Reduced or absent foetal movements

Reduced or absent foetal movements is a mother's perception that the strength, frequency or pattern of foetal movement has fallen, or that movement has stopped, after the gestation at which movements are normally established (from 24 weeks).

The main clinical point is that the symptom can be the earliest sign of placental insufficiency, foetal anaemia, infection, hypoxia or impending death.

It must be taken seriously at every contact, the foetal heart confirmed at once, and a structured assessment done the same day without dismissing the woman or relying on a single reassuring test.

Clinical relevance. Reduced movement is associated with stillbirth, growth restriction, preterm birth, neonatal admission and neurodevelopmental problems. Most women with a single episode and normal tests have a normal outcome, but recurrent episodes carry a higher risk, and delay in presentation worsens outcome.

Physiology. Movements are first felt at 18 to 20 weeks (16 to 18 weeks in women who have had a baby), increase in strength and frequency until about 32 weeks, and then plateau in frequency, although the pattern of movement continues to the onset of labour. Foetal sleep cycles last up to 40 minutes, rarely up to 90 minutes. Women learn their baby's usual pattern by 28 weeks.

Mechanisms. A hypoxic or acidotic foetus conserves energy by moving less. Other contributing mechanisms are reduced liquor, foetal anaemia, anomaly or neuromuscular disease, infection, drug effect and mechanical restriction.

Classification. By gestation: before 24 weeks (movement not yet established), 24 to 28 weeks, and 28 weeks to term. By pattern: a first episode, recurrent episodes, or absent movement. By finding: normal assessment, abnormal cardiotocography or ultrasound, or intrauterine death.

Key distinctions. There is no valid number of movements that defines reduced movement. A common tool is to count to ten distinct movements in 2 hours, but a change in the usual pattern matters more than any count. Absent movement for more than 12 to 24 hours in the third trimester is an emergency. A single normal test does not exclude a risk if the woman's concern persists.

History

• Gestation, due date and basis of dating, number of foetuses.
• Pattern: when movement was last felt, whether it has reduced in strength or frequency or stopped, duration of the change, and whether movements returned with food or a cold drink (these measures do not reliably reassure and should not delay assessment).
• Previous episodes of reduced movement in this pregnancy.
• Associated: vaginal bleeding, abdominal pain, leaking of fluid, contractions, headache, visual disturbance, swelling, fever, rash, vomiting, polyuria and polydipsia, itching.
• Risk factors for stillbirth: previous stillbirth, growth restriction or pre eclampsia; hypertension, diabetes, renal disease, thrombophilia, antiphospholipid syndrome, lupus, thyroid disease. Other risk factors: obesity (body mass index over 30), age over 35, smoking, alcohol and drug use; first pregnancy, multiple pregnancy; assisted conception; ethnic minority groups; social deprivation; sleeping supine in late pregnancy; anaemia.
• Current pregnancy findings: foetal growth (small for gestational age), antenatal screening results, liquor volume, placental location (anterior placenta dampens perception), foetal anomalies, rhesus status and antibodies, infection exposure (cytomegalovirus, parvovirus B19, toxoplasmosis, syphilis, listeria, malaria, HIV).
• Drugs: sedatives, opioids, antiepileptics, alcohol; recent antenatal corticosteroids (reduce movement for 2 to 3 days).
• Recent trauma, falls, domestic abuse, motor vehicle accident.

Examination

• Vital signs including blood pressure, temperature, pulse, oxygen saturation.
• Symphysis fundal height against gestation (plot on a customised chart), lie, presentation, tenderness, tone of the uterus, contractions, liquor volume (clinical impression).
• Foetal heart: auscultation with a Doppler device. Hand held Doppler can detect the maternal pulse and give false reassurance; if the heart is not clearly found, perform ultrasound at once.
• Urine dipstick for protein, glucose, ketones, infection; capillary glucose.
• Reflexes, clonus, signs of pre eclampsia.
• Speculum examination if fluid leakage or bleeding.

Red flags

• No foetal heart on auscultation.
• Absent movements for 12 hours or more, or sudden complete cessation.
• Vaginal bleeding or constant abdominal pain (abruption), or a scarred uterus with pain (rupture).
• Fever, flu like illness, rash, travel to a malaria region.
• Severe hypertension, proteinuria, headache or visual disturbance.
• Small symphysis fundal height, previous stillbirth or growth restriction.
• Second or repeated episode of reduced movement.
• Rhesus negative status with trauma or bleeding.
• Itching of palms and soles with raised bile acids (cholestasis).
• Diabetes with poor control or ketoacidosis.

Special groups. Women with obesity and anterior placenta perceive fewer movements. Women with a language barrier or low literacy need interpretation and plain information. Pregnancies after 37 weeks have greater risk, and the clinician should avoid false reassurance after a normal cardiotocography.

Organised by mechanism. Each cause is common unless marked serious or uncommon. Normal variation and perception

• Foetal sleep cycle, normal change of movement pattern in late pregnancy.
• Maternal factors: anterior placenta, obesity, distraction, sedation, reduced attention.
• Reduced movement after antenatal corticosteroids (usually settles in 2 to 3 days).

Placental insufficiency and reduced reserve

• Serious: foetal growth restriction (placental insufficiency from pre eclampsia, hypertension, smoking, thrombophilia, antiphospholipid syndrome).
• Serious: placental abruption, marginal bleeding, foetomaternal haemorrhage.
• Serious: umbilical cord problems (cord entanglement, prolapse, true knot, velamentous insertion, vasa praevia).
• Reduced liquor: oligohydramnios, ruptured membranes; polyhydramnios.
• Post term pregnancy.
• Maternal diabetes (poor control), obesity.
• Maternal hypotension, supine hypotension, anaemia, hypoxia, ketoacidosis, sepsis.

Foetal causes

• Serious: foetal anaemia (alloimmune haemolytic disease, parvovirus B19 infection, foetomaternal haemorrhage, twin to twin transfusion).
• Serious: foetal infection (cytomegalovirus, toxoplasmosis, rubella, syphilis, listeria, malaria, chorioamnionitis).
• Foetal anomaly (neuromuscular disease, akinesia sequences, skeletal dysplasia, central nervous system anomaly, chromosomal disorder).
• Foetal arrhythmia and heart disease.
• Multiple pregnancy, discordant growth or demise of a twin.
• Foetal hypoxia and acidosis.

Maternal disease and drugs

• Serious: intrahepatic cholestasis of pregnancy.
• Maternal sedatives, alcohol, opioids and illicit drugs.
• Maternal trauma, domestic abuse.
• Maternal fever and dehydration.
• Hypoglycaemia in the mother.
• Pregnancy complicated by systemic lupus erythematosus or other autoimmune disease.

Intrauterine death

• Serious: causes include placental disease (abruption, infarction), growth restriction, infection, cord accident, congenital anomaly, maternal diabetes, hypertension, antiphospholipid syndrome, obstetric cholestasis, foetomaternal haemorrhage and unexplained death.

Stepwise reasoning

1. Confirm the foetal heart immediately. If it is not found, confirm with real time ultrasound.
2. Review risk factors, growth chart and previous scans.
3. Perform cardiotocography for at least 20 to 30 minutes from 28 weeks (computerised analysis if available); use auscultation and ultrasound before 28 weeks.
4. Perform ultrasound the same day if there is a second episode, a risk factor, small symphysis fundal height, or an abnormal cardiotocography, and in any case within 24 hours when the woman remains concerned.
5. Decide on delivery or further observation by findings and gestation.
6. Test for the cause if the foetus has died.

Cardiotocography

• Normal: baseline 110 to 160 beats/min, variability 5 to 25 beats/min, accelerations present, no decelerations, over at least 20 minutes (30 to 40 minutes at earlier gestations).
• Abnormal features: baseline over 160 or under 110 beats/min, reduced variability (under 5 beats/min for over 90 minutes), repeated late or variable decelerations, absence of accelerations, sinusoidal pattern (severe anaemia or hypoxia).
• Computerised cardiotocography: short term variation (low values raise concern; under 3 milliseconds is abnormal before 34 weeks; reference ranges are gestation dependent).
• Normal cardiotocography is not a guarantee of foetal wellbeing and does not remove the need for ultrasound where criteria apply.

Ultrasound

• Foetal heart activity, number of foetuses, presentation, and anomalies.
• Estimated foetal weight and abdominal circumference centile (under the 10th centile suggests small for gestational age; under the 3rd centile or crossing centiles suggests growth restriction).
• Liquor: deepest vertical pool under 2 cm or amniotic fluid index under 5 cm indicates oligohydramnios; deepest pool over 8 cm or index over 24 cm indicates polyhydramnios.
• Umbilical artery Doppler (pulsatility index over the 95th centile, absent or reversed end diastolic flow). Middle cerebral artery Doppler (low pulsatility index suggests brain sparing or anaemia; peak systolic velocity over 1.5 multiples of the median suggests anaemia), cerebroplacental ratio, and ductus venosus Doppler in early severe growth restriction.
• Biophysical profile (each of breathing, movement, tone, liquor and non stress test scored 0 or 2 points): 8 to 10 normal, 6 equivocal and repeat, 4 or under abnormal and consider delivery.
• Placental appearance, retroplacental clot, cord insertion and cord around the neck (not itself diagnostic).

Maternal and foetal tests

• Blood pressure, urine protein; full blood count, urea, creatinine, electrolytes, liver function tests, bile acids (fasting bile acids over 10 micromol/L), glucose or HbA1c.
• Kleihauer or flow cytometry for foetomaternal haemorrhage (especially with sinusoidal cardiotocography, anaemia or trauma).
• Group, rhesus status and antibody screen; Coombs test.
• Infection screen if clinical or history: cytomegalovirus, toxoplasma, parvovirus B19, syphilis, rubella, HIV, hepatitis B and C, malaria film or rapid test, vaginal swab for group B streptococcus.
• Thrombophilia and antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti beta 2 glycoprotein I) after a stillbirth or severe growth restriction; thyroid function; antinuclear antibodies.

Tests after intrauterine death

• Kleihauer, full blood count, group and antibody screen, glucose or HbA1c, bile acids, liver and renal function, thyroid function, coagulation and fibrinogen.
• Infection: syphilis serology, cytomegalovirus, parvovirus B19, toxoplasma, rubella, listeria, group B streptococcus, vaginal and blood cultures if febrile, malaria in endemic regions.
• Thrombophilia and antiphospholipid antibodies.
• Foetal tests: examination by a perinatal pathologist, post mortem, placental histology, microarray or karyotype on foetal tissue or cord blood, and photographs and X rays as requested.

Limitations. Hand held Doppler does not exclude foetal demise and can pick up the maternal pulse. A normal cardiotocography is not a guarantee. Estimated foetal weight has an error of 10 to 15%. Ultrasound Doppler in a foetus with early disease may be normal. A normal result does not remove the risk after repeated episodes.

Immediate steps. Assess within the hour (same day assessment for all women with a concern).

Confirm the foetal heart rate and gestation. If there is vaginal bleeding, pain, hypertension or maternal compromise, treat the bleeding, pain, hypertension or maternal illness first and plan delivery. Do not send a woman home without cardiotocography at 28 weeks or later, and ensure a clear plan for anyone who remains worried.

Normal assessment (cardiotocography normal, no risk factors, ultrasound where indicated normal)

• Reassure, reinforce that the woman should present at once for any further change, and document the plan.
• Advise lying on the side (not supine) in the last trimester.
• Do not advise movement counting charts with fixed numbers as a routine, though counting to ten movements within 2 hours may be offered to women who ask for a method.
• A second episode after 36 weeks needs ultrasound for growth, liquor and Doppler, and consideration of delivery planning at 37 to 39 weeks. Individualise timing for recurrent episodes, growth restriction, diabetes, hypertension or other risk factors.

Abnormal cardiotocography

• Left lateral position, oxygen if hypoxic, intravenous fluid if dehydrated, and stop any oxytocin.
• Urgent senior review, continuous monitoring, and ultrasound.
• Delivery by emergency caesarean section (category 1 for bradycardia or sinusoidal pattern with maternal distress or suspected abruption or cord prolapse, with decision to delivery under 30 minutes; category 2 when there is foetal compromise without immediate threat, with birth within 75 minutes).
• Corticosteroids if under 34 weeks (betamethasone 12 mg intramuscularly twice, 24 hours apart).
• Magnesium sulphate for neuroprotection if under 30 weeks and delivery is imminent: 4 g intravenously over 15 to 30 minutes then 1 g/h for up to 24 hours (reduce the dose in renal impairment, monitor reflexes, respiratory rate and urine output).

Foetal growth restriction with abnormal Doppler. Specialist review, serial Doppler, and delivery timing by gestation: absent end diastolic flow, delivery at 32 to 34 weeks; reversed end diastolic flow, delivery at 30 to 32 weeks, earlier with abnormal ductus venosus or computerised cardiotocography. Give corticosteroids and magnesium sulphate before delivery when appropriate.

Oligohydramnios and post term. Check for ruptured membranes, treat the cause, and deliver at 37 to 38 weeks if isolated and persistent oligohydramnios; induce at 41 weeks for post term pregnancy, earlier with risk factors.

Anaemia. Foetal anaemia (Kleihauer positive, middle cerebral artery velocity raised): urgent referral to a foetal medicine unit for intrauterine transfusion; or birth if near term.

Cholestasis. Ursodeoxycholic acid 10 to 15 mg/kg daily in two or three divided doses (maximum 2 g daily, dose adjusted for liver disease), vitamin K 10 mg orally daily when the prothrombin time is raised. Plan delivery at 35 to 37 weeks if bile acids are 100 micromol/L or more, and at 37 to 38 weeks otherwise.

Maternal disease. Optimise diabetes control, treat hypertension and pre eclampsia, treat infection by cause (listeria: amoxicillin 500 mg orally three times daily for 7 days; ceftriaxone for sepsis). Syphilis: benzathine benzylpenicillin 2.4 million units intramuscularly weekly for 3 weeks in late latent disease or once in early disease, with specialist care of the foetus. Malaria: artemether and lumefantrine in the second and third trimesters.

Intrauterine death

• Confirm death by real time ultrasound by two experienced clinicians; show the image and explain to the couple privately and gently.
• Plan with the woman, with respect for her wishes: offer time to decide and to be with her family, in a quiet room away from the labour ward.
• Birth plan: vaginal birth is preferred unless there is a maternal indication for caesarean section. Admit immediately if there is sepsis, ruptured membranes, abruption, severe pre eclampsia, or coagulopathy.
• Induction: mifepristone 200 mg orally, followed 36 to 48 hours later by misoprostol
• From 24 to 28 weeks give misoprostol 100 microgram vaginally or orally every 6 hours up to 4 doses. From 28 weeks give 25 to 50 microgram vaginally or orally every 4 hours (maximum 6 doses), with continuous midwifery care
• Use lower doses or mechanical methods (balloon) and oxytocin if the woman has a uterine scar, because the risk of rupture rises. Do not use misoprostol in women with previous classical caesarean section or other major uterine surgery.
• Analgesia: epidural analgesia if no coagulopathy, patient controlled morphine, entonox, paracetamol 1 g every 6 hours; antiemetic cyclizine 50 mg every 8 hours.
• Anti D immunoglobulin for rhesus negative women, at least 500 IU intramuscularly within 72 hours from 20 weeks, with an additional dose calculated from the Kleihauer result (125 IU for each 1 mL of foetal red cells over 4 mL).
• Coagulopathy: check fibrinogen and platelets at admission and weekly if birth is delayed beyond 4 weeks after death.
• Lactation suppression: cabergoline 1 mg orally as a single dose in the first 24 hours after birth, or 0.25 mg orally twice daily for 2 days; contraindicated in hypertension, pre eclampsia, puerperal psychosis, and fibrotic valvular heart disease; supportive breast care otherwise.
• Thromboprophylaxis: enoxaparin 40 mg subcutaneously once daily for risk factors (20 mg once daily under 50 kg; 60 mg once daily for 91 to 130 kg; reduce for creatinine clearance under 30 mL/min to 20 or 30 mg once daily).
• Care of the baby: offer holding, naming, photographs, hand and foot prints, blessing and a memory box; ask about funeral and burial or cremation arrangements; discuss post mortem and genetic tests, with consent.
• Psychological care: bereavement support, midwife and counsellor contact, screening for depression and post traumatic stress, and partner and family support. Give a written plan and contacts.
• Contraception and next pregnancy: counsel on the cause, delay for physical recovery (at least 6 months for caesarean), and offer a preconception review. In the next pregnancy, offer early scans, growth surveillance, aspirin 150 mg orally nightly from 12 weeks to 36 weeks for women at risk, and delivery planned by cause.

Special groups. Multiple pregnancy: ultrasound each time, and plan delivery with specialist care if a co twin has died. Women with a language barrier: use a trained interpreter, and explain plans.

Women with a previous stillbirth: increased surveillance from 28 weeks. Region specific: ensure access to ultrasound and transport, and treat malaria and syphilis.

Monitoring. Repeat cardiotocography at the interval set by the findings; serial growth and Doppler scans every 1 to 2 weeks in growth restriction; fortnightly review for recurrent reduced movements; continuous monitoring in labour.

Referral and escalation. Refer the same day to the obstetric team for any abnormal cardiotocography, reduced liquor, growth restriction, repeat presentation, or maternal disease. Refer to foetal medicine for suspected anaemia, anomaly, or early severe growth restriction. Refer to bereavement and perinatal pathology services after intrauterine death. Refer to haematology for thrombophilia.

Admission criteria. Abnormal cardiotocography or Doppler, intrauterine death, bleeding, hypertension, maternal illness or sepsis, and women with unsafe social circumstances or poor access to emergency care.

Discharge and follow up. Discharge when the cardiotocography and any ultrasound are normal and the woman has been told how to return. Arrange follow up within 1 to 2 weeks, and a plan for repeated episodes. After intrauterine death, review at 6 weeks to discuss results, the cause, recurrence risk, contraception and plans for another pregnancy, and monitor for depression.

Safety netting. Return at once for any further reduction in movement, no movement, bleeding, pain, leaking fluid, headache, visual disturbance, fever or any concern. Do not wait for the next appointment.