~ ~

Fetal Surveillance
To test fetal well-being
Fetal physical activities
Movement
Breathing
Amniotic fluid production
Heart rate

Goal: to prevent fetal death

Tools for fetal

assessment
Fetal movements
Non-stress test
Biophysical profile
Contraction stress test
Amniotic Fluid Volume
Doppler ultrasound

Fetal Movements
Unstimulated fetal activity commences at 7 weeks
Rest-activity (1F-2F) cycles

Fetal Movements
75%
20-75
Perception of 10 fetal movements in up to 2

hours is considered normal

Self monitor, poor sensitivity and specificity

Fetal heart rates

assessment
Cardiotocography (CTG), Fetal monitor
Fetal activity acceleration determination (FAD)

Non-stress test (NST)

Fetal acoustic stimulation test (AST, FAST)
Vibroacoustic stimulation test (VAST)
Contraction stress test (CST)
Oxytocin challenge test (OCT)

External / Internal device

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gynecology/external_and_internal_heart_rate_monitoring_of_the_fetus_92,P07776/

Nomenclature
Baseline
Variability
Acceleration
Deceleration
Uterine contraction

Baseline
The mean fetal heart rate rounded to

increments of 5 bpm during a 10-min

segment, excluding:
Periodic or episodic changes
Periods of marked FHR variability
Segments of baseline that differ >25bpm

Normal FHR: 110~160bpm

Beat-to-beat variability
Variability is visually quantified as the

amplitude of peak-to-trough in bpm

Absentamplitude range undetectable
Minimalamplitude range detectable but5

bpm
Moderateamplitude range 6~25 bpm
Markedamplitude range >25 bpm

10

http://www.motherbabyuniversity.com/outreach/outreach/PeaPods/1835%20Fetal%20Monitoring/Pages/describing%20FHR%20patterns.html

Sinusoidal pattern
Visually apparent, smooth, sine wave-like

undulating pattern in FHR baseline with a

cycle frequency of 35 per minute which
persists for 20 minutes or more.

Acceleration
A visually apparent increase in the FHR from the

most recently calculated baseline

Duration: time from initial change in FHR from
the baseline to the return of the FHR to baseline
Acceleration
32 weeks: 15 bpm, duration 15 sec
<32 weeks: 10 bpm, duration 10 sec

Prolonged acceleration: duration 2min but <

10min
Tachycardia: 10 min
12

Deceleration
Early deceleration
Late deceleration
Variable deceleration
Prolonged deceleration: >2min, <10min
Bradycardia: >10min

13

Early Deceleration
Symmetrically

,
gradual decrease and
recovery
Onset to nadir 30
secs
Onset , peak and
ending
with
contraction
Caused by fetal head
compression
with
vagus nerve response
14

http://www.motherbabyuniversity.com/outreach/outreach/PeaPods/1835%20Fetal%20Monitoring/Pages/describing%20FHR%20patterns.html

Late deceleration
Periodic,

symmetrically
,
gradual
decrease
and recovery
Onset to nadir 30
secs
Related
to
ueroplacental
insufficiency
15

http://www.motherbabyuniversity.com/outreach/outreach/PeaPods/1835%20Fetal%20Monitoring/Pages/describing%20FHR%20patterns.html

Variable deceleration
Nadir <30 secs
Decrease > 15 bpm,

<2 min
Usually
associated
with cord compression,
may be associated
with acidosis

16

Variable deceleration Complicated

Nadir < 70 bpm, duration > 60 seconds

Slow return to baseline
Repetitive deceleration 3 times in 20 minutes
Recurrent deceleration with > 50% of uterine

contractions in any 20 minute segment

17

Major Guideline for CTG

ACOG (2009)
RCOG ( 2007)
SOGC ( 2007 )
RANZCOG
AOFOG

Antepartum NST / AST

Results
Reactive / Reassuring
Normal baseline, Moderate variability
Present of 2 accelerations in 20 minutes
No variable or late deceleration
Non-reactive / Non-reassuring
<2 accelerations in 20 minutes over 40 minute
periods
Reactive NST is highly predictive of a low risk of

fetal morality in the subsequent 3-7 days

depending on the indication for fetal testing.
NPV >90%, PPV 50 - 70%.

If non-reactive.
Further evaluation
Biophysical profile
Contraction stress test
Pregnancy termination as indicated

Intrapartum
interpretation
Category I, include all of following:
Baseline 110-160 bpm, Moderate variability, No late or

variable deceleration, Present or absent of acceleration

Category II, not categorize as I or III

Category III, include either:
Absent of baseline variability with recurrent late /

variable deceleration or bradycardia

Sinusoidal pattern

If not category I
Treatment of maternal hypotension (IV)
Provision of maternal oxygen (O2)
Change in maternal position (Left decubitus

position)
Discontinuation of labor stimulation
Treatment of tachysystole
Delivery if refractory

Medication affects results

Amniotic Fluid Volume

Decreased uteroplacental perfusion may lead

to diminished fetal renal blood flow,

decreased urine production, and ultimately,
oligohydramnios.
Amnionic fluid index < 5 cm or deepest
pocket < 2 cm are acceptable criteria for
oligohydramnios

Contraction Stress Test

Oxytocin challenge test / Nipple stimulation
Goal: 3 contractions of 40-60 sec present in 10
mins

Results:
Negative: no late or significant variable

decelerations
Positive: late decelerations in > 50%
contractions

 29

late
deceleration
100( )
A .
B .
C .
D .

 100( )
A .
B .
C .
D .
24 G2P1 42

variable deceleration
97( )
A .
B .
C .
D .

 98( )
A . contraction stress test

B . nonstress test 2 1
C . 20 2
15
15
D . 90 non-reactive

Non stress test

Score 2

Score 0

Reactive

Non-reactive

Fetal breathing

1 episode 30
Absent /
sec in 30 mins
Less than 30 mins

Fetal movement

3 body or limb
movement in 30
mins

2 or less

Fetal tone

1 in 30 mins

Absent / Extension
with no flexion

Amniotic fluid
volume

Normal

Oligohydramnios

~ Reassuring
~

~ Delivery ~

Modified biophysical
profile
Non-stress test + Amnionic fluid volume
Either one did not meet the criteria is

considered abnormal
Less time and labor consuming
False-negative rate 0.08%, False positive rate
of 1.5%

Fetal Death After Normal

BPP
Feto-maternal hemorrhage
Umbilical cord accidents
Placental abruption
Incidence: 1/1000

 biophysical

profile

102( )

A . 12
B . 0

fetal acidosis
C . 2 4 0

D . 10 pH

33 G4P2A1 33

biophysical profile, BPP 4

101( )

BPP 6
BPP 8
BPP 8

Doppler Blood Flow

Velocity
Fetal vessels for growth restriction evaluation
Umbilical artery, Middle cerebral artery, Ductus

venosus

Uterine artery for placental function

However, most perinatal outcome doesnt

change while identification of abnormality,

only umbilical artery Doppler is recommend
by ACOG for fetal surveillance

Umbilical Artery Doppler

S/D ratio: most commonly used index
About 4.0 at 20 weeks, 2.0 at 40 weeks
Generally < 3.0 after 30 weeks
Wave form: End diastolic flow
Perinatal mortality
Absent end-diastolic flow: 10%
S
Reversed end-diastolic flow: 33%
D

Middle Cerebral Artery

Hypoxic

fetus attempts brain sparing by

reducing cerebrovascular impedance and thus
increasing blood flow, but no significant
differences in pregnancy outcome compare to
biophysical profile
Useful for detection and management of fetal
anemia of any cause
If PSV > 1.5 MoM

Fetal blood sampling

Transfusion if needed

Ductus Venosus
The best predictor of perinatal outcome
Negative or reversed flow in the ductus

venosus was a late finding because these

fetuses had already sustained irreversible
multiorgan damage due to hypoxemia

https://iame.com/online/multi_vessel_doppler/figure_3a.jpg

Uterine Arteries
Most helpful assessing pregnancies at high

risk of uteroplacental insufficiency

Perinatal benefits of uterine artery Doppler
screening have not yet been demonstrated
Notch indicates increased
resistance

In summary
Antepartum fetal surveillance telling more

about the well-being of the baby

An abnormal result not always mean that the
baby is in trouble. It simply mean that you
need special care or test

23 G2P1 35

103( )

A .
B .
C .
D .

23 G2P1 35

103( )

A .
B .
C .
D .

103( )

A.Absence of end-diastolic flow velocity

B.Reversed end-diastolic velocity
C.Decrease of middle cerebral arterial flow
D.Increase of middle cerebral arterial flow

Classification
ACOG
Category
Category 1
Category 2
Category 3

RCOG
Classification
Normal
Suspicious
Pathological
Reassuring
Non-reassuring
Abnormal

SCOG
Classification
Normal
Atypical
Abnormal

Baseline
ACOG
Definition

Normal

The mean FHR rounded to

increments of 5 beats per minute
during a 10-minute segment,
excluding
Periodic or episodic changes
Periods of marked FHR variability
Segments of baseline that differ
by more than 25 beats per minute

RCOG
FHR trace is stable
excluding acceleration
and deceleration in 5 to
10 mins

SCOG
Mean FHR rounded to
increments of 5 beats in 10
-minute segment, excluding
Periodic or episodic
changes or periods of
marked FHR Variability(>25)

110-160 bpm

110-160 bpm

110-160 bpm

Tachycardia

>160 bpm

Moderate 161-180
Abnormal <180

>160 bpm > 10

mins

Bradycaridia

<110 bpm

Moderate 100-109
Abnormal <100

<110 > 10 mins

ACOG
Variability is visually quantitated
as the amplitude of peak-totrough in beats per minute.
Absentamplitude range
undetectable
Minimalamplitude range
detectable but 5 beats per minute
or fewer
Moderate (normal)amplitude
range 625 beats per minute
Markedamplitude range
greater than 25 beats per minute

RCOG
3-5 cycles / mins
-Reassuring >=5
-Non-reassuring
< for 40-90 mins
-Abnormal
<5 for 90 mins

SCOG
Variability refers to the
fluctuations in the baseline
FHR.
It is determined by choosing
one minute of a 10-minute
section of the FH tracing with at
least 2 cycles/minute (normal is
2 to 4 cycles/minute) that is free
from accelerations and
decelerations, and measuring
the difference between the
lowest and highest rate. The
difference is the range /
amplitude of variability.

Acceleration
A visually apparent abrupt increase (onset to peak in
less than 30 seconds)

>= 32 weeks , > 15 bpm for > 15 secs- 2 mins

< 32 weeks , > 10 bpm for 10 secs- 2mins

ACOG SCOG

Prolonged acceleration lasts 2 minutes or

more but less than 10 minutes in duration.
If an acceleration lasts 10 minutes or
longer, it is a baseline change.

Early Deceleration
ACOG
Visually apparent usually symmetrical gradual
decrease and return of the FHR associated with a
uterine contraction
A gradual FHR decrease is defined as from the
onset to the FHR nadir of 30 seconds or more.
The decrease in FHR is calculated from the
onset to the nadir of the deceleration.
The nadir of the deceleration occurs at the same
time as the peak of the contraction.
In most cases the onset, nadir, and recovery of
the deceleration are coincident with the
beginning, peak, and ending of the contraction,
respectively.

SCOG
They are associated with fetal
head compression during
labour and are generally
considered benign and
inconsequential.
This FHR pattern is not
Normally associated with fetal
acidemia.

ACOG
The decrease in FHR is calculated from
the onset to the nadir of the deceleration.
The deceleration is delayed in timing, with
the nadir of the deceleration occurring after
the peak of the contraction.
In most cases, the onset, nadir, and
recovery of the deceleration occur after the
beginning, peak, and ending of the
contraction, respectively

SCOG
Late decelerations are found in
association with Uteroplacental
insufficiency and imply some
degree of hypoxia.

Variable
Deceleration

Nadir <30 secs

Decreased > 15 bpm , <2 mins
Cord pressure

ACOG
Visually apparent abrupt decrease in
FHR

An abrupt FHR decrease is

defined as from the onset of the
deceleration to the beginning of
the FHR nadir of less than 30
seconds.
The decrease in FHR is
calculated from the onset to the
nadir of the deceleration.
The decrease in FHR is 15 beats
per minute or greater, lasting 15
seconds or greater, and less than
2 minutes in duration.
When variable decelerations are

SCOG
a visually apparent abrupt
decrease in the FHR with the
onset of the deceleration to
the nadir of less
than 30 seconds.63 The
deceleration should be at
least 15 beats below the
baseline, lasting for at least
15 seconds, but less than 2
minutes in duration

Prolong variable
deceleration
10 mins > de > 2 mins