Management of Decreased Fetal Movement in Pregnancy

Immediate Next Step

Cardiotocography (CTG) is the most appropriate immediate next step for a pregnant woman presenting with decreased fetal movement. 1, 2, 3

CTG provides immediate assessment of fetal oxygenation and acid-base balance, which is critical when evaluating decreased fetal movement as a potential sign of fetal compromise 1
A reactive NST (≥2 fetal heart rate accelerations in 20 minutes) has high negative predictive value, effectively ruling out acute fetal distress in the majority of cases 1, 4
CTG is non-invasive, quick to perform, and easily repeatable, making it the ideal first-line screening tool in this clinical scenario 1
92% of women presenting with decreased fetal movement will have a reassuring CTG, and these patients have excellent perinatal outcomes with no perinatal deaths following normal CTG 4

After initial CTG, the evaluation should proceed as follows:

If CTG is reactive (reassuring):

Add amniotic fluid volume assessment to create a modified biophysical profile, which is the recommended approach rather than proceeding directly to full BPP 1
Maximum vertical pocket (MVP) ≥2 cm is considered normal throughout gestation 1
If both CTG and amniotic fluid are normal, the patient can be reassured and return to routine prenatal care 1, 4

If CTG is non-reassuring or abnormal:

Proceed to full biophysical profile including fetal breathing movements, discrete body movements, fetal tone, and amniotic fluid (score of 8-10 is normal) 1
Consider umbilical artery Doppler if fetal growth restriction is suspected 1
Patients with abnormal or persistently non-reassuring CTG have significantly higher rates of emergency cesarean delivery, neonatal resuscitation, and NICU admission 4

If oligohydramnios is detected:

Full BPP is indicated, as oligohydramnios may indicate uteroplacental insufficiency and fetal compromise 1
Fetal biometry should be performed if not recently done, to assess for growth restriction (estimated fetal weight <10th percentile) 1

Ultrasound alone (Option B):

While ultrasound is important for assessing amniotic fluid and fetal growth, it does not provide immediate information about current fetal oxygenation status 1
Ultrasound should be performed after or concurrent with CTG, not as the sole initial test 1, 3

Biophysical profile (Option C):

Full BPP is reserved as a secondary test when NST is non-reactive or other abnormalities are detected 1
Starting with full BPP is unnecessarily time-consuming when 92% of cases will have reassuring CTG 1, 4

Fetal kick chart (Option D):

The patient has already perceived decreased movement, making prospective kick counting irrelevant at this point 3
No proposed definitions of decreased fetal movements have been proven superior to subjective maternal perception for identifying at-risk populations 3
Kick charts are for ongoing surveillance, not acute assessment 3

Women presenting with decreased fetal movement have higher risk of stillbirth, fetal growth restriction, fetal distress, and preterm birth 2, 3
Women presenting on multiple occasions with decreased fetal movement are at increased risk of poor perinatal outcomes 2
No antenatal test can predict acute events such as placental abruption or cord accidents, which account for many stillbirths even with normal recent testing 1
Normal CTG is highly reassuring, with false negatives (stillbirth within 1 week of normal test) being uncommon 1

Do not dismiss maternal perception of decreased movement as anxiety without objective testing, as this population has documented increased risk 2, 3
Do not delay CTG to perform ultrasound first, as CTG provides the most immediate information about fetal well-being 1, 4
Do not assume a single normal test provides indefinite reassurance if the patient continues to perceive decreased movement 2