University of Michigan Health System

Womens, Childrens and Behavioral Health Nursing Services

Womens Hospital Birth Center

Nonstress Test (NST) Guideline

Guideline #WHBC-89-34B
Date Issued: 10/17/1989
Revision Date: 1/22/2004
Review Date: 12/1/07
Replaces: Non-Stress Test (NST) Guideline (WHBC-89-34A)
I.

PURPOSE OF THE GUIDELINE

The purpose of this guideline is to articulate the use and interpretation of fetal
heart reate monitoring in the antepartum population and the steps in determining
the disposition of patients in the various areas of the Birth Center performing
antepartum non-stress testing.

II.

DEFINITION
Observation of the fetal heart rate (FHR) baseline and accelerations when the
uterus is at rest.

III.

INDICATIONS
1. History of decreased fetal movements
2. Medical complications such as diabetes, hypertension, etc.
3. Obstetrical problems such as prior intrauterine fetal demise, post-dates
pregnancy, etc.
4. Other indications for NST may include amniocentesis, prostaglandin gel
placement, etc.
5. There are no contraindications to this procedure.

IV.

FETAL ASSESSMENT PROTOCOL

The guideline: Fetal Assessment Protocol is utilized by the provider to determine
the frequency of antepartum testing for patients.

V.

PROCEDURAL ACTIONS AND RESPONSIBILITIES

1. EQUIPMENT:
A. Electronic fetal heart monitor with toco- and ultrasound transducers.
B. Record for documentation
C. Stethoscope
D. (optional) fetoscope
E. (optional) hand-held doppler
F. (optional) sphygmomanometer
2. PROCEDURE:
A. Testing should occur in a quiet environment, free of distractions, ensuring
patient privacy. Place the patient in a comfortable, reclining chair or in bed

B.

C.
D.
E.
F.
G.
H.
3.

in a semi-reclining or left lateral tilt position. The uterus should be

displaced and not compressing the vena cava and/or aorta.
Assess the following prior to initiation of this test:
1. Review watchchild prenatal record as needed to review OB history and
any prior testing results.
2. Medications (eg., atenolol (Tenormin) may precede a nonreactive test
due to sympathetic depression; methadone and phenobarbital increase
the length of time for the fetus to become reactive; with central
nervous system depressants, the test should be delayed, if possible,
until 8 hours after the last dose.)
3. Time of last cigarette (she should not smoke for at least 2 hours before
testing.
4. Time of last fluid intake (to assess risk of dehydration with uterine
hypoperfusion and fetal hypoxia).
5. Fetal movement by palpation and maternal perception.
Assess patient and/or family for knowledge of NST procedure and testing
rationale and explain any identified need.
Assess BP and maternal pulse.
Assess gestational age, fetal position(s) by Leopolds maneuvers.
Palpate uterus and assess uterine activity.
Check monitor for proper functioning and recording of time/date.
Apply external monitor transducers.

PATIENT DISPOSITION
A. Birth Center Antepartum Inpatient (4th or 7th floor patients) (see
Algorithm for Inpatient Antepartum NST Strip Review & Interpretation)
1. NSTs ordered by the physician are to be done daily between 6am
7am.
2. The RN will read the strip and make an initial interpretation.
a. If reactive:
1) send strip & NST form to 4 East to be read by 3rd or 4th year
resident at board rounds
2) document in caremap initial reading
3) If the NST is reactive, and in the absence of any other
abnormal findings, the nurse may discontinue the fetal monitor
once the NST is completed.
b. If non-reactive:
1) continue EFM
2) send strip to 4 East as above
3) call 3rd or 4th year resident with findings. Discuss plan & time
frame for follow-up testing.
4) Document strip interpretation and plan in caremap
c. If unsatisfactory
1) continue EFM for additional 20 minutes
2) follow interpretation algorithm for reactive or non-reactive
strip

3. The NST tracing is placed in the East board room for the 3rd or 4th year
resident to read at 7am 8am during daily board rounds.
a. 3rd or 4th year resident will interpret the strip
1) reactive:
(a) enter interpretation into watchchild prenatal record (AST
section) by 8:15 am
(b) complete paper NST record for billing
2) non-reactive
(a) enter interpretation into watchchild prenatal record (AST
section) by 8:15 am
(b) complete paper NST record for billing
(c) notify patients RN of plan for follow-up testing and time
frame
b. The RN will look in watchchild prenatal record by 8:30am for the
MDs interpretation information.
1) Information present: continue patient care
2) Information not present:
(a) page the resident
(b) follow Chain of Command as necessary.
4. For any strip requiring follow-up (unsatisfactory or non-reactive)
a. If follow-up plan is not initiated within the planned time frame, the
RN will page the 3rd or 4th year resident or the resident will page
the RN (depending on who is responsible for the next step of the
plan)
b. The Chain of Command will be used as necessary to assist with
follow-up.
B. Triage
1. Regularly scheduled NSTs performed in Triage when the PAC is
closed for holidays
a. If the NST is reactive, and in the absence of any other abnormal
findings, the patient may be discharged by the Triage nurse.
b. The FHR tracing will be placed in the designated location for the
house officer to read and complete the billing sheet.
c. The FHR tracing interpretation will be entered into the Watchchild
prenatal record antenatal testing section by the house officer.
d. The FHR tracing will be read for the final interpretation by the
physician covering the Triage area within 24 hours of the testing.
2. NST performed for any reason other than PAC coverage of scheduled
antenatal testing, the FHR tracing will be evaluated by the provider
covering the Triage area to determine disposition of the patient.
VI.

INTERPRETATION:
1. Reactive-- 2 accelerations within a 20 minute period during a maximum of 40
minutes of testing. At gestations under 32 weeks, an NST is reactive when

each acceleration peaks at least 10 bpm above the baseline and lasts at least 10
seconds. For gestations >32 weeks each acceleration will peak at least 15
beats per minute (bpm) above the baseline and last at least 15 or more seconds
at its base. Once a fetus has demonstrated a 15x15 acceleration pattern
(regardless of gestational age), the NST is reactive only using that criteria. A
reactive test should also include a baseline with minimal to average
variability. Uniform accelerations suggest the presence of oligohydramnios or
umbilical cord vulnerability.
2. Nonreactive-- less than 2 accelerations or accelerations that peak at less than
15 bpm above the baseline and/or last less than 15 seconds at their base, with
or without fetal movement during 40 minutes of testing. Variability should be
minimal to average. Continue monitoring and call provider for further
actions.
3. A sinusoidal pattern is considered nonreactive as soon as the pattern is seen.
Continue monitoring and call provider for further actions.
4. Unsatisfactory--the quality of the tracing is not adequate for interpretation.
5. Variable decelerations that last 15 seconds (from baseline to baseline) and
drop 15 or more bpm in the presence of oligohydramnios require further
evaluation or delivery. Further evaluation may include an ultrasound to
confirm umbilical cord position and to determine amniotic fluid volume.
6. To allow further evaluation time, the NST ends after 40 minutes. This may
cause a false non-reactive test, i.e., fetus is not acidotic, but did not accelerate
in the designated time or the monitoring occurred during a 40-minute fetal
sleep cycle. The use of the vibro-acoustic stimulator prior to the end of the 40
minute testing period should lower the false non-reactive rate.
7. Administration of glucose-containing solutions, while not contraindicated,
does not increase fetal oxygen delivery nor increase the number of reactive
nonstress tests.
VII.

DOCUMENTATION:
1. Nurse documentation on caremap:
a. Date/time monitor applied & removed
b. Reason for test
c. Vital signs
d. Signatures of nurse(s) who evaluated the strip
e. Communication(s) to provider as indicated
f. Follow-up plans
2. Physician documentation in watchchild antenatal testing section:
a. Interpretation of strip
b. Signature of provider who interpreted the strip
c. Follow-up plans as indicated.

3. The FHR tracing is archived in the watchchild system.

VIII.

REFERENCES:
Murray, Michelle. Antepartal and Intrapartal Fetal Monitoring, 2nd Ed.,
Chapter 8: Procedure, Nonstress Test (NST) (1997).
Feinstein, N & McCartney, P (Eds.) AHWONN Fetal Heart Monitoring Principles
and Practice 2nd ed. Chapter 4 Appendix 4d: Vibroacoustic Stimulation
(1997)

IX.

ATTACHMENT
Algorithm for Inpatient Antepartum NST Strip Review and Interpretation

X.

AUTHORS/APPROVAL:
Perinatal Joint Practice Committee, 2003
WHBC Clinical Practice Committee, 1/2004