When should pregnant individuals start tracking fetal kick counts and what is the protocol if decreased fetal movement is detected?

Fetal Kick Counts: When to Start and Response Protocol

Pregnant individuals should begin daily fetal movement counting at 28 weeks gestation, and any report of decreased fetal movement requires immediate evaluation with cardiotocography (NST) and ultrasound assessment of amniotic fluid volume and fetal well-being, regardless of whether formal alarm criteria are met.

When to Initiate Fetal Movement Counting

• Start at 28 weeks gestation for all pregnancies, particularly those at high risk for complications 1, 2, 3
• High-risk conditions warranting surveillance include advanced maternal age, obesity, hypertensive disorders, diabetes, chronic renal disease, history of stillbirth, intrauterine growth restriction, and amniotic fluid abnormalities 4
• The 28-week threshold aligns with when antenatal surveillance typically begins (32-34 weeks for most high-risk patients, but movement counting can start earlier) 4

Recommended Counting Method

The "Count-to-10" method is the most practical and evidence-based approach:

• Begin counting at a selected time each day when the fetus is typically active 3
• Count 10 distinct fetal movements and record the elapsed time from the first to the tenth movement 3
• Most women complete this count within 2 hours; the entire process should not exceed 12 hours 2, 5
• An alternative is counting movements for 15 minutes every evening and establishing an individual baseline from the first five counts 2

Alarm Criteria: When to Report Decreased Movement

Immediate evaluation is required for any of the following:

• Fewer than 10 movements in 12 hours 3, 5
• No perception of movement in an 8-hour period 3
• Any change in the usual pattern of fetal movement, even if formal criteria aren't met 3
• Sudden increase in violent movements followed by complete cessation 3
• Maternal perception of decreased activity, regardless of count numbers 1, 6

Critical Pitfall to Avoid

Approximately 30% of women report decreased movement despite no formal alarm signal, and 31% fail to report when alarm criteria are met 2. Therefore, clinical response should be based on maternal concern about decreased movement, not solely on whether counting criteria are violated 5.

Immediate Response Protocol for Decreased Fetal Movement

When a pregnant individual reports decreased fetal movement, the following evaluation must occur promptly:

Initial Assessment (Same-Day Evaluation Required)

• Nonstress test (NST/cardiotocography) to assess immediate fetal oxygenation and acid-base balance 7, 4

  • Reactive NST: ≥2 fetal heart rate accelerations in 20 minutes (15 bpm above baseline for 15 seconds at ≥32 weeks; 10 bpm for 10 seconds at <32 weeks) 7
  • Non-reactive NST after 40 minutes requires further evaluation 7

• Ultrasound assessment of amniotic fluid volume to evaluate chronic placental function 7, 4

  • Maximum vertical pocket (MVP) ≥2 cm is normal throughout gestation 7
  • Amniotic fluid index (AFI) ≥5 cm at ≥37 weeks or ≥8 cm at <37 weeks 7
  • Oligohydramnios may indicate uteroplacental insufficiency 7

Extended Evaluation Based on Initial Findings

If NST is non-reactive or amniotic fluid is abnormal:

• Full biophysical profile (BPP) including fetal breathing movements, discrete body movements, fetal tone, and amniotic fluid 7

  • Score of 8-10 is normal, 6 is equivocal, ≤4 is abnormal 7

• Umbilical artery Doppler assessment if fetal growth restriction is suspected 7, 8

  • Absent or reversed end-diastolic flow is always abnormal and requires urgent management 7, 8

• Fetal biometry if not recently performed, to assess for growth restriction 7

  • Growth restriction defined as estimated fetal weight <10th percentile 7

Clinical Benefits and Evidence Quality

• Fetal movement counting improves identification of fetal growth restriction (87% vs 60% detection rate) and reduces low Apgar scores (0.4% vs 2.3%) without increasing consultation rates or unnecessary interventions 1
• The intervention reduces maternal anxiety rather than increasing it, with lower worry scores compared to controls 6
• Approximately 79% of pregnant women are willing and able to perform daily movement counting 2
• No antenatal test can predict acute events like placental abruption or cord accidents, but normal testing is highly reassuring with rare false negatives 4

Management After Reassuring Evaluation

• If initial evaluation is completely normal (reactive NST, normal amniotic fluid, appropriate growth), reassure the patient but maintain heightened awareness 5
• Do not dismiss maternal concern—instruct the patient to return immediately if decreased movement recurs 3, 5
• Continue daily fetal movement counting throughout the remainder of pregnancy 1, 6
• Consider increasing surveillance frequency (twice-weekly NST) if concerns persist, even with normal testing 4