Management of Decreased Fetal Movement
The most appropriate next step is cardiotocography (CTG), which serves as the primary screening tool to immediately assess fetal well-being and identify any acute fetal compromise. 1
Immediate Assessment with CTG
CTG should be performed first as it provides rapid, real-time assessment of fetal status and is the most reliable screening indicator of fetal well-being in women presenting with decreased fetal movements. 1 This approach is supported by evidence showing:
- Normal non-stress CTG reliably excludes acute fetal compromise in 92% of cases presenting with reduced fetal movements 1
- CTG can be performed immediately upon presentation, providing results within 20-40 minutes 2
- Abnormal or non-reassuring CTG identifies the 5-8% of cases requiring urgent intervention or comprehensive assessment 1, 3
Why CTG Takes Priority Over Other Options
Ultrasound alone is insufficient as the initial test because it does not assess real-time fetal oxygenation status or acute distress patterns that CTG reveals through heart rate variability and decelerations 2, 1. While ultrasound is important for identifying chronic conditions like fetal growth restriction, it should follow CTG rather than replace it 4, 5.
Biophysical profile is too time-consuming for initial assessment and is typically reserved for cases where CTG is non-reassuring or when chronic placental insufficiency is suspected 4.
Fetal kick charts are retrospective tools used for ongoing monitoring, not acute assessment when a patient already reports decreased movements 6, 5.
Algorithmic Approach After Initial CTG
If CTG is Reassuring (Normal baseline 110-160 bpm, moderate variability, accelerations present):
- Proceed to ultrasound assessment to evaluate for chronic conditions 4, 5
- Assess amniotic fluid volume, fetal growth parameters, and placental appearance 4
- Consider umbilical artery Doppler if growth restriction is identified 2
If CTG is Non-Reassuring or Abnormal:
- Pathological CTG (absent variability with recurrent decelerations or bradycardia) requires immediate delivery planning 2
- Non-reassuring patterns warrant repeat CTG within 1 hour or continuous monitoring 1
- Emergency cesarean delivery may be indicated based on severity of abnormalities 2
Critical Clinical Pitfalls
Do not discharge patients with decreased fetal movements without CTG assessment, even if fetal heart tones are audible on auscultation, as this misses the opportunity to detect subtle signs of fetal compromise 5, 1.
Multiple presentations with decreased fetal movements significantly increase risk of stillbirth, fetal growth restriction, and preterm birth, warranting more intensive surveillance 4, 5.
Pathological CTG findings (22.7% of cases) are associated with poor pregnancy outcomes including emergency cesarean delivery, neonatal resuscitation needs, and NICU admission 1, 3.
Evidence Quality Considerations
The recommendation for CTG as the primary assessment tool is based on consistent findings across multiple studies showing its reliability as a screening test 1, though no randomized controlled trials have definitively established optimal management protocols 4, 6. The approach of combining CTG with ultrasound provides both acute and chronic fetal assessment, addressing the full spectrum of conditions associated with decreased fetal movements 4, 5.