What is the best course of action for a pregnant woman at 35 weeks gestation with decreased fetal movement, 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 is Strongly Recommended

At 35 weeks gestation with severe oligohydramnios (AFI 3 cm), fetal growth restriction (fundal height 10th percentile), and decreased fetal movements, this pregnancy requires immediate delivery, with cesarean section being the preferred route given the high-risk clinical scenario. 1, 2

Critical Assessment Required Before Delivery Decision

Umbilical Artery Doppler - Must Be Obtained Immediately

The single most important test to perform right now is umbilical artery Doppler velocimetry, as this determines both the urgency and the mode of delivery 1, 2:

• If absent end-diastolic flow (AEDV): Delivery should have already occurred by 33-34 weeks; proceed immediately with cesarean section 1, 2
• If reversed end-diastolic flow (REDV): Delivery should have already occurred by 30-32 weeks; cesarean section is indicated 1, 2
• If decreased diastolic flow: Delivery should occur by 37 weeks; at 35 weeks, proceed with delivery now 1, 2
• If normal Doppler: Delivery at 37 weeks is recommended for FGR with estimated fetal weight <10th percentile, but severe oligohydramnios at 35 weeks argues against expectant management 1, 2

Continuous Cardiotocography - Perform Immediately

Obtain continuous fetal heart rate monitoring now to assess current fetal well-being 1, 2:

• Non-reassuring pattern: Proceed directly to urgent cesarean section 2
• Reassuring pattern: Does NOT exclude severe compromise in FGR - normal heart rate patterns can persist even with severe placental dysfunction 1

Why Cesarean Section is Strongly Recommended

The combination of severe oligohydramnios (AFI 3 cm) with FGR creates a 75-95% risk of requiring cesarean delivery for intrapartum fetal heart rate abnormalities, even if current monitoring is reassuring 1, 2:

• Severe oligohydramnios represents chronic uteroplacental insufficiency with decreased fetal renal perfusion and urine production 3
• AFI of 3 cm is an independent indication for delivery consideration 2
• FGR fetuses with oligohydramnios have minimal amniotic fluid cushioning during labor, dramatically increasing cord compression risk 2
• If umbilical artery Doppler shows AEDV or REDV, cesarean delivery should be strongly considered based on the complete clinical scenario 1, 2

Why Expectant Management (Option C) is Contraindicated

Continuing this pregnancy beyond immediate assessment and delivery planning places the fetus at unacceptable risk 1, 2:

• Decreased fetal movements in the setting of FGR and severe oligohydramnios signals potential fetal decompensation 4, 5
• The combination of decreased amniotic fluid volume and decreased fetal movements is significantly associated with adverse outcomes 6
• At 35 weeks, the fetus has reached sufficient maturity that the risks of continued intrauterine exposure to severe oligohydramnios and placental insufficiency outweigh prematurity risks 1, 2

Why Tocolytics (Option D) are Absolutely Contraindicated

Tocolytics are never indicated in this scenario - they are used to delay preterm labor, not to manage FGR with oligohydramnios 3. This fetus needs delivery, not pregnancy prolongation.

Why Induction of Labor (Option B) is High-Risk but Possible

Induction could be considered ONLY if all of the following criteria are met 1, 2:

• Umbilical artery Doppler is completely normal (not just decreased flow)
• Continuous cardiotocography is reassuring
• Cervix is favorable for induction
• Continuous fetal monitoring capability is available throughout labor
• Immediate cesarean section capability is available

However, given the severe oligohydramnios and FGR combination, cesarean section remains the safer option 1, 2.

Essential Perinatal Interventions

Antenatal Corticosteroids

Administer betamethasone or dexamethasone immediately if not already given, as delivery at 35 weeks is anticipated 3, 1:

• Indicated for anticipated delivery before 36 6/7 weeks 1
• Reduces neonatal respiratory distress syndrome, intraventricular hemorrhage, and neonatal death 3

Magnesium Sulfate - Not Indicated at 35 Weeks

Magnesium sulfate for fetal neuroprotection is recommended only for pregnancies less than 32 weeks gestation 3, 1. At 35 weeks, this is not indicated.

Common Pitfall to Avoid

Do not be falsely reassured by a normal or reactive nonstress test 1. The American College of Obstetricians and Gynecologists explicitly states that normal fetal heart rate testing does not exclude severe FGR and should never be used as the sole surveillance method 1. Heart rate changes occur late in the deterioration sequence - abnormal patterns typically appear only after significant vascular changes are already present on Doppler studies 1.