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GROUP 2

Fetal
Movement

Passive unstimulated fetal activity commences as


early as 7 weeks (Vindla and James, 1995)
Beyond 8 menstrual weeks, fetal body movements
are never absent for periods exceeding 13
minutes (DeVries and co-workers, 1985).
20 and 30 weeks, general body movements
become organized & fetus starts to show restactivity cycles movement (Sorokin and co-workers,
1982).
In third trimester, fetal maturation continues until
approximately 36 weeks, when behavioral states
are established in most normal fetuses

Nijhuis & colleagues (1982) Described 4 fetal


behavioral state:
State 1F - quiescent statequiet sleep - narrow
oscillatory bandwidth of fetal heart rate
State 2F frequent gross body movements,
continuous eye movements & wider oscillation of
fetal heart rate.
State 3F continuous eye movements. No body
movements/ heart rate accelerations.
State 4F vigorous body movement , continuous
eye movements & heart rate accelerations.

Oosterhof and co-workers (1993) study revealed

SLEEP AWAKE
CYCLE

- 1ST Determinant of fetal activity

SLEEP CYCLICITY has been described as varying


from 20 minutes to 75 minutes.
Timor-Tritsch and associates (1978) - mean length of
quiet/ inactive state for term fetuses was 23 minutes.
Patrick and associates (1982) measured fetal body
movements for 24-hour & found longest period of
inactivity to be 75 minutes.

Amniotic Fluid volume


- 2ND Determinant of fetal activity

Sherer and colleagues (1996)


Decreased fetal activity with diminished amniotic
volumes
Restricted uterine space might physically limit
fetal movements

Sadovsky and colleagues


- 3 categories of fetal movements
- Weak,
- Strong
- Rolling movements

Mean number of weekly


movements for 12 hour
recordings
20 weeks 200
32 weeks 572
40 weeks - 282

Clinical Application
Fetal movement is a way of
prognosticating well-being.
Tocodynamometer, visualization with
sonography, and maternal subjective
perceptions are used.
The American College of Obstetricians and
Gynecologists (2002) suggests that the
woman count distinct fetal movements
daily after 28 weeks gestation.
Perception of 10 distinct movements in up
to 2 hours is considered reassuring.
Counting can be discontinued for that day

Harrington and colleagu


es (1998)
Pregnancy outcomes for
women who complained
of decreased fetal
movement were not
significantly different
from those for women
without this complaint

Fetal Breathing

1972
inward and outward
flows of tracheal fluid in sheep =
BMs
BMs differ from FMs
Paradoxical =inspiration collapse
expiration distend
Not continuous
May be coughing to expel A
debris
Essential for fetal development

TYPES OF BMS
Gasps/sighs = 1-4/ minute
Irregular bursts = up to 240c/m
As GA
BMs rate and
volume
At 33 36 weeks lung
maturation =
Weeks 40 30
diurnal variation
after meals

If BMs are not seen:


Extend U/S evaluation for up to 2
hours before diagnosis of absent
BMs

Factors affecting BMs


Hypoxia
Hypoglycemia
Labor
Impending PTL
Amniocentesis

. Sound
. Cigarette
. FHR
. GA

BMs as a marker of fetal


wellbeing
Unfulfilled because multiple
factor it affect it, but it
included in BPP with Other
indices.

Contraction
Stress Test

CONTRACTION STRESS TEST


(CST)

CST is a useful method for


determining fetal well-being.
It is a stress test based on the
fact that uterine contractions
decrease uteroplacental blood
flow. This transient decrease
may be enough to evoke a
significant response in the
compromised fetus.

Two methods to induce


contractions:

1.Nipple Stimulation
Test
2.Oxytocin Challenge
Test (OCT)

Nipple Stimulation Test


One method recommended by the
American College of Obstetricians and
Gynecologists (2007) involves a woman
rubbing one nipple through her clothing
for 2 minutes or until a contraction begins.
She is instructed to restart after 5 minutes
if the first nipple stimulation did not induce
three contractions in 10 minutes.
Longer stimulation may evoke
exaggerated uterine activity.
If this is not effective, proceed to an
oxytocin challenge test.

Oxytocin Challenge
Test

Patients is placed in the semi-fowler


position.
An external FHR monitor (usually Doppler
ultrasound) and a uterine activity (toco)
monitor are placed on the mothers abdomen.
FHR and uterine activity are observed for
1030 min (base- line).
Oxytocin is then administered by
controlled IV infusion pump at a rate of 0.5
mU/min and doubled every 20 minutes
until a satisfactory contraction pattern is

Interpretation

Non Stress Test

NON-STRESS TEST
Test of FETAL well being
Aka NST
Describe fetal heart rate acceleration in
response to fetal movement as a sign of fetal
health
NST is primarily a test of fetal condition, whereas,
the CST, is a test of uteroplacental function
Currently, the most widely used primary testing
method for assessment of fetal well-being; and now
also a part of the BPS (Biophysical Profile Scoring)
testing system.

FETAL HEART RATE


ACCELERATION
- Normally increase or decrease by autonomic influences
mediated by SNS or PNS impulses from the BS centers
Beat-to-beat variability is also under the control of ANS
Pathological loss of acceleration seen with significantly
decreased beat-to-beat variability of FHR
Central depression 2ndary to meds also result in loss
of reactivity & associated with sleep cycles
- NST is based on the hypothesis that the HR of a fetus
who is not acidotic as a result of hypoxia or neurological
depression will temporarily accelerate in response to fetal
movement
- Fetal movement during testing are identified by the
maternal perception & recorded

In a woman w/ diabetic
ketoacidosis:
TRACING A: obtained during
maternal & fetal acidemia: Shows
absence of accelerations,
diminished variability, & late
decelerations w/ weak spontaneous
contractions
TRACING B: return of normal
accelerations & variability of the
fetal HR following correction of
maternal academia

Percentage of body movements


accompanied by acceleration & the
amplitude of these accelerations increased
w/ gestational age
The NICHHD definition of NORMAL
ACCELERATION:
> 32 weeks AOG:The acme of
acceleration is 15 bpm or more above the
baseline rate,& the acceleration lasts 15
seconds or longer but less than 2 minutes.
< 32 weeks AOG: accelerations are
defined as having an acme 10 bpm or
more above baseline for 10 seconds or
longer.

WAYS TO PERFORM NST


Involved the use of Doppler-detected
fetal HR acceleration coincident w/
fetal movt perceived by mother

NORMAL NST
2 or more accelerations that peak 15
bpm or more above baseline, each
lasting 15 sec or more & all
occurring w/in 20 min of the
beginning the test
Fetal movements indicated by
vertical marks on the lower part of

It was also recommended that


accelerations w/ or w/out fetal
movement be accepted, & that a 40
min or longer tracing to account for
fetal sleep cycles should be
performed before concluding that there
was insufficient fetal reactivity
Vibroacoustic stimulator can produce a
high sound like the take off of a jet w/c can
stimulate the baby to wake up

Average sleep cyclicity of baby is 23


mins, max at 25 mins

Abnormal NST
Silent oscillatory pattern: consisted of a
FHR baseline that oscillated less than 5
bpm & presumably indicated absent
acceleration & beat-to-beat variability
Terminal Cardiotocogram: baby is about
to expire
Baseline oscillation of less than 5 bpm
Absent accelerations
Late decelerations w/spontaneous
uterine contraction

NOTE: Oxytocin challenge test can


also be done to show decelerations
- The lack of FHR acceleration, when
not d/t maternal sedation, is an
ominous finding. Can be d/t:

Fetal-growth restriction
Oligohydramnios
Fetal acidosis
Meconium
Placental Infarction

- NST that were nonreactive for 90


mins were almost invariably (94%)
associated w/ significant perinatal

INTERVAL B/W TESTING


- Reactive NST: Good
- The interval b/w test, originally 7 days, has
been shortened as experience evolved w/ NST
- More frequent testing for the following
conditions:
postterm pregnancy
multifetal gestation
Type 1 DM
Fetal growth restriction
Gestational Htn
2x wkly tests are advised w/ additional
testing performed for maternal or fetal
deterioration
- Others perform NST daily or even more

Decelerations during NST


Fetal movts commonly produce HR
decelerations
Variable decelerations, if nonrepetitive &
brief less than 30 secs do not indicate
fetal compromise or the need for
obstetrical intervention
In contrast, repetitive variable
decelerations at least 3 in 20 mins
even if mild, have been associated w/ an
increased risk of cesarean delivery for
fetal distress
Decelerations lasting 1 min or longer
have an even worse prognosis

INTERPRETATION OF NST
False-normal NST
Causes fetal death w/in 1 wk of normal NST:
Postterm pregnancy
Most common autopsy finding was meconium
aspiration
Intrauterine infection
Abnormal cord position
Malformations
Placental abruption
NST was inadequate to preclude such an acute
asphyxia event; other biophysical characteristics
might be beneficial adjuncts like:
BPS testing
Counting & recording of fetal movements

Acoustic
Stimulation
Test

ACCOUSTIC
STIMULATION TEST

Loud external sounds used to startle the fetus


that provoke heart rate acceleration.
acoustic stimulator is placed on the
maternal abdomen and stimulate up to 1 to
2 seconds
This may be repeated for up to 3 seconds
Positive response is defined as the
appearance of a qualifying acceleration
following stimulation.
Shorten the average stimulation time for
non-stress from 24 to 15 mins.

Biophysical
Profile

Fetal biophysical variables are the


accurate means of assessing fetal
health
Equipments required
Sonography machine and Doppler
ultrasound to record fetal heart rate
Tests require 30 to 60minutes
Five biophysical components assessed,
which includes: (1) fetal heart rate
acceleration, (2) fetal breathing, (3)
fetal movements, (4)fetal tone, and (5)
amnionic fluid volume.

Biophysical Profile
Score

Interpretation

Pregnancy
Management

Biophysical
ProfileNo Score,
Normal, non
fetal
asphyxiated
intervention; repeat
Interpretation,
and Pregnancy
testing per protocol
Management
8/10 (Decreased
Chronic fetal
Deliver
8/10 (Normal AFV)

AFV)

asphyxia suspected

Possible fetal
asphyxia

Probable fetal
asphyxia

If amnionic fluid
volume abnormal ,
deliver
If normal fluid at
>36 weeks with
favorable cervix,
deliver
If repeat test 6,
deliver
If repeat test >6,
observe and repeat
per protocol
Repeat testing same
day; if biophysical
profile score 6,

Component

Score 2

Score 0

2 accelerations
of
0 Scores
or 1 acceleration
Components
and
Their
for
15 beats/min for 15 within 2040 min
sec
the Biophysical
Profile

Nonstress test/Fetal
heart rate

within 2040 min

Fetal breathing

1 episode of rhythmic
breathing lasting 30
sec within 30 min

<30 sec of breathing


within 30 min

Fetal movement

3 discrete body or
limb movements within
30 min

<3 discrete movements

Fetal tone

1 episode of
extremity
extension/flexion

0 extension/flexion

Amnionic fluid volume

Largest single vertical


pocket of amnionic fluid pocket 2 cm
measures at least 2 cm
in
two planes
perpendicular to each
other (2x2 cm pocket)

MOST COMMON CAUSES OF FETAL


DEATH AFTER ASSESING
BIOPHYSICAL PROFILE

Fetomaternal hemorrhage
Umbilical cord accidents
Placental abruption
Severe growth restriction
Severe immune hemolytic anemia
Rarely fetal acidemia

Studies had be conducted with


measurement of umbilical venous
blood pH values obtained via
cordocentesis
biophysical score of 0 was
invariably associated with
significant fetal acidemia which
explains abnormal pH leading to
abnormal biophysical profile ,
whereas normal score of 8 or 10
was associated with normal pH

Mean umbilical vein pH in relation


to fetal
biophysical profile score

Modified Biophysical
Profile
As biophysical profile is labor intensive so , it
as abbreviated as the first-line antepartum
screening test
Specifically, combined biweekly nonstress
tests with the amnionic fluid index and
considered 5 cm to be abnormal.
Required approximately 10 minutes to perform
After many studies ,concluded that this test is
as predictive of fetal well-being as other
approaches to biophysical fetal surveillance

Amnionic Fluid
Volume

AMNIONIC(amniotic) FLUID
VOLUME (AFI) :
It is an estimate of the
amount of amnionic fluid and is
an index for the fetal wellbeing. It
is a part of biophysical profile. AFI
is the score ( expressed in cm )
given to the amount of amnionic
fluid seen on ultrasonography of a
pregnant uterus.

PHYSIOLOG
Y

Change in volume through


gestation
10 weeks gestation it is about
10 to 20 ml
At 16 weeks gestation ~250 ml
At 33 weeks gestation ~ 800 ml
At 38-39 weeks reaches a
plateau of ~ 1000 ml
Finally decrease at weeks to

RATE OF CHANGE
*At 8 weeks the volume increase by ~10 ml/week
*At 13 weeks the AFV increase by 25 ml/week &
reaches a maximum rate of 60ml/week at 21 weeks
gestation.
*The weekly volume increment then decrease and
reaches zero at about 33weeks of gestation at
which point the mean AFV reaches its peak.
*AFV declines at a rate of ~8 per week.
*The first half of pregnancy AFV is closely
correlated with fetal weight.
*The ratio of amniotic fluid to fetal volume increase
until about 30weeks gestation and then appears to
decline.

Radiographic
assessment

Ultrasound
- is the modality of choice of assessing
amniotic fluid volumes
The AFV can be assessed by ultrasound
by using 3 main indirect parameters:
- single deepest (maximum vertical)
pocket method.
- amniotic fluid index
- two diameter pocket method .

Doppler
Velocimetry

Doppler history
Fitzgerald & drumm. Umbilical artery
studies 1977.
Eik nes et al. fetal aortic
velocimetry:dupplexscanner 1980 lancet.
Campbell et al. utero-plancental
circulation: dupplexscanner 1983 lancet
Wladimiroff et al. MCA/UA PL ratio 1987
OG
Kiseud et al. ductus venosus velocimerty
1991 lancet.

Basic principals
Echoes from stationary tissues are
the same from pulse to pulse.
Echoes from moving objects exhibit
slight differences in the time for the
signal to be returned to the receiver.
The differences can be measured as
phase shift from which the doppler
frequency is obtained.

ObstetricsAtechniqueusedto
analyzebloodflowwaveforms,
allowingaccurate,
noninvasivemeasurementofv
olumeandvelocityofbloodflo
w.
The first use of doppler
ultrasonography was reported
in 1977.

Who gets the test?


Doppler velocimetry is a way to
make sure that your baby is getting a
healthy supply ofblood. You may
need it if earlier tests showed that
your baby could be having problems.
Maybe your baby is growing slowly or
hasanemia. You may also need the
test if you have preeclampsiaor
have a low level ofamniotic fluid.

What the test does?


Doppler
velocimetry
usesultrasoundto
checkbloodflow in the
umbilical cord or between
the
uterus
and
the
placenta. If the blood
supply is restricted, your

How the test is done?


Doppler velocimetry is painless and
safe. It's similar to a standard
ultrasound. A technician will gently
press an ultrasound probe against
the outside of your belly.

What to know about test


results
If your doctor finds abnormal results,
you may need further testing or
closer monitoring. In some cases,
your doctor may recommend early
delivery to help your baby.

Current
Antenatal T
esting

Recommendation
s

According to the American


College of Obstetricians and
Gynecologists
(2007),
THERE IS NO BEST TEST
TO EVALUATE FETAL
WELLBEING

Three testing systems


Contraction stress test
Nonstress test
Biophysical profile

The American College of


Obstetricians and Gynecologists
(2002) patient education pamphlet
describes these tests of fetal wellbeing and summarizes as follows:
Monitoring helps you and your doctor
during your pregnancy by telling more about
the well-being of the baby. If a test result
suggests that there may be a problem, this
does not always mean that the baby is in
trouble. It simply may mean that you need
special care or more tests. Discuss any
questions you have about monitoring with
your doctor.

Consideration to begin
antepartum testing
- Prognosis for neonatal survival
- Severity of maternal disease

High-risk pregnancies,
testing begin by 32 to 34
weeks.
Pregnancies with severe
complications might require
testing as early as 26 to 28
weeks.
The frequency for repeating
tests, 7 days, but more frequent

Significance of Fetal
Testing

Does antenatal fetal testing really


improve fetal outcome?
Platt and co-workers (1971 to1985)
Fetal surveillance increased from less
than 1 percent of pregnancies in the
16
early 1970s to 15
percent in the mid14
12
1980s.
10
8
6
4
2
0

1970

1980
Series 3

These authors concluded that


such testing was clearly
beneficial, because the fetal
death rate was significantly less
in the tested high-risk
pregnancies compared with

the rate in those not tested.

Whether antepartum
fetal surveillance identifies fetal asphyxia early enough to prevent brain damage???

attempted to correlate
cognitive development in infants up to age 2
years following either abnormal umbilical artery
Doppler velocimetry or nonstress test results.
Only abnormal nonstress tests were associated
with marginally poorer cognitive outcomes.
Todd and co-workers (1992)

These investigators concluded that by the time fetal


compromise is diagnosed with antenatal testing, fetal
damage has already been sustained.

Manning and co-workers(1998)


Incidence of cerebral palsy in 26,290
highrisk pregnancies managed with serial
biophysical profile testing.
They compared these outcomes with
those of 58,657 low-risk pregnancies in
which antepartum testing was not
performed.
The rate of cerebral palsy was 1.3 per 1000 in
tested pregnancies compared with 4.7 per
1000 in untested women.

Sonography In
Obstetrics

OBSTETRIC
SONOGRAPHY/ULTRASONOGRAPHY

MEDICAL ULTRASONOGRAPHY
IN PREGNANCY

SOUNDS WAVES ARE USED TO


CREATE REAL-TIME VISUAL
IMAGES OF THE DEVELOPING
EMBRYO OF FETUS IN ITS
MOTHERS UTERUS (WOMB)

SONOGRAPHY (PRENATAL)
INCLUDES FIRST AND SECOND

TRIMESTER FETAL ANATOMIC


EVALUATION AND SPECIALIZED STUDIES
PERFORMED TO CHARACTERIZE
ABNORMALITIES

ANOMALIES INCREASINGLY DIAGNOSED


= FIRST TRIMESTER

PRODUCED BY SOUND WAVES THAT


ARE REFLECTED BACK FROM FLUID
AND TISSUE INTERFACES OF THE:

FETUS
AMNIOTIC FLUID
PLACENTA

ULTRASOUND TRANDUCERS,
OFTEN CALLED PROBES, COME
IN DIFFERENT SHAPES AND
SIZES FOR USE IN DIFFERENT
SCANNING SITUATIONS. FOR
EXAMPLE, IN AN OBSTETRIC
SCAN

SECTOR ARRAY
TRANSDUCER
CONTAIN
PIEZOELECTRIC
CRYSTALS
- CONVERT
ELECTRICAL ENERGY
INTO SOUND WAVES,
WHICH ARE EMITTED
IN SYNCHRONIZED
PULSES

DENSE TISSUE SUCH AS BONE

PRODUCES HIGH-VELOCITY REFLECTED


WAVES DISPLAYED A BRIGHT ECHOES
ON THE SCREEN

FLUID GENERATES FEW REFLECTED


WAVES AND APPEARS DARK OR
ANECHOIC

DIGITAL IMAGES GENERATED AT 50 TO

MORE THAN 100 FRAMES PER SECOND


UNDERGO POST PROCESSING THAT
YIELDS THE APPEARANCE OF REAL-TIME
IMAGING

ULTRASOUND
REFERS TO SOUND WAVES TRAVELLING AT A

FREQUENCY ABOVE 20, 000 HERTZ 9CYCLE PER


SECOND)

HIGHER FREQUENCY TRANSDUCERS YIELD BETTER


IMAGE RESOLUTION

LOWER FREQUENCY PENETRATE TISSUE


EFFECTIVELY

INDICATIONS FOR FIRST-TRIMESTER


ULTRASOUND EXAMINATION
CONFIRM AN INTRAUTERINE
PREGNANCY

EVALUATE A SUSPECTED ECTOPIC


PREGNANCY

DEFINE THE CAUSE OF VAGINAL


BLEEDING

EVALUATE PELVIC PAIN


ESTIMATE GESTATIONAL AGE

DIAGNOSE AND EVALUATE MULTIFETAL


GESTATIONS

CONFIRM CARDIAC ACTIVITY


ASSIST CHORIONIC VILLUS SAMPLING,
EMBRYO TRANSFER, AND LOCALIZATION
AND REMOVAL OF AN INTRAUTERINE
DEVICE

ASSESS FOR CERTAIN FETAL ANOMALIES


SUCH AS ANENCEPHALY, IN HIGH-RISK
PATIENTS

EVALUATE MATERNAL PELVIC MASSES


AND/OR UTERINE ABNORMALITIES

MEASURE NUCHAL TRANSLUCENCY


WHEN PART OF A SCREENING PROGRAM
FOR FETAL ANEUPLOIDY

EVALUATE SUSPECTED GESTATIONAL


TROPHOBLASTIC DISEASE

COMPONENTS OF STANDARD
ULTRASOUND EXAMINATION
BY TRIMESTER
FIRST TRIMESTER

GESTATIONAL SAC SIZE, LOCATION, AND NUMBER


EMBRYO AND/OR YOLK SAC IDENTIFICATION
CROWN-RUMP LENGTH
FETAL NUMBER, INCLUDING AMNIONICITY AND
CHORIONICITY OF MULTIFETAL GESTATIONS

EMBRYONIC/FETAL CARDIAC ACTIVITY

ASSESSMENT OF EMBRYONIC/FETAL
ANATOMY APPROPRIATE FOR THE FIRST
TRIMESTER

EVALUATION OF THE MATERNAL UTERUS,


ADNEXA, CUL-DE-SAC

EVALUATION OF THE FETAL NUCHAL


REGION, WITH CONSIDERATION OF FETAL
NUCHAL TRANSLUCENCY ASSESSMENT

AND
CHORIONICITY OF MULTIFETAL
GESTATIONS

FETAL CARDIAC ACTIVITY


FETAL PRESENTATION
PLACENTAL LOCATION, APPEARANCE, AND
RELATIONSHIP TO THE INTERNAL CERVICAL
OS,
WITH DOCUMENTATION OF PLACENTAL
CORD
INSERTION SITE WHEN TECHNICALLY
POSSIBLE

AMNIOTIC FLUID VOLUME

GESTATIONAL AGE ASSESSMENT


FETAL WEIGHT ESTIMATION
FETAL ANATOMICAL SURVEY, INCLUDING
DOCUMENTATION OF TECHNICAL LIMITATIONS

EVALUATION OF THE MATERNAL UTERUS, ADNEXA,


AND CERVIX WHEN APPROPRIATE

INDICATIONS FOR SECOND OR THIRD


TRIMESTER ULTRASOUND EXAMINATION
MATERNAL INDICATIONS

VAGINAL BLEEDING
ABDOMINAL/PELVIC PAIN
PELVIC MASS
SUSPECTED UTERINE ABNORMALITY
SUSPECTED ECTOPIC PREGNANCY

SUSPECTED MOLAR PREGNANCY


SUSPECTED PLACENTA PREVIA AND
SUBSEQUENT SURVELLIANCE

SUSPECTED PLACENTAL ABRUPTIO


PRETERM PREMATURE RUPTURE OF
MEMBRANES , AND OR PRETERM LABOR

CERVICAL INSUFFICIENCY
ADJUNCT TO CERVICAL CERCLAGE
ADJUCT TO AMNIOCENTESIS OR OTHER
PROCEDURE

ADJUCT TO EXTERNAL CEPHALIC VERSION

FETAL INDICATIONS

GESTATIONAL AGE ESTIMATION


FETAL-GROWTH EVALUATION
SIGNIFICANT UTERINE SIZE/CLINICAL DATE
DISCREPANCY

SUSPECTED MULTIFETAL GESTATION


FETAL ANATOMICAL EVALUATION
FETAL ANOMALY SCREENING

ASSESSMENT FOR FINDINGS THAT MAY


INCREASE THE ANEUPLOIDY RISK

ABNORMAL BIOCHEMICAL MARKERS


FETAL PRESENTATION DETERMINATION
SUSPECTED HYDRAMNIOS OR
OLIGOHYDRAMNIOS

FETAL WELL-BEING EVALUATION

FOLLOW-UP EVALUATION
OF A FETAL ANOMALY

HISTORY OF CONGENITAL
ANOMALY IN PRIOR
PREGNANCY

SUSPECTED FETAL DEATH


FETAL CONDITION
EVALUATION IN LATE
REGISTRANTS FOR
PRENATAL CARE

Normal And
Abnormal
Fetal Anatomy

Central Nervous System


Anomalies of the fetal brain are among the most
common, and sonography is extremely useful to detect
and characterize them.

TRANSTAHLAMIC VIEW
- is used to measure BPD, HC and includes the thalami
and cavum septum pellucidum.

TRANSVENTRICULAR VIEW
- includes the atria of the lateral ventricles, which
contain the echogenic choroid plexus

TRANSCEREBELLAR VIEW
- Is obtained by angling the view
back through the posterior fossa.
- Between 15 and 22 weeks, the
cerebellar diameter in millimeters is
roughly equivalent to the gestational
age in weeks.
- Abnormalities detected in any of
these three views suggest a possible

fetal brain anomaly.

Specialized evaluation may permit


accurate diagnosis of abnormalities
such as:
- Neural-tube defects
- Ventriculomegaly
- Holoprosencephaly
- Hydranencephaly
- Dandy-Walker malformation
- Agenesis of the corpus callosum
- Porencephaly, or intrtacranial
tumor.

NEURAL TUBE DEFECT


These malformations are the second most
common class of congenital anomalies
Cardiac anomalies are the most common.
Neural-tube defects are found in approximately
1.6 per 1000 live births in the United States.
Defects result from incomplete closure of the
neural tube by the embryonic age of 26-28 days
.

ANENCEPHALY
is a lethal defect characterized by absence
of the brain and cranium above the base
of the skull and orbit.
It can be diagnosed in the late first
trimester, and with adequate visualization,
All cases may be diagnosed in the second
trimester.

CEPHALOCELE
also termed encephaloceleis a
herniation of meninges and brain
tissue through a cranial defect,
typically an occipital midline defect
Associated hydrocephalus and
microcephaly
are common, and there is a high
incidence of mental impairment among
surviving infants.

SPINA BIFIDA
is an opening in the vertebrae through
which a meningeal sac may protrude.
OR
Is a disorder in which the two sides of
vertebral arches, usually in lower
vertebra ,fail to fuse during
development ,resulting in an OPEN
VERTRBRAL CANAL .

2 types of S. Bifida
S.aperta and s.occulta
The commonest type is S.bifida
occulta ,in which there is a defect in
the vertebral arch of L5 or S1.
The most severe form of S.bifida
involves complete failure of fusion of
posterior arch at the lumbosacral
junction with a large outpouching of
meninges.

Arnold-Chiari II
malformation
associated with spina bifida occurs when
downward displacement of the spinal cord
pulls a portion of the cerebellum through
the foramen magnum into the upper
cervical canal.
The result in the blockage of the exist in
the roof of the ( 4 th) ventricle to the CSF,
causing internal HYDROCEPHALUS.

It is commonly associated with


craniovertebral anomalies or
various forms of S.bifida.
S&S: realated to the pressure on
the cerebellum and M.oblongata
& involvement of LAST 4
C.NERVE are associated with this
condition.

cranial findings:
scalloping of the frontal bones
the so-called lemon
sign
bowing of the cerebellum
with effacement
of the cisterna magnathe

banana sign

VENTRICULOMEGALY
Enlargement of the cerebral ventricles is a
nonspecific marker of abnormal brain
development.
The lateral ventricle is commonly measured at its
atrium, which is the confluence of the temporal
and occipital horns
The atrial measurement is normally between
5 and 10 mm from 15 weeks until term

MILD VENTRICULOMEGALY
10 to 15 mm.

SEVERE VENTRICULOMEGALY
>15 mm

HOLOPROSENCEPHALY
With this abnormality, the
prosencephalon fails to divide completely
into two separate cerebral hemispheres
and underlying diencephalic
structure.

As a result, in the most severe form


alobar holoprosencephalya single
monoventricle

DANDY WALKER MALFORMATION


this abnormality of the posterior fossa is
characterized by agenesis of the cerebellar
vermis, enlargement of the posterior
fossa, and elevation of the tentorium.
Dandy-Walker malformation is associated
with a large number of genetic and
sporadic syndromes, aneuploidies,
congenital
viral infections, and some teratogens, all
of which greatly affect the prognosis.

CYSTIC HYGROMA
This is a malformation of the lymphatic
system in which fluid filled sacs extend
from the posterior neck
They typically develop as part of a
lymphatic obstruction sequence, in which
lymph from the head fails to drain into the
jugular vein and
accumulates instead in
jugular lymphatic sacs.

Approximately 60 to 70 percent of cystic


hygromas cases are associated with
aneuploidy.
When cystic hygromas are diagnosed in
the first trimester, the most common
aneuploidy is trisomy 21
If fetuses with cystic hygromas diagnosed
in the second trimester, approximately 75
percent of aneuploid cases are 45,XTurner
syndrome

THORAX
The lungs are best visualized after 20
to 25 weeks and appear as
homogeneous structures surrounding
the heart.
variety of thoracic malformations
including cystic adenomatoid
malformation, extralobar pulmonary
sequestration , bronchogenic cyst,
may be seen sonographically.

DIAPHRAGMATIC HERNIA
They are leftsided and posterior in 90
percent, and the most common
sonographic
finding is repositioning of the heart to
the middle or right side of the thorax by
the stomach and bowel.
Associated findings include absence of
the stomach bubble within the abdomen,
small abdominal circumference, and
bowel peristalsis seen in the fetal chest.

HEART
Cardiac malformations are the most common
congenital anomalies with an incidence of
approximately 8 per 1000 live birth.

Almost 90 percent of cardiac defects are multifactorial


or polygenic.
Up to 30 to 40 percent of cardiac defects diagnosed
prenatally are associated with chromosomal
abnormalities

50 to 70 percent of aneuploid fetus have


extracardiac anomalies that are
identifiable sonographically.
In 75 percent of fetus with congenital
heart anomalies had an axis angle that
exceeded 75 degrees.
45 percent of those with abnormal hearts
had left axis deviation.

The American Institute of


Ultrasound in Medicine (2007)
recommends that if technically
feasible, each standard examination
should attempt to evaluate both left
and right ventricular outflow tracts.

A specialized examination with fetal


echocardiography is typically
performed if there are any of the
following.

ABDOMINAL WALL
GASTROSCIHISIS

This is a full-thickness abdominal wall defect typically


located to
the right of the umbilical cord insertion, and bowel
herniates
through the defect into the amnionic cavity.

Fetuses with gastroschisis are at risk for growth


restriction at increased , affecting 15 to nearly 40
percent

Infants with growth restriction, however, did not have


increased mortality rates or longer hospitalization
compared with affected infants who were normally grown

OMPHALOCELE
This anomaly complicates approximately 1
per 5000 pregnancies.
It forms when the lateral ectomesodermal
folds fail to meet in the midline, leaving
the abdominal contents covered only by a
two-layered sac of amnion and
peritoneum.
In over half of cases, an omphalocele is
associated with other major anomalies or
aneuploidy

GIT
stomach is visible in nearly all fetuses
after 14 weeks, and the liver, spleen,
gallbladder, and bowel can be identified in
many second- and third trimester.
Nonvisualization of the stomach within the
abdomen is associated with a number of
abnormalities.
These include esophageal atresia,
diaphragmatic hernia, abdominal wall
defects, and neurological abnormalities
that inhibit fetal swallowing.

KIDNEY
Kidney lie retroperitoneal space
slightly above the level of the
umbilicus.
They range in length and weight
,respectively from approximately
,from 6 CM, AND 24 g, in a full term
NEWBORN.
IF > 12 CM, AND 150 g, IN AN
ADULT

KIDNEY AND URINARY


TRACT
Fetal kidneys are easily visible adjacent to
the fetal spine, frequently as early as 14
weeks, and routinely by 18 weeks.

The placenta and membranes are the


major source of amnionic fluid early in
pregnancy
But after 18 WEEKS MOST OF THE FLUID IS
PRODUCED BY KIDNEY.
Unexplained oligohydramnios suggests a

RENAL AGENESIS
One or both kidneys are congenitally absent in
1 in 4000 births. The kidney is not visible, and
the adrenal gland typically enlarges to fill the
renal fossa.
Aptly termed this the LYING DOWN ADRENAL
SIGN.
If renal agenesis is bilateral, no urine is
produced, and the resulting anhydramnios
leads to pulmonary hypoplasia, limb
contractures, a distinctive compressed face,
and death from cord compression or pulmonary
hypoplasia.

POLYCYSTIC KIDNEY
DISEASE

It is hereditary polycystic diseases,


only the infantile form of autosomal
recessive polycystic kidney disease
may be reliably diagnosed antenatally.
The abdominal circumference is
enlarged, and there is SEVERE
OLIGOHYDRAMNIOS.

BLADDER OUTLET
OBSTRUCTION
This distal obstruction of the urinary tract is more
common in male fetuses, and the Most common
etiology is POSTERIOR URETHRAL VALVES.
Oligohydramnios portends a POOR PROGNOSIS
because of pulmonary hypoplasia.
Prenatal diagnosis allows some affected fetuses
to benefit from early intervention postnatally or
even consideration of in utero therapy.

3 And 4
Dimensional
Sonography

3D SONOGRAPHY
The goal is to obtain and
enhance real time 2d findings.
Special transducers use to obtain
volumes and images of 3D.
It can produce a 3D portrait of
the fetal face and most popular
technique in the public.

For selected anomalies such


in the face and the skeleton
3D may provide additional
formation.
Comparing 3D and 2D
sonography in diagnosing
congenital anomalies it
doesnt show any
improvement in overall
detection.

According to the American


College of Obstetricians and
Gynecologist the clinical
advantage of 3D sonography
in general is lacking.
But the precise utility of this
technology has yet to be fully
determined.

One potential advantage of 3D


sonography it can reformat
images in any plane.
For example the image is
obatined in axial plane it can be
reformatted in saggital, coronal
or oblique plane.
Sequential slices can be
generated similar to CT or MRI
imaging.

In viewing fetal surface structure


it must be surrounded by
amnionic fluid.
With crowding adjacent
structures it is difficult to
understand the image.
According to American college of
Obstetricians and Gynecologist
recommends that 3D ultrasound
used only as adjunct to
conventional sonography.

4D IMAGING
It is used to improve the
visualization of cardiac
anatomy.
It can also view the blood
flow of the heart and the
great vessels and
measurement of ventricular
blood volume.

Doppler

USE in Obstetrics
-primarily in the
areas of duplex
velocimetry and color
mapping.
IMPORTANCE in
Obstetrics
-Used to determine
the volume and rate of
blood flow

2 types of Doppler

Doppler Equation

Umbilical a.
Has forward flow with the cardiac cycle,
and the amount flow during diastole
increase as gestation advances.
S/D ratio decreases from about 4.0 at 20
weeks to 2.0 at term.
The measurement is considered to be
useful adjunct in the management of
complicated by fetal-growth restriction.
Abnormal if the S/D ratio is above 95 th
percentile for gestational age.

Ductus arteriosus
Doppler evaluation of
Ductus arteriosus used
primarily to monitor fetus
exposed in indomethacin
and others NSAIDS

Middle Cerebral Artery


(MCA)
Doppler measurement of
MCA clinically for detection
of fetal anemia and in
assessment of growth
restriction

Ductus Venosus
Severe fetal-growth restriction and
cardiac dysfunction may lead to
venous flow abnormalities, including
pulsatile flow on the umbilical vein
and abnormal ductus wave forms.
Use of Venous Doppler for the
management of fetal-growth
restrictions require demonstration of
perinatal benefit before adoption

M
Mode
Echocardiograph
y

M- Mode
Echocardiography
Motion- mode (M-Mode)
sonography
Linear display of events of
cardiac cycle
X- axis time
Y- axis motion
Measures fetal heart rate,
deviations normal rate and

Allows precise characterization of


arrhythmia
Includes separate evaluation of atrial
and ventricular waveforms
Used to assess ventricular function
and atrial and ventricular outputs
New applications have color mapping
which permits exquisite evaluation of
wall motion and blood velocity
Detects supraventricular tachycardias
and premature atrial contractions

Fetal Imaging
MRI

netic Resonance Imaging (M

Mid-1980s
SSFSE Single Shot Fast Spin Echo
HASTEHalf-Fourier Acquisition Single
RARE

shot Turbo spin Echo


Rapid Acquisition with
Relaxation Enhancement

Echo-planar imaging

Images

Acquired
within
1sec
No need
for
sedation &
motion
artifact

Sonograph
y

portable
Fast
acquisition

MRI
Hindered only
minimally
by bony interfa
ces,
obesity, oligoh
ydramnios,
engaged fetal
he ad
Adjunct to feta
l so
complex abnor no for
malities
No ionizing rad
iation

Sono

Preferred
method of
imaging
fetal
intracrania
l abn

MRI

CNS

Accurate determination of
lesion bilaterally
Superior especially because
of the improved resolution
Adjunct in the antenatal dx
of some suspected cranial
anomalies
Exquisite detail of posterior
fossa, midline structures,
cerebral cortex
Acquisition of images in the
axial, coronal, & sagittal planes
irt the fetus or maternal pelvis

Fetal Brain
Development &
nd
2 Opinion MR
Evaluation
MRIImaging
more accurate
in
evaluating subtle early
migrational abnormalities
Isolated ventriculomegaly
most
common
reason
for fetal MR

Cerebral Lesions with


Multifetal Gestation
MRI evaluate monochorionic twin
gestations

Hemorrhage
Periventricular
leukomalacia
Twin-twin transfusion
syndrome or

Sono
Adjunct with
MRI for
congenital
abn

MRI
Further

Thorax

evaluate
thoracic
Evaluate
masses abn to
delineate location &
size
Quantify
the volume
of remaining lung
tissue
Excellent adjunct to sono
to evaluate for congenital
diaphragmatic hernia

Aids determination of liver


position & ID of abd
contents within the chest

Abdomen
Sono
Accurately dx
GU abn
Preferred
modality

MRI
Useful to evaluate (+)
oligohydramnios/materna
l obesity & complex
anomalies
Differentiate b/w GU
& GI abn

Sono
Used to ID
myometrial
invasion
Excellent to
determine
myometrial
involvement

MRI

Placenta

Help in
surgical
planning
Help in patient
counseling
Used as adjunct
in
indeterminate
Posterior
placenta
cases
accrete dxd accurately
by MRI
Superior to evaluate
myometrial invasion

Fetal & Uterine


Volumetry

MRI determine specific


organ volumes
+ potential use to
reconstruct a 3-D image

Pelvimetry
MRI assess pelvic capacity &
predict vaginal delivery

None has been found


clinically valuable

Electronic Fetal
Monitoring

Electronic fetal
monitoringis a procedure in
which instruments are used to
continuously record the
heartbeat of thefetusand
the contractions of the
mother's uterus during labor
INDICATIONS Previous h/o stillbirth
Complications of pregnancy
Induction of Labor
Preterm labor
Nonreassuring fetal status;
fetal movement
Meconium staining of
amniotic fluid

Internal
Monitoring

External (Indirect) Monitoring

MONITORING
PATTERNS
Baseline FHR = 120 160 bpm
Tachycardia baseline above 160 BPM
Bradycardia baseline below 110 BPM
Wandering baseline - rate is unsteady
& wanders between 120-160 beats/ min

VARIABILITY
- Normal/ increased variability or irregularity of a
cardiac rhythm.
- Divided into short term and long term.
- Absence or decreased variability, or a smooth flat
baseline, is a sign of fetal Causes
compromise.
of
Causes of decreased
variability
Hypoxia and acidosis
Medications
Sleep cycle
Preterm status

increased
variability
Fetal breathing
Fetal body
movements
Advanced
gestation

Undetectable,
absent variability
Minimal
variability, 5
beats/min
Moderate (normal)
variability, 6 to 25
beats/min.
Marked variability,
25 beats/min
Sinusoidal pattern
differs from variability in
that it has a smooth, sine
like pattern of regular

Periodic changes in the FHR

ACCELERATIONS
A visually apparent increaseonset to peak in less
than 30 secin the FHR from the most recently
calculated baseline decelerations.
Proposed mechanisms
fetal movement
stimulation by uterine contractions
umbilical cord occlusion
fetal stimulation during pelvic examination
Fetal scalp blood sampling
acoustic stimulation
without any apparent stimulus.

EARLY DECELERATIONS

In association with
a uterine
contraction, a
visually apparent,
usually symmetrical,
gradual onset to
nadir 30 sec
decrease in FHR with
return to baseline
Related to Head
Compression
Seen in active
labor between 4-7
cm cervical

VARIABLE
DECELERATIONS

Variable An abrupt
onset to nadir 30 sec,
visually apparent
decrease in the FHR
below the baseline
Related to cord
compression

LATE
DECELERATIONS
Late In
association with a
uterine contraction,
a visually apparent,
gradualonset to
nadir 30 sec
decrease in FHR
with return to
baseline
Related to
decreased
uteroplacental
perfusion

PROLONGED
DECELERATIONS
Prolonged - isolated deceleration lasting
2 minutes or longer but less than 10
minutes from onset to return to baseline
Causes

Cervical examination
Uterine hyperactivity
Cord entanglement
Maternal supine hypotension

Complications of EFM
Application at other sites e.g. eye
Fetal vessel rupture
Severe cord compression
Placental penetration, uterine
perforation
Increased risk of puerperal infection
Scalp wounds & cranial osteomyelitis

Other
Intrapartum
Assessment

Techniques

Fetal scalp blood


sampling
Measurements of the pH in capillary scalp blood
may help to identify the fetus in serious distress,
also emphasized that neither normal nor abnormal
scalp pH results have been shown to be predictive
of infant outcome.(According to the American
College of Obstetricians and Gynecologists 1995 )

Techniques
An illuminated endoscope is inserted
through the dilated cervix after
membrane rupture so as to press
firmly against the fetal scalp .
An incision is made through the skin
to adepth of 2 mm with a special
blade on a long handle. So the blood
drops can immediately collected into
a heparinized glass capillary tube.

Scalp stimulation
In 1984 Clark and associates have
suggested that scalp stimulation is
an alternative to scalp blood
sampling which was based on the
observation that acceleration of the
heart rate in response to pinching of
the scalp with an Allis clamp is just
prior to obtaining blood was
invariably associated with a normal
pH.

Later, in 1997
Elimian and
associates reported that of 58
cases in which the fetal heart rate
accelerated 10 beats/min or more
after 15 seconds of gentle digital
stroking of the scalp, 100 percent
had a scalp pH of 7.20 or greater.
Without an acceleration, however,
only 30 percent had a scalp pH less
than 7.20.

Vibroacoustic
Stimulation
Vibroacoustic
stimulation
is
considered normal if a fetal heart rate
acceleration of at least 15 beats/min
for at least 15 seconds occurs within
15 seconds after the stimulation
It was reported by some investigators
that vibroacoustic stimulation in
second-stage labor is associated with
fetal heart rate reactivity,

Fetal Pulse Oximetry


Its similar to adult pulse oximetry, which may
allow assessment of fetal oxyhemoglobin
saturation once membranes are ruptured.
Transcervical
device
has
been
used
extensively by many investigators and has
been reported to reliably register fetal oxygen
saturation in 70 to 95 percent of women
throughout 50 to 88 percent of their labors.
( Vintzileos and associates 2005 , Yam and coworkers 2000 )

fetal oxygen saturation normally varies


greatly when measured in umbilical artery
blood
According to the report of Bloom and
associates (1999) brief, transient fetal oxygen
saturations below 30 percent were common
during labor because such values were
observed in 53 percent of fetuses with normal
outcomes. However if its persist more than 2
minutes or longer were associated with an
increased risk of potential fetal compromise.

Cesarean delivery for fetal distress was


performed when pulse oximetry values
remained less than 30% for the entire interval
between two contractions or when the fetal
heart rate patterns met predefined guidelines.
The use of fetal pulse oximetry significantly
reduced the rate of cesarean delivery for
nonreassuring fetal status from 10.2 to 4.5 %.
There were no neonatal benefits or adverse
effects associated with fetal pulse oximetry. In
2000 FDA approved marketing of the Nellcor N400 Fetal Oxygen Monitoring System.

Fetal Electrocardiography
Technique requires internal monitoring of the
fetal heart rate and special equipment to
process the fetal ECG
Hypoxemia develops an elevated ST segment
with a progressive rise in T-wave height that
can be expressed as a T:QRS ratio . It is
postulated that increasing T:QRS ratios reflect
fetal cardiac ability to adapt to hypoxia and
appears
before
neurological
damage.
Progression of hypoxia results in an
increasingly negative ST-segment deflection
such that it appears as a biphasic waveform

ST abnormalities might
occur late in the course of
fetal compromise.

Intrapartum Doppler
Velocimetry
Doppler analysis of the umbilical artery
has been studied as another potential
adjunct to conventional fetal monitoring.
abnormal Doppler waveforms may signify
pathological umbilical-placental vessel
resistance. From their review, Farrell and
co-workers (1999) concluded that this
technique was a poor predictor of adverse
perinatal outcomes and also Doppler
velocimetry had little, if any, role in fetal
surveillance during labor.

Fetal Distress

> when the fetus does not


receive adequate amounts of
O2 during pregnancy or labor.
> an antepartum or
intrapartum diagnosis.
Committee on Obstetric Practice, American
College of Obstetricians and Gynecologists

Committee on Obstetric
Practice of the American
Congress of Obstetricians and
Gynecologists (ACOG)
fetal distress non reassuring

National Institute of Child Health and Human Development (2008)

Conditions Behind Fetal Distress


-

meconium in the amniotic fluid


oligohydraminos
anemia
pregnancy induced hypertension (PIH)

Management options

Tocolysis

terbutaline sulfate 0.25 mg


IV/subqutaneous injection
nitrogycerin 60 to 180 ug IV

Amnioinfusion
miyazaki and taylor (1983)
infused saline trough an intrauterine
pressure catheter in laboring women who
had either variable decelerations or
prolonged decelerations attributed to cord
entrapment. Such therapy improve the
heart rate pattern in half of the women
studied.
1985- found that those who were treated
with amnioinfusion required caesarean
delivery for fetal distress less often.

Current recommendations:
The methods most commonly used for fetal
heart rate monitoring include auscultation
with a fetal stethoscope or a Doppler
ultrasound device, or continuous Electronic
monitoring of the heart rate and uterine
contractions.
No scientific evidence has identified the
most effective method, including the
frequency or duration of fetal surveillance
that ensures optimum results.

Intrapartum
Surveillance
Monitoring Of
Uterine Activity

Uterine muscle efficiency to


effect delivery varies greatly.
To use an analogy, 100meter sprinters all have the
same muscle groups yet cross
the finish line at different
times.

Internal Uterine Pressure Monitoring


Amnionic fluid pressure is measured between and
during contractions by a fluid-filled plastic
catheter with its distal tip located above the
presenting part .
The catheter is connected to a strain-gauge
pressure sensor adjusted to the same level as the
catheter tip in the uterus.
The amplified electrical signal produced in the
strain gauge by variation in pressure within the
fluid system is recorded on a calibrated moving
paper strip simultaneously with the fetal heart
rate recording
Intrauterine pressure catheters are now available
that have the pressure sensor in the catheter tip,

External Monitoring
Uterine contractions canbemeasured by a
displacement transducer in which the
transducer button, orplunger, is held
against the abdominal wall.
As the uterus contracts, the button moves
in proportion to the strength of the
contraction. This movement is converted
into a measurable electrical signal that
indicates the relative intensity of the
contraction.
It has generally been accepted to not give
an accurate measure of intensity

Patterns of Uterine Activity


Montevideo units
uterine performance is the product of
the intensityincreased uterine
pressure above baseline toneof a
contraction in mm Hg multiplied by
contraction frequency per 10 minutes.
For example, three contractions in 10
minutes, each of 50 mmHg intensity,
would equal 150 Montevideo units

Patterns of Uterine Activity


During the first 30 weeks of pregnancy,
uterine activity is comparatively
quiescent.
Contractions are seldom greater than 20
mm Hg, and these have been equated
with those first described in 1872 by John
Braxton Hicks.
Uterine activity increases gradually after
30 weeks, and it is noteworthy that these
Braxton Hicks contractions also increase
in intensity and frequency
Further increases in uterine activity are
typical of the last weeks of pregnancy,

clinical labor usually commences


when uterine activity reaches values
between 80 and 120 Montevideo
units.
This translates into approximately
three contractions of 40 mm Hg
every 10 minutes.
Importantly, there is no clear-cut
division between prelabor and labor,
but rather a gradual and progressive
transition

During first-stage labor, uterine contractions increase


progressively in intensity from approximately 25 mm
Hg at commencement of labor to 50 mm Hg at the
end.
At the same time, frequency increases from three to
five contractions per 10 minutes, and uterine baseline
tone from 8 to 12 mm Hg.
Uterine activity further increases during second-stage
labor, aided by maternal pushing.
Indeed, contractions of 80 to 100 mm Hg are typical
and occur as frequently as five to six per 10 minutes.
the duration of uterine contractions60 to 80
secondsdoes not increase appreciably from early
active labor through the second stage

Presumably, this duration constancy serves fetal


respiratory gas exchange. During a uterine
contraction, as the intrauterine pressure exceeds
that of the intervillous space
uterine contractions are clinically palpable only after
their intensity exceeds 10 mm Hg. Moreover, until
the intensity ofcontractions reaches 40 mm Hg, the
uterine wall can readily be depressed by the finger.
Uterine contractions usually are not associated with
pain until their intensity exceeds 15 mm Hg,
presumably because this is the minimum pressure
required for distending the lower uterine segment
and cervix.
It follows that Braxton Hicks contractions exceeding
15 mm Hg may be perceived as uncomfortable
because distention of the uterus, cervix, and birth
canal is generally thought to produce discomfort.

The uterus is expected to remain well relaxed


during pregnancy, to contract effectively but
intermittently during labor, and then to
remain in a state of almost constant
contraction for several hours postpartum.
Uterine activity progressively and gradually
increases from prelabor through late labor.
uterine contractions after birth are identical
to those resulting in delivery of the infant.
It is therefore not surprising that the uterus
that performs poorly before delivery is also
prone to atony and puerperal hemorrhage

Origin and Propagation of


Contractions

The normal contractile wave of labor originates near the


uterine end of one of the fallopian tubes. Thus, these areas
act as pacemakers.
The right pacemaker usually predominates over the left
and starts most contractile waves. Contractions spread
from the pacemaker area throughout the uterus at 2
cm/sec, depolarizing the whole organ within 15 seconds.
This depolarization wave propagates downward toward the
cervix.
Intensity is greatest in the fundus, and it diminishes in the
lower uterus. This phenomenon is thought to reflect
reductions in myometrial thickness from the fundus to the
cervix.
this descending gradient of pressure serves to direct fetal
descent toward the cervix and to efface the cervix
all parts of the uterus are synchronized and reach their

A contractile wave begins in one cornual-region pacemaker,


but does not synchronously depolarize the entire uterus.
As a result, another contraction begins in the
contralateralpacemaker and produces the second
contractile wave of the couplet. These small contractions
alternating with larger ones appear to be typical of early
labor.
Indeed, labor may progress with such uterine activity,
albeit at a slower pace.
labor would progress slowly if regular contractions were
hypotonicthat is, contractions with intensity less than 25
mm Hg or frequency less than 2 per 10 minutes.
The authors suggested that these levels of uterine activity
should be sought before consideration of cesarean delivery
for presumed dystocia

New Terminology for Uterine


Contractions
This has been recommended by the
American College of Obstetricians and
Gynecologists (2013b), for the description
and quantification of uterine contractions.
Normal uterine activity is defined as five
or fewer contractions in 10 minutes,
averaged over a 30-minute window.
Tachysystole was defined as more than
five contractions in 10 minutes, averaged
over 30 minutes. Tachysystole can be
applied to spontaneous or induced labor.
The term hyperstimulation was abandoned

Complications of Electronic Fetal


Monitoring

Electrodes for fetal heart rate evaluation and


catheters for uterine contraction measurement
An intrauterine pressure catheter during
placement may lacerate a fetal vessel in the
placenta. Also with insertion, placental and
possibly uterine perforation can cause
hemorrhage, serious morbidity,
Severe cord compression has been described
from entanglement with the pressure catheter.
Injury to the fetal scalp or breech by a heart
rate electrode is rarely severe

Both the fetus and the mother may be at


increased risk of infection from internal monitoring
Scalp wounds from the electrode may become
infected, and subsequent cranial osteomyelitis
has been reported.
The American Academy of Pediatrics and the
American College of Obstetricians and
Gynecologists (2012) have recommended that
certain maternal infections, including human
immunodeficiency virus (HIV), herpes simplex
virus, and hepatitis B and C virus, are relative
contraindications to internal fetal monitoring.