ANTENATAL ASSESSMENT OF FETAL WELL BEING

INTRODUCTION
The main goal of antenatal fetal assessment is to avoid fetal death. Clinical examination of fetal
well-being depends on suitable maternal health throughout pregnancy. At every antenatal visit,
the following clinical parameters such as Maternal weight gain, Blood pressure and Assessment
of the size of the uterus and height of the fundus are taken into account for assessment of
satisfactory progress of gestation. Biochemical, Biophysical and Cytogenetic methods are used
to antenatal assessment of fetal well-being in early pregnancy. Prevention of fetal death and
avoidance of unnecessary interventions are checked in the late pregnancy. Biochemical test,
Biophysical tests are used for fetal movement count, ultrasonography, cardiotocography,
Doppler ultrasound, vibroacoustic stimulation test etc. Test for fetal pulmonary maturity and
severity of Rh iso-immunization is assessed during the late pregnancy
Majority (80%) of foetal deaths occur in the antepartum period. The important causes of deaths
are
1. Chronic foetal hypoxia(IUGR)
2. Maternal complications e.g., diabetes, hypertension, infection
3. Foetal congenital malformation
4. Unexplained causes
There is progressive decline in maternal deaths all over the world. Currently more interest is
focussed to evaluate the health. The primary objective of antenatal foetal assessment is to avoid
foetal death. As such simultaneously with good maternal care during pregnancy and labour,
the foetal health in utero should be supervised with equal vigilance.
Aims of antenatal foetal monitoring
 To ensure satisfactory growth and wellbeing of the foetus throughout pregnancy.
 To screen out the high risk factors that affect the growth of the foetus.
Common indications for antepartum foetal monitoring
 Pregnancy with obstetric complications: IUGR, Multiple pregnancy, Polyhydramnios
or oligohydramnios, Rhesus alloimmunisation.
 Pregnancy with medical complications: Diabetes mellitus, Hypertension, Epilepsy,
Renal or Cardiac disease, Infection (Tuberculosis), SLE.
 Others: advanced maternal age, (>35 years), previous still birth or recurrent abortion,
previous birth of a baby with structural (anencephaly, spina bifida) or chromosomal
(autosomal trisomy) abnormalities.
 Routine antenatal testing.
Rationality of Antenatal Foetal Testing
 Tests must provide information superior to that of clinical evaluation
 Test results should be helpful on management to improve perinatal outcome
 Benefits of tests must outweight the potential risks and the costs.

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Measures that can be taken when a foetus is found compromised
 Bed rest
 Foetal surveillance
 Drug therapy
 Urgent delivery of the foetus – term or preterm.
 Neonatal Intensive Care
 Termination of pregnancy for foetal congenital anomaly.
CLINICAL EVALUATION OF FOETAL WELL BEING AT ANTENATAL CLINIC
 Non-invasive methods
a. Ultrasound
b. MRI
c. Electronic fetal assessment
d. Biophysical assessment of fetus
e. Biochemical assessment of fetus
 Invasive methods
a. Amniocentesis
b. Amniotic fluid studies
c. Chorionic villus biopsy
d. Percutaneous umbilical blood sampling
e. Fetal tissue sampling.
AT FIRST VISIT
The initial antenatal examination should be carried out in the first trimester. At this examination
a record is kept of the size of the uterus following bimanual examination or by ultrasonography.
This is of immense help in estimating the correct duration of gestation in the last trimester.
Foetal wellbeing depends on satisfactory maternal health throughout pregnancy. After a
through clinical examination of the mother, investigations are initiated as early as possible.
Routine investigations
 Blood: Haemoglobin, haematocrit, ABO, Rh grouping, VDRL are done. Blood glucose
and antibody screening are done in selected cases
 Urine: Protein, sugar and pus cells. If significant protein urea is found, “clean catch”
specimen of midstream urine is collected for culture and sensitivity test. To collect the
midstream urine, the patient is advised to clean the vulva and to collect the urine in a
clean container during the middle of act of urination. Presence of nitrates and/ or
leucocyte esterase by dipstick indicates urinary tract infections.
 Cervical cytology study by Papanicolaou stain has become a routine on many clinics.
Special investigations
 Serological tests for rubella, hepatitis B virus and HIV
 Genetic screen: Maternal Serum Alpha Feto Protein
 Ultrasound examinations.

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AT SUBSEQUENT VISITS
At every antenatal visits, the following clinical parameters ate taken into account for
assessment of satisfactory progress of gestation.
1. Maternal weight gain: During the second half of pregnancy, the average weight gain
is 1 kg a fortnight. Any excess weight gain may be due to excess fluid retention and
could be the first sign of pre-eclampsia. If the weight gain is less than normal, stationary
or even falling, one should be on the lookout for intrauterine growth restriction.
2. Blood pressure: Initial recording of blood pressure prior to 12 weeks helps to
differentiate a pre-existing chronic hypertension from a pregnancy induced
hypertension developing later on. Hypertension, pre-existing or pregnancy induced
may impair the foetal growth.
3. Assessment of the size of uterus and height of the fundus: In early weeks, the size
of the uterus is of great value in confirming the calculated duration of gestation. The
height of the fundus should be at each visit. The top of the uterine fundus is measured
from the superior border of the symphysis pubis (bladder should be empty) using a tape.
After 24 weeks of pregnancy the distance measured in cm normally corresponds to the
period of gestation in weeks. A variation of 1-2 cm is acceptable.
Provided the patient is sure about her date of last normal menstrual period a
measurement of symphysis fundal height in later month of pregnancy is a useful
screening test for further investigation. The measurement is compared to the expected
distance plotted on a chart. If the measurement falls below the 10th centile, foetal growth
restriction id suspected and more specific investigation should be done.
4. Clinical assessment of excess liquor should be recorded, as well as any scanty liquor
in the last trimester. Evidence of scanty liquor may indicate placental insufficiency and
the need for undertaking other placental function tests.
5. Documentation of the girth of the abdomen in the last trimester of pregnancy
should form a routine part of abdominal examination. This is measured at the lower
border of the umbilicus. Normally, the girth increases steadily up to term. If the girth
gradually diminishes beyond term or earlier, it arouses suspicion of placental
insufficiency. This is of particular value in suspecting placental insufficiency in the
high risk cases such as pre-eclampsia, chronic hypertension and IUGR.

SPECIAL INVESTIGATIONS
About 30% of antepartum foetal deaths are due to asphyxia (IUGR, postdates), 30 % due to
maternal complications (pre eclampsia, placental abruption, and diabetes mellitus), 15% to
congenital malformations and chromosomal abnormalities and 5 % to infection. About 20% of
stillbirths have no obvious cause. About 50 % of first trimester spontaneous abortions and about
5% of stillbirth infants have chromosomal abnormalities.
Congenital abnormalities may be
1. Chromosomal: numerical or structural
2. Single gene
3. Polygenic and multifactorial
4. Teratogenic disorders

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Apart from clinical evaluation, biochemical and biophysical methods have also been used for
the diagnosis. Some of these methods carry risks to the mother and or foetus are also expensive.
Therefore, their application should provide definite benefits that clearly outweighs the potential
risks and the costs.
EARLY PREGNANCY
1. Biochemical
2. Biophysical
3. Cytogenetic
Antenatal assessment of foetal wellbeing in early pregnancy is primarily designed to detect
foetal congenital abnormalities. Women who are screen positive should be offered foetal
karyotyping for confirmation.
1. BIOCHEMICAL
 Maternal serum alpha fetoprotein (MSAFP)
AFP is an oncofoetal protein (Molecular weight 70,000). It is produced by yolk sac and foetal
liver. Highest level of AFP in foetal serum and amniotic fluid is reached around 13 week and
thereafter it deceases. Maternal serum level reaches a peak level around 32 weeks. MSAFP
level is elevated in a number of conditions:
- Wrong gestational age
- Open neural tube defects
- Multiple pregnancy, Rh isoimmunisation
- IUFD
- Anterior abdominal wall defects
- Renal anomalies
Low levels are found in trisomies (Down’s syndrome), gestational trophoblastic diseases.
Test is done between 15 to 20 weeks. MSAFP value of 2.5 multiplies of the median (MOM)
when adjusted with maternal weight and ethnicity, is taken as cut off point. A typical normal
range is 0.5 to 2.0 or 2.5 MoM. Elevated MSAF detects 85% of all neural tube defects. Cases
with such high values are considered for high resolution ultrasound imaging and /or
amniocentesis.
Blood is drawn from veins in the mother’s arm and sent off to a laboratory for analysis. Results
are usually returned between one and two weeks. All pregnant women should be offered the
MSAFP screening, but it is especially recommended for:
 Women who have a family history of birth defects
 Women who are 35 years or older
 Women who used possible harmful medications or drugs during pregnancy
 Women who have diabetes
Maternal AFP levels in pregnancy start to rise from about 14th week of gestation up until about
32 weeks gestation. Between week 15 and 20 weeks, levels usually range between 10 ng/ml to
150 ng/ml.

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  Triple test
It is a combined biochemical test which includes MSAFP, hCG, and UE3 (unconjugated
oestriol). Maternal age in relation to confirmed gestation age is also taken into account. It is
used for detection of Down’s syndrome. In addition to Down syndrome, the triple and
quadruple screens assess risk for fetal trisomy 18 also known as Edward's syndrome, open
neural tube defects, and may also detect an increased risk of Turner syndrome, triploidy,
trisomy 16 mosaicism, fetal death, Smith-Lemli-Opitz syndrome, and steroid sulfatase
deficiency In affected pregnancy, level of MSAFP and UE3 tend to be low while that of hCG
is high. It is performed at 15-18 weeks. It gives a risk ratio and for confirmation amniocentesis
has to be done. The result is considered to be screen positive if the risk ratio is 1: 250 or greater.
Interpretation

AFP UE3 hCG Associated conditions

low low High Down syndrome

low low Low trisomy 18 (Edward's syndrome)

neural tube defects (like spina bifida that may have associated increased
levels of acetylcholinesterase in the amniotic fluid), omphalocele,
high n/a n/a
gastroschisis, multiple gestation (like twins or triplets), or an
underestimation of gestational age.

If only two of the hormones above are tested for, then the test is called a double test. A quad
test tests an additional hormone, inhibin. Furthermore, the triple test may be combined with
an ultrasound measurement of nuchal translucency.
Double test
Free beta hCG and PAPP-A are measured. However, the maternal age, weight, ethnicity etc.
are still included.
Quadruple test
A test of levels of dimeric inhibin A (DIA) is sometimes added to the other three tests, under
the name "quadruple test." Other names used include "quad test", "quad screen", or "tetra
screen." Inhibin A will be found high in cases of trisomy 21 and low in cases of trisomy 18.

Inhibin A Associated conditions

High Trisomy 21 (Down syndrome)

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 Low Trisomy 18 (Edwards syndrome)

Variable Trisomy 13 (Patau syndrome)

 Acetyl choline esterase (AChE)

Amniotic fluid AChE level is elevated in most cases of open neural tube defects. It has got
better diagnostic value than AFP. The presence of ACHE in the amniotic fluid may be tested
in early pregnancy. A sample of amniotic fluid is removed by amniocentesis, and presence of
ACHE can confirm several common types of birth defect, including abdominal wall defects
and neural tube defects. Raised levels (greater than or equal to 4.5 munits/ml) of
acetylcholinesterase (AChE) activity in amniotic fluid at 14--23 weeks of pregnancy were
significantly associated with open fetal neural-tube defects
 Inhibin A
It is a dimeric glycoprotein. It is produced by the corpus luteum and the placenta. Serum level
of inhibin A is raised in women carrying a foetus with Down’s syndrome.

 First trimester screening

( hCG, MSAFP, PAPP-A(Pregnancy associated plasma protein A is a hormone that is
produced by the placenta in pregnancy. It is one of two hormones that are measured during the
12 week combined screening test. Low levels of PAPP-A can be associated with Down's
syndrome. A MoM of 1.00 is average; higher than 1.00 is above average; and lower than 1.00
is below average.) can detect trisomy 21 in 85% with a false positive rate of 5%. When nasal
bone detection is combined together, the detection rates rise to 97%.
 Second trimester screening(15-18 weeks):
Triple test (MSAFP,UE3, Total hCG) and quadruple test (MSAFP,UE3,Total
hCG, inhibin A ) can detect trisomy 21 in 70% and 80% of affected pregnancies respectively.

 Prenatal genetic diagnosis

Can be made directly from foetal tissue obtained by amniocentesis, chorionic villus sampling
(CVS) or by cordocentesis.
Structural chromosomal abnormalities (translocations, inversions, mutations) can be detected
by Fluorescence In Situ Hybridisation (FISH)
Fluorescence in situ hybridization (FISH) is a molecular cytogenetic technique that uses
fluorescent probes that bind to only those parts of the chromosome with a high degree of
sequence complementarity. Often parents of children with a developmental disability want to
know more about their child's conditions before choosing to have another child. These concerns
can be addressed by analysis of the parents' and child's DNA. In cases where the child's
developmental disability is not understood, the cause of it can potentially be determined using
FISH and cytogenetic techniques. Examples of diseases that are diagnosed using FISH include

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Prader-Willi syndrome, Angelman syndrome, 22q13 deletion syndrome, chronic myelogenous
leukemia, acute lymphoblastic leukemia, Cri-du-chat, Velocardiofacial syndrome, and Down
syndrome. FISH on sperm cells is indicated for men with an abnormal somatic or meiotic
karyotype as well as those with oligozoospermia, since approximately 50% of oligozoospermic
men have an increased rate of sperm chromosome abnormalities.[17] The analysis of
chromosomes 21, X, and Y is enough to identify oligozoospermic individuals at risk.
Chromosome specific probes can be used to detect the unknown DNA.

 Amniocentesis
It is invasive procedure. It is performed between 14 and 16 weeks under ultrasonographic
guidance. Amniocentesis is the deliberate puncture of the amniotic fluid sac per abdomen.
Applications
The main use is in diagnosing chromosomal disorders like trisomy 21. Amniotic fluid cells are
cultured and Karyotyping done, which may take up to 3 weeks. Using fluorescent in situ
hybridisation (FISH), reults from chromosomes X, Y, 21, 18 and 13 can be made available
within 48 hours.
Indications
 Diagnostic
Early months (15-20 weeks) antenatal diagnosis of chromosomal and genetic disorders
(genetic amniocentesis):
1. Sex linked disorders
2. Karyotyping
3. Inborn errors of metabolism
4. Neural tube defects
Later months
1. Fetal maturity
2. Degree of fetal haemolysis in Rh sensitised mother: spectrophotometric analysis
of amniotic fluid and deviation bulge of the optical density at 450nm is obtained.
3. Meconium staining of liquor-an evidence of fetal distress.
 Therapeutic
a. First half:
- Induction of abortion by instillation of chemicals such as hypertonic
saline, urea or prostaglandins
- Repeated decompression of the uterus in acute hydramnios.
b. Second half:
- Decompression of uterus in unresponsive cases of chronic hydramnios
producing distress or to stabilise the lie when it is not axial prior to
induction
- To give intrauterine fetal transfusion in severe haemolysis following Rh
isoimmunisation

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 - Amnioinfusion: Infusion of warm normal saline into the amniotic cavity
is done trans abdominally or trans cervically to increase the volume of
amniotic fluid.
Indications of amnioinfusion
Oligohydramnios: to prevent fetal lung hypoplasia, to minimise
umbilical cord compression during labour.
To dilute meconium stained amniotic fluid
Procedure
.
 After emptying the bladder, the patient remains in dorsal position
 After ultrasound to confirm viability, gestational age, placental location and liquor
volume, the skin is cleansed with antiseptic
 The abdominal wall is prepared aseptically and draped
 The proposed site of puncture is infiltrated with 2 ml of 1% lignocaine.
A 20-22 gauze spinal needle about 4” in length is inserted into the amniotic cavity under real
time sonographic control, with the stiletto in. Injury to the placenta, umbilical cord and fetus is
to be avoided. The stiletto is withdrawn and few drops of liquor are discarded. Initial 1-2 ml of
fluid is either used for AFP or is discarded as it is contaminated with maternal cells. Rest is
used for fetal karyotyping. About 30 ml of fluid is collected in a tube for diagnostic purposes.
Fetal cardiac motion is to be seen after the procedure.
Precautions
 Prior sonographic localisation of placenta is desirable to prevent bloody tap and feto
maternal bleeding.
 Prophylactic administration of 100mg of antiD immunoglobulin in Rh negative no
immunised mother.
Hazards are reduced significantly when it is done under direct ultrasound control compared to
the blind procedure.
Hazards
Maternal complications are
 Infection
 Haemorrhage (placental or uterine injury)
 Premature rupture of the membrane and premature labour
 Maternal isoimmunisation in Rh negative cases.
Fetal hazards
 Fetal loss
 Trauma
 Feto maternal haemorrhage
 Olighydramnios due to leakage of amniotic fluid and that may lead to
– Fetal lung hypoplasia

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 - Respiratory distress
- Talipes
Early amniocentesis (11-14 weeks) is less satisfactory as cell culture failure rate is high. Less
fluid withdrawn. Rates of complications are high. Amnifiltration has been used to increase the
cell yield.
Cytogenic analysis
The desquamated fetal cells in the amniotic fluid, obtained by amniocentesis or trophoblast
cells from CVS or fetal blood cells obtained by cordocentesis are cultured, G banded and
examined to make a diagnosis of chromosomal anomalies e.g. trisomy 21, monosomy X and
others
DNA analysis
Single gene disorders can be diagnosed using specific DNA probes. DNA amplification is done
by polymerase chain reaction. The specific chromosomal region containing the mutated gene
can be identified.
Biochemical
Amniotic fluid AFP level is high when the foetus suffers from open neural tube defects. This
is also confirmed by ultrasound scanning. The normal AFP concentration in liquor amnii at the
16th weeks is about 20mg/litre. Amniotic fluid level of 17 hydroxyprogesterone is raised in
congenital adrenal hyperplasia.
Early amniocentesis has been carried out at 12-14 weeks gestation. Amniofiltration has been
used to increase the cell yield.

 Chorionic villus sampling (CVS)

This method has shifted prenatal diagnosis first trimester. CVS enables first trimester diagnosis
of chromosomal abnormalities and single gene defects, thus avoiding late terminations and is
an early source of reassurance to the couple. The chorion frondosum can be sampled
transcervically or transabdominally but the latter is usually preferred. It is done between 10 and
12 weeks under ultrasound guidance to remove a small amount of chorionic tissue. Many
operators prefer transabdominal approach for an anterior placenta and transcervical for a
posterior placenta. A 20 mg sample is ideal for cytogenetic analysis.
It is performed for prenatal diagnosis of genetic disorders. It is carried out transcervically
between 10-12 weeks and trans abdominally from 10 weeks to term. Diagnosis can be obtained
by 24hrs, and such, if termination is considered, it can be dome in the first trimester safely. A
few villi are collected from the chorion frondosum under ultrasonic guidance with the help of
a long malleable polyethylene catheter introduced transcervically along the extra ovular space.
While it provides earlier diagnosis than amniotic fluid studies, complications like foetal loss
(1-2%), oromandibular limb deformities or vaginal bleeding are higher. False positive results
are there due to placental mosaics and maternal cell contamination. In such a situation,
amniocentesis should be performed to confirm the diagnosis. Limb Reduction Defects (LRD)
are high when CVS was performed at less than 10 weeks of gestation. CVS when performed
between 10 and 12 weeks of gestation are safe and accurate as that of amniocentesis. Anti-D

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immunoglobulin 50 µg IM should be administered following the procedure to an Rh negative
woman.
Applications
Chorionic villi are an extremely good source of fetal DNA and thus ideal for PCR and DNA
analysis to diagnose single gene defects like the haemoglobinopathies, cystic fibrosis and
Duchenne muscular dystrophy. It can be used for rapid karyotyping using FISH but the problem
is due to a 1% chance of placental mosaicism. It 1s usually not due to true mosaicism, but
represents confined placental mosaicism. (In this condition, the fetus and placenta have
differing karyotype and the aneuploidy may be confined to extrafetal tissues while the fetus
has a normal karyotype. This may lead to an error in diagnosis.) In cases where a CVS result
shows mosaicism, an amniocentesis will have to be performed to determine whether the fetus
is affected. It can also be used for biochemical testing to diagnose storage diseases like Tay
Sachs and Gaucher’s disease. Congenital adrenal hyperplasia by biochemical testing and DNA
analysis.
Risk
The fetal loss rate may be about 1%. Transabdominal route is generally associated with less
fetal loss. When CVS is done prior to 10 weeks, severe limb reduction defects and
oromandibular agenesis have been reported. Hence the current recommendation are that CVS
should be done only after 10 weeks by an appropriately trained operator.

PRENATAL DIAGNOSIS : CVS, AMNIOCENTESIS AND CORDOCENTESIS

Chorion villus sampling Amniocentesis Cordocentesis

Time Trans cervical 10-12 14-16 weeks 18-20 weeks
week (early 12-14 weeks)
Trans abdominal 10
weeks to term
Materials Trophoblast cells  Fetal  Fetal white
for study fibroblasts blood cells
 Fluid for (others-
biochemical infection and
study biochemical
study)
Karyotype  Direct  Culture-3-4  Culture-24-48
Results preparation-24-48 weeks hours
hrs
 Culture-10-14
days
Fetal loss 0.5-1% 0.5% 1-2%
Accuracy Accurate; may need Highly accurate Highly accurate
amniocentesis for
confirmation
Termination 1st trimester – safe 2nd trimester – risky 2nd trimester – risky
of

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 pregnancy
when
indicated
Maternal Very little More traumatic; Same as amniocentesis
effects physically and
following psychologically
termination
of
pregnancy

 FETAL BLOOD SAMPLING/ CORDOCENTESIS (Percutaneous umbilical

blood sampling)
This is also called cordocentesis and involves percutaneous cord blood sampling with a fine
needle under ultrasound guidance. The common site is the umbilical vein at the placental cord
insertion. It is usually done at or after 20 weeks.
Indication
The main present day indication is in the assessment and treatment of Rh and platelet
isoimmunisation and to perform intravascular transfusion simultaneously. It may be useful
when rapid Karyotyping is needed and FISH is not available. It is also useful for diagnosis of
haemoglobinopathies and other genetic disorders and for diagnosing fetal infection. Now with
the advent of PCR. DNA analysis of tissue obtained by CVS or amniocentesis is replacing FBS
for the diagnosisnof single gene defects. Hence, the indication for FBS are declining though it
is still the gold standard in the diagnosis and treatment of isoimmunisation.
A 22 gauze spinal needle 13 cm. in length is inserted through the maternal abdominal and
uterine wall under real time ultrasound guidance using curvilinear probe. The needle tips
progressed carefully and it puncture the umbilical vein approximately 1-2 centimetre from the
placental insertion. Generally 0.5 to 2ml. of fetal blood is collected. It is performed under local
anaesthetic usually from18 weeks gestation.
Risks
This invasive procedure may lead to abortion, preterm labour and intrauterine fetal death. These
may be due to bleeding, cord hematoma formation, infection (amnionitis), feto-maternal
haemorrhage or preterm rupture of membranes. Overall fetal loss is 1-4%. Anti D
immunoglobulin 100 µg IM should be given to Rh negative, yet unimmunised women.
All the information is obtained is amniocentesis or chorion villus sampling, could be gathered.
Additional values are mentioned below
Haematological - for fetal anaemia, bleeding disorder (autoimmune thrombocytopenia)
comma Rhesus disease and hemoglobinopathies
Fetal infections - toxoplasmosis, viral infections
Fetal blood gas and acid base status - in fetal growth restriction
Fetal therapy - blood transfusion, drug therapy

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  FETOSCOPY
Small fibreoptic scopes can be introduced into the amniotic cavity under ultrasound guidance
and tissue biopsies performed. Examples are liver and muscle biopsy. Skin biopsy has been
done for some skin conditions. These are not done today as many of the responsible gene has
been identified making PCR for DNA analysis possible.
2. BIOPHYSICAL
Ultrasonographic examination of the fetus in the early pregnancy can detect (10-14 weeks)
fetal anomalies. Crown Rump length (CRL) smaller than the gestational age is associated with
the risk of chromosomal anomalies (trisomy or triploidy). Increased nuchal translucency (NT)
at10-14 weeks is associated with many chromosomal abnormalities (trisomy, monosomy,
triploidy). Detection rate is about 70-80% with a false positive rate of 5-6%. Absence of nasal
bone (NB) on USG at 10-12 weeks is associated with fetal Down syndrome. When NB and
NT where combined detection rate of trisomy 21 was 92 percentage with a false positive rate
of 3.5 %

ANTEPARTUM FETAL SURVEILLANCE (LATE PREGNANCY)

It is important in pregnancies at high risk for fetal compromise such as those complicated by
intrauterine growth restriction, preeclampsia, diabetes and post term pregnancies. The goal are
prevention of fetal death and avoidance of unnecessary interventions.
Objectives are
 Prevention of fetal death and
 Avoidance of unnecessary interventions
Methods
 Clinical
 Biochemical
 Biophysica
Biochemical methods
Done mainly for assessment of pulmonary maturity
Biophysical
Principle
Biophysical profile is a screening test for utero-placental insufficiency. The fetal biophysical
activities are initiated modulated and regulated through fetal nervous system. The fetal CNS
is very much sensitive to diminished oxygenation.
Hypoxia metabolic acidosis CNS depressionchanges in fetal biophysical activity
The following bio physical test are used
 Fetal movement count
 Cardiotocography
 Non stress test( NST)
 Fetal biophysical profile(BPP)
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  Doppler ultrasound
 Vibroacuostic stimulation test
 Contraction stress test( CST)
 Amniotic fluid volume

FETAL MOVEMENT COUNT

It is an established practice to enquire regarding fetal movements in late pregnancy as a
measure of fetal well-being. Reduction and cessation of movements may precede fetal death
by a day or two.
 Cardif ‘Count 10’ Formula
The patient count fetal movement starting at 9:00 a.m. The counting comes to an end as soon
as 10 movement are perceived. She is instructed to report the physician if
I. less than 10 movement occur during 12 hours on two successive days or
II. no movement is perceived even after 10 hours in a single day

 Daily Fetal Movement Count( DFMC)

3 count each of one hour duration (morning, noon and evening) are recommended. The total
count multiplied by 4 gives daily (12 hour) fetal movement count (DFMC) is there is
diminution of the numbers of ‘kicks’ to less than 12 hours(less than 3 in each hour), it indicate
compromise.
 Mothers perceives 88% of the fetal movements detected by Doppler Imaging. The count
should be performed daily starting at 28 weeks of pregnancy.
Loss of fetal movements is commonly followed by disappearance of FHR within next 24 hours.
In either of the above methods, if the results is omnious, the candidate is subjected to NST.
Maternal perception of fetal movements may be reduced with fetal sleep (quiet), fetal
anomalies (CNS), anterior placenta, hydramnios, obesity, drugs (narcotics), chronic smoking
and hypoxia.

NON STRESS TEST (NST)

Nonstress testing by cardiotocography is currently the most commonly used method of
assessing fetal wellbeing. It has also been incorporated into the biophysical profile. It utilises
the physical principle of the Doppler Effect in which sound waves hitting a
moving object are reflected back at an altered frequency. In the nonstress test, the woman is
made comfortable either in a left lateral or semi-recumbent position to avoid supine
hypotension. An exter rnal ultrasound transducer for recording fetal heart rate and
tocodynamometer for recording uterine activity are attached to the mother’s abdomen. The
recording is carried out for a period of 20-60 min depending on the pattern obtained. External
stimulation with palpation can be done if the test remains nonreactive. The test is based on the
hypothesis that the heart rate of a fetus which is not acidotic due to hypoxia, will accelerate in
response to fetal movement. The baseline fetal heart rate, beat to beat variability, presence or
absence of accelerations in response to movement and presence or absence of decelerations is
looked for.

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In non-stress test, a continuous electronic monitoring of the fetal heart rate along with recording
of fetal movements (cardiotocography) is undertaken. There is an observed association of FHR
acceleration with fetal movements, which when present, indicates a healthy fetus. It can
reliably be used as a screening test. The accelerations of the FHR associated with fetal
movements are presumably reflex mediated.it should be emphasised that the test is valuable to
identify the fetal wellness rather than illness.
Interpretation
 Reactive (reassuring)
When two or more accelerations of more than 15 beats per minute above the baseline and
longer than 15 seconds in duration are present in a 20 minute observation.
A reactive NST is defined as the presence of two or more fetal heart rate accelerations during
a 20 min period, with each acceleration of 15 beats or more per min and lasting 15 or more sec,
usually occurring simultaneously with fetal movement. Accelerations without fetal movements
are also accepted and the tracing is extended to 40 min or more before concluding that the test
is nonreactive. As sleep periods in fetuses may last for up to 75 min, some investigators
recommend a longer period of even up to 2 hours of testing, before concluding that the fetus is
nonreactive.
 Non-reactive (non reassuring)
Absence of any foetal reactivity.
A nonreactive NST is usually associated with fetal hypoxia. Other causes are sleep periods in
the fetus and gestational age less than 28 weeks. A non NST should be seriously and action
taken. Usually, a reactive NST is reassuring for at least 7 days. Exceptions are acute insults
like abruption and cord prolapse, in which cases false normal results might have been obtained.
Variable decelerations if nonrepetitive and brief are not significant. But repetitive or prolonged
variable decelerations are considered abnormal.
A reactive NST is associated with perinatal death of about 5 per 1000. But perinatal death is
about 40 per 1000 is when the NST is nonreactive. Testing should be started after 30 weeks
and frequency should be twice weekly. The test has a false negative rate of 0.5% and false
positive rate of 50%.

VIBROACUOSTIC STIMULATION TEST

It is used to change the foetal sleep state from quiet (non REM) to active (REM) sleep. A
reactive NST after VAS indicates a reactive foetus. The procedure is harmless. An acoustic
stimulator is placed on the maternal abdomen and a stimulus applied for 1-2 second. The basis
is that the external sound may stimulate the fetus provoking fetal heart rate acceleration in cases
thought to be nonreactive. This is termed the startle response. An added advantage is that the
average time for NST can be shortened. Only 2% of NST’s are nonreactive to VAST.

14
 Biophysical profile scoring (Manning-1992)
Observations for 30 minutes
Normal score = 2 Abnormal=0
Parameters Minimal normal criteria Score
 Non stress test(NST) Reactive pattern 2

 Fetal breathing movements ≥1 episode lasting 2

>30 sec

 Gross body movements ≥3 discrete body/ limb movements 2

 Fetal muscle tone ≥1 episode of extension (limb or trunk) with 2

return of flexion.

 Amniotic fluid ≥1 pocket measuring 2 cm in two 2

perpendicular planes (2x2cm pocket)
BPP SCORING, INTERPRETATION AND MANAGEMENT
BPP Interpretation Management
score
8-10 No fetal asphyxia Repeat testing at weekly interval or more

If > 36 weeks  deliver; but if L/S <2.0 repeat test

6 Suspect Chronic asphyxia in 4-6 hrs.

If ≥36 weeks deliver; if <32 weeks repeat testing in
4-6 hrs.
4 Suspect Chronic asphyxia
Test for 120 min. persistent score ≤ 4 deliver
regardless of gestational age.
0-2 Strongly suspect asphyxia

FETAL BIOPHYSICAL PROFILE (BPP)

Considerssw2 several parameters. BPP using real time ultrasonography has a high predictive
value.
Indication
 Nonreactive stress NST
 High risk pregnancy
Test frequency weekly after a normal NST, and twice weekly after an abnormal test.

15
 Component Score2 Score3
Non stress test At least 2 accelerations of ≥15 bpm for ≥ 15 0 or 1 acceleration
sec
Fetal breathing At least 1 episode of FBM lasting ≥ 30 min <30 sec of FBM
movements
Fetal movement At least 3 discrete body or limb movement. <3 discrete movements
Fetal tone At least 1 episode of extension of a fetal No movement or no
extremity with return to flexion or opening or extension/ flexion
closing of hand
Amniotic fluid Single deepest pocket 2 cm or more single deepest pocket
volume <2 cm

Modified biophysical profile

This was devised because the biophysical profile is time consuming and needs special
ultrasound expertise. This is a combination of NST and amniotic fluid volume. The first is
indicative of acute fetal hypoxia and the second of chronic fetal hypoxia. It is today accepted
as one of the best available method of antepartum fetal surveillance and eliminates the
disadvantages of the biophysical profile. It is especially useful in cases of IUGR with abnormal
Doppler to decide on timing of delivery. If it is abnormal, then the other components of the
biophysical profile should be looked for. It consist of NST and ultrasonographically determined
amniotic fluid index (AFI). Modified BPP is considered abnormal (nonreassuring) when the
NST is non-reactive and /or the AFI is <5

FETAL CARDIOTOCOGRAPHY
A normal tracing after 32 weeks, would show base line heart rate of 110 -150 beats per minute
(bpm) with an amplitude of base line variability 5-25 bpm. There should be no deceleration or
there may be early deceleration of very short duration. Importantly there should be two or more
acceleration during a 20- minute period.

ULTRASONOGRAPHY
IUGR can be diagnosed accurately with serial measurement of BPD, AC, HC, FL and amniotic
fluid volume.AC is the single measurement which best reflects fetal nutrition. The average
increase of biparietal diameter beyond 34 weeks is 1.7 mm per week. When the HC/AC ratio
is elevated (>1.0) after 34 weeks, IUGR is suspected. Only with the development of ultrasound
was a non-invasive, direct in utero visualization of the fetus possible.
Ultrasound has provided obstetric healthcare providers a technique to delineate accurately
normal and abnormal fetal anatomy with considerable detail. Fetal parts can be measured for
growth and determination of gestational age. Heart motion can be seen and cardiac structure
and function assessed. Fetal body and eye movements, breathing, sucking, swallowing, and
urination are easily visualized with sonography. Ultrasound guidance may be used in invasive
diagnostic procedures, such as amniocentesis, chorionic villus sampling, fetal blood sampling,
and even tissue sampling (i.e., biopsies).
Ultrasound is the transmission of low-energy, high- frequency sound waves through a medium,
such as fluid or tissue. The intensity and delay time for reflected echoes are recorded. A
transducer, containing crystals that vibrate in response to an electronic stimulus and produce

16
an electric signal, generates sound waves. As sound is generated, it passes through various
tissues at different speeds based on the density and elasticity of the tissue structure. In general,
the denser the tissue, the higher the velocity of sound transmission. Sound travels through tissue
until it comes to another tissue of a different density, a tissue interface (boundary). The change
in density results in a small proportion of sound energy being reflected back toward the
transducer. The echoes are received by the transducer crystals, converted into electric signals,
and displayed on a monitor.
Ultrasonic information can be displayed in a variety of ways. Real-time B-scan is the mainstay
of obstetric ultrasonic imaging. Dots on a monitor produced by electronic signals display
motion-picture-like, two-dimensional (2D) sectional images. The brightness of the dots reflects
the strength of the signal. The differences among these signals indicate anatomic structures:
 Black areas that are completely devoid of echoes frequently relate to fluid areas, such
as amniotic fluid. These regions are called anechoic.
 Bright white areas are generated by strong reflectors such as bone tissue.
 Gray areas are generated by small echoes arising from tissues of intermediate density,
such as cardiac, renal, or brain tissue.
Currently, state-of-the-art equipment displays signal strengths in 128 shades of gray, and
prototype methods are available for color conversion of these images. Real-time scanning also
provides a method of visualizing fetal heart activity, fetal behavior, and fetal bladder and
stomach filling and emptying.
Another display of information used in obstetric ultrasound is M-mode, which yields lines that
depict movement of anatomic structures versus time. M-mode provides valuable information
about cardiac structure and dynamic changes occurring in the fetal heart.
Finally, Doppler ultrasound analyses data on the frequencies of returning echoes to determine
the velocity of moving structures. The primary use of Doppler ultrasound in obstetrics has been
to detect and measure blood flow in the uterine arteries and fetal umbilical, carotid, and
intracranial vessels.
Three-Dimensional Ultrasound
Traditional 2D real-time ultrasound provides easily visualized and accurate images of normal
fetal anatomy and pathologic findings. 2D sonography, however, provides only a linear (length
and width) observation of fetal structures. These images may be confusing and difficult to
construe because they must be interpreted to form a three-dimensional (3D) impression of the
anatomic structures represented (Hamper et al., 1994). For several years, clinicians have been
investigating the use of 3D sonography to visualize the fetus. In this three continual different
planes, representing longitudinal, transverse, and horizontal sections, are displayed
simultaneously. These three planes can be rotated and computer translated to obtain accurate
anatomic sections needed for diagnosis and geometric measurements, such as distances, areas,
and volume (Kuo et al, 1992; Steiner et al, 1994). Thus, 3D sonography may provide new fetal
assessment parameters, such as surface views of fetal organs and the fetal face, fetal organ
volumes, and weight-length correlations (Lee et al, 1994; Pretorius et al., 1995). While
currently being used in tertiary centres only, 3D sonography has the potential to be used in
primary care settings. In this situation, computerized images would be transferred by computer
modem for online assessment by specialists (Pretorius et al.. 1995).
17
M-Mode Echocardiography
Real-time directed M-mode echocardiography supplies information about a single portion of
the linear sector display and plots it over time. The result is a wavy pattern in the presence of
movement. M-mode echocardiography is a useful supplement to cross-sectional (real-time B-
scan) imaging for evaluating myocardial wall thickness, chamber dimension, and valve and
wall motion. The detection of such conditions by M-mode echocardiography allows for
pharmacologic intervention that averts in utero heart failure.

DOPPLER ULTRASOUD VELOCIMETRY

Doppler flow velocity wave forms are obtained from arterial and venous beds in the fetus.
Arterial Doppler waveforms are helpful to assess the downstream vascular resistance. The
arterial Doppler waveform is used to measure the peak systolic(s), peak diastolic (D) and mean
(M) volumes. From these values S/D ratio, pulsatility index (PI) [PI=(S-D)/M)] are calculated.
In a normal pregnancy the S/D ratio, PI and RI decreases as the gestational age advances.
Higher values greater than 2 SDs above the gestational age mean indicates reduced diastolic
velocities and increased placental vascular resistance. These features are at increased risked
risk for adverse pregnancy outcome.
Venous Doppler parameter provide information about cardiac forward function (cardiac
compliance, contractility and afterload). Foetuses with abnormal cardiac function show
pulsatile flow in the umbilical vein (UV). Normal UV flow is monophasic.
Antenatal Doppler Ultrasound And The Suggestive Features Of A Compromised Fetus
Vessel Change Pathophysiological basis Clinical Significance
 Umbilical Reduced or absent or Failure of villous resistance in
artery reversed end trophoblast invasion Feto-placental
(UA) diastolic flow circulationIUGR,
Pre-eclampsia
 Middle  diastolic velocity; Dilatation of cerebral ‘Brain Sparing’
cerebral  S/D or PI vessels effects in response to
artery hypoxemia.
(MCA)
 Ductus Doppler index*; CVP Fetal academia
venosus Absent/ Reversed
(DV) flow(a-wave)
 Umbilical Doppler index; CVP or Fetal academia
vein Pulsatile flow Cardiac compliance
*increased Doppler indices means there is increased vascular flow resistance
Cardiotomography
Cardiotomography is a high-definition ultrasonographic procedure that aims to evaluate the
fetal cardiac structural and functional Parameters and study the effect of maternal diseases such
as diabetes on fetal cardiac condition
Assessment is highly valuable for the following purposes:
 To understand the status of the fetal heart in normal and abnormal conditions
 To plan proper intervention with interdisciplinary team members

18
  To plan for counselling the couples if abnormality is detected
 Plan in service education programme for health care professionals
Cardiotomography is useful in the following:
 Assessing the structures of heart
 Studying the function and cardiac cycle
 Identifying congenital heart disease and cardiovascular malformations
 Detecting valve atresia, stenosis, or dysplasia
 Identifying atrioventricular septal defects
 Any other cardiac abnormalities
Thus cardiotomography has an important role in studying the fetal cardiovascular system.
Uses of Diagnostic Ultrasound in Obstetrics
Ultrasonogram is used for diagnosing both normal and abnormal conditions in obstetrics.
 Normal conditions
Early stage of pregnancy
- Visualization of gestational sac: 2-2% weeks of pregnancy
- Yolk sac: 5 weeks of gestation
- Measuring the size of embryo: 5% weeks
- Observation of heart beat: 6-7 weeks
- Crown rump length: 7-13 weeks
- Diagnosing fetal growth and determination of fetal age: Biparietal diameter of
fetal head, head circumference, crown-heel length, and length of femur can be
measured after 13 weeks
Later stage of pregnancy
- Presence of living fetus: Single tone or multiple fetuses
- Estimation of gestational age
- Position of fetus
- Position of placenta
- Amount of amniotic fluid
 Abnormal conditions
- Miscarriage as early as 6-7 weeks of pregnancy
- Detection of congenital anomalies: Down syndrome
- Ovarian tumours
- Ectopic pregnancy
- Suspected hydatidiform mole
- Abruptio placenta
- Intrauterine growth restriction
Although it is widely believed among medical practitioners that ultrasonography is safe and
beneficial, research continues to eliminate unwanted reactions and ensure the well-being of the
woman and the fetus. Additional research that increases awareness of potential risk factors or

19
lack thereof and improved technology that lessens the frequency of exposure to ultrasound will
be instrumental in this pursuit (Sabbagha, 1994).
The Ultrasound Examination
Ultrasound examinations may take one of the three forms: the basic examination, the targeted
examination, and the limited examination (American College of Obstetricians and
Gynaecologists, 1993). Every client who undergoes ultrasound assessment should have a basic
examination that includes the following:
 Determination of fetal number
 Presentation
 Documentation of fetal life
 Placental location
 Amniotic fluid volume
 Gestational dating
 Detection and evaluation of maternal pelvic masses
 Survey of fetal anatomy for gross malformation
This examination is adequate for most obstetric clients and takes an average of 20 minutes.
However, a client who has a fetus with a known or suspected defect should be sent for a targeted
examination (i.e., an examination that is performed by a sonographer who has more expertise
in sophisticated scanning techniques). An examination of this type may take up to 40 minutes
to perform. The third type of ultrasound examination, the limited examination, is performed in
situations in which only specific or limited urgent clinical information is required, but it is
unnecessary or impossible to perform a complete fetal anatomic survey. A limited examination
could include the fetal biophysical profile (FBP), amniotic fluid assessment, confirmation of
fetal cardiac activity, fetal number and presentation, and placental localization.
Obstetric ultrasound may be performed by two techniques: Trans abdominal scanning or Trans
vaginal scanning. Trans abdominal scanning is the more traditional method and can be used
throughout all trimesters of pregnancy regardless of the size of the pregnant uterus. In a first
trimester pregnancy, a filled bladder is required for the examination because most pelvic
structures are located behind gas filled loops of bowel. An ultrasound beam is unable to
penetrate gas; water, however, is an excellent transmission medium. Bladder distention
displaces the bowel out of the pelvis, lift the uterus from to the pelvic structure. Bladder filling
is usually unnecessary for the second and third trimester scans, because there normally is
sufficient amniotic fluid to serve as an acoustic window, and the expanded uterus pushes the
intestine out of the way. One of the expectations to this is when a client is undergoing
sonographic examination for placental localization.

20
Preparing a Client for a Trans Abdominal Ultrasound Scan
Procedure Rationale
1. In the first trimester of pregnancy, the Having the client drink water will distend
woman should be instructed to drink her bladder. Bladder distention displaces
four 8-oz glasses of water 2 h prior to the bowel out of the pelvis, lifts the uterus
the examination and not to void. This is from behind the symphysis, and provides
not necessary for second and third an acoustic window, enabling optimal
trimester pregnancies. imaging of the fetus. During the second and
third trimesters of pregnancy, amniotic
fluid serves as an acoustic window, while
the gravid uterus displaces the bowel.
2. A special gown is not needed foe the As long as the client’s abdomen can be
procedure. On arrival for a trans adequately exposed with her own clothing,
abdominal scan, the client may remain she does not need to change into gown.
in her own clothing
3. The client should be instructed to lie Exposure of the abdomen from the costal
supine on the examining table and margin to the symphysis will provide a
either lift or lower her clothing to complete area for fetal visualization.
expose her abdomen from the costal
margin on to the symphysis
4. From approximately 20 weeks Lying supine can result in hypotension
gestation on, the client should be resulting from compression of the vena
observed for symptoms of supine cava by the enlarged uterus which also
hypotension. These symptoms include reduces uteroplacental and renal perfusion.
sudden onset of faintness, dizziness, Turning the client to her left side will
nausea, ringing in the ears, and alleviate the compression and increase
numbing of the extremities. Immediate blood flow
treatment of this phenomenon involves
turning the client on her left side.
5. After the client is comfortably situated Coupling gel eliminate the air interface
on the examining table coupling gel is between the ultrasound transducer and the
generously applied to the abdomen. A client’s skin, there by providing a better
towel or sheet should be provided to the transmission and reception of the
client to protect her clothing. ultrasound waves. Even though the gel is
Ultrasound gel is notoriously cold, and usually water soluble and does not stain, it
gel warmers can be used to ease client can leave a temporary mark on clothing
discomfort. until the gel dries.

Transvaginal ultrasound scanning consist of placing an elongated ultrasound transducer within

the vagina to visualise the pelvic structures. One of the advantages of transvaginal ultrasound
over abdominal scanning is that no acoustic window is required for transvaginal scanning.
Clients, therefore, do not have to fill their bladders and may find this technique more
comfortable. A second advantage is that the transvaginal probe is closer to the pelvic structures
than the abdominal transducer, allowing these structures to be visualized more clearly (Rebar,
1988). This technique is especially useful in obese women, women with abdominal wall
scarring, or clients who display interfering bowel gas. Obstetric indications for transvaginal
scanning include documentation of early intrauterine pregnancy, identification of early ectopic
pregnancy, assessment of embryonic development and detection of anomalies, and cervical

21
incompetence (Berman, 1991). Transvaginal ultrasound has limited use in fetal anatomic
visualization and biometrics after 16 weeks’ postmenstrual age, being used primarily to
evaluate the presenting fetal part in middle to late pregnancy (Procedure 12-2).
Important to any ultrasound examination is documentation of the study. A written report of the
ultrasound findings should be included in the client's medical record. The report should contain
any measurements made and the anatomic findings observed during the examination. A
permanent record of ultrasound images obtained during the examination should be added to
the client's record. Various recording devices can produce a record of an ultrasound
examination. A multiformat camera uses X-ray film, which requires developing. Nine images
can be recorded on a single sheet of film. Instant-film cameras, such as a Polaroid, are a
common method of recording images. The major disadvantage of this method is the expense
of the film; the cost per picture is often just under a dollar. A popular method of recording
images is a video image recorder. This device records images on a sheet of thermal paper,
resulting in a good-quality picture at a relatively inexpensive cost (ie, less than 10 cents per
picture). Dynamic imaging as obtained by real-time ultrasound can be saved on a video
recorder. The value of this device is that complete ultrasound examinations can be recorded
and referred to another physician for a second opinion. Lastly, ultrasound images can be saved
on computer disks, allowing approximately 10 images per disk. The major disadvantage of this
method is that it is time consuming. Whatever method is used for recording an ultrasound
examination, the images should be labelled with the client’s name and the date of the
examination.
Procedure Rationale
1. No pre-examination preparation is involved No acoustic window is required for a
in transvaginal scanning transvaginal scan because the
transducer is in direct contact with
the pelvic organs.

2. Upon arrival for the examination, the client is The sonographer must have access to
asked to remove any clothing below the the vagina.
waist.
3. The client should be placed in a lithotomy Elevating the client's hips will
position, or a pillow may be placed under her provide better imaging of higher
buttocks to raise the pelvic area. pelvic structures

Coupling gel will eliminate the air

4. A transducer sheath or a condom partially interface between the transducer and
filled with coupling |gel is placed over the the client's skin. Lubricant applied to
vaginal transducer. A lubricant can be placed the transducer will facilitate gentle
over the outside of the transducer sheath for insertion of the transducer without
ease of insertion client discomfort

5. The transducer is then inserted through the A female chaperon should be present
introitus and into the midvagina. Although as with any pelvic examination
clinics follow varying practices, it is
recommended that a female chaperon be
present when the transvaginal scan is
performed.

22
 6. At the end of the examination, the condom is Disinfectant is used to eliminate the
removed, and the transducer is cleaned with spread of any possible infection
Cidex or some other disinfectant (Berman,
1991).

Clinical Applications of Ultrasound

Detection of Early Intrauterine Pregnancy ultrasound in the first 11 postmenstrual weeks
can have a significant role in the diagnosis of early intrauterine pregnancy and embryonic life.
In a normal pregnancy, the gestational sac can routinely be detected with transvaginal
ultrasound between 4 and 5 postmenstrual weeks (de Crespigny et al., 1988). The mean sac
diameter should be measured; in a normally developing pregnancy, the sac should be 5 mm at
5 weeks (Nyberg et al, 1985). The accuracy of the mean sac diameter for dating purposes is +/-
2 weeks (Du Bose, 1991). During the middle of the fifth postmenstrual week. The embryo
measures between 2 and 5mm. After postmenstrual weeks, heart pulsation can be detect with
vaginal ultrasound, whereas abdominal sound may detect heart motion between 7 and 8 weeks.
By the end of the ninth week of development, the embryonic head, body, and extremities can
clearly be identified with either abdominal or vaginal ultrasound, and fetal movements are
clearly recognizable. Deviation from normally identified sonographic signs could indicate
complications of early pregnancy, such as blighted ovum, incomplete or complete abortion, or
an embryonic pregnancy (Fleischer et al, 1991).
Fetal Measurements Sonographic measurement of the fetus is important in determining the
gestational age of the fetus, evaluating fetal growth to identify IUGR, and detecting congenital
malformations. During the ultrasound examination, measurements are made with electronic
calipers as the sonographer identifies the desired fetal part.
Crown-to-Rump Length: The crown-to-rump length (CRL) is the longest demonstrable
length of the embryo or fetus, excluding the limbs and yolk sac (Robinson et al, 1975). The
CRL is considered one of the most accurate indicators of fetal age due to the excellent
correlation between length and age in early pregnancy when growth is rapid and minimally
affected by pathologic disorders. At about 9 week gestation, extension and development of the
head and regression of the tail occur. Coupled with the fetus assuming its natural curvature,
this is an appropriate time to make an accurate CRL measurement (Goldstein et al, 1994).
Therefore, it has been argued that CRL measurements may be inappropriate before 7 weeks
gestation (Harrington et al, 1993). The CRL can be used reliably until 12 weeks’ gestation,
after which a linear measurement of the fetus is difficult because of increasing flexion and
extension of the fetal trunk. For purposes of dating, the accuracy of the CRL is +3 days from 7
to 10 weeks’ gestation and +5 days between 10 and 14 weeks (Jeanty, 1991).
Measurements of the Fetal Head: The biparietal diameter (BPD) is the maximum distance
between the two fetal parietal bones. It is one of the most widely used measurements in
obstetric ultrasound because it is easy to obtain, has 2 distinctive appearance, and provides a
relatively accurate measurement (Fleischer et al, 1991). The BPD is used ir determining
gestational age and fetal weight and diagnosing anomalies, such as microcephaly and
hydrocephaly. The measurement is taken at the widest portion of the fetal skull with the
thalamic positioned midline (Hadlock et al., 1982). The BPD can be measured as carly as 9-10

23
weeks’ gestation when the head can be differentiated from the rump; however, at this time, the
internal anatomy of the head is not consistently visualized. This measurement can be used most
reliably from 12 to 20 weeks when internal structures of the head are routinely identified
(Hearn-Stebbins, 1995). Accuracy of the BPD decreases with increasing gestational age due to
shaping of the fetal head, growth disturbances, and individual variation. At 16 weeks’ gestation,
the BPD has an accuracy of +/-5 to 7 days, whereas at more than 28 weeks’ gestation, the
accuracy is +/-3 weeks.
Cephalic index (CI) is the ratio of the BPD to occipito-frontal diameter. The CI is used to
determine if the shape of the fetal head is normal. During the course of pregnancy, pressure
from the maternal parts, such as the ribs, pelvic bones, or tumours, can result in an abnormal
shaping of the fetal head. The fetal head can become dolichocephalic (flattened and elongated)
or brachycephalic (short and widened). If these conditions occur, the BPD should not be used
to determine gestational age. In normal conditions, the CI ranges between 0.74 and 0.83 (+/-1
standard deviation) and should remain constant throughout pregnancy (Sabbagha, 1994).
Head circumference (HC) in the fetus can be computed from measurements of the BPD and
the occipito-frontal diameter
(OFD) = (BPD + OFD) X 1.57
They also can be directly measured with a digitizer, map reader, or the assistance of computer
software installed in state-of-the-art ultrasound equipment. The HC is not affected by an
abnormal head shape as is the BPD therefore, it can be used to determine gestational age. It is
also used in the diagnosis of IUGR and various anomalies such as microcephaly.
Measurement of fetal body: abnormal circumference (AC) is used as a parameter in the
diagnosis of IUGR. It is an estimation of the size of the fetus at the level liver and the left portal
vein. The measurement of abdomen is taken at this location because the o fetal liver will be
most severely affected in growth retarded foetuses. The AC also reflects subcutaneous fat
which has been influence on fetal weight. The AC is also used in the determination of
gestational age.AC can be used from 16 weeks gestation to term; however, optimal use is at 34
weeks (+/-1week; Hearn-Stebbins, 1995). As in HC, the AC can be measured mechanically,
electronically, or computationally:
AC = (Transverse diameter of the abdomen + antero-posterior diameter) X 1.57
The AC measurement should be reinforced with other methods of measurement.
Measurement of the Fetal Extremities: Fetal long bones are good indicators of fetal growth
because the bones are not subject to changes in shape due to pressure or position. Although all
long bones of the fetus can be identified and measured with real-time ultrasound, the femur
length (FL) is the most widely used parameter. The fetal femur is the largest, easiest to identify,
and least movable of the long bones of the fetal body. It is also one of the most reproducibly
measured structures obtained in obstetric ultrasound. Fl. is used as a parameter in determining
gestational age and is considered to be as accurate as the BPD by some investigators (Jeanty et
al, 1984b; Wolfson et al, 1986). It is also used in the diagnosis of skeletal dysplasias. The femur
is measured from the origin to the distal end of the shaft and can be obtained as early as 10
weeks gestation.

24
Determination of Fetal Age Although it is customary to use Naegele’s rule to determine the
period of gestation and estimated date of confinement from the first day of the last menstrual
period, this method is fraught with error for various reasons. In at least 20% of women,
menstrual age is not a reliable factor in determining gestational age because of a history of
abnormally infrequent menstruation (oligomenorrhea), bleeding in the first trimester, or
becoming pregnant after the use of oral contraceptives or during the postpartum period. In
addition, a significant number of women fail to remember exact dates. In these women, only
70% delivered within +/-2 weeks of their estimated date of confinement (Campbell et al.,
1985). Physical measurements, such as fundal height, are increasingly inaccurate as the woman
approaches term. In the first trimester, a physical examination may predict fetal age to +/-2
weeks; by the third trimester, the fundal height may vary by as much as +4 to 6 weeks (Kurtz
et al, 988). In the case of an uncomplicated pregnancy, not knowing the exact length of
gestation may not represent a serious problem. In the high-risk woman for whom timing of the
delivery is critical, however, the information is vital.
Real-time ultrasound has become the standard for determining gestational age. There are,
however, some constraints on the use of ultrasound as a dating tool. As a rule, the most accurate
sonographic measurements of gestational age are those made early in pregnancy before
individual growth patterns have much effect on the fetus. These individual patterns emerge in
the third trimester of pregnancy and account for the lack of precision in sonographic dating
after 28 weeks’ gestation. Although any published fetal size-age nomograms may be used for
dating purposes, some differences in normal growth patterns may exist owing to environmental
and genetic factors, such as altitude and race. Though these differences may be small in most
instances, nomograms should be developed for each specific population being served.
However, this is not always practical or possible. Therefore, the examiner should select
nomograms that were generated from a population that most closely mirrors the population
being examined.
Other than CRL, 4 single morphometric measurement is not accurate for dating purposes,
especially during the third trimester of pregnancy. An average of sonographically determined
ages of multiple fetal parameters (BPD, HC, AC, and FL) yield a more accurate estimation of

CONTRACTION STRESS TEST (CST)

It is based to observe the response of fetus at risk for utero placental insufficiency in relation
to uterine contractions. This is also termed the oxytocin challenge test. This test is based on the
fact that uteroplacental blood flow decreases markedly during uterine contractions. A normal
fetus can withstand this hypoxic stress without difficulty. But a fetus with chorionic or acute
problems will not be able to tolerate this decrease in oxygen supply and this will result in late
decelerations. Fetal heart rate and uterine contractions are recorded with an external monitor.
If atleast 3 spontaneous contraction of 40 sec or more are present in 10 min, no oxytocin
stimulation is needed. If not, contractions are induced with oxytocin infusions. This test in
many cases gives an indication as to whether the fetus will withstand the stress of labour. The
disadvantage is that it is time consuming, invasive and van rarely cause severe fetal hypoxia.
Therefore it is not much used. A negative test shows no late decelerations or significant variable
decelerations. A positive test is the presence of late decelerations following 50% or more of
the contractions. An equivocal test is the presence of intermittent late decelerations or
significant variable decelerations. A suspicious test is one when inconsistent decelerations are

25
present but not with all contractions. An unsatisfactory test is when there are less than 3
contractions in 10 min or a tracing, which is not interpretable.
NIPPLE STIMULATION TEST
Nipple stimulation in late pregnancy institute a neurohyophyseal reflex resulting in oxytocin
release and uterine contractions. This is the basis of the nipple stimulation test and is cheaper,
less invasive, less harmful and less time consuming than the oxytocin CST. The woman is
asked to rub one nipple through her clothing for 2 min or until a contraction begins.

AMNIOTIC FLUID VOLUME

Amniotic fluid volume is primarily dependent upon the fetal urine, output, pulmonary fluid
production and fetal swallowing. Decreasing AFV may be the result of fetal hypoxia and
placental insufficiency. A vertical pocket of amniotic fluid ≥2 cm is considered normal.
Amniotic fluid index (AFI) is the sum of vertical pocket from four quadrant of uterine cavity.
AFI ≤5 is associated with increased risk of perinatal mortality and morbidity.
Amniotic fluid index (AFI)
AFI is calculated by dividing the uterus into four quadrants and measuring the largest cord free
vertical pocket of liquor in each of the four quadrants. The sum of the four measurements is
the AFI in cm. A range of 5-24 is considered normal. Less than 5 is considered significant
oligohydramnios.
Single deepest pocket (SDP)
SDP is the depth of a single cord free pocket of amniotic fluid. The normal range is 2-8 cm. o
Over 8cm is considered polyhydramnios. Less than 2cm is considered as oligohydramnios.

OTHER INVESTIGATIONS IN LATE PREGNANCY

Amniocentesis in late pregnancy
 Test for fetal pulmonary maturity
 Assessment of severity of Rh iso-immunization
Pulmonary maturity: confirmation of lungs maturation reduced the incidence of respiratory
distress syndrome (RDS) in the new-born. The risk of RDS is high for infants that are delivered
preterm. RDS is caused by the deficiency of pulmonary surfactant which is synthesised by the
type 2 alveolar cells. Surfactant is packaged in lamellar bodies discharged in the lung alveoli
 carried in the pulmonary fluid carried into the amniotic fluid.
Assessment of fetal pulmonary maturity
1) Estimation of pulmonary surfactant by Lecithin/Sphingomyelin (L/S) ratio. Amniotic
fluid L/S ratio at 31-32 weeks is 1; at 35 weeks L/S ratio is 2. L/S ratio ≥2 indicates
pulmonary maturity
2) Shake test or Bubble test (Clement’s): This is useful bed side test, rapidly performed
with a fair degree of accuracy. The test is based on the ability of pulmonary surfactant
to form a foam or bubble, on shaking which remains stable for at least 15 minutes.
Increasing dilutions of amniotic fluid are mixed with 96 % ethanol, shaken for 15
second s and inspected after 15 minutes for the presence of a complete ring of bubbled

26
 at the meniscus. If it is present, the test is positive and indicates maturity of the fetal
lungs.
3) Foam stability index (FSI) is based on surfactant detection by shake test. FSI is
calculated by utilising serial dilutions of amniotic fluid to quantitate the amount of
surfactant present. FSI > 47 virtually excludes the risk of RDS.
4) Presence of phosphatidyl glycerol (PG) in amniotic fluid reliably indicates lung
maturation.PG is tested by thin layer chromatography similar to L: S measurement.
5) Saturated phosphatidyl choline ≥500ng/ml indicates pulmonary maturity.
6) Fluorescence polarisation: This test utilises polarised light to quantitate surfactant in
the amniotic fluid. The ratio of surfactant to albumin is measured by an automatic
analyser. Presence of 55mg of surfactant per gram of albumin indicates fetal lung
maturity.
7) Amniotic fluid optical density at 650 µg greater than 0.15 indicates lung maturity.
8) Lamellar body is the storage form of surfactant in the amniotic fluid. They can be
counted as the size is same as that of platelets. A lamellar body count > 30,000/µl
indicates pulmonary maturity.
9) Orange coloured cells- desquamated fetal cell obtained from the centrifuged amniotic
fluid are stained with 0.2% Nile blue sulphate. Presence of orange coloured cells > 50%
suggests pulmonary maturity.
10) Amniotic fluid turbidity: During first and second trimesters, amniotic fluid is yellow
and clear. At term it is due to vernix.
Assessment of severity of Rh isoimmunisation is done by amniocentesis for estimation of
bilirubin on the amniotic fluid by spectrophotometric analysis. The optical density difference
at 450 nm gives the prediction of the severity of fetal haemolysis.
SUMMARY : ANTENATAL ASSESSMENT OF FETAL WELL BEING

Fetal surveillance  Cytogenetic study  Absent

In early pregnancy   Biophysical (USG)  congenital malformations 
 Biochemical  Present
 Normalcontinue monitoring
clinical monitoring + DFMCR(from 28 weeks) 
AbnormalNST
 Reactive
  Normal  Repeat test at weekly interval
 Non-Reactivemodified BPP 
Abnormal detailed BPP & Doppler
Velocimetry study

 Management as on BPP score and Doppler study report

CONCLUSION
Approximately 3% of live born infants have a major birth defects. Majority fetal deaths occurs
antenatally. The main goal of antenatal fetal assessment is to avoid fetal death. Clinical
examination of fetal well-being depends on suitable maternal health throughout pregnancy. At
every antenatal visit, the following clinical parameters such as Maternal weight gain, Blood
pressure and Assessment of the size of the uterus and height of the fundus are taken into account

27
for assessment of satisfactory progress of gestation. Biochemical, Biophysical and Cytogenetic
methods are used to antenatal assessment of fetal well-being in early pregnancy. Prevention of
fetal death and avoidance of unnecessary interventions are checked in the late pregnancy.
Biochemical test, Biophysical tests are used for fetal movement count, ultrasonography,
cardiotocography, Doppler ultrasound, vibroacoustic stimulation test etc. Test for fetal
pulmonary maturity and severity of Rh iso-immunization is assessed during the late pregnancy
RESEARCH ABSTRACT
Topic 1: Antenatal fetal wellbeing
Abstract
There is increasing awareness that many stillbirths can be prevented; however, there is no
single optimal antenatal monitoring modality that can reliably confirm fetal wellbeing. Early
identification and appropriate monitoring when risk factors become evident, particularly in
previously ‘low risk’ pregnancies, is imperative. Tests of antenatal wellbeing are tools that aid
a clinician's decision making regarding the need for and the timing of intervention and delivery.
At pre-term gestations, the need for delivery at the appropriate time is particularly important
as inappropriate or early delivery could expose the fetus unnecessarily to complications of
prematurity. Here we review the current evidence and the limitations for widely used methods
of antenatal monitoring including the use of fetal movements, symphysis-fundal height
measurement, cardiotocography, biophysical profile and fetal Doppler assessment.
Topic 2: Changes with time in fetal heart rate variation, movement incidences and
haemodynamics in intrauterine growth retarded fetuses: a longitudinal approach to the
assessment of fetal well being
Abstract
Fetal heart rate (FHR) variation, general movements (FGM), breathing movements (FBM) and
haemodynamics were studied longitudinally in 19 intra-uterine growth retarded fetuses, who
eventually were delivered by caesarean section (CS) because of fetal distress, in order to
determine changes occurring with time. The fetuses were studied for the last 10 days on average
before delivery (range 2–14 days). During this period on average eight 1-h FHR records were
made and three 1-h movement recordings. The FHR pattern was analyzed numerically; the
incidence of FGM and FBM was quantified and expressed as percentage of time. Blood flow
velocity waveforms were measured in the umbilical artery (n = 19) and in the internal carotid
artery (n = 14). In 14 of 19 fetuses abnormal velocity wave forms were present from the
beginning of the study onwards. FHR variation was initially just within or below the norm and
fell further during the last 2 days before CS. FGM and FBM fell below the normal range later
and in a lower rate of occurrence than FHR variation. FGM showed a more or less consistent
fall in time, whereas FBM showed a wide range throughout the period of observation. The
poorest outcome occurred in fetuses with reversed end-diastolic velocities and rapid fall in
FHR variation. It is concluded that with progressive deterioration of the fetal condition
abnormal velocity wave form patterns occur first; FHR variation is reduced subsequently and
FGM and FBM are the last to become abnormal. Assessment of fetal activity may be of help
in fetuses with a marginally reduced FHR variation, in which prolongation of pregnancy is
considered desirable to allow further maturation in utero.

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Topic 3: Fetal movement counting for assessment of fetal wellbeing
Abstract
Not enough evidence on counting the baby's movements in the womb to check for wellbeing.
Mothers can usually feel their babies moving in their wombs from around 16 to 20 weeks.
Babies' activities in the womb can vary considerable, some being very active and some not. A
decrease in a baby's normal pattern of movements may be a sign that the baby is struggling for
some reason and it might be better for the baby to be born early. Hence, it has been suggested
that if the mother counts her babies' movements each day, and there are several ways of doing
this, she may be able to identify a decrease in her baby's normal movement patterns. It is further
suggested that if the mother informs caregivers of this, then the caregivers can do additional
tests and some babies can be prevented from dying before birth. However, sometimes fetal
movement‐counting tests can cause considerable anxiety for women and may not be easy for
some women especially when a mother is busy at work or caring for other small children, so it
is important to assess if these tests are effective in identifying babies in difficulties with time
to intervene. The review of trials found four studies, involving 71,370 women, comparing two
fetal movement counting methods, fetal movement counting and hormonal analysis and the
one that compared routine fetal movement counting with selective fetal movement counting.
The trials identified no advantages but the numbers and the methodological quality of studies
were insufficient to assess stillbirths accurately. Further trials are suggested, and it would be
very important to assess women's anxieties and views in addition to the ability of the counting
to prevent unexplained stillbirths
Topic 4: The association between maternal serum alpha-fetoprotein and preterm birth, small
for gestational age infants, preeclampsia, and placental complications
Low levels of second-trimester maternal serum AFP are associated with a very low risk of
preterm birth, preeclampsia, and placental complications. High levels of serum AFP are
strongly associated with preterm birth, preeclampsia, and placental abnormalities. There is a
modest association between AFP levels (both low and high) and SGA birth.

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