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Overview of antepartum fetal

assessment
Authors: Caroline Signore, MD, MPH, Catherine Spong, MD
Section Editor: Vincenzo Berghella, MD
Deputy Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer
review process is complete.

Literature review current through: Mar 2022. | This topic last

updated: Mar 17, 2022.

INTRODUCTION

The main techniques for fetal assessment are the nonstress

test, biophysical profile, modified biophysical profile,
contraction stress test, and fetal movement count.
Assessment of amniotic fluid volume (independent of the
biophysical profile and modified biophysical profile) and
Doppler velocimetry of fetal and funic vessels provide
additional information about fetal status. Despite widespread
use of these techniques, there is limited evidence to guide
their optimal use or demonstrating their effectiveness for
improving perinatal outcomes.

This topic will provide an overview of antepartum fetal

assessment. Detailed discussions of the various techniques
and their use and efficacy for improving perinatal outcome in
specific clinical settings are available separately:

● (See "Nonstress test and contraction stress test".)

● (See "Biophysical profile test for antepartum fetal
assessment".)
● (See "Decreased fetal movement: Diagnosis, evaluation,
and management".)
● (See "Assessment of amniotic fluid volume".)
● (See "Doppler ultrasound of the umbilical artery for fetal
surveillance in singleton pregnancies".)

GOAL

The goals of antepartum fetal assessment are to (1) identify

fetuses at risk of intrauterine death or developing neurologic
complications from slowly progressive (chronic) intrauterine
hypoxia and (2) intervene to prevent these adverse outcomes,
if possible.

PHYSIOLOGIC BASIS
Tests for antepartum fetal assessment are based on the
premise that the fetus responds to slowly progressive
(chronic) hypoxemia with a detectable sequence of
biophysical changes, beginning with signs of physiological
adaptation and potentially ending with signs of physiological
decompensation ( figure 1) [1,2]. Studies in animal models
support this premise by demonstrating that fetal biophysical
activities (eg, heart rate, movement, breathing, tone) are
sensitive to fetal oxygen and pH levels, and changes in fetal
biophysical activities occur in response to, or in association
with, hypoxemia and acidemia [3]. However, fetal biophysical
parameters can be affected by factors unrelated to
hypoxemia, such as gestational age, maternal medication,
maternal smoking, fetal sleep-wake cycles, and fetal
disease/anomalies.

Because the sequence of biophysical changes over time

described in the figure does not occur in the setting of an
acute hypoxemic insult, such as a complete placental
abruption, periodic fetal antepartum testing rarely identifies
fetuses at risk of death/neurologic complications from an
acute insult and thus does not provide an opportunity for
intervention to prevent these adverse outcomes.

EFFICACY
Antepartum fetal assessment has had an established role in
obstetric practice since the 1970s [4], although its ability to
improve pregnancy outcome has not been evaluated by large,
well-designed randomized trials [5]. Efficacy is based
primarily on two lines of evidence: (1) observational studies
that reported lower rates of fetal death in pregnancies that
underwent fetal testing than among historic controls with the
same indication for testing but no fetal testing and (2) the
same or lower rates of fetal death in tested pregnancies
(primarily high risk) than in a contemporary untested general
obstetric population (primarily low risk) [6-10].

Both of these lines of evidence have obvious limitations [11].

Given multiple advances in maternal and neonatal care over
time, contemporary pregnant people can be expected to have
better pregnancy outcomes than historic controls, and the
better outcomes generally cannot be attributed to the single
intervention evaluated in observational studies. Furthermore,
the low rate of fetal death in tested pregnancies may be
related to more intense prenatal care and intervention in
these pregnancies compared with untested pregnancies
(Hawthorne effect). Patients undergoing testing may have
more provider visits, which are extra opportunities to detect
an acute serious maternal or fetal problem, and they are
more likely to undergo induction of labor, which can
substantially reduce the risk of stillbirth since stillbirth can
only occur in ongoing pregnancies.
POTENTIAL BENEFITS AND HARMS

The gaps in the evidence regarding the efficacy of

antepartum testing in preventing fetal neurologic injury or
death preclude clear conclusions about the benefits and
harms of antepartum testing and a clear understanding of its
costs.

● Potential benefits:

• If effective (see 'Efficacy' above), the major benefit

would be the ability to identify fetuses in whom
appropriate timely intervention would prevent death
or adverse neurologic outcomes.

● Potential harms:

• The major harm would be false-positive tests that

lead the provider to unnecessary additional fetal
evaluation and/or intervention (particularly
iatrogenic preterm birth).

• False-negative tests that do not alert the provider to

the need for further fetal evaluation and/or
intervention is another potential harm.

• A theoretic concern is that cerebral palsy and

stillbirth may share a common etiologic pathway
since they have some common risk factors (eg, fetal
 growth restriction, congenital anomalies, fetal
hypoxia) [12]. If true, identification and prompt
delivery of fetuses with nonreassuring antenatal
testing may allow those with neurologic injury who
would have died in utero to survive with permanent
neurologic impairment.

● Uncertain effects:

• Little is known about the effects of antenatal testing

on maternal mental states. Antenatal testing may
provoke anxiety but can also offer reassurance of
fetal well-being when the tests are normal [13].

• Potential costs include the actual dollars spent on

tests and their interpretation, opportunity costs of
patients' and practitioners' time spent in testing, and
maternal and infant morbidity (or even mortality)
from iatrogenic delivery because of abnormal results,
especially given the frequency of false-positive tests.

INDICATIONS FOR FETAL ASSESSMENT

The American College of Obstetricians and Gynecologists'

(ACOG) practice bulletin on antepartum fetal assessment is
the good practice standard in the United States [14]. The
bulletin suggests antepartum testing for pregnancies in
which the risk of antepartum fetal demise is increased, which
ACOG has defined as a stillbirth rate greater than 0.8 per
1000 and associated with a relative risk (RR) or odds ratio for
stillbirth >2.0 compared with pregnancies without the
condition [15]. This stillbirth rate was chosen because it is the
false negative rate of the biophysical profile.

It is not possible to list every clinical setting where tests for

antepartum fetal assessment might be useful to identify
fetuses at risk of intrauterine demise or other complications
of asphyxia. The more common clinical settings in which
antepartum fetal testing is typically performed are listed
below and discussed in more detail in individual reviews on
each topic.

● Diabetes – Preexisting or gestational diabetes treated

with pharmacotherapy. Gestational diabetes in which
glucose levels are normal on nutritional therapy does
not appear to be associated with an increased risk of
stillbirth, so antepartum fetal testing can be omitted.
(See "Gestational diabetes mellitus: Obstetric issues and
management", section on 'Fetal surveillance' and
"Pregestational (preexisting) diabetes mellitus: Obstetric
issues and management".)

● Hypertensive disorders – Chronic hypertension or

pregnancy-related hypertension. (See "Preeclampsia:
Management and prognosis", section on 'Assessment of
fetal well-being' and "Gestational hypertension", section
 on 'Fetal assessment' and "Chronic hypertension in
pregnancy: Preconception, pregnancy, and postpartum
issues and management", section on 'Tests to monitor
fetal well-being'.)

● Fetal growth restriction – (See "Fetal growth restriction:

Evaluation and management", section on 'Nonstress
test and biophysical profile'.)

● Twin pregnancy – (See "Twin pregnancy: Routine

prenatal care", section on 'Antepartum fetal testing' and
"Twin pregnancy: Overview".)

● Postterm pregnancy – Testing is often initiated between

41+0 and 42+0 weeks of gestation but may be initiated
at estimated gestational age of 39+0 to 40+0 weeks in a
suboptimally dated pregnancy [16]. (See "Postterm
pregnancy", section on 'Alternative approach: Expectant
management with fetal monitoring'.)

● Decreased fetal activity – (See "Decreased fetal

movement: Diagnosis, evaluation, and management".)

● Systemic lupus erythematosus – (See "Pregnancy in

women with systemic lupus erythematosus", section on
'Maternal-fetal monitoring'.)

● Antiphospholipid syndrome – (See "Antiphospholipid

syndrome: Obstetric implications and management in
 pregnancy", section on 'Antepartum maternal and fetal
monitoring'.)

● Sickle cell disease – (See "Sickle cell disease: Pregnancy

considerations", section on 'Prenatal care'.)

● Alloimmunization to red blood cell antigens – (See "RhD

alloimmunization in pregnancy: Management", section
on 'MCA-PSV ≤1.5 MoMs for gestational age' and
"Management of non-RhD red blood cell alloantibodies
during pregnancy", section on 'Prenatal management'.)

● Oligohydramnios or polyhydramnios – (See

"Polyhydramnios: Etiology, diagnosis, and
management", section on 'All patients' and
"Oligohydramnios: Etiology, diagnosis, and
management", section on 'Third trimester'.)

● Prior fetal demise – (See "Stillbirth: Incidence, risk

factors, etiology, and prevention", section on 'Strategies
for prevention of recurrent stillbirth'.)

● Preterm prelabor rupture of membranes – Preterm

prelabor rupture of membranes may be associated with
oligohydramnios and possibly subclinical intrauterine
infection. The goal of antenatal testing in this setting is
early recognition of intraamniotic infection necessitating
delivery. (See "Preterm prelabor rupture of membranes:
 Management and outcome", section on 'Fetal
monitoring'.)

An ACOG Committee Opinion on indications for outpatient

antenatal fetal surveillance provides a list of potential
maternal, fetal, placental, and obstetric indications [15]. The
American College of Radiology Appropriateness Criteria for
assessment of fetal well-being also provide a broad list of
conditions that the American College of Radiology believes
may warrant judicious use of tests of fetal well-being [17].

Possible indications for antenatal testing — Epidemiologic

data suggest a small increased risk of fetal demise associated
with a number of additional conditions, including:

● Advanced maternal age. (See "Management of

pregnancy in women of advanced age".)

● Obesity. (See "Obesity in pregnancy: Complications and

maternal management".)

● Major fetal structural anomalies [18] (refer to topics on

individual anomalies).

● Abnormalities in first- and second-trimester maternal

biochemical trisomy 21 (Down syndrome) screening
results [19,20].

Whether a policy of antenatal testing in pregnancies with

these risk factors can reduce the incidence of fetal demise or
fetal injury is unknown. The use of fetal testing in these
pregnancies is decided on a case-by-case basis.

FETAL ASSESSMENT TECHNIQUES

Fetal movement counting — Objective maternal

assessment of fetal movements is based on evidence that
fetal movement decreases in response to fetal hypoxemia
[21]. Although there is universal consensus opinion that
patients with decreased fetal movement should undergo
further fetal assessment, available evidence does not support
a clear fetal movement threshold or "alarm limit" indicating
when the risk of fetal death or injury is increased and
randomized trials of fetal movement counting for assessment
of fetal well-being found no conclusive evidence of a benefit
of this intervention. The available evidence, as well as
approaches for counseling pregnant patients about how and
when to monitor fetal activity and evaluation of those with
decreased fetal activity can be found separately. (See
"Decreased fetal movement: Diagnosis, evaluation, and
management".)

Cardiotocographic techniques

Nonstress test — The nonstress test (NST) was developed

as a result of observations that (1) the presence of two or
more fetal heart rate (FHR) accelerations during a contraction
stress test (CST) often predicted a negative CST, and (2) the
absence of accelerations on a baseline FHR tracing was
associated with adverse perinatal outcomes [4]. FHR
accelerations, spontaneous or provoked (eg, by vibroacoustic
stimulation), are a good indicator of normal fetal autonomic
function and absence of acidosis and neurologic depression.
Although a meta-analysis of randomized trials found no clear
evidence that antenatal cardiotocography improved perinatal
outcome, the quality of evidence was low or very low [22].
These data, as well as NST interpretation and use, are
described in detail separately. (See "Nonstress test and
contraction stress test", section on 'Nonstress test'.)

The main advantage of the NST over the CST is that it does
not require an intravenous line, oxytocin, or contractions.
Disadvantages are that the false-negative and false-positive
rates are higher than for the CST (a false-negative NST is
when an antepartum stillbirth occurs within one week of a
reactive test; a false-positive NST is a nonreactive test that is
followed by a normal back-up test, such as a negative CST or
high biophysical profile [BPP] score) ( table 1) [6,23]. (See
"Nonstress test and contraction stress test", section on
'Nonstress test'.)

Nonstress test with assessment of amniotic

fluid — Sonographic assessment of amniotic fluid volume
(AFV) is often performed as an adjunct to the NST to improve
sensitivity (ie, decrease the rate of false-negative reactive
tests). Only low-quality data support this hypothesis. A small
retrospective study reported pregnancies with reactive NSTs
and low amniotic fluid index (0 to 5 cm) were at increased risk
for meconium passage and five-minute Apgar score <7 at
delivery compared with those with a normal amniotic fluid
index [24]. A study in postterm pregnancies reported
decreased AFV and variable decelerations were associated
with an increased incidence of fetal distress, even when the
NST was reactive, but the performance of the combined test
was similar to that of either test alone [25]. (See 'Assessment
of amniotic fluid volume' below.)

Contraction stress test — The CST is based on the fetal

response to a transient reduction in fetal oxygen delivery
during uterine contractions. If the fetus becomes hypoxemic
(fetal arterial pO2 below 20 mmHg [26,27]), reflex slowing of
the FHR occurs, which can manifest clinically as late
decelerations ( waveform 1 and waveform 2). The
change in the FHR is mediated by fetal chemoreceptors and
baroreceptors and by parasympathetic and sympathetic
fibers to the heart and cerebral vessels. Performance of the
CST, as well as its interpretation and use, are described in
detail separately. (See "Nonstress test and contraction stress
test", section on 'Contraction stress test'.)

The CST is seldom performed given the wide availability of

other tests (eg, NST, BPP) that do not have its major
drawbacks: the need to stimulate contractions with
intravenous oxytocin, the contraindication to inducing
contractions in some conditions (eg, placenta previa), and the
high false-positive rate (ie, fetus goes on to tolerate labor
without FHR changes necessitating intervention). However,
the false-negative rate (ie, rate of fetal death within one week
of a negative test) is very low ( table 1), thus providing
reassurance of adequate fetal oxygenation after a normal
test result [28].

Sonographic techniques

Biophysical profile — The BPP combines the NST with

ultrasonographic fetal assessment by assigning points to the
following parameters: fetal breathing movements, fetal body
movements, reflex/tone/flexion-extension movements, and
AFV ( table 2) [29]. Thus, this test assesses indicators of
both acute hypoxia (NST, breathing, body movement, tone)
and chronic hypoxia (AFV). The BPP score has a direct linear
correlation with fetal pH ( figure 2).

The modified biophysical profile (mBPP) consists of the NST

as a measure of acute oxygenation and assessment of AFV as
a measure of longer-term oxygenation. The mBPP is
considered abnormal if the NST is nonreactive, no single
deepest vertical pocket of amniotic fluid ≥2 cm is present, or
both.

The false-negative rates for the BPP and mBPP are very low,
but the false-positive rates are high ( table 1) (a false-
negative BPP or mBPP is when an antepartum stillbirth
occurs within one week of a high score; a false positive is a
low score that is followed by a normal back-up test).
Performance of the BPP and mBPP are described in detail
separately. (See "Biophysical profile test for antepartum fetal
assessment".)

Assessment of amniotic fluid volume — In the hypoxemic

fetus, cardiac output is redirected to the brain, heart, and
adrenals and away from less vital organs, such as the kidney;
the reduction in renal perfusion leads to decreased fetal urine
production, which may result in decreased AFV
(oligohydramnios) over time. This is the main rationale for
assessment of AFV as an adjunct to the NST and as a routine
component of the BPP. FHR abnormalities may be observed
since cord compression is more likely in the setting of
oligohydramnios. (See "Oligohydramnios: Etiology, diagnosis,
and management".)

AFV can be assessed qualitatively or quantitatively. The single

deepest pocket and the amniotic fluid index method are
commonly used methods of assessment and equivalent in
their prediction of adverse outcome in singleton pregnancies.
Assessment of AFV, as well as its interpretation and use, is
described in detail separately. (See "Assessment of amniotic
fluid volume".)

Doppler velocimetry
 Overview — Measurement of blood flow velocities in
the maternal and fetal vessels provides information about
uteroplacental blood flow and fetal responses to physiologic
challenges. Abnormal vascular development of the placenta,
such as in preeclampsia, results in progressive hemodynamic
changes in the fetoplacental circulation. Doppler indices from
the umbilical artery increase when 60 to 70 percent of the
placental vascular tree is compromised [30]; eventually, fetal
middle cerebral artery impedance falls and fetal aortic
resistance rises to preferentially direct blood to the fetal brain
and heart [31,32]. Ultimately, end diastolic flow in the
umbilical artery ceases or reverses and resistance increases in
the fetal venous system (ductus venosus, inferior vena cava)
[2,32-34]. These changes occur over variable periods of time
and correlate with fetal acidosis [35].

In contrast to most other methods of fetal assessment,

Doppler-based tests have been rigorously evaluated in
randomized trials. The information derived from velocity
waveforms varies according to the specific vessel
interrogated. Umbilical artery Doppler is the most common
Doppler technique used for fetal assessment where fetal
hypoxemia is a concern. Fetal middle cerebral artery-peak
systolic velocity (MCA-PSV) is the best tool for predicting fetal
anemia in at-risk pregnancies.

Umbilical artery — Umbilical artery Doppler

assessments are most useful for monitoring fetuses with
early-onset growth restriction due to uteroplacental
insufficiency [36]. The umbilical artery waveform pattern is
compatible with a low-resistance system: forward blood flow
occurs throughout the cardiac cycle. Umbilical artery flow
velocity waveforms of normally growing fetuses are
characterized by high-velocity diastolic flow, whereas in
growth-restricted fetuses, umbilical artery diastolic flow is
diminished, absent, or even reversed in severe cases [37].
This progressive reduction of umbilical artery diastolic flow is
associated with increasing obliteration of tertiary villi [38]. In
the growth-restricted fetus, absent or reversed end diastolic
flow is associated with fetal hypoxemia and acidemia, and
increased perinatal morbidity and mortality [34,38,39]. The
technique for Doppler interrogation of the umbilical artery, as
well as interpretation and use of umbilical artery Doppler, is
described in detail separately. (See "Doppler ultrasound of
the umbilical artery for fetal surveillance in singleton
pregnancies".)

The American College of Obstetricians and Gynecologists'

practice guidelines support the use of umbilical artery
Doppler assessments in the management of suspected fetal
growth restriction, but not for normally grown fetuses [14].
When monitoring the growth-restricted fetus, umbilical artery
Doppler should be used with standard fetal assessment (NST
and/or BPP score). In a systematic review of 16 randomized
trials including over 10,000 high-risk patients where the
definition of "high risk" varied among trials, use of Doppler
ultrasound resulted in a variable decrease in perinatal
mortality (perinatal mortality: 1.2 versus 1.7 percent, odds
ratio 0.71, 95% CI 0.52-0.98, number needed to treat 203)
[40]. (See "Fetal growth restriction: Evaluation and
management", section on 'Umbilical artery'.)

There is no strong evidence to support umbilical artery

Doppler assessment in settings other than suspected fetal
growth restriction. In a systematic review of five randomized
trials including over 14,000 low-risk or unselected obstetric
patients, routine umbilical artery Doppler screening did not
improve perinatal outcomes [41].

Middle cerebral artery — Doppler assessment of the

fetal middle cerebral artery-peak systolic velocity (MCA-PSV) is
the best tool for monitoring for fetal anemia in at-risk
pregnancies, such as those affected by RhD
alloimmunization. (See "RhD alloimmunization in pregnancy:
Management", section on 'Assess for severe anemia using
MCA-PSV in fetuses at risk'.)

MCA Doppler is under investigation as an additional tool for

assessment of pregnancies complicated by growth restriction.
Its use in this setting is based on the premise that systemic
blood flow in these fetuses is redistributed from the
periphery to the brain and Doppler measurement of flow
velocity in the fetal MCA can detect this brain-sparing effect
[31,42-44]. Specifically, the cerebroplacental ratio, calculated
by dividing the Doppler indices of the MCA by the umbilical
artery, is emerging as a potential predictor of adverse
outcome for both growth-restricted and appropriately-grown
fetuses [45]. (See "Fetal growth restriction: Evaluation and
management", section on 'Cerebroplacental ratio'.)

Venous system — Venous Doppler parameters may be

abnormal due to several abnormalities in cardiovascular
function. These include decreased cardiac compliance and
contractility, marked elevations in cardiac afterload, and
abnormalities of cardiac rhythm and rate. The clinical utility of
venous Doppler velocimetry is therefore greatest in fetal
conditions with cardiac manifestations and/or marked
placental insufficiency. These conditions include fetal growth
restriction due to placental insufficiency, twin-twin
transfusion, fetal hydrops [46,47], and fetal arrhythmia. (See
"Fetal growth restriction: Evaluation and management",
section on 'Ductus venosus' and "Twin-twin transfusion
syndrome: Screening, prevalence, pathophysiology, and
diagnosis" and "Twin-twin transfusion syndrome:
Management and outcome" and "Fetal arrhythmias".)

The fetal precordial veins (ductus venosus and inferior vena

cava) and the umbilical vein are the vessels most commonly
evaluated in clinical practice, although flow velocity
waveforms have been reported for many other venous
vessels. Blood flow in the umbilical vein is continuous in
normal pregnancies >15 weeks of gestation. In pathological
states, such as fetal growth restriction, flow in the umbilical
vein may be pulsatile, which reflects cardiac dysfunction
related to increased afterload. The ductus venosus regulates
oxygenated blood in the fetus [48] and is resistant to
alterations in flow except in the most severely growth-
restricted fetuses.

Uterine artery — A number of investigators have

explored the use of uterine artery Doppler for third-trimester
fetal assessment among patients with complicated
pregnancies, but its role in these settings has not been clearly
defined [49-51]. Impedance to flow in the uterine arteries
normally decreases as pregnancy progresses. Failure of
adequate trophoblast invasion and remodeling of maternal
spiral arteries is characterized by a persistent high-pressure
uterine circulation and increased impedance to uterine artery
blood flow. Elevated resistance indices and/or persistent
uterine artery notching at 22 to 24 weeks of gestation
indicate reduced blood flow in the maternal compartment of
the placenta and have been associated with development of
preeclampsia, fetal growth restriction, and perinatal death
[52]. (See "Fetal growth restriction: Screening and diagnosis"
and "Early pregnancy prediction of preeclampsia", section on
'Uterine artery Doppler velocimetry'.)

CHOICE OF TEST
Although observational studies have described the use of the
nonstress test (NST), contraction stress test (CST), and
biophysical profile score (BPP) for monitoring high-risk
pregnancies, no method has been evaluated in well-designed
randomized trials, and it is not clear which method, if any, is
superior. The choice depends on multiple factors, including
gestational age (up to 50 percent of NSTs are not reactive in
healthy 24- to 28-week fetuses [53]), availability, desire for
fetal biometry or follow-up of a congenital anomaly, ability to
monitor the fetal heart rate (eg, the NST and CST may not be
interpretable in a fetus with an arrhythmia), and cost.

Doppler assessment of the umbilical artery should be used to

monitor the growth-restricted fetus, given its proven efficacy
in reducing perinatal death in this setting when used with
standard fetal testing (NST, BPP) and appropriate intervention
[54]. It has only modest ability to predict fetal compromise in
other high-risk pregnancies [55]. (See "Fetal growth
restriction: Evaluation and management", section on 'Doppler
velocimetry' and "Doppler ultrasound of the umbilical artery
for fetal surveillance in singleton pregnancies".)

TIMING

Testing should begin as soon as an increased risk of fetal

demise is identified and delivery for perinatal benefit would
be considered if test results are abnormal.
In the general obstetric population, observational data show
that rate of stillbirth in non-growth-restricted fetuses
significantly rises between approximately 32 to 34 weeks and
term [56]. Based on these data and data from large series of
high-risk pregnancies [57-59], 32 weeks has become a
common threshold for initiating fetal assessment when a
condition potentially associated with a late preterm or term
stillbirth is present. Testing is initiated before 32 weeks when
the pregnancy is complicated by multiple high-risk conditions
or a condition with a high risk of fetal demise before 32
weeks (eg, severe growth restriction) is present. In such
cases, testing is initiated at the gestational age at which
delivery for perinatal benefit would be considered if test
results are abnormal.

(See "Nonstress test and contraction stress test" and

"Biophysical profile test for antepartum fetal assessment"
and "Decreased fetal movement: Diagnosis, evaluation, and
management".)

FOLLOW-UP OF PREGNANCIES WITH NORMAL

TEST RESULTS

Negative predictive value of a normal test result — The

negative predictive value for stillbirth within one week of a
normal test ranges from 99.8 to 100 percent [14]. A normal
test result for the nonstress test (NST), contraction stress test,
or biophysical profile is reassuring that the fetus is at low risk
of antepartum stillbirth proximate to testing and in the
absence of development of an acute maternal or fetal
disorder, such as placental abruption or cord compression.

Follow-up of pregnancies with a normal result and a

transient condition as indication for testing — A single
normal test result without follow-up testing is adequate if the
test was performed for a nonrecurring indication in an
otherwise low-risk pregnancy (eg, reactive NST after a minor
motor vehicle accident and no signs of labor or vaginal
bleeding).

Follow-up of pregnancies with a normal result and a

chronic condition as indication for testing — There are no
data from randomized trials on which to base
recommendations for the optimum frequency of fetal
monitoring (daily, every other day, twice per week, once per
week) in pregnancies with an ongoing indication for fetal
testing. These decisions are based on expert opinion, clinical
experience with similar high-risk pregnancies, and
community standards.

Testing is typically performed weekly in pregnancies at

modestly increased risk of fetal demise because of an
ongoing maternal or fetal disorder (see 'Indications for fetal
assessment' above), but the frequency is often increased to
two to seven times per week:
 ● If a change in pregnancy status occurs (eg, fetal growth
percentile falls from 10th percentile to 3rd percentile,
worsening preeclampsia).

● In clinical settings considered to be very high risk for

fetal demise (eg, fetal growth restriction with absent or
reversed diastolic flow, hydrops fetalis, patients with
preeclampsia with severe features who are not being
induced, preterm prelabor rupture of membranes).

● At 36 weeks of gestation. As the risk of stillbirth

increases with advancing gestational age, testing may
begin weekly at 32 weeks and then increased to twice
per week at 36 weeks.

Fetuses with normal results are tested until the onset of

labor. In the absence of spontaneous labor, the decision to
continue antepartum testing versus induction of labor (or
scheduled cesarean delivery) depends on the indication for
testing. For example, patients with preeclampsia without
features of severe disease are routinely delivered at 37 weeks
of gestation (see "Preeclampsia: Management and
prognosis", section on 'Timing of delivery'). Pregnant patients
undergoing testing for conditions only modestly associated
with an increased risk of stillbirth, such as advanced maternal
age or obesity without comorbidities, might prefer induction
at 39 weeks of gestation rather than expectant management
plus fetal testing since the risk of stillbirth is lower with
induction [11].

MANAGEMENT OF PREGNANCIES WITH

ABNORMAL TEST RESULTS

The clinical setting needs to be considered, as described

below.

Transient condition as cause of abnormal test — If a

temporary maternal condition, such as diabetic ketoacidosis
or acute bronchospasm, may account for the abnormal test
result, prompt treatment of the maternal condition may also
improve fetal oxygenation and lead to a normal test result on
subsequent testing. Similarly, if a maternal medication is
likely affecting fetal behavior or heart rate, then withholding
the drug (if possible) and repeating the test when the effects
have dissipated will allow a clearer assessment of fetal status.
If the repeat test becomes normal, follow-up is as described
above. (See 'Follow-up of pregnancies with normal test
results' above.)

Chronic condition as cause of abnormal result — Given the

high rate of false-positive tests ( table 1) and the high
negative predictive value of a normal test, an abnormal test
result is generally followed by additional testing with a
different test (eg, contraction stress test [CST] or biophysical
profile [BPP] after a nonreactive nonstress test [NST]) to
provide more information about fetal status. However, clinical
judgment should guide decision making regarding delivery
versus follow-up testing after an abnormal test result, taking
into account a combination of factors, as described below.

● Gestational age (eg, lower threshold for delivery at term

versus preterm).

● Severity of maternal and fetal disease (eg, low threshold

for delivery for hydrops fetalis, for diabetes with poor
glycemic management versus good glycemic
management, or for fetal growth restriction at 3rd
percentile with oligohydramnios and abnormal umbilical
artery Doppler flow versus 10th percentile with normal
amniotic fluid volume and normal umbilical artery
Doppler flow).

● Progression of disease (eg, low threshold for delivery

when fetal growth falls from the 10th percentile to the
3rd percentile versus stable or slow but progressive
growth).

● Other available information (eg, low threshold for

delivery when late or variable decelerations, absent
variability, or a prolonged deceleration on a nonreactive
NST; BPP score 0 versus 4 or 6; absence of accelerations
on a positive CST; intrauterine growth restriction with
absent or reversed Doppler flow in umbilical artery).
Route of delivery — If delivery is indicated by the specific
clinical setting and abnormal test results, induction of labor is
not contraindicated. For example, after a positive CST, up to
40 percent of fetuses tolerate labor without fetal heart rate
changes necessitating intervention [60]. Similarly, a BPP score
of 0/10 does not exclude the possibility of a trial of labor if the
baseline fetal heart rate and variability are normal and
decelerations are absent. However, cesarean birth rather than
a trial of induction is usually indicated for a category III
tracing. (See "Intrapartum category I, II, and III fetal heart
rate tracings: Management", section on 'Category III
pattern'.)

In most cases, the decision to attempt a trial of labor is a

clinical judgment that must take into account the full clinical
scenario, as described above (see 'Chronic condition as cause
of abnormal result' above), as well as whether labor is likely
to be relatively short or long. A fetus with abnormal
antepartum testing should have continuous electronic fetal
monitoring during labor and may have a normal intrapartum
fetal heart rate tracing during a short labor, but may not be
able to tolerate a long labor. A long labor is more likely in
nulliparous patients, at earlier gestational ages, with
unfavorable cervical status, and in multiparous patients with
no prior vaginal births.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from
selected countries and regions around the world are provided
separately. (See "Society guideline links: Fetal surveillance".)

SUMMARY AND RECOMMENDATIONS

● Goal: The goal of antepartum fetal assessment is to

identify the fetus that will benefit from early
intervention, such as in utero resuscitation or delivery,
and thereby prevent fetal death or neurologic injury.
(See 'Introduction' above.)

● Physiologic basis: Antepartum testing is based on the

premise that the fetus responds to hypoxemia with a
detectable sequence of biophysical changes ( figure 1
). (See 'Physiologic basis' above.)

● Efficacy: Antepartum fetal assessment has had an

established role in obstetric practice since the 1970s,
although its ability to improve pregnancy outcome has
not been evaluated by large, well-designed randomized
trials. Efficacy is based on (1) observational studies that
reported lower rates of fetal death in pregnancies that
underwent fetal testing than among historic controls
with the same indication for testing but no fetal testing
and (2) the same or lower rates of fetal death in tested
pregnancies (primarily high risk) than in a contemporary
 untested general obstetric population (primarily low
risk). (See 'Efficacy' above.)

● Patient selection: Antepartum fetal testing is indicated

in pregnancies in which the risk of antepartum fetal
demise is increased. (See 'Indications for fetal
assessment' above.)

● Tests:

• Techniques for assessment of fetal well-being

(nonstress test, contraction stress test, biophysical
profile, modified biophysical profile) are described in
the table ( table 1). (See 'Fetal assessment
techniques' above.)

• The optimal choice of technique(s) for fetal

assessment has not been determined and depends
on multiple factors, including gestational age,
availability, desire for fetal biometry or follow-up of a
congenital anomaly, ability to monitor the fetal heart
rate, and cost. The best evidence supports umbilical
artery Doppler assessment for monitoring fetuses
with early-onset growth restriction due to
uteroplacental insufficiency, given its proven efficacy
in reducing perinatal death in this setting when used
with standard fetal testing (nonstress test,
biophysical profile score) and appropriate
intervention. (See 'Choice of test' above.)
● Timing and frequency:

• Antepartum fetal assessment is initiated at the

gestational age when an increased risk of fetal
demise is identified and delivery for perinatal benefit
would be considered if test results are abnormal. In
most pregnancies, this is at 32 weeks of gestation.
(See 'Timing' above.)

• Testing is typically performed weekly, but the

frequency is generally increased if there is a change
in pregnancy status or in clinical settings considered
to be very high risk. (See 'Follow-up of pregnancies
with normal test results' above.)

● Interpretation: An abnormal test result is generally

followed by additional testing with a different test, given
the high rate of false-positive results ( table 1). The
clinical setting also needs to be considered. If a
temporary maternal condition may account for the
abnormal test result, prompt treatment of the maternal
condition may also improve fetal oxygenation and lead
to a normal test result on subsequent testing. In chronic
conditions, clinical judgment guides management and
needs to consider case specific factors. (See
'Management of pregnancies with abnormal test results'
above.)
 Use of UpToDate is subject to the Terms of Use.

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Topic 457 Version 40.0
GRAPHICS

Sequence of fetal response to stress

Note that the depicted sequence is an approximation, and the actual

may vary depending upon the characteristics of the chronic deprivat
individual fetal ability to cope.

Reproduced with permission from Maulik D. Doppler velocimetry for fetal surveillance
perinatal outcome and fetal hypoxia. In: Maulik D (Ed), Doppler Ultrasound in Obstet
Gynecology, 1997; 349 New York, Springer Verlag. Copyright © 1997 Springer-Verlag.
Graphic 56906 Version 3.0
Interpretation and outcome of various
antenatal fetal testing methods

Results/ False
Name Components
scoring negativ

Contraction Continuous FHR Negative: No late 0.04%

stress test monitoring or significant
(oxytocin variable
At least 3
challenge decelerations
contractions of
test)
≥40s duration Positive: Late
within 10 minutes decelerations
following ≥50% of
contractions, even
if there are <3
contractions in 10
minutes

Equivocal -
suspicious:
Intermittent late
decelerations or
significant variable
decelerations

Equivocal -
hyperstimulatory:
 Decelerations with
contractions
occurring more
frequently than
every 2 minutes or
lasting >90s

Unsatisfactory: <3
contractions in 10
minutes or
uninterpretable
FHR tracing

Nonstress Continuous FHR Reactive: ≥2 0.2 to

test monitoring accelerations 0.65%
within 20 minutes
FHR
(may be extended
accelerations:
to 40 minutes)
≥32w: Reaching
15 bpm above Nonreactive: <2
baseline and accelerations in 40
lasting ≥15s minutes

<32w: Reaching
10 bpm above
baseline and
lasting ≥10s

Biophysical Presence or Each component is 0.07 to

profile absence of 5 assigned a score of 0.08%
components 2 points if all
within 30 criteria for the
minutes: component are
Reactive present and 0
NST points if all criteria
for the component
are not present;
 ≥1 episode maximum score is
of fetal 10/10
breathing Normal:
movements ≥8/10 or 8/8
lasting excluding
≥30s NST
≥3 discrete Equivocal:
body or 6/10
limb Abnormal:
movements ≤4/10
≥1 episode
of
extremity
extension
with return
to flexion
or opening
or closing
of a hand
Maximum
vertical AF
pocket >2
cm

Modified NST Normal: Reactive 0.08%

biophysical Maximum NST and maximum
profile vertical AF vertical AF pocket
pocket >2 cm >2 cm

Abnormal:
Nonreactive NST
and/or maximum
vertical AF pocket
≤2 cm
s: seconds; NST: nonstress test; AFI: amniotic fluid index; FHR:
fetal heart rate; w: weeks; bpm: beats per minute.

* Stillbirth rate was derived from large series and corrected for
lethal congenital anomalies and unpredictable causes of fetal
demise.

References:
1. Freeman RK, Anderson G, Dorchester W. A prospective multi-
institutional study of antepartum fetal heart rate monitoring. II.
Contraction stress test versus nonstress test for primary surveillance.
Am J Obstet Gynecol 1982; 143:778.
2. Lagrew DC Jr. The contraction stress test. Clin Obstet Gynecol 1995;
38:11.
3. Platt LD, Walla CA, Paul RH, et al. A prospective trial of the fetal
biophysical profile versus the nonstress test in the management of
high-risk pregnancies. Am J Obstet Gynecol 1985; 153:624.
4. Lavery JP. Nonstress fetal heart rate testing. Clin Obstet Gynecol 1982;
25:689.
5. Phelan JP, Cromartie AD, Smith CV. The nonstress test: the false negative
test. Am J Obstet Gynecol 1982; 142:293.
6. Rochard F, Schifrin BS, Goupil F, et al. Nonstressed fetal heart rate
monitoring in the antepartum period. Am J Obstet Gynecol 1976;
126:699.
7. Boehm FH, Salyer S, Shah DM, Vaughn WK. Improved outcome of twice
weekly nonstress testing. Obstet Gynecol 1986; 67:566.
8. Manning FA, Morrison I, Harman CR, et al. Fetal assessment based on
fetal biophysical profile scoring: experience in 19,221 referred high-risk
pregnancies. II. An analysis of false-negative fetal deaths. Am J Obstet
Gynecol 1987; 157:880.
9. Manning FA, Morrison I, Lange IR, et al. Fetal assessment based on
fetal biophysical profile scoring: experience in 12,620 referred high-risk
pregnancies. I. Perinatal mortality by frequency and etiology. Am J
Obstet Gynecol 1985; 151:343.
10. Dayal AK, Manning FA, Berck DJ, et al. Fetal death after normal
biophysical profile score: An eighteen-year experience. Am J Obstet
Gynecol 1999; 181:1231.
 11. Miller DA, Rabello YA, Paul RH. The modified biophysical profile:
antepartum testing in the 1990s. Am J Obstet Gynecol 1996; 174:812.
12. Clark SL, Sabey P, Jolley K. Nonstress testing with acoustic stimulation
and amniotic fluid volume assessment: 5973 tests without unexpected
fetal death. Am J Obstet Gynecol 1989; 160:694.
13. Nageotte MP, Towers CV, Asrat T, et al. The value of a negative
antepartum test: contraction stress test and modified biophysical
profile. Obstet Gynecol 1994; 84:231.
14. Vintzileos AM, Knuppel RA. Multiple parameter biophysical testing in
the prediction of fetal acid-base status. Clin Perinatol 1994; 21:823.

Graphic 50223 Version 6.0

Late decelerations

Late decelerations are characterized by a gradual decrease and retur

of the fetal heart rate associated with uterine contractions. The dece
delayed in timing, with the nadir of the deceleration occurring after t
contraction. The onset, nadir, and recovery usually occur after the on
termination of a contraction. In this example, variability is minimal.

Courtesy of Robert L Barbieri, MD.

Graphic 67464 Version 3.0

Late decelerations 2

Late decelerations are characterized by gradual decrease and return

deceleration is delayed in timing, with the nadir of the deceleration o
occur after the onset, peak, and termination of a contraction. In this
Graphic 96432 Version 1.0
Criteria for the biophysical profile test

Nonstress test: 2 points if reactive, defined as at least 2

episodes of FHR accelerations of at least 15 bpm and at least
15 seconds duration from onset to return associated with fetal
movement.

Fetal breathing movements: 2 points if one or more episodes

of rhythmic breathing movements of ≥30 seconds within a 30-
minute observation period.

Fetal tone: 2 points if one or more episodes of extension of a

fetal extremity or fetal spine with return to flexion.

Amniotic fluid volume: 2 points if a single deepest vertical

pocket ≥2 cm is present. The horizontal dimension should be
at least 1 cm.

Fetal movement: 2 points if three or more discrete body or

limb movements within 30 minutes of observation. An episode
of active continuous movement is counted as one movement.

Zero points are assigned for any criteria not met. A score of
10/10, 8/8 (nonstress test not done), or 8/10 (including +2
points for amniotic fluid) is a normal test result. A score of 6/10
(including +2 points for amniotic fluid) is an equivocal test
result, as a significant possibility of developing fetal asphyxia
cannot be excluded. A score of 6/10 or 8/10 with
oligohydramnios (0 points for amniotic fluid) is an abnormal
test, and further assessment and correlation with the clinical
setting are indicated. A score of 0 to 4/10 is abnormal; the risk
of fetal asphyxia within one week is high if there is no
intervention, and delivery is usually indicated. Refer to
UpToDate topic on the fetal biophysical profile for additional
information.
FHR: fetal heart rate; bpm: beats per minute.

Graphic 79813 Version 10.0

The relationship between fetal umbilical venous p
(±2 SD) by cordocentesis and the fetal biophysical
profile score

The correlation was linear, inverse, and very significant (R2 0.912; p
<0.01).

SD: standard deviation.

Data from: Manning FA. Dynamic ultrasound-based fetal assessment: The fetal
biophysical profile score. Clin Obstet Gynecol 1995; 38:26.

Graphic 65562 Version 5.0

Contributor Disclosures
Caroline Signore, MD, MPH No relevant financial relationship(s)
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relevant financial relationship(s) with ineligible companies to
disclose. Vincenzo Berghella, MD Consultant/Advisory Boards:
ProtocolNow [Clinical guidelines]. All of the relevant financial
relationships listed have been mitigated. Vanessa A Barss, MD,
FACOG No relevant financial relationship(s) with ineligible
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