Antenatal Fetal Monitoring

Learning Objectives

Definition of fetal monitoring and wellbeing

Purpose of doing fetal monitoring techniques
Parameters and indications for monitoring
Types of fetal monitoring:

Fetal wellbeing
A) Fetal growth B)
- Fetal movement/ kick chart
-) Maternal weight gain
-) SFH measurement- Electronic fetal heart monitoring
- Ultrasound Doppler
-) Ultrasound scan
- Fetal Biophysical Profile
- Fetal Scalp pH
- Fetoscope

Introduction
Antenatal fetal monitoring/surveillance is
the assessment of fetal well being in utero
before onset of labour
Early detection of fetus at risk so that
timely management to prevent further
deterioration
To find out normal fetuses and avoid
unnecessary interventions

Aims of Fetal Monitoring

Assessment of fetal well being
especially in high risk mother
Assessments of fetal growth
Identification of fetal abnormalities
and condition in all stages of
pregnancy
Determination of gestational period
To ensure safe delivery

Indications for Monitoring

Maternal
Hypertension
DM
Heart disease
Chronic renal disease
Acute febrile illness
Pneumonia/Asthma
Epilepsy

Fetal
Fetal growth restriction
Rh isoimmunization
In utero infection

Pregnancy related condition

Pre eclampsia
Multiple pregnancy
Post date
Reduced fetal movement
GDM
Oligo/polyhydramnious

Types of Fetal Monitoring

FETAL GROWTH
Maternal weight gain.
Symphysiofundal height measurement.
Ultrasound scan

Maternal Weight Gain

Weight gain during pregnancy
consists of:
Products of conception
Increase in maternal tissues (uterus,
breasts, blood, extracellular fluid, fat
stores)

Estimates 1.6kg in the 1st trimester,

0.45kg per week in 2nd trimester and
0.4kg per week in the third trimester.

 Cheap and simple method

Reduce weight gain : possibilities of
IUGR, persistent nausea and vomitting
Excess weight gain : PIH (fluid
retention), renal disease,
polyhydramnios

Symphysiofundal Height
Measurement
Measure the length in cm from the top of
uterus fundus to the upper border of
symphysis pubis.
Should be measured during each antenatal
visit and the measurement must be recorded
The measurement in cm should roughly
correspond to the period of gestation. +/- 2
weeks

Method

Ultrasound Scan
Ultrasound is the principal imaging
modality used in obstetrics.
Diagnostic ultrasound is used to
screen all pregnancies in most
developed countries.

Function of ultrasound
Diagnosis and
confirmation of
viability in early
pregnancy

Determination
of gestational
age and
assessment of
fetal size and
growth

Diagnosis of
fetal
abnormality
and multiple
pregnancy

Placental
Localization

Amniotic fluid
volume
assessment

Assessment of
cervical length

Assessment of
fetal well being

Other
(intrauterine
death, fetal
presentation)

In early pregnancy
Gestational sac 4-5 weeks
Visible heartbeat about 6 weeks
Transvaginal ultrasound plays a key
role in the diagnosis of disorders of
early pregnancy such as incomplete
or missed miscarriage, ectopic
pregnancy.

Measurement for
gestational age

BPD
FL
AC

Crownrump
length

(CRL until 13
weeks + 6
days)

14 to 20 wks

12 to 20 wks

SFH from
25 weeks
Third trimester

the Nageles
rule

Second trimester

HC

First trimester

Calculation
from LMP

HC,BPD,FL,
AC

Fetal Measurement
Crown-rump length

Biparietal diameter and Head

circumference

The correct plane for the measurement of HC and BPD

must include the cavum septum pellucidum, thallamus
and choroid plexus in the atrium of the lateral
ventricles.

Abdominal Circumference

The Abdominal Circumference must include

the portal section from the umbilical vein,
the stomach and a true cross section of the
spine with 3 ossification centres

Femur Length

Fetal Growth Chart

Consistent growth of
small fetus

Slowed growth
Fetal compromise

Fetal growth
HC,BPD and AC help to differentiate
different type of growth restriction
Symmetrical: HC, BPD, AC all will be
small
Asymmetrical: HC will be relatively
large compared to AC due to brain
sparing effect
Cessation of growth is an ominous
sign of placental failure

Fetal Symmetry
HC: Hydrocephalus
HC: Microcephaly
FL: constitutional short stature,
achondroplasia
AC: triploidy / trisomy 18

Amniotic Fluid Volume

Assessment
Ultrasound can be used to identify both increased and
decreased amniotic fluid volume
Fetus swallows amniotic fluid, absorbs it in the gut and
later excretes urine into the amniotic sac
Congenital abnormalities that impair fetuss ability to
swallow (eg anencephaly, oesophageal atresia) cause
increase amniotic fluid
Cogenital abnormalities that result in failure urine
production (eg renal agenesis) cause decrease amniotic
fluid

Amniotic Fluid Index

Uterus divided into 4 quadrants.
It measures the sum of all the
maximum vertical pool of liquor from
the 4 quadrant of the uterus
In 3rd trimester, normal AFI should
be between 10 and 25cm
AFI -< 5cm -oligohydramnios
->25cm -polyhydramnios

FETAL WELLBEING
Fetal movement/kick chart
Electronic fetal heart monitoring
Ultrasound Doppler
Fetal Biophysical Profile
Fetal Scalp pH
Fetoscope

Fetal Movement/Kick Chart

Used in third trimester pregnant
mother to record the activity of the
fetus
Roughly, fetal must move at least 10
times in 12 hours
Decrease in movement of fetus must
be noted by mother and straight
away go to the nearest health centre

Electronic Fetal Heart Monitoring

Cardiotocograph is used to monitor fetal heart activity

Used for continuous tracing of fetal heart to assess fetal
well being
Features which are reported in from a CTG includes:

Baseline rate
Baseline variability
Accelerations
Decelerations

 Transient reduction of fetal heart rate of 15 beats per minute or more lasting
for at least 15 seconds
Decelerations can be indicative of fetal hypoxia or umbilical cord
compression

Increase in the fetal heart rate of at least 15 beats per minute lasting for at
least 15 seconds
Presence of 2 or more accelerations on 20-30 minutes defines reactive trace

Normal baseline variability reflects normal fetal autonomic nervous system

Considered abnormal when it is less than 10 beats per minute

Normal fetal heart rate at term is 110-150 beats per minute

Higher rates are defined as fetal tachycardia and lower rates is defined as
fetal bradycardia
Baseline heart rate is best determined over a period of 5-10 minutes
Advancing gestational age will cause heart rate to fall

Deceleratio
ns

Accelerati
ons

Baseline
Variabilit
y

Baseline
rate

Normal antepartum CTG can be defined as :

Fetal heart rate of 110-150 beats per minute
Baseline variability exceeding 10 beats per minute
More than 1 accelerations seen in under 20-30 minute
tracing

Normal CTG Tracing

Early Decelerations

Late Decelerations

Variable Decelerations

Biophysical Profile
Done in an effort to refine the ability of fetal CTG to identify
antenatal hypoxia
Additional fetal parameters are measured which are
abolished in the hypoxic state
Takes up 30 minutes to complete ultrasound scan

Biophysical profile can be time consuming

Fetuses spend 30% of their time asleep, during which time they
are not very active and do not exhibit breathing movements
Therefore, it is necessary to scan them long enough to exclude
physiological cause of a poor score
Another problem with biophysical profile is that by the time the
fetus develops an abnormal score, it is likely to be severely
hypoxic

Doppler Investigation

Doppler ultrasound allows the assessment of the velocity of

blood within fetal and placental vessels
Makes use of the phenomenon of the Doppler frequency
shift
Data obtained from the umbilical artery provide indirect
information about placenta function
Data from the fetal vessels provide information on the fetal
response to hypoxia

Umbilical Artery

Provide information on placental resistance to blood flow

and hence indirectly placenta health and function
An infarcted placenta secondary to maternal hypertension
will high higher resistance to flow

Fetal Vessels

Falling oxygen level in the fetus result in redistribution of

blood flow to protect vital organs
So called centralization of flow

Fetal Scalp pH
A procedure that is done to see adequate oxygenation to
the fetus
The procedure is performed transvaginally with a blood
lancet
Usually done when CTG record fetal distress

Interpretation
pH
Normal

7.25-7.35

pCO2

pO2

Base

40-50mmHg 20-30mmHg

<10

Metabolic
Acidosis

<7.25

45-55mmHg

<20mmHg

>10

Respiratory
Acidosis

<7.25

>50mmHg

Varies

<10

Fetoscope

Device used to listen to the fetal heart

Fetoscope is the term used formerly and currently Pinnard
Stetoscope is used to listen to the heart sound
However, most people nowadays used Doppler to listen to
the heart instead of Pinnard Stetoscope