• To screen high risk pregnancy.
• To prevent, detect and treat untoward complications.
• To educate mother, remove fear and improve psychology.
• To discuss with couples the time, place and mode of delivery.

 

• Prevention, early detection and treatment of pregnancy related complications, such as preeclampsia and eclampsia.
• Prevention, early detection and treatment of medical disorders, such as anemia and diabetes.
• Detection of malpresentations, malpositions and disproportion that may influence the decision of labor.
• Instruct the pregnant woman about hygiene, diet and warning symptoms.
• Laboratory studies of parameters that may affect the fetus, such as blood group, HIV and syphilis.
• Pre-pregnancy classes on labor and infant care can be offered whenever possible.

 

• Every 4 weeks till 28 weeks
• Every 2 weeks up to 36 weeks
• Every week during the last month
• Frequent visits are indicated in high-risk pregnancy.

 

• Give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by written information (on topics such as diet and lifestyle considerations, pregnancy care services available, maternity benefits and sufficient information to enable informed decision making about screening tests).

  • Identify women who may need additional care and plan pattern of care for the pregnancy.
  • Check blood group and RhD status.
  • Offer screening for anemia, hepatitis B virus, HIV, rubella susceptibility and syphilis.
    2
  • Offer screening for Down's syndrome, if available.

    • ◊ Nuchal translucency at 11–14 weeks
    • ◊ Serum screening at 14–20 weeks
• Offer early ultrasound scan for gestational age assessment as far as possible. Ultrasound scans determine gestational age using:

  • Crown rump measurement if performed at 10–13 weeks
  • Biparietal diameter or head circumference at or beyond 14 weeks
  • Offer ultrasound screening for structural anomalies (20 weeks)
  • Record weight and blood pressure.

 

• Review, discuss and document the results of all screening tests undertaken; reassess planned pattern of care for the pregnancy and identify women who need additional care
• Investigate a hemoglobin level of less than 10 g/dL and start iron supplementation
• At 18–20 weeks, an ultrasound scan should be performed for the detection of structural anomalies.

 

• Measure and plot symphysis-fundal height
• Give information with an opportunity to discuss issues and ask questions
• Offer screening for gestational diabetes, if possible
• Offer a second screening for anemia
• Offer anti-D to rhesus-negative women where available and indicated
• First dose of immunization with injection (tetanus and diphtheria/tetanus toxoid) Td/TT.

 

• Measure blood pressure
• Measure and plot symphysis-fundal height
• Review, discuss and document the results of screening tests undertaken at 28 weeks
• Second dose of immunization with injection Td/TT.

 

• Measure blood pressure
• Measure and plot symphysis-fundal height
• Check position of baby
• For women whose babies are in breech presentation consider external cephalic version where expertise is available or refer to a district hospital for further management
• Review ultrasound scans report if placenta extended over the internal cervical os at previous ultrasound.

 

• Closer antepartum surveillance
• Measure blood pressure
• Measure and plot symphysis-fundal height
• Check position of baby
• Consider induction, if inducible and favorable cervix.

 

• Underweight (BMI less than 18 at first visit)
• Obesity (BMI 35 or more at first visit)
• Extremes of age
• Anemia
• Cardiac disease
• Hypertension (essential as well as pregnancy induced)
• Renal disease
• Thyroid, diabetes and other endocrine disorders
• Epilepsy requiring anticonvulsant drugs
• Asthma and other respiratory disorders
• Hematological disorder
• HIV or HBV infected
• Drug use such as heroin, cocaine
• Autoimmune disorders
• Psychiatric disorders
• Malignant disease.

• Recurrent pregnancy loss
• Preterm birth
• Severe pre-eclampsia, HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count) or eclampsia
  3
• Rhesus isoimmunization or other significant blood group antibodies
• Uterine surgery including cesarean section, myomectomy or cone biopsy
• Antepartum or postpartum hemorrhage
• Puerperal psychosis
• Grand multiparity (more than five pregnancies)
• A stillbirth or neonatal death
• A baby with a congenital anomaly (structural or chromosomal).

   

• Pregnant women should be informed of their maternity rights and benefits.
• The majority of women can be reassured that it is safe to continue working during pregnancy provided there are no medical or obstetrical complications.

     

• Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and up to 12 weeks gestation, reduces the risk of having a baby with neural tube defects (anencephaly, spina bifida). The recommended dose is 400 µg per day.
• Iron, protein and calcium supplementation should be offered routinely to all pregnant women.

                                       

• Washing hands before handling food
• Thoroughly washing all fruits and vegetables before eating
• Thoroughly cooking raw meat and fish
• Wearing gloves and thoroughly washing hands after handling soil.

           

• From 11 weeks to 14 weeks

  • Nuchal translucency (NT)
  • The combined test [NT, hCG and PAPP-A (pregnancy associated plasma protein A)]
• From 14 weeks to 20 weeks

  • The triple test [hCG, AFP (alpha fetoprotein) and uE3 (unconjugated estriol)]
  • The quadruple test (hCG, AFP, uE3, inhibin A)
• From 11 weeks to 14 weeks and 14 weeks to 20 weeks

  • The serum integrated test (PAPP-A + hCG, AFP, uE3, inhibin A)

           

• Fetal movement (FM) count
• Non-stress test (NST)
• Contraction stress test (CST)
• Biophysical profile (BPP)
• Vibroacoustic stimulation test (VAST) and fetal acoustic stimulation test (FAST)
• Biochemical tests
• Doppler
• Cordocentesis and other invasive technique.

• To ascertain which assessment to employ in an individual patient
• To decide which test to use and how often to obtain such an assessment
• To utilize the test results in the most efficacious manner and also in a cost-effective fashion.

 

1. Uteroplacental insufficiency (form the bulk of indications)
2. Fetal disorders.

   

• Post-term
• Chronic hypertension
• Diabetes mellitus
• Intrauterine growth retardation (IUGR)
• Pregnancy induced hypertension
• Placental abruption (stable)
• Unexplained third trimester bleeding
• Previous unexplained fetal loss
• Previous small for gestational age (GA) neonate
• Multiple gestation
• Maternal age more than 40 years
• Unexplained high maternal serum alpha-fetoprotein
• Systemic lupus erythematosus
• Other connective tissue disease
• Chronic renal disease
• Severe pulmonary disease
• Oligohydramnios
• Placenta previa
• Hyperthyroidism
• Hemoglobinopathies
• Maternal cyanotic heart disease
• Chromosomally aberrant placenta.

 

• Twin-to-Twin transfusion
• Isoimmunization
• Anomalous fetus (options discussed with family)
• Hydramnios
• Premature rupture of membranes
• Decreased FM
• Congenital infection.

   

• Real time ultrasonography
• Recording maternal perception of in utero movement

     

• Lie in lateral recumbent position
• Quiet room
• Concentrate on FM
• Note the time taken for 10 F.M.
• Usually 30 minutes

  Advantages:	– Fewer time restriction – Inexpensive – No contraindication
  Disadvantage:	– High degree of maternal compliance required. Gross body movements are unaffected by recent meal, therefore it is not necessary that the point is postprandial.

 

• Record FM for 1 hour after every meal - breakfast, lunch and dinner
• Keep record of FM.
• Done between 28 weeks and 43 weeks of gestation
• A gradual decline in total amount of fetal body movement is expected in last trimester and is related to:

  • Improved coordination
  • Decreased amniotic fluid volume
  • Increased fetal size.

 

• Seen after 20 weeks (real time sonography)
• Number of FMs (lowest in morning, highest in evening)
• The mean hourly number of gross fetal body movement is greatest during late night hours (between 21:00–01:00 hours).

 

• It is difficult to differentiate abnormally low activity pattern and physiological rest period.
• Half hour periods of maternal self recording are recommended by veral investigators for patient's convenience.
• One hour period may be better since it minimizes the risk of unjustified suspicion of fetal activity for 2 consecutive hours which is abnormal and requires further evaluation.

 

• An average of 40 or more perceived fetal motions per hour for at least 14 days
• Six percent of general population
• Prognosis is good.

 

• The ratio of acceleration to movement, per total movement increment was found to increase with GA.

 

• Human fetal response to stimulation with an electronic artificial larynx reflects functional maturation of CNS.
• An external vibratory acoustic stimulus causes a change from a state of sleep to a state of wakefulness in near term healthy fetuses.

 

• Vigorous shaking or forceful manipulation of uterus and fetus will not cause an unarousable fetus to become active.
• Body movements accompanying contractions were longer than those not associated with contractions.

 

• Sedating drugs like alcohol, barbiturates, narcotics, methadone or benzodiazepines are known to cross the placenta readily and may reduce the duration and number of FMs.
• Altered behavior reverses after clearance of the drug.
  8
• Antiepileptic drugs do not possibly have any effect on FM.
• Sonographically guided injection of Pancuronium into fetal gluteal muscles to temporary arrest FM during techniques such as:

  • Intravascular transfusions RH affected fetus
  • Bladder shunt placement in fetus and obstructive uropathy
  • Percutaneous umbilical blood sampling resulted in short-term paralysis with no apparent delirious effect.
• Changes in fetal activity ranging from reduction to cessation seen in patients who received steroids for enhancement of fetal lung maturity.

  • Changes were transient and FMs returned to normal within 24 hours of last injection.
  • Accompanying non-reactive FHR pattern was also temporary.
• Maternal cigarette smoking temporarily reduces fetal body motion and breathing. This is due to depressant action of nicotine on CNS and decreased maternal levels of carboxyhemoglobin.
• Caffeine has no effect on fetal breathing and whole body movements.

   

• Cessation of fetal activity is a sensitive warning of impending death even in the presence of reassuring FHR, associated with complication in which fetal distress was chronic rather than acute.
• However, not all antepartum still births can be anticipated or avoided.
• Unfavorable outcome despite previous reassuring activity patterns relate more to acute changes, presumably, from umbilical cord entanglements or placental abruption.

 

• Number of movements and evidence of fetal inactivity did not differ significantly from findings in a similar group of normotensive women.
• Chronic hypertension and cessation or marked reduction have unfavorable outcomes.
• The majority have reassuring fetal activity patterns and favorable outcome.

 

• Most malformed infants are perceived as being active in utero.
• Those perceived as being inactive are all with major malformations visualized ultrasonographically before delivery.

• ■ These include:

  Hydrocephalus Non-immune hydrops Bilateral renal agenesis Bilateral hip dislocation

• Lack of vigorous motion may relate to abnormalities of CNS pathway, muscular dysfunction and mechanical restriction of lower extremity motion.
• Fetus with open neural tube defect is commonly active in utero.
• However, quality of extremity motion is affected.
• Spastic positioning and limb motion is seen which is characteristic of upper motor neuron lesion.
• Movements are possible despite the severe reduction in amount and alterations in organization of fetal nervous system.

 

• Whole body movements in twins are significantly more frequent than those in singletons.
• Patient's observation that both fetuses are quite active is reassuring.
• ‘Boxing matches’ with rounds lasting for few minutes and separated by rest period can be seen on ultrasonography.
• The increased activity in twins is related to an additive effect of two normally active fetuses.

 

• Fetuses of diabetic women are often quite active with strict maternal glucose control.
• Whether fetal activity fluctuates with a change in maternal glucose level is uncertain, but some workers suggest that fetal body movements decrease with maternal hyperglycemia and increase with hypoglycemia.
• A tight metabolic control achieved with continuous insulin infusion does not necessarily prevent these disturbances in development.

 

• Most mildly growth retarded fetuses have whole body activity patterns that are clinically 9indistinguishable from those of appropriately sized fetuses.
• Only severely growth retarded fetus (lower than fifth percentile of EBW) have diminished activity.

 

• Fetal movement monitoring is not sensitive enough for use in post-mature fetuses.
• Fetal activity may decrease in certain pregnancies continuing 2 weeks or more beyond the estimated date of confinement. But patterns are often indistinguishable from those of comparable term pregnancies.

 

• Monitoring fetal activity is particularly useful in long standing fetal anemic process which may lead to fetal heart failure, hydropic changes and ascites.
• A documented decrease or lack of whole body movements may be the first sign of fetal compromise.

 

• Our ignorance of the biological roles played by most serum markers.
• The probability that peripheral serum maker concentration does not reflect fetal or intervillous space hemostasis.
• The assumption that the production of serum marker is reliably and predictably altered when the fetoplacental unit is endangered.
• Individual patient and time variability associated with biological tests.
• The problem of specificity, sensitivity and predictive value of each serum maker.
• Difficulty in assigning sample biochemical end points to very complex clinical events.

 

• It is a method of antepartum fetal surveillance since three decades.
• Non-stress testing originated with the early work of Hammaches which linked the occurrence of fetal heart accelerations with fetal well-being.
• The linkage between FMs and reactive accelerations was observed by Patrick in their study of normal third trimester pregnancies:

  • Decreased accelerations (amplitude and frequency)
  • Decreased incidence of FMs
  • Decoupling of accelerations and movements
  • Absence of accelerations and movements with or without the presence of spontaneous decelerations.

• Sympathetic discharge and adrenergic receptors
• Behavioral states
• Circadian rhythms
• Gestational age and maturation
• Intrinsic rate of myocardial contractility
• Baroreceptor/chemoreceptor reflexes
• Exogenous dietary substrate and drugs

 

• Gestational age more than 26 weeks (varies with the institutions)
• Time of day: 8 a.m. to 1 p.m.
• Maternal dietary state: 2 hours PP
• Maternal activity sedentary for 1 hour
• Maternal position: Semi-Fowlers (with lateral hip displacement)
• No smoking/sedative drugs
• Monitoring system: Tocodynamometer
• Fetal movements: Corroborated by observation
• Baseline recording period of 20 minutes increased up to 90 minutes (vital signs every 15 minutes).

 

• Adequate pen heat
• Paper speed
• Information

 

• Baseline FHR: It is the mean level of FHR when this is stable without accelerations and decelerations
• (N) Range at term: 110–160 BPM
• In less than 34 weeks: A baseline of 160 BPM is acceptable

• ■ Bradycardia:

  A baseline FHR less than 110 BPM 100–110 BPM suspicious Less than 100 BPM pathological

  10

• Tachycardia:

  A baseline FHR more than 150 BPM 150 suspicious 170 BPM pathological

• Acceleration: Transient increase in FHR of 15 BPM or more lasting for 15 seconds or more.
• Deceleration: A transient episode of slowing of FHR below the baseline level of more than 15 BPM and lasting 15 seconds or more.
• Baseline variability: It is the degree to which the baseline varies within a particular band width excluding accelerations and decelerations:

  0–5 BPM	=	Silent pattern
  6–10 BPM	=	Reduced
  11–25 BPM	=	Normal
  > 25 BPM	=	Saltatory

 

• Early: They are synchronous with contractions.
• Late: They follow contractors. Their onset nadir and recovery are out of phase with contraction.
• Variable: They vary in shape and timing with each other.

   

• Sleep/Quiet phase
• Hypoxia
• Prematurity
• Tachycardia
• Drugs (sedatives, antihypertensives, anesthetics)
• Congenital malformations
• Cardiac arrhythmias

 

• It is defined as a baseline FHR of more than 150 BPM. It is common in preterm fetuses as the sympathetic system matures earlier.
• Pathological causes include maternal hypovolemia and anemia.

 

• It is defined as FHR less than 110 BPM.
• Pathological causes include fetal arrhythmias.

   

• They are also known as Type I dips.
• It occurs due to compression of the fetal head
• Intracranial pressure
• Stimulation of vagal nerve
• Bradycardia
• They are symmetrical bell-shaped curves.

 

• They are also known as Type II dips.
• They are late in timing with respect to a uterine contraction.

  • Contraction
  • Using up of reservoir of O₂ in retroplacental space by fetus
  • Restricted blood supply
  • Hypoxic deceleration.

   

• The umbilical vein has a thinner wall and lower intraluminal pressure than umbilical arteries.
• When compression occurs, blood flow through vein is interrupted before that through the artery. Fetus, therefore, loses some of its circulating blood volume.
• Fall in BP is more than stimulation of before captors.
• Temporary rise in FHR.
• Thus, a small acceleration appears at the start of a variable deceleration. Once umbilical arteries are occluded:

  • Increased systemic pressure
  • Stimulation of baroreceptors
  • Precipitous fall in FHR
  • Deceleration is at its nadir when both vessels are occluded.
• During release of cord compression arterial flow is restored first.
  11
• Automatically mediated sharp rise in FHR due to system hypotension blood is pumped out.
• Small acceleration occurs after the deceleration. These accelerations before and after decelerations are called ‘Shouldering’. It is a manifestation of a fetus coping well with cord compression.

 

1. Normal Pattern

   • Baseline: 110–150 BPM
   • Baseline variability: 5–20 BPM
   • Absence of deceleration
   • Presence of two or more accelerations in 10 minutes.
2. Suspicions Pattern
   Any one of the following:

   • Baseline: 160–170 BPM or 100–110 BPM
   • Amplitude of variability between 5 BPM and 10 BPM for more than 40 minutes
   • Increased variability above 25 BPM
   • Absence of accelerations for more than 40 minutes
   • Sporadic decelerations
3. Pathological

   • Baseline FHR less than 110 BPM or more than 170 BPM
   • Variability less than 5 BPM for more than 40 minutes
   • Periodically recurring repeated decelerations of any type
   • A sinusoidal pattern.

   

• Baseline FHR 110–150 BPM
• Amplitude of FHR variability between 5 BPM and 25 BPM

 

• Baseline FHR between 150 BPM and 170 BPM or 100BPM and 110 BPM
• Amplitude of variability between 5 BPM and 10 BPM more than 40 minutes
• Increased variability more than 25 BPM
• Variable decelerations

 

• Baseline FHR less than 100 or more than 170 BPM or between 100 BPM and 110 BPM.
• Amplitude of variability less than 5 BPM for more than 40 minutes repetitive early decelerations.
• Prejudiced decelerations.
• Late decelerations with loss of baseline variability.
• Sinusoidal pattern.

 

• It is based on principle of gradually developing uteroplacental insufficiency.
• A stage of fetal compromise can be identified by exposing the fetus to graded stress.
• Partial pressure of O₂ is transiently decreased in the fetus. If the fetus has a baseline O₂ deficit then late decelerations with contractions can be apparent.
• Increase (IUP > 30 mm Hg).
• Increase intramyometrial pressure which exceeds arterial pressure.
• Cessation of uterine perfusion.
• Cessation of entry of oxygenated blood in intervillous space.
• Decreased O₂ supply to fetus.

 

• Cord compression
• Uteroplacental insufficiency

• Decreased maternal blood flow to placenta
• Decreased surface area of placenta
• Decreased membrane thickness within the placenta

 

• Non-reactive NST
• IUGR
• Post-maturity
• Hypertensive disorders

 

• Compromised fetus
• Preterm labor
• Antepartum hemorrhage

 

• Left lateral position
• Baseline BP taken
• FHR recorded by electronic monitoring
• Intravenouss oxytocin infusion started 0.5 mU/ minute and increased every 20 minutes till adequate contractions achieved
• Clinical monitoring for uterine response is also done
• Fetal heart rate during contraction and 1 minute thereafter is recorded

 

Negative:	No FHR deceleration with contractions in 10 minutes
Positive:	Persistent late deceleration
Suspicious:	Late deceleration present but not persistent
Hyperstimulation:	Late deceleration with contractions lasting more than 90 seconds or frequency every 2 minutes
Unsatisfactory:	Poor quality contractions

   

• FHR
• Breathing
• Movements
• Fetal tone
• Amniotic fluid index (AFI)

 

• Added placental grading
• Physical profile is used to evaluate fetal well-being distinguished between a healthy (non-asphyxiated) and unhealthy (asphyxiated) fetus.

TABLE 1A   Biophysical profile scoring: Techniques and interpretation Physical profile Normal (Score = 2) Abnormal (Score = 0) FBM At least one episode of 30 seconds duration in 30 minutes Absent FBM or no episode of > 30 seconds in 30 minutes Gross body movements At least three discrete body or limb movements in 30 minutes (episodes of active continuous movements considered a single movement) Two or fewer episodes of body or limb movements in 30 minutes Fetal tone At least one episode of active extension with return to flexion of fetal limbs, spine, or trunk. Opening and closing of hand considered normal tone. Slow extension with return to partial flexion, movement of limb in full extension, or absent fetal movements Reactive FHR At least two episodes of FHR acceleration of > 15 beats/min and of at least 15 second's 30 minutes Less than two episodes of acceleration of FHR or acceleration of < 15 beats/min in 30 minutes Qualitative AFV At least one pocket of AF that measures at least 2 cm in two perpendicular planes No AF pocket of 2 cm in two perpendicular planes FBM – Fetal breathing movements; FHR – Fetal heart rate; AFV – Amniotic fluid volume; AF – Amniotic fluid

TABLE 1B   Biophysical profile scoring: Management protocol Score Interpretation Management 10 Normal infant, low risk for chronic asphyxia Repeat testing at weekly intervals. Repeat twice weekly in patients with diabetes, IUGR, and > 41 weeks’ gestation 8 Normal infant, low risk for chronic asphyxia Repeat testing at weekly intervals. Repeat testing twice weekly in patients with diabetes, IUGR, and > 41 weeks’ gestation. Oligohydramnios may be an indication for delivery, depending on gestational age 6 Suspect chronic asphyxia Repeat testing in 4-6 hours. Delivery is recommended if oligohydramnios is present > 36 weeks 4 Suspect chronic asphyxia If > 36 weeks with favorable cervixc, delivery is recommended. If < 36 weeks and L/S 2, repeat test in 24 hours. If repeat score 4, delivery is recommended 0-2 Strong suspicion of chronic asphyxia Extend testing time to 120 minutes. If persistent score < 4, delivery is recommended regardless of gestational age

Manning's Scoung	Criteria	Score
BT	Reactive	2
Fetal breathing	One episode more than 30 seconds	2
Body movement	Three movements	2
Muscle tone	One episode of extension	2
AFI	Pocket more than 2 cm	2

     

• FHR
• Fetal breathing movements
• Fetal tone
• Fetal movements

 

• AFI
• Placental grading

Tone	-	Cortex
Movement	-	Cortex nuclei
Breathing	-	Ventral surface of fourth ventricle
Heart rate	-	Post-hypothalamus medulla

 

• Can be performed with in 20 minutes
• Less false positive results
• Provide complete information about fetus
• Widely applicable
• Assurance of high-risk pregnancy

 

• Needs a trained personnel

 

Definition	A technique using a tocodynamometer applied to the maternal abdomen to obtain continuous recording of uterine activity.
Advantage	Non-invasive Can be used with intact membrane and no Cx dilation. No known risk to mother and fetus
Limitations	Imprecise Information is limited to frequency and duration of contraction Uncomfortable belts
Indication	Uterine activity and/or fetal movement recording
Contraindications	None known

• Normal uterine pressure in the first stage of labor is 25–50 mm Hg with a baseline tone of 8–12 mm Hg.
• In the second stage: 80–100 mm Hg

 

• It was initially introduced to prevent intrapartum still birth but is now extended to detect evidence of fetal stress which may be associated with cerebral damage.
• It is used to predict the fetus which was developing acidemia in labor and to enable intervention before permanent damage sets in.
• Pitfall: It has led to an increase in operative intervention in labor without any clear evidence of benefit in terms of neonatal out comes.

 

• Ability of human fetus to respond to external stimuli was suggested in 1925 which showed increased FMs in response to applause (clapping).
• Non-stress test performed on high-risk pregnant mothers is reactive in 85% cases. Change in fetal arousal may benefit 15% of fetuses who have a non-reactive NST result.
• With a non-reactive NST, several methods can be used to assess fetal conditions further. Because prematurely fetal sleep states are frequent causes of non-reactive NST, additional tests are necessary for intervention.

       

• As GA increases fewer stimuli are required to evoke a reactive VAST.

 

• Used to improve the efficiency of antepartum FHR testing.
• Opportunity to study change of fetal behavior.
• Intrapartum assessment of fetal well-being.
• Assessment of abnormal FHR tracing.
• Part of fetal admission test.
• Brisk FM may permit alteration of fetal behavior to improve visualization for stic ultrasonography.
• Its use in C/o abnormal FHR tracing in labor increases the frequency with which fetal scalp blood sampling is necessary.
• Assessment of fetus ability to habituate to this stimulus may allow insight into function of fetal nervous system.
• Overall fetal death rate after a reactive FAST was 1.9 per 1,000.
• Acceleration evoked by VAS appeared to be valid in predicting fetal well-being.
• Vibroacoustic stimulations may improve the efficiency of antepartum fetal surveillance without reducing the predictive reliability of normal test.

 

Type	I:	No response or prolonged deceleration
	II:	An acceleration response
	III:	A biphasic response with an acceleration fib deceleration. Operative intervention for fetal distress or depressed 5 minutes; Apgar score was observed more frequently with Type 1 response than Type 2 response.