[OBSTETRICS ] ANTEPARTUM ASSESSMENT
ANTEPARTUM ASSESSMENT OUTLINE OF THE LECTURE
• Fetal Movements
FETAL SURVEILLANCE • Fetal Breathing
• Check the health, activity level and growth of the fetus • Electronic Fetal Monitoring
during pregnancy (antepartum) and during labor ✓ Non-Stress Test
(intrapartum) ✓ Contraction Stress Test
• Ultrasound Surveillance
• OBJECTIVE: ✓ Fetal Biometry
✓ To detect fetal compromise in order to: ✓ Biophysical Scoring
- Prevent stillbirth ✓ Doppler Velocimetry
- Decrease neonatal mortality
- Minimize the long-term morbidity associated with FETAL MOVEMENT
fetalcompromise
• Perception of the fetal movements by the mother can
• Antepartum Assessment was used to be done for help us monitor the fetal condition.
high-risk pregnancies only but now this is done in ⚫ 7 weeks
majority of pregnancies, especially in developed ✓ Passive unstimulated activity
countries. ⚫ >8 weeks
✓ Fetal movements are never absent for periods more than
PPT Notes: The theory is that by identifying the
13 minutes
hypoxia-associated physiological changes before the
⚫ 20 to 30 weeks
fetus has suffered from long term irreversible ✓ Organized general body movements
damages, preventive measures can be implemented. ✓ Rest-activity cycles
⚫ 36 weeks
✓ Established behavioral states in 80% of fetuses
• SOME INDICATIONS FOR FETAL SURVEILLANCE:
PRIMARILY MATERNAL
⚫ Sleep Cycle
• Cyanotic Heart Disease
✓ Varies between 20 to 70 minutes
• Chronic Renal Disease
• Overt Diabetes RATIONALE: Fetal movement decreases with hypoxia
• Marked Uterine Anomalies
PRIMARILY PLACENTAL
PPT Notes: Various methods have been described to
• APAS (Antiphospholipid Antibody Syndrome) quantify fetal movement as a way of prognosticating
• SLE (Systemic Lupus Erythematosus) well-being. Methods include use of a tocodynamometer,
• Hypertensive Disorders visualization with sonography, and maternal subjective
• Thrombophilia perceptions.
• Marked Placental Abnormalities Although several fetal movement counting protocols
PRIMARILY FETAL have been used, neither the optimal number of
• Decreased Fetal Movement movements nor the ideal duration for counting them has
• Disorders of Amniotic Fluid been defined. For example, in one method, perception
• Disorders in Fetal Growth of 10 fetal movements in up to 2 hours is considered
• Fetal Anomalies normal (Moore and Piaquadio, 1989). In another,
• Multifetal Pregnancy women are instructed to count fetal movements for 1
MISCELLANEOUS hour a day, and the count is accepted as reassuring if it
• In Vitro Fertilization Pregnancy equals or exceeds a previously established baseline
• Previous Stillbirth count (Neldam, 1983). The American College of
• Teratogen Exposure Obstetricians and Gynecologists (2002) suggests that
one approach to assessing fetal movement is to have the
woman count distinct fetal movements on a daily basis
after 28 weeks' gestation. The perception of 10 distinct
• Additional to PRIMARILY MATERNAL: movements in up to 2 hours is considered reassuring.
✓ Also done for Gestational Diabetes and The counting can be discontinued for that day after 10
Hypertensive Disorders of Pregnancy movements.
1
, [OBSTETRICS ] ANTEPARTUM ASSESSMENT
4 FETAL BEHAVIORAL STATES FETAL MOVEMENT COUNTING
⚫ State 1F • Best practice recommendations
✓ Quiescent state (quiet sleep) ✓ ACOG (2002): Daily fetal movement count after 28 weeks'
✓ With a narrow oscillatory bandwidth of the fetal heart rate gestation. The perception of 10 distinct movements in up
to 2 hours is considered reassuring. The counting can be
• Present on the 36th week onwards discontinued for that day after 10 movements.
✓ No fetal movement threshold or “alarm limit” below
which fetal risk is increased
⚫ State 2F
✓ Includes frequent gross body movements, continuous eye • Exact number of fetal movements can vary so
movements, and wider oscillation of the fetal heart rate much
✓ This state is analogous to rapid eye movement (REM) or ✓ During the day, the fetus can move 20 to 200
active sleep in the neonate times, sometimes 800 times
⚫ State 3F • Mother came complaining of sluggish fetal
✓ Includes continuous eye movements in the absence of movements
body movements and no accelerations of the heart rate ✓ Upon Non-Stress Test (NST), it showed
✓ The existence of this state is disputed reassuring fetal heart rate pattern
✓ We can ask the mother to do her own monitoring
• Still questionable if there is such a state
of the fetus based on the perception of fetal
movements → Record on a piece of paper the
⚫ State 4F movements during the day
✓ Is one of vigorous body movement with continuous eye ✓ What we do in practice is we tell the mother to
movements and fetal heart rate accelerations monitor the fetal movements around 3-4 times a
✓ This state corresponds to the awake state in infants day → If there are at least 6 movements per
hour, we consider it reassuring → Come back to
Fetuses spend most of their time in states 1F and 2F the clinic after 2-3 days and do NST again
- Usually done, especially for high- r is k mothers
SLEEP–AWAKE CYCLES
• The sleep-awake cycles of infants are independent of the ✓ Best predictor may still be the maternal sense that fetal
maternal sleep-awake state activity is reduced and that any such report warrants
further evaluation
• Sleep Cyclicity has been described as varying from about 20
minutes to as much as 75 minutes • We should not disregard the perception of the
✓ Mean length of 23 minutes for the quiet or inactive state
mother that she feels that her baby is moving.
for term fetuses (1F)
In the absence of a reassuring count, further fetal
• Non-Stress Test → Based on the presence of
assessment is recommended.
accelerations with fetal movements
✓ Sometimes the fetus may not be moving because
FETAL BREATHING
the fetus is asleep.
✓ Sometimes, we have to wait for as much as 25 • Paradoxical chest movements are due to coughing of
minutes → Too long for the sonologist → What clearamniotic fluid debris
they do usually is they startle the fetus
SIGNIFICANCE OF FETAL MOVEMENT IN DETERMINING FETAL
WELL BEING
• Methods to Quantify Fetal Movements:
✓ Use of a tocodynamometer
✓ Visualization with ultrasound Notes from PPT: The fetus exhibits paradoxical chest
✓ Maternal perceptions wall movement which means during inspiration, the
chest wall paradoxically collapses and the abdomen
Notes from PPT: Most investigators reported excellent protrudes, whereas during expiration, the chest wall
correlation between maternally perceived fetal motion expands. The opposite occurs in the newborn and
and movements documented by instrumentation adults.
2
ANTEPARTUM ASSESSMENT OUTLINE OF THE LECTURE
• Fetal Movements
FETAL SURVEILLANCE • Fetal Breathing
• Check the health, activity level and growth of the fetus • Electronic Fetal Monitoring
during pregnancy (antepartum) and during labor ✓ Non-Stress Test
(intrapartum) ✓ Contraction Stress Test
• Ultrasound Surveillance
• OBJECTIVE: ✓ Fetal Biometry
✓ To detect fetal compromise in order to: ✓ Biophysical Scoring
- Prevent stillbirth ✓ Doppler Velocimetry
- Decrease neonatal mortality
- Minimize the long-term morbidity associated with FETAL MOVEMENT
fetalcompromise
• Perception of the fetal movements by the mother can
• Antepartum Assessment was used to be done for help us monitor the fetal condition.
high-risk pregnancies only but now this is done in ⚫ 7 weeks
majority of pregnancies, especially in developed ✓ Passive unstimulated activity
countries. ⚫ >8 weeks
✓ Fetal movements are never absent for periods more than
PPT Notes: The theory is that by identifying the
13 minutes
hypoxia-associated physiological changes before the
⚫ 20 to 30 weeks
fetus has suffered from long term irreversible ✓ Organized general body movements
damages, preventive measures can be implemented. ✓ Rest-activity cycles
⚫ 36 weeks
✓ Established behavioral states in 80% of fetuses
• SOME INDICATIONS FOR FETAL SURVEILLANCE:
PRIMARILY MATERNAL
⚫ Sleep Cycle
• Cyanotic Heart Disease
✓ Varies between 20 to 70 minutes
• Chronic Renal Disease
• Overt Diabetes RATIONALE: Fetal movement decreases with hypoxia
• Marked Uterine Anomalies
PRIMARILY PLACENTAL
PPT Notes: Various methods have been described to
• APAS (Antiphospholipid Antibody Syndrome) quantify fetal movement as a way of prognosticating
• SLE (Systemic Lupus Erythematosus) well-being. Methods include use of a tocodynamometer,
• Hypertensive Disorders visualization with sonography, and maternal subjective
• Thrombophilia perceptions.
• Marked Placental Abnormalities Although several fetal movement counting protocols
PRIMARILY FETAL have been used, neither the optimal number of
• Decreased Fetal Movement movements nor the ideal duration for counting them has
• Disorders of Amniotic Fluid been defined. For example, in one method, perception
• Disorders in Fetal Growth of 10 fetal movements in up to 2 hours is considered
• Fetal Anomalies normal (Moore and Piaquadio, 1989). In another,
• Multifetal Pregnancy women are instructed to count fetal movements for 1
MISCELLANEOUS hour a day, and the count is accepted as reassuring if it
• In Vitro Fertilization Pregnancy equals or exceeds a previously established baseline
• Previous Stillbirth count (Neldam, 1983). The American College of
• Teratogen Exposure Obstetricians and Gynecologists (2002) suggests that
one approach to assessing fetal movement is to have the
woman count distinct fetal movements on a daily basis
after 28 weeks' gestation. The perception of 10 distinct
• Additional to PRIMARILY MATERNAL: movements in up to 2 hours is considered reassuring.
✓ Also done for Gestational Diabetes and The counting can be discontinued for that day after 10
Hypertensive Disorders of Pregnancy movements.
1
, [OBSTETRICS ] ANTEPARTUM ASSESSMENT
4 FETAL BEHAVIORAL STATES FETAL MOVEMENT COUNTING
⚫ State 1F • Best practice recommendations
✓ Quiescent state (quiet sleep) ✓ ACOG (2002): Daily fetal movement count after 28 weeks'
✓ With a narrow oscillatory bandwidth of the fetal heart rate gestation. The perception of 10 distinct movements in up
to 2 hours is considered reassuring. The counting can be
• Present on the 36th week onwards discontinued for that day after 10 movements.
✓ No fetal movement threshold or “alarm limit” below
which fetal risk is increased
⚫ State 2F
✓ Includes frequent gross body movements, continuous eye • Exact number of fetal movements can vary so
movements, and wider oscillation of the fetal heart rate much
✓ This state is analogous to rapid eye movement (REM) or ✓ During the day, the fetus can move 20 to 200
active sleep in the neonate times, sometimes 800 times
⚫ State 3F • Mother came complaining of sluggish fetal
✓ Includes continuous eye movements in the absence of movements
body movements and no accelerations of the heart rate ✓ Upon Non-Stress Test (NST), it showed
✓ The existence of this state is disputed reassuring fetal heart rate pattern
✓ We can ask the mother to do her own monitoring
• Still questionable if there is such a state
of the fetus based on the perception of fetal
movements → Record on a piece of paper the
⚫ State 4F movements during the day
✓ Is one of vigorous body movement with continuous eye ✓ What we do in practice is we tell the mother to
movements and fetal heart rate accelerations monitor the fetal movements around 3-4 times a
✓ This state corresponds to the awake state in infants day → If there are at least 6 movements per
hour, we consider it reassuring → Come back to
Fetuses spend most of their time in states 1F and 2F the clinic after 2-3 days and do NST again
- Usually done, especially for high- r is k mothers
SLEEP–AWAKE CYCLES
• The sleep-awake cycles of infants are independent of the ✓ Best predictor may still be the maternal sense that fetal
maternal sleep-awake state activity is reduced and that any such report warrants
further evaluation
• Sleep Cyclicity has been described as varying from about 20
minutes to as much as 75 minutes • We should not disregard the perception of the
✓ Mean length of 23 minutes for the quiet or inactive state
mother that she feels that her baby is moving.
for term fetuses (1F)
In the absence of a reassuring count, further fetal
• Non-Stress Test → Based on the presence of
assessment is recommended.
accelerations with fetal movements
✓ Sometimes the fetus may not be moving because
FETAL BREATHING
the fetus is asleep.
✓ Sometimes, we have to wait for as much as 25 • Paradoxical chest movements are due to coughing of
minutes → Too long for the sonologist → What clearamniotic fluid debris
they do usually is they startle the fetus
SIGNIFICANCE OF FETAL MOVEMENT IN DETERMINING FETAL
WELL BEING
• Methods to Quantify Fetal Movements:
✓ Use of a tocodynamometer
✓ Visualization with ultrasound Notes from PPT: The fetus exhibits paradoxical chest
✓ Maternal perceptions wall movement which means during inspiration, the
chest wall paradoxically collapses and the abdomen
Notes from PPT: Most investigators reported excellent protrudes, whereas during expiration, the chest wall
correlation between maternally perceived fetal motion expands. The opposite occurs in the newborn and
and movements documented by instrumentation adults.
2
