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Reduced Fetal Movements – Guidelines for assessment of risk and management V3 Author: Original working party – , Updated by L Matthews

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Last Review: January 2020 Next Review: January 2023 Contact: L Matthews, Clinical Risk and Quality Standards Midwife

Approved by: Maternity Service Governance Group January 2020Guideline Register No: C70/2004 Number allocated retrospectively in 2015

,

Reduced Fetal Movements - Guidelines for assessment of risk and management

C70/2004 Maternity

1. Introduction and who the guideline applies to:

This guideline is intended for the use of obstetric and midwifery staff involved in the care of pregnant women with a history of reduced fetal movements. (RFM) This guideline applies to care in both the community and the hospital setting. This guideline excludes the management of reduced fetal movements in multiple pregnancy. As is apparent from the low grading of the evidence for many of the recommendations, it has been developed to provide a broad practical guide for midwives and obstetricians in clinical practice. However, it is recognised that in individual women alternative approaches may be reasonable

Limitations of data used in this guideline

Interpreting studies of women perceiving RFM is complicated by multiple definitions of normal and abnormal fetal movements and a paucity of large-scale (over 1000 participants) descriptive or intervention studies. The recent AFFIRM study found that a care package which recommended all women have an ultrasound assessment of fetal biometry, liquor volume and umbilical artery Doppler following presentation with RFM after 26 weeks’ gestation, and offered induction of labour for recurrent episodes of RFM after 37 weeks’ gestation did not significantly reduce stillbirths, but was associated with an increase in induction of labour and caesarean section. However, this care pathway reduced the number of SGA fetuses born at or after 40 weeks’ gestation

. The main outcome of interest – stillbirth – is relatively uncommon and adequately powered studies of different management protocols would require large numbers of participants. Consequently, many studies have limitations in terms of definition of RFM and outcomes, ascertainment bias and selection bias.

This guideline has been updated to take into account the Saving Babies Lives care bundle V2, and its implementation

Reduced Fetal Movements – Guidelines for assessment of risk and management V4 Author: Original working party – updated by M Finney

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NB: Paper copies of this document may not be most recent version. The definitive version is in the Policy and Guidelines Library

2. Recommendations

1. Women should be advised of the nature and individual pattern of fetal movements(FM) up to and including the onset of labour. Fetal movements should be discussed and documented at each contact. By 26 weeks gestation, appropriate written information [Leaflet / website] regarding to RFM, should be provided to each woman. Fetal movements should be assessed by subjective maternal perception of fetal movements.

2. Women should be advised that any reduction or complete lack of FM should bereported immediately by the woman to the Community Midwife if less than 26 weeks gestation or the Maternity Unit if from 26 weeks gestation.

3. Women who are concerned about RFM must be advised not to wait until the nextday for assessment of fetal wellbeing.

4. Upon presenting with RFM at any gestation, a full examination should beundertaken and where additional risk factors are present management should be individualised. This should involve using the Management of Reduced Fetal Movements checklist

5. Women with a single episode of RFM before 26 weeks of gestation should haveconfirmation of viability with a Doppler hand held device.

6. Women who present with RFM at 26 weeks gestation or more should have fetalviability confirmed, followed by CTG monitoring. This should be a computerised CTG if available.

7. Ultrasound scan assessment should be undertaken in first presentation of RFM ifthere are any additional risk factors for FGR/stillbirth. This is not necessary if the woman had an ultrasound within the last 2 weeks. This should involve using the Management of Reduced Fetal Movements checklist to aid decision making.

8. In cases of a single episode of RFM from 39 weeks gestation, induction of labourshould be discussed (risks, benefits, mother’s wishes) with all women, but not offered routinely. However, offer IOL at 39 weeks to women with recurrent RFM.

9. Women who present with recurrent reduced RFM require individualisedmanagement

10. All assessments and advice should be accurately documented in the healthrecord


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Women should be informed that:

Perceived fetal movements are defined as the maternal sensation of any discreetkick, flutter, swish or roll. The normal fetus is active and capable of physicalmovement, and goes through periods of both rest and sleep. There is no universallyagreed definition of RFM.

Fetal activity is influenced by a wide variety of factors. There is some evidence thatwomen perceive most fetal movements when lying down, fewer when sitting andfewest while standing. It is therefore not surprising that pregnant women who arebusy and not concentrating on fetal activity often report a misperception of areduction of fetal movements. Johnson demonstrated that when attention is paid tofetal activity in a quiet room and careful recordings are made, fetal movements thatwere not previously perceived are often recognised clearly.

There are no data to support formal fetal movement counting (kick charts) afterwomen have perceived RFM in those who have normal investigations.

From 18–20 weeks of gestation, most pregnant women become aware of fetalactivity, although some multiparous women may perceive fetal movements as earlyas 16 weeks of gestation and some nulliparous women may perceive movementmuch later than 20 weeks of gestation.

The number of spontaneous movements tends to increase until the 32nd week ofpregnancy. From this stage of gestation, the frequency of fetal movements plateausuntil the onset of labour.

Changes in the number and nature of fetal movements as the fetus matures areconsidered to be a reflection of the normal neurological development of the fetus. From as early as 20 weeks of gestation, fetal movements show diurnal changes. The afternoon and evening periods are periods of peak activity. Fetal movements are usually absent during fetal ‘sleep’ cycles, which occur regularly throughout the day and night and usually last for 20–40 minutes. These sleep cycles rarely exceed 90 minutes in the normal, healthy fetus.

Clinicians should be aware that instructing women to monitor fetal movements ispotentially associated with increased maternal anxiety.

Women should be advised not to use hand held dopplers for reassurance

1. Women should be advised of the nature and individual pattern of fetalmovements up to and including the onset of labour. Fetal movementsshould be discussed and documented at each contact. By 26 weeksgestation, appropriate written information [Leaflet / website] regarding toRFM, should be provided to each woman.Fetal movements should be assessed by subjective maternal perception offetal movements.


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Women should be advised that there is no specific number of movements which is normal. They should familiarise themselves with their baby’s individual pattern of movements. By 26 weeks gestation, appropriate written information [Leaflet / website] regarding to RFM, should be provided to each woman. RFM should then be discussed and documented at each visit

Clinicians should be aware that:

Prior to 26+0 weeks of gestation, an anteriorly positioned placenta may decrease awoman’s perception of fetal movements.

Sedating drugs which cross the placenta such as alcohol, benzodiazepines,methadone and other opioids can have a transient effect on fetal movements.

Several observational studies have demonstrated an increase in fetal movementsfollowing the elevation of glucose concentration in maternal blood, although otherstudies refute these findings. From 30 weeks of gestation onwards, the level ofcarbon dioxide in maternal blood influences fetal respiratory movements, and someauthors report that cigarette smoking is associated with a decrease in fetal activity.

The administration of corticosteroids to enhance fetal lung maturation has beenreported by some authors to decrease fetal movements and fetal heart ratevariability detected by cardiotocography (CTG) over the 2 days followingadministration.

Fetuses with major malformations are generally more likely to demonstrate reducedfetal activity. However, normal or excessive fetal activity has been reported inanencephalic fetuses. lack of vigorous motion may relate to abnormalities of thecentral nervous system, muscular dysfunction or skeletal abnormalities.

Fetal presentation has no effect on perception of movement.

Fetal position might influence maternal perception: 80% of fetal spines lay anteriorlyin women who were unable to perceive fetal movements despite being able tovisualise them when an ultrasound scan was performed.

A history of RFM should be taken, including the duration of RFM, whether there hasbeen absence of fetal movements and whether this is the first occasion the womanhas perceived RFM.

2. Women should be advised that any reduction or complete lack of FM shouldbe reported immediately by the woman to the Community Midwife if less than 26 weeks gestation or Maternity Unit if 26 weeks gestation or more.


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The history must include a comprehensive stillbirth risk evaluation (see pink box onflow chart).

Clinicians should be aware that a woman’s risk status is fluid throughout pregnancyand that women should be transferred from midwife led to consultant led care ifcomplications occur

Every effort must be made to ensure that women are aware of the importance ofreporting any RFM as soon as they suspect it.

Women must be asked about FM at every antenatal contact from 24 weeks, By 26weeks gestation, appropriate written information [Leaflet / website] regardingto RFM, should be provided to each woman

When discussing awareness of FM midwives should refer women to the informationabout RFM which is within their hand held record.

A full antenatal check should be carried out.

The Management of Reduced Fetal Movements checklist should be used toaid management

Fetal viability should be confirmed. In most cases, a handheld Doppler device willconfirm the presence of the fetal heart beat. This should be available in the majorityof community settings in which a pregnant woman would be seen by a midwife orgeneral practitioner. The fetal heart beat needs to be differentiated from thematernal heart beat. This is easily done in most cases by noting the differencebetween the fetal heart rate and the maternal pulse rate.

If the presence of a fetal heart beat is not confirmed, immediate referral forultrasound scan assessment of fetal cardiac activity must be undertaken.

Methods employed to detect SGA fetus should include abdominal palpation,measurement of symphysis–fundal height and ultrasound biometry. Consideration

3. Women who are concerned about RFM must be advised not to wait until the nextday for assessment of fetal wellbeing.

4. Upon presenting with RFM at any gestation, a full examination should be undertakenand where additional risk factors are present management should be individualised. This should involve using the Management of Reduced Fetal Movements checklist (Appendix 2)


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should be given to the judicious use of ultrasound to assess fetal size in women in whom clinical assessment is likely to be less accurate, for example those with a raised body mass index.

As pre-eclampsia is also associated with placental dysfunction, it is prudent tomeasure blood pressure and test urine for proteinuria in women with RFM.

Where the woman has presented with reduced fetal movements and has a high riskpregnancy the case should be discussed with an obstetrician regardless of whetherit is the first or recurrent episode if the woman is 28 weeks or more.

5. Women with a single episode of RFM before 26 weeks gestation should haveconfirmation of viability with a Doppler hand held device.

If a woman presents with RFM prior to 26 weeks gestation, the presence of a fetalheartbeat should be confirmed by auscultation with a Doppler handheld device.

If fetal movements have never been felt by 24 weeks of gestation, referral to aspecialist fetal medicine centre should be considered to look for evidence of fetalneuromuscular conditions.

Between 26 and 28 weeks where there are concerns about fetal growth or there is a recurrent epsiode of RFM ultrasound consider offering an ultrasound examination within 72 hours.

CTG monitoring of the fetal heart rates provides an easily accessible means ofdetecting fetal compromise. The presence of a normal fetal heart rate pattern (i.e.showing accelerations of fetal heart rate coinciding with fetal movements) isindicative of a healthy fetus with a properly functioning autonomic nervous system.

Computer systems for interpretation of CTG provide objective data, reduce intra- and inter-observer variation and are more accurate than clinical experts inpredicting umbilical acidosis and depressed APGAR scores. The informationproduced by the Computerised system is highlighted as ‘advisory only’ and clinicaldecisions remain the responsibility of the clinician undertaking the fetal monitoring.PLEASE NOTE – The computerised CTG is not suitable for use when the woman isin labour.

6. Women who present with RFM at 26 weeks gestation or more should have fetalviability confirmed, followed by (preferably) computerised CTG monitoring,


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Where there is any difficulty in interpretation of the computerised criteria the CTGshould be reviewed by an Obstetrician and if repeat CTG is requested it should becarried out for a minimum of 20 minutes.

Escalation should take place as highlighted in the Maternity Assessment UnitGuideline

If a computerised CTG has been performed and is normal and there are no otherindications for an ultrasound scan then a scan is not required for a first presentationof RFM but should be offered for women reporting recurrent RFM if she has not hada scan within the last 2 weeks.

7. Ultrasound scan assessment should be undertaken in first presentation of RFM ifthere are any additional risk factors for FGR/stillbirth. This should involve using the Management of Reduced Fetal Movements checklist to aid decision making

If an ultrasound scan assessment is deemed necessary, it should be performedwhen the service is next available – ideally within 72 hours.

Ultrasound scan assessment should include the assessment of abdominalcircumference and/or estimated fetal weight to detect the SGA fetus, and theassessment of amniotic fluid volume.

Ultrasound should include assessment of fetal morphology if this has not previouslybeen performed and the woman has no objection to this being carried out.

An ultrasound assessment is not necessary if one has been carried out withinthe past 2 weeks and the results are normal. Review timing and results ofprevious ultrasound assessments along with any pending appointments priorto booking an ultrasound.

Some women will already be on a GROW pathway and having regular ultrasoundexaminations, for example women with diabetes, and the need for furtherassessment by ultrasound should be discussed with the Obstetrician.

Obesity is a recognised risk factor for FGR/stillbirth (RCOG 2011). Women with aBMI ≥30kg/m2 and RFM should be considered for further assessment byultrasound.

A low PAPPA-A result is a recognised risk factor for stillbirth and placentalinsufficiency

An extreme of maternal age is also a recognised risk factor (RCOG 2011). For thepurpose of this guideline women under 20 and over 40 should be considered forfurther assessment by ultrasound.


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Smoking is another risk factor and so further assessment by ultrasound should beconsidered.

Where there are issues with access to care, language barrier, single unsupported orunemployed further assessment by ultrasound should also be considered.

Where a woman is already under the care of the Fetal Medicine Team managementshould be discussed with them.

Where the woman has a high risk pregnancy the case should be discussed with anobstetrician.

8. In cases of a single episode of RFM after 38+6 weeks discuss, but do notroutinely offer induction of labour, but offer delivery to women with recurrent RFM after 38+6 weeks

Prior to 39 weeks gestation, induction of labour or operative delivery is associatedwith small increases in perinatal morbidity and neurodevelopmental delay. Thus, arecommendation for delivery needs to be individualised and based upon evidence

of fetal compromise (for example, abnormal CTG, EFW <10th centile or

oligohydramnios) or other concerns (for example, concomitant maternal medicaldisease, such as hypertension or diabetes, or associated symptoms such asantepartum haemorrhage).

At 39 weeks gestation and beyond, induction of labour is not associated with anincrease in caesarean section, instrumental vaginal delivery, fetal morbidity oradmission to the neonatal intensive care unit. The option of induction of labourtherefore should be discussed (risks, benefits and mother’s wishes) with womenpresenting with a single episode of RFM after 38+6 weeks gestation, but IOL doesnot need to be offered routinely in the absence of any other concerns.

It is important that women presenting with recurrent RFM are additionally informedof the association with an increased risk of stillbirth and given the option of deliveryfor RFM alone after 38+6 weeks.

9. Women who present with recurrent RFM require individualised management.

All women with who have presented with a single episode of RFM in whominvestigations are normal should be advised to contact their maternity unit if theyhave a further episode of RFM


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When a woman recurrently perceives RFM, ultrasound scan assessment should beundertaken as part of the investigations.

When a woman recurrently perceives RFM, her case should be reviewed by anobstetrician to exclude predisposing causes.

Caregivers should be aware of the increased risk of poor perinatal outcome in women presenting with recurrent RFM. Women presenting with recurrent RFM are additionally informed of the association with an increased risk of stillbirth and given the option of delivery for RFM alone after 38+6 weeks

10. All assessments and advice should be accurately documented in the healthrecord.

It is important that full details of assessment and management are documented.

This should involve using the Management of Reduced Fetal Movementschecklist

Where a computerised CTG is performed, a patient identification sticker must beused at the beginning of the trace and analysis of the trace documented at the end.A print out of the analysis should be stored securely in orange CTG envelope andfiled in the health record.

Advice given about follow-up and when/where to present if a further episode ofRFM is perceived must be documented in the patient record.

Accurate record keeping is needed in sufficient detail to ensure that the consultationand outcome can be easily audited and continuity of care provided.

Women who present with reduced fetal movements should be assessed forsuitability to birth at St Mary’s Birth Centre, Orchard Birth Centre, Meadow BirthCentre or at home if that is their chosen place of delivery. This can be decided bythe midwife caring for the woman and providing there are no other risk factors orconcerns and this is the first episode of reduced fetal movements the woman candeliver at St Marys Birth Centre, Orchard Birth Centre, Meadow Birth Centre or athome.

Women who present in labour and have had reduced fetal movements within theprevious 24 hours should deliver at the Consultant Led unit as they requirecontinuous electronic fetal monitoring.

Women with risk factors should always be reviewed by the Obstetrician.


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3. Education and Training:

None

4. Monitoring Compliance

What will be measured to monitor compliance

How will compliance be monitored

Monitoring Lead

Frequency Reporting arrangements

Percentage of women booked for antenatal care who had received leaflet/information by 28+0weeksof pregnancy

Audit of notes Annually

Percentage of women who attend with RFM who have a computerised CTG


Percentage of stillbirths which had issues associated with RFM management identified using PMRT

PMRT tool kit Perinatal Mortality Group

Rate of induction of labour when RFM is the only indication before 39+0weeks’ gestation


5. Supporting References and Bibliography:

1. © Royal College of Obstetricians RCOG Green-top Guideline No. 57

2. NHS England (2016). Saving Babies’ Lives: a care bundle for reducing stillbirth.NHS England (2019).Saving Babies’ Lives. Version 2 March 2019

3. Low PAPP-A: what are the clinical implications?https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025130/ Published online 2015 Dec 31.

4. RayburnWF. Fetal body movement monitoring.Obstet Gynecol Clin North Am 1990;17:95–110.

5. Harrington K, Thompson O, Jordan L, Page J, Carpenter RG, Campbell S. Obstetric outcome inwomen who present with a reduction in fetal movements in the third trimester of pregnancy. J PerinatMed 1998;26:77–82.

6. Efkarpidis S, Alexopoulos Elkin L, Liu D, FayT. Case-control study of factors associated withintrauterine fetal deaths. MedGenMed 2004;6:53.

7. Fossen D, Silberg IE. Perinatal deaths in the county of Ostfold 1989–97. Tidsskr Nor Laegeforen1999;119:1272–5. Article in Norwegian.

8. Saastad E,Vangen S, Frøen JF. Suboptimal care in stillbirths – a retrospective audit study.ActaObstet Gynecol Scand 2007;86:444–50.

9. Eller DP, Stramm SL,Newman RB.The effect of maternal intravenous glucose administration on fetalactivity. Am J Obstet Gynecol 1992;167:1071–4.

10. D’Elia A, Pighetti M,Moccia G, Santangelo N. Spontaneous motor activity in normal fetuses. EarlyHum Dev 2001;65:139–47.

11. Cito G, Luisi S,Mezzesimi A,Cavicchioli C,Calonaci G, Petraglia F.Maternal position during non-stresstest and fetal heart rate patterns. Acta Obstet Gynecol Scand 2005;84:335–8.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025130/


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12. Tveit JV, Saastad E,Bordahl PE, Stray-Pedersen B, Frøen JF.The epidemiology of decreased fetalmovements. Proceedings of the Norwegian Perinatal Society Conference.Oslo,Norway; 2006.

13. Velazquez MD,RayburnWF.Antenatal evaluation of the fetus using fetal movement monitoring.ClinObstet Gynecol 2002;45:993–1004.

14. JohnsonTR, Jordan ET, Paine LL.Doppler recordings of fetal movement: II.Comparison with maternalperception. Obstet Gynecol 1990;76:42–3.

15. JohnsonTR.Maternal perception and Doppler detection of fetal movement.Clin Perinatol1994;21:765–77. UHL Audit department . Audit management of pregnant patients with low PAPP-Alevels Audit number 9587

16. Robertson SS,Dierker LJ. Fetal cyclic motor activity in diabetic pregnancies: sensitivity to maternalblood glucose. Dev Psychobiol 2003;42:9–16.

17. Zisser H, Jovanovic L,Thorsell A,Kupperman A,Taylor LJ, Ospina P , et al.The fidgety fetushypothesis: fetal activity is an additional variable in determining birth weight of offspring of womenwith diabetes.Diabetes Care 2006;29:63–7.

18. Magee LA,Dawes GS,Moulden M,Redman CW. A randomised controlled comparison ofbetamethasone with dexamethasone: effects on the antenatal fetal heart rate. Br J Obstet Gynaecol

1997;104:1233–8.

19. Mulder EJ,Derks JB,Visser GH.Antenatal corticosteroid therapy and fetal behaviour: a randomisedstudy of the effects of betamethasone and dexamethasone.Br J Obstet Gynaecol 1997;104:1239–47.

20. Jackson JR,Kleeman S,Doerzbacher M, Lambers DS.The effect of glucocorticosteroid administrationon fetal movements and biophysical profile scores in normal pregnancies. J Matern Fetal NeonatalMed 2003;13:50–3.

21. Christensen FC,RayburnWF. Fetal movement counts.Obstet Gynecol Clin North Am 1999;26:607–21.

22. Tveit JV, Saastad E, Stray-Pedersen B,Børdahl PE, Flenady V, Fretts R, et al.Reduction of latestillbirth with the introduction of fetal movement information and guidelines – a clinical qualityimprovement.BMC Pregnancy Childbirth

23. 2009;9:32. Erratum in:BMC Pregnancy Childbirth 2010;10:49.

24. Kean LH, Suwanrath C,Gargari SS, Sahota DS, James DK.A comparison of fetal behaviour in breechand cephalic presentations at term.Br J Obstet Gynaecol 1999;106:1209–13.

25. Fisher ML.Reduced fetal movements: a research-based project.Br J Midwifery 1999;7:733–7.

26. Lowery CL,RussellWA Jr,Baggot PJ,Wilson JD,Walls RC, Bentz LS, et al.Time quantified detectionof fetal movements using a new fetal movement algorithm.Am J Perinatol 1997;14:7–12.

27. MelendezTD,RayburnWF, Smith CV.Characterization of fetal body movement recorded by theHewlett-Packard M 1350-A fetal monitor.Am J Obstet Gynecol 1992;167:700–2.

28. Heazell AE, Frøen JF.Methods of fetal movement counting and the detection of fetal compromise. JObstet Gynaecol 2008;28:147–54.

29. Elbourne D,Grant A. Study results vary in count-to-10 method of fetal movement screening.Am JObstet Gynecol 1990;163:264–5.

30. Liston RM,Bloom K,Zimmer P.The psychological effects of counting fetal movements.Birth1994;21:135–40.

31. Mikhail MS, Freda MC,Merkatz RB, Polizzotto R,Mazloom E, Merkatz IR.The effect of fetal movementcounting on maternal attachment to fetus.Am J Obstet Gynecol 1991;165:988–91.

32. Smith CV,Davis SA,RayburnWF. Patients’ acceptance of monitoring fetal movement.A randomizedcomparison of charting techniques. J Reprod Med 1992;37:144–6.

33. Frøen JF,Tveit JV, Saastad E,Børdahl PE, Stray-Pedersen B, Heazell AE, et al.Management ofdecreased fetal movements. Semin Perinatol 2008;32:307–11.

34. Saastad E,AhlborgT, Frøen JF. Low maternal awareness of fetal movement is associated with smallfor gestational age infants. J MidwiferyWomens Health 2008;53:345–52.

35. Heazell AE,Green M,Wright C, Flenady V, Frøen JF.Midwives’ and obstetricians’ knowledge andmanagement of women presenting with decreased fetal movements.Acta Obstet Gynecol Scand2008;87:331–9.

36. Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI). 8th Annual Report.London:Maternal and Child Health Research Consortium; 2001.

37. Royal College of Obstetricians and Gynaecologists.Greentop Guideline No. 31: The Investigation andManagement of the Small-for-gestational-age Fetus. London:RCOG; 2002[http://www.rcog.org.uk/files/rcog-corp/uploadedfiles/ GT31SmallGestationalAgeFetus.pdf].


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38. National Collaborating Centre forWomen’s and Children’s Health. Intrapartum care.Care of healthywomen and their babies during childbirth. London:RCOG Press; 2007[http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline..

Keywords:

Reduced fetal movements, fetal well being, cardiotocograph, ultrasound, intrauterine growth

____________________________________________________

DEVELOPMENT AND APPROVAL RECORD FOR THIS DOCUMENT

Author / Lead Officer:

Original Working Party Job Title: Consultant Obstetricians and Midwives

Reviewed by: M Finney

Approved by: Maternity Service Guidelines and Governance Group Date Approved: 1.06.15 and 15.06.15 20.04.16 21.09.16 15.03.17

REVIEW RECORD

Date Issue Number

Reviewed By Description Of Changes (If Any)

June 2015 V2 As above General update

November 2015

V2 As above Clarification on IOL for women who present with the first episode reduced fetal movements. Flow chart amended and colours changed for easier reading

April 2016 V2 L Matthews CTG for at least 20 minutes removed as Dawes Redman used. Brought into line with MAU guidance

October 2016 V2 L Matthews and J Morrissey

Flow charts made clearer. Risk factors box and assessment added to recurrent RFM flowchart. Clarification on process of suitability to deliver in midwife led unit or home following episodes of RFM

March 2017 V3 L Matthews New simplified flow chart. Scan not required if already done within the last 2 weeks unless change in clinical picture. Review of previous results and future appointments should be considered before booking a scan. Scan timeframe within 72 hours.

December 2019

V4 M Finney Reviewed in line with saving babies lives 2 NHS England. Introduction of new checklist for management. Added new evidence of risk factor low PAPPA-A

DISTRIBUTION RECORD:

Date Name Dept Received

07.15 All Midwives and Obstetricians Maternity





1/2020 All Midwives and Obstetricians Maternity


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Appendix 1:

Algorithm for Management of Reduced Fetal Movement > 26 weeks gestation

First telephone contact Confirm gestation and if is 1

st episode of RFM

Below 26 weeks gestation

See CMW for full A/N examination including FH auscultation

26 weeks and 1st

episode. Attend MAU

(Labour Ward out of hours)

Obtain history/Identify risk factors

Check observations including urinalysis

Measure & plot fundal height measurement

Auscultate fetal heart using Pinnard/Doppler

Perform computerised CTG using Dawes/Redman

(DR) analysis

If no fetal heart refer woman to Antenatal Services for senior obstetric review

Suspicious or Pathological CTG Dawes/Redman criteria not met

Normal CTG (D/R criteria met)

1st Episode:

No risk factors

Well

SFH in normal range

Fetal movements felt

1st Episode with:

Risk factors identified or

SFH below 10th centile /fall off in growth

2nd or more Episode

Record number ofepisodes in notes

Discharge home

Advise to report furtherRFM episodes

Routine A/N care

Discuss IOL if 39 weeksor more

Offer IOL at less than 39weeks only if there isevidence of fetalcompromise or otherconcerns in relation to thehistory of RFM

Scan for growth, liquor & Doppler within 72 hours if last scan > 2 weeks

ago

Scan abnormal or last scan < 2 weeks ago or Multiple episodes of RFM

Senior Obstetric review for an Individualised Management Plan

Normal Scan

Risk Factors for stillbirth

BMI > 30 Age <20yr or >40yr Diabetes Smoker Post-dates (> 42 weeks) HTN or PET Low PAPPA-A SFD / IUGR Previous episodes RFM Known congenital or genetic abnormality


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Appendix 2:

Checklist for the Management of Reduced Fetal Movements (RFM)

1. Ask

Confirm there is maternal perception of RFM? How long has there been RFM? Is this the first episode? When were movements last felt?

2. Act

Auscultate fetal heart (hand-held Doppler/Pinnard) to confirm fetal viability.

IN THE EVENT OF BEING UNABLE TO AUSCULTATE THE FETAL HEART, ARRANGE IMMEDIATE ULTRASOUND ASSESSMENT

Assess fetal growth by reviewing growth chart, perform SFH if not performed within last 2 weeks.

Perform CTG to assess fetal heart rate in accordance with national guidelines (ideally computerised CTG should be used).

Ultrasound scan for fetal growth, liquor volume and umbilical artery Doppler needs only to be offered on first presentation of RFM if there is no computerised CTG or if there is another indication for scan (e.g. the baby is SGA on clinical assessment).

Ultrasound scan for fetal growth, liquor volume and umbilical artery Doppler should be offered to women presenting with recurrent RFM after 28+0 weeks’ gestation.

Scans are not required if there has been a scan in the previous two weeks

3. Advise

Convey results of investigations to the mother. Mother should be encouraged to re-attend if she has further concerns about RFM.

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