Decreased fetal movements

Maternal perception of decreased fetal movements (DFM) is a common reason for presentation to hospital.

There is no agreed upon objective definition of DFM and while the nature of the movements may change as pregnancy advances, there is no evidence that the number of movements changes.

There is a demonstrated association between DFM and:

• stillbirth
• fetal growth restriction
• preterm birth
• neonatal low Apgars and acidaemia
• fetomaternal haemorrhage.

Increasing maternal and clinical awareness of DFM and its causes, particularly fetal growth restriction, may lead to fewer stillbirths.

This information is provided to guide management of women with singleton pregnancies who report DFM in the third trimester.

In cases of DFM, antenatal fetal surveillance is undertaken to exclude fetal death and serious fetal compromise. It can also demonstrate fetal wellbeing, exclude fetal compromise, and identify pregnancies at risk of adverse outcome, while avoiding unnecessary interventions.

Pregnancy care and maternal education

All maternity care providers are responsible for providing information to women about fetal movements, including actions to take in the event of decreased or absent fetal movement.

• Give all women information about the importance of fetal movements: Movements Matter
• Provide written information at time of booking in to the hospital and again at 28 weeks.
• Emphasise the importance of maternal awareness of fetal movements at every pregnancy visit.
• Advise women to contact their maternity care provider if they have concerns about decreased or absent fetal movement; tell them not to wait until the next day to report their concerns.
• Maternal concern overrides any definition of DFM based on the number of movements felt.

Decreased fetal movements before 28 weeks

• Decreased fetal movements between 24.0 and 27.6 weeks of gestation: If a woman presents with DFM between 24.0 and 27.6 weeks of gestation, confirm the presence of a fetal heartbeat by auscultation with a Doppler handheld device.
• If fetal movements have never been felt by 24 weeks of gestation, consider referring the woman to a specialist obstetrician.

Decreased fetal movements at or after 28 weeks

See Management flow chart : Decreased fetal movements (DFM) Care pathway for women with singleton pregnancies from 28+0 weeks gestation.

Women who are concerned about DFM should be advised to:

• contact the hospital or qualified maternity care provider immediately
• attend the health care service for immediate assessment.

Do NOT advise women to:

• wait until the next day for assessment
• rest and monitor movements
• drink iced water or have something to eat.

Assessment of decreased fetal movements

On the telephone

• Use the Telephone record tool.

Initial assessment

When a woman presents with DFM:

• the first priority is to confirm fetal heart immediately
• CTG should be performed within two hours of presentation
• if the presence of a fetal heart beat is not confirmed, arrange an urgent ultrasound scan to assess fetal cardiac activity.

The fetal heartbeat needs to be differentiated from the maternal heartbeat.

Additional assessment

• Take a complete history:
  • Duration/pattern of DFM
  • Maternal lifestyle issues (for example: exercise, smoking)
  • Medication, alcohol or sedating drug use
  • Abdominal pain
  • Risk factors for stillbirth, such as diabetes, smoking, obesity, hypertension, IUGR, congenital malformation, poor obstetric history (complete list).
• Ask questions:
  • What is the duration of reduced fetal movements?
  • How long since the woman last felt the baby move?
  • Is this the first occasion of reduced fetal movements?
• Baseline maternal observations:
  • Temperature
  • Pulse
  • Blood pressure
  • Respiratory rate
  • Urinalysis.
• Abdominal palpation:
  • Symphysis-fundal height measurement and assessment of fetal size and amniotic fluid level - is it appropriate for gestational age?
  • Fetal lie and presentation
  • Palpated movements
  • Contractions
  • Tension or guarding.

CTG interpretation

Criteria for a normal antenatal CTG are:

• baseline of 110-160 bpm
• variability 6-25 bpm
• two accelerations - 15 bpm for 15 seconds - within 20 minutes
• no decelerations.

If the CTG does not meet criteria for a normal antenatal trace within 90 minutes, escalate to a senior clinician.

If the CTG is normal and the woman is now happy with the fetal movements, fetal growth is clinically normal and there are no significant risk factors:

• reassure the woman and advise her to return if DFM recurs
• provide her with written information about expected fetal movements
• ensure she has a plan for ongoing antenatal care with a qualified maternity care provider
• document and sign related CTG forms as per local guidelines.

If the CTG is normal but fetal movements do not return to normal, escalate care to a senior clinician.

Ultrasound investigation

Consider an ultrasound assessment for amniotic fluid volume (AFI) and/or fetal biometry within 24 hours when:

• maternal perception of DFM persists, despite a normal CTG
• this is a second or subsequent presentation with DFM
• fetal growth restriction is suspected
• a bedside AFI is not normal
• there are other risk factors for stillbirth.

If an ultrasound is performed, assess fetal morphology if not done so previously. If the ultrasound is abnormal, manage the situation clinically. See flow chart.

Feto-maternal haemorrhage (FMH) investigation

Massive fetal to maternal haemorrhage (varying from >50 ml to >150 ml) has been demonstrated in approximately four per cent of stillbirths and in 0.04 per cent of neonatal deaths.

Other clinical signs of FMH include:

• uterine activity
• uterine tenderness
• vaginal bleeding.

Clinical risk factors do not reliably predict the likelihood of massive FMH and DFM may be the only history suggesting this possibility.

Consider testing for FMH in the preliminary investigations of all women who present with DFM.

If you are uncertain about the preferred mode of testing or capacity for testing in your service, consult with a specialist for further advice.

Care must be planned according to clinical findings and the woman's individual needs.

• Ensure the woman has a clear plan for ongoing care, including any need for:
  • admission or outpatient follow up
  • repeat CTG
  • US examination
  • investigation for FMH.
• Give all women information about the importance of fetal movements: Movements Matter.
• Ensure the woman has the contact number for the health service.
• Advise women to contact their hospital or clinician if they have another episode of DFM.
• If a woman has recurrent presentations with DFM, escalate care to a senior clinician.
• Women who are concerned about reduced fetal movements should not wait until the next day for assessment of fetal wellbeing.

It is recommended that written and verbal information be provided to meet each woman’s individual needs to ensure shared decision making around the benefits and risks of planned births.

• Document full details of assessment and management in the woman's medical record and hand held record.
• Record the advice given about follow-up and where/when to present if the woman has another episode of DFM.
• Ensure documentation of CTG as per RANZCOG Intrapartum Fetal Surveillance guideline.

Audit and performance improvement

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Auditable standards for DFM include:

• assessment within two hours of reporting DFM
• escalation of abnormal CTG findings as per guidance
• escalation or recurrent presentations with DFM as per guidance.

For further information or assistance with auditing, contact us via maternityclinicalnetwork@safercare.vic.gov.au

The Safer Baby Bundle evidence-based eLearning module provides a suite of educational resources based on the latest clinical best practice in stillbirth prevention including Decreased Fetal Movements.

• Free and accredited CPD training
• Safer Baby Bundle eLearning Modules  

• Perinatal Society of Australia and New Zealand and Centre of Research Excellence Stillbirth. Clinical practice guideline for the care of women with decreased fetal movements with a singleton pregnancy from 28 weeks’ gestation. Centre of Research Excellence in Stillbirth. Brisbane, Australia, September 2019.
• Royal College of Obstetricians and Gynaecologists (RCOG) 2011. Green-top guideline 57 - Reduced fetal movements.
• Maternal, Perinatal and Infant Mortality Committee 2014. Maternal, perinatal and infant mortality in South Australia 2012. Adelaide: SA Health, Government of South Australia.
• O'Sullivan, O, Stephen, G, Martindale, E & Heazell, AE 2009, 'Predicting poor perinatal outcome in women who present with decreased fetal movements', J Obstet Gynaecol; 29:705-10.
• NSW Health 2011, Maternity - reduced fetal movements in the third trimester. Maternity Guideline. NSW Health. Government of NSW.
• Western Australia Department of Health 2014, Decreased fetal movements: Maternal Fetal Assessment Unit - quick reference guide. Clinical Guidelines, Obstetric and Midwifery, Women and Newborn Health Service, King Edward Memorial Hospital.
• Hofmeyr, GJ & Novikova, N 2012, 'Management of reported decreased fetal movements for improving pregnancy outcomes'. Cochrane Database Syst Rev. 2012 Apr 18;4:CD009148. doi: 10.1002/14651858.CD009148.pub2.
• RANZCOG (2019) Online Fetal Surveillance Education Program.
• Royal Australia and New Zealand College of Obstetricians and Gynaecology (RANZCOG), Intrapartum Fetal Surveillance : Clinical Guideline – Third Edition 2014 {internet} (cited Oct 2019) Available here. 
• Gardener, G. et.al. 2016, Clinical practice guideline for the care of women with decreased fetal movements. The Stillbirth and Neonatal Death Alliance of the Perinatal Society of Australia and New Zealand.