Vibroacoustic Stimulation Fetal
Vibroacoustic stimulation fetal produces changes in fetal heart rate and movement. This may make nonstress tests more effective, but the underlying mechanisms remain unknown.
This Cochrane Review was updated in September 2013. This update includes 12 new trials involving 6822 women. The results of this update showed that acoustic stimulation improved the effectiveness of antepartum non-stress testing.
Background
Vibroacoustic stimulation of the human fetus profoundly alters fetal behaviour and uterine rhythm. There are reports of severe fetal distress following this type of stimulation, resulting in tightening of the nuchal cord, bradycardia and caesarean section (Sherer 1988; Sherer 1991). In addition, there is concern that exposure of the fetus to this kind of sound can induce fetal’startle response’, which is a physiologic reflex to protect the fetus from intrauterine stressors. Despite these concerns, a number of authors have reported success using fetal vibroacoustic stimulation in conjunction with antepartum non-stress cardiotocography tests or other tests of fetal wellbeing and that this improves their predictive reliability.
A fetal startle test has been developed which uses a hand-held probe to apply a low frequency, high intensity vibroacoustic stimulus to the maternal abdomen. It is intended to mimic a fetal kick or a contraction. In one trial, the test was compared with the non-stress cardiotocography test and in the other with a standard fetal movement monitoring device. In both trials, the test was found to be superior to the standard fetal movement monitoring device in detecting reactive uterine tracings and predicting good fetal outcome at delivery.
In a further study of a group of patients with high-risk pregnancies, the sensitivity of the test was compared to a standard fetal heart rate trace and the fetal Apgar score at birth. The sensitivity of the test was 81% and specificity 89%, both of which were significantly improved over that of the fetal heart rate trace alone. Maternal perception of fetal movements in response to the vibration was also tested and found to have a good diagnostic performance (81% sensitivity and 90% specificity).
However, there is a lack of randomised controlled trials relating to important outcomes such as fetal hearing impairment or impaired neurological development, gestation at delivery and maternal satisfaction and anxiety. Randomised trials should be encouraged to evaluate not only the optimum frequency, intensity and duration of fetal vibroacoustic stimuli but also their effectiveness, safety and perinatal outcome in conjunction with cardiotocography and other tests of fetal wellbeing.
Methods
In studies on the use of external vibroacoustic stimulation in labor, varying methods and protocols have been used. Regardless of the method, the fetal response to acoustic stimulation is usually characterized by an acceleration of the fetal heart rate (FHR). A number of investigations have also described changes in fetal movement patterns during this test. The clinical significance of these changes is still unclear.
The ability of acoustic stimulation to elicit a rapid fetal heart rate response may be useful in decreasing the testing time for a biophysical profile and may result in fewer non-reassuring tests. However, the use of acoustic stimuli in human pregnancy has not yet been proven to be effective in reducing the false positive rates associated with nonreactive biophysical profiles.
A study of 435 normal second and third trimester pregnancies was undertaken to examine the effects of vibratory acoustic stimulation (VAS) on fetal movement (FM) and fetal heart rate (FHR). The fetal response to acoustic vibration, including the onset of FHR acceleration, was recorded using real-time ultrasound. A five-second VAS was given and FM and the amplitude of FHR acceleration were assessed.
The sensitivity of the fetal response to vibration was found to be high, and it was not affected by gestational age or maternal weight. The specificity of the test was 89%. In five cases where the fetal heart rate tracings were pathological, stimulation nevertheless produced a fetal movement and outcome was good. This was attributed to the fact that the fetal heart rate response to vibration is not modulated by maternal beta-adrenergic blocking drugs. This is supported by a case report in which chronic oral administration of propranolol was shown to depress the fetal response to vibratory acoustic stimulation in a patient with Marfan’s syndrome with existing aortic dilation.
Results
Vibroacoustic stimulation fetal is an easy to perform bed side test and has been shown to improve the sensitivity and specificity of non-stress tests (NST) for detecting fetal well being in high risk pregnancies. This study is a prospective clinical trial comparing the NST and VAST in 150 patients with high risk pregnancy fulfilling inclusion criteria. Using the VAST the sensitivity and specificity were found to be higher in predicting poor perinatal outcome than the NST alone.
The results from this study indicate that fetal vibroacoustic stimulation is able to elicit FHR accelerations and significantly reduce the false positive rate associated with NST. It can be used as a noninvasive adjunct to NST in antepartum monitoring to enhance the detection of fetal distress and to identify acidemic fetuses. It can also be used to distinguish between a fetus in labour and a fetus that is unwell.
In a previous study, the sound pressure level of the vibratory stimulus was measured in amniotic fluid using a hydrophone placed under the uterus. The sound intensity was found to increase with gestational age, which suggests that a portion of the fetal auditory system has matured by 28 weeks. This explains the higher sensitivity of the fetus to vibration at this stage.
It has also been shown that fetal movements are more reactive to acoustic stimulation at 36-40 weeks of gestation than at earlier gestational ages, suggesting a maturation of the auditory sensory and central nervous system. This explains why the frequency of fetal startle movement and blinking is also higher after VAS at 36-40 weeks of gestation compared with earlier gestational age groups.
The sensitivity, specificity, and positive and negative predictive value of the fetal heart beat pattern obtained by VAS were 94.7%, 94.4%, and 75% respectively, whereas the sensitivity of the NST was only 68.7%, and the specificity was 91.6%. The VAS is therefore a more accurate and reliable fetal assessment tool in identifying high risk pregnancies. Moreover, it can be performed in addition to the NST with good fetal safety and efficiency.
Conclusions
Vibroacoustic stimulation is a simple bed side test that increases the specificity, positive predictive value and reduces the number of nonreassuring tests in high risk pregnancies. It is a valuable addition to NST, especially in fetuses that are unresponsive to NST and those with a low scalp blood pH. However, as with any test, it is important to understand its limitations. In particular, the response to vibroacoustic stimulation can be modulated by maternal medication such as beta-blockers and should be evaluated in those patients.
Fetal movement is inversely related to gestational age, and the ability of vibroacoustic stimulation to elicit fetal movement decreases with increasing gestational age. This may explain the sensitivity of NST to detect fetal movement and highlight the importance of considering gestational age in NST interpretation.
We have investigated the effects of gestational age on fetal heart rate (FHR) responses to vibroacoustic stimulation using a computerized analysis system. Observational data on 3453 pregnant women were collected and evaluated for 10-minute periods of nonstress testing (NST) and vibroacoustic stimulation (VAS). FHR parameters were analyzed according to gestational age. The mean baseline FHR and the percentage acceleration time in the VAS tracings differed significantly by gestational age. The results of this study demonstrate that a relationship exists between gestational age and the amplitude of FHR accelerations during NST and after VAS, which is similar to that observed with other noninvasive techniques.
Fetal responses to vibroacoustic stimulation can elicit periodic and nonperiodic FHR accelerations, decreasing the false positive rate associated with nonreactive nonstress testing. These results suggest that vibroacoustic stimulation has the potential to improve fetal acidosis diagnosis in labor and may be useful for screening and diagnosing fetal malignancy. A large prospective study is necessary to validate the clinical usefulness of this technique.
