Arch Gynecol Obstet (2002) 267:19–22
O R I G I N A L A RT I C L E
M. Krapp · S. Denzel · A. Katalinic · C. Berg
U. Germer · U. Gembruch
A preliminary study of fetal ductus venosus blood flow during
the first stage of labor
Received: 2 July 2001 / Accepted: 25 September 2001
Abstract Objective: The measurement of fetal ductus
venosus blood flow during labor by means of color
Doppler sonography. Methods: 26 women between 37
and 41 weeks of gestation were included in the study. At
various stages of cervical dilation (<2 cm, 2–4 cm, 6–
8 cm, and fully dilated) blood flow velocity waveforms of
the fetal ductus venosus during and between contractions
were studied in fetuses with a negative non-stress test.
The Pulsatility index for veins (PIV) and the Peak veloci-
ty index for veins (PVIV), respectively were calculated
off-line. The mean±standard deviation between and dur-
ing contractions were determined for descriptive analysis.
Results: Waveforms were visualized during 139 contrac-
tions and 159 episodes of uterine relaxation in 24 of 26
fetuses (92.3%) in normal labor. Three and more wave-
forms were recorded, in 59.0% during contractions
(82/139) and in 57.9% between contractions (92/159), re-
spectively. The mean PIV and PVIV values during con-
tractions were 1.68±1.02 and 1.46±0.72, respectively.
Between contractions the values were 0.49±0.21 for the
PIV and 0.44±0.18 for the PVIV, respectively. Conclu-
sion: Ductus venosus blood flow can be visualized in
labor. Further studies are needed to establish normal
values.
Keywords Labor · Ductus venosus · Fetus · First stage
of labor · Doppler-sonography · Fetal hypoxemia
The study was supported by a grant of the German Research
Foundation (GE 1058/1-1).
M. Krapp (✉) · S. Denzel · C. Berg · U. Germer · U. Gembruch
Division of Prenatal Medicine,
Department of Obstetrics and Gynecology,
Medical University of Lübeck, Ratzeburger Allee 160,
D-23538 Lübeck, Germany
e-mail: DrMartinKrapp@web.de
Tel.: ++49-451-5002155, Fax: ++49-451-5002192
A. Katalinic
Institute of Social Medicine, Medical University of Lübeck
© Springer-Verlag 2002
Introduction
Electronic fetal heart rate monitoring is widely used for
fetal surveillance during labor. The sensitivity of this
method is considered to be very high [2], whereas speci-
ficity is low resulting in an increase in cesarean section
rates for fetal distress without a significant improvement
of perinatal outcome [7, 17, 22].
Ultrasound examination of the fetal ductus venosus
was introduced ten years ago [12, 14] and reference
ranges were established [9]. In hypoxemic and acedemic
growth-retarded fetuses increased pulsatility of the duc-
tus venosus blood flow resulting from an elevated central
venous pressure may be caused by myocardial dysfunc-
tion and increased cardiac afterload [18]. The grade of
deterioration of venous indices showed a good correla-
tion to the fetal acid base status [10, 18]. Furthermore an
increase of pulsatility of ductus venosus blood flow has
been reported in fetal cardiac dysfunction of different
etiologies [11, 15, 25]. According to these studies it is
possible, that hypoxemia-induced cardiac dysfunction in
labor may be followed by alterations of fetal ductus
venosus blood flow velocity waveforms. We therefore
decided to investigate, whether the measurement of the
fetal ductus venosus blood flow during labor by means
of color Doppler sonography is feasible.
Materials and methods
With approval of the local Ethic Committee 26 women, admitted
to the labor and delivery ward of the Department of Obstetrics and
Gynecology, Medical University of Lübeck, Germany, were en-
rolled in the study between August 1999 and February 2000 after
written informed consent.
Inclusion criteria were gestational age between 37 and 41
weeks confirmed by crown-rump-length in the first trimester
and/or last menstrual cycle and normal fetal growth. Pulsatility
and resistance indices of the umbilical artery and the middle cere-
bral artery of all fetuses were within normal limits. All women
were in the first stage of labor with a negative non-stress test.
Exclusion criterias were fetal anomalies, multiple pregnancy, pre-
eclampsia, polyhydramnios, breech presentation, preterm ruptures
of membranes [20], and meconium-stained amniotic fluid [27].
20
During and between uterine contractions blood flow velocity
waveforms of the fetal ductus venosus were visualized by a
4.0-Mhz phased array sector scanner (Acuson XP 128/10 OB;
Acuson Inc., Mountain View, California, USA). The ductus venosus
was investigated either in a midsagittal longitudinal plane or in an
oblique or transverse plane during fetal apnea by means of grey-
scale, color-coded, and pulsed wave Doppler sonography. The com-
plete ultrasound examinations were recorded on videotapes for sub-
sequent analysis of the pulsatility index for veins (PIV) and the peak
velocity index for veins (PVIV) as published by Hecher et al. [9] in
1994. The ultrasound examinations were performed at various stag-
es of cervical dilation (<2 cm, 2–4 cm, 6–8 cm, and fully dilated).
The mean±standard deviation of the PIV and PVIV of all measure-
ments between and during contractions were calculated.
Umbilical arterial blood gas measurements and APGAR scores
were used for the evaluation of fetal outcome.

Results
We examined a total of 26 fetuses during the study. In
24 of these cases (92.3%) we were able to visualize the
fetal ductus venosus blood flow in normal labor between
(Fig. 1a) and during (Fig. 1b) uterine contractions. In the
remaining two cases the ductus venosus was not display-
able by color Doppler sonography because of obesity of
the mothers and unsuitable presentation of the fetuses.
Clinical data of these 24 cases are displayed in Table 1.
Blood waveforms of the ductus venosus were record-
ed during 139 contractions and 159 episodes of uterine
relaxation at four different stages of cervical dilation
(Fig. 2). We were able to record three or more velocity
waveforms of the ductus venosus in 59.0% during con-
tractions (82/139) and in 57.9% between contractions
(92/159) (Fig. 3). Because of the limited amount of cases
Fig. 1a, b Ductus venosus blood flow velocity waveforms, a be- with three or more consecutive waveforms, we used de-
tween contractions at 4 cm of cervical dilation, b during contrac- scriptive rather than statistical analysis.
tions at 4 cm of cervical dilation The insonation angle was above 10° in all cases and
therefore unsuitable for absolute measurements of maximal
Table 1 Clinical data of 24 cases
velocities. Angle correction was not used because the inso-
nation angle of the ductus venosus was not clearly verifi-
n=24 able in the oblique or transverse scanning planes, which
were used most of the time. The mean PIV and PVIV val-
Maternal age in yearsa 27.6±4.38 ues during contraction were 1.68±1.02 and 1.46±0.72 re-
Gestational age in weeksa 39.4±1.50
Percentage of epidural anasthesia 58.3% spectively. Between contraction the values were 0.49±0.21
Mode of delivery for the PIV and 0.44±0.18 for the PVIV. During all mea-
Spontaneous [%] 18 (75) surements the fetal heart rate ranged between 120 and 160
Forceps [%] 3 (12.5) beats per minute (mean: 142±15.7). The arterial blood pH
Cesarean section [%] 3 (12.5)
at birth ranged from 7.19 to 7.42 (mean: 7.31; SD: 0.063).
a All values are given as mean±standard deviation There were no APGAR scores <7 in the study population.

Fig. 2 Distribution of the ductus venosus blood flow measurements during labour in 24 patients

Fig. 3 Distribution of numbers of recorded waveforms cycles of
the ductus venosus per measurement attempt during and between
contraction
Discussion
After introduction of Doppler sonography research
groups interrogated different fetal vessels during labor.
Early studies visualized blood flow in the umbilical ar-
tery [4] and middle cerebral artery [16]. Maesel et al.
[16] revealed no differences in blood flow velocity indi-
ces of the middle cerebral artery between and during
contractions in fetuses with a negative non-stress test,
whereas in presence of abnormal fetal heart rate pattern
and reduced oxygen saturation the indices were signifi-
cantly increased [21]. Fleischer et al. [4] demonstrated
constant umbilical artery waveforms over a wide range
of uterine pressures. Many studies used intrapartum um-
bilical artery Doppler velocimetry as a labor admission
test. However, a recent systematic review by Farrell et
al. [3] demonstrated that this method is a poor predictor
of adverse perinatal outcome. Tadmor et al. [23] used
computerized Doppler waveforms to analyse umbilical
artery flow parameters during fetal variable decelera-
tions. In their opinion it may be possible to differentiate
between two groups of variable decelerations. Firstly,
variable decelerations which are caused by umbilical ar-
tery occlusion and thus preceded by a measurable in-
crease in umbilical artery resistance and secondly, vari-
able decelerations caused by fetal hypoxia which are not
preceded by a measurable increase in umbilical artery re-
sistance but elevated venous pressure. Increased venous
resistance, common in compromised fetuses, is detect-
able by fetal venous blood flow alterations [1, 5, 8, 13,
18, 24]. Furthermore an increase of pulsatility of ductus
venous blood flow has been reported in fetal cardiac dys-
function of different kinds [6, 11, 15, 25]. From these
studies it appears, that fetal hypoxemia in labor may be
21
caused by cardiac dysfunction detectable by alterations
of fetal ductus venosus blood flow.
We therefore wanted to investigate, whether the mea-
surement of fetal ductus venosus blood flow by color
Doppler sonography is feasible during labor.
In this study we were able to demonstrate fetal ductus
venosus blood flow velocity waveforms in 92.3% of the
26 cases. Only in two cases was image quality unsuffi-
cient. Furthrmore, we only succeeded in recording three
or more cycles of ductus venosus waveforms in 57.9%
during episodes of uterine quienscence and in 59% during
contractions in the remaining 24 fetuses. This low rate of
visualization was due to unsuitable position of the fetus,
obesity of the mother and non-cooperation of patients
during contractions despite an epidural anasthesia rate of
58.3%, which is more effective than parenteral analgesia
or transcutaneous nerve stimulation in pain and dis-
comfort relief [19, 26]. This should be improved in future
studies by state-of-the-art ultrasound equipment and more
experienced examiners. Commonly at least three cycles
of waveforms are needed for analysis. Because of the
limited numbers of patients, who fullfilled the require-
ments, we used descriptive rather than statistical analysis.
During uterine quiesence the Doppler waveforms were
triphasic with antegrade flow during atrial contraction.
Because of high insonation angles we were not able to
measure absolute velocities in the fetal ductus venosus. In
our opinion angle correction is not an option in these
cases because the insonation angle of the ductus venosus
was not clearly verifiable in the oblique or trans-
verse abdominal scanning planes, which were used most
of the time. The PVIV and PIV values between con-
tractions were within normal limits compared to prenatal
normal values. However, during contractions the ductus
venosus blood flow showed a marked increase in pulsati-
lity confirmed by elevated PVIV and PIV levels.
These findings suggest that more data during uterine
contraction and quiescence should be collected to exam-
ine whether there is a significant difference between them
and to establish normal values before studying wave-
forms during labor complicated by fetal distress.
References
1. Baschat AA, Gembruch U, Reiss I, Gortner L, Weiner CP,
Harman CR (2000) Relationship between arterial and venous
Doppler and perinatal outcome in fetal growth restriction. Ul-
trasound Obstet Gynecol 16:407–413
2. Evertson LR, Gautier RJ, Schifrin BS, Paul RH (1979) Ante-
partum fetal heart rate testing. I. Evolution of the nonstress
test. Am J Obstet Gynecol 136:29–33
3. Farrell T, Chien PFW, Gordon A (1999) Intrapartum umbilical
artery Doppler velocimetry as a predictor of adverse perinatal
outcome: a systematic review. Br J Obstet Gynaecol 106:783–
792
4. Fleischer A, Anyaegbunam AA, Schulman H, Farmakides G,
Randolph G (1987) Uterine and umbilical artery velocimetry
during normal labor. Am J Obstet Gynecol 157:40–43
5. Gembruch U (1996) Assessment of the fetal circulatory state
in uteroplacental insufficiency by Doppler ultrasound: which
vessel are the most practicable? Ultrasound Obstet Gynecol
8:77–81
22
6. Gembruch U, Krapp M, Germer U, Baumann P (1999) Venous
Doppler in the sonographic surveillance of fetuses with supra-
ventricular tachycardia. Eur J Obstet Gynecol Reprod Biol
84:187–192
7. Gilstrap LC, Hauth JC, Hankins GDV, Beck AW (1987) Sec-
ond stage fetal heart rate abnormalities and type of neonatal
acidemia. Obstet Gynecol 70:191–195
8. Gonser M, Erz R, Goelz R, Franz HBG (1996) Circulatory
Doppler parameters in fetal hypoxaemia. Prenat Diagn
16:755–759
9. Hecher K, Campbell S, Snijders R, Nicolaides K (1994) Refer-
ence ranges for fetal venous and atrioventricular blood flow
parameters. Ultrasound Obstet Gynecol 4:381–390
10. Hecher K, Snijders R, Compbell S, Nicolaides K (1995) Fetal
venous, intracardiac, and arterial blood flow measurements in
intrauterine growth retardation: relationship with fetal blood
gases. Am J Obstet Gynecol 173:10–15
11. Hecher K, Ville Y, Snijders R, Nicolaides K (1996) Doppler
studies of the fetal circulation in twin-twin transfusion syn-
drome. Ultrasound Obstet Gynecol 5:318–324
12. Huisman TWA, Stewart PA, Wladimiroff JW (1992) Ductus
venosus blood flow velocity waveforms in the human fetus-A
doppler study. Ultrasound Med Biol 18:33–37
13. Kiserud T (1999) Hemodynamics of the ductus venosus. Eur
J Obstet Gynecol Reprod Biol 84:139–147
14. Kiserud T, Eik-Nes SH, Blaas H-G, Hellevik LR (1991) Ultra-
sonographic velocimetry of the fetal ductus venosus. Lancet
338:1412–1414
15. Krapp M, Gembruch U, Baumann P (1997) Venous blood flow
pattern suggesting tachycardia-induced ”cardiomyopathy” in
the fetus. Ultrasound Obstet Gynecol 10:32–40
16. Maesel A, Lingman G, Marsal K (1990) Cerebral blood flow
during labor in the human fetus. Acta Obstet Gynecol Scand
69:493–495
17. Parer JT, Livingston EG (1990) What is fetal distress? Am
J Obstet Gynecol 162:1421–1427
18. Rizzo G, Capponi RE, Talone D, Arduini D, Romanini C
(1996) Doppler indices from inferior vena cava and ductus
venosus in predicting pH and oxygen tension in umbilical
blood at cordocentesis in growth-retarded fetuses. Ultrasound
Obstet Gynecol 7:401–410
19. Sheiner E, Shoham-Vardi I, Sheiner EK, Press F, Hackmom-
Ram R, Mazor M, Katz M (2000) A comparison between the
effectiveness of epidural analgesia and parenteral pethidine
during labor. Arch Gynecol Obstet 263:95–98
20. Sheiner E, Segal D, Shoham-Vardi I, Ben-Tov J, Katz M,
Mazor M (2000) The impact of early amniotomy on mode of
delivery and pregnancy outcome. Arch Gynecol Obstet
264:63–67
21. Sütterlin MW, Seelbach-Göbel B, Oehler MK, Heupel M,
Dietl J (1999) Doppler ultrasonographic evidence of intrapar-
tum brain-sparing effect in fetuses with low oxygen saturation
according to pulse oximetry. Am J Obstet Gynecol 181:216–
220
22. Sykes GS, Molloy PM, Johnson P, Stirrat GM, Turnball AC
(1983) Fetal distress and the condition of the newborn infants.
BMJ 287:943–945
23. Tadmor O, Bocker Y, Rabinowitz R, Aboulafia Y, Yagel S,
Stark M, Diamant YZ, Nitzan M (1999) Analysis of umbilical
artery flow parameters during fetal variable decelerations
using computerized Doppler waveforms. Fetal Diagn Ther
14:2–10
24. Tchirikov M, Rybakowski C, Hüneke B, Schröder HJ (1998)
Blood flow through the ductus venosus in singleton and multi-
fetal pregnancies and in fetuses with intrauterine growth retar-
dation. Am J Obstet Gynecol 178:943–949
25. Tulzer G, Gudmundsson S, Wood DC, Cohen AW, Weiner S,
Huhta JC (1994) Doppler in non-immune hydrops fetalis.
Ultrasound Obstet Gynecol 4:279–283
26. Van der Spank JT, Cambier DC, De Paepe HM, Danneels LA,
Witvrouw EE, Beerens L (2000) Pain relief in labour by trans-
cutaneous electical nerve stimulation (TENS). Arch Gynecol
Obstet 264:131–136
27. Ziadeh SM, Sunna E (2000) Obstetric and perinatal outcome
of pregnancies with term labour and meconium-stained amni-
otic fluid. Arch Gynecol Obstet 264:84–87