**2. Physiology**

Mothers usually report fetal movements from around 20 weeks gestation with a peak at 28- 34 weeks gestation (Mangesi & Hofmeyr, 2007). Fetal movements have been defined as any discrete kick, flutter swish or roll (Neldam, 1983). Multiparous women may notice movements earlier (16-20 weeks gestation) than primiparous women (20-22 weeks gestation) (Grant *et al*., 1989). FM follow a circadian pattern and are an expression of fetal wellbeing. Fetal movements are usually absent during fetal sleep, periods which usually last 20-40 minutes and rarely exceed 90 minutes (Patrick *et al*., 1982). A recent study confirmed that fetal movements are significantly better in the evening than in the morning (Ozkaya *et al*., 2011). A gradual decline during the third trimester is suggested to be due to improved fetal

failure of (a) the mother to report reduced FM, (b) the clinician explaining the importance of changes in FM to the woman and (c) professionals to act appropriately when decreased FM

Fetal congenital malformation (i.e. neurological, musculo-skeletal)

Acute or chronic hypoxia from placental insufficiency leading to

Administration of corticosteroids for promotion of fetal lung maturity

ii. Small for gestational age fetus (SGA)/ intrauterine growth restriction (IUGR)

Maternal sedating drugs which cross the placenta (alcohol, benzodiazepines, barbiturates,

Table 1. Conditions associated with maternal perception of reduced fetal movements

In February 2011, the Royal College of Obstetricians & Gynaecologists has issued a clinical practice guideline (Green-top Guideline 57) on the management of reduced fetal movements which summarises the current evidence of how to best manage these complicated

This chapter provides a comprehensive overview of the clinical significance, investigation and management of reduced fetal movements in the low risk pregnant population over 24 weeks gestation. It will further provide guidance to the clinician in the critical assessment of these pregnancies to ensure high quality antepartum and intrapartum care, safe delivery

Mothers usually report fetal movements from around 20 weeks gestation with a peak at 28- 34 weeks gestation (Mangesi & Hofmeyr, 2007). Fetal movements have been defined as any discrete kick, flutter swish or roll (Neldam, 1983). Multiparous women may notice movements earlier (16-20 weeks gestation) than primiparous women (20-22 weeks gestation) (Grant *et al*., 1989). FM follow a circadian pattern and are an expression of fetal wellbeing. Fetal movements are usually absent during fetal sleep, periods which usually last 20-40 minutes and rarely exceed 90 minutes (Patrick *et al*., 1982). A recent study confirmed that fetal movements are significantly better in the evening than in the morning (Ozkaya *et al*., 2011). A gradual decline during the third trimester is suggested to be due to improved fetal

the

i. Reduced amniotic fluid volume (oligohydramnios) or

A busy mother who is not concentrating on fetal activity Maternal anaemia, metabolic disorders, hypothyroidism

Acute or chronic feto-maternal haemorrhage

occur.

Fetal sleep Fetal position

Intrauterine fetal death (IUD)

Fetal anaemia or hydrops

Increased maternal weight Anterior placental localisation

methadone, narcotics)

(Unterscheider *et al*., 2009)

and improved perinatal outcomes.

Polyhydramnios

Smoking

pregnancies.

**2. Physiology** 

coordination and reduced amniotic fluid volume, coupled with increased fetal size (Grant *et al*., 1989). Some ultrasound studies on fetal behaviour show that fetal movements do not become less frequent in the third trimester but that the movements change as coordination improves and a pattern of cycling becomes established.

Decreased FM are regarded as a marker for suboptimal intrauterine conditions, possibly of placental dysfunction and intrauterine stress and should alert the clinician to pregnancies at risk. The fetus responds to chronic hypoxia by conserving energy and the subsequent reduction of FM is an adaptive mechanism to reduce oxygen consumption. It is recognised that an IUD is preceeded by cessation of FM for at least 24 hours (Sadovsky & Yaffe, 1973). Over 55% of women experiencing a stillbirth perceive a reduction in fetal movements prior to diagnosis (Efkarpidis *et al*., 2004).
