In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A–D) are defined at the end of the "Major Recommendations" field.
What Are Considered Normal Fetal Movements during Pregnancy?
C - Most women are aware of fetal movements by 20 weeks of gestation.
B - 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.
How Can Fetal Movements Be Assessed?
C - Fetal movements should be assessed by subjective maternal perception of fetal movements.
Should Fetal Movements Be Counted Routinely in a Formal Manner?
B - There is insufficient evidence to recommend formal fetal movement counting using specified alarm limits.
C - 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.
C - 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.
B - Clinicians should be aware that instructing women to monitor fetal movements is potentially associated with increased maternal anxiety.
What Is the Optimal Management of Women with Reduced Fetal Movements (RFM)?
The initial goal of antenatal fetal surveillance in cases of RFM is to exclude fetal death. Subsequent to this, the aim is to exclude fetal compromise and to identify pregnancies at risk of adverse pregnancy outcome while avoiding unnecessary interventions.
What Should Be Included in the Clinical History?
B - Upon presenting with RFM, a relevant history should be taken to assess a woman's risk factors for stillbirth and fetal growth restriction (FGR).
C - 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.
A history of RFM should be taken, including the duration of RFM, whether there has been absence of fetal movements and whether this is the first occasion the woman has perceived RFM. The history must include a 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 FGR, hypertension, diabetes, extremes of maternal age, primiparity, smoking, placental insufficiency, congenital malformation, obesity, racial/ethnic factors, poor past obstetric history (e.g., FGR and stillbirth), genetic factors and issues with access to care. 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 programmes 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.
What Should Be Covered in the Clinical Examination?
B - If a woman presents with RFM in the community setting with no facility to auscultate the fetal heart, she should be referred immediately to her maternity unit for auscultation.
B - When a woman presents with RFM in the community or hospital setting, an attempt should be made to auscultate the fetal heart using a handheld Doppler device to exclude fetal death.
Clinical assessment of a woman with RFM should include assessment of fetal size with the aim of detecting small-for-gestational-age (SGA) fetuses.
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. This should be available in the majority of community settings in which a pregnant woman would be seen by a midwife or general practitioner. The fetal heart beat needs to be differentiated from the maternal heart beat. This is easily done in most cases by noting the difference between the fetal heart rate and the maternal pulse rate. If the presence of a fetal heart beat is not confirmed, immediate referral for ultrasound scan assessment of fetal cardiac activity must be undertaken. If the encounter with the woman has been over the telephone and there is thus no additional reassurance of auscultation of the fetal heart, the woman should be advised to report for further assessment. [Evidence level 2+]
Methods employed to detect SGA fetuses include abdominal palpation, measurement of symphysis–fundal height and ultrasound biometry. The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on the investigation and management of the SGA fetus recommend use of a customised fundal height chart. Consideration 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 to measure blood pressure and test urine for proteinuria in women with RFM.
What Is the Role of Cardiotocography (CTG)?
B - 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.
What Is the Role of Ultrasound Scanning?
B - Ultrasound scan assessment should be undertaken as part of the preliminary investigations of a woman presenting with RFM after 28+0 weeks of gestation if the perception of RFM persists despite a normal cardiotocography or if there are any additional risk factors for fetal growth restriction/stillbirth.
C - Ultrasound scan assessment should include the assessment of abdominal circumference and/or estimated fetal weight to detect the SGA fetus, and the assessment of amniotic fluid volume.
A - Ultrasound should include assessment of fetal morphology if this has not previously been performed and the woman has no objection to this being carried out.
Is There Any Role for the Biophysical Profile (BPP)?
B - There may be a role for the selective use of biophysical profile in the management or investigation of RFM.
What Is the Optimal Surveillance Method for Women Who Have Presented with RFM in Whom Investigations Are Normal?
C - Women should be reassured that 70% of pregnancies with a single episode of RFM are uncomplicated.
C - There are no data to support formal fetal movement counting (kick charts) after women have perceived RFM in those who have normal investigations.
What Is the Optimal Management of the Woman Who Presents Recurrently with Reduced RFM?
C - When a woman recurrently perceives RFM, her case should be reviewed to exclude predisposing causes.
B - When a woman recurrently perceives RFM, ultrasound scan assessment should be undertaken as part of the investigations.
There are no studies to determine whether intervention (e.g. delivery or further investigation) alters perinatal morbidity or mortality in women presenting with recurrent RFM. Therefore, 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.
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.
Grades of Recommendation
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++ and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic review of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies; e.g., case reports, case series
4 Expert opinion