FETAL

SURVEILLANCE L
PRESENTED BY
DR. F.O. UJUJU
10TH MARCH 2017
 OUTLINE
INTRODUCTION
THE IDEAL SCREENING TEST
AETIOLOGY OF FETAL COMPROMISE
PATHOPHYSIOLOGY OF FETAL COMPROMISE
ANTEPARTUM FETAL SURVEILLANCE
INTRAPARTUM FETAL SURVEILLANCE
CLINICAL RELEVANCE
CONCLUSION
REFERENCES
INTRODUCTION
Perinatal fetal loss in low resource setting
1 of the factors responsible – lack of FS in HRP
With adequate fetal monitoring, can be reduced
FS- all measures taken in pregnancy or labour to
determine and improve wellbeing of fetus upto
delivery of a healthy baby
Fetal monitoring in pregnancy & labour naturally will
be expected to reduce perinatal mortality & morbidity.
Developed World – good pregnancy outcomes
Rare adverse perinatal outcome
Developing World – Reverse is the case
Pregnancy & childbirth – a physiological event
However in some pregnancies, certain problems in
mother & fetus or environment may predispose a
fetus to IUGR or IUFD, hence increased need for
surveillance.
FS are in 2 parts – Antepartum FS & Intrapartum FS
AFS – antenatal measures instituted before onset of
labour to determine & improve fetal wellbeing
IFS – more intensive measures instituted during
labour – a time uterine contractions introduces a
further risk of fetal hypoxia
Aetiology of fetal compromise
Maternal
Fetal
Placental
Environmental
PATHOPHYSIOLOGY OF FETAL COMPROMISE
Normal Fetus:
Gross body movt (GBM)
Breathing movt (BM)
Regular cycling between quiescence & activity
Fetal heart reactivity
 Compromised Fetus:
 dec GBM, BM

Reverts to normal if hypoxia is removed

Progresses when hypoxia is continuous or
severe.
Dec GBM, BM, FHR
Redistribution of blood:
increased in brain, heart and adrenals.
(dec) in kidneys and other systems.
(Dec) RBF  (Dec) GFR  Oliguria -
Liquor volume
Ultimately (dec) fetal growth.
ANTEPARTUM FS / MONITORING - modalities
Biochemical tests
Symphysio – fundal height measurement.
Fetal movement counting
Ultrasonography.
Fetal cardiotocography
Biophysical profile
Doppler studies
BIOCHEMICAL TESTS

Indirect tests that assess placental & fetal

hormones.
Traditionally urinary and serum oestriol & hPL
used.
Oestriol (34-36 weeks) – 6- fold increase in
PNMR, 3 folds increase in IUGR.
hPL – 4 – fold reduction in PNMR.
Serum AFP @ 20 -24 wks ; 4 fold increased risk
of FGR
All have poor predictive values, expensive,
difficult to carry out
Only speaks for the fetus @ the time of the test
In a nutshell,they are ltd
All now largely abandoned
SYMPHYSIOFUNDAL HEIGHT
Identifies SGA & large for date babies
Factors influencing measurement. E.g. maternal
size, ht, transverse lie, engagement & intra and
inter observer variations
Most commonly used worldwide to assess fetal
growth – cheap, easy & good reliability
When repeatedly done, aids in identification of
fetal growth abnomalities
 FETAL MOVEMENT COUNTING

 F.M: starts early in life (U.S – 7 weeks)

 First maternal perception (16-20wks).
 Hypoxia and fetal movt
 Types: Cardiff count to ten
 Usefulness in low risk pregnancy doubtful
 Useful in high risk pregnancies  referral for
CTG,
 Limited by low P.P.V for IUGR
 Grant et al (1989) – in a RCT 68,000 women
concluded that FMC vs informal inquiry at ANC
offered no advantage.
 ULTRASONOGRAPHY
 Indications in 3rd trimester – growth & well
being .
 Biometric parameters – HC, AC, FL, BPD
 HC: AC ratio. In normal fetus, it is > 1 before
32 wks, 1 @ 32 – 34 wks & < 1 after 34 wks
 In asymmetric IUGR , HC/AC is elevated
 In symmetric IUGR, both HC and AC are
reduced & the ratio remains normal
 The use of customized fetal growth charts.
Adjusted for weight of previous children,
maternal weight & height, ethnic group.
AMNIOTIC FLUID VOLUME
The degree of reduction in liquor volume appears to
correlate well with the degree of fetal hypoxaemia.
AFP – DVP (2-8cm)
AFI - 10-25cm (< 10 Oligohydramnios; > 25
Polyhydraminos)
 FETAL CARDIOTOCOGRAPHY
 Non Stress Test
 Most commonly performed antenatal test of
fetal well being in developed countries.
 Quick & simple to perform.
 Interpretation can be difficult, indeed over 20
studies have shown differing options b/w
experts in assessing the various parameters of
the CTG.
 However, a normal NST has the following:
 Normal baseline rate of 110 – 160 bpm
 Baseline variability >5 bpm
 2 or more accelerations in 20 mins
 No deceleration
 No significant effect on perinatal outcome
parameters.
 RCTs: Risk of PNM
 FETAL STRESS TEST
 Shaking
 Nipple stimulation
 Vibro-acoustic stimulation
 Oxytocin infusion

 When used in conjunction with CTG reduces

the number of non-reactive traces due to fetal
sleep.
 However, effect on predictive ability of CTG
obscure.
BIOPHYSICAL PROFILE
Combines parameters obtained via ultrasonography
and NST.
Involves testing over 30mins.
Observational studies: High negative predictive
value (99.94%)
Low positive predictive value (35%) for perinatal
morbidity e.g low APGAR, HIE, fetal distress
Component Definition
Fetal movements 3 body or limb movements
Fetal tone One episode of active extension and
flexion of the limbs; opening and
closing of hand
Fetal breathing episode of >= 30 seconds in 30
movement minutes Hiccups are considered
breathing activity.
Amniotic fluid volume single 2 cm x 2 cm pocket is
considered adequate.
Non-stress test 2 accelerations > 15 beats per
minute of at least 15 seconds
duration.
Normal score : 8 – 10
Borderline score – 6. Associated with 6 fold
increase in PNMR, indicating that the the test
may not give enough time for intervention.
Time consuming
Increased risk of interventions without any
concomitant decrease in PNM when compared
to NST or AFV measurement alone.
DOPPLER STUDIES –
Principles
Blood vessels studied:
Uterine artery
Fetal aorta
Umbilical artery
Middle cerebral artery
Inferior vena cava
Uterine artery & umbilical artery doppler
waveforms have been extensively studied.
PI, RI, S/D ratio.
In pulsatile arteries, there is no blood flow
during diastole.
In the uterine & umbilical circulations however,
flow is continuous during diastole, hence S/D
ratio is low, (hence decreased resistance to
flow).
Uterine artery doppler showing ‘notching’ has
been shown to be highly predictive of FGR.
Umbilical artery, doppler wave forms showing
AEDF or REDF have very high predictive values
for PNM in SGA fetuses.
UADW has proven superior to BPP score or
computerized CTG.
Uterine artery
MCA
Fetal Aorta
Umbilical artery
Uterine artery
INTRAPARTUM MONITORING
Aimed at monitoring fetal wellbeing.
Aimed at reducing birth asphyxia, PNM, PN morbidity, or
longterm handicap e.g cerbral palsy.

MODALITIES
Intermittent ausculation - Pinard’s stethoscope /handheld
doppler
CTG admission vs continuous
Ancillary Tests:
Fetal blood sampling
Fetal scalp stimulation
Fetal ECG
Pulse oximetry
INTERMITTENT AUSCULATION
1st stage – every 15 mins lasting 60 secs after
each contraction.
2nd stage – every 15 mins.
Recommended in low risk patients.
Main form of monitoring available in low
resource setting.
PROBLEMS
Standards often not achievable on busy delivery
wards.
Gradual FHR changes may be missed.
No certification process for practitioners.
No hard record.

Admission CTG
Initially used for both low & high risk patients.
However associated with increased operative
intervention with no significant reduction in adverse
perinatal outcome.
No longer recommended for low risk patients.
CONTINUOUS CTG
Mainstay of high risk fetal assessment
Normal 1st Stage CTG
Baseline rate – 110 – 160b/min
Variability - > 5b/min
Presence of accelerations
ABNORMAL 1ST STAGE CTG
Baseline rate – Tachycardia or bradycardia or
rising baseline.
Variability – prolonged (> 90 mins) loss of
variability
Accelerations: absent
Decelerations:
Variable decelerations
Late decelerations
NORMAL 2ND STAGE CTG
Yet no consensus
90% of all second stage CTGs show some abnormally
or the other.

ABNORMAL 2ND STAGE

Baseline rate: continuous progressive tachycardia.
Variability: absent
Late decelerations: increased risk of low 5 mins
APGAR.
 ANCILLARY TESTS

FETAL BLOOD SAMPLING

FETAL ECG
Recent work showed that combining fetal ECG ST wave
analysis & conventional CTG resulted in less metabolic acidosis
(Amer-Wahlin et al, 2001).

FETAL PULSE OXIMETRY

Largest trial to date, have failed to show any overall reduction in
operative delivery through detection of acidosis was improved.
Position for fetal blood sampling
 Clinical Relevance
In any pregnancy at risk of IUGR outcome;
History,
Physical examination,
baseline investigations-
pregnancy test, blood tests, Clinical
Relevance ultrasound.
 Monitoring Normal SGA

Conservative management by fetal

surveillance.
Delvery if evidence of feta compromise.
Be watchful in late 3rd trimester. Doppler
studies may be misleading.
BPP most appropriate- best parameter.
Monitoring Growth-restricted Fetus
Weigh risk of pregnancy continuation with timely
delivery.
GRIT(Growth Restriction Intervention Trial)2003.
If IUGR diagnosis > 34wks- delivery;
< 34wks- steroids, delivery
28-34wks- for monitoring as appropriate, then
delivery
<28wks- management strategy uncertain.
 Conclusion
Myriads of fetal monitoring devices are in clinical
use, but we are yet to incorporate the more
modern ones into our clinical practice.
Despite their shortcomings, they have been shown
to be very useful in fetuses cosidered to be at
high risk.
The heavy burden of overwhelming perinatal
morbidity and mortality in Nigeria and other
developing countries, will continue to weigh us
down if concerted efforts are not made to drive
fetal monitoring into the 21st century.
THANK YOU