REDUCED FETAL MOVEMENTS - HOW TO PROCEED BY DR SHASHWAT JANI

Dr. Shashwat Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : drshashwatjani@gmail.com

Over 55% of women experiencing a stillbirth perceive a
reduction in fetal movements prior to diagnosis (Efkarpidis
et al., 2004).
Early recognition of (DFM) makes it possible for the clinician
to intervene at a stage when the fetus is still compensated,
and thus prevent progression to fetal or neonatal injury or
death.(Heazell et al; 2008).
23-Aug-16Dr Shashwat Jani. 99099441602
In 8th annual report (London 2001) The Confidential Enquiry
into Stillbirths and Deaths in Infancy (CESDI) under the
umbrella of NICE reviewed 422 stillbirths and found that 69
cases (16.4%) were related to altered or reduced fetal
movements.

Prevalence
23-Aug-16 Dr Shashwat Jani. 9909944160 3
40 % of pregnant women
experience DFM one or more times
during pregnancy most of them are
transient.(Saastad et al; 2012).

 Respiratory movement
 Simple movement : like kicks or limb
movement.(short duration-variable amplitude)
 Rolling movement : Due to changing
position.(long duration-high amplitude).
 Hiccough like movement.
 OTHER activities like suckling the thumb or
blinking.
Types of Fetal movements

Daily fetal movement count(DFMC)
 Clinically important parameter of fetal wellbeing.
 It is the EASIEST & MOST AVAILABLE method for
evaluating fetal condition.
 Fetal movements should be assessed by subjective
maternal perception of fetal movements.

 FM is one of the first signs of fetal life.
 Fetal activity serves as an indirect measure of
CNS integrity and function.
 Regular FM can, therefore, be regarded as an
expression of fetal well-being .
 Pregnant women usually sense FM from 18 to
20 weeks of gestation .
 Some multiparous women may perceive FMs
at 16 weeks of gestation .

 Start around 20 weeks gestation
 peak at 28- 34 weeks gestation
(Mangesi & Hofmeyr, 2007).
 Multiparous may notice movements earlier (16-20
wks) than primi (20-22 wks gestation)
(Grant et al., 1989).
 Fetal movements tend to plateau at 32 weeks of
gestation, there is no reduction in the frequency of
fetal movements in the late third trimester.
 By term, the average number of movements per
hour is 30,with the longest period between
movements ranging from 50 to 75 minutes.

 Women should be advised to be aware of
their baby's individual pattern of movements. If they are
concerned about a reduction in or cessation of fetal
movements after 28+0 weeks of gestation, they should
contact their maternity unit.
 If women are unsure whether
movements are reduced after 28+0 weeks of gestation,
they should be advised to lie on their left side and focus
on fetal movements for 2 hours. If they do not feel 10 or
more discrete movements in 2 hours, they should
contact their midwife or maternity unit immediately.

Fetal movements show diurnal changes. The afternoon and
evening periods are periods of peak activity. (Minors et al; 1979).
Fetal movements follow a circadian pattern and absent
during fetal sleep, periods which usually last 20-40 minutes
and rarely exceed 90 minutes (Harrington et al; 1998) , (Velazquez et al; 2002).

Two common ways to record fetal kicks.
1. Cardiff Count to Ten Method.
This is an 8 to 12 hour period that records at least 10
of baby’s movement.
2. One to Two Hours Method.
This is done while lying down on your left side for 30
minutes after eating without distractions. After an
evening meal might be ideal time to record.
Baby should move 10 times within an hour to 75
minutes.

Factors associated with RFM
Maternal Perception Foetal movement
 Busy mother
 Anxiety
 Placenta ant.prior 28 wga.
 Poly hydramnios
 Glucose& CO2 conc. In
matrnal blood
 lying down/sitting/standing
 Alcohol,sedatives,
 Corticosteroides
 Fetal sleep.
 Placental insufficiency
 IUGR
 NEURO-MUSCULAR
anomalies(anencephaly )
 Oligo-hydramnios

Pregnancy factors and outcomes associated
with decreased fetal movements
Pregnancy factors associated
with DFM
Outcomes associated with
DFM
 Fetal growth restriction
 Small for gestational age
 Placental insufficiency
 Oligohydramnios
 Threatened preterm
labour
 Fetomaternal transfusion
 Intrauterine infections
 Congenital malformation
 Preterm birth
 Perinatal brain injury
 Disturbed neurodevelopment
 Low birth weight
 Low Apgar score
 Hypoglycemia
 Cesarean section
 Induction of labour
 Fetal death
 Neonatal death23-Aug-16 12Dr Shashwat Jani. 9909944160

What Is the Optimal Management of
Women with Reduced Fetal Movements (RFM)?
exclude fetal death,
exclude fetal compromise,
and to identify pregnancies at risk of adverse
pregnancy outcome
while avoiding unnecessary interventions.

What Should Be Included in the
Clinical History?
 Time since onset of DFM
 any fetal movements have been felt – can the DFM be
attributed to being too busy to feel movements?
 previous episodes of DFM
 known intrauterine growth restriction (IUGR), placental
insufficiency or congenital malformation
 maternal factors such as the presence of hypertension,
diabetes, smoking, extremes of age, primi parity,
obesity, racial or ethnic risk factors
 previous obstetric adverse events.

What Should Be Covered in the
Clinical Examination?
 The key priority when a woman presents with RFM
is to confirm fetal viability. In most cases, a handheld
Doppler device will confirm the presence of the
fetal heart beat(exclude fetal death)
 If the presence of a fetal heart beat is not
confirmed, immediate referral for ultrasound scan
assessment of fetal cardiac activity must be
undertaken.

 BP measuerment to exclude pregnancy
associated HTN.
 Assessment of fetal size with the aim
of detecting (SGA) fetuses.
 Urine analysis (ptnuria).  PET.

Clinical Approaches :
1. physical examination including FHS
2. non-stress and contraction stress tests.
3. ultrasound examination (biophysical profile
[BPP]).
4. umbilical artery Doppler.
5. testing for fetomaternal hemorrhage (eg,
Kleihauer-Betke test).
6. Amnioscopy.

Fetal movement counting (count-to-ten kickcharts)
The use of kickcharts is easy, simple and can be done at home.

What Is the Role of Cardiotocography
(CTG)?
 After fetal viability has been confirmed and
history confirms a decrease in fetal
movements, arrangements should be made
for the woman to have a cardiotocography to
exclude fetal compromise if the pregnancy is
over 28+0 weeks of gestation.

The negative predictive
value of NST alone for predicting
stillbirth within 1 week of a normal
test is 99.8%;
for BPP, modified BPP, and CST, it
is greater than 99.9%.
ACOG 2014.

 RFM persists despite a normal CTG
 risk factors for FGR/stillbirth.
 AC
 EFW {detect the SGA}
 Amniotic Fluid Volume
 Fetal Movements
 Fetal Anatomic survey
 Fetal Doppler : more useful test of fetal wellbeing
than CTG or BPP.
What Is the Role of Ultrasound ?

Remember
The most 2 important US markers are :
 Amniotic fluid volume
 Abdominal circumference
Perfusion
Growth velocity

Biophysical profile (BPP)
A normal BPP score along with a reactive NST is an
indication of fetal well-being. ACOG 2014
A total biophysical score of <4 is abnormal and suggestive
of fetal compromise and increased risk of adverse outcome.
ACOG 2014
Randomized controlled trials does not support the use of
BPP as a test of fetal wellbeing .
There was no significant difference between the groups in
perinatal deaths. (Cochrane review Lalor et al.,2008)

Doppler Velocimetry
Useful only if IUGR is diagnosed.
A study of 599 cases of DFM evaluated by nonstress testing found
no additional benefit of Doppler assessment ( Dubiel et al;1997).
Doppler demonstrated a pathological pattern in 1 % of the
1151 cases.
Most of these abnormalities were associated with growth restricted
fetuses.
In 940 cases ; after exclusion of cases of non reactive CTG
and IUGR fetuses >>>>>Doppler velocimetry was abnormal Only in 1
Case. Norwegian Perinatal Society Conference, November
2006

Sequence of fetal response to stress

ACOG support the use of UA Doppler assessments only in
the management of suspected IUGR, instructing that
decisions regarding the timing of delivery should be based
on UA Doppler results in combination with other tests of
fetal well-being .
No evidence that inclusion of umbilical artery Doppler in
antenatal surveillance provides additional benefit in the
assessment of a normally growing fetus.
ACOG 2014

Testing for feto-maternal transfusion
Kleihauer-Betke stain or flow cytometry
Pregnant patient who presents with DFM +
• sinusoidal fetal heart rate pattern or
• unexplained fetal tachycardia or
• Fetal hydrops on ultrasound associated with elevated
middle cerebral artery Doppler velocity.

Persistent DFM and normal evaluation
There are no studies evaluating the optimal
frequency and method of follow-up of pregnancies
complicated by persistent DFM in which the
antepartum evaluations are all normal.
No data from randomized trials to guide
practice recommendations for management of
DFM (Cochrane Database Syst Rev 2012 ).

Management of patients with persistently
decreased fetal movement depends on:
1. Gestational age
2. Presence of other identifiable risk factors for stillbirth.
If no cause for decreased fetal movement is determined,
pregnancies under 37 weeks of gestation be monitored
with nonstress testing and ultrasound examination twice
weekly. ACOG 2014
After 37 wks >> labor induction of these pregnancies when
the cervix is favorable ( Grade 2C ).

RFM before 24 wga
 Presence of a fetal heartbeat should be
confirmed by auscultation with a Doppler
handheld device.
 If fetal movements have never been felt by 24
weeks of gestation, referral to a specialist
fetal medicine centre should be considered to
look for evidence of fetal neuromuscular
conditions .

RFM (24-28 wga)
Presence of a fetal heartbeat should be
confirmed by auscultation with a Doppler
handheld device.

•Every mother who presents with the concern of reduced or altered
fetal movements should be taken seriously .
•The initial assessment should include a detailed history + AC to rule
out IUGR. + CTG.
Summary and recommendation
If the mother re-presents or
initial assessment is non-
reassuring further tests
should be performed
include amniotic fluid
assessment and EFW.
If this is reassuring for
the mother and clinician,
no further evaluation is
needed.

Kickcharts are of no value and should therefore
not be given out to pregnant women.
UA Doppler velocimetry and vibroacoustic stimulation are
of limited use in the assessment of reduced FM.
BPP scoring has not been shown to be of benefit.
As Previously Said ,
NST alone for predicting stillbirth within 1 week of a normal
test is 99.8%;
for BPP, modified BPP, and CST, it is greater than 99.9%.23-Aug-16 Dr Shashwat Jani. 9909944160 34

THANK YOU…!!!

REDUCED FETAL MOVEMENTS - HOW TO PROCEED BY DR SHASHWAT JANI

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