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P RACTICE BULLET IN
clinical management guidelines for obstetrician – gynecologists
Number 145, July 2014 (Replaces Practice Bulletin Number 9, October 1999)
Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins—Obstetrics with the assis-
tance of Dwight J. Rouse, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These
guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs
of the individual patient, resources, and limitations unique to the institution or type of practice.
VOL. 124, NO. 1, JULY 2014 Practice Bulletin Antepartum Fetal Surveillances 183
commonly associated with a fetal sleep cycle but may with a markedly increased risk of both cesarean deliv-
result from any cause of central nervous system depres- ery for a nonreassuring FHR pattern and fetal demise
sion, including fetal acidemia. (32–34). In this setting, the decision to deliver should
The patient may be positioned in either the be made with consideration of whether the benefits
semi-Fowler position (sitting with the head elevated outweigh the potential risks of expectant management.
30 degrees) or lateral recumbent position. In one small
randomized study, it took less time to obtain a reactive Biophysical Profile
NST when patients were placed in the semi-Fowler posi- The BPP consists of an NST combined with four obser-
tion (18). The FHR is monitored with an external trans- vations made by real-time ultrasonography (35). Thus,
ducer. The tracing is observed for FHR accelerations that the BPP comprises five components:
peak (but do not necessarily remain) at least 15 beats per
minute above the baseline and last 15 seconds from base- 1. Nonstress test––may be omitted without compro-
line to baseline. The NST should be conducted for at least mising test validity if the results of all four ultra-
20 minutes, but it may be necessary to monitor the trac- sound components of the BPP are normal (35)
ing for 40 minutes or longer to take into account the 2. Fetal breathing movements––one or more episodes
variations of the fetal sleep–wake cycle. Vibroacoustic of rhythmic fetal breathing movements of 30 seconds
stimulation may elicit FHR accelerations that are valid or more within 30 minutes
in the prediction of fetal well-being. Such stimulation 3. Fetal movement––three or more discrete body or
offers the advantage of safely reducing the frequency of limb movements within 30 minutes
nonreactive NSTs by 40% and the overall testing time
by almost 7 minutes without compromising detection 4. Fetal tone––one or more episodes of extension of a
of the acidotic fetus (19–22). To perform vibroacoustic fetal extremity with return to flexion, or opening or
stimulation, the device is positioned on the maternal closing of a hand
abdomen and a stimulus is applied for 1–2 seconds. If 5. Determination of the amniotic fluid volume––a
vibroacoustic stimulation fails to elicit a response, it may single deepest vertical pocket greater than 2 cm
be repeated up to three times for progressively longer is considered evidence of adequate amniotic fluid
durations of up to 3 seconds. (36–38)
Nonstress test results are categorized as reactive
Each of the five components is assigned a score of
or nonreactive. Various definitions of reactivity have
either 2 (present, as previously defined) or 0 (not present).
been used. The most common definition of a reactive, or
A composite score of 8 or 10 is normal, a score of 6 is
normal, NST is if there are two or more FHR accelera-
tions (as previously defined) within a 20-minute period considered equivocal, and a score of 4 or less is abnor-
(23). A nonreactive NST is one that lacks sufficient FHR mal. Regardless of the composite score, oligohydramnios
accelerations over a 40-minute period. The NST of the (defined as an amniotic fluid volume of 2 cm or less in
normal preterm fetus is frequently nonreactive: from 24 the single deepest vertical pocket) should prompt further
weeks to 28 weeks of gestation, up to 50% of NSTs may evaluation (37, 39).
not be reactive (24), and from 28 weeks to 32 weeks of Although oligohydramnios has been commonly
gestation, 15% of NSTs are not reactive (15, 25, 26). defined as a single deepest vertical pocket of amniotic
Thus, the predictive value of NSTs based on a lower fluid of 2 cm or less (not containing umbilical cord or
threshold for accelerations (at least 10 beats per minute fetal extremities) and an amniotic fluid index of 5 cm
above the baseline and at least 10 seconds from baseline or less, available data from randomized control trials
to baseline) has been evaluated in pregnancies at less than (RCTs) support the use of the deepest vertical pocket of
32 weeks of gestation and has been found to sufficiently amniotic fluid volume of 2 cm or less to diagnose oligo-
predict fetal well-being (27, 28). Variable decelerations hydramnios (36–38, 40, 41).
may be observed in up to 50% of NSTs (29). Variable
decelerations that are nonrepetitive and brief (less than Modified Biophysical Profile
30 seconds) are not associated with fetal compromise or In the late second-trimester or third-trimester fetus, amni-
the need for obstetric intervention (29). Repetitive vari- otic fluid volume reflects fetal urine production. Placental
able decelerations (at least three in 20 minutes), even dysfunction may result in diminished fetal renal per-
if mild, have been associated with an increased risk of fusion, leading to oligohydramnios (5). Amniotic fluid
cesarean delivery for a nonreassuring intrapartum FHR volume assessment can, therefore, be used to evaluate
pattern (30, 31). Fetal heart rate decelerations during an uteroplacental function. This observation fostered the
NST that persist for 1 minute or longer are associated development of what has come to be termed the “modified
VOL. 124, NO. 1, JULY 2014 Practice Bulletin Antepartum Fetal Surveillances 185
surveillance in RCTs (which would require the random
allocation of pregnant patients to prenatal care that Box 1. Indications for Antepartum
included antepartum fetal surveillance versus prenatal Fetal Surveillance Testing ^
care that did not include antepartum fetal surveillance)
is unlikely to be conducted in a setting that can be gen- Maternal conditions
eralized to current U.S. obstetric practice. In spite of its • Pregestational diabetes mellitus
unproven value, antepartum fetal surveillance is widely • Hypertension
integrated into clinical practice in the developed world. • Systemic lupus erythematosus
What are the indications for antepartum fetal • Chronic renal disease
surveillance? • Antiphospholipid syndrome
• Hyperthyroidism (poorly controlled)
Because antepartum fetal surveillance results have not
been definitively demonstrated to improve perinatal • Hemoglobinopathies (sickle cell, sickle cell–
outcome, all indications for antepartum testing must hemoglobin C, or sickle cell–thalassemia disease)
be considered somewhat relative. In general, antepar- • Cyanotic heart disease
tum fetal surveillance has been used in pregnancies in Pregnancy-related conditions
which the risk of antepartum fetal demise is increased.
Accordingly, some of the conditions for which testing • Gestational hypertension
may be indicated include, but are not limited to, those • Preeclampsia
listed in Box 1. • Decreased fetal movement
• Gestational diabetes mellitus (poorly controlled or
When during gestation should antepartum medically treated)
fetal surveillance be initiated?
• Oligohydramnios
Choosing the appropriate point in gestation to begin • Fetal growth restriction
antepartum fetal testing depends on several consider- • Late term or postterm pregnancy
ations, including the prognosis for neonatal survival, the
risk of fetal death, the severity of maternal disease, and • Isoimmunization
the potential for iatrogenic prematurity complications • Previous fetal demise (unexplained or recurrent risk)
resulting from false-positive test results. The importance • Monochorionic multiple gestation (with significant
of the last consideration is illustrated by the experience growth discrepancy)
of one large center, in which 60% of infants delivered
because of an abnormal antepartum test result had no Data from Liston R, Sawchuck D, Young D. Fetal health surveil-
lance: antepartum and intrapartum consensus guideline. Society of
evidence of short-term or long-term fetal compromise Obstetrics and Gynaecologists of Canada, British Columbia Perinatal
(20). Both theoretic models and large clinical studies Health Program [published erratum appears in J Obstet Gynaecol Can
suggest that initiating antepartum fetal testing no earlier 2007;29:909]. J Obstet Gynaecol Can 2007;29:S3–56. (Level III)
than 32 0/7 weeks of gestation is appropriate for most
at-risk patients (61–63). However, in pregnancies with
multiple or particularly worrisome high-risk conditions
(eg, chronic hypertension with suspected fetal growth testing in an otherwise uncomplicated pregnancy), test-
restriction), testing might begin at a gestational age ing need not be repeated. When the clinical condition
when delivery would be considered for perinatal benefit that prompted testing persists, the test should be repeated
(64–69). periodically to monitor for continued fetal well-being
until delivery. If the maternal medical condition is stable
What is the recommended frequency of and test results are reassuring, tests of fetal well-being
testing? (NST, BPP, modified BPP, or CST) are typically repeated
at weekly intervals (17, 20); however, in the presence
There are no large clinical trials to guide the frequency of certain high-risk conditions, some investigators have
of testing, and thus, the optimal frequency remains performed more frequent testing, although the optimal
unknown; it depends on several factors and should be regimen has not been established.
individualized and based on clinical judgment. If the In pregnancies complicated by fetal growth restric-
indication for testing is not persistent (eg, a single episode tion, the optimal interval for fetal growth assessment and
of decreased fetal movement followed by reassuring the optimal surveillance regimen have not been estab-
VOL. 124, NO. 1, JULY 2014 Practice Bulletin Antepartum Fetal Surveillances 187
36 0/7 weeks of gestation with intact membranes and
oligohydramnios, the decision to proceed with expectant
Summary of
management or delivery should be individualized based Recommendations and
on gestational age and the maternal and fetal condition.
If delivery is not undertaken, follow-up amniotic fluid
Conclusions
volume measurements, NSTs, and fetal growth assess- The following conclusions are based on good and
ments are indicated. If the oligohydramnios results from consistent scientific evidence (Level A):
fetal membrane rupture, follow-up amniotic fluid volume
assessment often may be safely omitted. The use of the deepest vertical pocket measurement,
as opposed to the amniotic fluid index, to diagnose
oligohydramnios is associated with a reduction in un-
What is the role of umbilical artery and other necessary interventions without an increase in
Doppler velocimetry studies? adverse perinatal outcomes.
In growth-restricted fetuses, umbilical artery Doppler In growth-restricted fetuses, umbilical artery Doppler
velocimetry used in conjunction with standard fetal velocimetry used in conjunction with standard fetal
surveillance, such as NSTs or BPPs, or both, is associ- surveillance, such as NSTs, or BPPs, or both, is
ated with improved outcomes (70, 77). Umbilical artery associated with improved outcomes.
Doppler velocimetry has not been shown to be predic-
tive of outcomes in fetuses without growth restriction. The following recommendation is based on limited
Investigation of other fetal blood vessels with umbilical or inconsistent scientific evidence (Level B):
artery Doppler velocimetry, including assessments of the
middle cerebral artery and the precordial venous system, Abnormal results from an NST or from a modified
BPP generally should be followed by additional test-
has been explored in the setting of fetal growth restric-
ing with either a CST or a BPP.
tion. However, these flow measurements have not been
shown to improve perinatal outcome, and the role of
The following recommendations are based pri-
these measures in clinical practice remains uncertain (see
marily on consensus and expert opinion (Level C):
the American College of Obstetricians and Gynecologists
Practice Bulletin Number 134, Fetal Growth Restriction) Initiating antepartum fetal testing no earlier than
(70, 75, 78–83). 32 0/7 weeks of gestation is appropriate for most at-
risk patients. However, in pregnancies with multiple
Should all women perform daily fetal move- or particularly worrisome high-risk conditions (eg,
ment assessment? chronic hypertension with suspected fetal growth
restriction), testing might begin at a gestational age
Multiple studies have demonstrated that women who when delivery would be considered for perinatal
report decreased fetal movement are at an increased risk benefit.
of adverse perinatal outcomes (84). Although fetal kick
counting is an inexpensive test of fetal well-being, the When the clinical condition that prompted testing
persists, the test should be repeated periodically to
effectiveness in preventing stillbirth is uncertain (see
monitor for continued fetal well-being until delivery.
Practice Bulletin Number 102, Management of Stillbirth)
If the maternal medical condition is stable and test
(85, 86). Consistent evidence that a formal program
results are reassuring, tests of fetal well-being (NST,
of fetal movement assessment in low-risk women will
BPP, modified BPP, or CST) are typically repeated
result in a reduction in fetal deaths is lacking (87, 88).
at weekly intervals; however, in the presence of cer-
Moreover, whether fetal movement assessment adds
tain high-risk conditions, some investigators have
benefit to an established program of regular fetal surveil-
performed more frequent testing, although the opti-
lance has not been evaluated. Formal fetal movement mal regimen has not been established.
assessment may increase, by a small degree, the number
of antepartum visits and fetal evaluations. In RCTs, how- In the absence of obstetric contraindications, deliv-
ever, this increased surveillance did not result in a higher ery of the fetus with an abnormal test result often
rate of intervention (12, 86, 88). Although not all women may be attempted by induction of labor, with con-
need to perform a daily fetal movement assessment, if tinuous intrapartum monitoring of the FHR and
a woman notices a decrease in fetal activity, she should uterine contractions.
be encouraged to contact her health care provider, and Based on expert opinion, in the setting of otherwise
further assessment should be performed. uncomplicated isolated and persistent oligohydram-
VOL. 124, NO. 1, JULY 2014 Practice Bulletin Antepartum Fetal Surveillances 189
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Copyright July 2014 by the American College of Ob ste
tri
counting for assessment of fetal wellbeing. Cochrane
cians and Gynecologists. All rights reserved. No part of this
Database of Systematic Reviews 2007, Issue 1. Art. No.:
publication may be reproduced, stored in a retrieval system,
CD004909. DOI: 10.1002/14651858.CD004909.pub2.
posted on the Internet, or transmitted, in any form or by any
(Meta-analysis) [PubMed] [Full Text] ^
means, electronic, mechanical, photocopying, recording, or
88. Saastad E, Winje BA, Stray Pedersen B, Froen JF. Fetal otherwise, without prior written permission from the publisher.
movement counting improved identification of fetal
Requests for authorization to make photocopies should be
growth restriction and perinatal outcomes--a multi-centre,
directed to Copyright Clearance Center, 222 Rosewood Drive,
randomized, controlled trial. PLoS One 2011;6:e28482.
Danvers, MA 01923, (978) 750-8400.
(Level I) [PubMed] [Full Text] ^