Antepartum Fetal and Heart Rate Testing: Current Status

I. Objectives
A. Physiologic and technologic principles of antepartum fetal heart rate testing (AFHRT)
B. Application and interpretation of AFHRT
C. Areas of controversy and testing pitfalls
II. Fetal movement (FM) Counting
A. Physiologic background
1. Healthy fetuses move 20-30 times per hour
2. Fetal movement occupies 10-15% of 24h day
3. Active fetus has high likelihood of good result
4. Feud compromise may follow decreased FMs
B. Basis for maternal perception of FM
1. Inexpensive, simple No equipment needed
3. May be done in home, office, hospital
4. Patient is engaged in her care process
C. Application
1. Each fetus acts as own control
2. Baseline record of activity can be established
3. Clinical alerts: decreased or absent Fms
4. Note: same conditions for each session
D. Follow up
1. Supplement other forms of testing
2. Decreased FM 6 more intensive testing
3. NOTE: inform patient that absolute FM count may vary considerably between sessions
E. Limitations
1. Limited numbers of good clinical trials
2. Low sensitivity to prediction of acute distress
3. Normal “slow” or “hyperactive” fetus?
4. Variation in ability to educate the patient and compliance
III. Principles: Physiologic Bases
A. Fetal heart rate testing: applications
1. NST: office/hospital possibly home. 20-30 min to t-2 h
2. VAS' similar to NST. 10-20 min
3. ACTG: similar to NST CST: office/hospital. 20-30 min to 2-3 h
B. Nonstress test (NST)
1. What does the NST test?
a) Selected FHR baseline features
(1) Accelerations with FMs (<)
(2) Baseline rate and variability (?)

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 (3) Decelerations: spontaneous (<)
b) Physiologic
c) Pathophysiologic
d) Brainstem function
e) Hypoxia./acidosis
f) ANS/reflex control
g) Malnutrition
h) Maturation of FHR
i) Cord compression
j) Circadian rhythms
k) Placental insufficiency
1) Behavioral state
m) CV and CNS anomalies
2. Physiologic basis for NST
a) FM is normal, episodic phenomenon
b) Third trimester fetuses respond to FM with coupled accelerations (>90%)
c) Hypoxia, asphyxia, malnutrition reduce FMs. decrease coupling
fewer accelerations
3. NST interpretation
a) Reactive: accelerations + Fms
b) Nonreactive
(1) Accelerations present, too few
(2) Accelerations absent. FMs present
(3) Accelerations, FMs absent
4. Nonreactivity sequence
a) Decreased acceleration counts, amplitude
b) Decreased FM counts
c) Uncoupling accelerations and Fms
d) No accelerations or Fms
e) Spontaneous decelerations
5. Causes of nonreactive NST
a) Compromised fetus
b) Behavioral state
c) Immaturity
d) Maternal diet/drugs
e) Fetal anomalies
6. Testing conditions
a) Length of observation: 30'-60' needed for 1 acceleration m 95%. of
normal fetuses
b) Devoe, McKinzie, et al. Am JOb Gyn 1985
(1) Reactivity in 95% within 70 minutes
(2) Nonreactivity (>90') ~ abnl CST (95 %)

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 c) Corollary: prolonged NR NST at term --~ consider delivery
d) Effects of immaturity on FHR baseline
(1) Lower amplitude accelerations
(2) More frequent decelerations
(3) Less coupling
(4) Standard reactivity takes longer to obtain
e) Pathologic tracing as significant as in term
(1) Prolonged NR
(2) Late decelerations
(3) Absent variation
(4) Severe variables
f) Maternal drugs
(1) $-blockers, CNS depressants
(2) Nicotine, cocaine
g) Maternal diet
(1) Hypoglycemia: decreased FM only if profound
2) Hyperglycemia: more FBM. less FM,
7. Sequential nonstress tests
a) Concept of using each fetus as its own control
b) Devoe, et al. Am JOb Gyn. 1986
(1) 16 of 18 fetuses with eventual compromise showed abnormal trends in NSTs before tests fell
below threshold for normalcy
2) Recommend testing under same conditions
C. Contraction stress test (CST), oxytocin challenge test (OCT
1. Basis
a) Response of FHR base:line to reduced or spontaneous uterine contractions (Ucs)
b) FHR-UC association (see Figure 1)
c) Influences
(1) Contraction frequency, intensity
(2) Maternal buffering capacity, position
(3) Fetal oxygenation, acid-base levels
d) Sequence of events leading to positive test
2. Significance
a) CST reflection of 02, acid-base balance, placental reserve
b) Positive CST may reflect
(1) Fetal compromise
(2) Maternal hypoxia, hypotension
(3) Uterine hyperstimulatoin
(4) Umbilical cord vulnerability
V. Interpretive Criteria
Table 1 NST lnterperative Data

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 Study (year) Baseline period (min) Acceleration number (amplitude) Other baseline
alterations

Lee (1976) 15 4 (10, 15) No

Rochard (1976) 15 4 (10, 15) Variability
Schifrin (1979) 10 2 (15) No
Evertson (1979) 20 5 (15) No
Devoe (1980) 30 3 (15) No
Flynn (1979) 20 4 (15) Variability,
Brown (1981) Up to 120 5 (15) decelerations
Mendenhall(1980) 30 1 (10) No
Krebs (1978) 30 5-parameter score No
Visser (1977) 20-30 4 patterns unscored
Aladjem (1981) 30 % FM and acceleration >51
Devoe (1986) 30 Total accel time x 100
Total test time

Table 2 CST Interpretive Criteria

Result Description

Negative No late decelerarion(s) present on tracing with uterine activity that is adequate

Positive Late decelerations present with mos: (>1/2) of the UCs (unless hypertension
present), even if uterine activity is less than adequate

Suspicious Adequate uterine activity present with some late deceleration(s), but does not meet
criteria for a positive test

Hyperstimulation Late deceleration(s) present with or following excessive uterine activity

Unsatisfactory Quality of tracing inadequate for accurate interpretation or adequate uterine activity
cannot be achieved

VI. Vibroacoustic Stimulation

A. Physiologic basis
1. Signal = broad-band (20-10K)
2. SPL = 82 db in air, 110 db in water
B. EAL provides two components
1. Vibrator'5' (+)
2. Acoustic (-)
C. Shortens testing time
D. Predictive accuracy is similar to standard NST
E May be useful intrapartum
F. No apparent adverse side-effects NST

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 G. Maybe useful intrapartum
H. No apparent adverse side effects in newborn
I. Normal fetal responses to VAS signal
1. 95% will become reactive post-VAS
2. 85 5 will have increased FHR baseline
10 bpm, >180 seconds
3. Mean onset: 7.5 sec
4. Mean duration: 600 sec
5. Modal duration: 300 sec
6. Median duration: 360 sec
J. Post-VAS responses reflect change in state
K. Post-VAS responses … spontaneous stimuli
L. Failed VAS does not exclude normal outcome
M. Safety remains to be firmly established
N. Efficacy trials are limited
VII. Actocardiotocography (ACTG)
A. Combined recording of Doppler-derived FHR and FMs in same time
B. Commercial units now available
C. Evaluated as potential for extending capability of NST
D. Studies are very limited
VIII. Test Selection/Diagnostic Values
A. NST vs CST
1. Contraindications
a) NST: none CST
(1) Third trimester bleeding
(2) Premature rupture of membranes
(3) Hypersensitivity
(4) Possible previous uterine surgery
2. Applications
a) NST: safer to perform
b) CST: potential hazard of UCs
3. Similar
a ) Test length: ff nipple-stimulation used
b) Specificity
c) Negative predictive value
4. Varies with interpretive criteria
a) Sensitivity
b) Positive predictive value
5. Note: few prospective studies of sufficient size exist to establish clear-cut advantage of either approach
6. Most recent study suggests that NST and nipple stimulation CST are virtually equivalent predictors of
outcome in similar obstetric populations managed in a similar manner
B. Diagnostic values

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 1. Specificity, negative predictive values are excellent with both tests
2. SensitMty varies with criteria, population tested (see Table 3)
3. False-negative test is uncommon and usually results from nonpredictable events (see Table 4)
4. False-positive rate is extremely variable but in most studies approximates 50%
5. Conclusions: both tests are most useful in determining health but. without the use of ancillary
information, fall short of good diagnostic methods for determining disease

Table 3 Diagnostic Values (%) of NST and CST for Perinatal Morbidity

Study No of Test Sensitivity Specificity False- False-

Patients Positive Negative
Fox 209 CST 22 90 40 10
Devoe 297 CST 50 84 57 12
Keane 566 CST 47 98 15 10
Krebs 260 CST 55 99 14 7
Mendenhall 367 NST 55 85 82 3
Devoe 297 NST 52 82 78 5
Keane 566 NST 53 88 54 10
Krebs 253 NST 55 93 47 7
Weingold 509 NST 38 90 89 2

Table 4 Diagnostic Values (%) of NST and CST for Perinatal Morbidity

Study No of Test Sensitivity Specificity False- False-

Patients Positive Negative
Devoe 297 CST 33 85 98 1

Weingold 381 CST 60 94 87 1

Keane 566 CST 22 91 96 1

Freeman 390 CST 43 85 85 4

Devoe 297 NST 33 79 98 1

Evertson 795 NST 67 63 97 1

Mendenhall 367 NST 80 83 94 0

Keane 566 NST 33 81 97 1

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Table 5 Cumulative Reports of Per/natal Deaths Following Normal Tests Less Than 7 Days

Reported Mortality Uncorrected Mortality Rate Corrected Mortality Rate

Cumulative (NST):8,0433 6.2/1,000 2.5/1,000
Cumulative (NST):2,15490 10.3/1,000 4.2/1 ,000
Cumulative (CST1:4,62690 8.4/1,000 3.5/1,006

Exclusions for congenital malformations, cord prolapse, sepsis, immaturity

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