The nurse finds that the nonstress test of a pregnant patient is nonreactive

FAQ098
Published: May 2019
Last reviewed: October 2021

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This information is designed as an educational aid for the public. It offers current information and opinions related to women's health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer.

What is a nonstress test?

A nonstress test is done during pregnancy. It measures the heart rate of the unborn baby (fetus) in response to its movements. In most cases, the heart rate of a healthy baby increases when the baby moves. The nonstress test is usually done in the last trimester (weeks 29 to 40) of pregnancy.

Why might I need a nonstress test?

Your healthcare provider may advise a nonstress test in any of these cases:

• Your pregnancy is high risk because you have diabetes, high blood pressure, a clotting or blood disorder, or thyroid, kidney, or heart disease

• Your baby is moving less than usual, has slow growth, has too much or too little amniotic fluid, or is overdue

• You had a stillborn baby in the past

• Your blood is Rh negative

• You are having 2 or more babies (multiple pregnancy)

What are the risks of a nonstress test?

There are no risks to either the mother or baby during a nonstress test.

How do I get ready for a nonstress test?

You don’t need to do any special preparation before the test.

What happens during a nonstress test?

The test may be done in a special prenatal testing area of the hospital. Or it may be done in your healthcare provider's office.

The procedure may vary, but a typical nonstress test may go like this:

• You'll lie in a comfortable position on an exam table. The provider puts gel on your belly. They put a belt around your belly. A device called a transducer is attached to the belt. It’s an external fetal heart rate monitor. The provider puts it over the baby's heartbeat. 

• The baby's heart rate is recorded on a monitor and on a paper printout.

• You'll be asked to push a button on the monitor each time you feel your baby move.

• This test usually lasts for 20 to 40 minutes.

In some cases, the test takes place during a baby’s sleep cycle, when there is little fetal movement. A special sound (acoustic) device may be used to awaken the baby. It is placed against the mother's belly and makes a noise like a buzzer. This isn't harmful to the baby. But it may help a sleepy baby become more active. Your baby may also awaken if you eat or drink.

What happens after a nonstress test?

The provider will remove the belt and transducer and wipe off the gel. You'll be told the results of the test. 

Test results of the nonstress test may be:

• Reactive (normal). The baby's heart rate goes up 2 or more times in the testing period.

• Nonreactive. There's no change in the baby's heart rate when the baby moves. This may mean you'll need other tests.

A nonreactive nonstress test doesn’t always mean your baby has a problem. The baby may simply be asleep or too immature. It’s common for preterm babies to have nonreactive nonstress tests, especially before 28 weeks. Your healthcare provider will tell you if you need other prenatal testing.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you're having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you're to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you didn't have the test or procedure

• Any alternative tests or procedures to think about

• When and how you'll get the results

• Who to call after the test or procedure if you have questions or problems

• How much you'll have to pay for the test or procedure

Continuing Education Activity

Fetal movements felt by pregnant women are a sign that the fetus is growing in size and strength. The mother is usually the first to feel these movements, which can later be perceived by others. Women are often taught by their health care provider to monitor or be aware of the movements of the fetus. Decreased fetal movement can be a warning sign of potential fetal impairment or risk, and may warrant further evaluation. This activity reviews the evaluation of fetal movement and discusses the role of the interprofessional team in educating patients on how to track fetal movement which can improve patient outcomes.

Objectives:

• Describe the significance of maternal self-monitoring of fetal movement.

• Identify methods for self-monitoring of fetal movements.

• Review the warning signs of decreased fetal movement.

• Summarize the importance of coordination of care amongst the interprofessional team to improve the education of pregnant patients regarding self-monitoring of fetal movements to improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Fetal movements felt by pregnant women are a sign that the fetus is growing in size and strength. The pregnant woman is usually the first to feel these movements, which can later be perceived by others. Women are often taught by their health care provider to monitor or be aware of the movements of the fetus. This can be a general awareness of fetal movements, or the women can be taught to count the number of kicks they feel in a set amount of time. Reduced fetal movement can be worrisome for both the mother and the attending healthcare provider. Decreased fetal movement can be a warning sign of potential fetal impairment or risk, and therefore, warrants further evaluation by the healthcare provider.[1][2]

Function

The first fetal movements which are felt by the mother are called quickening. One function of these movements is to alert the pregnant woman that she has a fetus growing in her uterus. Quickening often occurs between the 16th to the 22nd week of pregnancy. This is called a presumptive sign of pregnancy as the other movements of the woman's body can mimic early fetal movements such as flatus, peristalsis, and abdominal muscle contractions. A multiparous woman will usually first notice these fluttering movements of the fetus at an earlier gestation than a primiparous woman. A multiparous woman might feel movements as early as 16 weeks, whereas a primiparous woman may not feel anything until 20 to 22 weeks. At around 20 weeks of gestation, the trained healthcare provider can feel fetal movement externally through the abdomen. This is considered a positive sign of pregnancy.[3]

Most providers recommend that pregnant women monitor fetal movements, especially by the third trimester. This can be accomplished by simply instructing the woman to have a general awareness of the fetus and determine if the fetus is moving less than normal on any given day or about the same as other days. Alternatively, healthcare providers might recommend a more formal fetal movement count (FMC), sometimes called a kick count. Clinicians often recommend starting this surveillance around 28 weeks gestation and continuing throughout the remainder of the pregnancy. The "count to 10" method includes the instructions for the woman to count fetal movements at the same time each day. If the woman experiences less than ten movements in a 2 to 3-hour period, she is instructed to contact her healthcare provider. One study noted that having women count fetal movements can improve maternal-child bonding during pregnancy as the mother starts to get to know her unborn child.[3]

Issues of Concern

The issues of concern would include perceived or actual decreased fetal movement. Historically, cases of a compromised fetus or infant have usually been preceded by decreased fetal movement. Therefore, the assumption is that if a woman notices a decrease in fetal movement and has it evaluated, then a possible adverse event with the fetus might be avoided by the use of interventions. Many studies have attempted to verify a correlation between decreased fetal movement and placental functioning, abnormalities of the uterus, fetal growth restriction, twin to twin transfusion, tight nuchal cords, or to demonstrate that kick counts can prevent intrauterine fetal demise. Although this type of monitoring is often recommended, tracking does not always prevent complications. However, due to the low cost and potential benefit, it is recommended. Decreased fetal movement can indicate a need for more evaluation and has the potential to save lives. There is a worse outcome in pregnancies with reduced fetal movement, with one study demonstrating the highest incidence of poor outcomes in small for gestational age fetuses.[4] 

One potential side effect of routine monitoring of fetal movement could be an increase in prenatal visits, either outpatient or inpatient. However, most research has not found this type of increase to be true. Usually, the fetal movement count (FMC) is reassuring to pregnant women and prevents unnecessary visits. The healthcare provider should remember that some women are more vigilant at fetal movement monitoring than others. Therefore other methods of surveillance might be needed if the mother of the baby is less likely to comply with the fetal movement count. Numerous studies are trying to determine various new methods to track fetal movements while the pregnant woman is at home or work. Some methods could allow a more consistent and objective method of measuring frequency and possible strength of movements. The advance of three-dimensional ultrasound has allowed researchers to study normal movements of the fetus throughout pregnancy. This includes facial expressions and rapid eye movement (REM) during sleep. The arm movements of twins compared to singleton births are being studied and evaluated. Researchers find that fetal movement changes throughout pregnancy and can indicate normal or abnormal development. It is of note that studies have shown that obese women can feel fetal movement as well as women with normal body mass index (BMI). However, due to more common maternal and fetal complications, obese women will likely notice decreased fetal movement more often than their lower BMI counterparts.[5][6]

Clinical Significance

Any decrease in perceived fetal movement should be followed up by the healthcare provider with a non-stress test. This non-invasive test can evaluate fetal movement and fetal heart rate accelerations. A reactive non-stress test must have accelerations of the fetal heart of a specific size, duration, and frequency. This includes at least three fetal heart tone (FHT) accelerations, which are at least 15 beats per minute above the baseline and last at least 15 seconds, all within a 20-minute window. A non-reactive non-stress test, one that does not have the three accelerations, could indicate fetal sleep or fetal compromise, and further testing should be done. Usually, the non-stress test is first extended for a longer time to determine if the lack of accelerations was just due to fetal sleep. If the non-stress test continues to be non-reactive, then a BPP (biophysical profile) is often completed. This is an ultrasound of the fetus to assess fetal breathing movement, fetal movement of the body or limbs, fetal tone, and amniotic fluid volume. If this test does not reassure the healthcare provider, then the delivery of the fetus should be considered.[7] One study found that increased fetal movements may be used to predict adverse neonatal outcomes such as large for gestational age.[8] One study found that instructing women on fetal counting compared to not instructing them was not associated with a clear improvement of pregnancy outcomes.[9] Fetal movement count monitoring is a low-cost and low-tech method that has the potential to prevent worsening problems with unborn babies and merits the attention of providers and pregnant women.

Enhancing Healthcare Team Outcomes

The care of pregnant patients is best undertaken with an interprofessional team approach. Healthcare providers of women during pregnancy have the responsibility to screen and monitor the fetus to identify potential problems. This allows the practitioner to provide patient-centered, targeted treatment, and follow-up. Patients should be educated about the importance of self-monitoring of fetal movements. When decreased fetal movement is perceived, the team should work together to evaluate the fetus further. Many techniques for monitoring fetal movement are controversial and lack sufficient study to document their efficacy. In theory, detecting risk factors and complications during pregnancy could lower neonatal morbidity and mortality.[10] More study is needed to evaluate current methods and their effectiveness in both detection and long-term effects. Monitoring and then subsequent response with interventions have the potential to improve patient outcomes.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses participate in the evaluation of neonates after maternal reports of decreased fetal movement. Interventions may include applying an external fetal heart monitor, monitoring for contractions, assessing maternal vital signs, and assessing for rupture of maternal membranes. The nurse may also be involved in the care of the woman during further ultrasound assessment of the fetus (biophysical profile) and in communicating the assessments to the patient and her family as well as the primary care clinician.

The nurse in labor and delivery may need to assist in the induction of labor of the patient or cesarean delivery of a compromised fetus if the evaluation is not favorable or reassuring. Communication with all parties is a very important role of the nurse as well as providing empathy and assistance to the patient and family when the pregnancy/birth are not as planned or expected. This can help improve patient outcomes for both mother and baby.

Nursing, Allied Health, and Interprofessional Team Monitoring

Ongoing monitoring by nurses employed in medical offices that care for pregnant women should include education of women about fetal movements and prompt response to reports of decreased fetal movements. All office personnel that are in contact with a pregnant woman either during phone triage or prenatal assessments need to understand the importance of fetal movement monitoring and the need to listen to patient reports. Communication of concerns to the primary care clinician is critical in obtaining further evaluation, which has the potential of improving patient outcomes, especially with prompt assessment and intervention.

Review Questions

Figure

Development of the Fetal Membranes and Placenta, Fetus of about eight weeks; enclosed in the amnion, Umbilical cord, Chorionic, Placenta. Contributed by Gray's Anatomy Plates

Figure

Nonstress test showing fetal heart rate tracing, fetal movement and contraction tracing. Contributed by Otto Umana, MD

References

Das R, Jana N, Arora N, Sengupta S. Ultrasound assessment of fetal hearing response to vibroacoustic stimulation. J Matern Fetal Neonatal Med. 2020 Jul;33(14):2326-2332. [PubMed: 30618302]

Kapaya H, Almeida J, Karouni F, Anumba D. Management of reduced fetal movement: A comparative analysis of two audits at a tertiary care clinical service. Eur J Obstet Gynecol Reprod Biol. 2020 May;248:128-132. [PubMed: 32203823]

Flenady V, Ellwood D, Bradford B, Coory M, Middleton P, Gardener G, Radestad I, Homer C, Davies-Tuck M, Forster D, Gordon A, Groom K, Crowther C, Walker S, Foord C, Warland J, Murphy M, Said J, Boyle F, O'Donoghue K, Cronin R, Sexton J, Weller M, McCowan L. Beyond the headlines: Fetal movement awareness is an important stillbirth prevention strategy. Women Birth. 2019 Feb;32(1):1-2. [PubMed: 30563769]

Sterpu I, Pilo C, Koistinen IS, Lindqvist PG, Gemzell-Danielsson K, Itzel EW. Risk factors for poor neonatal outcome in pregnancies with decreased fetal movements. Acta Obstet Gynecol Scand. 2020 Aug;99(8):1014-1021. [PubMed: 32072616]

Daly LM, Boyle FM, Gibbons K, Le H, Roberts J, Flenady V. Mobile applications providing guidance about decreased fetal movement: Review and content analysis. Women Birth. 2019 Jun;32(3):e289-e296. [PubMed: 30139669]

Bradford B, Cronin R, McKinlay C, Thompson J, McCowan L. Maternally perceived fetal movement patterns: The influence of body mass index. Early Hum Dev. 2019 Nov 15;140:104922. [PubMed: 31739267]

Heazell AEP, Budd J, Li M, Cronin R, Bradford B, McCowan LME, Mitchell EA, Stacey T, Martin B, Roberts D, Thompson JMD. Alterations in maternally perceived fetal movement and their association with late stillbirth: findings from the Midland and North of England stillbirth case-control study. BMJ Open. 2018 Jul 06;8(7):e020031. [PMC free article: PMC6042603] [PubMed: 29982198]

Huang C, Han W, Fan Y. Correlation study between increased fetal movement during the third trimester and neonatal outcome. BMC Pregnancy Childbirth. 2019 Dec 04;19(1):467. [PMC free article: PMC6894290] [PubMed: 31801506]

Bellussi F, Po' G, Livi A, Saccone G, De Vivo V, Oliver EA, Berghella V. Fetal Movement Counting and Perinatal Mortality: A Systematic Review and Meta-analysis. Obstet Gynecol. 2020 Feb;135(2):453-462. [PubMed: 31923063]

Haws RA, Yakoob MY, Soomro T, Menezes EV, Darmstadt GL, Bhutta ZA. Reducing stillbirths: screening and monitoring during pregnancy and labour. BMC Pregnancy Childbirth. 2009 May 07;9 Suppl 1(Suppl 1):S5. [PMC free article: PMC2679411] [PubMed: 19426468]

What is an indicator for performing a contraction stress test quizlet?

Which factor during a nonstress test of a pregnant patient indicates it is non reactive?

Which test does the nurse recommend for the patient to help assess fetal genetic abnormalities?

Which test would the nurse recommend for an obese pregnant patient to assess the risk for intrauterine growth restriction?