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CLINICAL OBSTETRICS AND GYNECOLOGY Volume 45, Number 4, 986–992 © 2002, Lippincott Williams & Wilkins, Inc.

Nonstress Test: Evidence-Based Use in High-Risk Pregnancy
LAWRENCE D. DEVOE, MD, and CHANDRA R. JONES, MD Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, Georgia

For three decades, the nonstress test (NST) has been accepted as a primary fetal surveillance tool for pregnancies at risk for intrauterine death. Subsequently, the NST has been used in combination with ultrasound observations of fetal activity and amniotic fluid volume as the biophysical profile. More recently, this test has been modified by the addition of vibroacoustic stimulation (VAS) or by Doppler recordings of fetal movement (actocardiotocography [ACTG]). The NST’s popularity stems from its ease of application in ambulatory settings, modest technical requirements, and lack of contraindications. Extensive clinical experience has been reported on use of the NST; however, the bulk of the evidence supporting its role in antepartum management is based on level II-3 evidence (multiple time series) rather than level I evidence (randomized controlled trials). In spite of this caveat, the incorporation of the NST into high-risk antepartum protocols has been associated with an apparent reduction in intrauterine feCorrespondence: Lawrence Devoe, MD, Medical College of Georgia, Department of OB/GYN, 1120 15th Street, Suite BA 7300, Augusta, GA 30912-3305. E-mail: ldevoe@mcg.edu
CLINICAL OBSTETRICS AND GYNECOLOGY /

tal death.1 This monograph will address the biologic basis of the NST in antepartum assessment, its application and interpretation, as well as the best evidence to support its continued use in the care of complicated pregnancies.

Developmental and Physiologic Basis
The NST is derived from intrapartum electronic fetal monitoring, in which the observation of fetal heart rate (FHR) accelerations presaged a good perinatal outcome.2 The generation of FHR patterns requires intact electrical conduction pathways, appropriate myocardial neurohormone receptors, sympathetic and parasympathetic reflex arcs, and inherent myocardial contractility. The FHR patterns that signal cellular hypoxia and acidosis include relatively fixed FHR baselines, loss of FHR variation and accelerations, and/or the appearance of spontaneous late FHR decelerations.3 The NST is also affected by constitutional and environmental factors such as fetal state and maturation, maternal state and medications, and diurnal biorhythms. As the
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the time required to obtain test reactivity may need to be extended.Nonstress Test in High-Risk Pregnancy fetus approaches term. 987 Doppler signals are not exact reproductions of electrocardiographic R-R intervals. the recent consensus statement on FHR interpretation suggests that long-term trends in FHR variability can be adequately approximated in such tracings. longer observation may be needed to register sufficient acceleration counts. No absolute or major relative contraindications exist for the NST. Although these . such as beta-blocking agents. Typical VAS responses of healthy term fetuses show at least a 10-bpm rise in baseline. lower mean baseline FHR and reduce acceleration frequency. gross body movements linked with FHR accelerations increase. they typically last about 20 minutes but may persist for 2 hours in normal term fetuses.5 In preterm pregnancies (24–32 weeks’ gestational age). nicotine) may raise FHR baseline and decrease acceleration amplitude. the latter condition may not be detected by the NST for days to weeks.10 ACTG Special Doppler filtering systems have permitted the registration of low-frequency shifts that occur with fetal movements. such as fed state and glycemia. selected fetal anomalies.7. Besinger and Johnson11 have reported strong correlations of Doppler-detected fetal activity with that observed by concurrent realtime ultrasonography. and maternal diabetes mellitus. and lasting from 5 to 10 minutes. and Follow-Up All pregnant women at high risk for intrauterine fetal compromise are candidates for NSTs. as would be obtained from a direct fetal scalp electrode. occurring within 10 seconds. variability. VAS-induced responses become more consistent as the fetus matures and during quiet sleep states. These systems are now incorporated in many currentgeneration electronic fetal monitors. Quiet sleep states contain decreased levels of fetal activity and FHR variability. NSTs in this age group have lower mean amplitude (10 bpm) accelerations and brief spontaneous decelerations associated with movement. maturation of FHR central regulatory centers is incomplete. Maternal factors. Common test indications include prolonged pregnancy. Indications. intrauterine growth restriction (IUGR). In both circumstances. Antihypertensive drugs. opiates) may prolong quiet sleep states. Acute hypoxemia produces sudden and profound declines in numbers of fetal movements and accelerations. maternal hypertensive disorders. intrauterine growth restriction.6 Quiet sleep states are also more common. more chronic hypoxemia. Interpretation. while chronic hypoxemia is associated with more gradual declines in these parameters. Test Methods STANDARD NST Continuous wave Doppler transducers produce the signal sequences that are processed to generate a baseline rate. and cardiac disease. Consequently.8 Acute fetal hypoxemia may exert effects on resting FHR patterns that differ from those seen with milder. Fetal wakeful states are the periods when reactive FHR accelerations are most likely to be registered.9 VAS Fetal VAS with an electronic artificial larynx has been used as a primary method of FHR testing. and movements in the same time frame. They enable better discrimination of fetal behavioral states by incorporating FHR reactivity.4 Fetal behavioral states influence the appearance of the NST. Central nervous sytem depressants (barbiturates. Rh sensitization. while stimulants (cocaine. have inconsistent effects on NST appearance. renal disease.

numerous antepartum. Critical reviews of testing standards and diagnostic values have shown a wide range of test sensitivity. a subsequent decrease in the incidence of fetal movements. amplitude of 10 bpm (<32 weeks’ gestational age) versus 15 bpm (>32 weeks’ gestational age)—should reflect gestational age norms. Since the screening performance of the NST declines with increasing test interval. a single qualifying acceleration must occur after application of the stimulus. most protocols recommend at least weekly testing. intrapartum. a qualifying reactive tracing should contain at least two accelerations of amplitude more than 15 bpm in 20 minutes. no prospective randomized controlled trial containing sufficient numbers of patients adequately matched for gestational age. respectively. decoupling of accelerations with fetal movements.000 and a perinatal death rate of 2. high-risk conditions. The false-positive rate of nonreactive NSTs is sufficiently high to support addi- tional testing. or fetal arrhythmia. Recently. Moreover. Adverse perinatal outcomes after normal or reassuring FHR tests are uncommon. averaging 50%. The relatively low prevalence of poor outcomes in most of the older reports (usually 10 – 15%) accounts for the decreased positive predictive value. The interval between tests may vary according to specific medical/obstetric conditions. periodic late or variable decelerations. and finally the disappearance of both accelerations and movements. This suggests that the NST is better at ruling out than at ruling in fetal compromise. amniotic fluid volume. the NICHD Workshop on Fetal Heart Rate Monitoring concurred that a minimum threshold for acceleration recognition—that is. Predictive values.3/1. are often lumped together. such as severe IUGR or brittle diabetes mellitus. maternal . neonatal death. positive and negative.1 For the VAS. and postnatal outcomes. The threshold for neonatal survival should determine the earliest such testing would be practical at a given institution (generally >24 weeks’ gestation).3/1. are typically less than 50% and more than 90%. Immediate antepartum management after a nonreactive NST might include other studies. decreased variability.13 Validation and Supportive Evidence The NST was incorporated into routine obstetric practice without rigorous randomized clinical trials. testing might be performed daily.14 Most reports on the NST demonstrate relatively high specificity (>90%) but much lower sensitivity. Our group reported on the use of the NST in 1. specificity.988 DEVOE AND JONES Test reactivity requires a minimum frequency of qualifying FHR accelerations during a specified time period. and the mode of test follow-up. spontaneous decelerations or bradycardias. or obstetric management has yet been conducted. and neonatal intensive care. intrapartum fetal distress.000 consecutive high-risk patients15 categorized by test indications (eg. Appropriate use of the NST must consider the gestational age at test initiation.13. Sequential studies of NSTs in the same fetus12 suggest that fetal compromise may be signaled by a gradual decrease in acceleration counts.1 A cumulative review of available literature shows that a normal test confers a corrected antenatal mortality rate of only 0. or a complete biophysical profile.1 NST nonreactivity is defined as the absence of or an inadequate number of qualifying accelerations.1 In selected and generally unstable high-risk conditions. low Apgar scores.9 In term gestations. Additional qualifying features of an abnormal NST include sustained tachycardia (rate >160 bpm) or bradycardia (rate <110 bpm). the frequency of test repetition. While the following supportive evidence represents the best that is currently available. and predictive values.000. including ultrasound assessment of fetal anatomy. such as fetal death. Such lumping of outcomes that are not all readily predictable in the antepartum state may confound the assessment of the real value of this modality.

postdatism) (Fig. Finally. 1). Cardiotocography for antepartum fetal assessment. screening values varied significantly according to the indication for testing. 2002.98–1. Meta-analyses of these three trial methodologies are discussed below. is an order of magnitude smaller than the minimum number required to demonstrate efficacy in reducing perinatal mortality in high-risk populations (approximately 15. Issue 1. These have consisted of NST (study group) versus NST concealed or not performed (control group). First. NST (control group) versus VAS (study group). The best NST screening performances (sensitivities >70%) were associated with tests performed for IUGR or maternal hypertension. 1. Effects of NST for Fetal Assessment on Outcomes Odds Ratio 1.63–1.62 Modified from Pattison N.37 0.09 1. Cochrane Library.41 1. In this study.94 1. these conclusions must be tempered by a number of considerations. NST versus non-NST (concealed or not performed). 1.Nonstress Test in High-Risk Pregnancy 989 FIG.01 95% CI 0. 1.16 The four studies included in this review were performed in the United Kingdom during the mid-1980s.17 Few trials have compared these two testing methods for the major question of interest: can the TABLE 1.Table 1 summarizes the primary outcomes of interest examined in the metaanalysis. The meta-analysis of the randomized controlled trials comparing the NST with VAS is shown in Table 2. and some discretion was allowed in clinical management.79–1.69–1. and NST (control group) versus biophysical profile (study group). not all of these trials used similar methods of randomization.06 3.000). Oxford: Update Software.85–1. they reflect practices of two decades ago and were applied to rather broadly defined obstetric populations.19–7. Screening performance of NST versus test indications. While it would appear that the use of the NST alone did not decrease the rates of adverse outcomes or obstetric interventions. Outcome C-section IP Abnl FHR Low Apgar score Abnl NN CNS NICU admission Perinatal death hypertension. RANDOMIZED CONTROLLED TRIALS Prospective randomized controlled trials of the effectiveness of the NST have been very limited. NST versus VAS.58 0. Next. IUGR. Cochrane Review. .08 1.579 subjects. the number enrolled. McCowan L.88 0. 2.27 0. diabetes mellitus.24 0.

lacks the power to convince clinicians that the more complex biophysical profile scheme is superior to the NST alone in reducing perinatal death or preventing unneeded interventions. neonatal morbidity. including methods of randomization. 3.27–7. A major concern for this study was that only 400 patients were enrolled and that sample size was determined a priori by the number needed to show a 50% reduction in neonatal intensive care duration. Outcome Perinatal death 5Ј Apgar <7 Intrapartum fetal distress NICU admission A recent randomized controlled trial has been performed that compares visual analysis versus computer analysis of the NST.58–2.12 0.18 Modified from Alfirevic Z. Chichester. While more than 2. The cumulative sample size. this review suggests that conclusions on efficacy in reducing perinatal death would require significantly larger numbers of subjects.74 0. Cochrane Library. 2002. The use of automated FHR analysis appeared to reduce the need for subsequent testing without increasing perinatal morbidity or mortality.14 95% CI 0. NONRANDOMIZED PROSPECTIVE TRIALS BPP: Effects on Perinatal Outcomes Odds Ratio 1.20 reporting on more than 7. The intent to demonstrate the superiority of the complete biophysical profile over simpler surveillance techniques (eg. Cochrane Review.39–1.30 1.61 1. This study was biased in patient selection (more patients in the CST arm. NST versus biophysical profile.49–0.40 0. and details of clinical management. full biophysical profile) and selected birth outcomes of interest (Apgar score. criteria for entry.19 This type of trial may become more important as automated FHR analytic systems gradually migrate into clinical settings. shorter VAS test be substituted for the standard NST without jeopardizing fetal management? Testing time in the trials included was reduced by an average of 5 minutes. the NST was used in the control arm.48 TABLE 2.21 0.990 DEVOE AND JONES VAS: Effects on Perinatal Outcomes Odds Ratio 0. Issue 1. Cochrane Library. NST) was not upheld by the cumulative data shown in Table 3. Oxford: Update Software. either alone or with an additional biophysical component (usually the amniotic fluid index). showed that both tests were effective but noted higher antepartum death rates and perinatal morbidity occurred when the NST rather than the CST was used as the primary surveillance method. 2002. as the NST is an important component of the biophysical profile.75–1.75 0.91 0. UK) that has been extensively studied over the past two decades.01–2. Neilson JP.43 0. The computer system used was a commercially available automated FHR analysis system (Oxford Sonicaid System 8000. Cochrane Review.000 subjects were included in the cumulative metaanalysis. There is TABLE 3.18 While the study designs varied in nearly all of these trials. Biophysical profile for fetal assessment in high-risk pregnancies. Freeman et al. the contraction stress test (CST).92 0.18 95% CI 0. Fetal vibroacoustic stimulation for facilitation of tests of fetal well-being. again. Issue 1. A metaanalysis has been performed on the randomized controlled trials designed to compare the NST (control) versus the full biophysical profile (study group). perinatal death). Few large studies have compared the NST with its predecessor.86 0.96 0. Modified from Tan KH. Smyth R. more low-birthweight infants in the NST arm) and lacked standardization of test . Outcome Nonreactive test 5Ј Apgar <7 IPFD Stillbirth also the potential irony of comparing a test with itself.39–1.00–9. Oxford: Update Software. Two groups (visual analysis and computer analysis) were compared for the need for additional testing (eg. an older testing method that was believed to be a more rigorous assessment of fetal-placental function.000 patients. The benefit of reducing overall testing time and the number of “nonreactive” tests (thereby decreasing unnecessary subsequent testing) was achieved without higher risks of fetal compromise.

1982. Am J Obstet Gynecol. pred value (%) 613 11. It should be clear that the NST can only be intended as a single rather than the sole part of the comprehensive evaluation of such patients.03 0.134:36.39 Modified from Devoe LD. American College of Obstetricians and Gynecologists. Clinical management.3 48 99 92 94 CST 582 11. potentially risky interventions. Ikenoue T.39 0. Both arms were similar for gestational age. Similar conclusions may be drawn for the use of VAS testing. Martin CB. Antepartum Fetal Surveillance. Am J Obstet Gynecol. Powell OH. The effectiveness of different testing schemes can be objectively measured by comparing their use versus either no testing or alternative tests. A recent large survey of ACTG found that the predictive values of Doppler movement detection were as reli- able as those provided by standard NST parameters. et al. including the VAS and biophysical profile. the most recent meta-analyses suggest that the sample sizes reported were too small to provide conclusive evidence on the actual effectiveness of the NST or its various modifications. high-risk conditions. Finally. 1. Morrison J. Few clinical. Murata Y. Fetal heart rate accelerations and late decelerations during the course of intrauterine death in chronically catheterized rhesus monkeys. A prospective comparative study of the extended nonstress test and nipple stimulation contraction stress test. including obstetric interventions. Devoe et al21 reported a prospective study comparing the NST and nipple stimulation CST in 1.91 0. More importantly.5 30 99 80 92 P Value — 0. and test follow-up.Nonstress Test in High-Risk Pregnancy interpretation or follow-up. October 1999. Further advances in FHR testing methods such as automated analysis and eventually expert systems may improve the technical performance of the NST. 2. Practice Bulletin 9. 3. Am J Obstet Gynecol. Comparative Data of the NST-CST Prospective Trial NST Number of patients Adverse outcomes (%) Sensitivity (%) Specificity (%) Pos. References TABLE 4. MacKenna JL. Melville A. nonrandomized trials of ACTG have been reported. Fetal heart rate acceleration in labor: Excellent prognostic indicator.200 patients (Table 4). The best evidence to date shows that antepartum surveillance may use the NST but should not rely on it as a sole screening tool. many of which were acquired in a different clinical era. 1987. greatest ease of use. 991 Conclusions In contemporary practice. 1979. such improved tools may encourage the much larger population trials needed to answer the central question posed in this monograph on NST effectiveness. 4. pred value (%) Neg.30 0. The slightly greater sensitivity of the NST was counterbalanced by its increased mean testing time. NST interpretation. Turok R. 157:531. Washington DC. Any fetal well-being test can have significant consequences since it may launch subsequent. and highest effectiveness within the real constraints of time and cost. . should be based on a composite picture that incorporates as much patient information as possible and that includes adequate determination of fetal age and maturity. In turn. Natale R. et al.22 This review has demonstrated that the best evidence supporting the effectiveness of the NST is based on very limited population surveys. obstetricians are constantly seeking a surveillance scheme that can provide the widest application. Neither testing approach was associated with significant differences in perinatal mortality or morbidity rates. Martin J.144:218. Nasello-Patterson C. it is important to place a proper perspective on the role of FHR testing in the larger picture of clinical management of high-risk pregnancies.

163:1040. 16. 11.142:535. 18. Am J Obstet Gynecol. Am J Obstet Gynecol. 1989. Neilson JP. Devoe LD. Cochrane Review.160:172. Oxford: Update Software.143:771. et al. Clinical experience with the Hewlett Packard M1350 fetal monitor: Correlation of Dopplerdetected fetal body movements with fetal heart rate parameters and perinatal outcome. 7. Richardson B. Am J Obstet Gynecol. et al. Besinger RE. 1982. Castillo R. Devoe LD. Broussard PM. 19. 1985. 21. McCowan L. Issue 1. Risk of perinatal mortality and morbidity according to antepartum fetal heart rate test results. Cochrane Review. . Doppler recordings of fetal movement: Clinical correlation with real-time ultrasound. Boehm F. Freeman RK. Berkelman RL. Devoe LD. 10. 1999.74:277. Goodman JDS. Devoe L. Thacker SB. et al. Am J Obstet Gynecol. Alfirevic Z. and body movements of normal term fetuses. McKenzie J. Antepartum fetal heart rate testing: III. 1989. The effect of maternal glucose administration on the specificity of the nonstress test. Johnson TRB. Tan KH. Issue 2. The preterm nonstress test: effects of gestational age and length of study. 1980. Byrne DW. and heart rate accelerations and decelerations at 24 to 32 weeks of gestation. Am J Obstet Gynecol. Am J Obstet Gynecol. Devoe LD. et al.137:459. 9.41:121. Cochrane Review. Bracero LA.177:1385. A prospective comparative study of the extended nonstress test and nipple stimulation contraction stress test. Oxford: Update Software. 2001. The nonstress test as a diagnostic test: A critical reappraisal. et al.181:1254–1258. 5. 20. Pattison N. Am J Obstet Gynecol. 152:1047.161:524. 1994. Morgan S. Obstet Gynecol. 13. Cochrane Library. The effect of phenobarbital on the nonstress test. 1989. Cardiotocography for antepartum fetal assessment. 12. Briggs ML. Dear C. Am J Obstet Gynecol. A prospective multi-institutional study of antepartum fetal heart rate monitoring: I. and Doppler velocimetry in screening a general high risk population. 1985. Assessing the diagnostic accuracy and efficacy of selected antepartum fetal surveillance techniques. 2002. et al. Gardner P. et al. Castillo RA. Biophysical profile for fetal assessment in high-risk pregnancies. body movements. Diurnal and other cyclic variations in human fetal heart rate near term. Smyth R. Electronic fetal heart rate monitoring: research guidelines for interpretation. 6. Martin J. 1997. 1987.992 DEVOE AND JONES Longitudinal measurements of fetal breathing. Fetal vibroacoustic stimulation for facilitation of tests of fetal well-being. amniotic fluid measurement. Paul RH. Cochrane Library.157:531. Castillo RA. Am J Obstet Gynecol. Sherline DM. Oxford: Update Software. 1982. Levine DH. heart rate. Morrison J. Visser GHA. 8. 2002. Devoe KD. 14. Toomey C. 15. Sequential non-stress testing using each fetus as its own control. Dorchester W.151:256. breathing activity. Am J Obstet Gynecol. Obstet Gynecol Surv. Arthur M. Comparison of visual and computerized interpretation of nonstress test results in a randomized controlled trial. et al.170:650. Cochrane Library. Issue 1. Am J Obstet Gynecol. Ruedrich DA. The diagnostic values of concurrent nonstress testing. Am J Obstet Gynecol. Am J Obstet Gynecol. National Institute of Child Health and Human Development Research Planning Workshop. Am J Obstet Gynecol. 1990. Paul R. 1979.133:579. Anderson G. Searle NA. 1986.154:931. The effects of vibroacoustic stimulation on baseline heart rate. 17. Keegan KA. 1986. Castillo RA. 22. Devoe LD.