Antepartum Fetal Surveillance ‘HELLO BABY, HOW ARE YOU?’

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.

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

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

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

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

8. Patient: Kay SarahDoc: I. Ben Cursed M.D. • G 2 P1-0-0-0 • Previous stillbirth @ 39 weeks • Present gestation is 37 weeks • Has been keeping a Fetal Activity Diary (FAD) since 36 weeks • Now to begin surveillance with weekly NST

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: • Position sitting, semi-Fowler’s with tilt to either side • Good quality EFM tracing for 20-40 min • May monitor up to 60 min

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

15. Baseline Variability Accelerations Decelerations Uterine Activity Fetal Movement

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

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

18. Example at term

19. Example 31 weeks

21. Back to Ms. Sarah • Her NST is reactive • Anything else? • Chart the 5 parameters on strip & chart • Call HCP and report • Schedule next appointment • Continue FAD

22. 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

23. Patient: Ms. HertzelotDoctor: I. Ben Cursed M.D. • 37 weeks gestation • G1 P0 • Has not felt baby move for 8 hours • Please do NST

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

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

26. Results of FAST • Causes ‘Moro’ or startle reflex if CNS intact • Increase in FHR • 1 accel of 15 bpm over 2 minutes • 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

27. Vibroacoustic Stimulation

28. Back to Ms. Hertzelot • Well, now what? • NST reactive with FAST • Monitor until BL is restored • Home with FAD • Document on Strip and Chart

29. Patient: Ms. Shirley I. M. LateDoctor: I Ben Cursed M.D. • 40 & 5/7 weeks gestation • Please do NST • Results: • NST: non-reactive • FAST (or VAS): still non-reactive • More monitoring: still non-reactive

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

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

32. Interpretation • FHR response to stress of contractions • 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!) • > 50% of contractions--need to deliver • ‘Equivocal’ is presence of some lates • <50% of contractions • Hyperstimulation or Unsatisfactory Results • Considered testing failure and are not clinically useful • ‘Suspicious’ • Variable Decelerations

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

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

35. Scoring

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

37. Back to Ms. Late • Well, now what? • NST: non-reactive • CST: negative • BPP: 6/10 (FT-2, FM-2, FBM-0, AFI-2, NST-0) • Report to HCP/document all findings • Home with FAD • Reschedule for repeat NST/BPP in 2-3 days

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

39. Other Surveillance Options • Doppler Flow Studies • Checks BP of uterine and placental vessels • Associated with fetal growth deficiency

40. Other Surveillance Options (cont’d) • Chorionic Villus sampling • early prenatal genetic studies

42. References: American Academy of Pediatrics, American College of Obstetricians & Gynecologists, Guidelines for Perinatal Care (5th ed. 2002), Antepartum surveillance, pp. 89-107. AWHONN Fetal Heart Rate Monitoring Principles and Practices 4th 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 (3rd ed. 2002), Performing fetal surveillance testing, pp. 411-413. Mattson, S., Smith, J.E., Core Curriculum for Maternal-Newborn Nursing (3rd. ed.,2004), Clinical practice pp. 165-166. Simpson, K. R., Creehan, P.A., Perinatal Nursing (2nd ed., 2001), Fetal surveillance, pp. 147-154.