**3. Definition**

There is a lack of consensus on how many movements are regarded as normal or abnormal. FM in a healthy fetus vary from 4 to 100 per hour (Mangesi & Hofmeyr, 2007). Maternal perception of fetal movements range from 4-94% of actual movements seen on concurrent ultrasound scanning (Heazell *et al*., 2008). The positive predictive value of the maternal perception of reduced FM for fetal compromise is low, 2% to 7% (Macones & Depp, 1996).

Haezell *et al* recently confirmed that there is little agreement amongst midwives and obstetricians on the definition of reduced FM. Definitions ranged from less than 10 movements in 2 hours (Whitty *et al.*, 1991) to 12 and 24 hours. In this study, the maternal perception of decreased movements for 24 hours gained the greatest acceptance and the authors suggest this is currently the most appropriate method to identify reduced FM (Heazell *et al*., 2008; Heazell & Frøen, 2008). Reports on published definitions found most midwives and obstetricians favoured the definition of less than 10 movements in 12 hours (Heazell *et al*., 2008). This concurs with the 1976 definition of Pearson and Weaver who developed the 'count-to-ten kickchart'. Using this kickchart, women record their first 10 movements of each day, and if this is not reached after 12 hours, are advised to seek further assessment (Grant *et al*., 1989; Heazell *et al*, 2008; Person & Weaver, 1976). A recent prospective cohort study showed that the mean time to perceive 10 movements is approximately 10 minutes in normal third trimester pregnancies (Winje *et al.*, 2011). Other studies showed that the mean time to perceive 10 movements varied between 21 minutes for focused counting to 162 minutes with unfocused perception of fetal movements (Grant et al., 1989; Moore & Piacquadio, 1989).

There is no evidence that any formal definition of reduced FM is of greater value than subjective maternal perception in the detection of fetal compromise. Therefore maternal perception of reduction or sudden alteration of fetal movements should be considered clinically important. There is currently no universally agreed definition of reduced FM.

### **4. Current practice**

A wide range of investigations are performed for the complaint of reduced FM. Investigations considered include symphyseal fundal height measurement (SFH), cardiotocography (CTG), biophysical score (BPP), fetal weight estimation (EFW), liquor

Reduced Fetal Movements 211

Every patient who presents with reduced FM over 24 weeks gestation should have the

A clinical opinion about the size of the baby including abdominal palpation and the measurement of SFH should be part of every assessment and is helpful in the management of reduced FM. Despite the fact that abdominal palpation only detects 30% of small for gestational age fetuses (RCOG, 2002), SFH measurement has a positive predictive value of 60% and a negative predictive value of 76.8% (Heazell *et al*., 2005). This implies that if the SFH is within normal limits, fetal growth restriction or placental insufficiency is unlikely to be present. Serial SFH measurements have an increased specificity and sensitivity (Heazell *et al*, 2005; Pearce & Campbell, 1987) as the trend in growth is of more value than a single measurement in predicting poor fetal outcome. As 50-70% of fetuses with a birthweight below the 10th centile are constitutionally small (RCOG, 2002), Gardosi *et al* suggested that plotting measurements on customised SFH charts adjusted for maternal weight, height, parity and ethnic group results in increased detection of growth restriction and fewer hospital referrals (Gardosi & Francis, 1999). The SFH mean at 36 weeks gestation on drawn charts is 34-34.8cm (Calvert, Quaranta, Nottingham) which implies that using '*SFH in cm equals gestational age in weeks*' would lead to significant over-diagnosis of SGA fetuses.

We conclude that, in the absence of anything better, the measurement of SFH and its plotting on customised charts is recommended in selecting which patients should undergo

CTG it is widely accepted as the primary method of antenatal fetal monitoring to assess the current status of the fetus (Pattison & McCowan, 2000) but its use is particularly difficult and cannot be recommended before 28 weeks gestation (Preboth, 2000). Between 24 and 28 weeks gestation auscultation of the fetal heart may be sufficient and CTG can be performed. A reactive CTG is defined by two accelerations exceeding 15bpm, sustained for at least 15 seconds in a 20 minute period (Devoe, 1990). Loss of variability is associated with fetal sleep, sedation or central nervous system depression, including fetal acidosis. The absence of accelerations or appearance of decelerations along with a history of reduced FM may indicate fetal hypoxia (Lee & Drukker, 1979) and is associated with fetal demise and Caesarean section delivery (ACOG, 2000). CTG is useful in the detection of acute hypoxia

**5. Assessment methods** 

**5.1.1 Basic Assessment** 

following assessed:

**5.1 Which investigations are beneficial?** 

Detailed history/ duration of the presenting complaint.

Maternal blood pressure, pulse rate, temperature and urinalysis.

 Auscultation of the fetal heart or a CTG over 15-20 minutes (Preboth, 2000) Clinical examination including abdominal palpation and SFH measurement

Risk factors in this or the previous pregnancy.

**5.1.2 Symphyseal fundal height measurement (SFH)** 

further investigation (Unterscheider *et al*., 2009).

**5.1.3 Non stress test – Cardiotocography (CTG)** 

assessment, umbilical artery (UA) Doppler velocimetry, formal fetal movement counting (kickcharts) and vaginal examination. These investigations may lead to interventions such as a membrane sweep or induction of labour.

An anonymous structured web-based questionnaire recently performed amongst 96 Irish obstetricians (Unterscheider *et al*., 2010) found that there was a lack of guidance in the management of reduced FM with only one third of clinicians having a clinical practice guideline in their institution. Table 2 summarizes the management and assessment methods. Results of this study demonstrated that CTG was the most favoured method of assessing fetal wellbeing (93%) followed by the use of kickcharts (64%), while 54% of obstetricians assessed the fetus with a biophysical score and 52% performed an ultrasound scan to assess liquor volume. Only 34% applied simple SFH measurement and 23% assessed umbilical artery Doppler velocimetry. In the same study, fetal biometry was performed by 20% of obstetricians and the same percentage offered vaginal examination to assess favourability. The minority recommended admission (2%) or induction of labour (4%). The study confirmed that clinicians apply multiple combinations of assessment methods with 98% of doctors performing more than one investigation. This highlights the uncertainty over optimal assessment methods in this common clinical scenario.

Table 2. Management and assessment methods of reduced fetal movements employed by Obstetricians in Ireland (Unterscheider *et al*., 2010)

Haezell *et al* recently reviewed the current practice in the United Kingdom where most obstetricians (70%) had institutional guidelines available. In contrast to the Irish study they found that only 3% of midwives and 5% of obstetricians were using kickcharts in their routine antenatal care. The majority of respondents in this questionnaire performed CTG and SFH measurement. Further evaluation including fetal biometry, umbilical artery Doppler or full biophysical profile was based on results of CTG, SFH measurement and clinical situation. The most frequently reported management option for both midwives and obstetricians was to consider admission and delivery.

There are no randomised controlled trials addressing the optimal management of reduced FM. All published studies are limited by the variation in definition and outcomes. The main outcome measure of interest, stillbirth, is relatively uncommon with an incidence of 1 in 200 births in developed countries (Stanton *et al.*, 2006), therefore large scale studies would be required to answer the question of optimal management.

assessment, umbilical artery (UA) Doppler velocimetry, formal fetal movement counting (kickcharts) and vaginal examination. These investigations may lead to interventions such

An anonymous structured web-based questionnaire recently performed amongst 96 Irish obstetricians (Unterscheider *et al*., 2010) found that there was a lack of guidance in the management of reduced FM with only one third of clinicians having a clinical practice guideline in their institution. Table 2 summarizes the management and assessment methods. Results of this study demonstrated that CTG was the most favoured method of assessing fetal wellbeing (93%) followed by the use of kickcharts (64%), while 54% of obstetricians assessed the fetus with a biophysical score and 52% performed an ultrasound scan to assess liquor volume. Only 34% applied simple SFH measurement and 23% assessed umbilical artery Doppler velocimetry. In the same study, fetal biometry was performed by 20% of obstetricians and the same percentage offered vaginal examination to assess favourability. The minority recommended admission (2%) or induction of labour (4%). The study confirmed that clinicians apply multiple combinations of assessment methods with 98% of doctors performing more than one investigation. This highlights the uncertainty over

favourability.

Table 2. Management and assessment methods of reduced fetal movements employed by

Haezell *et al* recently reviewed the current practice in the United Kingdom where most obstetricians (70%) had institutional guidelines available. In contrast to the Irish study they found that only 3% of midwives and 5% of obstetricians were using kickcharts in their routine antenatal care. The majority of respondents in this questionnaire performed CTG and SFH measurement. Further evaluation including fetal biometry, umbilical artery Doppler or full biophysical profile was based on results of CTG, SFH measurement and clinical situation. The most frequently reported management option for both midwives and

There are no randomised controlled trials addressing the optimal management of reduced FM. All published studies are limited by the variation in definition and outcomes. The main outcome measure of interest, stillbirth, is relatively uncommon with an incidence of 1 in 200 births in developed countries (Stanton *et al.*, 2006), therefore large scale studies would be

as a membrane sweep or induction of labour.

optimal assessment methods in this common clinical scenario.

Obstetricians in Ireland (Unterscheider *et al*., 2010)

obstetricians was to consider admission and delivery.

required to answer the question of optimal management.
