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 at 35 Weeks with Severe Oligohydramnios and Fetal Growth Restriction

This patient requires immediate delivery—the combination of decreased fetal movements, severe oligohydramnios (AFI 3 cm), and fetal growth restriction at 35 weeks represents significant fetal compromise that mandates expedited delivery rather than expectant management. 1

Critical Assessment Required Before Delivery Decision

Umbilical Artery Doppler (Perform Immediately)

The mode and urgency of delivery depends entirely on umbilical artery Doppler findings, which must be obtained immediately if not already done 1:

• Reversed end-diastolic velocity (REDV): Cesarean delivery is indicated—delivery should have occurred by 30-32 weeks 1, 2
• Absent end-diastolic velocity (AEDV): Cesarean delivery should be strongly considered—delivery should have occurred by 33-34 weeks 1, 2
• Decreased diastolic flow: Proceed with immediate delivery (should have occurred by 37 weeks)—induction is reasonable if fetal monitoring reassuring 1
• Normal Doppler: Induction of labor is reasonable with continuous fetal monitoring 1

Continuous Cardiotocography (Perform Immediately)

Assess fetal well-being with continuous CTG monitoring 1:

• Non-reassuring fetal heart rate pattern: Urgent cesarean section required 1
• Reassuring pattern with normal Doppler: Induction of labor reasonable 1

Critical caveat: Normal fetal heart rate testing does NOT exclude severe fetal compromise in growth-restricted fetuses—heart rate changes occur late in the deterioration sequence, only after significant vascular changes are already present 2

Why Each Option is Appropriate or Inappropriate

Option D (Tocolytics): Contraindicated

Tocolytics are absolutely contraindicated in fetal growth restriction with oligohydramnios—they are used to delay preterm labor in otherwise healthy pregnancies, not to manage established fetal compromise 1

Option C (Expectant Management): Inappropriate and Dangerous

The combination of severe oligohydramnios (AFI 3 cm) with fetal growth restriction at 35 weeks significantly increases perinatal risk and argues strongly against expectant management 1:

• Severe oligohydramnios is an independent indication for delivery 1
• International guidelines state that abnormal amniotic fluid volume with IUGR at term mandates delivery consideration 1
• Decreased fetal movements combined with severe oligohydramnios indicates chronic uteroplacental insufficiency with decreased fetal renal perfusion 1, 3
• The fetal death rate doubles in fetuses with growth restriction below the 10th percentile 2

Option B (Induction of Labor): Appropriate IF Doppler Normal and CTG Reassuring

Induction is reasonable when 1:

• Umbilical artery Doppler is normal
• Continuous fetal monitoring shows reassuring pattern
• Mandatory requirement: Continuous electronic fetal monitoring during labor, as IUGR fetuses are at high risk for intrapartum hypoxia 1
• Warning: 75-95% of IUGR pregnancies with severe oligohydramnios require cesarean delivery for intrapartum fetal heart rate abnormalities 1

Option A (Cesarean Section): Strongly Consider Based on Doppler

Cesarean delivery is indicated when 1, 2:

• Abnormal umbilical artery Doppler (AEDV or REDV)
• Non-reassuring fetal heart rate pattern on CTG
• Severe oligohydramnios with abnormal Doppler carries 75-95% risk of requiring cesarean for intrapartum complications 1

Essential Immediate Interventions

Antenatal Corticosteroids (Administer Immediately)

Give betamethasone or dexamethasone immediately if not already administered, as delivery at 35 weeks is anticipated—this reduces neonatal respiratory distress syndrome, intraventricular hemorrhage, and neonatal death 1, 2

Clinical Context and Risk Stratification

The highest risk for poor neonatal outcome (18.4%) in pregnancies with decreased fetal movements occurs in small-for-gestational-age fetuses 4. This patient's fundal height at the 10th percentile with severe oligohydramnios places her in this highest-risk category.

The association between decreased amniotic fluid and decreased fetal movements is well-established and occurs irrespective of gestational age 3. Severe oligohydramnios before adequate term (37 weeks) is associated with significantly poor outcomes, including lower Apgar scores, increased fetal distress during labor (10%), meconium presence (17%), and increased cesarean delivery rates 5.

Bottom line: Expectant management and tocolytics are inappropriate. The decision between induction versus cesarean section depends on umbilical artery Doppler and continuous fetal monitoring results, which must be obtained immediately.