JOGC

No. 197a-Fetal Health Surveillance: Antepartum Consensus Guideline

      Abstract

      Objective

      This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum care in Canada.

      Options

      Consideration has been given to all methods of fetal surveillance currently available in Canada.

      Outcomes

      Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered.

      Evidence

      A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care ( Table 1).

      Sponsor

      This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program.

      Recommendation 1: Fetal Movement Counting

      • 1.
        Daily monitoring of fetal movements starting at 26 to 32 weeks should be done in all pregnancies with risk factors for adverse perinatal outcome (I-A).
      • 2.
        Healthy pregnant women without risk factors for adverse perinatal outcomes should be made aware of the significance of fetal movements in the third trimester and asked to perform a fetal movement count if they perceive decreased movements (I-B).
      • 3.
        Women who do not perceive six movements in an interval of two hours require further antenatal testing and should contact their caregivers or hospital as soon as possible (III-B).
      • 4.
        Women who report decreased fetal movements (<6 distinct movements within 2 hours) should have a complete evaluation of maternal and fetal status, including non-stress test and/or biophysical profile. Prior to considering an intervention for fetal well-being, an anatomical scan to rule out a fetal malformation should be done, if one has not already been done. Management should be based upon the following:
        • Non-stress test is normal and there are no risk factors: the woman should continue with daily fetal movement counting (III-B).
        • Non-stress test is normal and risk factors or clinical suspicion of intrauterine growth restriction intrauterine growth restriction/oligohydramnios is identified: an ultrasound for either full biophysical profile or amniotic fluid volume assessment within 24 hours. The woman should continue with daily fetal movement counting (III-B).
        • Non-stress test is atypical/abnormal: further testing (biophysical profile and/or contraction stress test and assessment of amniotic fluid volume) should be performed as soon as possible (III-B).

      Recommendation 2: Non-Stress Test

      • 1.
        Antepartum non-stress testing may be considered when risk factors for adverse perinatal outcome are present (III-B).
      • 2.
        In the presence of a normal non-stress test, usual fetal movement patterns, and absence of suspected oligohydramnios, it is not necessary to conduct a biophysical profile or contraction stress test (III-B).
      • 3.
        A normal non-stress test should be classified and documented by an appropriately trained and designated individual as soon as possible, (ideally within 24 hours). For atypical or abnormal non-stress tests, the nurse should inform the attending physician (or primary care provider) at the time that the classification is apparent. An abnormal non-stress test should be viewed by the attending physician (or primary care provider) and documented immediately (III-B).

      Recommendation 3: Contraction Stress Test

      • 1.
        The contraction stress test should be considered in the presence of an atypical non-stress test as a proxy for the adequacy of intrapartum uteroplacental function and, together with the clinical circumstances, will aid in decision making about timing and mode of delivery (III-B).
      • 2.
        The contraction stress test should not be performed when vaginal delivery is contraindicated (III-B).
      • 3.
        The contraction stress test should be performed in a setting where emergency Caesarean section is available (III-B).

      Recommendation 4: Biophysical Profile

      • 1.
        In pregnancies at increased risk for adverse perinatal outcome and where facilities and expertise exist, biophysical profile is recommended for evaluation of fetal well-being (I-A).
      • 2.
        When an abnormal biophysical profile is obtained, the responsible physician or delegate should be informed immediately. Further management will be determined by the overall clinical situation (III-B).

      Recommendation 5: Uterine Artery Doppler

      Tabled 1
      Previous obstetrical history
      • Previous early onset gestational hypertension
      • Placental abruption
      • Intrauterine growth restriction
      • Stillbirth
      Risk factors in current pregnancy
      • Pre-existing hypertension
      • Gestational hypertension
      • Pre-existing renal disease
      • Long-standing type I diabetes with vascular complications, nephropathy, retinopathy
      • Abnormal maternal serum screening (hCG or AFP > 2.0 MOM)
      • Low PAPP-A (consult provincial lab for norms)
      • 1.
        Where facilities and expertise exist, uterine artery Doppler may be performed at the time of the 17 to 22 weeks' gestation detailed anatomical ultrasound scan in women with the following factors for adverse perinatal outcome (II-A).
      • 2.
        Women with a positive uterine artery Doppler screen should have the following:
      • A double marker screen (for alpha-fetoprotein and beta hCG) if at or before 18 weeks' gestation (III-C).
      • A second uterine artery Doppler at 24 to 26 weeks. If the uterine artery Doppler is positive at the second scan, the woman should be referred to a maternal-fetal medicine specialist for management (III-C).

      Recommendation 6: Umbilical Artery Doppler

      • 1.
        Umbilical artery Doppler should not be used as a screening tool in healthy pregnancies, as it has not been shown to be of value in this group (I-A).
      • 2.
        Umbilical artery Doppler should be available for assessment of the fetal placental circulation in pregnant women with suspected placental pathology (I-A). Fetal umbilical artery Doppler assessment should be considered (1) at time of referral for suspected growth restriction, or (2) during follow-up for suspected placental pathology.
      • 3.
        Depending on other clinical factors, reduced, absent, or reversed umbilical artery end-diastolic flow is an indication for enhanced fetal surveillance or delivery. If delivery is delayed to improve fetal lung maturity with maternal administration of glucocorticoids, intensive fetal surveillance until delivery is suggested for those fetuses with reversed end-diastolic flow (II-1B).

      Key Words

      Abbreviations:

      AFI ( amniotic fluid index), AFP ( alpha-fetoprotein), BPP ( biophysical profile), CST ( contraction stress test), IUGR ( intrauterine growth restriction), IUT ( intrauterine transfusion), MCA ( middle cerebral artery), NICU ( neonatal intensive care unit), NST ( non-stress test), PSV ( peak systolic velocity), RCT ( randomized controlled trial)
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