**1. Introduction**

206 From Preconception to Postpartum

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Maternal awareness of fetal movements serves as an indicator of fetal wellbeing and its reduction alerts clinicians to pregnancies at risk of complications. A reduction of fetal movements (FM) causes concern and anxiety, both for the mother and obstetrician, and is a common reason for referral to hospital. Decreased fetal movements affect up to 15% of pregnancies (Sergent *et al*., 2005; Heazell *et al*., 2008). Of those women, 85% are concerned about fetal wellbeing and 53% are afraid that the baby might die (Tveit *et al*., 2006). The perception of reduced movements is highly subjective to the mother and has clinical significance as a predictor of adverse pregnancy outcome - therefore any concerns should be taken seriously and assessed appropriately.

Conditions associated with diminished fetal movements are summarised in Table 1 and may vary from serious clinical diagnoses such as intrauterine fetal death, intrauterine fetal growth restriction and oligohydramnios, hydrops fetalis and polyhydramnios to other causes such as fetal sleep, anterior placental location, increased body mass index, maternal smoking, metabolic and endocrine disorders or a busy mother who is simply not concentrating on fetal movements. The most common single cause of stillbirth is intrauterine fetal growth restriction (IUGR). Some reports suggest 11-29% of women presenting with reduced FM carry a small for gestational age (SGA) fetus under the 10th centile (Heazell *et al*., 2005; Sinha *et al*., 2007). Sergent *et al*retrospectively reviewed 160 patients complaining of reduced FM and reported 4.3% of fetuses with severe growth restriction in their cohort (Sergent *et al*., 2005). The clinical significance of reduced FM may be unclear until pathological underlying causes have been excluded. Placental dysfunction has been identified as a key factor in pregnancies affected by diminished FM (Warrander *et al*., 2011). There are a wide variety of investigations available, some of which are not proven to be useful in the detection of a fetus at risk or to promote timely intervention. This can lead to unnecessary investigation of otherwise uncomplicated pregnancies, which results in maternal anxiety, inconvenience and increased obstetric intervention.

The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) under the umbrella of the National Institute for Clinical Excellence (NICE) collected and analysed data of deaths between 20 weeks gestation and one year of life. In their 8th annual report they reviewed 422 stillbirths and found that 45% of them were associated with suboptimal care; 69 cases (16.4%) were related to altered or reduced fetal movements. Concerns were raised over the

Reduced Fetal Movements 209

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

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

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

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.

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

improves and a pattern of cycling becomes established.

to diagnosis (Efkarpidis *et al*., 2004).

al., 1989; Moore & Piacquadio, 1989).

**4. Current practice** 

**3. Definition** 

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 occur.


Table 1. Conditions associated with maternal perception of reduced fetal movements (Unterscheider *et al*., 2009)

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 pregnancies.

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 and improved perinatal outcomes.
