When and how should fetal movement be monitored during pregnancy?

When and How to Monitor Fetal Movement

Timing of Fetal Movement Monitoring

Mothers should be taught to monitor fetal movements during the last 8-10 weeks of pregnancy (starting around 28-32 weeks' gestation) and report immediately any reduction in the perception of fetal movements. 1

• For high-risk pregnancies (including gestational diabetes, hypertension, advanced maternal age, obesity, chronic renal disease, thyroid disorders, history of stillbirth, or intrauterine growth restriction), formal antepartum fetal surveillance should be initiated at 32-34 weeks' gestation 1, 2
• Women with gestational diabetes specifically should begin self-monitoring of fetal movements during the last 8-10 weeks of pregnancy 1
• Low-risk pregnancies do not require formal antenatal testing beyond maternal awareness of fetal movements, as routine testing can cause iatrogenic prematurity from false-positive results 2

How to Monitor Fetal Movements

Self-Monitoring Approach

Women should develop daily awareness of their baby's normal movement pattern rather than using rigid counting methods. 3, 4

• Most women (69.5%) concentrate on fetal movements daily using a non-structured approach, which is acceptable for monitoring 5
• Women should recognize their individual fetus's pattern, as there is great interindividual variation that does not allow general normal limits 4
• Normal patterns include increasingly strong movements as pregnancy advances, with most strong movements felt in the evening (72.8%) and at night-time/bedtime (74.5%) 3
• Fetal hiccups are perceived by most women (78.8%) and are normal 3
• Women are more likely to perceive moderate or strong movements when sitting quietly compared with other activities 3

Structured Counting Methods (Optional)

• Some women (9.9%) use daily structured counting methods, such as counting the time necessary for 10 fetal movements 4, 5
• Alternative method: counting the number of fetal movements during a 15-minute period 4
• Women using structured daily counting had lower risk of neonatal nursery transfer (RR 0.25,95% CI 0.03-0.94) compared to non-structured monitoring 5

What Constitutes Abnormal Fetal Movement

A pronounced decrease up to cessation of fetal movements represents a "movements alarm signal" indicating severely disturbed fetus and impending intrauterine fetal death, requiring immediate evaluation. 6

• Decreased fetal movements are seen in chronic fetal distress (preeclampsia, hypertension) 6
• Sudden increase of fetal movements can indicate acute fetal distress (cord complications, placental abruption) 6
• Fetal movements cease before fetal death while fetal heart beats remain audible for at least 12 hours 6
• Any reduction in perception of fetal movements, particularly in the evening when movements are normally strongest, should prompt immediate reporting 1, 3

Clinical Response to Decreased Fetal Movements

Initial Assessment

When a woman reports decreased fetal movements, perform a nonstress test (NST) to assess immediate fetal oxygenation and acid-base balance. 2

• A reactive NST (≥2 fetal heart rate accelerations in 20 minutes) is reassuring 2
• Assess amniotic fluid volume with maximum vertical pocket (MVP) ≥2 cm considered normal 2
• Fetal movement monitoring is more reliable than urinary estriol determination in predicting impending fetal death 6

Extended Evaluation if Initial Testing Abnormal

• Perform full biophysical profile (BPP) if NST is non-reactive or amniotic fluid is abnormal, with score of 8-10 considered normal 2
• Conduct umbilical artery Doppler assessment if fetal growth restriction is suspected 2
• Perform fetal biometry if not recently done to assess for growth restriction (estimated fetal weight <10th percentile) 2

Critical Limitations and Caveats

No antenatal test can predict stillbirth related to acute events such as placental abruption or cord accidents, regardless of test frequency or type. 1, 2

• False negatives (stillbirth within 1 week of normal test) are uncommon but possible 1
• Weekly or twice-weekly formal testing has become standard in high-risk pregnancies, though optimal interval lacks rigorous evidence 1, 2
• FHR changes appear 1-4 days after the movements alarm signal appears 6
• Continuous electronic fetal monitoring is recommended during labor for all cases with decreased fetal movement concerns 1, 2