Antepartum Surveillance 6.

Contraction stress test

- Should be done in labor delivery unit
Techniques - Give oxytoxics to induce uterine contraction via IV
Obstetrics II fluids
Dr. de Castro - Do not do in a preterm pregnancy (below 26 weeks)
December 17, 2007 → might induce labor and eventual delivery

80% of perinatal morbidity and mortality lies in
Intrapartum prematurity
- During labor - Not contraindicated for gestational diabetes mellitus
- Assess for - Contraction at least 90mmHg → stress to the fetus
1. Fetal heart tone
60-80 → strong contractions
2. Character of amniotic fluid 40-60 → moderate contractions
- Assessed after rupture of bag of water 30-40 → mild contractions
- Clear: indicates fetal health < 30 → hypotonic
- Stained: evidence of fetal hypoxia 80-100 → tetanic contractions
3. Electronic fetal monitoring trace - Contractions induce hypoxia in baby → stress
- Will appreciate two things: - A fetal heart rate deceleration is a POSITIVE
- Fetal heart rate STRESS TEST → not good
- Fetal heart tone - What we want is a NEGATIVE STRESS TEST
- Note for decelerations
Unlike NST where what we want is a REACTIVE test
- Late decelerations not a NON-REACTIVE test
- Variable decelerations
- Early decelerations Goal of Fetal Testing

Tocodynamometer → measures force of uterine contraction - Detection of chronic & intermediate-term compromise to:
- Prevent stillbirth
Antepartum - Decrease neonatal mortality
- Before labor pain sets in (mother not in labor) - Minimize long-term morbidity
- Baby is still in utero
Chronic compromise e.g. IUGR
- If something wrong is suspected
1. Biometry No technique devised so far to detect
- Measurement of the fetal age - Acute antenatal compromise
- Parameters are: - Chance events e.g. placental abruption or cord accident
- Biparietal diameter (BPD) - In twin pregnancy with only one gestational sac →
- Femur length compromise → cord entanglement
- Abdominal circumference - US cannot detect abruption placenta efficiently →
- Useful for mothers with irregular menstruation since waterloo of US; can only detect placenta previa
LMP will not be reliable - Unmonitored onset of labor
- Can give prediction when labor is due
2. Fetal movement counting Ideal Monitoring System
- Very practical - Gather wide range of information
- Monitor fetal movement in a 24 hour basis - Versatile for all maternal & fetal conditions
- To assess fetal behaviour - Flexible for all gestational ages
- 80% of fetal movement occurs during 11am to 6pm - Allows for varying degrees of onset, duration & severity of
3. Non-stress test intrauterine challenges
- Uses electronic fetal monitor Notes:
- 1 sensor to detect fetal movement ( or fetal kick)
Biometry can be done at any age of gestation however biophysical
- 1 sensor for fetal heart rate profile can only be done >28 weeks of pregnancy because if there is
- No stress induced at all, you depend on fetal kick → complication due to test and baby is <28 weeks, baby will not survive
a good response is acceleration of fetal heart rate of due to lack of viability which is mainly due to respiratory distress
+15 beats per minute/kick from the baseline fetal syndrome → lack of lung surfactant
heart rate → 3 accelerations/ 10 minutes
- Can be done in doctors office Pitfalls of Fetal Monitoring
- A good response is labelled as: REACTIVE - Single parameter monitoring causes iatrogenic injury & demise
- No response: NON-REACTIVE → however does not from prematurity
mean that fetus is in definite distress or hypoxia → - Ensuring fetal safety while biding for maturation time is more
80% is still doing well demanding than simple delivery

How to differentiate the 20% → do contraction stress
test Lesson

Can also use vibroacoustic stimulator (VAS) placed - Only through a broad combination of variables can fetal status,
on the maternal abdomen where the perceived fetal ear normal or abnormal, be depicted accurately
should be to awaken fetus and evoke fetal movement
→ gives off vibration and sound Modalities
4. Biophysical profile - Ultrasonography
- 5 criteria - Biometry
- Amniotic fluid volume quantification - Anatomic survey → congenital scanning (optimum time:
- Fetal heart rate reactivity 18-22 weeks)
- Fetal breathing movement - Biophysical score
- Fetal movement - Doppler velocimetry
- Fetal tone → least important - Electronic fetal monitoring or CTG (cardiotocograph)

Each is given 2 points - Non stress test

Perfect score is then 10/10 - Contraction stress test

Acceptable is 8/10 – 10/10 - Examination of body fluids (invasive)

If 6/10 → equivocal (nonconlusive) → extend - Amniocentesis → sample of about 30cc
the test from 10 minutes to even about 30 minutes - Genetic amniocentesis → detect chromosomal
5. Fetal umbilical velocimetry aberration; 15-18 weeks; processing takes two weeks
- Measures amount of RBC that passes through and abortion is only allowed until 20 weeks
- Gives contraction rate: systole and diastole rate internationally (But not in UST!)
- Can also be done to determine lung maturity
- Done >28 weeks

1
 - Lung maturity is at >34 weeks when lung
surfactants are already formed; ratio of 2 lecithin: 1
sphingomyelin
- Below 33 weeks, ratio is 1 lecithin to 1
sphingomyelin
- Lamellar bodies 20,000/cu.mm. → sign of fetal
lung development
- Cordocentesis (PUBS: percutaneous umbilical blood
sampling) → analyse pH → to detect hypoxia
Application
- Clinical scenario
- What is the problem?
- What management decision/s must I make?
- What information do I need?
- Which test will give this information?
- Technique
- How does each test work?
- Principle
- Results
- Interpretation
Fetal Biometry
- Test if big or small for fetal age (appropriate age for size)
- Is there adequate growth?
- Measure biparietal diameter, femur length, abdominal
circumference, sonographical estimate of fetal weight

Fetal weight is estimated using abdominal circumference

Fetal dating: biparietal diameter, femur length
- Nomograms for gestational ages
- Graph for particular fetus
Fetal Movement Counting
- Assumption: Compromised fetus reduces its activity in
response to decreased oxygenation.

Tomultous movement → not good
- Presence of a vigorous fetus is reassuring
- “Kicks count”
- Pregnant woman records length of time that fetus takes to
make 10 movements (Book: 10 kicks in 40 minutes)
- Select any period of day to count these.
- Each fetus has its own degree of activity.
- Most usually move 10x in < 60 minutes
- Physician must be able to check that the mother is able to
distinguish between uterine contraction & fetal movement
- Instruction: If fetus requires more than two (2) hours for 10
kicks or the mother perceives activity that is less from the usual,
patient should contact their physician
- Simplest & least expensive
- Evidence lacking that it can be an independent test for
predicting IUGR, malformations or stillbirth
- A screening test
- Patients reporting reduced or cessation of movement must be
evaluated further
Non-Stress Test
- Heart rate of the fetus that is not acidotic or neurologically
depressed will accelerate with fetal movement
- Heart rate reactivity is a good indicator of normal fetal
autonomic function
- Differentiate from contraction stress test, non-stress test does
not record uterine contractions
- Every time the mother feels fetal movement, the mother
presses a button, which makes a mark in the paper
- Loss of Reactivity
- Commonly associated with fetal sleep cycle
- May result from any cause of CNS depression including
fetal acidosis
- Procedure
- Using CTG of EFM, patient in lateral recumbent or supine
position
- Record for 20-60 minutes
- FHT range within normal 120-160 bpm
- Interpretation
- Reactive: At least 2 accelerations of at least 15 bpm for at
least 15 secs within 20 min-period
- If non-reactive after 20 min, continue recording for another
20 min to account for sleep period
- If non-reactive after 40 min of testing, proceed with
biophysical profile or contraction stress test
- Vibro acoustic stimulator: Wakes up the fetus with sound
Biophysical Profile
- Components
- Non Stress Test plus 4 variables observed by
ultrasonography…
- Fetal breathing movements: 1 or more episodes of
rhythmic fetal breathing movements of 30 seconds or
more within 30 minutes
- Fetal gross body movement: 3 or more discrete body or
limb movements within 30 minutes
- Fetal tone (muscle tone)
- 3 or more episodes of extension of a fetal extremity
with return to flexion, or opening or closing of
hands
- Continuous extension means a bad prognosis, limp
muscles
- Amniotic fluid volume
- Single vertical pocket of amniotic fluid > 2 cm
- Amniotic fluid index: Sum of deepest cord-free fluid
pockets
- Principle
- Non-stress test, fetal breathing movement, Gross body
movement, fetal tone
- Parameters demonstrable if respective brain center
intact, i.e. well-oxygenated
- In hypoxia, there is initially brain-sparing.
- If parameter is not exhibited, hypoxia may be so severe
that even brain is not spared
- Amniotic fluid volume
- In hypoxia, blood is shunted to priority areas: heart,
brain, adrenals.
- Kidney is not a priority area: decreased GFR,
decreased urine formation
- Placental dysfunction → diminished renal perfusion →
Oligohydramnios
- Procedure: Each of the components is given a score of 2
(normal or present) or 0 (abnormal, absent or insufficient) for a
total of 10
- Interpretation
- Composite score of:
- 8 or 10: Normal
- 6: Equivocal
- 4 or less: Abnormal (possible hypoxia)
- Oligohydramnios requires further evaluation regardless of
composite score
- AF production reflects fetal urine production during the 2nd half
of pregnancy
- AF volume can be used to assess long-term uteroplacental
function
Modified Biophysical Profile
- Normal: reactive NST and AFI > 5 cm
- Abnormal: Nonreactive NST or AFI 5 cm or less
Abnormal BPS
- Evaluation or intervention depending on the circumstances.
- Term fetus: Preparation should be made for delivery
- Fetus who is remote from term requires conservative
management, since the risk of fetal death is similar to the
neonatal mortality rate resulting from prematurity. In these
patients, daily testing often is performed
Fetal Umbilical Artery Doppler Velocimetry
- Umbilical flow velocity waveform of normally growing fetus has
high-diastolic flow
- Absent or reversed end-diastolic flow reflects extreme placental
vascular resistance (ominous)
- Value most established in pregnancies with IUGR
- During systole: there is more blood in the vessels passing
under the Doppler (Upstroke)
- Baseline not totally zero during diastole
- Normally: < 3:1 ratio
- To monitor circulation
- Abnormal pattern of blood flow warrants
- close surveillance (values beyond cut-off) or intervention
(AEDV or ARED)
2
 - AEDV: absent end diastolic volume Proven Intrauterine Growth Restriction
- ARED: Absent reversed end diastolic (Resistance is - Functional signs normal → Serial assessment, non-intervention
great, diastolic flow is poor) until fetal maturity ot favorable condition for delivery
- Umbilical artery: More commonly examined - Functional signs abnormal (BPS < 4, oligohydramnios, AEDV,
- MCA Doppler (If baseline diastole, there is compensatory state) ARED) → Deliver
& Ductus venosus: used as back up or to stretch out the time
for premature fetus Transcribed by: Fred Monteverde
- Deterioration of the fetal condition Notes from: Charlene Santos
- Abnormal umbilical cord blood flow patterns occur first, Lecture recorded by: Lala Nieto
subsequently
- FHR variation is reduced Fred Monteverde Mae Olivarez
- Followed by loss of breathing movements Emy Onishi Lala Nieto
- General fetal movements & tone are the last parameters to Cecile Ong Chok Porciuncula
demonstrate abnormal results Mitzel Mata Section C 2009!
Regina Luz
Contraction Stress Test
- Attempt to mimic labor by inducing uterine contractions by
- Oxytocin
- Nipple stimulation, which stimulate release of oxytocin
- Heart rate pattern compared with contraction pattern
- Presence of late decelerations suggests placental insufficiency
- Used if
- Other tests results are suspicious
- When NST is nonreactive
- Contraindicated when labor is contraindicated
- Previous classical CS: Scars are prone to ruptire
- Placenta previa
- If with oxytocin stimulation, there are more decelerations with
increased contraction: means that the fetus is easily
compromised

Indications for Testing

- Decreased fetal movement
- Maternal disease
- Fetal growth restriction
- Post-term pregnancy
- Prolonged rupture of membrane
- Oligohydramnios

Timing
- Antepartum testing using the biophysical profile or other method
should not be performed earlier than the gestational age at
which extrauterine survival or active intervention for fetal
compromise is possible
- Testing usually begins when diagnosis is established (3rd
trimester)
- 32-34 weeks (If mother is diabetic or with chronic hypertension:
28 weeks)

When not to do?

- No indications exist for testing in a fetus at term when
- Likelihood of successful induction is high
- Vaginal delivery is contraindicated for obstetric

How Frequent?
- Varies according to the clinical variables in each patients
- Increases in direct proportion to the severity of the maternal or
fetal condition
- in most high-risk pregnancies, testing plans start with weekly
testing
- Twice-weekly testing is the standard for pregnancies beyond 42
weeks & for patients with insulin-dependent diabetes

Post-term Pregnancy
- For patients with a low probability of successful induction, the
BPP is a useful tool that can be used while waiting for cervical
ripening.
- In these patients, the purpose of the BPP is to avoid the
maternal morbidity resulting from failed induction followed by
cesarean delivery

Pregnancy induced Hypertension

- Doppler velocimetry: Increased S/D & RI at 28 weeks
- BPS weekly: AFI 5 cm at 34