Antenatal Fetal Assessment: Contraction

Stress Test, Nonstress Test, Vibroacoustic

Stimulation, Amniotic Fluid Volume, Biophysical
Profile, and Modified Biophysical Profile—An Overview
Lawrence D. Devoe, MD

Antenatal fetal assessment was introduced into the United States in the 1970s. The initial
antepartum test, the oxytocin challenge test, later renamed as the contraction stress test,
became the gold standard for fetal surveillance. Its labor intensive requirements and
contraindications made it inapplicable to some high-risk pregnancies. Other testing
schemes were developed subsequently, the nonstress test and its alternative, vibroacous-
tic stimulation, the semiquantitative assessment of amniotic fluid volume, the biophysical
profile and its modified version, the modified biophysical profile. This article is a brief
critical review of these testing methods and focuses on the following: (1) physiologic
bases; (2) testing methodologies; (3) supportive evidence from randomized controlled and
observational trials; and (4) areas needing further investigation.
Semin Perinatol 32:247-252 © 2008 Elsevier Inc. All rights reserved.

KEYWORDS antepartum testing, contraction stress test, nonstress test, amniotic fluid,
biophysical profile

T he modern era of fetal assessment was ushered in by the

use of continuous electronic fetal monitoring (EFM) dur-
ing the labors of near-term patients. Intrapartum fetal heart
ing their use, and indicate areas of concern and opportunities
for further research.

rate (FHR) patterns were correlated with neonatal outcomes
and specific FHR patterns emerged that provided surrogate
measures of fetal oxygenation. A consensus was reached
eventually on those patterns predictive of adequate fetal ox-
ygenation or of fetal hypoxia and acidosis.1 Intrapartum EFM
findings led to the initial fetal assessment test that was used in
the United States, the oxytocin challenge test (OCT).2 The
increasing use of obstetric ultrasonography led to other fetal
surveillance methods such as the biophysical profile (BPP).
The goals of fetal assessment are to identify fetuses that are
well oxygenated or at risk for hypoxia and to enable appro-
priate intervention so that perinatal mortality and morbidity
can be prevented or reduced. This article will describe the
basis for these assessment tests, review the evidence support-
Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecol-
ogy, Medical College of Georgia, Augusta, GA.
Address reprint requests to Lawrence D. Devoe, MD, Department of Obstet-
rics and Gynecology, Medical College of Georgia, 1120 15th Street,
Augusta, GA 30912. E-mail: ldevoe@mail.mcg.edu
Contraction Stress Test
The contraction stress test (CST), formerly known as the
OCT, was introduced in the early 1970s.2 It was based on
intrapartum observations that linked recurrent late FHR de-
celerations with fetal hypoxemia. Previous studies3 had
shown that as fetal arterial pO2 fell below 20 mm Hg, most
uterine contractions would generate a late FHR deceleration.
The underlying mechanism for this event is a bradycardic
response to transient systemic hypertension provoked by a
reduction in arterial oxygen levels. As developed by Freeman
and colleagues,4 the CST was performed with intravenous
oxytocin until at least three moderate or strong contractions
per 10 minutes were generated in a 20-minute window.
Later, maternal nipple stimulation was substituted for intra-
venous oxytocin. Except for a possibly higher risk of uterine
hyperstimulation, the nipple stimulation test has performed
similarly to the standard CST.5,6
Test classification is as follows:
Negative: No late or significant variable decelerations
Positive: Late decelerations with at least 50% of contractions

0146-0005/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. 247
doi:10.1053/j.semperi.2008.04.005
248
Suspicious: Intermittent late or variable decelerations
Hyperstimulation: Decelerations with contractions ⬎90
seconds’ duration or 2-minute frequency
Unsatisfactory: Fewer than three contractions per 10 min-
utes or an uninterpretable tracing
A positive CST could result from maternal conditions (car-
diorespiratory disorders, hypovolemia, uterine hyperstimu-
lation) or fetal conditions (placental insufficiency, umbilical
cord compression). Variable decelerations prompt ultra-
sound evaluation of the amniotic fluid volume and umbilical
cord localization.7 Equivocal tests are usually repeated within
24 hours unless other indications for delivery are present.
Management of preterm pregnancies with positive CST re-
sults require individualization based on the presence or ab-
sence of reactivity and fetal maturity.8 Nonreactive positive
CSTs correlate well with fetal growth restriction, increased
incidence of late decelerations in labor, and low 5-minute
Apgar scores.9
In a prospective observational cohort study, Freeman and
coworkers noted a very low rate of false-negative tests, ie, risk
of fetal death within 1 week of a negative CST.10 False-posi-
tive rates, ie, delivery of an unaffected infant after a positive
CST, have been estimated at approximately 30%.9 Few direct
comparisons of the CST with other testing methods such as
the nonstress test (NST) or BPP have been obtained through
prospective observational studies.11-13
Summary
The CST was the first important antepartum assessment test
used in the United States. It has been used less often after
other biophysical testing modalities were introduced, eg, the
NST, the BPP, and Doppler velocimetry. Most supportive
evidence for use of the CST is based on Level II-2 and II-3
data. It is associated with a very low false-negative rate of
estimated at 0.04% (Level II-1) evidence and false-positive
rate estimated at 30% (Level II-3).
The Nonstress Test
It was noted that the presence of FHR accelerations modified
the significance of an apparently “positive” CST14 and usually
resulted in the delivery of nonhypoxic infants. The presence
of two accelerations in a 20-minute window predicted a neg-
ative CST in most cases and formed the basis for the most
widely used test reactivity criteria.15 Other investigators16,17
studied resting antepartum FHR baseline tracings and
showed that the presence of accelerations was associated with
a low likelihood of fetal compromise, while their absence
increased the risk of adverse perinatal outcomes (hypoxia,
acidosis, growth restriction, placental insufficiency, and
anomalies). The conventions of the NST evolved during a
number of studies performed during the late 1970s and early
1980s as summarized by Devoe.18
NST reactivity occurs through an autonomic neural link-
age between peripheral fetal activity and midbrain car-
dioregulatory centers, which strengthens as the fetus ma-
tures. At term, nearly 90% of fetal movements elicit reactive
L.D. Devoe
accelerations. The criteria for nonreactivity varied initially.18
Current test criteria typically consider an NST to be reactive
if there are two accelerations exceeding 15 beats per minute
amplitude and 15 seconds’ duration in a 20-minute window
for term pregnancies and 10 beats per minute amplitude and
10 seconds’ duration for gestational ages below 32 weeks.9
Nonreactivity may be associated with three differing scenar-
ios which fail to meet reactivity criteria, progressing from the
presence of accelerations of inadequate amplitude or fre-
quency through the absence of accelerations in the presence
of fetal movements (uncoupling) to the complete absence of
accelerations and fetal movements. This uncoupling phe-
nomenon has been well characterized by several groups.19,20
Nonreactivity may be associated with prolonged fetal sleep
states, immaturity, maternal ingestion of sedatives, and fetal
cardiac or neurologic anomalies. Cumulative studies of NST
performance suggest a false-negative rate of 0.3% within 1
week of a reactive NST and a false-positive rate of 50%.18
There have been four randomized controlled trials, con-
taining fewer than 1500 patients in which study groups re-
ceived NSTs and control groups received standard care.21 A
meta-analysis did not show use of the NST reduced rates of
perinatal death or neonatal seizures. Two prospective trials
have compared the NST to the CST.11,12 Freeman and col-
leagues, reporting on more than 6000 patients,11 found that
the CST provided better prediction of fetal health (false-neg-
ative rate of 0.4/1000) than the NST (false-negative rate of
3.2/1000); however, this study was heavily weighted toward
the CST as a primary method by a 3:1 ratio. Devoe and
coworkers studied nearly 1300 patients who received either
twice-weekly NSTs or weekly CSTs.12 No perinatal deaths
were reported within 1 week of either a negative CST or
reactive NST.
Vibroacoustic Stimulation (VAS)
A variation on the standard NST evolved during the 1980s
and was based on previous observations that sound and vi-
bratory stimuli could elicit changes in FHR baseline.22 Brief
exposure to a vibroacoustic signal (producing 82 decibels at
1 meter in air) has been shown to reduce testing time and the
incidence of “false” nonreactive NSTs in otherwise healthy
fetuses.22 This response is present throughout the third tri-
mester and results in a typical increase in FHR baseline
within 10 seconds of at least 10 bpm for at least 180 sec-
onds.23,24 A positive response is defined as the rapid occur-
rence of a qualifying acceleration following VAS. While data
are limited, fetal exposure to VAS does not appear to be
associated with adverse long-term effects on child develop-
ment.25 Positive (reactive) VAS tests appeared comparable to
standard reactive NSTs26 and negative CSTs.27 Perinatal out-
comes following positive VAS appear to be similar to those
associated with reactive NSTs, while testing time was shorter
with VAS.28 A meta-analysis of the trials comparing VAS and
NST confirmed that the incidence of nonreactive tests and
test duration were reduced. Testing efficacy could not be
established due to the limited sample sizes enrolled.29
Antenatal fetal assessment
Summary
Level I evidence supporting the NSTs use comes from
limited trials performed in an early era of antepartum test-
ing. Most supportive data come from case control trials
(Level II-2) or retrospective cohort analyses (Level II-3).
Compared with the CST, most available evidence (Level
II-3) suggests that the NST has higher false-negative and
false-positive rates. The rate of “false” nonreactivity can be
reduced by VAS, extending the observation period beyond
20 minutes to account for fetal sleep states,30 and using ges-
tational age-specific criteria for preterm gestations.31 A recent
overview suggests that use of the NST in antepartum care of
high-risk patients is associated with an apparent reduction in
stillbirths (Level II-2, Level II-3).32
Amniotic Fluid
Volume (AFV) Assessment
AFV evaluation began in the early 1980s but has rarely been
used as a sole fetal assessment method. AFV fluctuations tend
to occur more gradually than do the other dynamic measures
of fetal status; therefore, AFV assessment has been used to
reflect a “chronic” measure of the intrauterine environment.33
In the third trimester, AFV is the byproduct of fetal urination,
gastrointestinal motility, tracheal efflux, and amniotic mem-
brane transfer to and from fetal and maternal water compart-
ments. The historic “gold standard” for AFV measurement
uses dye-dilution determinations obtained through amnio-
centesis, an approach not feasible for repeated measurements
during pregnancy. Semiquantitative estimates of AFV using
ultrasound measurements of AF pockets became part of BPP
testing in the early 1980s.34 Two common approaches for
estimating AFV have evolved: maximum vertical pocket
(MVP) and amniotic fluid index (AFI).35 Nomograms for
semiquantitative AFV have been developed also for the
course of normal pregnancy.36 Both MVP and AFI have been
correlated with actual AFV as measured with dye dilution.37
These estimates of AFV tend to correlate well with actual AFV
within the normal range but over- and underestimate the
extremes of AFV, oligohydramnios, and polyhydramnios, re-
spectively. With this understanding, AFI and MVP have been
used as markers for intrauterine condition rather than as
measures of actual AFV. Although MVP was the initial
method of assessing AFV,38 Rutherford and coworkers devel-
oped the four-quadrant AFI35 and this method has achieved
ascendancy in current practice. Alternative schemes using
gestational-age nomograms have also been studied.39
Early observational studies correlated adverse perinatal
outcomes with MVPs ⬍2 cm and showed increased risks of
congenital anomalies, fetal growth restriction, and perinatal
death.40 Although a number of adverse conditions can reduce
AFV, prolonged gestation exceeding 41 or 42 weeks has been
the best studied of these indications for AFV assessment.41
Using a criterion of AFI above or below 8 cm, studies by
Lagrew and coworkers42 and Wing and coworkers43 suggest
that at less than 41 weeks gestation, weekly testing is suffi-
249
cient if AFI exceeds 8 cm, while twice weekly testing should
apply to pregnancies in which AFI is below 5 cm.
More rigorous assessment of AFV as an independent pre-
dictor of perinatal outcome is limited. Few studies have com-
pared the relative merits of either MVP or AFI for predicting
adverse perinatal outcome. Chauhan and coworkers44 sur-
veyed 18 studies with more than 10,000 patients. A criterion
of AFI ⬍5 cm predicted a 2.2-fold increased risk for cesarean
delivery and a 5.5-fold increased risk for 5-minute Apgar
score below 3. In a prospective trial of BPP using either MVP
or AFI, Magann and colleagues45 found that MVP yielded a
lower frequency of oligohydramnios and equivalent predic-
tion of cesarean delivery for fetal distress. These investigators
also compared three criteria for oligohydramnios: AFI ⬍5 cm
and two nomograms for AFI below the 5th percentile for
gestational age.39 None of these criteria effectively predicted
the risk of cesarean delivery for fetal distress, 5-minute Apgar
score below 3, umbilical artery pH ⬍7.00, or birth weight
below the 5th percentile.
Summary
Varying thresholds and standards have been used for semi-
quantitative AFV estimation. The best data (Level II-2 and
II-3) suggest that MVP and AFI are similar predictors of ad-
verse perinatal outcomes but neither is an effective sole ob-
servation for fetal assessment.
Fetal Biophysical Profile
The BPP was developed in the early 1980s as evaluation of
AFV and fetal breathing, body, and reflex movements could
be obtained with real-time ultrasound systems. Manning and
coworkers34 reported on a multiple parameter fetal testing
scheme that combined a standard NST with real-time ultra-
sound observation of fetal breathing, body movements, reflex
activity, and AFV estimation. The BPP was assigned a score
ranging from 0 to 10 based on the criteria established for each
parameter: (1) Nonstress test, reactive or nonreactive; (2)
fetal breath movements, present or absent for 30 seconds; (3)
fetal body movements, present or absent; (4) fetal reflex
movements, present or absent; (5) AFV, above threshold for
oligohydramnios. It was proposed that either acute hypoxia
(NST, breathing, or movement) or chronic hypoxia (reflex
activity, AFV) could alter each parameter predictably. Vintzi-
leos and coworkers46 hypothesized that hypoxia affect the
neurologic centers responsible for biophysical behavior in an
order inverse to the timing of their maturation. Subsequent
observations by this group were consistent with this hypoth-
esis.47
Based on the observations of Manning,48 score has been
correlated with the risk of intrauterine asphyxia or death and
recommended clinical response obtained from two decades
of observation (Level II-3).49-52 This series of nearly 90,000
patients suggests that the BPP has a false-negative rate of
0.6/1000, based on a weekly interval between normal tests.
The BPP has a false-positive rate of approximately 50%.53
250
Timing of the initiation of the BPP has varied, although
most data come from testing after 30 weeks gestation.54 A
weekly testing interval has been recommended following a
normal BPP score9; however, prospective trials to support
this approach are lacking. Consequently, individualization of
testing intervals for specific high-risk conditions has been
recommended.48
Rigorous trials of the efficacy of biophysical testing have
been limited and compared the full BPP to the NST alone.2
Meta-analysis of these trials55 does not show that use of the
BPP significantly reduced perinatal mortality or morbidities.
Nageotte and coworkers56 compared the BPP to the CST for
primary surveillance and found the BPP to provide compa-
rable performance with fewer interventions. This study was
not powered to address the prevention of perinatal death.
Summary
There is considerable Level II-2 and Level II-3 evidence to
support the BPP as an alternative to the CST or NST for
primary fetal surveillance. The BPP appears to have false-
negative rates similar to those of the CST, although direct
comparisons are very limited. Putative advantages of full BPP
testing are its noninvasiveness, potential for observation of
fetal anatomy, and parameters that reflect acute and chronic
responses to fetal hypoxia. Conversely, it requires more op-
erator skill and time than does the NST or AFV assessment
alone.
Modified Biophysical Profile
Given the relative labor-intensiveness of the standard BPP,
interest in developing a simpler screening test grew during
the 1980s. Termed the modified BPP (MBPP), this scheme
took advantage of two biophysical parameters for reflecting
acute fetal oxygenation and acid-base balance (NST) and
chronic fetal oxygenation (AFV). The NST is believed to be
the first parameter usually affected by hypoxia,49 while AFV
decreases gradually when perfusion to the brain and heart is
increased and renal blood flow is reduced. This model, con-
sistent with the pathophysiology of fetal growth restriction,
was supported by Manning and coworkers, who showed a
geometric increase in fetal death as single MVP measure-
ments declined from 2.0 cm.57
The standards for reactivity and AFV estimation in the
MBPP are similar to those of the full BPP. The MBPP has
become increasingly popular with surprisingly little objective
data on its efficacy. An early study of postdates pregnancy
compared the MBPP to standard FHR testing, followed by the
addition of fetal movement elements of the full BPP, and
finally the addition of AFV estimation.58 The addition of AFV
estimation appeared to make the greatest improvement in
test efficacy. In this study, the MBPP compared favorably to
the CST as a primary screening test. Eden and colleagues59
supported the use of the MBPP as a primary screening test
with the full BPP as a backup test. In a retrospective evalua-
tion, of the false-negative rates of the MBPP and the CST,
Nageotte and coworkers showed that false-negative rates of
L.D. Devoe
Table 1 Test Indications—Pregnancies at Highest Risk for
Intrauterine Asphyxia
Obstetric Medical
Postdates Diabetes
Growth retardation Chronic hypertension
Previous stillbirth Cardiac disease
Decreased fetal movement Renal disease
Pregnancy-induced hypertension Thyroid disease
Premature rupture of membranes SLE
Discordant twins (20%) Thrombophilias
Cholestasis of pregnancy
Rh-isoimmunization
Oligohydramnios (5 cm)
Polyhydramnios (24 cm)
the MBPP and CST were similar.13 The largest observational
series was reported by Miller and coworkers54on more than
15,000 patients undergoing more than 50,000 MBPPs. Their
false-negative rate was 0.8/1000; their false-positive rate was
60%.
Summary
Level II-2 and Level II-3 evidence suggest that the MBPP has
efficacy similar to the CST and full BPP. More rigorous pro-
spective and adequately powered trials are still lacking.
General Testing
Considerations: Areas of Concern
Indications for Testing
Table 1 lists indications commonly recommended for ante-
natal fetal surveillance.8 Although it is assumed that antepar-
tum tests will have similar value in for all indications in
determining the risk of adverse perinatal outcome, Konto-
poulos and Vintzileos have questioned this assumption.60
Devoe and coworkers tested 1000 consecutive patients with
common high-risk indications: hypertension, diabetes melli-
tus, postdatism, and suspected fetal growth restriction.61
Screening performance varied with test indication, being best
for patients with hypertension and fetal growth restriction
and worst for postdates pregnancies. As individual tests, the
NST and Doppler velocimetry performed better than did
AFV assessment for each of these conditions.
Timing of Testing Initiation
Most data on efficacy of antepartum surveillance methods
have been obtained in near term pregnancies with fewer data
as gestational age decreases. The largest studies cited in this
article have limited numbers of fetuses ⬍32 weeks gestation.
As for a false-positive test resulting in iatrogenic prematurity,
this risk must be weighed against the risk of delaying delivery
of a compromised infant. Miller and colleagues54 addressed
this issue in their retrospective survey of MBPP testing. Their
data showed that all fetal deaths could have been avoided if
testing had started at 28 weeks gestation rather than 32
weeks. However, there was a 1.5% rate of iatrogenic prema-
Antenatal fetal assessment
Table 2 Quality of Evidence and Strength of Recommendations for Antepartum Test Methods
Test Level of Evidence
Contraction stress test II-2
Nonstress test II-2
Vibroacoustic stimulation II-1
Amniotic fluid volume II-2
Assessment (MVP, AFI) II-3
Biophysical profile II-2
Level of evidence: I, at least one adequate randomized controlled trial; II-1, well-designed nonrandomized controlled trial; II-2, well-designed
cohort or case-control trial; II-3, multiple time series reported.
Strength of recommendation: A, good evidence to support recommendation; B, fair evidence to support recommendation; C, insufficient
evidence to support or reject recommendation.
turity for a false-positive test, and 20% of these infants had
complications due to prematurity. More data are needed to
address the reliability of antepartum testing and the toll ex-
acted for test-based interventions in gestations below 32
weeks.
Selection of Testing Method
A summary of the tests examined in this article is presented in
Table 2. The criteria for level of evidence and strength of
recommendations are based on those recommended by the
US Preventive Services Task Force. None of these tests are
well supported by the most rigorous trials expected for eval-
uation of screening, diagnostic, or therapeutic interventions.
While there is no evidence to support these tests for use in
low-risk pregnancies, there is only fair evidence to justify
their use as recommended in high-risk pregnancies.
Conclusions
Antepartum fetal surveillance has entered its fourth decade
and millions of fetuses have been evaluated with at least one
antenatal test during this time period. Although the use of
biophysical testing schemes to screen high-risk pregnancies
has become routine, they have evolved with limited high-
quality scientific data. Serious questions remain open at
present. What is the best initial testing approach for high-risk
pregnancies? What is the optimal timing of test initiation and
how should high-risk conditions affect test initiation? How
often should antenatal tests be repeated if not completely
normal and reassuring? How should test indications influ-
ence the testing method chosen and how might that method
affect the likelihood of adverse outcome? How should ante-
natal testing in the fetus between 24 and 32 weeks gestational
age be best conducted? These questions must be answered if
the best application of antenatal surveillance techniques is to
be accomplished.
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