UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
POLICY AND PROCEDURE
TITLE: ULTRASOUND AND NON-STRESS TEST GUIDELINES
Effective Date: January, 2004 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed March, 2005 May, 2008 January 2012
PURPOSE: To define the process and responsibilities of the Ob/Gyn and Family Practice staff and physicians
in scheduling, performance, and interpretation of viability ultrasound and non-stress tests (NSTs) at the 20 S.
POLICY: Staff will utilize the following procedures for viability ultrasound and non-stress tests to ensure
consistent management of patients’ testing and results.
1. Scheduling office
A completed ultrasound requisition, including type of exam, indications, and diagnosis code, should
be faxed to 20 S. Park after appointment has been scheduled.
When scheduling viability ultrasounds, primary care office should provide clear instructions for
patient disposition on the requisition should the scan indicate non-viability.
Generally, viability ultrasounds should not be scheduled on a day when the primary physician is not
in the office for follow up.
If physician is not in the office, he/she should make arrangements with one of his/her partners for
next steps and communicate them clearly to staff and/or note them on the ultrasound requisition.
Generally, it should be possible to schedule a visit with primary physician the same day for follow
2. Ultrasound tech (for non-viable pregnancies):
Confirm real time with Ob/Gyn physician (either primary or on-call).
Contact primary physician regarding results for them to determine next steps.
Make arrangements with nursing staff for Resolve Through Sharing (RTS).
3. Ob/Gyn physicians (for non-viable pregnancies):
Confirm real time with ultrasound tech
Inform patient of results- there is no obligation to counsel patient.
Offer Resolve Through Sharing (RTS) through nursing staff
Let patient know how the primary physician wants to follow up
4. RTS nursing staff
Provide RTS information and packet if patient desires it
Provide follow up phone call as necessary
1. Scheduling office
A completed NST requisition, including diagnosis code, should be received before the patient
When scheduling NSTs, the primary physician should provide clear instructions on the NST
requisition for next steps should the test be non-reactive
Generally, NSTs should not be scheduled on a day when the ordering physician is not in the office
for follow up.
If ordering physician is not in the office, he/she should make arrangements with one of his/her
partners for next steps and communicate them clearly to staff.
2. Nursing staff (when performing NST for Family Practice offices)
Fax strip to ordering physician for review (call office to inform them fax is forthcoming and that
review is needed).
Send original strip to ordering physician via ID mail.
Make arrangements for next steps, if needed.
Communicate plan to patient.
3. Ordering physicians
Review strip and sign off.
If non-reactive, communicate plan to nursing staff performing the NST.
Guidelines for Reactive NST
At least two heart rate accelerations within a 20 minute window
Fetal heart rate acceleration is defined as: an increase of 15 beats above the baseline that lasts for at
least 15 seconds after the start of the acceleration.
Normal baseline rate (110-160 beats per minute)
Long term variability amplitude of 10 or more beats per minute
NOTE: If criteria for a reactive tracing are not met within a total of 40 minutes of testing, the test is
4. Documentation (Progress Notes section of HeathLink) in patient record
Patient education regarding testing
Test performed, date & time completed
Results of test: Reactive or Non-reactive
Actions taken, i.e. provider notification of non-reactive, etc.
How patient tolerated procedure
Follow-up care/discharge instructions
WRITTEN BY: Margaret Bowman, RN, Team Leader
REVISED BY: Carol Decker, RN, MSN, Clinical Staff Educator
REVIEWED BY: Barbara Hostetler, MD and Marc Tumerman, MD, 2008
Jill Rockwell, CMA, Team Leader, OB/GYN 20 S. Park St Clinic
1. ACOG Technical Bulletin, January 1994
2. Lowdermilk, D.L., Perry, S.E., Bobak, I.M. (2000). Maternity & Women’s Health Care (7th ed,).St.
Louis, MO., Mosby.
3. Young, B.K. (October 17, 2011). Intrapartaum fetal heart rate assessment. In C.L. Lockwood & V.A.
Barss (Eds.). UptoDate. Retrieved January, 16, 2012, from
Medical Director Date