What is the recommended course of action for a 38-week pregnant woman with a history of decreased fetal movement, now presenting with a reactive non-stress test (NST)?

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Management of 38-Week Pregnancy with Reactive NST Following Decreased Fetal Movement

A reactive NST at 38 weeks following decreased fetal movement provides reassurance of current fetal well-being, but you must immediately assess for additional risk factors—particularly oligohydramnios and fetal growth restriction—before deciding between expectant management with continued surveillance versus proceeding to delivery. 1

Immediate Assessment Required

Essential Next Steps

  • Perform ultrasound to assess amniotic fluid volume using either amniotic fluid index (AFI) or maximum vertical pocket measurement, as oligohydramnios at term warrants delivery consideration 1, 2

  • Obtain estimated fetal weight (EFW) to rule out fetal growth restriction, as this fundamentally changes management even with a reactive NST 3, 2

  • Perform umbilical artery Doppler velocimetry if any concern for growth restriction exists, as abnormal Doppler findings mandate immediate delivery at this gestational age 1, 3

Clinical Decision Algorithm

If Normal Amniotic Fluid AND Normal Fetal Growth:

  • Reassure the patient that the reactive NST indicates fetal well-being for approximately one week 4

  • Continue routine prenatal care with delivery planning at 39-40 weeks 1

  • Counsel on continued fetal movement monitoring and return precautions for recurrent decreased movement 5

  • Schedule repeat NST in 3-7 days if patient remains concerned or has ongoing perception of decreased movement 1

If Oligohydramnios Detected (AFI <5 cm):

  • Proceed to delivery at 38 weeks, as oligohydramnios at term represents chronic uteroplacental insufficiency and is an independent indication for delivery 1, 2

  • Induction of labor is reasonable if fetal monitoring remains reassuring and no other contraindications exist 1

If Fetal Growth Restriction Identified:

With Normal Umbilical Artery Doppler:

  • Deliver at 38-39 weeks when EFW is between 3rd-10th percentile 3, 2
  • Induction of labor is appropriate with continuous fetal monitoring 3

With Abnormal Umbilical Artery Doppler:

  • Decreased diastolic flow: Deliver immediately at 38 weeks (should have occurred by 37 weeks) 3
  • Absent end-diastolic velocity (AEDV): Strongly consider cesarean delivery (should have occurred by 33-34 weeks) 3, 2
  • Reversed end-diastolic velocity (REDV): Cesarean delivery indicated (should have occurred by 30-32 weeks) 3, 2

If FGR with Oligohydramnios:

  • Cesarean delivery should be strongly considered due to 75-95% risk of intrapartum fetal heart rate abnormalities requiring emergency cesarean 2

  • Continuous fetal monitoring is mandatory if attempting induction 3, 2

Critical Caveats About Reactive NST

Limitations to Understand:

  • A reactive NST only confirms brainstem function and adequate oxygenation at that moment—it does not predict acute events like cord accidents or abruption that can occur after testing 6

  • False negative rate exists: Fetal death can occur within 7 days of a reactive NST in approximately 0.026% of cases, typically from cord accidents or abruption 6

  • NST cannot detect structural abnormalities: Severe congenital brain malformations can exist despite reactive tracings, as the test only measures brainstem reflexes 7

  • Routine antenatal testing cannot predict stillbirth from acute changes in maternal-fetal status 1

Common Pitfalls to Avoid:

  • Do not rely solely on NST for surveillance in high-risk pregnancies—combine with ultrasound assessment of amniotic fluid and growth 1

  • Do not use biophysical profile (BPP) or modified BPP as sole surveillance method for fetal growth restriction management 3

  • Do not delay delivery at 38 weeks if oligohydramnios or FGR is present, even with a reactive NST, as these conditions independently increase perinatal risk 1, 2

  • Watch for decelerations on the NST tracing, as their presence may identify fetuses at risk for cord accidents despite overall reactivity 6

Surveillance Frequency if Expectant Management Chosen

  • Weekly NST and amniotic fluid assessment is standard for continued surveillance in high-risk pregnancies 1

  • Twice-weekly testing may be appropriate for certain high-risk conditions like insulin-requiring diabetes 8

  • Patient should return immediately for recurrent decreased fetal movement, vaginal bleeding, contractions, or rupture of membranes 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Intrauterine Growth Restriction at 38 Weeks with Severe Oligohydramnios

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Timing of Delivery for Fetal Growth Restriction (FGR) with Abnormal Dopplers

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Research

The fetal non-stress test.

The Journal of family practice, 1983

5
Research

Decreased fetal movements: background, assessment, and clinical management.

Acta obstetricia et gynecologica Scandinavica, 2004

6
Research

The nonstress test: the false negative test.

American journal of obstetrics and gynecology, 1982

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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