What is the best course of action for a pregnant woman at 35 weeks gestation with decreased fetal movement, oligohydramnios (low amniotic fluid level), and a small for gestational age (SGA) fetus with a fundal height at the 10th percentile?

Immediate Delivery is Indicated - Cesarean Section Should Be Strongly Considered

At 35 weeks gestation with fetal growth restriction (fundal height at 10th percentile), severe oligohydramnios (AFI 3 cm), and decreased fetal movements, delivery should occur immediately rather than expectant management or tocolysis. The critical decision between cesarean section versus induction of labor depends urgently on umbilical artery Doppler findings and fetal heart rate monitoring, which must be obtained immediately. 1, 2

Immediate Assessment Required

Before determining the mode of delivery, two critical evaluations must be performed immediately:

Umbilical Artery Doppler (Highest Priority)

• Obtain umbilical artery Doppler studies immediately - this single test determines both the urgency and the mode of delivery 1, 2
• Serial umbilical artery Doppler assessment is the primary surveillance tool once fetal growth restriction is diagnosed, not heart rate monitoring alone 3, 4
• The Doppler findings will dictate whether this pregnancy should have already been delivered weeks ago 1, 2

Continuous Cardiotocography

• Perform continuous fetal heart rate monitoring immediately to assess for signs of fetal compromise 1, 2
• Normal fetal heart rate testing does not exclude significant fetal compromise in growth-restricted fetuses - heart rate changes occur late in the deterioration sequence 4
• Decreased fetal movements combined with growth restriction and oligohydramnios significantly increases the risk of abnormal fetal heart rate patterns 5, 6

Decision Algorithm Based on Doppler Results

If Umbilical Artery Doppler Shows Normal Flow:

• Proceed with induction of labor at this 35-week gestation 1
• Delivery at 38-39 weeks is recommended for fetal growth restriction with normal Doppler when estimated fetal weight is between 3rd-10th percentile, but severe oligohydramnios (AFI 3 cm) is an independent indication for earlier delivery 3, 1
• The combination of growth restriction with severe oligohydramnios significantly increases perinatal risk and mandates delivery rather than expectant management 1
• Continuous electronic fetal monitoring during labor is mandatory as growth-restricted fetuses are at high risk for intrapartum hypoxia 1, 4

If Umbilical Artery Doppler Shows Decreased Diastolic Flow:

• Delivery should have already occurred by 37 weeks - proceed immediately with delivery 3, 1, 2
• Either induction or cesarean section is reasonable depending on cervical favorability and fetal heart rate pattern 1
• At 35 weeks, this finding alone warrants immediate delivery 3, 2

If Umbilical Artery Doppler Shows Absent End-Diastolic Velocity (AEDV):

• Delivery should have already occurred by 33-34 weeks - this pregnancy is significantly overdue for delivery 3, 1, 2
• Cesarean delivery should be strongly considered based on the clinical scenario 3, 1, 2
• Studies report 75-95% of pregnancies with growth restriction and AEDV require cesarean delivery for intrapartum fetal heart rate abnormalities 1, 2
• Neonatal morbidity/mortality rates with AEDV exceed complications of prematurity at 33-34 weeks 2

If Umbilical Artery Doppler Shows Reversed End-Diastolic Velocity (REDV):

• Delivery should have already occurred by 30-32 weeks - this represents severe placental dysfunction with high risk of fetal demise 3, 1, 2
• Cesarean delivery is indicated - do not attempt induction of labor 1, 2
• This finding represents severe fetal compromise requiring immediate delivery 3, 2

If Fetal Heart Rate Shows Non-Reassuring Pattern:

• Proceed directly to urgent cesarean section regardless of Doppler findings 1, 2
• An ominous cardiotocography pattern in the setting of growth restriction at 35 weeks with severe oligohydramnios indicates established fetal compromise 2
• Induction of labor is contraindicated when the fetus is already demonstrating severe compromise 2

Why Expectant Management (Option C) is Contraindicated

Expectant management is absolutely inappropriate in this clinical scenario for multiple reasons:

• At 35 weeks with fetal growth restriction between 3rd-10th percentile and normal Doppler, delivery is already recommended at 38-39 weeks - this patient is only 3-4 weeks away from that threshold 3, 1
• Severe oligohydramnios (AFI 3 cm) is an independent indication for delivery and argues strongly against expectant management 1
• The combination of growth restriction with oligohydramnios significantly increases perinatal risk 1, 7
• Decreased fetal movements in the context of growth restriction and oligohydramnios suggests possible fetal compromise requiring immediate evaluation and likely delivery 5, 6
• Patients presenting with decreased fetal movements on multiple occasions are at increased risk of fetal death, intrauterine growth restriction, and preterm birth 5

Why Tocolytics (Option D) are Contraindicated

Tocolytics have absolutely no role in this clinical scenario:

• Tocolytics are used to delay preterm labor, but this patient is not in labor - she is presenting with decreased fetal movements and evidence of fetal compromise 3
• The goal in fetal growth restriction with oligohydramnios is delivery, not pregnancy prolongation 3, 1
• Sildenafil and activity restriction are specifically recommended against for in utero treatment of fetal growth restriction 3
• Prolonging pregnancy in the setting of growth restriction with severe oligohydramnios increases the risk of fetal death 1, 7

Additional Management Considerations

Antenatal Corticosteroids

• Administer antenatal corticosteroids immediately given delivery at 35 weeks is indicated 3, 2, 4
• Corticosteroids should be given between 24+0 and 34+0 weeks but may be given up until 38+0 weeks in cases of elective cesarean section 3
• For pregnancies between 34 0/7 and 36 6/7 weeks at risk of delivery within 7 days, corticosteroids are recommended 2, 4

Magnesium Sulfate

• Magnesium sulfate for fetal neuroprotection is not indicated at 35 weeks as it is recommended only for pregnancies <32 weeks gestation 3, 2, 4

Critical Pitfalls to Avoid

• Do not rely on reassuring fetal heart rate testing alone - normal heart rate patterns do not exclude significant fetal compromise in growth-restricted fetuses 4
• Do not delay delivery waiting for "more data" - the combination of growth restriction, severe oligohydramnios, and decreased fetal movements at 35 weeks mandates immediate action 1, 2
• Do not attempt induction if Doppler shows AEDV or REDV - these findings strongly favor cesarean delivery due to high rates of intrapartum fetal heart rate abnormalities requiring emergency cesarean 1, 2
• Do not use biophysical profile or cardiotocography as the sole surveillance method - umbilical artery Doppler is the primary tool for managing fetal growth restriction 3, 4