Antepartum Fetal Surveillance 1

Antepartum Fetal Surveillance

Antepartum fetal assessment is indicated in pregnancies that are at high risk for perinatal morbidity and mortality.
Testing methods include fetal movement counting, the nonstress test, the contraction stress test, and the biophysical
profile.
I. Testing methods
A. Fetal movement counting
1. Maternal perception of fetal movement is a noninvasive method of assessing fetal well-being. The patient is
asked to relax on her left side 30 minutes after eating and to concentrate on fetal movement. The patient
should note each time the baby kicks or moves. A healthy fetus should move three to five times per hour. The
pregnant woman records the length of time that the fetus takes to make 10 movements. If the fetus requires
more than 2 hours for 10 kicks, the woman should contact her physician. If the test result is not reassuring,
the patient should undergo a nonstress test.
2. All pregnant patients should be counseled about assessment of fetal movement.
B. Nonstress test
1. The nonstress test is an indirect measurement of uteroplacental function. It is based on the premise that the
heart rate of a well-oxygenated fetus will temporarily accelerate with fetal movement. A Doppler ultrasound
transducer and a tocodynamometer are used to monitor the fetal heart rate and uterine activity simultaneously.
2. A reassuring, or reactive, nonstress test exhibits at least two accelerations in the fetal heart rate in a 20-minute
period that are at least 15 beats per minute above the baseline and last at least 15 seconds. A nonreactive test
does not meet these criteria.
3. A nonreactive nonstress test suggests that the fetus may be compromised by acidosis, and a biophysical
profile is indicated. Other factors that may be responsible for a nonreactive test are maternal use of sedatives
or narcotics, as well as severe fetal anomalies of the cardiovascular or central nervous system. Accelerations
are predictive of fetal well-being.
C. Contraction stress test
1. The contraction stress test may identify fetuses that are only marginally compromised by assessing their
reserve when subjected to the stress of uterine contractions. The goal of the test is to achieve three uterine
contractions in a 10-minute period with nipple stimulation or an oxytocin infusion. If oxytocin is used, it should
be started at an infusion rate of 0.5 to 1.0 mU per minute and doubled every 15 minutes until the desired
contraction pattern is achieved. The test carries a small risk of uterine hyperstimulation, and it is
contraindicated in patients who are at high risk for premature labor, in those who have a classic uterine scar
or full-thickness scar from uterine surgery other than a low transverse cesarean section, and in those who have
a placenta previa.
2. The test is considered negative if no late decelerations are observed. It is considered positive if late
decelerations are detected with more than 50 percent of the contractions. The test should raise suspicion if
an occasional late deceleration is seen. If variable decelerations occur, an ultrasound examination should be
performed to assess amniotic fluid volume.
D. Biophysical profile
1. The biophysical profile is an ultrasonographic assessment of fetal behavior. The BPP evaluates indicators of

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chronic fetal hypoxia and placental function, such as amniotic fluid volume, and it evaluates acute indicators
of hypoxia and placental function, such as fetal breathing, movements and tone.
2. The biophysical profile is a scored test with five components, each of which is given 2 points if present. A score
of 8 to 10 points is considered reassuring. A score of 6 points is suspicious and requires further evaluation.
A score of 4 points or less is ominous and indicates the need for immediate intervention. A low score may also
reflect normal fetal sleep or fetal sedation from maternal use of narcotics. A decreasing score correlates with
poor outcome and increasing fetal acidemia.

Components of the Biophysical Profile

Parameter Normal (score = 2) Abnormal (score = 0)

Nonstress test $2 accelerations $15 beats per minute above baseline during test <2 accelerations
lasting $15 seconds in 20 minutes

Amniotic fluid volume Amniotic fluid index >5 or at least 1 pocket measuring 2 cm x 2 cm in AFI <5 or no pocket >2 cm x 2 cm
perpendicular planes

Fetal breathing movement Sustained FBM ($30 seconds) Absence of FBM or short gasps only <30
seconds total

Fetal body movements $3 episodes of either limb or trunk movement <3 episodes during test

Fetal tone Extremities in flexion at rest and $1 episode of extension of extremity, Extension at rest or no return to flexion after
hand or spine with return to flexion movement

A total score of 8 to 10 is reassuring; a score of 6 is suspicious, and a score of 4 or less is ominous.

Amniotic fluid index = the sum of the largest vertical pocket in each of four quadrants on the maternal abdomen intersecting at the umbilicus.

E. Modified biophysical profile is an alternative to the biophysical profile. It consists of a nonstress test and an
amniotic fluid index. It has been shown to be as effective as a full biophysical profile in assessing fetal well-being.
F. Vibroacoustic stimulation uses an artificial larynx to generate sound in two or three one-second bursts over
the maternal abdomen near the fetal head, waking a sleeping fetus. Fetuses that respond to VAS with an
acceleration on a nonstress test or a startle response on a biophysical profile have very low rates of death within
one week.

Guidelines for Antepartum Testing

Indication Initiation Frequency

Post-term pregnancy 41 weeks Twice a week

Preterm rupture of the membranes At onset Daily

Bleeding 26 weeks or at onset Twice a week

Oligohydramnios 26 weeks or at onset Twice a week

Polyhydramnios 32 weeks Weekly

Diabetes Class
A1 (well-controlled, no complications) 36 weeks Weekly
Class A2 and B (well-controlled, no complications) 32 weeks Twice a week
Class A or B with poor control, Class C-R
28 weeks Weekly

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Indication Initiation Frequency

Chronic or pregnancy-induced hypertension 28 weeks Weekly. Increase to twice-weekly at 32

weeks.

Steroid-dependent or poorly controlled asthma 28 weeks Weekly

Sickle cell disease 32 weeks (earlier if symptoms) Weekly (more often if severe)

Impaired renal function 28 weeks Weekly

Substance abuse 32 weeks Weekly

Prior stillbirth At 2 weeks before prior fetal death Weekly

Multiple gestation 32 weeks Weekly

Congenital anomaly 32 weeks Weekly

Fetal growth restriction 26 weeks Twice a week or at onset

Decreased fetal movement At time of complaint Once

II. Management
A. A screening test with abnormal findings should be followed by a more sensitive and specific test in order to avoid
acting on a false-positive result. A patient with decreased fetal movement should undergo a nonstress test; if the
test is nonreassuring, a biophysical profile should be performed.
B. A test with equivocal or suspicious results should either be acted on (ie, with delivery if at term) or repeated. §

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