Overview
Reduced Fetal Movements
1. Clinical Overview
Summary
Reduced fetal movements (RFM) refers to maternal perception of decreased fetal activity below the established pattern. It is a critically important presentation that requires urgent assessment as it can be a warning sign of impending stillbirth due to fetal compromise.
Key Facts
| Aspect | Detail |
|---|---|
| Normal Movement | Usually first felt at 18-20 weeks ("Quickening"); should follow a consistent pattern |
| Assessment | Focus on pattern change, not kick counting |
| Risk | ~50% of stillbirths are preceded by RFM |
| Urgency | Requires same-day assessment if ≥28 weeks |
Clinical Pearls
- Pattern is Key: No specific number of movements is "normal" - it's the change from the baby's usual pattern that matters
- No Kick Charts: "Count to 10" kick charts are no longer recommended as they increase anxiety without improving outcomes
- Urgent Assessment: Any woman presenting with RFM after 28 weeks should be assessed within 2 hours
- Recurrent RFM: Two or more episodes of RFM require specialist review and enhanced surveillance
2. Epidemiology
Prevalence & Demographics
- RFM is reported in 4-15% of pregnancies in third trimester
- Most common reason for unscheduled antenatal presentation
- Accounts for approximately 5% of all ED/DAU attendances
Risk Factors
| Risk Factor | Notes |
|---|---|
| Maternal obesity | Reduced perception of movements (BMI ≥30) |
| Anterior placenta | May cushion movements |
| Smoking | Associated with placental insufficiency |
| Previous stillbirth | Higher risk for recurrence |
| FGR/SGA fetus | Chronic hypoxia |
| Oligohydramnios | Reduced space for movement |
| Maternal medications | Sedatives, opioids, antihistamines |
3. Pathophysiology
Mechanism of Reduced Movements
Placental Insufficiency / Fetal Compromise
↓
Reduced Oxygen Delivery
↓
Fetal Metabolic Adaptation
↓
Decreased Energy Expenditure
↓
REDUCED FETAL MOVEMENTS
↓
If Unrecognised → Fetal Acidosis → Stillbirth
Causes of Reduced Movements
| Category | Examples |
|---|---|
| Placental | Insufficiency, abruption, infarction |
| Fetal | Sleep cycle (20-40 min), FGR, anaemia, infection |
| Maternal | Sedating medications, position, distraction |
| Amniotic | Oligohydramnios, polyhydramnios |
Important Distinction
- Physiological reduction: Brief periods (20-40 min) due to fetal sleep cycle - normal
- Pathological reduction: Prolonged decrease representing fetal compensation to hypoxia
4. Clinical Presentation
History Taking - Essential Questions
| Question | Purpose |
|---|---|
| When did you last feel normal movements? | Establish timeline |
| What is baby's usual pattern? | Baseline comparison |
| Any movements at all today? | Severity assessment |
| Previous episodes of RFM? | Recurrent pattern |
| Contractions or bleeding? | Rule out labour/abruption |
| Medications taken? | Sedating drugs |
Associated Red Flags
Complete absence of movements
Common presentation.
Vaginal bleeding
Common presentation.
Severe abdominal pain
Common presentation.
Maternal fever
Common presentation.
History of reduced movements in previous pregnancy with adverse outcome
Common presentation.
5. Clinical Examination
Systematic Assessment
| Examination | Purpose |
|---|---|
| Maternal observations | BP, pulse, temperature |
| Abdominal palpation | Fundal height, lie, presentation |
| SFH measurement | Growth assessment |
| Auscultation | Confirm fetal heart |
| CTG (if ≥28 weeks) | Assess fetal wellbeing |
CTG Interpretation
| Feature | Normal | Abnormal |
|---|---|---|
| Baseline rate | 110-160 bpm | <110 or >160 bpm |
| Variability | 5-25 bpm | <5 bpm for >40 min |
| Accelerations | Present (≥2 in 20 min) | Absent |
| Decelerations | Absent | Present |
6. Investigations
First-Line Investigations
| Investigation | Timing | Purpose |
|---|---|---|
| CTG | Immediate if ≥28 weeks | Assess fetal heart rate pattern |
| Handheld Doppler | If <28 weeks | Confirm fetal heart |
Second-Line Investigations (if indicated)
| Investigation | Indication | Findings |
|---|---|---|
| Ultrasound scan | Abnormal CTG, recurrent RFM, risk factors | Growth, liquor volume, Dopplers |
| Biophysical profile | Persistent concerns | Tone, breathing, movement, liquor |
| Doppler studies | FGR suspected | UA, MCA, ductus venosus |
| Kleihauer test | Suspected fetomaternal haemorrhage | Fetal cells in maternal blood |
7. Management
Management Algorithm
RFM Presentation (≥28 weeks)
↓
Immediate Auscultation / Handheld Doppler
↓
┌────────────────┬────────────────┐
↓ ↓ ↓
FH Absent FH Present <28 weeks
↓ ↓ ↓
Confirm with CTG Assessment Handheld
USS (aim <2 hrs) Doppler
↓ ↓ ↓
Stillbirth Normal CTG FH confirmed +
Protocol + Reassuring Clinical review
↓
┌───────┴───────┐
↓ ↓
First episode Recurrent/Risk factors
↓ ↓
Reassure + Ultrasound:
Safety-net Growth, Liquor,
Dopplers
Key Management Principles
| Principle | Action |
|---|---|
| Urgency | Assess within 2 hours of presentation |
| Never reassure by phone | All RFM requires face-to-face assessment |
| CTG is first-line | Not a substitute for clinical assessment |
| Low threshold for USS | If any concern, recurrent, or risk factors |
When to Deliver
| Finding | Action |
|---|---|
| Normal CTG + normal USS | Reassure, monitor, safety-net |
| Abnormal CTG | Continuous monitoring, senior review, consider delivery |
| Abnormal Dopplers | Timing depends on specific findings |
| Absent end-diastolic flow | Urgent senior review, likely delivery |
| Reversed end-diastolic flow | Immediate delivery |
Safety-Netting Advice
- "If movements don't return to normal pattern, come back immediately"
- "Don't wait until the next day - if worried, come straight in"
- "Trust your instincts - you know your baby's pattern"
8. Complications
Potential Outcomes if RFM Not Investigated
| Complication | Significance |
|---|---|
| Stillbirth | 50% preceded by RFM |
| Perinatal morbidity | HIE, long-term neurological impairment |
| Emergency delivery | Due to fetal distress |
Recurrent RFM
- Associated with:
- FGR (4x increased risk)
- Stillbirth (increased risk)
- Preterm birth
- Lower birthweight
9. Prognosis & Outcomes
Overall Prognosis
| Scenario | Outcome |
|---|---|
| Single episode, normal investigations | Excellent - most pregnancies continue normally |
| Recurrent episodes | Requires enhanced surveillance |
| Abnormal findings | Depends on underlying cause |
Key Statistics
- 55% of women with RFM and normal CTG have normal outcome
- Appropriate investigation of RFM could prevent up to 30% of stillbirths
- Majority of RFM presentations have no underlying pathology
10. Evidence & Guidelines
Key Guidelines
| Organisation | Guideline | Key Recommendations |
|---|---|---|
| RCOG | Green-top 57 (2011) | Assessment within 2 hrs, CTG first-line |
| Tommy's | Count the Kicks | Focus on pattern, not numbers |
| NICE | Antenatal Care (2021) | No routine kick counting |
Evidence Summary
- AFFIRM trial: Awareness package - no significant reduction in stillbirth
- MAAU study: Standardised management package improved outcomes
- Kick counting not recommended (increased anxiety, no outcome improvement)
11. Patient / Layperson Explanation
For Patients
What does "reduced fetal movements" mean? It means your baby is moving less than usual. Every baby has their own pattern of movements, and what matters is if this pattern changes.
When should I be concerned?
- If you notice your baby is moving less than their normal pattern
- If you haven't felt movements at all for several hours
- If movements feel weaker than usual
What should I do if I'm worried?
- Don't wait - never leave it until the next day
- Lie on your left side in a quiet room and focus on movements for 2 hours
- If still concerned, call your maternity unit immediately
- Don't use home dopplers - they can be falsely reassuring
What will happen when I come in?
- We will check your baby's heartbeat
- You will likely have a CTG - a trace of the baby's heart rate
- Sometimes we may do an ultrasound scan
- Most of the time, everything is fine
Remember: "If in doubt, check it out" - it's always better to be checked and reassured.
12. References
- RCOG Green-top Guideline No. 57: Reduced Fetal Movements (2011)
- Heazell AEP, et al. Stillbirths: economic and psychosocial consequences. Lancet. 2016;387(10018):604-616.
- Norman JE, et al. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM). Lancet. 2018;392(10158):1629-1638.
- Warrander LK, et al. Maternal perception of reduced fetal movements is associated with altered placental structure and function. PLoS One. 2012.
- Tommy's Campaign - Count the Kicks. https://www.tommys.org