Audit: Management of women with perceived reduced fetal
movement
Maternity Unit, Southern General Hospital, Glasgow
Angela Gillan
University of Glasgow
MBChB 5
August 2011
Page 1
Background
Maternal perception of fetal movements, although subjective is the most commonly used method to
assess fetal wellbeing. A sudden change or reduction in fetal movements is an important clinical sign
that has been reported to precede intrauterine fetal death by 24hours1, however there is little
agreement as to what constitutes normal fetal movement2. Current NICE guidelines state that fetal
movement counting should not form part of routine antenatal screening but that women who do
experience RFM should present for further assessment, however the guideline does not detail how
the woman should be investigated3.
This has led to the Royal College of Obstetricians and
Gynaecologists (RCOG) to produce their own set of guidelines, to provide a format for maternal and
fetal investigation.
Aims
To compare the management of women presenting to the maternity unit at the Southern General
Hospital, Glasgow reporting reduced fetal movement (RFM) with the recommended management as
outlined in the Royal College of Obstetricians and Gynaecologists Green-top Guideline 57, published
February 2011.
Standards
Royal College of Obstetricians and Gynaecologists Green-top Guideline 57, published February
20114.
Within this guideline is a flow chart detailing the management of RFM for those >28weeks gestation,
see figure 1
Page 2
Figure 1
Methods
A list of all women who presented to maternity services during the month of June 2011 reporting
RFM was obtained by going through records held from daycare phone-in book, daycare
appointments list, and maternity assessment arrivals book. Patient notes were requested from
Maternity Records department and patient data was collected from case notes using a designed
audit pro-forma, see appendix 1.
Completed pro-forma sheets were recorded using Microsoft Excel spreadsheet and analysed using
statistical programs; Minitab and SPSS.
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Results
A total of 134 (10.8%) patients reported RFM during June 2011 out of a possible 1241 patients who
reported to the department whether over the phone or attended. Figure 2 details the loss of
patients from study.
Figure 2
One hundred and three patients were therefore analysed for the purpose of this audit. The mean
age of women was 29.8yrs (16yrs - 43yrs), see figure 3. Fifty nine (57%) women were married, 41
(40%) in a relationship and 2 (2%) patients were single. Ninety one (88%) women were non smokers,
8 smoked less than 10/day, and 4 patients had no mention of smoking status. Eighty five (82.5%)
women reported no alcohol consumption at booking, for seventeen women this part of notes was
blank, and one patient said they drank 1-2 units per week. The mean BMI was 25.8 kg/m2 (18.0-37.9
kg/m2), with 55% of women being classified as overweight or obese, see figures 4 and 5.
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The mean gestation of the women was 34.728 weeks, ie 34+5 weeks, range 19 – 41+5 weeks, see
figure 6. Fetal presentation was mainly cephalic, 62 women (60.2%), 6 (5.8%) women had a breech
position, two women were carrying twins in which one was cephalic and the other transverse and
breech, and in a further 33 (32%) women, fetal presentation was not recorded in patient notes.
Data for delivery, sex and weight of baby was available for those women who had delivered by the
time data collection for this audit was finished at the end of July 2011. Thirty five (34.0%) women
delivered by SVD, 16 (15.5%) ended up requiring an EMLUSCS, 4 (3.9%) had an ELLUSCS. Seven
women required an assisted delivery. Of those that had delivered 33 (32%) women had a boy and
28 (27.2%) a girl. The mean weight of the newborns was 3.50kg (1.82 – 4.68kg), see figure 7.
What is the optimal management of women with RFM?
RCOG guidelines state that the initial goal is to exclude fetal death and then ‘exclude any fetal
compromise and identify any pregnancies at risk of adverse outcome whilst avoiding unnecessary
interventions’.
Section 8.1 – What should be included in the clinical history?
‘Risk factors for stillbirth and fetal growth restriction (FGR), such as multiple consultations for RFM,
known FGR, hypertension, diabetes, extremes of maternal age, primiparity, smoking, placental
insufficiency, congenital malformation, obesity, racial/ethnic factors, poor past obstetric history (eg
FGR and stillbirth and genetic factors)’.
‘If there are no risk factors and there is the presence of a heart beat on auscultation, she can be
reassured and no other investigations are necessary’.
In this audit all the relevant information was found relatively easily from patient notes, but not all in
one place. It appears only a detailed history is taken if the woman is transferred to a ward.
However it is likely history is taken by midwives when the woman arrives and whilst being attached
to monitor, just not explicitly recorded.
Eighty five women (82.5%) did not have hypertension, two women had gestational hypertension and
were on medication, one woman attended clinic but was not on any medication and 15 had no
mention in their notes. There were no patients found to have diabetes mellitus or gestational
diabetes however there were 14 (13.6%) women who did not have information available in notes.
Fifty three women (51.5%) were primigravida, and the remaining 50 (48.5%) women, multigravida.
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87% reported no fetal abnormalities, see table 1 for known anomalies. Seventy five (72.8%) of
women had no significant past pregnancy history, see table 2. Fifty women, (48.5%) did not have
any significant medical factors regarding themselves, see table 3.
Eighteen women (17.5%) were kept in hospital and an ultrasound scan arranged, all other women
were reassured and went home.
8.2 – What should be covered in the clinical examination?
‘In the community setting, a handheld Doppler device should be used to auscultate fetal heart, if this
is not available then the woman should be referred to the maternity unit. Clinical assessment should
include assessment of fetal size with the aim of detecting SGA foetuses by way of abdominal
palpation, measurement of symphysis-fundal height and ultrasound biometry. As pre-eclampsia is
also associated with placental dysfunction, blood pressure and urinalysis are of benefit’.
In this audit it appears measures of SGA were not routinely undertaken, and were detected by
ultrasound either previously or as a result of presenting with RFM. Although in order for a CTG
monitor to be appropriately placed a clinical examination needs to be carried but may not have been
recorded in notes.
Blood pressure measurement and urinalysis were routine investigations in all women and there is no
mention of any patient being diagnosed with pre-eclampsia on admission.
8.3 – What is the role of the CTG?
‘After fetal viability has been confirmed, a CTG for at least 20 minutes should be arranged to exclude
fetal compromise if gestation >28 weeks. Presence of a normal fetal heart rate is indicative of a
healthy fetus’.
In the 89 women at gestations above 28 weeks, CTG was performed in 88 (99%) women, the
remaining woman did not have a mention of this in notes. Of the 88 women, only 5 (5.7%) had an
abnormal CTG. Abnormal findings as stated in patient notes included; initial decelerations then
recovery to normal rate (x2), initial poor variability before becoming reassuring, initial reduced
variability and decelerations before returning to normal after an hour and variable decelerations
down to 80bpm despite mother position change.
8.4 - What is the role of ultrasound scanning?
‘Ultrasound scan should be undertaken in RFM after 28 weeks gestation if the perception of RFM
persists despite a normal CTG, or if there are any additional risk factors for FGR/stillbirth and should
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include abdominal circumference and/or estimated fetal weight to detect the SGA fetus, and
measurement of amniotic fluid volumes’.
Ultrasound measurements were gathered by looking at most recent ultrasound scan and results if
women went on to be rescanned after RFM. One woman (1%) had oligohydramnios (max pool
1.7cm), and two (1.9%) patients had polyhydramnios (max pools 10cm and 10.6cm). Fifty six (54.4%)
were within the normal range and 44 measurements were not available.
There were 25 (23.8%) babies within the 10th-50th growth centile, and 27 (25.7%) were in the 50th 95th growth centile. There was one baby below the 5th centile and five babies above the 95th centile.
Forty seven sets of notes did not have this data available. There were two occasions where the baby
appeared to have growth tailing off; one twin had dropped from 10th to 5th centile in last 3 weeks
and another baby had dropped slightly from between 50th-95th centile 5 weeks earlier to the 50th
centile..
Eighteen (17.5%) women were subsequently arranged an ultrasound scan after CTG. Only 3 patients
had a clear indication written in notes regarding reasons for the ultrasound scan including patient
still unaware of fetal movement, to check fetal lie and to check fetal presentation. Furthermore only
3 patients had an abnormal CTG, including initial decelerations which then improved and two
women had initial poor variability then reassuring.
For fifteen (83.3%) women this was their first presentation. The remaining three had presented with
RFM once before. Significant past pregnancy history includes one patient suffering post natal
depression, one previous PPH, one previous pre-eclampsia, one with a previous stillbirth and preeclampsia, and one who had severe pre-eclampsia requiring early delivery.
Amniotic fluid volumes
were normal in all eighteen (100%) women. Doppler results were available in fifteen (83.3%)
women and were all normal. Half the babies (50%) scanned were in the 10th-50th growth centile, and
the other 50% were in the 50th-95th growth centile.
9. What is the optimal surveillance method for women who have presented with RFM in whom
investigations are normal?
‘Women should be reassured that 70% of pregnancies with a single episode of RFM are
uncomplicated. There is no evidence to support formal fetal movement counting (kick charts) in
those with normal investigations’.
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For Eighty one (79%) women this was their first presentation of RFM, 17 patients had been once
before reporting RFM, two had been twice and 3 women had attended three times previously
regarding RFM. No information was recorded about use of kick charts.
10. What is the optimal management of a woman who presents recurrently with RFM?
‘Exclude predisposing causes and arrange an ultrasound scan. There are no studies to determine
whether intervention alters morbidity or mortality therefore the decision whether or not to induce
labour when all investigations are normal is at the discretion of the consultant’.
Of the 33 women who had presented with RFM before, none had an abnormal CTG. One woman
was induced but due to SPD pain not fetal concern, one woman was already booked for induction
the next day and one woman wasn’t induced but a membrane sweep was performed. Only three
women had an ultrasound, all parameters were normal and they were not induced.
11. What is the optimal management of RFM before 24 weeks of gestation?
‘The presence of a fetal heart beat should be confirmed by auscultation with a handheld Doppler
device. If movements have never been felt by 24 weeks, referral to a specialist fetal medicine centre
should be considered’.
There were six (5.8%) women below 24 weeks of gestation (19+0 – 23+4 weeks). All women had a
doptone and confirmed fetal heart beat.
12. What is the optimal management of RFM between 24 and 28 weeks of gestation?
‘Presence of a fetal heartbeat should be confirmed by auscultation with a handheld Doppler device.
There are no studies looking at the outcome of women at this gestation. History must include a
comprehensive stillbirth risk evaluation. There is no evidence to recommend the routine use of CTG
surveillance in this group but if there is suspicion of FGR, consider ultrasound assessment’.
There were eight (7.8%) women who presented with RFM between 24 and 28 weeks gestation. Five
women had a CTG, four were between 26 and 28 weeks gestation and one was at 24+5 weeks. The
three remaining women were investigated by handheld Doptone at gestations of 24 and 25+4
weeks. No abnormalities were found. There were no known fetal anomalies or any relevant history.
Page 8
Conclusions
Each patient has a brief history taken, BP measured and urinalysis and most depending on gestation
are investigated by CTG, however clinical examination and history was seen to be lacking in patient
notes, especially if only seen in maternity assessment and not seen on a ward by a doctor.
Recommendations
1. Introduction of a formal algorithm for investigation of perceived RFM, incorporating
gestational variances.
2. Greater use of the handheld Doppler and not immediate CTG investigation especially in
cases <28 weeks.
3. Introduction of explicit guidelines for the use of ultrasound in RFM cases, as currently it
appears to be the decision of the registrar/consultant, which has lead to a lack of
consistency.
4. Introduction of a special RFM maternity assessment form to be filled in upon admission to
the department which details all the risk factors for still birth, IUGR and SGA. This would
provide a fitting structure to admission and allow for explicit notation of the clinical
examination, relevant history and investigation results.
Page 9
References
1. Froen JF., Arnestad M., Frey K., Vege A., Saugstad OD., Stray-Pedersen B. Risk factors for
sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in
Oslo, Norway, 1986-1995. Am J Obstet Gynecol. 2001. 184(4):694-702
2. Froen JF., Tveit JV., Saastad E., Bordahl PE., Stray-Pedersen B., Heazell AE., Flenady V., Fretts
RC. Management of Decreased Fetal Movements. Semin Perinatol. 2008. 32:307-311
3. National Institute for Health and Clinical Excellence (NICE) guideline CG62 Antenatal Care:
routine care for the healthy pregnant woman. 2008.
4. Royal College of Obstetricians and Gynaecologists. Green-top Guideline 57. Reduced Fetal
Movements. February 2011.
Word count: 1998 (excluding titles)
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Tables and figures
Figure 3 – Boxplot of age of women presenting to maternity with RFM during June 2011
45
40
Age (yrs)
35
30
25
20
15
Figure 4 – Boxplot of BMI of women presenting to maternity with RFM during June 2011
40
BMI (kg/m2)
35
30
25
20
Page 11
Figure 5 – BMI of women presenting to department with RFM during June 2011 according to NHS
BMI classification
Figure 6 – Boxplot of gestation of women who presented to maternity with RFM during June 2011
45
Gestation (weeks)
40
35
30
25
20
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Figure 7 – Weight of babies born to women who presented to maternity with RFM during June 2011
5.0
4.5
Weight (kg)
4.0
3.5
3.0
2.5
2.0
Girls
Boys
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Table 1 – Known fetal abnormalities reported in the notes of women presenting to maternity with
RFM during June 2011
Fetal abnormality
Large baby (>95th centrile)
Increased MSAFP
Large fetal heart, structure normal
Initially SGA
Left foot abnormality
Polyhydramnios + low lying placenta
Previous audible decelerations at ANC
Pyelectasis of R fetal kidney
R kidney hydronephrosis
Splayed L vertebrae
Heart anomalies – tricuspid
atresia,large VSD,> normal head size
No abnormalities reported in notes
Totals
Frequency
2
2
1
1
1
1
1
1
1
1
1
Percentage
1.94
1.94
0.97
0.97
0.97
0.97
0.97
0.97
0.97
0.97
0.97
90
103
87.4
100%
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Table 2 – Significant factors relating to mother as reported in notes. NB: frequency refers to number
of women who had that factor noted but one woman may have several factors thus one woman may
be counted several times in this table and table totals therefore do not equal the number of women
being analysed ie 103.
Significant mother factors
Group B strep infection
Anaemic
SPD pain
Anxious
Hx of depression/self
harm/overdose
Pre-eclampsia symptoms
Current candida infection
Lupus +ve
Uterine/Cervical fibroids
Backache
Current discharge
Recurrent UTIs
Previous abusive relationship
Chest pain
Prev DVT/PE
SOB
Thrombocytopenia
Braxton Hicks
Asthma
Hypothyroidism
Prev cocaine and cannabis use
Prev diagnosis anorexia nervosa
as a teenager
B-thalassaemia carrier
Epilepsy
FHx Down syndrome
Flu symptoms
GI upset
Obstructed bowel at 32 weeks
Diarrhoea and vomiting
Bells Palsy
Current emotional/physical
abuse
Prev CIN, had LLETZ
One functioning kidney
Hyperthyroidism
Hydrosalpinx
Rash on abdomen
On going social work input
Frequency
7
7
5
4
4
3
3
3
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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FHx spina bifida and
hydrocephalus
Scoliosis
Assault at 26 weeks
Previous detached retina
Small stature
SROM day before
Twin pregnancy
None
1
1
1
1
1
1
1
50
Table 3 – Significant past pregnancy history as reported in notes. NB: frequency refers to number of
women who had that factor noted but one woman may have several factors thus one woman may
be counted several times in this table and table totals therefore do not equal the number of women
being analysed ie 103.
Significant past pregnancy history
Post natal depression
Pre-eclampsia
EMLUSCS
IVF pregnancy
Previous forceps delivery
APH
PPH
Twin pregnancy
Baby with ventricular megaly
Prev SIDS
Stillbirth at 35wks
Placental abruption
2nd and 3rd degree tears
Prev large baby (4.84kg)
Gestational hypertension
Son with muscular dystrophy
none
Frequency
5
5
4
3
2
2
2
2
1
1
1
1
1
1
1
1
75
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Appendix 1
Subject number
CHI/SGH number
Mother criteria
Age at presentation
Race
Relationship status
Smoking status
Alcohol consumption (units/week at
booking)
BMI
Hypertension
circle appropriately
single
yes
in relationship
no
married
divorced
no
attends clinic
Diabetes
Parity
no
yes on insulin
on medication
yes on oral
medication/diet
GDM
1st presentation of RFM?
Significant past obstetric Hx?
Yes
yes (give details)
yes (give details)
Significant current obstetric issues?
Any known abnormalities prior to
presentation of RFM?
Gestation
Investigations
Blood sugar
Hypoxic?
BP
Urinalysis normal?
CTG performed?
abnormal CTG
Ultrasound performed?
amniotic fluid normal vol
growth centile?
evidence of growth 'tailing off'?
doppler normal?
placenta position
Fetal presentation
Subsequently arranged for induction?
no
no
no
yes (give details)
no
yes
no
yes
yes
yes (give details)
yes
yes
no (give details)
no
no
no
no (give details)
yes (give details)
yes
anterior
no (give details)
posterior
fundal
no
yes
no
lateral
Baby delivered? How?
Sex and weight
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