Key Facts

Reduced fetal movements are subjectively perceived decreased movements that may indicate fetal compromise. Prompt assessment is essential as RFM is associated with increased risk of stillbirth, fetal growth restriction, and adverse perinatal outcomes.

Epidemiology

• Reported in 5-15% of pregnancies in the third trimester
• RFM is one of the most common reasons for unscheduled antenatal attendance
• 50% of women who experience stillbirth report RFM in the days preceding the event
• Most assessments for RFM result in reassuring findings (>95%)

Aetiology

• Fetal compromise: hypoxia, growth restriction, placental insufficiency
• Fetal sleep cycle: normal quiet periods last 20-40 minutes (rarely >90 minutes)
• Anterior placenta: may reduce perception of movements
• Maternal factors: increased maternal activity, obesity (BMI >30), medication (sedatives, opioids)
• Amniotic fluid volume: oligohydramnios may reduce perceived movement

Pathophysiology

• In fetal compromise, decreased movement is a response to reduced oxygen delivery
• Fetus conserves energy by reducing movement (analogous to the dive reflex)
• Progressive hypoxia leads to further reduction in movement, reduced variability on CTG, and eventually fetal death
• Early detection and intervention can prevent adverse outcomes

Assessment Points

• Subjective maternal perception of decreased fetal movements compared to the usual pattern
• Movements typically perceived from 18-20 weeks (primigravida) or 16-18 weeks (multigravida)
• Movements should be assessed after 28 weeks gestation
• No defined minimum number of movements per day

Red Flags

• Absent fetal movements for >12 hours after 28 weeks
• Recurrent RFM (≥2 presentations)
• RFM associated with vaginal bleeding or abdominal pain
• Known FGR or other high-risk pregnancy
• Concurrent reduced liquor volume
• Absent fetal heart sounds on auscultation

Bedside

• Handheld Doppler/Pinard stethoscope: confirm fetal heart beat
• CTG: from 28 weeks; assess baseline heart rate, variability, accelerations, decelerations
• Maternal observations: HR, BP, temperature, urinalysis

Bloods

• Not routinely required on first presentation if CTG reassuring
• If recurrent RFM: FBC, Kleihauer test (to exclude large fetomaternal haemorrhage)
• Pre-eclampsia screen if indicated (FBC, LFTs, U&Es, PlGF)

Imaging

• USS: indicated if recurrent RFM (≥2 presentations), abnormal CTG, or risk factors
  • Fetal biometry (EFW plotted on customised chart)
  • Amniotic fluid volume (deepest vertical pool or AFI)
  • Umbilical artery Doppler
• If USS shows FGR: full Doppler assessment (UA, MCA, DV)

Special Tests

• Kleihauer test if suspecting fetomaternal haemorrhage
• PlGF testing if <37 weeks and pre-eclampsia suspected

Non-pharmacological

• Antenatal education: advise all women from 28 weeks about normal fetal movement patterns and when to seek assessment
• Women should attend maternity triage promptly if movements are reduced (do not wait until the next day)
• Do not use kick-counting charts (associated with increased anxiety without clear benefit)
• Should be assessed within 2 hours of presentation

Pharmacological

• No specific pharmacological management for RFM itself
• Treat underlying causes if identified (e.g. pre-eclampsia, FGR)
• Antenatal corticosteroids if preterm delivery anticipated

Surgical/Interventional

• If CTG abnormal: consider immediate delivery (category 1 or 2 CS/instrumental)
• If USS shows severe FGR with abnormal Dopplers: plan delivery as per FGR guidelines
• If recurrent RFM with no identifiable cause after full assessment: consider delivery from 37 weeks

Referral Criteria

• First presentation with reassuring CTG: routine follow-up, advise to return if recurs
• Recurrent RFM (≥2 episodes): USS within 24 hours, consultant review
• Abnormal CTG: immediate obstetric review
• FGR diagnosed: refer to fetal medicine for surveillance

• >95% of women presenting with RFM have reassuring assessment and good outcome
• RFM associated with 2-3 fold increased risk of stillbirth
• Recurrent RFM (≥2 presentations): risk of adverse outcome approximately 6% (stillbirth, FGR, preterm delivery)
• Prompt assessment and appropriate intervention can prevent a proportion of stillbirths
• No intervention has been shown in RCT to reduce stillbirth in RFM (AFFIRM trial showed no significant reduction in stillbirth)

RFM Assessment Algorithm (RCOG GTG 57)

AFFIRM Trial