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ANTEPARTUM SURVEILLANCE Goal of Fetal Testing -detection of chronic &intermediate term compromised to: Prevent stillbirth Decrease neonatal mortality Minimize long term morbidity No technique devised so far to detect -Acute antenatal compliance INDICATIONS for TESTING: Decrease fetal movement Maternal disease Fetal growth restriction Post-term pregnancy PROM Oligohydramnios TECHNIQUES MODALITIES US EFM Examination of Body fluid (Invasive) Reactive: at least 2 accelerations of at least 15 bpm for at least 15 seconds w/in 20 min period (term) 32 wks AOG: accel of 10 bpm (10 secs) *With acceleration, movement is detected!

LOSS OF REACTIVITY - Associated with fetal sleep cycle - May result form any cause of CNS depression inc. fetal acidosis - Nonreactive after 20 minscontinue monitoringanother 20 min to account for sleep pd. - Nonreactive after 40 minsproceed to BPP or CST to verify fetal condition BPP NST plus 4 variables observed by US: -Fetal Breathing Movts -Fetal movement -Fetal tone -AF Volume *When Oxygen delivery is normalnormal metabolismCNS regulation good Normal manifestation of parameter regulated by that reg. centerGood BPS Hypoxemia (or hypoxia?), anemia, ischemia, malnutrition, hypoglycemia, Abn metabolism, Exog. Fx (tranquilizers) adversely affect CNS regulation suppression of parameter FBM: 1 or more of rhythmic FBM of 30 seconds or more within 30 mins FM: (hehe, di ko nacopy, I think nasa APMC) Fetal Tone: 3 or more episodes of extension of fetal extremities with return to flexion or opening/closing of hand AFV: Single vertical pocket of AF >2cm --may reflect hypoxia if less than 2cm *AF productionfetal urine production at 2nd half of pregnancy Placental dysfunction dec. Renal perfusionoligohydramnios Renal perfusionurine AF Priority organs: Brain, Heart, Adrenals AFV: assess long term uteroplacental function AFI sum of deepest cord-free fluid pockets BPS Procedure: Each component= score of 2 Normal 0 if (-)/ insufficient 8-10: Normal 6: Equivocal 4 or <: Abnormal Oligohydramnios require further evaluation regardless of composite score Algorithm in BPS - US first - IF Normal no more NST - IF BPS not perfect NST ABN BPS/BPP

-Fetal Movt Counting -Non-stress test (EFM) -Biophysical Profile (US, EFM) -Fetal Umbilical Art. Velocimetry(US) -Contraction Stress Test (EFM)

IDEAL MONITORING SYSTEM Gather wide range of information Versatile for all maternal and fetal conditions All Gestational ages Varying degree of onset, deviation, severity PITFALLS OF FETAL MONITORING 1. 1 Parameter-iatrogenic injury & demise 2. Ensuring fetal safety while biding for maturation time is more demanding than single delivery Lesson: Combination of variables Fetal status Abn/N Accurate FETAL MOVEMENT COUNTING Compromised fetus reduces its activity in response to decreased oxygenation (+) of vigorous fetus is reassuring KICKS COUNT Pregnant Px: Records length of time that fetus to make 10 movements Select any period of day to count these Each fetus has its own degree IF fetus requires >2 hrs for 10 kickscontact Physician! (Normal: 2 hrs-10 min) - Simple, least expensive - Evidence lack in IUGR, Malformation, Stillbirths - A screening test, look for danger signals - (+) Danger signs: Px reports to Physician! NON-STRESS TEST - HR of fetus normal, not acidotic or (-) neurologic depressed will accelerate w/ fetal movement - HR reactivity is a good indicator of NORMAL fetal autonomic function EFM - Using CTG (cardiotocography?) Px in lateral recumbent position - Recording for 20 minutes - FHT range w/in Normal 120-160 bpm

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evaluation/ intervention term: prepare for delivery Fetus who is remote from termconservative! o Risk of fetal death is similar to neonatal mortality rate resulting from prematurity

: BPS weekly- AFI 5 cm at 34 wks - hydrate the mother!

FETAL UMBILICAL ART. VELOCIMETRY -Umbilical flow velocity waveform of Normal- High diastolic flow -Absurd or reversed end-diastolic flow reflects extreme placental vascular resistance (ominous) *Resistance thru placenta is high, precludes flow at diastole

Proven IUGRFunctional Ss NormalSerial assessment Non-intervention until fetal maturity Abn BPS <4 Delivery! Oligohydramnios AEDV/ARED

-reverse flow - valuable: IUGR - Abn patern of BF warrants: - Close surveillance (values beyond cut off using BPS) or - Intervention (Absent end diastolic vol or AEDV Or ARED) CONTRACTION STRESS TEST -attempt to mimic labor by inducing uterine contractions using: Oxytocin Nipple stimulation - HR pattern compared with contraction pattern - (+) of LATE DECELERATIONS suggest placental insufficiency - used if : other tests suspicious NST nonreactive CI when labor is CI: Previous Classical C/S Placental previa *Timing: antepartum- you can offer extrauterine support, alternative environenment when intrauterine envi is hostile TESTING 32-34 wks AOG: Lung maturity 26-28 wks AOG: in diabetes, chronic Hpn & isoimmunizations WHEN NOT TO DO : no indication at Term - likelihood of successful induction is high - High risk: weekly testing - 2x weekly: Standard for pregnancy 42 wks or > & for Px with IDDM NST can be done daily DETORIATION OF FETAL CONDITION- BPS 1.Abn umbilical cord BF Umb. Cord velocimetry 2. FHR variation is reduced 3. Loss of breathing movt 4. General fetal movt and tones are the last pattern to demonstrate abn results POST TERM PREGNANCY : Px: probability of successful induction, BPP useful while waiting for cervical opening : Purpose of BPP: avoid maternal morbidity failed induction followed by C/S delivery PIH : Doppler velocimetry- increased S/D & RI at 28 wks