Fetal Health Surveillance (FHS): Part 3 - Antepartum

Fetal Health Surveillance (FHS): Part 3 - Antepartum

Fetal Health Surveillance (FHS): Part 3 Antepartum Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia, 2013 *FHS: Parts 1 and 2 should be viewed prior to review of this module References

www.sogc.org Objectives To review guidelines for recommended antepartum fetal health surveillance (FHS): Indications Methods: Fetal movement awareness and counting Non-stress test (NST) Biophysical profile (BPP) and modified BPP

Uterine artery Doppler Contraction stress test Interpretation and recommended actions Indications for Antepartum FHS With one exception, initiation of antepartum FHS is advised only when there are existing or developing risk factors for adverse outcomes.

There is no evidence to support routine use of antepartum surveillance in uncomplicated pregnancies < 41+0 weeks gestation. Indications Based on Previous Pregnancy Maternal: Hypertensive disorders of pregnancy (HDP) Abruption

Fetal: Stillbirth Intrauterine growth restriction (IUGR) *full list SOGC guideline page S11 Current Pregnancy Indications Maternal:

Postterm pregnancy (> 42+0 wks) Pre-pregnancy/insulin requiring diabetes Motor vehicle accident Fetal: Suspected oligohydramnios or polyhydramnios Multiple pregnancy

IUGR Hypertensive disorders Decreased fetal of pregnancy (HDP) movement Morbid obesity Advanced maternal age *full list SOGC guideline page S11

Fetal Movement (FM) The only method of FHS recommended for all women, is maternal awareness of fetal movement. Normal fetal activity suggests a healthy, non-hypoxic fetus. Fetal movements are

more frequent in the evening; best perceived when sidelying or semirecumbent. Normal fetal activity 6 movements in 2 hours Recommendations about Fetal Movement Counting All healthy pregnant women should be

informed of the significance of fetal movements (after 24 to 26 weeks gestation) and encouraged to perform a fetal movement count if they perceive decreased movements. In pregnancies with risk factors for adverse outcomes, daily monitoring of fetal movement starting at 26 to 32 weeks gestation is advised. If there are < 6 movements in 2 hours, further testing is recommended.

If < 6 Movements in 2 Hours. Non-Stress Test (NST) Normal NST No Risk Factors Continue FM Counting Normal NST Risk Factors

BPP or AFV in 24 hours Atyp. or Abn. NST* BPP (or CST) ASAP *Urgent delivery may be indicated Non-Stress Test (NST)

By definition, an NST is a fetal assessment without the stress of labour. An EFM tracing of FHR and uterine activity is obtained for a minimum of 20 minutes; tocotransducer is always applied. An NST should be obtained only in situations of risk for adverse outcomes. Normal NST Baseline within normal range 110 to 160 bpm

Moderate variability 6 to 25 bpm No decelerations or occasional variable decelerations < 30 seconds At least 2 accelerations of at least 15 bpm lasting at least 15 seconds ( 32 weeks gestation) or at least 10 bpm lasting at least 10 seconds (<32 weeks gestation) in < 40 minutes G1 36 Weeks Gestation NST due to Insulin Requiring

Diabetes Accelerations Baseline 150 G2 with Bleeding at 29 Weeks Twin Pregnancy at 35 Weeks

Atypical NST Baseline 100 to 110 bpm, > 160 bpm for < 30 minutes, or rising Minimal or absent variability for 40 to 80 minutes Variable decelerations lasting 30 to 60 seconds < 2 accelerations in 40 to 80 minutes Abnormal NST Baseline < 100 bpm, > 160 bpm for > 30

minutes or erratic Minimal or absent variability for > 80 minutes, marked variability for > 10 minutes, or sinusoidal Variable decelerations lasting > 60 seconds; late(s) < 2 accelerations in > 80 minutes Recommended Actions Normal NST: Depending on the clinical picture, further

investigation is generally not indicated. Atypical NST: Additional fetal assessment and a review of maternal and fetal health status is required. Recommended Actions Abnormal NST: Immediate further investigation is essential; urgent delivery may be indicated. Clearly stated, readily accessible protocols

identifying interdisciplinary team member responsibilities and actions must be in place. (SOGC, 2007) G1 with HDP at 37 weeks < 6 FM in 2 hours Old and Moldy Practices (CPPC) Common, ineffective measures Maternal glucose administration

Manual fetal manipulation .not recommended Biophysical Profile (BPP) Ultrasound assessment of 3 fetal behaviors i.e. movements, breathing movements, and tone Ultrasound assessment of amniotic fluid volume (AFV) NST

Components of BPP Component Criteria 1. Movements 3 body or limb movements 2. Breathing movements

1 episode of > 30 seconds 3. Tone An episode of extension with return to flexion of a limb or trunk or Opening and closing of the hand 4. AFV

1 amniotic fluid pocket of 2 cm x 2 cm 5. NST Normal Scoring each component: 0 absent; 2 present The total score is reported Amniotic Fluid Volume (AFV) Amniotic fluid volume is a key component

of the BPP. AFV is affected by the production and flow of fetal urine. Decreased amniotic fluid (in the absence of ROM, renal malfunction or obstructed urinary tract) will occur when blood is redistributed away from the kidneys in response to chronic hypoxia. BPP Scoring A score of 8/10 is considered normal

provided it includes 2 for AFV. A score of 6/10 is considered equivocal (provided the score for AFV is 2); further investigation is required. A score of 0 for AFV or a total score of 4/10 is abnormal and associated with a high probability of fetal asphyxia; delivery will likely be indicated. Practices Related to the BPP In some facilities, an NST is not routinely

part of the BPP, provided a perfect score for all ultrasound components is achieved. Score will be 8/8 A modified BPP involves an NST and the AFV component only. Umbilical Artery Doppler Ultrasound measurement of the velocity of blood flow away from the fetus through the umbilical arteries into the placenta

There is normally a positive flow toward a healthy placenta as resistance in the placental bed is lower than in the umbilical arteries. If resistance in the placenta is increased, blood flow is impaired and gas exchange between the placenta and fetus is compromised. End-Diastolic Blood Flow Velocity

Indirect assessment of resistance within the placental bed and overall functioning of the placenta Results: normal, reduced, absent or reversed Risk of perinatal mortality increases as arterial blood flow slows, stops or reverses. Contraction Stress Test (CST) Oxytocin is administered until the woman experiences 3 contractions in 10 minutes, each lasting 1 minute.

It is considered positive if there are late decelerations occurring with 50% of the contractions; negative if the tracing is normal without late decelerations. CSTs are rarely done because of the risk of tachysystole and options for ultrasound assessments that are more readily accessible. In summary The only method of antepartum FHS

recommended for all women is maternal awareness of fetal movement, with fetal movement counting if a decrease in movements is perceived. Other methods should be initiated only in pregnancies at risk for adverse outcomes. Each unit should have clearly stated, readily accessible protocols identifying interdisciplinary team member responsibilities and actions related to results of antepartum FHS.

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