Reduced Fetal Movements

Reduced fetal movements is a woman's perception of fewer or weaker fetal movements after 28 weeks, or fewer than 10 distinct movements in 2 hours. Causes include placental insufficiency, growth restriction, oligohydramnios, fetal anomaly, maternal sedatives, alcohol, infection, anaemia and fetomaternal haemorrhage, and in many the pregnancy is normal. It matters because reduced movements often precede stillbirth.

• Movements are first felt at 16 to 20 weeks and are strongest at 28 to 32 weeks.
• Risk factors: smoking, hypertension, diabetes, growth restriction, obesity, anterior placenta, sedative or alcohol use.
• Same day assessment is needed.

The woman reports less movement than before, often over 24 hours or more. Examine blood pressure, fundal height, fetal heart rate and lie, and ask about bleeding, fever and trauma.

• Sudden stop in movements.
• Small or large fundal height.
• Differential diagnosis: normal fetal sleep, anterior placenta, obesity, growth restriction, oligohydramnios, fetal anomaly, fetal death, infection, fetomaternal haemorrhage, maternal sedation.
• Complications: stillbirth, fetal hypoxia, neonatal death, preterm birth, emergency caesarean section.

The approach is same day clinical assessment, fetal heart auscultation and cardiotocography.

• Auscultate the heart with a Pinard or hand-held Doppler; if not heard, confirm death by ultrasound.
• Cardiotocography for at least 20 minutes (extend to 40 minutes if not reactive) from 28 weeks.
• Ultrasound for growth, deepest vertical pocket, umbilical artery Doppler, anomaly and placental position if movements remain reduced or risk factors exist.
• Blood pressure, urine protein, random glucose, full blood count, malaria rapid test, syphilis test, blood group and Kleihauer test in RhD negative women or with abdominal trauma.

The principle is to confirm fetal wellbeing at once, find the cause and deliver if the fetus is compromised or movements stay reduced at term.

• Supportive: reassure when the cardiotocography and scan are normal; teach counting to 10 movements within 2 hours; advise to return at once for another reduction; admit for abnormal tracing or growth restriction.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for fever; artemether-lumefantrine 4 tablets (each 20 mg and 120 mg) oral at 0, 8, 24, 36, 48 and 60 hours for malaria; benzathine benzylpenicillin 2.4 million units IM once weekly for 3 weeks for syphilis; labetalol 200 mg oral every 8 to 12 hours (maximum 2.4 g daily) or nifedipine modified release 30 to 60 mg oral once daily (maximum 120 mg) for hypertension; betamethasone 12 mg IM twice, 24 hours apart, between 24 and 34 weeks and 6 days if delivery is likely; insulin or metformin for diabetes.
• Procedures: induction at 37 weeks or later when movements stay reduced despite normal tests, using misoprostol 25 micrograms vaginal 6-hourly (maximum 4 doses) or a Foley catheter with a 30 mL balloon; emergency caesarean section for pathological cardiotocography.
• Special groups: RhD negative women with a Kleihauer test showing fetal cells give anti-D immunoglobulin 500 IU IM within 72 hours, increased by 125 IU for each 1 mL of fetal red cells above 4 mL; women with diabetes or hypertension are scanned at the first visit.
• Red flags: no fetal heart, abnormal cardiotocography, oligohydramnios, absent or reversed end diastolic flow, bleeding, abdominal pain.
• Follow-up: repeat count and review in 24 hours if symptoms continue; growth scan in 1 to 2 weeks; antenatal visit within 1 week.