COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF MIDWIFERY
MATERNITY AND RH NURSING POSTGRADUATE
CLASS
Lecture on Antepartum Fetal Surveillance

08/04/2021 By Yibelu B. (BSc, MSc) 1

 Presentation outline
 Objectives
 Introduction
 Methods of antepartum fetal assessment
Interpretation of AFS results
Management of abnormal test results
Summary
 Reference

08/04/2021 By Yibelu Bazezew 2

 Objectives
At the end of this session the learners will be
able to:
Define antepartum fetal monitoring
Recognize antepartum fetal assessment methods
Interpret AFS results
Identify possible management options for
abnormal test results

08/04/2021 By Yibelu B. (BSc, MSc) 3

Introduction
What is AFS?
What are the methods that used to test the fetus
in the antepartum period?
How do the health professionals perform
AFS?
 How do you interpret test results?

08/04/2021 By Yibelu B. (BSc, MSc) 4

 Introduction cont’d

 Antepartum fetal testing: a collection of

methods formulated to differentiate normal
from compromised fetuses prior to the onset
of labor.
 Ideal test: allows intervention before fetal
death or damage from asphyxia occur
 Preferable test: treat disease process &
allow fetus to go to term

08/04/2021 5
Introduction cont’d

80% fetal death occurs in the antepartum

period and
 many of the fetal deaths occur in woman at
risk for uteroplacental insufficiency
Goals of antepartum fetal surveillance
• Prevention of fetal death
• Avoidance of unnecessary interventions

08/04/2021 By Yibelu B. (BSc, MSc) 6

 Indications of AFS
 Woman at high risk for uteroplacental insufficiency
Maternal chronic medical disorders
DM, chronic HTN, chronic lung dx, renal/cardic dx, etc.
Pregnancy related conditions: Post term pregnancy,
PIH, multiple gestations, unexplainable previous
perinatal death, IUGR, Rh sensitized pregnancy,
PROM, oligohydramnios, decreased maternal
perception of fetal movement, etc.

08/04/2021 By Yibelu B. (BSc, MSc) 7

 Methods of antepartum fetal surveillance

What are the techniques that used to assess

the fetal health condition in the antepartum
period?

08/04/2021 By Yibelu B. (BSc, MSc) 8

 Techniques of evaluation

1. Clinical methods
 Careful risk evaluation of the pregnancy
 SFH measurement: GA vs SFH
 Discrepancy: more than 2-3wks deviation
 Serial measurement of weight
 Auscultation of fetal heart sound
 U/S
 GA assessment, DX of multiple pregnancy, congenital
malformation, fetal growth pattern

08/04/2021 By Yibelu B. (BSc, MSc) 9

 …Techniques of evaluation
2. Biophysical methods
 Fetal movement counting
 Antepartum fetal heart rate testing
 NST and CST
 Fetal biophysical profile(BPP)
 Doppler velocimetry

08/04/2021 By Yibelu B. (BSc, MSc) 10

 Fetal movement

Begins as early as 7th wk but becomes more

sophisticated and coordinated near term
Usually 1st perceived by mother at 16-20wks
(quickening)
 mother can appreciate 50% of isolated limb
movements and 80% of trunk and limb movements
when correlated with U/S
Fetal sleep-awake cycles are important
determinants of fetal activity; varies from 20-75 min
Active state :for average 40 minutes

08/04/2021 By Yibelu B. (BSc, MSc) 11

 ……… Fetal movement

State FHR acc. Variability. FBM/Eye GBM

1F No/rare Diminish infrequent No

2F Increased increase yes Yes

3F No Dec Eye No

4F increased constant yes Continuous

08/04/2021 By Yibelu B. (BSc, MSc) 12

 …..Fetal movement
Methods to quantify fetal movements
Maternal subjective perception
Visualization with u/s

tocodynamometer

08/04/2021 By Yibelu B. (BSc, MSc) 13

 …..Fetal movement
Maternal fetal movement count methods
Sadovsky
Fetal movement count for 30-60min ,2-3x daily
if <3movements/60min or no movement for >12hrs
is alarming
further evaluation is indicated
Rayburn
Count for at least 60min/day
<3 mov’ts /60min for two consecutive days may be a
sign of fetal compromise
08/04/2021 By Yibelu B. (BSc, MSc) 14
 …..Fetal movement
Cardiff count to ten method
at least 10 movements should be perceived in 12hrs
Commonly used method

Factors that affect perception of fetal

movements:
Maternal , placental ,fetal

08/04/2021 By Yibelu B. (BSc, MSc) 15

 …..Fetal movement
Consequence of decreased FM
Fetuses with decreased FM are associated with:
Increased stillbirth rate
Fetal distress in labor
Low APGAR score

Severe IUGR

16
 Antepartum FHR assessment
 Two types of FHR patterns
Reassuring
Nonreassuring
 Regulation of FHR
FHR and its conduction systems develop b/n 3 and
6wks
Factors that regulate FHR become functional in
later GA
ANS ( parasympathetic (PNS) and sympathetic
(SNS)) regulates the FHR patterns
08/04/2021 By Yibelu B. (BSc, MSc) 17
 The parasympathetic innervation of the heart

Primarily mediated by the vagus nerve

The two parasympathetic influences on the
heart are:
(1) Slowing of FHR
Stimulation of the vagus nerve- ↓se in FHR
Medications (e.g. atropine)
(2)  An oscillatory effect → FHR variability

08/04/2021 By Yibelu B. (BSc, MSc) 18

The sympathetic innervations of the heart

Distributed throughout the myocardium of the

term fetus.
Sympathetic stimulation results acceleration of
the FHR & improves myocardial contraction
Blockade of sympathetic activity ↓es baseline
FHR & blunts accelerations.

08/04/2021 By Yibelu B. (BSc, MSc) 19

 Effect of GA on FHR
 The PNS exerts a progressively greater influence on FHR as GA
advances (ie, advancing GA→ slowing of the baseline FHR).
 E.g. at 20 wks the average FHR is 155 bpm, while at 30 wks
it is 144 bpm.
 FHR variability- rare before 24 wks, while its absence is
abnormal after 28 wks since the PNS is consistently developed
by the third trimester.

 Regardless of GA, loss of variability is an abnormal finding once

a fetus has demonstrated that its HR responds to the oscillatory
input of the PNS.

08/04/2021 By Yibelu B. (BSc, MSc) 20

 Effect of GA on FHR cont’d
Advancing GA is associated with ↑sed frequency &
amplitude of FHR accelerations, modulated by the SNS
50% of normal fetuses demonstrate accelerations with
FM at 24 wks; 95% at 30 wks.
Before 32 wks accelerations are only 10 bpm for 10
sec rather than the 15 bpm sustained for 15 sec noted
after 32 wks.

08/04/2021 By Yibelu B. (BSc, MSc) 21

 Cardiovascular response to hypoxia
Fetal oxygenation depends upon:
 adequate maternal oxygenation,
 uteroplacental & fetoplacental blood flow, and
 distribution of oxygenated blood to fetal tissues.

Reduced fetal oxygenation may result from

 Maternal disorders (eg, resp. insufficiency, hypotension),
 Acute/chronic placental dysfunction (eg, abruptio placentae,
infarction)
 Uterine factors (eg, rupture, hyper stimulation), and fetal factors
(eg, arrhythmia, fetal hydrops, umbilical cord compression).

08/04/2021 By Yibelu B. (BSc, MSc) 22

 Cardiovascular response to hypoxia cont’d
 Hypoxemia first results in
+ chemoreceptors in the fetal carotid arteries
Signal the fetal brain stem to divert blood to vital organs
The brain stem responds with sympathetic stimulation
to constrict peripheral arterial beds, resulting in
systemic Htn and ed FH→ Tachycardia
Then Baroreceptors respond by sending a signal to the
brain stem + vagus nerve→ ↓FH
The bradycardia can manifest as late or variable
decelerations, depending upon the aetiology (feto-
placental/cord compression)

08/04/2021 By Yibelu B. (BSc, MSc) 23

 Cardiovascular response to hypoxia cont’d

As hypoxemia worsens:

the normal efferent sympathetic response to fetal
mov’t is abolished
accelerations of the FHR disappear
This stage is reflected by non reactivity of the NST

08/04/2021 By Yibelu B. (BSc, MSc) 24

 Cardiovascular response to hypoxia cont’d
Prolonged &/or severe hypoxemia results in
persistent bradycardia or repetitive late
decelerations related to myocardial depression.
Variability is lost
Ultimately, loss of fetal biophysical activities
such as breathing, movement, & body tone.
At this stage, the fetus may be acidotic

08/04/2021 By Yibelu B. (BSc, MSc) 25

Antepartum FHR assessment Cont’d
Currently, it’s generally performed in
pregnancies in which the risk of fetal death is
known to be ed:
Pregnancies at risk uteroplacental insufficiencies
Fetal disorders, or any other condition potentially
associated with increased risk of fetal death

08/04/2021 By Yibelu B. (BSc, MSc) 26

 Nonstress test (NST)
 A short term indicator of fetal acid-base status

 It’s the most widely used primary testing method of fetal well
being assessment
 FHR accelerations occur during fetal movement
 Can be initiated when the fetal neurological maturity enables
FHR accelerations to occur(typically at 26-28wks)  the fetus is
believed to be at ed risk of death

08/04/2021 By Yibelu B. (BSc, MSc) 27

 NST cont’d 
FHR accelerations are observed during fetal
movement.
Healthy fetuses display normal oscillations &
fluctuations of the baseline FHR

Absence of FHR accelerations seems to

depict CNS depression caused by hypoxia,
drugs, fetal sleep, or congenital anomalies.

08/04/2021 By Yibelu B. (BSc, MSc) 28

 NST cont’d 

Advantage:
Cheap, simple, and can be performed in any
setting
No direct maternal or fetal risks
Disadvantage: high FP rate( 50-60%)

08/04/2021 By Yibelu B. (BSc, MSc) 29

 NST interpretation

A. Reactive NST:
If there are ≥2 FHR acceleration that peak at least
by 15bpm above baseline ,each lasting ≥15 sec, and
all occurring within 20min of beginning of the test
Prior to 32wks >2 accelerations of at least 10bpm,
lasting ≥10sec over 20min interval
Fetal death within 1wk of reactive NST =3-5/1000

08/04/2021 By Yibelu B. (BSc, MSc) 30

Reactive non-stress test

31
 NST interpretation cont’d
B. Non-reactive NST
If criteria for reactivity are not met over 40min
Can be sign of fetal hypoxemia or acidosis
Other causes:(benign and temporary)
Maternal drugs(e.g smoking,…)
Fetal sleep or
Fetal congenital anomalies or fetal immaturity

08/04/2021 By Yibelu B. (BSc, MSc) 32

 Management of nonreactive NST
Management options:
Performing VAS
Performed by placing an auditory source on maternal abdomen 
delivering burst of sound
Shortens the duration of time needed to produce an acceleration
Reduces the frequency of non-reactive NST
Performing additional tests (eg. BPP, Doppler velocimetry)

Modifying factors responsible for abnormal test results if

possible(eg. correction of maternal hypotension,…)

Delivery(c/s or induction) if term -fetal hypoxemia cannot be

definitively excluded
08/04/2021 By Yibelu B. (BSc, MSc) 33
 Interval between NST

Weekly
Twice weekly: post term, DM, FGR,PIH
In reviewing the literature, they noted that the fetal
death rate within 1 week after a NR NST was
significantly increased in both DM (14 per 1,000) and
IUGR (20 per 1,000).
Daily: severe preeclampsia remote from term

08/04/2021 By Yibelu B. (BSc, MSc) 34

 Contraction stress test(CST)
Oxytocine challenge test
A test of uteroplacental function
the response of the fetus at risk for uteroplacental
insufficiency to uterine contraction
FHR  uterine contractions are recorded
simultaneously with external monitor
In hypoxic fetus uterine contractions will elicit
FHR late deceleration
Contraction is induced either with oxytocine or
nipple stimulation ( at least 3/10’/40’’ )
08/04/2021 By Yibelu B. (BSc, MSc) 35
Interpretation of CST
Negative: no late/significant variable deceleration
Positive: late deceleration following ≥50% of
cont.(even if inadequate cont.)
Equivocal-suspicious: intermittent late dece. or
significant variable dece.
 Equivocal- hyper stimulatory : FHR dece. that
occur in the presence of cont. more frequent than
every 2min or lasting >90sec
Unsatisfactory: fewer than 3 cont. in 10min
08/04/2021 By Yibelu B. (BSc, MSc) 36
Positive CST

37
 CST Cont’d

08/04/2021 By Yibelu B. (BSc, MSc) 38

Other patterns during CST
Variable decelerations: consider
oligohydramnios or cord entrapment.
Loss of variability & blunting of
decelerations: warning sign
Sinusoidal pattern: warning pattern. It is
due to Fetal anemia or fetal-maternal
hemorrhage.

08/04/2021 By Yibelu B. (BSc, MSc) 39

 Indications of CST
Pregnant women at risk for uteroplacental
insufficiency (UPI), such as
 DM IUGR
 HTN Post term
 Isoimmunization Heart disease
 Renal disease

08/04/2021 By Yibelu B. (BSc, MSc) 40

 CST: Contraindications
Absolute contraindications Relative contraindications
 PROM  Previous preterm labor
 APH  Hydramnios or marked
uterine over distension
 Prior C/S
 Multiple gestation less
 Known hypersensitivity to
than 36 weeks
oxytocine
 Incompetent cervix
 Vasa previa, Funic
 Marked obesity
presentation
 NRNST

08/04/2021 By Yibelu B. (BSc, MSc) 41

C…
 Mx of CST
 A negative CST has been consistently associated with
good fetal outcome
 Incidence of perinatal death within 1 week of a
negative CST to be less than 1 per 1,000.
 Many of these deaths - cord accidents, malformations,
placental abruption, and acute deterioration of glucose
control in patients with DM
 If the CST is negative, a repeat study is usually
scheduled in 1 week.

08/04/2021 By Yibelu B. (BSc, MSc) 42

 Mx of CST Cont’d
 A positive CST has been associated with:
 an increased incidence of intrauterine death, late
decelerations in labor, low 5-minute APGAR scores,
IUGR, and meconium-stained amniotic fluid ,perinatal
death which has ranged from 7 to 15 %

Positive test: acted on according to clinical

condition

08/04/2021 By Yibelu B. (BSc, MSc) 43

 Mx of CST Cont’d
 A suspicious or equivocal CST should be
repeated in 24 hours. Most of these tests will
become negative

 Like the suspicious CST, a test that is

unsatisfactory or shows hyper stimulation
should be repeated in 24 hours.

08/04/2021 By Yibelu B. (BSc, MSc) 44

 CST cont’d
 Advantages:
Not affected by maternal drug ingestion
Not GA dependent
 Disadvantage:
Expensive
Time consuming
Invasive(needs iv line)
Potentially risky b/c cont. is induced
08/04/2021 By Yibelu B. (BSc, MSc) 45
FETAL BIOPHYSICAL PROFILE (BPP)
Refers to the sonographic assessment of 4
discrete biophysical variables:
Fetal tone (FT)
Fetal body movement(FGBM)
Fetal breathing movement(FBM)
Results of NST 
AF volumes

08/04/2021 By Yibelu B. (BSc, MSc) 46

 BPP Cont’d
 Activities that 1st appear in fetal development (FT,
FM) are the last to disappear and activities that
appear last (NST, FBM) are the 1st to disappear in
case of hypoxia  acidosis.
FT=7.5-8.5wks
FM=9wks
FBM=20-21wks
NST=24-28wks(but most reliable after 32wks)

08/04/2021 By Yibelu B. (BSc, MSc) 47

 BPP Cont’d
 Acute variables: FT, FBM, FM,NST
Flexible in times of stress since they are energy
dependent  fetal O2 requirement

the most O2 sensitive centers are the cardio

regulatory neurons controlling the coupling of FM
 FHR acceleration and FB center neurons

08/04/2021 By Yibelu B. (BSc, MSc) 48

 BPP Cont’d
Chronic variable : AFV
Fetal urine production primarily depends on renal
perfusion
Hypoxemia  redistribution of COP to the major
organsurine production  oligohydramnios
It takes 15days for a fetus to progress from
normal to abnormal AFV(in absence of ROM) 
23days to develop severe oligohydramnios
Hypoxemia Thick MSAF in oligohydramnios

08/04/2021 By Yibelu B. (BSc, MSc) 49

 BPP Cont’d

BPP scoring(Manning score)

08/04/2021 By Yibelu B. (BSc, MSc) 50

 BPP Cont’d
Case study 1
 A 30 years old GIII PII woman on her 35 weeks gestation
come to hospital with a complaint of decreased fetal
movement for one day duration and while you perform the
BPP, you identified 2 gross body movements in 30 min, two
acceleration of FHR more tan 15 bmp lasting more than 15
secs within 20-40min, 2 breathing movements lasting 35
sec/30min, one tonic activity and AF pocket of more than 2 cm
in two perpendicular planes? What is the score of the BPP?

08/04/2021 51
 BPP Cont’d

Case study2
 A 35 years old pregnant woman on her 38 weeks of gestational
age came to ANC clinic with a compliant of minimal bleeding per
vagina. The biophysical profile (BPP) assessment shows a non-
reactive NST, AF of one vertical packet of 3 cm and two episodes
of breathing movement each lasting more than 30 sec durations, 1
gross body movement and one Flexion and Extension of limbs
within 30 minutes.
A. What is the best description of the assessment of the BPP
of the fetus?

B. What is the most likely first step of the management of the

case?
08/04/2021 52
BPP scoring(Manning score)
COMPONENTS SCORE 2 SCORE O
NST Reactive Non-reactive
FBM ≥1 episode of breathing <30sec breathing
≥30sec within 30min within 30min
FM ≥3 discrete body or limb <3 discrete
mov’t within 30min movement
FT ≥1 episode of extremity No episode of
extension  subsequent extension/flexion
return to flexion
AFV Largest single vertical Largest single
pocket >2cm vertical pocket ≤2cm

08/04/2021 By Yibelu B. (BSc, MSc) 53

 BPP score, interpretation  Mx

BPP score interpretation Recommended Mx

10 Normal No intervention, repeat test(wkly/2x wk)
8/8(NST not Normal fetus, 
done) Nonasphyxiated
8/10AFV Suspect chr. Deliver
asphyxia
6 Possible asphyxia AFV Delivery
Normal AFV:
 GA> 36wks deliver if Cx is favorable
If GA<36wks repeat test, if ≤6 deliver
But if >6 repeat as per protocol
4 Probable asphyxia Repeat test same day, if BPP ≤6 deliver

0-2 Chr. Fetal asphyxia Deliver

08/04/2021 By Yibelu B. (BSc, MSc) 54

 BPP Cont’d
 Normal variables are highly predictive of a good neonatal
outcome
 Each abnormal variables may be associated with a FP rate

 If the NST is reactive, do not need the u/s parameters of the

BPP, only the AFV would add additional information

08/04/2021 By Yibelu B. (BSc, MSc) 55

 BPP Cont’d

Clinical value of BBP

 BPP is non-invasive, easily applied and highly accurate
means of predicting the presence of fetal acidemia
 Risk of fetal death within 1wk of a normal test is <1/1000 of
women tested .
 PPV of the BPP for evidence of true fetal compromise is only
50%

08/04/2021 By Yibelu B. (BSc, MSc) 56

 BPP Cont’d
Modified BPP
 developed to simplify the examination and reduce
the time necessary to complete testing
Combination of AFI and NST
 The rate of stillbirth within 1 wk of a normal test
is the same as with the standard BPP
AFI ≤5cm is abnormal

08/04/2021 By Yibelu B. (BSc, MSc) 57

 BPP Cont’d

08/04/2021 By Yibelu B. (BSc, MSc) 58

 Doppler Velocimetry
Doppler ultrasound is primarily used to
demonstrate the presence, direction, and
velocity of blood flow.
Flow velocity waveforms are used to calculate
the systolic/diastolic ratio, the pulsatility index,
and the resistance index.
These indexes are primarily used to assess
downstream resistance in the vessel being
interrogated.
08/04/2021 By Yibelu B. (BSc, MSc) 59
 ……..Doppler Velocimetry

 Doppler ultrasound is a noninvasive

technique to assess blood flow by
characterizing downstream impedance.
 Three fetal vascular circuits
the umbilical artery
middle cerebral artery, and
ductus venosus
 Maternal uterine artery Doppler velocimetry
has also been evaluated in efforts to predict
placental dysfunction.
08/04/2021 By Yibelu B. (BSc, MSc) 60
 Umbilical Artery Velocimetry

The umbilical artery waveform pattern is compatible

with a low-resistance system:
there is forward blood flow throughout the cardiac
cycle.
• Used to measure the peak systolic (S), peak diastolic
(D)and mean/average (M/A) volumes.
Commonly measured flow indices:
Systolic to diastolic ratio (S/D)
Resistance index (S-D/S)
Pulsatility index (S-D/A)
08/04/2021 By Yibelu B. (BSc, MSc) 61
 ……Umbilical Artery Velocimetry

Umbilical artery Doppler wave forms become

abnormal after 60-70% of small placental arterial
channels are obliterated
More than 40% of ventricular output directed to
placenta, so obliteration of vascular channels in the
placenta-umbilical circulation leads to fetal hypoxia
Higher values > 2 SDs above the GA mean:
 indicate reduced diastolic velocities and
increased placental vascular resistance
 increased risks for adverse pregnancy outcome

08/04/2021 By Yibelu B. (BSc, MSc) 62

 ……Umbilical Artery Velocimetry
 UA flow velocity waveforms are characterized by:

 high velocity diastolic flow in normally growing fetuses

 diminished, absent, or even reversed (severe cases)
UA EDF in IUGR fetuses
associated with fetal hypoxia and increased perinatal
morbidity and mortality.
 PMR for AEDF is approximately 10% and for
REDF is 33%.

08/04/2021 By Yibelu B. (BSc, MSc) 63

08/04/2021 By Yibelu B. (BSc, MSc) 64
 Fig. UA flow velocity waveform:(A)Normal; B) Abnormal—(i)
Reduced end-diastolic flow; (ii) Absent end-diastolic flow;
(iii) Reversed end-diastolic flow

08/04/2021 By Yibelu B. (BSc, MSc) 65

 …….Umbilical Artery Velocimetry

 No benefit has been demonstrated other than in

pregnancies with suspected FGR.
 By comparison, several RCTs have demonstrated that
routine UA Doppler screening of low risk obstetrical
populations does not improve perinatal outcomes.

08/04/2021 By Yibelu B. (BSc, MSc) 66

 Fig. Changes in the Doppler UA indices in progression of gestation in normal
pregnancy

08/04/2021 By Yibelu B. (BSc, MSc) 67

 Middle Cerebral Artery

 The hypoxic fetus attempts

brain sparing by reducing
cerebrovascular impedance
and thus increasing blood
flow.
 Doppler velocimetry of the
MCA is useful for detection
and mx of fetal anemia of any
cause.

Fig. MCA Doppler

08/04/2021 By Yibelu B. (BSc, MSc) 68
 ………Middle cerebral artery

Cerebral vessels have a higher resistance with

usual S/D ratios of 6 and RIs of greater than
0.80
However, in IUGR the fetus will spare his/her
brain, heart, and adrenals, when hypoxic
 result in a drop in resistance in MCA
end diastolic flow rises and the S/D ratio drops below 4
 looking like a waveform from the umbilical artery

08/04/2021 By Yibelu B. (BSc, MSc) 69

 ………Middle cerebral artery
Both UA and MCA waveform abnormalities
are early changes in IUGR, and, in isolation,
are not necessarily reasons to interrupt a
preterm pregnancy.
The oligohydramnios seen in IUGR is due to
autoregulation and is virtually always found in
association with increased end diastolic flow
in the MCA.

08/04/2021 By Yibelu B. (BSc, MSc) 70

 Ductus Venosus
Assessment of the fetal venous circulation is the most recent
application of Doppler.

Bilardo and colleagues (2004) prospectively studied UA and DV

Doppler results in 70 growth-restricted fetuses at 26 to 33 weeks'
gestation.
They concluded that DV Doppler velocimetry was the best
predictor of perinatal outcome.

But a late finding because these fetuses had already sustained

irreversible multiorgan damage due to hypoxemia.

08/04/2021 By Yibelu B. (BSc, MSc) 71

 ……Ductus Venosus
 Specifically, absent or reversed flow in the ductus
venosus was associated with profound generalized
fetal metabolic collapse.
 gestational age was a powerful cofactor in ultimate
perinatal outcome for growth-restricted fetuses delivered
before 30 weeks.

08/04/2021 By Yibelu B. (BSc, MSc) 72

 Antenatal Doppler U/S changes and the Suggestive Features of
a compromised Fetus
Vessel Change Pathophysiolo Clinical implication
gical basis
UA Reduced or absent or Failure of villous ↑ resistance in
Reversed EDF trophoblast fetoplacental
invasion circulation → IUGR,PE
MCA ↑ Diastolic velocity Dilatation of “Brain Sparing” effect
↓ S/D or PI cerebral in response to
vessels hypoxemia
DV ↑ vascular resistance ↑ Central Fetal acidemia
Absent/Reversed flow venous pressure
(CVP)
UV ↑ vascular resistance CVP or Fetal acidemia
↑Pulsatile flow ↓ Cardiac
compliance

08/04/2021 By Yibelu B. (BSc, MSc) 73

 Current Antenatal Testing Recommendations

There is no "best test" to evaluate fetal well-

being.
Condition or diagnosis specific approach
testing recommended

08/04/2021 By Yibelu B. (BSc, MSc) 74

 Summary

 One of the most important advances in perinatal health care is

the use of antepartum fetal testing.

 AFS methods include inexpensive tests such as fetal kick

counts or tests that can be quite expensive such as NST,BPP,
and Doppler assessments.
 Clinical experience, combined with recent literature, suggest
that there is no ideal test for all high-risk fetuses

 Some antepartum fetal tests may be more appropriate than

others, depending on the underlying pathophysiology or the
indication for testing.

08/04/2021 By Yibelu B. (BSc, MSc) 75

 Summary cont’d
 B/se many d/t Pathophysiological processes lead to
fetal acidemia & IUFD indication-specific testing is
logical, and cost-effective.
 Although there are no RCTs to show the benefits of
AFS, nonrandomized studies suggest that such testing
has most likely accomplished its primary objective,
which is to prevent fetal deaths.

08/04/2021 By Yibelu B. (BSc, MSc) 76

 References
Gabbe’s obstetrics essentials: normal and
problem Pregnancies 7th ed. 2017
 Williams Obstetrics, 25th edition, 2018 
 Up-to-date 21.2
Santo S, Reis-de-Carvalho C, et al, Glob. libr.
women's med.The Continuous Textbook of
Women’s Medicine Series – Obstetrics Module
Volume 5,2021
08/04/2021 By Yibelu B. (BSc, MSc) 77
 THANK YOU!!!

08/04/2021 By Yibelu B. (BSc, MSc) 78