What is the most appropriate next step in management for a pregnant woman presenting with decreased fetal movement?

Management of Decreased Fetal Movement

Cardiotocography (CTG) is the most appropriate next step in management for a pregnant woman presenting with decreased fetal movement, as it provides immediate assessment of fetal well-being within 20-40 minutes and can identify the need for urgent intervention. 1

Rationale for CTG as First-Line Assessment

The American Academy of Family Physicians recommends CTG as the primary screening tool because it rapidly identifies fetuses requiring immediate intervention or comprehensive assessment. 1 This approach is supported by multiple studies demonstrating that women presenting with decreased fetal movements have higher risk of stillbirth, fetal growth restriction, fetal distress, and preterm birth. 2, 3

CTG should be performed immediately upon presentation, as approximately 5-8% of cases will show abnormal or non-reassuring findings requiring urgent action. 1

Sequential Management Algorithm After Initial CTG

If CTG is Reassuring (Reactive)

• Proceed to ultrasound assessment to evaluate for chronic conditions, particularly:

  • Fetal growth restriction (estimated fetal weight or abdominal circumference <10th percentile) 4
  • Amniotic fluid volume, as decreased fetal movement alone is associated with 3.7 times greater likelihood of diminished amniotic fluid 5
  • Fetal anatomical survey if not previously completed 4

• If growth restriction is identified on ultrasound, obtain umbilical artery Doppler assessment immediately, as this is the single most important prognostic tool for determining ongoing management 4

If CTG is Non-Reassuring or Pathological

• Pathological CTG findings require immediate delivery planning, and emergency cesarean delivery may be indicated based on severity of abnormalities 1
• This represents the critical value of CTG as the first test—it can identify life-threatening situations requiring immediate intervention

Why Not the Other Options First?

Fetal kick chart (Option D) is inappropriate as an initial management step when a woman has already perceived decreased movement—this is a prospective monitoring tool, not a diagnostic test for acute presentation. 6

Ultrasound alone (Option B) misses the opportunity for immediate assessment of fetal well-being and cannot identify acute fetal compromise requiring urgent delivery. 3

Biophysical profile (Option C) is more time-consuming and is not recommended as the initial test. While it combines ultrasound parameters with CTG, starting with CTG alone is more efficient and provides the critical information needed first. 7

Common Pitfalls to Avoid

• Do not dismiss maternal perception of decreased fetal movement—women presenting on multiple occasions with decreased fetal movement are at significantly increased risk of poor perinatal outcomes including fetal death. 2

• Do not rely on reassuring CTG alone without ultrasound follow-up—the combination of CTG and amniotic fluid volume assessment is the most reasonable approach based on retrospective evidence. 5

• Do not delay CTG to schedule an ultrasound first—acute fetal compromise must be ruled out immediately before proceeding to evaluation for chronic conditions. 1, 3