MS NO: ONG-21-692

INTERIM UPDATE

ACOG PRACTICE BULLETIN

Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 229 (Replaces Practice Bulletin Number 145, July 2014)

Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins—
Obstetrics with the assistance of Dwight J. Rouse, MD.

INTERIM UPDATE: The content in this Practice Bulletin has been updated as highlighted (or removed as necessary) to reflect a
limited, focused change to align with American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No.
828, Indications for Outpatient Antenatal Fetal Surveillance, and provide updated information regarding fetal kick counts.

Antepartum Fetal Surveillance

The goal of antepartum fetal surveillance is to reduce the risk of stillbirth. Antepartum fetal surveillance techniques
based on assessment of fetal heart rate (FHR) patterns have been in clinical use for almost four decades and are used
along with real-time ultrasonography and umbilical artery Doppler velocimetry to evaluate fetal well-being. Ante-
partum fetal surveillance techniques are routinely used to assess the risk of fetal death in pregnancies complicated by
preexisting maternal conditions (eg, diabetes mellitus) as well as those in which complications have developed (eg,
fetal growth restriction). The purpose of this document is to provide a review of the current indications for and
techniques of antepartum fetal surveillance and outline management guidelines for antepartum fetal surveillance that
are consistent with the best scientific evidence.

formed in pregnancies in which the fetus ultimately

Background proved to be healthy, and ranges vary by gestational age
Physiology of Fetal Heart Response and (6). Although the degree of hypoxemia and acidemia at
Fetal Behavioral State Alteration which various indices of fetal well-being become abnor-
In animals and humans, FHR pattern, level of activity, and mal is not known with precision, it can be estimated
degree of muscular tone are sensitive to hypoxemia and based on data from published studies. In one investiga-
acidemia (1–4). Redistribution of fetal blood flow in response tion, the fetal surveillance was performed immediately
to hypoxemia may result in diminished renal perfusion and before cordocentesis. Fetuses with an abnormal test result
oligohydramnios (5). Surveillance techniques such as cardio- were found to have a mean (6standard deviation) umbil-
tocography, real-time ultrasonography, and maternal percep- ical vein blood pH of 7.28 (60.11). Cessation of fetal
tion of fetal movement can identify the fetus that may be movement appears to occur at lower pH levels; fetuses
undergoing some degree of uteroplacental compromise. Iden- with abnormal movement were found to have a mean
tification of suspected fetal compromise provides the opportu- umbilical vein blood pH of 7.16 (60.08) (7). Thus, a
nity to intervene before progressive metabolic acidosis results reasonable correlation between certain measurable
in fetal death. However, acute, catastrophic changes in fetal aspects of FHR and behavior and evidence of fetal met-
status, such as those that can occur with placental abruption or abolic compromise can be inferred.
an umbilical cord accident, are generally not predicted by tests Although abnormal fetal surveillance results may be
of fetal well-being. Therefore, fetal deaths from such events associated with acidemia or hypoxemia, they reflect
are less amenable to prevention. neither the severity nor duration of acid–base distur-
In humans, the range of normal umbilical blood gas bance. The degree and duration of acidemia is weakly
parameters has been established by cordocentesis per- correlated with adverse short-term and long-term

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neonatal outcomes. Furthermore, factors other than acid– (618.1) minutes. In another approach, women were in-
base and oxygenation status (eg, prematurity, fetal sleep– structed to count fetal movements for 1 hour three times
wake cycle, maternal medication exposure, maternal per week (14). The count was considered reassuring if it
smoking, and fetal central nervous system abnormalities) equaled or exceeded the woman’s previously established
can adversely affect biophysical parameters (8, 9). baseline count. Thus, regardless of the fetal movement
approach used, in the absence of a reassuring count, fur-
Antepartum Fetal ther fetal assessment is recommended.
Surveillance Techniques
Several antepartum fetal surveillance techniques (tests) Contraction Stress Test
are in clinical use. These include maternal perception of The CST is based on the response of the FHR to uterine
fetal movement, contraction stress test (CST), nonstress contractions. It relies on the premise that fetal oxygenation
test (NST), biophysical profile (BPP), modified BPP, and will be transiently worsened by uterine contractions. In the
umbilical artery Doppler velocimetry. suboptimally oxygenated fetus, the resultant intermittent
worsening in oxygenation will, in turn, lead to the FHR
Maternal–Fetal Movement Assessment pattern of late decelerations. Uterine contractions also may
produce a pattern of variable decelerations caused by fetal
A decrease in the maternal perception of fetal movement
may precede fetal death, in some cases by several days (10). umbilical cord compression, which in some cases is
This observation provides the rationale for fetal movement associated with oligohydramnios.
assessment by the mother (“kick counts”) as a means of With the patient in the lateral recumbent position,
antepartum fetal surveillance. However, a meta-analysis that the FHR and uterine contractions are simultaneously
included five randomized controlled trials (RCT) and more recorded with an external fetal monitor. An adequate
than 450,000 fetuses found no difference in perinatal out- uterine contraction pattern is present when at least three
come between the group that underwent fetal kick counts contractions persist for at least 40 seconds each in a 10-
and the group that did not (11). The incidence of perinatal minute period. Uterine stimulation is not necessary if the
death was 0.54% (1,252/229,943) in the fetal kick counts patient is having spontaneous uterine contractions of
group and 0.59% (944/159,755) in the control group (rela- adequate frequency. If fewer than three contractions of
tive risk [RR], 0.92; 95% CI 0.85–1.00). There were no 40 seconds’ duration occur in 10 minutes, contractions
statistical differences between other perinatal adverse out- are induced with either nipple stimulation or intravenous
comes; however, there were weak but statistically significant oxytocin. A spontaneous CST can be considered if the
increases in preterm delivery (7.6% versus 7.1%; RR 1.07, adequate number and strength of contractions are noted
95% CI 1.05–1.10), induction of labor (36.6% versus in the 10-minute time frame.
31.6%; RR 1.15, 95% CI 1.09–1.22), and cesarean delivery Nipple stimulation usually is successful in inducing
(28.2% versus 25.3%; RR 1.11, 95% CI 1.10–1.12) in the an adequate contraction pattern and allows completion of
fetal kick counts group. One RCT of more than 400,000 testing in approximately one half of the time required
fetuses (the Follow-up Investigation Rhythm Management than when intravenous oxytocin is used (15). The CST is
[AFFIRM] trial) contributed 82% of the data and informa- interpreted according to the presence or absence of late
tion regarding the characteristics of included women, and the FHR decelerations (16). A late deceleration is defined as
techniques used for surveillance and follow up were limited. a visually apparent and usually symmetrical gradual
The authors of the meta-analysis concluded that more trials decrease and return to baseline FHR in association with
of a similar size are necessary to determine whether there is uterine contractions, with the time from onset of the
benefit to this approach, and warn that there may be possible deceleration to its FHR nadir as 30 seconds or longer.
harm related to iatrogenic delivery (12). The deceleration is delayed in timing, with the nadir of
Although several counting protocols have been used, the deceleration occurring after the peak of the contrac-
neither the optimal number of movements nor the ideal tion. In most cases, the onset, nadir, and recovery of the
duration for counting movements has been defined. Thus, deceleration occur after the beginning, peak, and ending
numerous protocols have been reported and appear to be of the contraction, respectively (17). The results of the
acceptable. In one approach, the woman was instructed to CST are categorized as follows:
lie on her side and count distinct fetal movements (13). c Negative: no late or significant variable
Perception of 10 distinct movements in a period of up to 2 decelerations
hours was considered reassuring. The count was discon- c Positive: late decelerations after 50% or more of
tinued once 10 movements were perceived. The mean time contractions (even if the contraction frequency is
interval to perceive 10 movements was 20.9 fewer than three in 10 minutes)

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 c Equivocal–suspicious: intermittent late decelerations accelerations over a 40-minute period. The NST of the
or significant variable decelerations normal preterm fetus is frequently nonreactive: from 24
c Equivocal: FHR decelerations that occur in the weeks to 28 weeks of gestation, up to 50% of NSTs may
presence of contractions more frequent than every not be reactive (26), and from 28 weeks to 32 weeks of
2 minutes or lasting longer than 90 seconds gestation, 15% of NSTs are not reactive (17, 27, 28).
c Unsatisfactory: fewer than three contractions in Thus, the predictive value of NSTs based on a lower
10 minutes or an uninterpretable tracing threshold for accelerations (at least 10 beats per minute
The CST is a safe and effective method of investi- above the baseline and at least 10 seconds from baseline
gating FHR nonreactivity in preterm gestations (18). Rel- to baseline) has been evaluated in pregnancies at less
ative contraindications to the CST generally include than 32 weeks of gestation and has been found to suffi-
conditions that also are contraindications to labor or vag- ciently predict fetal well-being (29, 30). Variable decel-
inal delivery (19). erations may be observed in up to 50% of NSTs (31).
Variable decelerations that are nonrepetitive and brief
(less than 30 seconds) are not associated with fetal com-
Nonstress Test promise or the need for obstetric intervention (31).
The NST is based on the premise that the heart rate of a Repetitive variable decelerations (at least three in
fetus that is not acidotic or neurologically depressed will 20 minutes), even if mild, have been associated with an
temporarily accelerate with fetal movement. Heart rate increased risk of cesarean delivery for a nonreassuring
reactivity is thought to be a good indicator of normal fetal intrapartum FHR pattern (32, 33). Fetal heart rate decel-
autonomic function. Loss of reactivity is most commonly erations during an NST that persist for 1 minute or longer
associated with a fetal sleep cycle but may result from are associated with a markedly increased risk of both
any cause of central nervous system depression, includ- cesarean delivery for a nonreassuring FHR pattern and
ing fetal acidemia. fetal demise (34–36). In this setting, the decision to
The patient may be positioned in either the semi- deliver should be made with consideration of whether
Fowler position (sitting with the head elevated 30 the benefits outweigh the potential risks of expectant
degrees) or lateral recumbent position. In one small management.
randomized study, it took less time to obtain a reactive
NST when patients were placed in the semi-Fowler Biophysical Profile
position (20). The FHR is monitored with an external The BPP consists of an NST combined with four
transducer. The tracing is observed for FHR accelerations observations made by real-time ultrasonography (37).
that peak (but do not necessarily remain) at least 15 beats Thus, the BPP comprises five components:
per minute above the baseline and last 15 seconds from 1. Nonstress test––may be omitted without compro-
baseline to baseline. The NST should be conducted for at mising test validity if the results of all four ultrasound
least 20 minutes, but it may be necessary to monitor the components of the BPP are normal (37)
tracing for 40 minutes or longer to take into account the 2. Fetal breathing movements––one or more episodes of
variations of the fetal sleep–wake cycle. Vibroacoustic rhythmic fetal breathing movements of 30 seconds or
stimulation may elicit FHR accelerations that are valid in more within 30 minutes
the prediction of fetal well-being. Such stimulation offers
3. Fetal movement––three or more discrete body or
the advantage of safely reducing the frequency of non-
limb movements within 30 minutes
reactive NSTs by 40% and the overall testing time by
almost 7 minutes without compromising detection of the 4. Fetal tone––one or more episodes of extension of a
acidotic fetus (21–24). To perform vibroacoustic stimu- fetal extremity with return to flexion, or opening or
lation, the device is positioned on the maternal abdomen closing of a hand
and a stimulus is applied for 1–2 seconds. If vibroacous- 5. Determination of the amniotic fluid volume––a sin-
tic stimulation fails to elicit a response, it may be gle deepest vertical pocket greater than 2 cm is
repeated up to three times for progressively longer dura- considered evidence of adequate amniotic fluid (38–
tions of up to 3 seconds. 40)
Nonstress test results are categorized as reactive or Each of the five components is assigned a score of
nonreactive. Various definitions of reactivity have been either 2 (present, as previously defined) or 0 (not
used. The most common definition of a reactive, or present). A composite score of 8 or 10 is normal, a score
normal, NST is if there are two or more FHR acceler- of 6 is considered equivocal, and a score of 4 or less is
ations (as previously defined) within a 20-minute period abnormal. Regardless of the composite score, oligohy-
(25). A nonreactive NST is one that lacks sufficient FHR dramnios (defined as an amniotic fluid volume of 2 cm or

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less in the single deepest vertical pocket) should prompt monly measured flow indices, based on the characteris-
further evaluation (39, 41). tics of peak systolic velocity and frequency shift (S), end-
Although oligohydramnios has been commonly diastolic frequency shift (D), and mean peak frequency
defined as a single deepest vertical pocket of amniotic shift over the cardiac cycle (A), include the following:
fluid of 2 cm or less (not containing umbilical cord or c Systolic to diastolic ratio (S/D)
fetal extremities) and an amniotic fluid index of 5 cm or c Resistance index (S-D/S)
less, available data from randomized control trials
c Pulsatility index (S-D/A)
(RCTs) support the use of the deepest vertical pocket
of amniotic fluid volume of 2 cm or less to diagnose Randomized studies on the utility of umbilical artery
oligohydramnios (38–40, 42, 43). Doppler velocimetry generally have defined abnormal
flow as either absent or reversed end-diastolic flow (50–
58). To maximize interpretability, multiple waveforms
Modified Biophysical Profile should be assessed, and wall-filter settings should be
In the late second-trimester or third-trimester fetus, set low enough (typically less than 150 Hz) to avoid
amniotic fluid volume reflects fetal urine production. masking diastolic flow. Currently, there is no evidence
Placental dysfunction may result in diminished fetal renal that umbilical artery Doppler velocimetry provides infor-
perfusion, leading to oligohydramnios (5). Amniotic mation about fetal well-being in the fetus with normal
fluid volume assessment can, therefore, be used to eval- growth.
uate uteroplacental function. This observation fostered
the development of what has come to be termed the
“modified BPP” as a primary mode of antepartum fetal Clinical Considerations
surveillance. The modified BPP combines the NST, as a
short-term indicator of fetal acid–base status, with an
and Recommendations
amniotic fluid volume assessment, as an indicator of
long-term placental function (21). Thus, the results of
< How reassuring is a normal antepartum fetal
the modified BPP are considered normal if the NST is
surveillance result?
reactive and the amniotic fluid volume is greater than 2 In most cases, a normal antepartum fetal test result is
cm in the deepest vertical pocket and are considered highly reassuring, as reflected in the low false-negative
abnormal if either the NST is nonreactive or amniotic rate of antepartum fetal surveillance, defined as the
fluid volume in the deepest vertical pocket is 2 cm or incidence of stillbirth occurring within 1 week of a
less (ie, oligohydramnios is present). normal test result. The stillbirth rate, corrected for lethal
congenital anomalies and unpredictable causes of fetal
Umbilical Artery Doppler Velocimetry demise, was 1.9 per 1,000 in the largest series of NSTs
Doppler ultrasonography is a noninvasive technique used (5,861) versus 0.3 per 1,000 in 12,656 CSTs, 0.8 per
to assess the hemodynamic components of vascular 1,000 in 44,828 BPPs, and 0.8 per 1,000 in 54,617
resistance in pregnancies complicated by fetal growth modified BPPs (16, 22, 59). Based on these data, the
restriction. Umbilical artery Doppler velocimetry has negative predictive value is 99.8% for the NST and is
been adapted for use as a technique of fetal surveillance greater than 99.9% for the CST, BPP, and modified BPP.
for the growth-restricted fetus, based on the observation Although similar data from a large series are not avail-
that flow velocity waveforms in the umbilical artery of able for umbilical artery Doppler velocimetry, in one
normally growing fetuses differ from those of growth- randomized clinical trial among women with pregnancies
restricted fetuses. Specifically, the umbilical flow veloc- complicated by fetal growth restriction, no stillbirths
ity waveform of normally growing fetuses is character- occurred in 214 pregnancies in which umbilical artery
ized by high-velocity diastolic flow, whereas in growth- Doppler velocimetry was the primary means of antepar-
restricted fetuses, there is decreased umbilical artery tum fetal surveillance (negative predictive value of
diastolic flow (44–46). In some cases of severe fetal 100%) (51). The low false-negative rate of these tests
growth restriction, diastolic flow is absent or even depends on an appropriate response to any significant
reversed. The perinatal mortality rate in such pregnancies deterioration in the maternal clinical status, including
is significantly increased (47). Abnormal flow velocity retesting of the fetal condition. As previously mentioned,
waveforms have been correlated histopathologically with these tests generally do not predict stillbirths related to
small-artery obliteration in placental tertiary villi and acute changes in maternal–fetal status, such as those that
functionally with fetal hypoxemia and acidemia as well occur with abruptio placentae or an umbilical cord
as with perinatal morbidity and mortality (47–49). Com- accident. Moreover, recent normal antepartum fetal test

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results should not preclude the use of intrapartum fetal pregnant individual’s goals for pregnancy care are critical
monitoring. in decision making (63). Choosing the appropriate point
in gestation to begin antepartum fetal testing depends on
< Is there evidence that antepartum fetal surveil- several considerations, including the prognosis for neo-
lance decreases the risk of fetal demise or oth- natal survival, the risk of fetal death, the severity of
erwise improves perinatal outcomes? maternal disease, and the potential for iatrogenic prema-
turity complications resulting from false-positive test
Evidence for the value of antepartum fetal surveillance is
results. The importance of the last consideration is illus-
circumstantial and rests principally on the observation
trated by the experience of one large center, in which
that antepartum fetal surveillance has been consistently
60% of infants delivered because of an abnormal ante-
associated with rates of fetal death that are substantially
partum test result had no evidence of short-term or long-
lower than the rates of fetal death in both untested (and
term fetal compromise (22). Both theoretic models and
presumably lower-risk) contemporaneous pregnancies
large clinical studies suggest that initiating antepartum
from the same institutions and pregnancies with similar
fetal testing at 32 0/7 weeks of gestation or later is appro-
complicating factors that were managed before the
priate for most at-risk patients (63–66). However, in
advent of currently used techniques of antepartum fetal
pregnancies with multiple or particularly worrisome
surveillance (historic controls) (21, 22, 60). There is a
high-risk conditions (eg, chronic hypertension with sus-
lack of high-quality evidence from RCTs that antepartum
pected fetal growth restriction), testing might begin at a
fetal surveillance decreases the risk of fetal death (61,
gestational age when delivery would be considered for
62). A definitive evaluation of antepartum fetal surveil-
perinatal benefit (67–72).
lance in RCTs (which would require the random alloca-
tion of pregnant patients to prenatal care that included < What is the recommended frequency of
antepartum fetal surveillance versus prenatal care that did testing?
not include antepartum fetal surveillance) is unlikely to
be conducted in a setting that can be generalized to cur- There are no large clinical trials to guide the frequency
rent U.S. obstetric practice. In spite of its unproven value, of testing, and thus, the optimal frequency remains
antepartum fetal surveillance is widely integrated into unknown; it depends on several factors and should be
clinical practice in the developed world. individualized and based on clinical judgment. If the
indication for testing is not persistent (eg, a single
< What are the indications for antepartum fetal episode of decreased fetal movement followed by
surveillance? reassuring testing in an otherwise uncomplicated preg-
nancy), testing need not be repeated. When the clinical
Because antepartum fetal surveillance results have not
condition that prompted fetal testing persists, the testing
been definitively demonstrated to improve perinatal
should be repeated periodically to monitor for continued
outcome, all indications for antepartum testing must be
fetal well-being until delivery. If the maternal medical
considered somewhat relative. In general, antepartum
condition is stable and test results are reassuring, tests of
fetal surveillance has been used in pregnancies in which
fetal well-being (NST, BPP, modified BPP, or CST) are
the risk of antepartum fetal demise is increased. See
typically repeated at weekly intervals (19, 22); however,
ACOG Committee Opinion No. 828, Indications for Out-
in the presence of certain high-risk conditions, some
patient Antenatal Fetal Surveillance, Table 1 for exam-
investigators have performed more frequent testing,
ples of indications for antepartum fetal surveillance.
although the optimal regimen has not been established.
< When during gestation should antepartum See ACOG Committee Opinion No. 828, Indications
fetal surveillance be initiated? for Outpatient Antenatal Fetal Surveillance.
In pregnancies complicated by fetal growth restriction,
As with all testing and interventions, shared decision the optimal interval for fetal growth assessment and the
making between the pregnant individual and the clinician optimal surveillance regimen have not been established.
is critically important when considering or offering ante- Most growth-restricted fetuses can be adequately evaluated
natal fetal surveillance for individuals with pregnancies with once or twice weekly antenatal surveillance incorpo-
at high risk for stillbirth or with multiple comorbidities rating weekly BPP and Doppler assessments and serial
that increase the risk of stillbirth. This can be particularly ultrasonography for growth every 3–4 weeks; ultrasono-
important in situations that involve fetal structural or graphic assessment of growth should not be performed
genetic anomalies, or when initiating antenatal fetal sur- more frequently than every 2 weeks because the inherent
veillance around the threshold of viability, where the error associated with ultrasonographic measurements can

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preclude an accurate assessment of interval growth (63, 73, attempted by induction of labor, with continuous intra-
74). Any significant change in maternal or fetal status partum monitoring of the FHR and uterine contractions.
requires further reevaluation (see ACOG Practice Bulletin
No. 227, Fetal Growth Restriction). < How should a finding of oligohydramnios
affect the decision for delivery?
< What is the recommended management of an
abnormal antepartum fetal test result? Amniotic fluid volume is estimated using ultrasonography.
Commonly used definitions of oligohydramnios include a
An abnormal antepartum fetal test result should always single deepest vertical pocket of amniotic fluid of 2 cm or
be considered in the context of the overall clinical less (not containing umbilical cord or fetal extremities)
picture. Certain acute maternal conditions (eg, diabetic and an amniotic fluid index of 5 cm or less (38, 39, 42).
ketoacidosis or pneumonia with hypoxemia) can result in However, the use of a percentile of amniotic fluid should
abnormal test results, which generally will normalize as not be used in management decisions. The available data
the maternal condition improves. In these circumstances, from RCTs indicate that the use of the deepest vertical
correcting the maternal condition and retesting the fetus pocket measurement, as opposed to the amniotic fluid
may be appropriate. index, to diagnose oligohydramnios is associated with a
In cases in which an abnormal test result is not reduction in unnecessary interventions without an increase
associated with any clinical evidence of acute and in adverse perinatal outcomes (40, 43).
potentially reversible worsening in the maternal status, Determining when to intervene for oligohydram-
a stepwise approach to the investigation of the fetal nios depends on several factors, including gestational
condition should be undertaken. Because antepartum age, maternal condition, and fetal clinical condition as
fetal surveillance tests have high false-positive rates determined by other indices of fetal well-being. Because
and low positive predictive values, abnormal test results rupture of the fetal membranes can cause diminished
are usually followed by another test or delivery based on amniotic fluid volume, an evaluation for membrane
consideration of test results, maternal and fetal condition, rupture in the setting of oligohydramnios may be
and gestational age (25, 75). Such an approach takes appropriate; correspondingly, if membrane rupture is
advantage of the high negative predictive value generally documented, a low amniotic fluid measurement can no
longer be considered valid for prediction of diminished
exhibited by all commonly used antepartum tests
placental function. In the setting of otherwise uncom-
and minimizes the potential for unnecessary delivery
plicated isolated and persistent oligohydramnios (deep-
based on a single false-positive (ie, false-abnormal) test
est vertical pocket measurement less than 2 cm),
result. Therefore, the response to an abnormal test result
delivery at 36 0/7–37 6/7 weeks of gestation or at diag-
should be tailored to the clinical situation. nosis if diagnosed later is recommended (76, 77). In
Maternal reports of decreased fetal movement should be pregnancies at less than 36 0/7 weeks of gestation with
evaluated by an NST, CST, BPP, or modified BPP. Abnormal intact membranes and oligohydramnios, the decision to
results from an NST or from a modified BPP generally should proceed with expectant management or delivery should
be followed by additional testing with either a CST or a BPP. be individualized based on gestational age and the
A BPP score of 6 out of 10 is considered equivocal and maternal and fetal condition. If delivery is not under-
should prompt further evaluation or delivery based on taken, follow-up amniotic fluid volume measurements,
gestational age. In a fetus at or beyond 37 0/7 weeks of NSTs, and fetal growth assessments are indicated. If the
gestation, this score generally should prompt further evaluation oligohydramnios results from fetal membrane rupture,
and consideration of delivery, whereas in the fetus at less than follow-up amniotic fluid volume assessment often may
37 0/7 weeks of gestation, it should result in a repeat BPP in be safely omitted.
24 hours (39). A BPP score of 4 usually indicates that delivery
is warranted, although in pregnancies at less than 32 0/7 weeks < What is the role of umbilical artery and other
of gestation, management should be individualized, and
Doppler velocimetry studies?
extended monitoring may be appropriate. In most circum- In growth-restricted fetuses, umbilical artery Doppler
stances, a BPP score of less than 4 should result in delivery. velocimetry used in conjunction with standard fetal sur-
If delivery is not planned (eg, given early gestational age), then veillance, such as NSTs, BPPs, or both, is associated with
antenatal surveillance should not be performed because the improved outcomes (73, 78). Umbilical artery Doppler ve-
results will not inform management. locimetry has not been shown to be predictive of outcomes
In the absence of obstetric contraindications, deliv- in fetuses without growth restriction. Investigation of other
ery of the fetus with an abnormal test result often may be fetal blood vessels with umbilical artery Doppler

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velocimetry, including assessments of the middle cerebral Recommendations based primarily on consensus and
artery and the precordial venous system, has been explored expert opinion (Level C).
in the setting of fetal growth restriction. However, these
flow measurements have not been shown to improve peri- < Initiating antepartum fetal testing at 32 0/7 weeks of
natal outcome, and the role of these measures in clinical gestation or later is appropriate for most at-risk patients.
practice remains uncertain (see ACOG Practice Bulletin No. However, in pregnancies with multiple or particularly
worrisome high-risk conditions (eg, chronic hyperten-
227, Fetal Growth Restriction) ( 63, 73, 79–85).
sion with suspected fetal growth restriction), testing
< Should all women perform daily fetal move- might begin at a gestational age when delivery would
ment assessment? be considered for perinatal benefit.
< When the clinical condition that prompted fetal
Multiple studies have demonstrated that women who report testing persists, the testing should be repeated
decreased fetal movement are at an increased risk of periodically to monitor for continued fetal well-
adverse perinatal outcomes (86). Although fetal kick count- being until delivery. If the maternal medical con-
ing is an inexpensive test of fetal well-being, the effective- dition is stable and test results are reassuring, tests
ness of kick counting in the prevention of stillbirth is of fetal well-being (NST, BPP, modified BPP, or
uncertain (87, 88). Consistent evidence that a formal pro- CST) are typically repeated at weekly intervals;
gram of fetal movement assessment in low-risk women will however, in the presence of certain high-risk con-
result in a reduction in fetal deaths is lacking (89, 90). ditions, some investigators have performed more
Moreover, whether fetal movement assessment adds benefit frequent testing, although the optimal regimen has
to an established program of regular fetal surveillance has not been established.
not been evaluated. Formal fetal movement assessment may < In the absence of obstetric contraindications, delivery of
increase, by a small degree, the number of antepartum visits the fetus with an abnormal test result often may be at-
and fetal evaluations and may be associated with an tempted by induction of labor, with continuous intra-
increased risk of iatrogenic preterm birth, induction of labor, partum monitoring of the FHR and uterine contractions.
and cesarean birth (11). Although not all women need to
< In the setting of otherwise uncomplicated isolated and
perform a daily fetal movement assessment, if a woman persistent oligohydramnios (deepest vertical pocket
notices a decrease in fetal activity, she should be encour- measurement less than 2 cm), delivery at 36 0/7–37
aged to contact her health care provider, and further assess- 6/7 weeks of gestation or at diagnosis if diagnosed
ment should be performed. later is recommended. In pregnancies at less than
36 0/7 weeks of gestation with intact membranes
and oligohydramnios, the decision to proceed with
Summary expectant management or delivery should be indi-
of Recommendations vidualized based on gestational age and the maternal
and fetal condition.
Recommendations based on good and consistent scien-
tific evidence (Level A).

< The use of the deepest vertical pocket measurement, References

as opposed to the amniotic fluid index, to diagnose
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