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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.
The degree and duration of acidemia is weakly cor- recorded with an external fetal monitor. An adequate
related with adverse short-term and long-term neonatal uterine contraction pattern is present when at least three
outcomes. Furthermore, factors other than acid–base and contractions persist for at least 40 seconds each in a
oxygenation status (eg, prematurity, fetal sleep–wake 10-minute period. Uterine stimulation is not necessary if
cycle, maternal medication exposure, maternal smok- the patient is having spontaneous uterine contractions of
ing, and fetal central nervous system abnormalities) can adequate frequency. If fewer than three contractions of
adversely affect biophysical parameters (8, 9). 40 seconds’ duration occur in 10 minutes, contractions
are induced with either nipple stimulation or intravenous
Antepartum Fetal Surveillance oxytocin. A spontaneous CST can be considered if the
Techniques adequate number and strength of contractions are noted
Several antepartum fetal surveillance techniques (tests) in the 10-minute time frame.
are in clinical use. These include maternal perception of Nipple stimulation usually is successful in inducing
fetal movement, contraction stress test (CST), nonstress an adequate contraction pattern and allows completion
test (NST), biophysical profile (BPP), modified BPP, of testing in approximately one half of the time required
and umbilical artery Doppler velocimetry. than when intravenous oxytocin is used (13). The CST is
interpreted according to the presence or absence of late
Maternal–Fetal Movement Assessment FHR decelerations (14). A late deceleration is defined
as a visually apparent and usually symmetrical gradual
A decrease in the maternal perception of fetal movement decrease and return to baseline FHR in association with
may precede fetal death, in some cases by several days uterine contractions, with the time from onset of the
(10). This observation provides the rationale for fetal deceleration to its FHR nadir as 30 seconds or longer.
movement assessment by the mother (“kick counts”) as The deceleration is delayed in timing, with the nadir of
a means of antepartum fetal surveillance. the deceleration occurring after the peak of the contrac-
Although several counting protocols have been used, tion. In most cases, the onset, nadir, and recovery of the
neither the optimal number of movements nor the ideal deceleration occur after the beginning, peak, and ending
duration for counting movements has been defined. Thus, of the contraction, respectively (15). The results of the
numerous protocols have been reported and appear to be CST are categorized as follows:
acceptable. In one approach, the woman was instructed to
lie on her side and count distinct fetal movements (11). • Negative: no late or significant variable decelera-
Perception of 10 distinct movements in a period of up to tions
2 hours was considered reassuring. The count was dis- • Positive: late decelerations after 50% or more of
continued once 10 movements were perceived. The mean contractions (even if the contraction frequency is
time interval to perceive 10 movements was 20.9 (± 18.1) fewer than three in 10 minutes)
minutes. In another approach, women were instructed to • Equivocal–suspicious: intermittent late decelera-
count fetal movements for 1 hour three times per week tions or significant variable decelerations
(12). The count was considered reassuring if it equaled • Equivocal: FHR decelerations that occur in the pres-
or exceeded the woman’s previously established baseline ence of contractions more frequent than every 2 min-
count. Thus, regardless of the fetal movement approach utes or lasting longer than 90 seconds
used, in the absence of a reassuring count, further fetal
assessment is recommended. • Unsatisfactory: fewer than three contractions in
10 minutes or an uninterpretable tracing
Contraction Stress Test The CST is a safe and effective method of inves-
The CST is based on the response of the FHR to uterine tigating FHR nonreactivity in preterm gestations (16).
contractions. It relies on the premise that fetal oxygen- Relative contraindications to the CST generally include
ation will be transiently worsened by uterine contrac- conditions that also are contraindications to labor or
tions. In the suboptimally oxygenated fetus, the resultant vaginal delivery (17).
intermittent worsening in oxygenation will, in turn, lead
to the FHR pattern of late decelerations. Uterine contrac- Nonstress Test
tions also may produce a pattern of variable decelera- The NST is based on the premise that the heart rate of
tions caused by fetal umbilical cord compression, which a fetus that is not acidotic or neurologically depressed
in some cases is associated with oligohydramnios. will temporarily accelerate with fetal movement. Heart
With the patient in the lateral recumbent position, rate reactivity is thought to be a good indicator of nor-
the FHR and uterine contractions are simultaneously mal fetal autonomic function. Loss of reactivity is most