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INTRODUCTION
Fetal health is evaluated, in part, by assessment of fetal heart rate patterns. The
primary goal of antepartum fetal surveillance (antepartum testing) with the
nonstress test (NST) and the contraction stress test (CST) is to identify fetuses at risk
of hypoxic injury or death and intervene to prevent these adverse outcomes, if
possible. The secondary goal is to identify normally oxygenated fetuses so that
pregnancy can be continued safely, and unnecessary intervention can be avoided.
The NST and CST will be reviewed here. Intrapartum fetal evaluation and additional
techniques for assessing fetal health are discussed separately.
Physiologic development of the fetal heart occurs across gestation and affects fetal
heart rate (FHR) patterns. Changes in FHR result from moment-to-moment
autonomic modulation in response to many factors, including input from
chemoreceptors, input from baroreceptors, central nervous system activities (eg,
arousal, sleep), catecholamines, and blood volume [1].
● Transient fetal hypoxemia associated with uterine contractions can cause late
decelerations. Stimulation of chemoreceptors in the fetal carotid arteries and
aortic arch leads to a reflex increase in sympathetic outflow, causing
vasoconstriction in nonvital peripheral areas and preservation of, or increases
in, blood flow to vital organs (eg, adrenal glands, heart, brain). Peripheral
vasoconstriction causes elevated fetal blood pressure and, in turn, stimulation
of baroreceptors in the fetal carotid arteries and aortic arch, resulting in reflex,
vagally mediated, parasympathetic slowing of FHR shortly after the beginning
of the contraction.
By comparison, early decelerations are not caused by fetal hypoxemia and not
associated with adverse outcome. They are caused by fetal head compression,
which increases intracranial pressure, resulting in reflex slowing of the FHR.
Available evidence does not support fetal extracranial pressure exerted by uterine
contractions as a cause of fetal brain injury [7].
A recent generation of fetal monitors calculates FHR, FHR variability, and fetal QT
intervals from information obtained from multiple electrodes placed on the
maternal abdomen (eg, Monica AN24 monitor, MindChild Medical monitor). The
maternal ECG signal and ambient noise are filtered out by algorithms run by
microprocessors. This software provides noninvasive fetal ECGs that are purported
to be as accurate as the information obtained from a fetal scalp electrode [8-10]. It is
useful in patients with obesity in whom continuous Doppler ultrasound monitoring
is technically difficult and does not provide an adequate quality FHR tracing for
interpretation.
Nomenclature — The most commonly used American system for describing FHR
findings was developed by a workshop convened by the National Institute of Child
Health and Human Development ( table 1) [11].
Background — The NST and CST are used for antepartum fetal heart rate (FHR)
testing. Although one study reported a lower incidence of fetal death among high-
risk pregnancies undergoing antepartum testing (with NST and amniotic fluid index
[AFI]) compared with low-risk untested pregnancies, there remains no conclusive
evidence from randomized trials that use of NSTs and CSTs leads to a reduction in
fetal death or neurologic injury [12]. Nevertheless, performing NSTs or CSTs in
pregnancies deemed to be at high risk of adverse fetal outcome is a standard
obstetric practice in the United States and elsewhere, based on circumstantial
:
evidence and long-standing convention. (See 'Test performance' below.)
Test performance — Use of the NST and CST became widespread in the early 1980s
when a seminal observational study reported stillbirth rates (corrected for lethal
congenital anomalies and unpredictable causes of demise) after reactive and
nonreactive NSTs were 1.9 and 26 per 1000 births, respectively [14]. The stillbirth
rates after a negative CST, reactive positive CST, or nonreactive positive CST were
0.3, 0, and 88 per 1000 births, respectively. These findings supported use of these
tests to identify fetuses who might benefit from early delivery.
In 2015, a Cochrane review attempted to determine whether using the NST can
improve maternal or perinatal outcome by identifying high-risk pregnancies
requiring prompt induction of labor or immediate delivery by cesarean [15]. Six
randomized trials involving 2105 participants were included. Tested patients were
compared with controls who did not undergo NSTs or their test results were
concealed. No significant differences between groups were noted in maternal
outcomes, such as frequency of induction of labor or cesarean delivery, or in infant
outcomes, including perinatal mortality, low five-minute Apgar, neonatal intensive
care unit admission, and neonatal seizures. Perinatal mortality (adjusted for lethal
anomalies) in the testing group was higher than in controls (2.3 versus 1.1 percent,
four studies, n = 1627, odds ratio 2.05, 95% CI 0.95-4.42). By contrast, when the
authors compared computerized cardiotocography (automated evaluation of the
FHR) versus traditional cardiotocography, computerized cardiotocography was
associated with a statistically significant reduction in perinatal mortality (relative risk
[RR] 0.20, 95% CI 0.04-0.88, two trials, 0.9 versus 4.2 percent, n = 469). There was no
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statistically significant difference in potentially preventable deaths (RR 0.23, 95% CI
0.04-1.29, two trials, n = 469); however, the meta-analysis was underpowered to
assess this outcome.
There are many limitations to the trials in this meta-analysis, which preclude
definitive assessment of the value of the NST in current practice. Randomization
methods were suboptimal, which could have created bias. The total number of
adverse events, such as perinatal mortality and abnormal neurologic signs, was too
low to determine whether small, but statistically significant, differences in outcome
might result from testing. Furthermore, the trials were conducted in the early 1980s
when these tests were first introduced into clinical practice and clinicians were
inexperienced in test interpretation and subsequent pregnancy management. It is
possible that the tests would be interpreted and acted upon differently today with
different outcomes. Lastly, fetal assessment and neonatal care have changed since
the 1980s; the combined use of ultrasound and FHR testing may be more predictive
of fetal status and need for intervention than either test alone.
However, the CST is less convenient to perform than the NST since it requires either
an intravenous line for infusion of a dilute oxytocin solution or nipple stimulation,
and it tends to be more time consuming. It also has some relative contraindications.
(See 'Overview' below.)
Timing and frequency — NSTs and CSTs are initiated at the gestational age that the
fetus is believed to be at increased risk of death as long as the age is sufficiently
advanced that delivery for perinatal benefit would be considered. For the NST, fetal
neurologic maturity should be sufficient to enable FHR acceleration (typically no
:
earlier than 26 to 28 weeks).
NONSTRESS TEST
Reactive tests
Criteria — The NST is reactive from 32 weeks to term if there are two or more fetal
heart rate (FHR) accelerations reaching a peak of at least 15 beats per minute (bpm)
above the baseline rate and lasting at least 15 seconds from onset to return to
baseline (15 x 15) in a 20-minute period ( figure 2 and table 1) [6,13,21]. A
reactive test provides reliable evidence of normal fetal oxygenation, regardless of
the length of observation time needed to demonstrate reactivity [22].
The validity of the 10 x 10 criteria before 32 weeks was based on the following two
studies:
Minimal duration of FHR monitoring — The optimal duration of the NST has not
been established. Some sources recommend the NST should be continued for at
least 20 minutes, even if two qualifying accelerations have been observed before
that time [25]. However, large studies evaluating the predictive value of the NST
combined with amniotic fluid volume assessment have not included this
requirement [12,26,27].
Reactive NSTs with decelerations — The significance of a reactive NST with FHR
decelerations is unclear. Multiple observational studies have described an increased
frequency of intrapartum FHR decelerations and operative delivery when this
combination occurs [28-33], except when the decelerations are brief [34]; however,
outcomes are usually good. The majority of FHR decelerations during the NST are
variable decelerations, reflecting transient episodes of umbilical cord compression.
Intermittent fetal cardiac arrhythmias can also cause decelerations and may be
diagnosed by echocardiography. Management depends on the arrhythmia and
patient-specific factors. (See "Fetal arrhythmias".)
Nonreactive tests
Criteria and causes — A NST is nonreactive if it does not meet acceleration criteria
for a reactive NST (see 'Reactive tests' above). The FHR should be monitored for at
:
least 40 minutes before interpreting the test as nonreactive.
Other possible causes of a nonreactive NST include fetal immaturity, fetal sleep,
maternal smoking, fetal neurologic or cardiac anomalies, sepsis, or maternal
ingestion of drugs with cardiac effects [36]. Sleep is a common and benign cause of
a nonreactive NST. Sleep cycles may last up to 40 minutes [5]; one study reported
sleep cycles lasting up to 53 minutes [37]. In a study that observed late preterm
fetuses from uncomplicated pregnancies for 100 minutes, quiet sleep occurred at
least once in 30 percent of fetuses, but 96 percent of the fetuses cycled between
quiet sleep and active states during the period of observation [38].
● Perform a back-up test, (either CST or complete BPP) [13]. (See "Biophysical
profile test for antepartum fetal assessment".)
Vibroacoustic stimulation can decrease the number of nonreactive NSTs and shorten
:
test time without reducing the predictive value of a reactive NST. A vibroacoustic
source, typically an artificial larynx, placed on or just above the maternal abdomen,
is used to stimulate fetal movement. In a 2013 systematic review, vibroacoustic
stimulation decreased mean overall testing time by almost seven minutes,
compared with mock or no stimulation (-6.93, 95% CI -12.09 to -1.76), and reduced
the frequency of nonreactive NSTs by 40 percent (odds ratio 0.62, 95% CI 0.48-0.81)
[39]. There are no evidence-based standards for performing this procedure. It has
been performed as soon as five minutes after initiation of the NST. The stimulus is
applied for one to five seconds and may be repeated. The optimal placement and
number of applications of the stimulus have not been evaluated. The American
College of Obstetricians and Gynecologists suggests positioning the device on the
maternal abdomen and applying a stimulus for one to two seconds [13]. If no fetal
response occurs, the stimulus may be repeated up to three times for progressively
longer durations of up to three seconds.
Changing maternal position does not increase reactivity as long as the patient is
tested in a position that does not lead to hypotension from uterine compression of
the great vessels [46]. Cocoa and caffeine consumption may affect fetal movement,
but the dose, timing, and effect on NST reactivity have not been evaluated [47-49].
No randomized trials or observational studies have assessed the effect of maternal
hydration (oral or intravenous) on FHR reactivity. Maternal hydration (oral or
intravenous) may increase the AFI [50-52] and decrease the baseline FHR [53,54],
but there is no evidence that it increases fetal movement or heart rate reactivity.
:
CONTRACTION STRESS TEST
Overview — The CST is not used as often as the NST because it is less convenient to
perform (see 'Choice of test' above). It is also more limited by contraindications than
the NST. Relative contraindications to stimulating contractions for a CST are
conditions that are also contraindications to labor and vaginal delivery, such as
placenta previa, vasa previa, and previous classical cesarean delivery or extensive
uterine surgery. Preterm labor, patients at high risk for preterm delivery, and
preterm prelabor rupture of membranes are also relative contraindications.
Procedure — For the CST, either a dilute oxytocin solution is infused or nipple
stimulation is performed until three contractions occur within 10 minutes. There is
no standard technique for nipple stimulation. Patients gently massage the nipple of
one breast through their clothes for two minutes, stopping with onset of
contractions; stimulation is resumed if contractions are too infrequent for CST
interpretation. Both nipples can be stimulated if no contractions occur. In patients
who are having spontaneous contractions of adequate frequency, oxytocin or nipple
stimulation is unnecessary.
The American College of Obstetricians and Gynecologists has not defined what they
intended by the term "significant" variable decelerations. No data are available on
which to base a recommendation for the definition of "significant variable" in the
context of antepartum testing. The NICHD chose not to grade the severity of
intrapartum variable decelerations based on the depth of the deceleration, absolute
nadir, or duration [11]. However, one expert group defined significant variables
during labor as those that include either of the following characteristics: lasting >60
seconds and reaching a nadir >60 bpm below baseline or lasting >60 seconds and
reaching a nadir <60 bpm (regardless of baseline) [55].
In one study, 50 percent of reactive positive CSTs were false positives, whereas 100
percent of nonreactive positive CSTs were true positives [56]. Thus, the presence of
accelerations during the CST may reduce the need for intervention, but additional
evaluation (eg, BPP) is warranted [56,57].
● Changes in the fetal heart rate (FHR) reflect the fetal response to input from
chemoreceptors, baroreceptors, central nervous system activities, hormonal
regulation, and blood volume. Gestational age is a factor in interpretation of
FHR patterns. (See 'Physiologic basis of fetal heart rate changes' above.)
● NSTs and CSTs are initiated at the gestational age that the fetus is believed to
be at increased risk of death as long as the age is sufficiently advanced that
delivery for perinatal benefit would be considered. The frequency of testing
depends upon maternal and fetal status. Testing is usually performed once or
twice weekly as long as the indication for testing persists. Maternal or fetal
deterioration requires reevaluation despite recent normal test results. (See
'Timing and frequency' above.)
● The NST (with or without amniotic fluid assessment) has become the preferred
antepartum test of fetal oxygenation status because the CST, which usually
requires stimulation of uterine contractions, is more time-consuming, more
invasive, and more limited by contraindications than the NST. The biophysical
profile (BPP) is a reasonable alternative. (See 'Choice of test' above.)
Nonstress test
● The NST is considered reactive if there are two or more FHR accelerations
reaching a peak of at least 15 beats per minute (bpm) above the baseline rate
and lasting at least 15 seconds from onset to return to baseline in a 20-minute
period ( figure 2). There are no published data to confirm a benefit of
extending the duration of NST once two qualifying accelerations have been
observed. A reactive test reliably predicts normal fetal oxygenation at the time
of testing. (See 'Reactive tests' above.)
● The FHR should be monitored for at least 40 minutes before interpreting the
test as nonreactive. Abnormal test results may be due to interruption of fetal
oxygenation but should be interpreted within the context of the clinical
situation. Vibroacoustic stimulation is useful for decreasing the number of
nonreactive NSTs and for shortening test time. (See 'Nonreactive tests' above
and 'Evaluation of pregnancies with nonreactive NSTs' above.)
● Reactive positive CSTs are often false positives, whereas nonreactive positive
CSTs are generally true positives. Thus, the presence of accelerations during
the CST may reduce the need for intervention, but additional evaluation (eg,
BPP) is warranted. (See 'Evaluation of pregnancies with positive CSTs' above.)
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Topic 409 Version 38.0
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GRAPHICS
Adapted from: Park MI, Hwang JG, Cha KJ, et al. Computerized analysis of fetal heart
rate parameters by gestational age. Int J Gynaecol Obstet 2001; 74:157.
Variability
Fluctuations in baseline that are irregular in amplitude and frequency
Baseline rate
Bradycardia = below 110 bpm
The baseline rate is the mean bpm (rounded to 0 or 5) over a 10-minute interval, excluding
periodic changes, periods of marked variability, and segments that differ by more than 25
bpm. The baseline must be identifiable for two minutes during the interval (but not
necessarily a contiguous two minutes); otherwise, it is considered indeterminate.
Acceleration
An abrupt* increase in the FHR. Before 32 weeks of gestation, accelerations should last
≥10 sec and peak ≥10 bpm above baseline. As of 32 weeks gestation, accelerations should
last ≥15 sec and peak ≥15 bpm above baseline.
Late deceleration
A gradual* decrease and return to baseline of the FHR associated with a uterine
contraction. The deceleration is delayed in timing, with the nadir of the deceleration
occurring after the peak of the contraction. The onset, nadir, and recovery usually occur
after the onset, peak, and termination of a contraction.
Early deceleration
A gradual* decrease and return to baseline of the FHR associated with a uterine
contraction. The nadir of the FHR and the peak of the contraction occur at the same time.
The deceleration's onset, nadir, and termination are usually coincident with the onset,
:
peak, and termination of the contraction.
Variable deceleration
An abrupt* decrease in FHR below the baseline. The decrease is ≥15 bpm, lasting ≥15
secs and <2 minutes from onset to return to baseline. The onset, depth, and duration of
variable decelerations commonly vary with successive uterine contractions.
Prolonged deceleration
A decrease in FHR below the baseline of 15 bpm or more, lasting at least 2 minutes but
<10 minutes from onset to return to baseline. A prolonged deceleration of 10 minutes or
more is considered a change in baseline.
NICHD: National Institute of Child Health and Human Development; FHR: fetal heart rate;
bpm: beats per minute; sec: seconds.
* "Gradual" and "abrupt" changes are defined as taking ≥30 seconds or <30 seconds,
respectively, from the onset of the deceleration/acceleration to its nadir/peak.
Adapted from:
1. National Institue of Child Health and Human Development Research Planning Workshop. Am J Obstet
Gynecol 1997; 177:1385.
2. Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human
Development Workshop Report on Electronic Fetal Monitoring: Update on Definitions, Interpretation, and
Research Guidelines. Obstet Gynecol 2008; 112:661.
Reactive nonstress test. The baseline fetal heart rate is between 130 and 140
beats per minute. There are two accelerations >15 beats per minute; one peaks at
approximately 170 beats per minute and the other peaks at approximately 160
beats per minute. The duration of each acceleration exceeds 20 seconds.
Variability is moderate (6 to 25 beats per minute).
The top tracing is the fetal heart rate. The y-axis reflects the fetal heart rate
measured in beats per minute. The x-axis reflects time; each of the smallest
divisions represents 10 seconds with one minute between bold vertical lines.
The bottom tracing shows the frequency and duration of uterine contractions.
pH values were determined by cordocentesis in fetuses whose mothers were not in labor.
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