2.  Principles:  the ideal scheme to assess FWB should:  Take account of cycles of normal fetal behavior  detect impending harm accurately and in time to intervene to prevent it  give reassurance preferably up to 7 days  avoid causing unnecessary anxiety  allow detection of specific causes e.g hypoxia, infection, malf’n  produce measurable benefits in reducing perinatal loss/injury  such system is likely to involve tests which assess several fetal systems, CVS, NS,, RS and use >1 modality

3. Factors for increased fetal risk Medical complications: HTN, DM, AID, Hb pathies Fetal problems: IUGR, Non-lethal anamolies, prematurity, postdatism, hydrops IU problems: Bleeding, fever, meconium stain, oxytocin augment.

4. Utero-placental complex Uterus depends on placenta for diffusion of nutrients and respiratory gas exchange. Placental function depends on uterine blood flow (UBF) Uterine contraction leads to transient decreased UBF Borderline placenta may lead to fetal asphyxia during L&D Fetal compensatory responses limit the damage Prolonged or severe hypoxia may cause injury or death.

5. Non-invasive:  Fetal Movement Count:  Fetal Heart Recording….. CTG  Biophysical Profile {BPP} scoring  Doppler studies Invasive: Chorion villus Sampling Amniocentesis Umbilical artery canulation

6. Intrapartum Fetal Assessment Electronic Fetal Heart Monitoring Fetal Scalp pH ( and pCo2, pO2) Monitoring Fetal Scalp Stimulation Vibroacoustic Stimulation UA Velocimetry and Biophysical profile Fetal Pulse Oximetry Near-infrared Spectroscopy

7. Screening tool to assess the fetal state of oxygenation and predicts early signs of hypoxia and fetal distress.

8. Stimulus: Contractions/ fetal movements Baseline fetal heart rate Baseline variability Accelerations Decelerations

9.  baseline heart rate

10.  Baseline variability  Classification:  Silent 0-5 bpm  Reduced 6-10 bpm  Normal 11-25 bpm  Saltatory >25 bpm

11.  accelerations

12.  Decelerations:

14. Basal fetal oxygenation. The relationship of late decelerations to baseline fetal oxygenation during contractions

16. Signature + Date & Time

17. DEFINEDEFINE RISKRISK CONTRACTIONSCONTRACTIONS BASELINEBASELINE RATERATE VARIABILITYVARIABILITY ACCELERAT’NACCELERAT’N DECELERAT’NDECELERAT’N OVER ALL ASSESS MENT

18. Baseline Rate 110-150 bpm Amplitude of baseline variability 5/10-25 bpm Absence of decelerations, except for fleeting& short Presence of 2 or more accelerations during a 20 min period

19. Baseline rate of 150-170 bpm/ 100-110 bpm Amplitude of variability bn 5-10 bpm > 40 min Increased variability above 25 bpm {saltatory} Absence of accelerations for > 40 min Sporadic decelerations of any type, unless severe

20. Baseline heart rate 170 bpm Variability 40 min Recurrent decelerations of any type Severe variable or late decelerations A sinusoidal pattern Any of the following:

22.  Indications of use:  pregnancy location  viability  fetal number  dating  anomaly  placental localization, amniotic fluid  fetal growth and wellbeing  during invasive procedures

24.  Assessment of gestational age and fetal growth:  menstrual history unreliable in up to 45% of women  serial fundal height measurement provides a guide to fetal growth  USS: crown-rump length before 14 weeks  USS: BPD serial measurement every 2 weeks for fetal growth. Unreliable after 28 weeks for dating  USS: head/abd ratio, 2 weeks serial HC & AC for fetal growth.. IUGR AC< but initially HC ~.  USS: femur length, more precise guide to gestational age than BPD

25. Serial measurements are necessary to identify the growth pattern and detect any lag in the growth and IUGR

27. Biophysical Profile& Color Doppler ultrasound in the high risk pregnancy

28. BPP is applying to detect prenatal asphyxia Doppler ultrasound is a modality for detecting fetal hypoxia and acidosis Doppler can also predict later pre- eclampsia at the 24-26 gestational weeks.

29. Hypoxia: Low Oxygen tension Asphyxia: Low Oxygen and high CO2 Ischemia: Drop in blood flow

30.  BPP uses FHR monitor and real time USS to assess:  fetal breathing movement  discrete body or limb movement  fetal tone  FHR  amniotic fluid volume  Amniotic fluid volume is most important  Fetal breathing movement is the first to disappear in asphyxia  7 days reassurance in low risk, only 24 hours in high risk preg

31. Component Definition Fetal movements3 body or limb movements Fetal toneOne episode of active extension and flexion of the limbs; opening and closing of hand Fetal breathing movement episode of >= 30 seconds in 30 minutes Hiccups are considered breathing activity. Amniotic fluid volumesingle 2 cm x 2 cm pocket is considered adequate. Non-stress test2 accelerations > 15 beats per minute of at least 15 seconds duration.

32. comment As you know, oligohydramnios may be Mild AFI=5-8cm Moderate AFI=2-5cm Sever AFI<2cm only sever oligohydramnios is considered as an abnormal score.

33. Fetal movement and fetal tone develop between 7.5 and 9 weeks’ menstrual age Fetal breathing movements are detectable by, at least 17-18 weeks’ gestation The non-stress test is most reliable between 32 weeks and term (Ware, 1994).

37.  An early stage in fetal adaptation to hypoxemia - central redistribution of blood flow ( brain-sparing reflex) -increased blood flow to protect the brain, heart, and adrenals -reduced flow to the peripheral and placental circulations

41. Umbilical artery

42. Clinical Indications for Doppler Studies  most useful in assessing IUGR  identify only the sub-group which is hypoxemic bec/of inadequate placental function and may be abnormal for up to 18 weeks before any fetal problem is observed  no proven role in population screening for increased risk of pre-eclampsia or IUGR