This document provides guidelines for the optimal management of women who experience reduced fetal movements (RFM). It discusses: 1) Performing a history and examination to check for fetal viability, assess risk factors, and exclude complications like preeclampsia. 2) Using cardiotocography and ultrasound scanning when needed to check for fetal wellbeing and growth issues. 3) Providing additional surveillance and testing for women with recurrent RFM or RFM before 28 weeks, while reassuring low-risk women. 4) Documenting all assessments, advice, and plans for follow-up in the patient's records. The goal is to evaluate the fetus, identify at-risk pregnancies, and reassure women when the

1. EVIDENCE BASED APPROACH
BY:
Dr. AHMADM. FAROUK
Resident of GYN/OBS.; MTH
UNDER SUPERVISION OF:
DR YASSER EL-SAEED
MD. CONSULTANT OFGYN/OBS. ; MTH
2014

2.  FETAL MOVEMENTS
 DFMC (Nr.& abnr.)
 Factors affecting FM
 Optimal
management
I. HISTORY
II. EXAMINATIONS
III. CTG
IV. U/S
 MANAGEMENT of
special situations
I. RECURRENT
II. Before 24 wga
III. 24 -28 wga
 Documentation.

3. Types of Fetal movements
 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.

4. 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 .

5. Normally:
 Most women are aware of fetal movements by 20 wga.
 Increasing gradually till 32 wga (at 24wga=86….at
32wga=132/12 hrs.)however most of these movements are
not felt by the mother .
 Clinicians should be aware (and should advise women) that
although 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.
 SLEEP CYCLES :20-40 min. rarely exceed 90 min in nr.
Healthy fetus

6.  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.

7. 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

8. 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.

9. What Should Be Included in
the Clinical History?
 duration of RFM,
 whether :absence , first occasion OR recurrent RFM.
 The history must include
 comprehensive stillbirth risk evaluation, including a
review of the presence of other factors associated with
an increased risk of stillbirth, such as multiple
consultations for RFM, known IUGR,
hypertension, diabetes, extremes of maternal age,
smoking, congenital malformation, racial/ethnic
factors, poor past obstetric history,
 CORTICOSTEROIDS in last 48 hrs.

10. Clinicians should be aware that a woman's risk status
is fluid throughout pregnancy and that women should
be transferred from low-risk to high-risk care program if
complications occur.
 If after discussion with the clinician it is clear that the
woman does not have RFM, in the absence of further
risk factors and the presence of a normal fetal heart
rate on auscultation, there should be no need to
follow up with further investigations.

11. 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.

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

13. 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.

14.  At least 20 min.
 Normal FHR pattern healthy fetus with a
properly functioning autonomic nervous system.
 Computer systems for inter-pretation of CTG..!!!
 >80 MIN. no acceleration fetal compromise
 3.2% RFM.= ABNORMALITIES(IUGR-DISTRESS-
OLIGOHYDRAMNIOS-MALFORMATIONS)
 56% RFM +high risk pregnancy =abnormal CTG.

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

16. Is There Any Role for the Biophysical Profile
(BPP)?
 ± a role in high risk pregnancies.
 Systematic review of RCT: does not
support its use as a test of fetal
wellbeing
 Uncontrolled observational studies:
BBP has good NPV Fetal death is rare
with normal BPP.

17.  If after discussion with the clinician it is clear that the
woman does not have RFM, there are no other risk
factors for stillbirth and there is the presence of a fetal
heart rate on auscultation, she can be reassured.
However, if the woman still has concerns, she should
be advised to attend her maternity unit.

18. What Is the Optimal Surveillance Method for
Women Who Have Presented with RFM in Whom
Investigations Are Normal?
 Women should be reassured that 70% of pregnancies
with a single episode of RFM are uncomplicated.
 There are no data to support (kick charts) use.
 Another episode RFM =immediate contact matrnity
unit.
In a single retrospective cohort study, perinatal
outcome was worse in women who had presented on
more than one occasion with RFM. If a woman
experiences a further episode of definite RFM,she
should be referred for hospital assessment to
exclude signs of compromise through the use of CTG
and ultrasound.

19. Recurrent RFM
POOR perinatal
outcome.(IUGR-
stillbirth-PTL)
U/S
Exclude predisposing
causes
TOP at term in nr. CTG
&U/S.

20. 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 .

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

22. What Should We Document in the
Maternal Records?
 It is important that full details of assessment and
management are documented.
 It is also important to record the advice given about
follow-up and when/where to present if a further
episode of RFM is perceived.
 Accurate record keeping is needed in sufficient detail
to ensure that the consultation and outcome can be
easily audited and continuity of care provided.

23. RFM
YES
Recurrent
AUSCULTATE ,
CTG &U/S
1st episode
RISK
Auscultate,CTG
&U/S
NO RISK
Auscultate
&arrange for
CTG
NO
FHR nr.
Reassure &
Instruct

24. THANKS
SPECIAL THANKS TO DR/YASSER ELSAEED &DR WAFAA BENJAMIN