1. Antepartum Fetal Surveillance ‘HELLO BABY, HOW ARE YOU?’ Presented By: Janet L. Smith, RNC, BSN Author: Ruth Saathoff, RNC, BSN

2. OBJECTIVES: At the end of this class the learner will be able to: §Name 5 methods of monitoring the fetus for well- being § Describe the physiology of maternal and fetal circulation in the relationship to fetal reserve. § Identify the maternal and fetal conditions that indicate a need for fetal surveillance.

4. Indications for Fetal Evaluation §Maternal risk factors l Pre-existing maternal disease l Exposure to teratogens in 1 st trimester l Substance abuse l Infertility or conception within 3 months of last delivery (cont.)

5. Indications for Fetal Evaluation §Maternal Factors (cont) l History of OB complication Oligohydramnios, Gestational Hypertension, etc. l Previous pregnancy loss l PROM > 24 hours l Familial history of genetic abnormality l Post dates

6. Indications for Fetal Evaluation §Fetal risk factors l Prematurity l SGA or LGA l Intrauterine growth restriction (IUGR) l Known anomaly l History of IUFD l Fetal cardiac arrhythmias l Decreased fetal movement

7. Why and When §Why do we think of a well baby in terms of placental perfusion? l Oxygen & nutrients are needed for fetus l Risk factors may reduce delivery to fetus l Good oxygen & nutrient delivery results in movement and growth §When is surveillance started? l When risk is present l IDDM (type 1) - 32 weeks l Previous loss - 34 weeks

9. Fetal Movement Counts §FM indicator of intact Central Nervous System function §First line defense to identify the fetus in trouble §30-50% of IUFD occur in women with no identifiable risk factors §FAD

10. Methods for Fetal Movement Counts §Count-to-ten §Counting after meals §Evening monitoring

11. Interpretation §Report when criteria not met §Report no movement over 8 hours §Report sudden violent increase in fetal activity followed by cessation of movement §Report changes in normal pattern of fetal movement

13. Non-stress Test (NST) §Fetal movement typically accompanied by FHR accels when CNS intact and with adequate oxygenation §Procedure: l Position sitting, semi-Fowler’s with tilt to either side l Good quality EFM tracing for 20-40 min l May monitor up to 60 min

14. Interpretation §What to look at (5 parameters) l What’s the baseline? l Is there variability present? l Any uterine activity present? l Any accels present? l Any decels present? §Assessment

15. Baseline Variability Accelerations Decelerations Uterine ActivityFetal Movement

16. Interpretation §Reactive: 2 accels in 20 min. 15 bpm X 15 sec. l 15 sec. from start of accel to end of accel l 15 bpm at apex of accel l gestation < 32 weeks 10 bpm X 10 sec. frequent decels of 10-20 sec.

17. Interpretation §Nonreactive: does not meet above criteria l if not reactive in 60 min. unlikely to become so; call HCP l isolated decels seen in as many as 33%

18. Example at term

19. Example 31 weeks

21. Retesting §If no risk factors, unlikely to have FD in one week §With risk factors, repeat 2 times a week §If pregnancy status changes, repeat in 24-48 hours

22. Assessment §NST: Non-reactive after 40 min §Possible causes: l fetal sleep l smoking before coming l Maternal medications l immature CNS l fetal hypoxia

23. Well, now what? My NST is Non-Reactive §Juice myth §Do Fetal Acoustic Stimulation Test (FAST) l Usually elicited after 28 weeks l Can be done after 10 min of non-reactive pattern l Handheld device generates a low frequency (82 decibels) vibro-acoustic stimulus l Apply for 3-5 sec avoiding fetal head; may repeat X 2 at least 1 min apart l May cause some level of stress

24. Results of FAST §Causes ‘Moro’ or startle reflex if CNS intact §Increase in FHR l 1 accel of 15 bpm over 2 minutes l 2 accels of 15 bpm for at least 15 sec within 5 minutes of test §Useful way to reduce number of non- reactive NST's §Shortens testing time

25. Vibroacoustic Stimulation

26. Well, now what...My NST is Non- Reactive? §Options: l Contraction Stress Test (CST) assumes uteroplacental insufficiency will show hypoxia with late decels with contractions l Biophysical Profile (BPP) Ultrasound assessment of acute and chronic markers show good predictor of fetal well-being

27. CST §Modes l Nipple stimulation (BST) may be poorly received by patient noninvasive l IV oxytocin (OCT) requires invasive procedure l Spontaneous contractions

28. Interpretation §FHR response to stress of contractions l 3 contractions lasting 40-60 sec. in 10 min. §‘Negative’ is absence of late decels (That’s good!) §‘Positive’ is presence of late decels (That’s bad!) l > 50% of contractions--need to deliver §‘Equivocal’ is presence of some lates l <50% of contractions §Tachysystole or Unsatisfactory Results l Considered testing failure and are not clinically useful §‘Suspicious’ l Variable Decelerations

29. Negative Positive – Late Decelerations Suspicious – Variable Decelerations Test Failure - UterineTachysystole

30. BPP §Parameters l Fetal Tone (FT) ( 7-8wks) l Fetal Movement (FM) (9wks) l Fetal Breathing Movements (FBM)) (20-21wks) l Amniotic Fluid Index (AFI) > 6 cms l NST (Accelerations 30-32 wks) §Need high tech equipment/skilled technician §Non-invasive, highly predictive

31. Scoring Biophysical Variable Normal (Score = 2) Abnormal (Score = 0) Fetal breathing movements 1 or more episodes of ≥ 20 s within 30 minAbsent or no episode of ≥ 20 s within 30 min Gross body movements2 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 tone1 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 FHR2 or more episodes of acceleration of ≥ 15 bmp* 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 bmp within 20 min Qualitative AFV1 or more pockets of fluid measuring ≥ 2 cm in vertical axis Either no pockets or largest pocket <2 cm in vertical axis

32. Interpretation §Scoring l 10 point scale (if performed with a NST) l 8-10 indicates fetus in good condition l 6 indicates need to repeat in 4-6 hours l <6 indicates need for delivery l AFI < 6 cms indicates delivery

33. Other Surveillances §Amniocentesis l Fetal lung maturity l Testing- genetic, cultures, change in optical density §Ultrasound Examination l Uterine contents l Fetal biometry / dating l Fetal anatomic examination

34. Other Surveillance Options §Doppler Flow Studies l Checks BP of uterine and placental vessels l Associated with fetal growth deficiency

36. §References: American Academy of Pediatrics, American College of Obstetricians & Gynecologists, Guidelines for Perinatal Care (5 th ed. 2002), Antepartum surveillance, pp. 89-107. AWHONN Fetal Heart Rate Monitoring Principles and Practices 4 th Ed. Christensen FC, Olson K, Rayburn WF (2003). Cross-over trial comparing maternal acceptance of two fetal movement charts. Journal of Maternal-Fetal and Neonatal Medicine, 14(2), pp. 118-122. Devoe, L, Glob. libr. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10210 Martin, E.J., Intrapartum Management Modules (3 rd ed. 2002), Performing fetal surveillance testing, pp. 411-413. Mattson, S., Smith, J.E., Core Curriculum for Maternal-Newborn Nursing (3 rd. ed.,2004), Clinical practice pp. 165-166. Simpson, K. R., Creehan, P.A., Perinatal Nursing (2 nd ed., 2001), Fetal surveillance, pp. 147-154.