2. What is fetal movements
• Perceived fetal movements are defined as the
maternal sensation of any discrete kick, flutter,
swish or roll.
• Relevance: such fetal activity provides an
indication of the integrity of the central nervous
and musculoskeletal systems.
• Time: It can be first detected by most mothers
between 18 and 20 weeks of gestation and
rapidly acquire a regular pattern.
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3. Importance
• Maternal perception of fetal movement is
• a sign of fetal life
• a manifestation of fetal wellbeing.
• Reduced or absent fetal movements may be a
warning sign of impending fetal death.
• The majority of women (55%) experiencing a
stillbirth perceived a reduction in fetal
movements prior to diagnosis.
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4. Causes of decreased FM
• Intrauterine fetal death (IUD)
• Fetal sleep
• Fetal congenital malformation (i.e. neurological, musculo-skeletal)
• Fetal anaemia or hydrops
• Acute or chronic hypoxia from placental insufficiency leading to i. Reduced
amniotic fluid volume (oligohydramnios) or ii. Small for gestational age fetus
(SGA)/ intrauterine growth restriction (IUGR)
• Acute or chronic feto-maternal haemorrhage
• Polyhydramnios
• Increased maternal weight
• Anterior placental localisation
• Maternal sedating drugs which cross the placenta (alcohol,
benzodiazepines, barbiturates, methadone, narcotics) Smoking
• Administration of corticosteroids for promotion of fetal lung maturity
• A busy mother who is not concentrating on fetal activity
• Maternal anaemia, metabolic disorders, hypothyroidism
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5. How can fetal movements be
assessed?
• By subjective maternal perception of fetal
movements.
• No formal fetal movement counting using
specified alarm limits.
• Women should be advised to be aware of their
baby’s individual pattern of movements.
• Clinicians should be aware that instructing
women to monitor fetal movements is
potentially associated with increased maternal
anxiety. 20/03/2020Elbohoty
6. What are considered normal fetal
movements during pregnancy?
• Fetal movements are usually perceived by 20
weeks and tend to plateau at 32 weeks of
gestation
• There is no reduction in the frequency of fetal
movements in the late third trimester.
• Women should be advised of the need to be
aware of fetal movements up to and including
the onset of labour and should report any
decrease or cessation of fetal movements to
their maternity unit.
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8. Reduced FM after 28+0weeks of
gestation
• If a woman is concerned about a reduction in
or cessation of fetal movements presents to
the community setting with no facility to
auscultate the fetal heart
– she should be referred immediately to her
maternity unit for auscultation and should not
wait until the next day .
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11. History
• Analysis of her complain: The duration of RFM and previous perceived RFM.
• A comprehensive stillbirth risk evaluation,
– multiple consultations for RFM
– known FGR
– hypertension,
– Diabetes
– extremes of maternal age
– Smoking
– placental insufficiency
– congenital malformation,
– Obesity,
– past obstetric history (e.g.FGR and stillbirth)
– genetic factors
– Social history (domestic violence, drug abuse,….
– Primiparity
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12. If women are unsure whether
movements are reduced:
– they should be advised to lie on their left side
– 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.
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13. Clinical examination
• Measure blood pressure and test urine for
proteinuria
• Assessment of fetal size with the aim of
detecting SGA fetuses.
• An attempt should be made to auscultate the
fetal heart using a handheld Doppler device to
exclude fetal death.
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14. Actions
• She can be reassured if after discussion with the
clinician it is clear that
• the woman does not have RFM
• there are no other risk factors for stillbirth
• the presence of a fetal heart rate on auscultation
• Further investigation(s) NST is the 1st test to be done:
• Women noticing a sudden change in fetal activity
or
• in who mother risk factors for stillbirth are
identified
• the woman still has concerns
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15. CTG
• After a decrease in fetal movements and fetal
viability have been confirmed,
– a CTG should be arranged to exclude fetal
compromise if the pregnancy is over 28+0 weeks of
gestation.
– CTG monitoring of the fetal heart rate, initially for at
least 20 minutes
– presence of a normal fetal heart rate pattern (i.e.
showing accelerations of fetal heart rate) is
indicative of a healthy fetus
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16. Non stress test
Done using the cardiotocometry with the
patient in left lateral position
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17. Antenatal
NST Reassuring Non-Reassuring
Baseline rate 110 – 160 bpm •100 – 109 bpm
•161 – 180 bpm
Comments:
Variability 5 bpm or more < 5 bpm for 40-90 min Comments:
Accelerations present Comments:
Decelerations None •Unprovoked decelerations.
•Decelerations related to uterine
tightening (not in labor)
Comments:
Opinion
Normal NST
(all 4 features
reassuring)
Abnormal NST
(one or more of the non-
reassuring features)
Maternal Pulse Membranes ruptured: Y/N
State date and time if Yes
Liquor Color Gestational Age
Reason for NST
Action
Date:
Time:
Signature: Status:
ELBOHOTY 3/20/20
18. Ultrasound assessment
• Indications: It should be undertaken for any woman presenting
with RFM after 28+0 weeks of gestation if
– the perception of RFM persists despite a normal CTG
– there are any additional risk factors for FGR/stillbirth.
• Urgency: it should be performed when the service is next
available – preferably within 24 hours.
• It should include
– the assessment of abdominal circumference and/or
estimated fetal weight to detect the SGA fetus
– the assessment of amniotic fluid volume.
– assessment of fetal morphology if this has not previously
been performed and the woman has no objection to this
being carried out.
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20. BPP ??!!
• The systematic review concluded that the available
evidence from randomised controlled trials does not
support the use of BPP as a test of fetal wellbeing in
high-risk pregnancies.
• However, that there is evidence from uncontrolled observational studies that BPP in
high-risk women has good negative predictive value.
• There may be a role for the selective use of BPP in the management or investigation
of RFM ?!.
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21. Fetal Biophysical profile
Abnormal (score=
0)
Normal (score=2)Biophysical
Variable
Absent FBM or no
episode >30 s in 30
min
1 episode FBM of at least 30 s duration in
30 min
Fetal breathing
movements
2 or fewer body/limb
movements in 30 min
3 discrete body/limb movements in 30 minFetal movements
Either slow extension
with return to partial
flexion or movement
of limb in full
extension Absent fetal
movement
1 episode of active extension with return to
flexion of fetal limb(s) or trunk. Opening
and closing of the hand considered normal
tone
Fetal tone
Either no AF pockets
or a pocket<2 cm in 2
perpendicular planes
1 pocket of AF that measures at least 2 cm
in 2 perpendicular planes
Amniotic fluid
volume
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22. ManagementInterpretationTest Score Result
Intervention for obstetric and maternal factorsRisk of fetal asphyxia
extremely rare
10 of 10
8 of 10 (normal fluid)
8 of 8 (NST not done)
Determine that there is functioning renal
tissue and intact membranes. If so, delivery of
the term fetus is indicated. In the preterm
fetus less than 34 weeks, intensive
surveillance may be
preferred to maximize fetal maturity.
Probable chronic fetal
compromise
8 of 10 (abnormal fluid)
Repeat test within 24 hrEquivocal test, possible
fetal asphyxia
6 of 10 (normal fluid)
Delivery of the term fetus. In the preterm fetus
less than 34 weeks, intensive surveillance
may be preferred to maximize fetal maturity
Probable fetal asphyxia6 of 10 (abnormal fluid)
Deliver for fetal indicationsHigh probability of fetal
asphyxia
4 of 10
Deliver for fetal indicationsFetal asphyxia almost
certain
2 of 10
Deliver for fetal indicationsFetal asphyxia certain0 of 10 20/03/2020Elbohoty
23. RFM in whom investigations are
normal
• 70%of pregnancies with a single episode of
RFM are uncomplicated.
• Women should be advised to contact their
maternity unit if they have another episode of
RFM.
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24. Recurrent reduced RFM?
• There is an increased risk of poor perinatal outcome in
women presenting with recurrent RFM.
• When a woman recurrently perceives RFM, her case
should be reviewed to exclude predisposing causes.
• When a woman recurrently perceives RFM, ultrasound
scan assessment should be undertaken as part of the
investigations.
• The decision whether or not to induce labour at term in
a woman who presents recurrently with RFM when the
growth, liquor volume and CTG appear normal must
be made after careful consultant-led counselling of the
pros and cons of induction on an individualised basis.
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