal atresia, omphalocoele and hands or feet
anomalies. Such markers are present in about 85% of foetuses with
Down’s syndrome.

o Neural tube defects:

as anencephaly and open spina bifida produce increased level of alpha

fetoprotein into the amniotic fluid..

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o Rh-isoimmunization:

Follow up of such patients by determination of the bilirubin level in the

amniotic fluid.

V. Hormonal studies

1-Oestriol

 Maternal urinary and serum oestriol level is an important index for

the integrity of the fetal adrenal and liver as well as the placenta.
 Urinary oestriol increases as pregnancy advances to reach about
35-40 mg/ 24 hours at full term. Progressive fall in urinary oestriol
by serial measurement indicates that the foetus is jeopardous.

2-Progesterone

 Progesterone level can be detected in the serum and saliva of the

pregnant mother and its end product pregnandiol in 24 hours
collection of urine.
 It is of little practical value in comparison to urinary oestriol
detection as the foetus is not sharing in its synthesis.

3-Human Placental Lactogen (hPL)

 Although it was found that hPL falls before fetal death, it may be
within normal range until after fetal death.
 A single value of < 4 m g/ ml after 36 weeks is associated with
30% incidence of fetal distress.

4-Human Chorionic Gonadotrophin (hCG)

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It has no practical value as it can be detected up to few weeks after fetal

death or delivery.

VI. Vaginal smear

 In good pregnancy: 95% of the cells in the smear are of the

intermediate type (navicular cells) that have folded edges and
present in clusters. About 5% of the cells are of the superficial
type.
 In bad pregnancy: e.g. progesterone deficiency and placental
insufficiency more than 10% of the cells are of the superficial type.
 In inevitable abortion: trophoblastic cells may appear in the smear.
 In intrauterine fetal death: parabasal cells appear in the smear.
 In antepartum rupture of membranes: fetal cells appear in the
smear.
 At full term: 10% of the cells are of superficial type, clumping and
folding of the intermediate cells become less evident due to
decreasing progesterone level.

VII. Amnioscopy

Introduced through the cervix without rupturing the membranes. It may

reveal meconium stained liquor indicating placental insufficiency.

VIII. Fetoscopy

Direct visualisation of the fetus by fibroptic telescope introduced through

the abdominal and uterine walls.

Benefits:

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 Antepartum fetal assessment

 Direct visualization of congenital anomalies: e.g.

o Polydactyly.   
o Limb reductions.   
o Cranial and facial anomalies.
o Neural tube defects.  
o Exomphalos.
 Fetal blood sampling for prenatal diagnosis of:
o Haemoglobinopathies. 
o Haemophilia.  
o Galactosaemia.
o Duchenne muscular dystrophy.    
o Genetic diagnosis.
 Fetal skin biopsy for diagnosis of e.g.
o Epidermolysis bullosa. 
o Detailed cytogenetic pattern.

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