FETAL OUTCOME OF TERM PREGNANCY WITH NON-REACTIVE NON-STRESS TEST AT BIRAT MEDICAL COLLEGE TEACHING HOSPITAL

1* 2 3 4 Amit Deo , Raj Deb Mahato , Ram Bhakta Subedi , Tarun Pradhan Received : 28 May, 2021 Accepted : 08 July, 2021 Published : 04 November 2021 1512 ISSN: 2542-2758 (Print) 2542-2804 (Online) Birat Journal of Health Sciences Vol.6/No.2/Issue 15/May-Aug., 2021 Original Research Ar cle


INTRODUCTION
The maternal mortality rate has significantly decreased in developing countries. Thus, the objec ves have shi ed toward fetal health. Pregnancy and child birth is a normal physiological but has great pathological phenomenon poten al. Most of the pregnancies progress uneven ully but some pregnancies may lead to complica ons. Present obstetric prac ce demands care of both mother and her fetus. The fetus is a second pa ent with a high risk of morbidity and mortality. Fetal surveillance is very important for the delivery of a healthy fetus. The main aim of the current preven ve obstetrics prac ce consists of methods to detect, avoid and treat fetal asphyxia. In the last few decades advances in technology have contributed significantly to improve maternal and perinatal outcomes. During delivery of the fetus through the birth canal is a very stressful condi on which can be manifested by the fetus as a stress response in the form of fetal heart rate abnormali es. Some fetuses may have fetal heart rate abnormali es prior to the 1 onset of labor. To assess the fetal condi on during labor is very crucial for the trea ng obstetrician to minimize perinatal morbidity and mortality. To minimize the unwanted outcome, it is essen al to determine the intrauterine fetal condi ons which can be achieved by intrapartum fetal monitoring. Intrapartum fetal monitoring gives the idea about fetal condi on during labor and iden fies fetuses at risk of hypoxic damage so that perinatal outcome can be op mized by appropriate and mely interven on. According to American College of Obstetricians and Gynecologists (ACOG), the aim of antepartum fetal surveillance is to 2 prevent fetal death. Intrapartum fetal monitoring was tradi onally carried out by intermi ent ausculta on of the fetal heart. Electronic fetal heart rate monitoring (EFM) with Non-Stress Test(NST) is used to record the fetal heart rate (FHR) so as to determine the fetal well-being in order to detect signs of intrapartum hypoxia. Use of intrapartum electronic fetal monitoring with Non-Stress Test has steadily increased over the last three decades in an a empt to 3 decrease the risk of intrapartum fetal morbidity and mortality. Con nuous electronic fetal monitoring may not be possible in low resourced countries like Nepal and hence Non-Stress Test is be er alterna ve. A be er understanding of fetal physiology and increasingly advanced technology have changed the a tude towards fetal health. Antepartum assessment of fetal wellbeing is one of the primary tasks of 4 modern obstetric prac ce. For predic ng pregnancy outcome in uncomplicated pregnancies, we adopted nonstress test (NST). Freeman (1975) and Lee and colleagues introduced the NST. A sign of fetal health describes the fetal heart rate accelera on in response to fetal movement. In fetal asphyxia there is disturbed gas exchange, leading to progressive hypoxemia and hypercapnia with significant 5 metabolic acidosis. The NST looks for the presence of temporary accelera on of the fetal heart rate at the me of fetal movement that involves the cerebral cortex and is affected by physiologic or pathologic influences on the fetal brain. NST is a con nuous recording of fetal heart rate via an ultrasound transducer placed on the mother's abdomen. To assess the fetal well-being during labor and delivery process has been a central component of intrapartum care. The main jus fica on for NST is that the uterine contrac ons of labor place stress on placental circula on. NST has been able to 6 detect fetal distress with more reliability. Reac ve NST trace reassures both the mother and health care provider of good 7 fetal health. Abnormal NST is more common in meconium 8 aspira on syndrome. An abnormal tracing indicates a fetal hypoxia and hence iden fies fetal compromise at an early stage to allow an early interven on. Moreover, there is interobserver varia on in interpreta on of abnormal cardiotocography readings and recommenda ons for 9 interven ons. The great progress was made in antepartum diagnosis of fetal condi on by the introduc on of non-stress test (NST). NST registra on fetal heartbeats and uterine contrac ons simultaneously. Fetal heart beats decelera ons 10 occur during fetal asphyxia. Nowadays, almost all pregnant women antenatally monitored with NST, which probably 10 increases the fetal indica ons of Caesarean sec ons. Fetal asphyxia is a condi on of disturbed gas exchange, leading to progressive hypoxemia and hypercapnia with significant 11 metabolic acidosis. Asphyxiated baby may die, recover, manifest hypoxic ischemic encephalopathy (HIE) and later 10 have neurodevelopmental disorders. The admission nonstress test (NST) is used to indicate the state of oxygena on of the fetus on admission of the mother non-invasively and assess the fetal reserve by recording FHR during the uterine contrac on which temporary occlusion of the utero-placental blood supply so non-stress test tracing on admission helps Obstetrician to determine the ability of the fetus to cope 12 with the stress of labour. APGAR scoring is done at 1 and 5 minutes to assess the health of a new-born baby. A 5-minute APGAR score is of more value for correla on of long-term 13 neurological damage. Despite NST is associated with increased caesarean sec on rate, it remains a major method 14 of monitoring high-risk pregnancy. False posi ve NST trace means that the record is pathological and child is born, without acidosis; false nega ve NST trace means that with the normal NST trace and child is born is asphyxiated and depressed child with HIE is born and that will manifest later in neurodevelopmental disorders. This study was conducted with the aim to assess Fetal Outcome at Term Pregnancy with non-reac ve NST at Birat Medical College Teaching Hospital.

METHODOLOGY
A prospec ve, cross-sec onal hospital-based study was conducted for 6 months dura on in the department of Obstetrics and Gynecology at Birat Medical College Teaching Hospital (BMCTH). A purposive, total enumera on sampling technique was used to include the par cipants a er permission granted from IRC BMCTH. Informed consent was taken from par cipants for the study. A singleton uncomplicated healthy pregnancy with longitudinal lie, cephalic presenta on at term not in labor with non-reac ve NST was included in the study. Complicated pregnancy like hypertensive disorder, GDM, oligohydramnios, mul ple gesta on, anomalous fetus and pa ents admi ed for elec ve caesarean sec on were excluded from study. The NST tracings obtained were then categorized as Reac ve (Normal), Equivocal (suspicious), & Non-reac ve (Pathological) as per Na onal Ins tute of Clinical Excellence (NICE) Clinical guideline 2017. Par cipants fulfilling the inclusion criteria were kept in le lateral posi on, resuscita on with Dextrose IV fluid and oxygen with face mask were done and then pa ents were taken for emergency LSCS as per Hospital protocol. Categorical variables such as socio-demographic data and type of non-reac ve NST where collected, intraopera ve finding such as abnormal liquor colour was noted and fetal outcome was assessed by no ng APGAR score at 5 minutes and need of NICU. All the data were entered in Microso Excel sheets. Sta s cal analysis was done for percentage, frequency for categorical variable and chi-square and Pearson's correla on was done for level of significance.

RESULTS
There were a total of 115 pregnant women with nonreac ve NST. The sociodemographic profile of these pregnant women was shown in table 1. The age of pregnant women is in the range of 18 to 37 years. The mean age and standard devia on of the par cipants were 24.93±4.68 years of which 56.5 % were mul gravida, 63.5 % pregnant women were unhooked and 87% pregnant women from rural areas.  Table 2 shows NST finding of the par cipants. Decelera ons were found in 30.4 % of cases, decreased baseline variability was found in 28.7 % of cases, Persistent fetal tachycardia was found in 20% of cases and Decreased baseline fetal heart rate in 20.90 % of cases. All the pa ents with nonreac ve NST underwent an emergency caesarean sec on.  Table 3 shows fetal APGAR score at 5 minutes of birth in Non-reac ve NST. 3.5 % of babies had APGAR score 7/10 at 5 minutes of birth, 94.8% of babies had APGAR score 8/10 at 5 minutes of birth, and 1.7% of babies had APGAR score 9/10 at 5 minutes of birth.  Table 4 shows the cord abnormali es found in Non-reac ve NST. 93.9 % of cases no cord abnormali es were found only in 6.1 % of cases cord abnormali es were found.    Table 5 shows NICU admission of baby a er delivery of nonreac ve NST. only 12.2% of babies were admi ed to NICU a er delivery. Table 6 shows non-reac ve NST and amnio c fluid abnormality. 64.3 % of cases had clear liquor, 33.9 % case had meconium-stained liquor and 1.7 % cases had absent liquor.   Table 9: Associa on between non-reac ve NST and 5 minutes APGAR score (n =115)

DISCUSSION
Non-stress test (NST) has emerged as a modern noninvasive tool for detec ng fetal asphyxia in the last decade. NST is one of the reliable methods of fetal monitoring in 15 pregnancy and during labour. In majority of the hospitals of developed and developing countries, NST is the most commonly used tool for fetal surveillance. NST is superior method for fetal hypoxia detec on as it detects, the subtle changes in fetal heart rate which can be missed on 16 intermi ent ausculta on. NST reliability as a sole tool in diagnosing fetal distress is ques onable and can lead to unnecessary rise in caesarean sec on rates. This study was conducted to correlate the fetal outcome a er non-reac ve NST. In our study, Majority of par cipants were of age group 21-25 years (41.73%), followed by 26-30 years age group (25.21%). This is similar to study done by Rahman et al in which 42.5% of the par cipants were of age group 21-25 17 years. This is because of similar study se ng. In our study, in Non-reac ve NST, 27.9 % pa ents had meconium-stained liquor, none of newborn had APGAR score less than 7 at 5 minutes and 12.2% need NICU admission. The finding is inconsistent with the study done by Joshi et al (2019) shows 75% pa ents had meconium-stained liquor, 6.7% of the neonates had APGAR less than 7 at 5 minutes and 6.7% 18 needed NICU admission in Non-reac ve NST. In our study, all pa ents under gone caesarean sec on in Non-reac ve NST in contrast to study done by Banu et al (2016)shows 80% pa ents with Non-reac ve NST underwent caesarean 19 sec on. In our study caesarean sec on rates are high in Non-reac ve NST because pa ents and pa ents party are very much conscious about the baby and don't want to take any risk. In our study admission NST in uncomplicated pregnancies does not show any fetal advantage and increases the caesarean sec on rate. The finding is consistent with the study done by Bhar ya et al (2016) shows admission NST does not benefit the neonatal outcome in uncomplicated pregnancies and rather results in increased caesarean 20 sec on rate.

CONCLUSION
The admission NST is not beneficial for assessing intrapartum fetal hypoxia and increases the need for a caesarean sec on. So, the caesarean sec on rate increases. Hence, admission NST does not benefit the neonatal outcome in uncomplicated pregnancies and rather results in increased caesarean sec on rate. Thus, it is not beneficial as a screening test to detect intrapartum fetal hypoxia in uncomplicated pregnancies.

RECOMMENDATIONS
A large number of pregnant women based on randomized control trials is required for assessing efficacy of admission NST and fetal outcome in low-risk pregnancies.

LIMITATIONS OF THE STUDY
NST repor ng was done by different doctor so may be observer bias.