Decreased fetal movements
Obstetrics
Day assessment or triage, from 24 to 28 weeks onward
The first question
Is the fetus alive and well right now, and why did movements fall?
Two patients: the gestational age and the maternal stability first, then the fetal status.
- 01
Confirm life
Fetal heart on Doppler; ultrasound if not heard.
- 02
Assess wellbeing
A non-stress test (20 to 40 minutes); a biophysical profile if it is non-reactive.
- 03
Look for a reason
Growth, liquor, placental function; maternal illness, medication, hypertension, diabetes, a small fetus, a history of stillbirth.
- 04
Plan
Reassure with return advice if everything is normal; investigate further or deliver at term if it is not. Every recurrence is assessed again.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Duration and degree of the change
- Gestational age and any growth concern
- Hypertension, diabetes, bleeding, fluid loss
- Medications, sedatives, smoking, substance use
- Prior stillbirth or growth restriction
- Anterior placenta (dampens perception)
Examination that discriminates
- Maternal vital signs and blood pressure
- Fundal height
- Fetal heart rate
- Presentation and liquor clinically
Investigations
- Non-stress test (cardiotocography)
- Ultrasound: growth, liquor, umbilical artery Doppler, biophysical profile when indicated
- Kleihauer if a fetomaternal haemorrhage is suspected
What the image changes
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Normal variation, fetal sleep cycle | Reactive test, normal growth and liquor, movements resume | Non-reactive test, small fetus | routine |
| Growth restriction with placental insufficiency | Small fundal height, abnormal Doppler, oligohydramnios, hypertension | Normal growth and liquor | urgent |
| Fetomaternal haemorrhage or fetal anaemia | Sinusoidal tracing, tachycardia, raised MCA velocity, positive Kleihauer | Normal tracing | emergent |
| Intrauterine death | No heart on Doppler and ultrasound | Heart seen | urgent |
| Maternal sedation or medication | Recent opioid, sedative, magnesium | No medication | routine |
Pitfalls this pathway refuses
- Reassuring over the telephone
- Stopping the NST at 20 minutes when it is not yet reactive
- Sending a patient home with a non-reactive test and no further assessment