What is the management plan for a pregnant woman experiencing reduced fetal movement?

Management of Reduced Fetal Movement

When a pregnant woman reports reduced fetal movement, immediately perform cardiotocography (CTG/nonstress test) combined with ultrasound assessment of amniotic fluid volume—this modified biophysical profile approach provides both acute and chronic fetal well-being assessment and guides all subsequent management decisions. 1, 2, 3, 4

Immediate Assessment Protocol

Primary Testing (Perform Both)

• Cardiotocography (CTG/Nonstress Test): This provides real-time assessment of acute fetal oxygenation status within 20-40 minutes 1, 2

  • A reactive NST is defined as ≥2 fetal heart rate accelerations in 20 minutes 1
  • Reactive NST has a negative predictive value >99.9%, with stillbirth risk within 1 week of only 0.8 per 1,000 cases (0.08%) 1

• Amniotic Fluid Volume Assessment: This evaluates chronic placental function over the preceding week 1

  • Maximum vertical pocket (MVP) ≥2 cm is considered normal throughout gestation 1
  • Amniotic fluid index (AFI) ≥5 cm at ≥37 weeks or ≥8 cm at <37 weeks is normal 1
  • Oligohydramnios may indicate uteroplacental insufficiency and is an independent risk factor for stillbirth 1

Management Algorithm Based on Initial Testing

If BOTH NST is reactive AND amniotic fluid is normal:

• Reassure the patient—this combination is highly predictive of fetal well-being 1, 4
• No additional testing is warranted unless the patient has other high-risk conditions 4
• Counsel on continued fetal movement monitoring and when to return 1

If NST is non-reactive OR amniotic fluid is abnormal:

• Proceed immediately to full biophysical profile (BPP) 1, 2
• The full BPP includes fetal breathing movements, discrete body movements, fetal tone, and amniotic fluid 1
• BPP score of 8-10 is normal; score ≤6 requires immediate delivery regardless of gestational age 1

If oligohydramnios is detected:

• This is an indication for full BPP evaluation 1
• At term (≥37 weeks), oligohydramnios is an indication for delivery 1

Extended Evaluation When Indicated

Fetal Biometry Assessment

• Perform fetal biometry if not recently done to assess for growth restriction 1
• Growth restriction is defined as estimated fetal weight <10th percentile 1
• Women presenting multiple times with decreased fetal movements are at increased risk for intrauterine growth restriction 5, 3

Umbilical Artery Doppler

• Perform umbilical artery Doppler if growth restriction is suspected 1, 2
• Absent or reversed end-diastolic flow is always abnormal and requires urgent management 1
• Reversed end-diastolic flow represents extreme placental insufficiency and mandates delivery by cesarean section at ≥32 weeks after corticosteroids 1, 6
• Absent end-diastolic flow warrants delivery at ≥34 weeks after corticosteroids 1

High-Risk Context Recognition

Women with decreased fetal movements who also have the following conditions require heightened surveillance 1:

• Advanced maternal age or obesity
• Hypertensive disorders or diabetes
• Chronic renal disease or thyroid disorders
• History of unexplained stillbirth
• Multiple gestations
• Fetal arrhythmias

Critical Pitfalls to Avoid

• Do not perform routine fetal surveillance in low-risk pregnancies—this can cause iatrogenic prematurity from false-positive results 1
• Do not use non-reactive NST alone for delivery decisions—always perform additional testing such as BPP or modified BPP 1
• Do not ignore amniotic fluid assessment—oligohydramnios is an independent risk factor for stillbirth 1
• Do not rely on formal fetal movement counting protocols—maternal subjective perception of decreased movements is sufficient to warrant evaluation 7, 3

Important Limitations

• 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 are uncommon but possible with normal testing 1
• Women presenting on multiple occasions with decreased fetal movements are at significantly increased risk of poor perinatal outcomes including fetal death, growth restriction, or preterm birth 5, 3

Ongoing Surveillance if Initial Testing Normal

• For most high-risk patients, if surveillance is initiated, continue weekly or twice-weekly testing until delivery 1
• The optimal testing interval lacks rigorous scientific evidence, but this has become standard clinical practice 1
• Counsel patients to continue monitoring fetal movements and return immediately if concerns recur 1