1. Evaluation of fetal growth and fetal well- being
Martyna Stankiewicz

2. Fetal well being
eutrofic fetus-housed in the correct channels in the centile grids , which biophysical parameters are valid

3. historical methods now inapplicable (outdated)
Assessment level of: estriol- daily in the urine collection and in blood as the biochemical hPL (human placental lactogen)- human chorionic somatomammotropin (hCS) capacity PAPPA exponents of hCG (human chorionic gonadotropin) a placenta

4. currently: tests and examination of the biophysical
counting fetal movements: recommended from 28. week of pregnancy (since when obstetric interventions shall be):
-at least 2 periods of fetal activity: 10 express movements per hour during children's activity ( usually very early in the morning or late in the evening)
-evaluation of fetal activity during the day- at least 10 times (applies to people very well sleeping/working)
evaluation of the bottom of the uterus
-measuring the distance from the pubic symphysis to the bottom of the uterus
-ultrasonography:- fetal biometry
-the amount of amniotic fluid
-placenta maturity measurement
-transverse cross section of the cerebellum
-evaluation of fetal activity in ultrasound
-doppler ultrasound

5. Doppler ultrasound in the third trimester- in: umbilical artery
middle cerebral artery
umbilical vein
ductus venosus
coronary vessels ( ascending aorta)

6. Doppler ultrasound in Umbilical artery
the risk of hypoxemia and acidosis fetus inversely proportional to end-diastolic flow in the UA
lack of / reverse of the end- diastolic flow appears, on average, a week before the decompensation of the fetus

7. Doppler in the middle cerebral artery
high resistance flow
low flow in diastole
blood flow in the MCA illustrates the brain oxygenation and the index of PI in the proximal MCA correlates with oxygen depletion

8. MCA

9. Brain sparing effect
lowering pulse rate PI testifies to the fetal hypoxia- brain sparing effect,  which is a fetal adaptive reaction to placental insufficiency.
due to placental insufficiency, the central nervous system is preferentially perfused, which is intended to maintain oxygen supply to the brain as much as possible 
the fetus adapts to placental insufficiency by vasodilatation of the cerebral circulation, which can be detected as a decreased pulsatility index in the cerebral arteries
the indicator of the “brain-sparing effect” is a raised ratio between the umbilical artery pulsatility index and the middle cerebral artery pulsatility index ( called the U/C ratio)
 increased diastolic cerebral flow through the brain in cases of hypoxia.

10. Brain sparing effect
The term “brain-sparing” refers to relative protection of the brain as compared with other organs during fetal development, but this does not guarantee normal development after birth
Most commonly occurs as a response of the fetus on his hypoxia caused the bearing factor

11. Ductus Venosus
is a vessel, that carries oxygen-rich blood from the umbilical vein in such a way as to be able to bypass the liver and provide as much oxygen to the brain and upper half of the body of the fetus
has a beginning on the posterolateral lower surface of liver from a combination of left umbilical vein with the left branch of the portal vein and end up bumping into the inferior vena cava, right by the end of the absorbing left the portal vein.
within the venous system regulatory mechanism works similar to the sphincter, reducing excessive uterine muscle contraction during the venous return.
the specter of blood flow in every heart cycle has two maximums corresponding to the contraction and relaxation of the ventricles and the minimum corresponding to atrial relaxation
the correlation between abnormal flow spectrum in DV and fetal acidosis
evaluation of blood flow is the calculation of the pulse ratio for veins and wave „A” height (atrial contraction), which should not be negative or zero.

12. Doppler in the venous duct (DV)

13. Umbilical vein
in physiological conditions this flow is laminar and steady
at the time of the chest movements of the fetus may appear wavy flow as a variant of the standard
but slightly, wavy angular frequency is a symptom of pathology, which is likely to be indicative of an increased systemic venous pressure, for example, in the course of circulation failure of the fetus
Planck angular frequency is a picture of late-diastolic recurring decrease in blood volume flowing in the umbilical vein
for pulsation is probably responsible return flow in the vein of the lower main during atrial contraction (a symptom of damage to the heart)

14. UA and UV

15. Cardiotocography (CTG)
sometimes known as electronic fetal monitoring
 the most commonly used test for antepartum and intrapartum fetal surveillance in the majority hospitals of developed countries
 records changes in the fetal heart rate and their temporal relationship to uterine contractions

16. Cardiotocography /min – normal fetal cardiac activity > 160/min -tachycardia < 110/min -bradycardia
Fetal tachycardia
Fetal bradycardia
• nervousness
• mother fever
• fetal infection
• embryo/foetal anaemia
• fetal hypoxia
• prematurity
• cigarette smoking
an overactive thyroid gland
• fetal hypoxia • hypotension or shock • mother's umbilical cord compression • Abruption • defects (blocks) of the heart of the fetus • vagus nerve boost • inferior vena cava syndrome

17. Cardiotocography Acceleration Deceleration
transient increased FHR by 15 strokes over 15 ''
appear in conjunction with the movements of the fetus :
• uterine contractions are accompanied by
• the exponent of the welfare of the fetus
periodic lowering of FHR usually arising in connection with the contractions of the uterus
• early (stimulation of n. X during the heads tribulation in the canal )
• late (exponent of placental insufficiency)
• variable (compression of the umbilical cord)

18. Cardiotocography- Non Stress Test (NST)
a simple non-invasive test that can serve as screening tool to detect fetal distress already present or likely to develop and prevent unnecessary delay in intervention
 maternal perception of fetal movements
evaluation of the accompanying acceleration movements of the fetus
 provides direct and valuable information about neurological and myocardial function of the fetus
reactive (in 30 min record at least two acceleration)
non- reactive (no acceleration during 60 min)

19. Oxytocin challenge/ contraction stress test (OCT)
The purpose: to assess the fetal heart rate response to contractions
The results may be used to aid the decision making proces regarding mode and timing of delivery
Indications: this may include, patients with high risk pregnancies (presence of disease state in mother or fetus) or previous testing that may have indicated compromised fetal status
Interpretation : is based on the presence or absence of late decelerations, defined as decelerations that start after the nadir of the contraction and persist beyond the end of the contraction
Initial Vital Signs are assessed and the external monitor is applied - a continuous FHR tracing must be maintained for the duration of the test
Fetal heart rate baseline and current level of uterine activity must be established prior
to the initiation of the Oxytocin infusion
If current uterine activity consists of three contractions of at least forty seconds duration
occurring within a ten minute period, the fetal heart rate response to these contractions will be evaluated
the test is complete if the level of uterine activity does not meet the above criteria Oxytocin
will be given to stimulate or increase uterine contractions

20. Oxytocin challenge/contraction stress test (OCT)
The OCT will be interpreted using the following criteria:
NEGATIVE: no late or significant variable decelerations
POSITIVE: late decelerations following 50% or more of contractions (even if contractions are fewer than three in 10 minute window)
EQUIVOCAL- SUSPICIOUS: intermittent late decelerations or significant variable decelerations- requires repeat testing on following day
EQUIVOCAL- HYPERSTIMULATORY :fetal heart rate decelerations that occur in the presence of contraction more frequent than every two minutes or contractions that last longer than 90 seconds- requires repeat testing on following day.[1]
UNSATISFACTORY: fewer than three contractions in 10 minute window
or an uninterpretable tracing (quality of the tracing renders interpretation impossible)- requires repeat testing on following day
 A positive CST indicates high risk of fetal death due to hypoxia and is a contraindication to labour- usually consider operative delivery in such situations

21. Oxytocin challenge/ contraction stress test (OCT)
Is a method being used to evaluate utero-placental respiratory function before labor
Is done by recording fetal heart rate and uterine contractions on a strip chart by means of a suitable external fetal monitor
the FHR response of late deceleration suggest s utero-placental respiratory insufficiency
Uterine contractions are known to interfere with uterine blood flow and are used in this test to provide an intermittant hypoxic stress to the fetus
The test gives rapid information about fetal well- being
Has not been asssociated with an increased incidence of premature labour

22. OCT

23. Fetal biophysical profile (BPP)
 a prenatal ultrasound evaluation of fetal  well-being involving a scoring system, with the score being termed Manning's score
 has 5 components: 4 ultrasound(US) assessments and a nonstress test(NST)
The five discrete biophysical variables:
Fetal movement
Fetal tone
Fetal breathing
Amniotic fluid volume
Fetal Heart Rate

24. Biophysical profile (BPP)
Each assessment is graded either 0 or 2 points, and then added up to yield a number between 0 and 10
A result of 8 or 10 points is generally considered reassuring
The presence of these biophysical variables implies absence of significant central nervous system hypoxemia/acidemia at the time of testing
Each of the movements evaluated in the BPP results from efferent signals originating in different central nervous system (CNS) centers

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

26. Biophysical profile (BPP)
Recommended management
<=2
Labor induction 4
Labor induction if gestational age >32 week
Repeating test same day if >32 weeks, then delivery if BPP<6 6
Labor induction if >36 weeks if favorable cervix and normal AFI
Repeating test in 24 hours if <36 weeks and cervix unfavorable; then delivery if BPP <6, and follow-up if >6 8
Labor induction if presence of oligohydramnios

27. Thank you