Clinical Review: Reduced fetal movements

Contributed by Dr Ciaran Crowe, ST2 in obstetrics and gynaecology, Princess Royal Hospital, Haywards Heath, West Sussex.

Ultrasound scan of a 37-week old fetus; movements vary from about four to 100 per hour (Photograph: SPL)
Ultrasound scan of a 37-week old fetus; movements vary from about four to 100 per hour (Photograph: SPL)

Section 1: Epidemiology and definition
Reduced fetal movements (RFM) are a common presentation in general practice and hospital obstetrics. RFM is perceived as a state of fetal compromise by the mother and often poses a dilemma of management for the clinician.1

Although highly subjective, fetal movements have been defined as any kick, roll, slush or flutter reported by the mother.2

One of the greatest challenges is the lack of consensus on what is a 'normal' number of fetal movements and over what specified time frame. Fetal movements vary from four to 100 every hour and so definitions of RFM based on counting less than 10 movements in two, 12 or 24 hours are unhelpful.3

Research suggests a perception of RFM affects up to 15 per cent of pregnancies,4,5 with one study finding that in 55 per cent of cases where RFM had been reported a stillbirth occurred.6

Following the Confidential Enquiry into Stillbirths and Deaths in Infancy7, lack of prompt management has been recognised as a contributing factor for stillbirth.

Further concerns were raised over lack of education and therefore failure of mothers to report RFM, and a failure of the doctor to explain the importance of reporting changes in movements.8 Several studies suggest this may be related to the lack of consensus on definition between doctors and midwifes.9

Nonetheless, 85 per cent of women will be concerned about fetal movements and therefore RFM must be managed robustly to avoid an adverse perinatal outcome.1

Section 2: Making the diagnosis
Changing fetal activity with advancing gestation is an indication of an intact neurological system.10 Average fetal activity is usually reported from 18 to 20 weeks, with multiparous mothers feeling movements up to two weeks earlier.

Movements follow a circadian rhythm, peak at 28 to 32 weeks' gestation and then plateau.11 During this time 'sleep-wake' cycles occur regularly and last on average 30 minutes.12 Movements change as the autonomic system develops and the sleep-wake cycle becomes firmly established.13

There are many factors which influence a mother's perception of fetal movements including normal variations through to pathological conditions (see box). Differentiating these can be difficult.

Potential causes of reduced fetal movements
  • Position - most movements are felt in the supine position, fewest on standing.
  • Busy daily lifestyle.
  • Fetal sleep.
  • Maternal obesity.
  • Drugs: smoking, alcohol, corticosteroids, benzodiazepines, barbiturates, narcotics, methadone.
  • Oligo-/polyhydramnios.
  • Maternal conditions: metabolic disorders, autoimmune disorders (thyroid, anaemia).
  • Fetal conditions: neurological, musculoskeletal malformation, fetal anaemia.
  • Placental: anterior lying placenta, intrauterine growth restriction associated with placental insufficiency.

There is insufficient evidence that formally counting fetal movements over a specified time is better than relying on maternal perception of RFM after 28 weeks' gestation. Therefore if a mother presents with concern over RFM they should be advised to lie on their left side and focus on movements for two hours.

If she does not feel 10 or more discrete movements over this time, she should contact her midwife or be directed to the nearest maternity unit without delay.14 If movements are felt then the mother should be reassured and asked to remain mindful of her baby's individual movement pattern. If this changes and there is further concern she should not hesitate to seek medical input.

Investigations
Before 24 weeks' gestation the GP should perform a handheld Doppler assessment and if no fetal movements have been felt at all by this time, a referral to the local fetal medicine unit should be made to exclude structural abnormalities.

Doppler confirms the fetal heart and therefore reassures the mother and avoids referral.However if no fetal movements have been felt at all by this time, a fetal medicine opinion should be sought.

If a woman presents in general practice with a history of RFM beyond 24 weeks' gestation then a history of the presenting complaint should be taken, noting: the number of presentations of RFM; any hypertensive disease of pregnancy, diabetes or poor past obstetric history; if the baby is small for gestational age (SGA); if there are issues with access to care and willingness to have a hospital review.

In addition, assess the woman for risk factors, measure maternal BP, pulse and temperature, and perform urinalysis. Examine the abdomen including palpation and measurement of symphyseal fundal height (SFH) to exclude SGA.

Auscultate the fetal heart (it is recommended that all community settings have a handheld Doppler device) and ensure you palpate the maternal pulse to confirm you are hearing fetal heartbeat.

If there are no risk factors for stillbirth, the fetal heart is heard on auscultation, and examination is unremarkable, the woman can be reassured and advised to see her midwife within a week for further discussion.

She should be advised on monitoring fetal movements and if a second episode occurs should be directed to her maternity unit.

If the mother is not reassured, concerns are raised by the clinician, there are risk factors for stillbirth, or the RFM occurred suddenly then the woman should be referred to her maternity unit for further investigation.14

If she does not wish to attend, a community midwife appointment should be arranged as soon as possible, with advice given to the mother to monitor movements and assume the left side position if concerned.

General advice, including smoking cessation and drug/alcohol reduction/cessation, should be given and also documented.

Section 3: Managing the condition
Currently there is a wide range of interventions for RFM after the initial basic assessment. These include cardiotocography (CTG), ultrasound scan (USS; including biophysical profiling, umbilical artery Doppler assessment, estimated fetal weight and liquor volume) and kick charts.

These would be done in secondary care only if the woman presents with a subsequent episode of RFM (with or without other risk factors).

Royal College of Obstetricians and Gynaecologists (RCOG) guidelines recommend use of CTG only if gestation is beyond 28 weeks and only if fetal auscultation is unsatisfactory. CTG should be performed for 20 minutes to assess fetal wellbeing. One study found that a fetal abnormality was detected in 3.2 per cent of cases who underwent CTG.15

Ultrasound scan
USS is only recommended if there are additional risk factors and/or there is persistence of RFM on two or more occasions despite normal CTG. If USS is to be used then it should be carried out within 24 hours and assessment should include umbilical artery Doppler, estimated fetal weight and liquor volume. Umbilical artery Doppler velocimetry and fetal vibroacoustic stimulation testing are of limited use.16

Guidelines and algorithms
NICE guidance states that kick charts and formal counting should not be used.17 The RCOG green-top guideline includes a useful algorithm.14

Section 4: Prognosis
Some 70 per cent of women who have had one episode of RFM will have a normal outcome; 3 to 5 per cent will have recurrence of RFM that should be taken seriously as it is associated with a poor outcome.4, 18

There is little evidence on how to manage this group but the basic assessment as well as CTG and USS should be undertaken. If the patient has presented to the GP and basic assessment is performed they should still be referred immediately to their local maternity unit.

An individual case by case review regarding decisions on induction of labour/surgical delivery or to continue with the pregnancy should then be made.

RFM is a common presenting complaint in primary and secondary care but it need not be a management conundrum. Firstly, any presentation of RFM should be taken seriously. A history and examination with detailed record keeping should take place.

Handheld Doppler is recommended in all primary care sites to aid assessment and reassure the mother of fetal viability. SFH, auscultation and then CTG and USS should be the assessment modalities of choice.

This should lead to a standardised approach to the management of these women and limit uncertainty for both the mother and healthcare professional, thus improving patient safety.

Section 5: Case study
The patient was 35 to 36 weeks' gestation on presentation to the labour ward. She reported an initial period of three days of RFM. During this time her midwife reviewed her and the fetal heart has auscultated. On the day of presentation fetal movements had not been felt for 24 hours. Additionally, within the past few hours she had begun to experience cramp-like lower abdominal pain. There was no reported vaginal loss. She was otherwise well.

Prior to this presentation she had seen her midwife at 29, 32 and 34 weeks, at which time all was noted to be well with the pregnancy.

The patient had a poor obstetric history, with one live birth delivered vaginally at term, three years ago, and four other pregnancies that had ended in miscarriage at between five and 10 weeks.

Initially her antenatal care had been provided privately, where she had a multitude of tests to exclude causes of pregnancy loss, all of which had been negative. She had monthly USS up until 22 weeks of pregnancy; all were normal. There was no relevant past medical history and no current medications or allergies.

When the patient attended the labour ward an initial attempt to auscultate the fetal heart was made by midwifery staff and then the obstetric team. Unfortunately, no fetal heart was detectable and subsequent USS demonstrated lack of fetal heart action.

The patient underwent induction of labour to deliver a stillbirth baby at 36 weeks' gestation.

Section 6: Evidence base
Guidelines

Information on examination of the pregnant abdomen is given on page 253; there is also detail on all aspects of antenatal care.

The RCOG guidelines are up-to-date, concise and relevant, containing further, detailed information on the management of RFM.

  • Unterscheider J, Horgan R, O'Donoghue K, et al. Reduced fetal movements. The Obstetrician & Gynaecologist 2009; 11(4): 245-51.

This includes a useful flow chart outlining which interventions to use when for a first presentation of RFM

Key text

  • Sanfilippo JS, Smith RP. Primary Care in obstetrics and gynecology.

A handbook for clinicians (2nd edition). London, Springer, 2007.

Online

An excellent presentation from the GP shared care update forum in Australia, with much of the evidence being UK and Europe-based.

Both of these websites contain excellent support and information for mothers.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Make a handout about RFM to share with expectant mothers.
  • Write a practice guideline on RFM which includes relevant contact numbers.
  • Audit whether maternal pulse and fetal heart rate are documented in cases of RFM in practice.

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