FETAL WELLBEING

DEFINITION
Fetal well being means healthy fetus. In Fetal well being normal growth and development as well as its normal activity and viability
is checked.
Now a day’s antenatal care is given to antenatal mothers and there are tests that provide information and reassurance to mothers
regarding well being of the fetus e.g. fetal movements’ count. It elicits information about recent fetal movements to reassure the
mother. Patterns of fetal movements are reliable sign of fetal well being.
PURPOSES OF ANTENATAL FETAL MONITORING:
1. Assuring satisfactory growth and well-being of the fetus as well as the mother all throughout the pregnancy.
2. Screening out high risk cases and the adverse maternal and intrauterine factors which may affect the healthy growth of the
fetus.
3. Detecting early in pregnancy those congenital abnormalities or inborn metabolic disorders which are not compatible with
life or may lead to chronic ill health of the offspring. These may be eliminated by early termination of pregnancy.
FETAL WELL BEING TESTS:
For monitoring fetal well being many tests are there which can be broadly classified as:

I. Bio- Physical Tests

1. Bio-Physical Profile (BPP)
2. Ultrasonography
3. CST
4. Daily fetal movement count (DFMC)
5. Internal heart rate monitoring
6. Radiological exams
II. Biochemical Tests
1. Maternal
2. Fetal
3. Placental
III. Cytogenic Tests
1. CVS
2. Cordocentesis
3. Amniocentesis
IV. Maternal Assay

I. BIO- PHYSICAL TESTS

1. BIOPHYSICAL PROFILE (BPP):The biophysical profile (BPP) is a test performed to measure fetal well-being. It is a prenatal
evaluation of fetal wellbeing, involving a scoring system. It includes four ultrasounds and one NST. A BPP is commonly done in the
last trimester of pregnancy. If there is a chance that baby may have problems during pregnancy ( high-risk pregnancy), a BPP may be
done by 32 to 34 weeks or earlier. Some women with high-risk pregnancies may have a BPP test every week or twice a week in the
third trimester.
The biophysical profile (BPP) has 5 components:
1. fetal breathing
2. fetal body movement
3. fetal muscle tone
4. fetal reactivity
5. amniotic fluid index

Fetal breathing (FB) is measured by watching for movement of the fetal thorax and diaphragm. This is to assure breathing, and not
just chest wall movement. It is done by Ultrasound.

Fetal body movement is defined by gross arm, leg, or body activity. A score of two is given if there are at least three separate
limb/body movements during the 30-minute test. It is done by ultrasound, DFMC

Fetal muscle tone is defined by active extension and flexion of the fetal limbs, trunk, or hand; or if the hand remains in a flexed
position during the entire 30-minute test. It is also done by Ultrasound.

Fetal Reactivity: heart rate (FHR) variability is measured during fetal reactivity. The fetal heart rate is normally variable in nature.
Accelerations in FHR are usually seen in response to fetal movements and are therefore reassuring. Measuring FHR has two
different methods.

 External heart rate monitoring

 - by using fetoscope
- stethoscope
- Doppler
- USG

 Internal heart rate monitoring i.e from fetal scalp

FHR variability can be measured by two methods i.e. NST and CST.

Amniotic fluid volume is estimated for sufficiency. Since fetal anatomic structures do not allow full visualization of all the amniotic
fluid, it is estimated by measuring pockets of fluid from 0.39 to 0.78 in (1 to 2 cm) in height on ultrasound. A score of two is given if
at least one pocket of fluid measures 0.78 in (2 cm) or more in height. A score of zero is given when no such pockets can be
measured. Normal amniotic fluid volume peaks at about 750 ml at 32 weeks gestation, stays stable until term at 40 weeks, and then
declines to about 400 ml by 42 weeks. Excessive amniotic fluid amounts (hydramnios), such as might be seen in diabetic mothers,
may be as high as 1700 to 1900 ml. Oligohydramnios is defined by about 300 ml of fluid volume. The amniotic fluid is produced as
the fetus urinates and through lung secretions. The volume is controlled by fetal swallowing and by reabsorption through the
membranes. The amniotic fluid index (AFI) is also used to determine sufficiency of amniotic fluid. In this method, the largest
vertical column of fluid in each of the four uterine quadrants is measured and added up. Normal AFI value is between 5 to 25.
Because of the role of the fetus in the production and control of amniotic fluid, it is one variable in fetal wellbeing assessment.

Purposes

A biophysical profile (BPP) test is done to:

1. Learn about and keep track of fetal wellbeing. Special ultrasound’ methods are used to keep track of movement, increase in heart
rate with movement (nonstress test), muscle tone, breathing rate, and the amount of amniotic fluid surrounding your baby. If these
five areas are within a normal range, your baby is considered to be in good health.

2. It is a tool used near or at term by clinicians to assess the potential risk of fetal compromise or demise due to fetal hypoxia or
acidosis. Intervention such as maternal hospitalization or delivery may follow a BPP score of four or below.

3. It keep check on baby's health in case of:

 Hyperthyroidism.
 Bleeding problems.
 Lupus.
 Chronic kidney disease.
 Type 1 diabetes or gestational diabetes.
 High blood pressure (hypertension).
 Preeclampsia.
 A small amount of amniotic fluid (oligohydramnios) or too much amniotic fluid (polyhydramnios).
 A multiple pregnancy (such as twins or triplets). A pregnancy that has gone past your due date, between 40 and 42 weeks.

Preparation
 Usually a full bladder is needed for the test. If so, client is asked to drink water or other liquids just before the test and to
avoid urinating before or during the test.

 If client smoke, she is asked to stop smoking for 2 hours before the external monitoring test because smoking decreases
baby's activity.

 Because the BPP is done during the third trimester of pregnancy, there is sufficient amniotic fluid to provide contrast to
clearly visualize the fetus.

 No preparation is usually required before the test is performed.

 The mother may be asked to have a snack prior to the test to encourage a more active fetus.

 Because the mother's abdomen is exposed, curtains or a closed door should provide privacy.

 A comfortable room air temperature and the warming of the transducer gel can assist in putting the mother at ease.

 The mother should be asked if she wants her partner or support person with her during the test.
  A towel or cloth should cover the mother's clothing to avoid its getting wet from the transducer gel.

 For a transvaginal fetal ultrasound, the vaginal transducer is usually covered with a latex sleeve and a vaginal lubricant,
such as K-Y Jelly. If you are allergic to latex, tell the health professional before having the test.
Procedure
Most often, a biophysical profile (BPP) is performed by obstetrician. But it may be done by an ultrasound technologist or radiologist.
A BPP can be done in doctor's office, hospital, or clinic.
Nonstress test
 A nonstress test with electronic fetal heart monitoring and a fetal ultrasound are done as part of a biophysical profile.

 External fetal heart monitoring records baby's heart rate while baby is moving and not moving. It is usually done just
before a fetal ultrasound.

 This test can be done in the later stages of pregnancy.

 It is more frequently used in cases where the mother is going past her assigned due date to ensure fetal well-being.

 In some cases it is done as a precaution after problems in a previous pregnancy or because of high risk factors such as
diabetes, intrauterine growth retardation (IUGR), etc.

 External monitoring is done using two flat devices (sensors) held in place with elastic belts on your belly. One of these
uses reflected sound waves (ultrasound) to keep track of your baby's heart rate; the other measures the duration of your
contractions. The sensors are connected to a machine that records the information. Baby's heartbeat may be heard as a
beeping sound or printed out on a chart.

 If baby moves or mother have a contraction, she may be asked to push a button on the machine. Baby's heart rate is
recorded and compared to the record of movement or mother’s contractions. This test usually lasts about 30 minutes.

 Sometimes little ones don't cooperate during the testing and move. So the mother is offered a drink of something usually
containing sugar or bubbles to perk the baby up. If this doesn't cause the baby to move sometimes a loud sound will be
used to startle the baby into moving. Remember babies can and do sleep in utero.

Procedure of Ultrasonography
 Mother may need to have a full bladder. She may be asked to drink 4 to 6 glasses of liquid, usually juice or water, about an hour
before the test. A full bladder helps transmit sound waves and pushes the intestines out of the way of the uterus. This makes the
ultrasound picture clearer. She will not be able to urinate until the test is over. But the ultrasound technologist can be informed
if bladder is so full that she is in pain. If an ultrasound is done during the later part of pregnancy, a full bladder may not be
needed. The growing fetus will push the intestines out of the way.
 Lay the client on her back on a padded examination table. If she become short of breath or lightheaded while lying on your
back, her upper body may be raised or she may be turned on side.
 Often she do not need to remove her clothes for the ultrasound test; but shirt can be lift up and the waistband of skirt or pants
can be pushed down. If she is wearing a dress, a cloth is given to cover during the test.
 A gel is spread on abdomen.
 A small, handheld instrument called a transducer will be pressed against the gel on skin and moved across the abdomen several
times. Client may watch the monitor to see the picture of the fetus during the test.
 Lying on the back (or side) during the test may be uncomfortable. During a fetal ultrasound, client may have a feeling of
pressure in bladder. The gel may feel cool when it is first applied to abdomen. A light pressure from the transducer is felt as it
passes over your abdomen.
 When the test is finished, the gel is cleaned off. Client can urinate as soon as the test is done. Transabdominal ultrasound takes
about 30 to 60 minutes.
 Ultrasound technologists are trained to gather images of fetus but cannot tell whether it looks normal or not. Radiologist or
perinatologist can give this information after the ultrasound images have been reviewed.

Transvaginal ultrasound

 Mother will lie on her back with her hips slightly raised.
 A cover (such as a condom) will be placed over the thin vaginal transducer. The transducer will be inserted gently into
vagina, and then it will be moved and rotated to adjust the view displayed on the monitor. Some doctors may allow to
insert the transducer into vagina herself.
Risks
There is very little chance of either the mother or the baby having a problem from a biophysical profile (BPP). But she may feel
anxious if the ultrasound reveals a problem with her pregnancy or baby. A nonstress test may falsely show distress in a baby that is
actually healthy.

Scoring

Each ultrasound assessment is graded either 0 or 2 points, and then added up to yield a number between 0 and 8. Each variable
receives 2 points for a normal response or 0 points for an abnormal or absent response. A BPP of 6 to 8 is generally considered
reassuring. A BPP normally is not performed before the second half of a pregnancy, since fetal breathing movements do not occur in
the first half.

Biophysical profile

Measurement Breathing movement Abnormal (0 points)

Only 1 heart rate increase is seen, or the heart

Fetal 2 or more heart rate increases of 15 beats per minute or more are
rate does not increase by more than 15 beats
Reactivity seen with movement.
with movement.

Breathing Breathing movement lasts less than 30

1 or more breathing movements last at least 30 seconds.
movement seconds, or no breathing is seen.

Less than 3 movements of the arms, legs, or

Body movement 3 or more movements of the arms, legs, or body
body

The fetus extends slowly and only returns

partway to a normal position.
Arms and legs are usually flexed and the head rests on the chest.
The fetus extends but does not return to a
Muscle tone 1 or more extensions and return to flexion are seen, such as the
normal position.
opening and closing of a hand.
The arms, legs, or spine are extended, or a
hand is open.

Amniotic fluid At least one pocket of amniotic fluid of at least 2cm is seen in Not enough amniotic fluid is seen in the
volume the uterine cavity. uterine cavity.

Aftercare:The BPP uses an external transducer to visualize the fetus and the amount of amniotic fluid. A towel or cloth can be used
to wipe off excess gel and dry the abdomen after the test. In the event that test results indicate fetal compromise, a health
care professional should remain with the mother to provide emotional support and answer questions as needed.

Complications:Because the test is noninvasive in nature, complications from the test itself are unexpected.

What Affects the Test

Reasons you may not be able to have the test or why the results may not be helpful include:

 The baby is in a position that makes an ultrasound difficult.

 Being unable to lie still throughout the procedure, which can cause the picture of fetus to be unclear.
 Being overweight, which may make it difficult to correctly position the external monitoring device.
 An infection in either client or fetus.
 Low (hypoglycemia) or high (hyperglycemia) blood sugar levels.
 Taking medicine, such as magnesium sulfate.
 Steroids given to help the baby's lungs mature.
 Using alcohol or illegal drugs, such as cocaine.
 In rare cases, stool (feces) or air in the intestines or rectum interfering with the fetal ultrasound.
Recommendations
 Additional tests, such as a contraction stress test, may be recommended if your results are not normal. For more information,
see the medical test Contraction Stress Test.
 If there is a chance that client or fetus may have problems during pregnancy, she may have a biophysical profile test every week
or twice a week during the last 12 weeks of pregnancy. The chances of having problems may be higher if she have:
 Certain medical conditions, such as high blood pressure, kidney disease, diabetes, preeclampsia, or autoimmune
diseases.
 A history of a stillbirth or preeclampsia.
 A history of Rh incompatibility.
 A history of early labor, premature rupture of membranes (PROM), or placenta problems.
 A baby who seems small for the length of the pregnancy or is not growing (intrauterine growth retardation or
restriction).
 A biophysical profile may be done after an injury, such as a car crash or fall. Your doctor may recommend additional BPP tests
during the rest of your pregnancy.
 Research is being done on the usefulness of BPP testing during labor. Low BPP test scores may help predict the need for a
cesarean section or whether a baby will need specialty care after delivery.

Health care team roles: The BPP should be performed by a trained ultrasonographer. The NST may be performed by a nurse or a
radiology technician in the antenatal division of an obstetric department, in the radiology department, or in an obstetric
office. As with any test, patient anxiety is heightened with concerns of fetal compromise. Therefore, the ability of the

Results
A biophysical profile (BPP) test measures the health of fetus during pregnancy. The results are scores on five measurements in a 30-
minute observation period.
A score of 8 to 10 points means that fetus is healthy. A score of 6 to 8 points means that it may need to be retested in 12 to 24 hours.
A score of 4 or less may mean the baby is having problems. Further testing will be recommended.

2. FETAL ULTRASONOGRAPHY

Obstetric Ultrasound is the use of ultrasound scans in pregnancy. Since its introduction in the late 1950’s ultrasonography has
become a very useful diagnostic tool in Obstetrics.

Currently used equipments are known as real-time scanners, with which a continous picture of the moving fetus can be depicted on
a monitor screen. Very high frequency sound waves of between 3.5 to 7.0 megahertz (i.e. 3.5 to 7 million cycles per second) are
generally used for this purpose.

Fetal ultrasound is a test done during pregnancy that uses reflected sound waves to produce a picture of a fetus, the organ that
nourishes the fetus (placenta), and the liquid that surrounds the fetus (amniotic fluid). The picture is displayed on a TV screen and
may be in black and white or in color. The pictures are also called a sonogram, echogram, or scan, and they may be saved as part of
your baby's record.
Fetal ultrasound is the safest way to check for problems and get information about fetus, such as its size and position. It does not use
X-rays or other types of radiation that may harm fetus. It can be done as early as the 5th week of pregnancy. The sex of the fetus can
sometimes be determined by about the 18th week of pregnancy.

The main uses of ultrasonography are in the following areas:

1. Diagnosis and confirmation of early pregnancy.

The gestational sac can be visualized as early as four and a half weeks of gestation and the yolk sac at about five weeks. The embryo
can be observed and measured by about five and a half weeks. Ultrasound can also very importantly confirm the site of the
pregnancy is within the cavity of the uterus.

2. Vaginal bleeding in early pregnancy.

The viability of the fetus can be documented in the presence of vaginal bleeding in early pregnancy. A visible heartbeat could be
seen and detectable by pulsed doppler ultrasound by about 6 weeks and is usually clearly depictable by 7 weeks. If this is observed,
the probability of a continued pregnancy is better than 95 percent. Missed abortions and blighted ovum will usually give typical
pictures of a deformed gestational sac and absence of fetal poles or heart beat.

Fetal heart rate tends to vary with gestational age in the very early parts of pregnancy. Normal heart rate at 6 weeks is around 90-110
beats per minute (bpm) and at 9 weeks is 140-170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is associated with a high risk
of miscarriage.

3. Determination of gestational age and assessment of fetal size.

Fetal body measurements reflect the gestational age of the fetus. This is particularly true in early gestation. In patients with uncertain
last menstrual periods, such measurements must be made as early as possible in pregnancy to arrive at a correct dating for the
patient. In the latter part of pregnancy measuring body parameters will allow assessment of the size and growth of the fetus and will
greatly assist in the diagnosis and management of intrauterine growth retardation (IUGR).

The following measurements are usually made:

a. The Crown-rump length (CRL)

This measurement can be made between 7 to 13 weeks and gives very accurate estimation of the gestational age. Dating with the
CRL can be within 3-4 days of the last menstrual period. An important point to note is that when the due date has been set by an
accurately measured CRL, it should not be changed by a subsequent scan. For example, if another scan done 6 or 8 weeks later says
that one should have a new due date which is further away, one should not normally change the date but should rather interpret the
finding as that the baby is not growing at the expected rate.

b. The Biparietal diameter (BPD)

The diameter between the 2 sides of the head. This is measured after 13 weeks. It increases from about 2.4 cm at 13 weeks to about
9.5 cm at term. Different babies of the same weight can have different head size, therefore dating in the later part of pregnancy is
generally considered unreliable. Dating using the BPD should be done as early as is feasible.

c.The Femur length (FL)

Measures the longest bone in the body and reflects the longitudinal growth of the fetus. Its usefulness is similar to the BPD. It
increases from about 1.5 cm at 14 weeks to about 7.8 cm at term. Similar to the BPD, dating using the FL should be done as early as
is feasible.

d) The Abdominal circumference (AC)

The single most important measurement to make in late pregnancy. It reflects more of fetal size and weight rather than age. Serial
measurements are useful in monitoring growth of the fetus. AC measurements should not be used for dating a fetus.

Other important measurements are The weight of the fetus at any gestation can also be estimated with great accuracy using
polynomial equations containing the BPD, FL, and AC. computer softwares and lookup charts are readily available. For example, a
BPD of 9.0 cm and an AC of 30.0 cm will give a weight estimate of 2.85 kg.

4. Diagnosis of fetal malformation.

Many structural abnormalities in the fetus can be reliably diagnosed by an ultrasound scan, and these can usually be made before 20
weeks. Common examples include hydrocephalus, anencephaly, myelomeningocoele, achondroplasia and other dwarfism, spina
bifida, exomphalos, Gastroschisis, duodenal atresia and fetal hydrops. With more recent equipment, conditions such as cleft lips/
palate and congenital cardiac abnormalities are more readily diagnosed and at an earlier gestational age. First trimester ultrasonic
'soft' markers for chromosomal abnormalities such as the absence of fetal nasal bone, an increased fetal nuchal translucency (the area
at the back of the neck) are now in common use to enable detection of Down syndrome fetuses.

Ultrasound can also assist in other diagnostic procedures in prenatal diagnosis such as amniocentesis, chorionic villus sampling,
cordocentesis (percutaneous umbilical blood sampling) and in fetal therapy.
5. Placental localization.

Ultrasonography has become indispensible in the localization of the site of the placenta and determining its lower edges, thus
making a diagnosis or an exclusion of placenta previa. Other placental abnormalities in conditions such as diabetes, fetal hydrops,
Rh isoimmunization and severe intrauterine growth retardation can also be assessed.

6. Multiple pregnancies.

In this situation, ultrasonography is invaluable in determining the number of fetuses, the chorionicity, fetal presentations, evidence of
growth retardation and fetal anomaly, the presence of placenta previa, and any suggestion of twin-to-twin transfusion.

7. Hydramnios and Oligohydramnios.

Excessive or decreased amount of liquor (amniotic fluid) can be clearly depicted by ultrasound. Both of these conditions can have
adverse effects on the fetus. In both these situations, careful ultrasound examination should be made to exclude intraulterine growth
retardation and congenital malformation in the fetus such as intestinal atresia, hydrops fetalis or renal dysplasia.

8. Other areas.

Ultrasonography is of great value in other obstetric conditions such as:

a) confirmation of intrauterine death.

b) confirmation of fetal presentation in uncertain cases.
c) evaluating fetal movements, tone and breathing in the Biophysical Profile.
d) diagnosis of uterine and pelvic abnormalities during pregnancy e.g. fibromyomata and ovarian cyst.
Fetal ultrasound is done to learn about the health of the fetus. Different information is gained at different times (trimesters) during
your pregnancy.

 1st-trimester fetal ultrasound is done to:

o Determine how your pregnancy is progressing. Find out if you are pregnant with more than 1
fetus.
o Estimate the age of the fetus (gestational age).
o Estimate the risk of a chromosome defect, such as Down syndrome.
o Check for birth defects that affect the brain or spinal cord.
 2nd-trimester fetal ultrasound is done to:
o Estimate the age of the fetus (gestational age).
o Look at the size and position of the fetus, placenta, and amniotic fluid.
o Determine the position of the fetus, umbilical cord, and the placenta during a procedure, such as
an amniocentesis or umbilical cord blood sampling.
o Detect major birth defects, such as a neural tube defect or heart problems.
 3rd-trimester fetal ultrasound is done to:
o Make sure that a fetus is alive and moving.
o Look at the size and position of the fetus, placenta, and amniotic fluid.
 Transvaginal ultrasound is generally done early in a pregnancy to determine fetal age or to detect a suspected ectopic
pregnancy. It is occasionally done late in pregnancy to determine the location of the placenta or in a high-risk pregnancy to
monitor the length of the cervix.
Result
A fetal ultrasound scan uses reflected sound waves to produce a picture of the fetus, placenta, amniotic fluid.

may not receive information about the test right away. Full results are usually available in 1 or
Client
2 days.
Fetal ultrasound

Normal: The fetus is the size expected for its age.

The heart rate and breathing activity of the fetus is normal for its age.
If the test is done late in the pregnancy, the fetus is in the head-down position.
 The placenta is the size expected for the stage of the pregnancy and does not cover the cervix.
The uterus contains an adequate amount of amniotic fluid.

No birth defects can be seen. (Many minor defects and some major defects are not easily seen. Also, birth
defects do not always show up early in pregnancy.)

Abnormal: The fetus is growing more slowly than normal, is small, or is underdeveloped for its age.
The fetus is abnormally large for its age.
If this test is done late in the pregnancy, the fetus is in the buttocks-down (breech) position
Birth defects, such as absent kidneys or anencephaly, are present.
The placenta covers the cervix (placenta previa).
The uterus contains too much or too little amniotic fluid.
The fetus is developing outside of the uterus (ectopic pregnancy).
The scan shows abnormal tissue instead of a normal fetus (molar pregnancy).

The fetal heartbeat is not present. This can indicate fetal death.

What Affects the Test

Fetal ultrasound results may be affected by:

 Being very overweight or obese.

 Stool (feces) or air in the intestines or rectum.
 An abnormally low amount of amniotic fluid.
 Some fetal positions.
 Not being able to lie still during the procedure.
 A very active fetus.

 husband may be encouraged to be present during the fetal ultrasound test. A photograph or videotape of the ultrasound
image of the fetus is sometimes available to the parents.
 EDD date may be changed based on an ultrasound done in early pregnancy if the ultrasound predicts a different date, based
on fetal size and development.
 Ultrasounds do not always show birth defects.
 In the third trimester, fetal ultrasound does not accurately determine fetal age or weight.
 The effects of prolonged fetal ultrasound exposure have not been determined; therefore does not recommend fetal
ultrasound for nonmedical reasons, such as for identifying the sex of the fetus or as personal keepsakes.

Three-dimensional (3-D) fetal ultrasound is being tested for use in evaluating fetal abnormalities. It is not yet widely
available.

Doppler ultrasound (or duplex scanning) uses reflected sound waves to estimate the speed and direction of blood as it
flows to the placenta and within the fetus.

3. CONTRACTION STRESS TEST

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 the contractions and monitor the fetus to check for heart rate abnormalities. A
contraction stress test checks to see if the fetus will stay healthy during the reduced oxygen levels that normally occur during
contractions when client is in labor. It involves the release of oxytocin into the blood stream of the pregnant woman by the
stimulation of the nipples. The target is to achieve around three contractions every ten minutes. The test includes external fetal heart
monitoring. (nonstress test). The test is done when you are 34 or more weeks pregnant.

An oxytocin challenge test (OCT) is sometimes performed afterwards, usually if the CST failed to give clear readings or the uterus
did not contract at an appropriate rate. This involves oxytocin being given to woman via an intravenous drip.

History: The test was first introduced in 1972 and was standardized in 1975 when the parameters of contraction number and
frequency were given.

Purposes
A contraction stress test is done to check:

 Whether the fetus will stay healthy during the reduced oxygen levels that normally occur during contractions during labor.
 Whether the placenta is healthy and can support the fetus.
 A contraction stress test may be done when results from a nonstress test or a biophysical profile are not in the normal range.

Preparation

Client may be asked to not eat or drink for 4 to 8 hours before the test.
Empty bladder before the test.
If client smoke, stop for 2 hours before the test because smoking lowers baby's activity and heart rate.
Client is asked to sign an informed consent form before a contraction stress test after giving information regarding the need for the
test, its risks, how it will be done, or what the results will mean.
Procedure
 A contraction stress test may be done in doctor's office or hospital by a family medicine doctor or an obstetrician and a
trained laboratory technician or nurse.

 Usually it is not needed to stay overnight.

 During the test, client will lie on a bed with her back is raised. Client may tilt a little to her left side so will not have
pressure on the blood vessels.

 Two belts with sensors will be placed around the belly. One belt holds the sensor that records fetus heart rate; the other
sensor measures uterine contractions.

 Gel may be used on skin with the heart rate sensors.

 The sensors are hooked to a recording unit. The heart rate monitor may be moved if baby changes position.

 Baby's heart rate and client’s contractions are recorded for 10 minutes. Blood pressure and other vital signs are also
recorded.

 The hormone oxytocin is given in a low dose and increased until client have three contractions within 10 minutes, each one
lasting longer than 45 seconds. Or she may be asked to massage one of her nipples by hand to start contractions. If she
don't have a second contraction within 2 minutes of the first, she have to massage her nipple again. If contractions do not
occur within 15 minutes, she have to stimulate both nipples.

 After the test, she will be watched until her contractions go away or slow down to what they were before the test. A
contraction stress test may take 2 hours.

 Client may need to lie on her left side for the test. This position may be uncomfortable or painful when she is having labor
contractions. The belts holding the sensors may be uncomfortable. Most women say this test is uncomfortable but not
painful.
 A contraction stress test may show decelerations when fetus is not actually having problems. This is called a false-positive
result.
 Some doctors use oxytocin instead of nipple stimulation because nipple stimulation can cause long, uncontrolled
contractions

Risks

 Fetal heart monitoring may indicate that fetus is having problems when fetus is actually healthy. Fetal heart monitoring
cannot detect every type of problem, such as a birth defect.

 Causing labor to start earlier than your expected delivery date.

 Causing prolonged contractions that may cause problems with your baby. The contractions usually stop when the oxytocin
is stopped. You may be given a medicine to stop the contractions. If in the very rare case that your contractions do not stop,
your doctor may recommend delivery.

Contraindications

This "stress test" is usually not performed if there are any signs of premature birth or placenta praevia.

Results
A contraction stress test checks to see if fetus will stay healthy during the reduced oxygen levels that normally occur during
contractions when client is in labor.

Results of the test tell fetus health for 1 week. The test may need to be done more than once during pregnancy.
Contraction stress test

Normal: Normal test results are called negative.

Fetus heart rate does not get lower (decelerate) and stay low after the contraction (late decelerations). Note: There may
be a few times during the test when the heart rate decelerates, but it doesn't stay low so it is not a problem.
If three contractions occur during a 10-minute period of nipple stimulation or oxytocin infusion and there are no late
decelerations in baby's heart rate, baby is expected to be able to tolerate the stress of labor.

Abnormal: Abnormal test results are called positive.

A slower heart rate (late decelerations) that stays low after the contraction may mean that baby will have problems
during normal labor. It may also mean that baby will develop problems if delivery is delayed.
Contractions that last longer than 90 seconds and occur every few minutes are present. This is called hyperstimulation.

What Affects the Test

Reasons you may not be able to have the test or why the results may not be helpful include:

 Past pregnancy problems, such as a cesarean section with a midline (vertical) incision, placenta previa, or placenta abruptio.
The test also is not recommended if client is pregnant with more than one baby, are likely to have a premature rupture of the
amniotic sac (membranes), have an incompetent cervix, or have been given magnesium sulfate in pregnancy.
 A uterine surgery in the past. Strong contractions may cause the uterus to rupture.
 If you smoke or use cocaine.
 Movements of fetus during the test. It may be hard for the sensors to record baby's heart rate or contractions.
 Being very overweight.
 Having a full bladder.

4. FETAL MOVEMENT COUNT

Counting the fetal movements is a reliable marker for knowing how well the fetus is. There is an old saying that “A moving baby is a
healthy baby,” and this test helps mother to be more aware of those kicks and flutters by counting them for a period of time each day.
This simple, low-tech procedure, performed at home, can and should be used by all women. Most women enjoy the counting
process, as it makes them feel closer to their baby.

This test is important to perform during months 7, 8, and 9. health providers can askm to do this test daily during the third
trimester. It should be counted at the time of day when baby is usually moving. Not all babies move the same amount or at the same
time of day, so it is important for mother to be aware of baby’s pattern of movement.

Procedure

There are two methods of doing fetal heart rate monitoring.

- Cardif ‘count 10’ formula

- Daily fetal movement count

Cardif ‘count 10’ formula: The patient counts fetal movements starting at particular time, say for example 9 a.m. The counting
comes to an end as soon as 10 movements are perceived. She is instructed to report the physician if – 1) less than 10 movements
occur during 12 hours on 2 successive days or 2) no movement is perceived even after 12 hours in a single day.

Daily fetal movement count (DFMC): Three counts each of one hour duration (morning, noon, and evening) are recommended.
The total counts multiplied by four give daily (12 hour) fetal movement count. If there is diminution of the number of ‘kicks’ to less
than 10 in 12 hours (or less than 3 in each hour), it indicates fetal compromise.

Reason for less movement

 - Placental insufficiency
- Oligohydraminos

5. INTERNAL HEART RATE MONITORING

Internal electronic monitoring is the most precise method for assessing FHR and uterine contractions. A pressure sensing catheter is
passed through the vagina, into the uterine cavity and alongside the fetus, after the membranes have ruptured and the cervix has
dilated to at least 3 cm. As contraction puts pressure on the uterine contents, the pressure exerted on the catheter is recorded. The
FHR recording is obtained from a fetal scalp electrode. Once the fetal head is engaged, the electrode is inserted vaginally and
attached to the fetal scalp. A fetal electrocardiograph signal is obtained, amplified, and then fed into a cardio tachometer. The output
from the cardio tachometer is recorded on permanent graph paper. It is a invasive procedure, carries the risk of uterine infection, and
limits a woman’s movement.

6. RADIOLOGICAL TESTS
This may be used for detection of gross fetal malformations (bony), IUFD or for assessment of fetal maturity where
ultrasonography is not available. Thickness and density of the skull bone shadow, appearance and density of the ossification centers
in the upper end of the tibia (38-40 weeks) and lower end of the femur (36-37 weeks) are taken together to assess the maturity. It is
not done these days. X-rays may involve risks to an unborn child.

Principles of radiation in obstetrics:

 Benefits of radiation must outweigh the risks of the procedure

 Minimum radiation dose to be used
 Appropriate fetal shielding should be done
 First trimester should preferably be avoided
 Benefits and safety of ultrasonography must be considered as an alternative

Indications

a. Fetal
b. Maternal

Fetal

c. Diagnosis of pregnancy
d. Multiple pregnancy
e. Malpresentations
f. Hydraminos
g. IUD
h. Congenital malformations
i. Fetal maturity

Maternal

j. Patient with cardio-pulmonary disease may require chest X-ray but should be done beyond 12 week

X- Ray hazards

Like many medical tests, x-rays have risks as well as benefits. X-rays can result in damage of cells or DNA in living matter.

The risk of not having a needed x-ray can be much greater than the risk from any exposure to the radiation.

Fetuses can be unintentionally exposed to x-rays when a woman does not know she is pregnant, or does not inform the doctor or
technician of her pregnancy before an x-ray. Whether planned or unintentional, exposure of an unborn child to x-rays can cause
anxiety to the mother, which may be more harmful than the x-rays themselves.

Radiation is not directed towards the fetus during an x-ray of the mother's upper body (chest, teeth, neck and limbs). An x-ray of the
mother's lower body (abdomen, lower back, pelvis, kidneys) may direct radiation near, or through, the fetus. Generally these types of
x-rays only involve small amounts of radiation.
The two types of x-rays involving higher amounts of radiation are the abdominal or pelvic CT (computerized tomography) and
fluoroscopy. If an x-ray cannot be delayed until after pregnancy, special techniques are used to minimize the radiation exposure on
the fetus. The x-ray beam can be narrowed to expose only a small area, and in fluoroscopy the exposure time can be minimized as
well.

Fetuses are more susceptable than adults to the damaging effects of x-rays, partly because their cells are rapidly dividing and
growing into specialized cells and tissues. If x-rays cause changes in these cells, there is a slightly increased chance of birth defects
or certain illnesses, such as leukemia, later in life. However, most birth defects and childhood diseases are not attributed to exposure
to any known harmful agent during pregnancy.

Damage to fetal cells may result in miscarriage, birth defects, or mental impairment, depending on the amount of radiation and the
stage of pregnancy. The risks are higher during the first three months of pregnancy (first trimester). It is important to note that most
of these effects do not usually occur below 100 mGy - more radiation than three pelvic CT scans or 20 abdominal x-rays.

There is an increased risk of childhood cancer from DNA damage regardless of when in pregnancy the radiation occurred. The risk is
believed to be proportional to the amount of radiation, i.e. the smaller the amount of radiation, the smaller the risk of cancer. Most
studies show no increase in childhood cancer from small amounts of radiation. However, one study identifies the chance of a
childhood cancer from abdominal x-rays (in the 10 mGy range) at about one in 1,000 births. In comparison, the chance of a
childhood cancer in the general population is about two to three in 1,000 births.

II. BIOCHEMICAL TESTS

Pregnancy induces major physiological, hormonal and biochemical changes to achieve an optimal outcome for the baby and its
mother. When the pregnancy deviates from its normal course, there are many biochemical markers which can be used to assess these
abnormalities. As biochemistry is only one part of obstetric care, results should be interpreted in conjunction with clinical and
medical imaging data.

Biochemical markers are used to assess maternal, placental and fetal health. They help to diagnose and monitor maternal conditions
such as gestational diabetes and pre-eclampsia, trophoblastic disease and fetal chromosomal abnormalities such as Down's
syndrome. These biochemical and hormonal tests constitute only one aspect of obstetric care. They should be used together with
clinical findings and imaging, particularly ultrasonography.

Biochemical tests for common maternal, placental and fetal conditions

Condition Test

Maternal Gestational diabetes Glucose screening tests at 24-28 weeks: 50 g challenge test
or
2-hour 75 g oral glucose tolerance test
Pre-eclampsia* 1. Urinary protein (by dipstick testing or formal quantitation)
2. Serum uric acid
3. Renal function tests
4. Full blood count (for Hb concentration and platelet count)
Placental Trophoblastic disease* 1. HCG
(hydatidiform mole or 2. Free β-HCG
choriocarcinoma) 3. Urinary HCG when indicated
Fetal Down's syndrome* Maternal serum alpha fetoprotein, HCG, pregnancy-associated plasma
protein-A, and transnuchal ultrasound between 11 and 13 weeks gestation
Triple test - Maternal serum alpha fetoprotein, HCG, pregnancy-
associated plasma protein-A, and serum unconjugated oestriol in various
combinations between 15 and 18 weeks gestation
Neural tube defects Maternal serum alpha fetoprotein
or
Amniotic fluid alpha fetoprotein (less common)

Lung maturity Lecithin/Sphingomyelin (L/S) ratio

 1. BIOCHEMICAL ASSESSMENT OF MATERNAL HEALTH

Common problems in pregnancy include gestational diabetes and pre-eclampsia.

DIABETES

The prevalence of gestational diabetes mellitus ranges from 1 to 14% depending on the populations studied. In Australia, the
prevalence ranges from 5.5 to 8.8%. Screening for gestational diabetes mellitus in Australia is strongly advocated at 26-28 weeks of
gestation. This enables early intervention which results in significant improvements in both fetal and maternal outcomes.

Occasionally, the serum glucose is unexpectedly found to be in the diabetic range in the first trimester. By definition, this is
gestational diabetes mellitus, but does not distinguish between diabetes that may have preceded or occurred at the same time as
pregnancy. The diagnosis can be confirmed by further tests of fasting glucose concentration or a 75 g oral glucose tolerance test.
These patients should be reassessed in the postpartum period for evidence of diabetes. The woman's glycated haemoglobin should be
maintained in the normal range or as near normal as possible to ensure optimal fetal outcome.

PRE-ECLAMPSIA

Pre-eclampsia occurs typically in the third trimester and affects 4-8% of pregnancies. It constitutes a triad of pregnancy-associated
hypertension (that is, there is no pre-existing hypertension), marked proteinuria (greater than 300 mg daily) and pathological
oedema. It is thus critical that urinary dipstick testing for protein, which can be fully quantitated if required, is performed at each
antenatal visit together with blood pressure measurement and careful examination for oedema. Other findings include rises in serum
uric acid (which can antedate the onset of hypertension), urea and creatinine. Low haemoglobin and platelet concentrations are
informative if the patient is suspected to have the severe form of pre-eclampsia - haemolysis-elevated liver enzymes-low platelets
(HELLP). In the absence of pre-existing pathology, these biochemical parameters should return to normal after delivery.

2. BIOCHEMICAL ASSESSMENT OF PLACENTAL HEALTH

Ultrasonography has added another dimension to first trimester obstetric care to such an extent that many traditional biochemical
tests have been rendered redundant. Maternal serum human placental lactogen and serum or urinary oestriol concentrations which
were previously used extensively in the assessment of placental function, are rarely used nowadays.

HUMAN CHORIONIC GONADOTROPHIN (HCG)

Human chorionic gonadotropin (hCG) is a glycoprotein hormone produced in pregnancy that is made by the the developing
embryo soon after conception and later by the syncytiotrophoblast (part of the placenta). Its role is to prevent the disintegration of
the corpus luteum of the ovary and thereby maintain progesterone production that is critical for a pregnancy in humans. hCG may
have additional functions; for instance, it is thought that hCG affects the immune tolerance of the pregnancy. Early pregnancy
testing, in general, is based on the detection or measurement of hCG. In the second trimester an elevated serum HCG concentration
has been associated with a two-to threefold increased risk of fetal growth retardation.

In the second trimester an elevated serum HCG concentration has been associated with a two-to threefold increased risk of fetal
growth retardation.

Function

Human chorionic gonadotropin interacts with the LHCG receptor and promotes the maintenance of the corpus luteum during the
beginning of pregnancy, causing it to secrete the hormone progesterone. Progesterone enriches the uterus with a thick lining of blood
vessels and capillaries so that it can sustain the growing fetus. Due to its highly-negative charge, hCG may repel the immune cells of
the mother, protecting the fetus during the first trimester. It has also been hypothesized that hCG may be a placental link for the
development of local maternal immunotolerance. For example, hCG-treated endometrial cells induce an increase in T cell apoptosis
(dissolution of T-cells). These results suggest that hCG may be a link in the development of peritrophoblastic immune tolerance, and
may facilitate the trophoblast invasion, which is known to expedite fetal development in the endometrium. It has also been suggested
that hCG levels are linked to the severity of morning sickness in pregnant women.

Because of its similarity to LH, hCG can also be used clinically to induce ovulation in the ovaries as well as testosterone production
in the testes. As the most abundant biological source is women who are presently pregnant, some organizations collect urine from
pregnant women to extract hCG for use in fertility treatment.
Human chorionic gonadotropin also plays a role in cellular differentiation/proliferation and may activate apoptosis.

Testing

Levels of hCG may be measured in the blood or urine. Most commonly, this is done as a pregnancy test, intended to indicate the
presence or absence of an implanted embryo. Testing for hCG may also be done when diagnosing or monitoring germ cell and
trophoblastic tumors.

Most tests employ a monoclonal antibody (MAb), which is specific to the β-subunit of hCG (βhCG). This procedure is employed to
ensure that tests do not make false positives by confusing hCG with LH and FSH. (The latter two are always present at varying
levels in the body, whereas the presence of hCG almost always indicates pregnancy.)

 The urine test may be a chromatographic immunoassay or any of several other test formats, home-, physician's office-, or
laboratory-based. Published detection thresholds range from 20 to 100 mIU/ml (milli International Units per milli-liter),
depending on the brand of test. Early in pregnancy, more accurate results may be obtained by using the first urine of the
morning when hCG levels are highest. When the urine is dilute (specific gravity less than 1.015), the hCG concentration
may not be representative of the blood concentration, and the test may be falsely negative.

 The serum test, using 2-4 mL of venous blood, is typically a chemiluminescent or fluorimetric immunoassay that can
detect βhCG levels as low as 5 mIU/ml and allows quantitation of the βhCG concentration. The ability to quantitate the
βhCG level is useful in the monitoring germ cell and trophoblastic tumors, followup care after miscarriage, and in
diagnosis of and follow-up care after treatment of ectopic pregnancy. The lack of a visible fetus on vaginal ultrasound after
the βhCG levels have reached 1500 IU/ml is strongly indicative of an ectopic pregnancy.

Gestational trophoblastic disease like Hydatidiform moles ("molar pregnancy") or Chroiocarcinoma may produce high levels of
βhCG (due to the presence of syncytialtrophoblasts- part of the villi that make up the placenta) despite the absence of an embryo.
This, as well as several other conditions, can lead to elevated hCG readings in the absence of pregnancy.

hCG levels are also a component of the triple test, a screening test for certain fetal chromosomal abnormalities/birth defects.

hCG Levels

The following is a list of serum hCG levels. Note that these are merely typical values--a given woman's values may not fall within
these ranges. (LMP = since last menstrual period).

 3 weeks LMP: 5 - 50 mIU/ml

 4 weeks LMP: 5 - 426 mIU/ml
 5 weeks LMP: 18 - 7,340 mIU/ml
 6 weeks LMP: 1,080 - 56,500 mIU/ml
 7 - 8 weeks LMP: 7, 650 - 229,000 mIU/ml
 9 - 12 weeks LMP: 25,700 - 288,000 mIU/ml
 13 - 16 weeks LMP: 13,300 - 254,000 mIU/ml
 17 - 24 weeks LMP: 4,060 - 165,400 mIU/ml
 25 - 40 weeks LMP: 3,640 - 117,000 mIU/ml
 Non-pregnant females: <5.0 mIU/ml
 Postmenopausal females: <9.5 mIU/ml

Tumor marker

The β subunit of human chorionic gonadotropin is secreted also by some cancers including choriocarcinoma, germ cell tumors,
hydatidiform mole formation, teratoma with elements of choriocarcinoma (this is rare), and islet cell tumor. For this reason a
positive result in males can be a test for cancer, The normal range for men is between 0-5 IU/ml, although cancer should not
automatically be suspected if the level is <30.

Use as medication

Human chorionic gonadotropin is extensively used as a parenteral fertility medication in lieu of luteinizing hormone. In the presence
of one or more mature ovarian follicles, ovulation can be triggered by the administration of hCG. As ovulation will happen about 36-
48 hours after the injection of hCG, procedures can be scheduled to take advantage of this time sequence. Thus, patients that undergo
IVF, in general, receive hCG to trigger the ovulation process, but have their eggs retrieved at about 36 hours after injection, a few
hours before the eggs actually would be released from the ovary.
As hCG supports the corpus luteum, administration of hCG is used in certain circumstances to enhance the production of
progesterone.

In the male, hCG injections are used to stimulate the leydig cells to synthesize testosterone. The intratesticular testosterone is
necessary for spermatogenesis from the sertoli cells. Typical uses for hCG in men include hypogonadism and fertility treatment.

During first few months of pregnancy, the transmission of HIV-1 from woman to fetus is extremely rare. It has been suggested that
this is due to the high concentration of hCG, and that the beta-subunit of this protein is active against HIV-1.

Use in weight loss

A controversial usage of hCG is as an adjunct to the British endocrinologist Dr. A.T.W. Simeons’ ultra-low-calorie weight-loss diet.
Simeons, while studying pregnant women in India on a calorie-deficient diet, and “fat boys” with pituitary problems treated with
low-dose hCG, discovered that both lost fat rather than lean (muscle) tissue. He reasoned that hCG must be programming the
hypothalamus to do this in the former cases in order to protect the developing fœtus, and proceeded to use low-dose daily hCG
injections (125mg) in combination with a customized ultra-low-calorie (500 kcal/day, high-protein, low-carbohydrate/fat) diet to
help obese adults lose dramatic amounts of adipose tissue without loss of lean, at a Salvator Mundi International Hospital in Rome,
Italy, clinic mainly for celebrities.

3. BIOCHEMICAL ASSESSMENT OF FETAL HEALTH

The major aim of fetal assessment is to ensure satisfactory growth in utero. There are many factors which can cause fetal growth
retardation. These range from poor maternal nutritional state to placental insufficiency and fetal abnormality. Similar to placental
function, medical imaging is increasingly used to detect fetal abnormalities, thus reducing the utility of biochemical markers.

ALPHA FETOPROTEIN

Alpha fetoprotein is a fetal protein arising from the yolk sac and fetal liver. It can be detected in increasing concentrations in
maternal serum until 32 weeks of normal gestation. LabCorp, a large US clinical laboratory testing company, began offering AFP
screening tests in the early 1980s.

AFP test results often are reported as either ng/ml or MoM (multiple of the median, where the median is calculated for an
appropriate reference population).

The normal range of AFP for adults and children is variously reported as under 50, under 10, and under 5 ng/mL. At birth, normal
infants have AFP levels 4 or more orders of magnitude above this normal range, decreasing to within it over the first 1–2 years of
life. During this time, the normal range of AFP levels spans approximately 2 orders of magnitude. Correct evaluation of abnormal
AFP levels in infants must take into account these normal patterns.

There are two categories of AFP tests: tests performed on serum (blood plasma), and tests performed on amniotic fluid. Tests
performed on serum are further categorized by the reason for performing the test: maternal serum, adult tumor marker, and pediatric
tumor marker.

Tests performed on serum

The standard is a quantitative test, reporting a measured concentration of AFP in the sample, but there is also a less expensive
qualitative test, reporting only that the concentration is normal or high. The qualitative test is appropriate only in some
circumstances.

The resulting test report should specify the assay method and equipment used, and the report of a quantitative test should also
provide a reference range for the test result. Many laboratories report reference ranges that are based on all other samples tested in
that laboratory, necessarily including samples with abnormal AFP concentrations due to disease. Superior reference ranges are
produced by research on healthy subjects.

Maternal serum

Maternal serum AFP (MSAFP) varies by orders of magnitude during the course of a normal pregnancy. MSAFP increases rapidly
until about 32 weeks gestation, then decreases gradually. After the pregnancy ends it decreases rapidly, with a half-life of about 5
days.

Typically, MSAFP is measured in the beginning of the second trimester (14-16 weeks). It may be measured alone or as part of a
package of routine prenatal screening tests, such as a triple test or quad test.
Because MSAFP test results must be interpreted according to the gestational age, they often are reported in terms of multiple of the
median (MoM). Because the median is calculated from tests of other women's pregnancies at the same gestational age, in effect
MoM is independent of gestational age. A typical normal range is 0.5 to 2.0 or 2.5 MoM.

MSAFP above normal is seen in multiple gestation, when there is placental abruption, as well as in a number of fetal abnormalities,
such as neural tube defects including spina bifida and anencephaly, and abdominal wall defects. Other possibilities are errors in the
date of the gestation or fetal demise. Rarely, high MSAFP is due to endodermal sinus tumor (EST) or another germ cell tumor
containing EST. These tumors can occur in the pregnant woman (often as an ovarian tumor) or in the fetus.

MSAFP below normal is associated with a smaller number of conditions, including Down syndrome and Trisomy 18. Diabetic
patients also have lower levels.

Patients with abnormal MSAFP need to undergo detailed obstetric ultrasonography. The information is then used to decide whether
to proceed with amniocentesis. Genetic counseling usually is offered when the screening test result is positive.

Neural tube defects

In neural tube defects such as spina bifida and anencephaly, the concentration of alpha fetoprotein in the maternal serum is unusually
high in the first trimester because cerebrospinal fluid leaks into the amniotic fluid. Other causes of elevated alpha fetoprotein, such
as incorrect gestational date and multiple pregnancy, need to be excluded. As a marker of neural tube defects maternal serum alpha
fetoprotein, ideally, should be measured between 15 and 18 weeks of gestation. Any suspicion of a neural tube defect can be further
assessed with ultrasound, usually at 18-20 weeks. This scan also assesses for other fetal morphological abnormalities and placental
placement.

Down's syndrome

Down's syndrome is one of the common causes of fetal growth retardation. It is the result of either partial or total trisomy of
chromosome 21 and is a major obstetric concern, particularly in older women. Important biochemical markers include alpha
fetoprotein, HCG, unconjugated oestriol, pregnancy-associated plasma protein-A, serum inhibin-A and free β-HCG. These markers
are used in various combinations and together with ultrasound to increase the detection rate of Down's syndrome. It cannot be
overemphasised that the gestational age must be correct in order for screening parameters to be accurate.

Between 11 and 13 weeks (that is late first trimester), serum pregnancy-associated plasma protein-A, free β-HCG and ultrasound
assessment of nuchal thickness (the physiological space between the back of the neck and the overlying skin of the fetus) are most
commonly used in the assessment of Down's syndrome. Due to the changing concentrations of these markers in the normal pregnant
population, the results are mathematically corrected for easy comparison. The nuchal thickness is increased in Down's syndrome and
approximately 70% of cases will be detected by ultrasound in experienced centres. In combination with biochemical markers, the
detection rate increases to 85-90%. Abnormal results can be followed up with direct karyotyping using chorionic villous sampling,
but this carries a 0.5-1.0% risk of pregnancy loss in the first trimester.

In the second trimester, screening for Down's syndrome traditionally employs the triple test of maternal serum HCG, serum
unconjugated oestriol and alpha fetoprotein at 15-18 weeks of gestation. Some laboratories also measure serum pregnancy-
associated plasma protein-A. The combination of these markers and maternal age delivers a 60-65% detection rate, but this includes
the 5% of women who have a false positive result. Transnuchal thickness in the mid to late second trimester does not correlate well
with Down's syndrome and does not add to the value of biochemical markers.

The results of Down's syndrome screening in the first and second trimester are expressed as the proportion of affected pregnancies,
for example 1 in 488 chance of having Down's syndrome. This is accomplished using a risk-assessment program that incorporates
nuchal thickness (only in the first trimester), biochemistry results and maternal age.

BILIRUBIN IN AMNIOTIC FLUID

Another biochemical method of assessing fetal health is the analysis of amniotic fluid. The measurement of bilirubin concentration
in amniotic fluid is critical for assessing fetal intravascular haemolysis in the presence of Rhesus incompatability.

OTHERS

Recently, there has been a resurgence of interest using maternal growth hormone and insulin-like growth factor levels during the first
and second trimester of pregnancy as predictors of fetal outcome, but these are yet to be of routine clinical use.

ASSESSMENT OF FETAL PULMONARY MATURITY

Confirmation reduces the incidence of respiratory distress syndrome (RDS) in the new born. RDS is high in premature infants born
before 37 yrs. It is caused by deficiency of pulmonary surfactant synthesized by type II alveolar cells. Surfactant is packed in
lamellar bodies which is discharged in lung alveoli which is carried in the pulmonary fluid which carried into the amniotic fluid. By
Lecithin/ Sphingomylin (L/S) ratio Amniotic fluid L/S ratio at 31-32 weeks is 1, at 35 weeks is 2 and L/S ratio > 2 indicates lung
maturity. Other tests which determine lung maturity are:-

k. presence of Phosphatidyl glycerol

l. saturated Phosphatidyl choline > 500ng/ml

m. Amniotic fluid optical density at 650m greater than 0.15

n. Amniotic fluid color during 1st and 2nd trimester is yellow and clear. At term is turbid due to vernix

III. CYTOGENIC TESTS

They are helpful in prenatal diagnosis of genetic disorders. Different tests comes under this category are:-

1. Chorionic villus sampling

2. Cordocentesis

3. Amniocentesis

4. Chorionic villus sampling

Chorionic villus sampling (CVS) is a form of prenatal diagnosis to determine chromosomal or genetic disorders in the fetus. It
entails getting a sample of the chorionic villus (placental tissue) and testing it. The advantage of CVS is that it can be carried out 10-
13 weeks after the last period, earlier than amniocentesis (which is carried out at 16-20 weeks).

Chorionic villus sampling (CVS) is the removal of a small piece of placenta tissue (chorionic villi) from the uterus during early
pregnancy to screen the baby for genetic defects.

Indications

Possible reasons for having a CVS can include:

 Mother's age of 35 years or greater

 Abnormal first trimester screen results
 Increased nuchal translucency or other abnormal ultrasound findings
 Family history of a chromosomal abnormality or other genetic disorder
 Parents are known carriers for a genetic disorder The test is a way of detecting genetic disorders. The sample is used to
study the DNA, chromosomes, and enzymes of the fetus. It can be done sooner than amniocentesis, about 10 to 12 weeks
after your last menstrual period. Test results take about 1 to 2 weeks, whereas amniocentesis results may take longer.

Preparation

 Health care provider will explain the procedure, its risks, and alternative procedures such as amniocentesis. Genetic
counseling is recommended prior to the procedure. This will allow client to make an unhurried, informed decision
regarding options for prenatal diagnosis.
 Client will be asked to sign a consent form before this procedure, and may be asked to wear a hospital gown.
 The morning of the procedure client may be asked to drink fluids and refrain from urinating to fill bladder, which allows
adequate visualization so the sample may be taken. An obstetrician can perform this procedure in about 5 minutes, after the
preparation.

Procedure
  CVS can be done through the cervix (transcervical) or through the abdomen (transabdominal). The techniques are equally
safe when done by a provider with experience, although miscarriage rates are slightly higher when done through the
cervix. The health care provider will use ultrasound to pick the safest approach and as a guide during sampling.
 An abdominal ultrasound is performed to determine the position of the uterus, the size of the gestational sac, and the
position of the placenta within the uterus. Your vulva, vagina, cervix, and abdomen are cleaned with an antiseptic such as
Betadine.
 The transcervical procedure is performed by inserting a thin plastic tube through the vagina and cervix to reach the
placenta. The provider uses ultrasound images to help guide the tube into the appropriate area and then removes a small
sample of chorionic villus tissue.
 The transabdominal procedure is performed by inserting a needle through the abdomen and uterus and into the placenta.
Ultrasound is used to help guide the needle, and a small amount of tissue is drawn into the syringe.
 The sample is placed in a dish and evaluated in a laboratory. The ultrasound doesn't hurt. A clear, water-based conducting
gel is applied to the skin to help with the transmission of the sound waves. A handheld probe called a transducer is then
moved over the area. In addition, your health care provider may apply pressure on your abdomen to find the position of
your uterus.
 The antiseptic cleansing solution will feel cold at first asnd may irritate your skin if not washed off after the procedure.
Some people are allergic to Betadine. Notify your health care provider if you are allergic to Betadine or if you have any
other allergies.
 Some women say the vaginal approach feels like a Pap smear with some discomfort and a feeling of pressure. There may
be a small amount of vaginal bleeding following the procedure.

Results

Normal result

There are no signs of any genetic defects. However the test could miss some genetic defects.

Note: Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific
test results.

Abnormal Results

An abnormal result may be a sign of more than 200 disorders, including:

 Down syndrome
 Hemoglobinopathies
 Tay-Sachs disease

Limitations

A small percentage (1-2%) of pregnancies will have confined placental mosaicism, where some but not all of the placental cells
tested in the CVS will be abnormal, even though the pregnancy is unaffected. Cells from the mother can be mixed with the placental
cells obtained from the CVS procedure. Occasionally if these maternal cells are not completely separated from the placental sample,
this can lead to discrepancies with the results. This phenomenon is called Maternal Cell Contamination (MCC). CVS can not detect
all birth defects. It's used for testing chromosomal abnormalities or other specific genetic disorders only if there is family history or
other reason to test.

Risks

Possible complications include:

 Bleeding
 Infection
 Miscarriage
 Rh incompatibility in the mother
 Rupture of membranes
 Amniotic fluid leak which can further leads to
 Oligohydraminos if not treated and the amniotic fluid continues to leak it can result in the baby developing
 Hypoplastic lungs (underdeveloped lungs).
 CVS may also cause limb problems in the fetus. This risk appears to be very low (1 in 3,000) when CVS is performed after
10 weeks gestational age.
 Signs of complications include:

 Excessive bleeding
 Excessive vaginal discharge
 Fever

Any signs of complications should be reported to health care provider.

Considerations

 If your blood is Rh negative, client may RhoGAM to prevent Rh incompatibility.

 A follow-up ultrasound should be done 2 to 4 days after the procedure to make sure the pregnancy is proceeding normally.

5. CORDOCENTESIS: FETAL BLOOD SAMPLING

Cordocentesis or PUBS (Percutaneous umbilical blood sample) is a diagnostic test that examines blood from the fetus to detect fetal
abnormalities.

Time: Cordocentesis is usually done when diagnostic information can not be obtained through amniocentesis; CVS, ultrasound or
the results of these tests were inconclusive. Cordocentesis is performed at 18 weeks or after.

Objective

Cordocentesis detects chromosome abnormalities (i.e. Down syndrome) and blood disorders (i.e. fetal hemolytic disease.).
Cordocentesis may be performed to help diagnose any of the following concerns:

 Malformations of the fetus

 Fetal infection (i.e. toxoplasmosis or rubella)
 Fetal platelet count in the mother
 Fetal anemia
 Isoimmunisation

This test is different from amniocentesis in that it does not allow testing for neural tube defects.

Procedure

An advanced imaging ultrasound determines the location where the umbilical cord inserts into the placenta. The ultrasound guides a
thin needle (25 gauge spinal needle 13 cm in length) through the abdomen and uterine walls to the umbilical cord. The needle is
inserted into the umbilical vein aprox 1-2 cm from the placental insertion to retrieve a small sample of fetal blood (0.5 to 2 ml). The
sample is sent to the laboratory for analysis, and results are usually available within 72 hours.

The procedure is similar to amniocentesis except the objective is to retrieve blood from the fetus versus amniotic fluid. It is
performed under local anesthesia. Anti- D Immunoglobulin 100 g i/m given to Rh negative.

Result

Cordocentesis is a diagnostic test that detects chromosome abnormalities and certain blood disorders with high levels of accuracy.
Although the probabilities of identification are high, this test does not measure the severity of these disorders. This test also does not
help identify neural tube defects.

Side effects

Although cordocentesis is considered to be a safe procedure, it is recognized as an invasive diagnostic test that does pose potential
risks. Miscarriage is the primary risk related to cordocentesis occurring between 1 to 2 times out of every 100 procedures.

Other potential side effects include:

  Blood loss from the puncture site
 Haematoma formation
 Infection
 Drop in fetal heart rate
 Premature rupture of membranes

Contact your healthcare provider if these symptoms remain or get worse. You should also contact your healthcare provider if you
experience:

 Fever
 Chills
 Leaking of amniotic fluid

Reasons to test

The reasons to test or not test vary from person to person, couple to couple and physician to physician. Performing the tests and
confirming the diagnosis provides you with certain opportunities:

 Pursue potential medical interventions that may exist

 Begin planning for a child with special needs
 Start addressing anticipated lifestyle changes
 Identify support groups and resources
 Make a decision about carrying the child to term

6.AMNIOCENTESIS

It is the deliberate puncture of the amniotic fluid sac per abdomen.

Purposes
Diagnoses of chromosomal and genetic disorders
Early months
1. Sex-linked disorders
2. Inborn errors of metabolism
3. Neural tube defect

Later months
1. Fetal maturity
2. Degree of fetal hemolysis in Rh n-ve mother
3. Meconium staining
4. Amniography and fetography

Precedure

1. Empty the bladder

2. Lie on dorsal position
3. Proposed puncture site is infiltrated with 2ml of 1% lignocane
4. Sites are ;early pregnancy is 1/3rd of the way up the uterus from symphysis pubisand later is transisthemic
superapubis approach after lifting the presenting part or through the flanks in between the fetal limbs or below
the umbilicus behind the neck of the fetus
5. A 18 to 20 gauze spinal needle about 4’’ in length is pierced under USG with the stilette in.
6. Stiletto is withdrawn and few drops are discarded
7. 30ml of fluid is collected in a test tube

IV. MATERNAL ASSAY

Purposes
1. Prevention early detection and treatment of medical disorders as anaemia and diabetes.

2. Detection of malpresentations, malpositions and disproportion that may influence the decision of labour.

3. Instruct the pregnant woman about hygience, diet and warning symptoms.

4. Laboratory studies of parameters may affect the foetus as blood group, Rh typing, toxoplasmosis and syphilis.
Procedures at the visit
 The first visit should not be deferred beyond the second missed period.
 It may be earlier if the patient desires to terminate the pregnancy.
Frequency of antenatal visits.
 every month during the first 6 months.
 every 2 weeks during the 7th and 8th months.
 every week during the last month.
 More frequent visits are indicated in high risk pregnancy.

Method
a. Inspection –
 The size of the uterus
 The shape of the uterus
 Fetal movement
 Contour of the abdominal wall
 Skin changes
b. Palpations
 Hands should be clean and warm before doing palpations –
 as cold hands do not have the necessary acute sense of touch
 they tend to induce contraction of the uterine muscles and the mother resents the discomfort.

 Arms and hands should be relaxed and the pads, not the tips, of the fingers used with delicate precision.
 The hands are moved smoothly over the abdomen in a stroking motion in order to avoid causing contractions.
 Estimating the period of gestation
 Fundal palpation
 Lateral palpation
 Pelvic palpation

Fundal palpation

First maneuver
 Face the patient and warm your hands.
 Place them on her abdomen to determine fetal position in the uterine fundus.
 Curl your fingers around the fundus.
 With the fetus in vertex position, the buttocks feel irregularly shaped and firm.
 With the fetus in breech position, the head feels hard, round, and movable.

Second maneuver / lateral palpation

 Move your hands down the sides of the abdomen, and apply gentle pressure.
 If the fetus lies in vertex position, you'll feel a smooth, hard surface on one side — the fetal back.
 Opposite, you'll feel lumps and knobs — the knees, hands, feet, and elbows.
 If the fetus lies in breech position, you may not feel the back at all.

Third maneuver
 Spread apart the thumb and fingers of one hand.
 Place them just above the patient's symphysis pubis.
 Bring your fingers together. If the fetus lies in vertex position and hasn't descended, you'll feel the head.
 If the fetus lies in vertex position and has descended, you'll feel a less distinct mass.

Fourth maneuver
 Use this maneuver in late pregnancy when the fetus is in cephalic presentation.
 The purpose of the fourth maneuver
is to determine flexion or extension of the fetal head and neck.
 Place your hands on both sides of the lower abdomen.
 Apply gentle pressure with your fingers as you slide your hands downward, toward the symphysis pubis.
 If the head and neck are flexed, your hands will meet obstruction — the cephalic prominence — on the side opposite the
fetal back.
 If the head and neck are extended, the cephalic prominence will be palpated on the same side as the fetal back. Flexion of
the fetal head and neck facilitates vaginal delivery.

Palpation will help to identify

 Fundal height
 Lie
 Presentation
 Attitude
 Position
 Engagement – it means the descent of the biparietal diameter through the pelvic brim.
c. Auscultation

 The fetoscope and the Doppler stethoscope are basic instruments for auscultating fetal heart tones and assessing fetal heart
rate.
Fetoscope
 This instrument can detect fetal heartbeats as early as the 20th gestational week.
 As an assessment tool during labor, the fetoscope is helpful for hearing fetal heart tones when contractions are mild and
infrequent.