Guideline for the management of reduced fetal movements after 24 weeks gestation.

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1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Author: Contact Name and Job Title Directorate & Speciality Date of submission Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Guideline for the management of reduced fetal movements after 24 weeks gestation. Susan Brydon Midwife, Supervisor of Midwives, Clinical Educator Family health, obstetrics June 2016 All pregnant women with reduced fetal movements Version 5 If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Ratified by: 4 1 Senior Midwives, Consultant Obstetricians through the Maternity Guideline Group Maternity guideline group June 2016 Date: Target audience Review Date: (to be applied by the Integrated Governance Team) A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date, however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

2 REDUCED FETAL MOVEMENTS (RFM) INTRODUCTION Maternal perception of reduced fetal movements is a common cause of non-scheduled hospital attendance, admission and pregnancy intervention. (Tveit et al 2009, Unterscheider et al 2010). Decreased fetal movements will affect 5-15% of pregnancies (Sergent et al 2005, Heazell et al 2005) and is a significant cause of maternal anxiety. There is good evidence to demonstrate that a perception of reduced fetal movements is significantly associated with poor pregnancy outcome, including fetal growth restriction and fetal hypoxia ( Heazell et al 2008, Sinha et al 2007, Dutton et al 2012). Although the perception of reduced fetal movements is highly subjective, it remains a significant tool in the detection of the at risk fetus. Women should not be encouraged to count movements and instead should be asked to be aware of the normal rhythm of fetal movements and to report any change. Physiology Fetal movements are usually detected by the woman from 20 weeks gestation, although multiparous women may report movements as early as 16 weeks. Fetal movements are defined as a maternal sensation of a kick, flutter, swish or roll and such movements are an indication of the integrity of the central nervous and musculoskeletal systems. The number of movements tends to increase until 32 weeks of pregnancy and from then onwards the number of movements will plateau until labour commences. Fetal movements show diurnal changes and the afternoon and evening are commonly periods of peak activity. There is evidence to show that women feel most movements when lying down, fewer when sitting and are least likely to feel movements when standing (RCOG 2011). In addition fetal movements are usually absent during fetal sleep cycles, which usually last for minutes and rarely exceed 90 minutes in a healthy fetus ( Velazquez and Rayburn 2002). Changes in the number and nature of fetal movements as the fetus matures are considered to be a reflection of the normal neurological development of the fetus. It is known, however, that the fetus will respond to chronic hypoxia by moving less, thus conserving energy by reducing oxygen consumption. The need to differentiate between the normal variation in movements of the healthy fetus and the reduction in movements of the

3 compromised fetus presents a considerable challenge for staff and is known to be a cause of anxiety for mothers. Ultrasound studies have demonstrated that the fetus does not move less during the third trimester but the type of movements change as coordination improves and a cycle of movements is established (Unterscheider et al 2010) This change in the pattern or type of movements can result in a report of reduced fetal movements. Definition There is no consensus on the amount of times a normal healthy fetus will move over the course of a 24 hour period and it is known that there is a wide variation, ranging from movements per hour. It is not possible, therefore, to provide a definition of reduced fetal movements and at present there is no evidence that an absolute definition would be of any value in the detection of fetal compromise or the prevention of intrauterine fetal death. Current practice- detection. Formal counting aids such as the kick chart should not be used. Women should be advised to be aware of their baby s individual pattern of movements. If they are concerned about a reduction or cessation in fetal movements after the 24 th week of pregnancy, then they should contact their maternity unit. If women are unsure whether there is a reduction in fetal movements, then they should be advised to rest and concentrate on fetal movements. If the movements are reduced, or the woman is unsure that this is the case, then the woman should contact the maternity unit for advice. Investigations that are of assistance in assessing fetal movements and identifying the at risk fetus. All women > 26 weeks gestation who report a change in the pattern of or a reduction in fetal movements should be assessed using the following: Detailed history Clinical examination of the mother, particularly SFH (plotted), blood pressure and urinalysis. Fetal heart auscultation using a Pinard s stethoscope or a hand held Doppler device. It is important to differentiate between the maternal

4 pulse and the fetal heart rate and this can usually be achieved by counting and recording the rate of the fetal heart whilst simultaneously palpating the maternal pulse. If the presence of a fetal heart cannot be confirmed, then urgent referral for ultrasound assessment of fetal cardiac activity must be undertaken. If, on discussion with the practitioner, it is apparent that the woman does not have reduced fetal movements (RFM), in the absence of risk factors and in the presence of a normal fetal heart rate on auscultation, no further follow up is required. If RFM is confirmed a cardiotocograph (CTG) is required. Although there is no evidence to support the view that CTG use reduces the rates of still birth or neonatal death (Pattinson N, McCowan L. 2000), a normal trace is significantly more likely to be followed by a normal birth and normal neonatal condition than an abnormal trace; however, it only provides information about fetal wellbeing at that time. A woman with continuing concerns regarding RFM should be advised to report these. A CTG trace lasting at least 20 minutes that provides evidence of a normal fetal heart rate and variability with a normal accelerative pattern and no decelerations is indicative of a fetus with a functioning autonomic nervous system. The assessment of all CTG traces should be in accordance with the NUH antenatal fetal monitoring guideline If there are no other concerns, the CTG is normal and the woman feels fetal movements, she should be reassured and discharged with advice to report any further episodes of reduced without delay. Ultrasound scan (Growth, AFI, Doppler) Ultrasound scan assessment should be undertaken in a woman presenting with RFM in the presence of a clinical suspicion of a small for gestational age fetus or slowed growth velocity when the symphysiofundal height is plotted on the woman s growth chart a second episode of RFM CTG abnormalities not requiring immediate delivery, continued perception of reduced fetal movements despite a normal CTG or if there are any additional risk factors for stillbirth or fetal growth restriction

5 If scanning is considered necessary then it should be performed when the service is next available, preferably within 24 hours where possible. The process for assessing fetal movements Women should routinely be asked about fetal movements when seen in the hospital or community setting. Concerns that should prompt action are: 1. A significant change in the usual pattern of fetal movements. 2. A perceived reduction or absence of movements If a woman in the community setting reports RFM she should be advised to contact the maternity unit for investigation. City Hospital Campus: o 0830h 1900h Antenatal Baby Care (ABC): o 1900h 0830h Delivery Suite: QMC Campus o Labour Suite (at certain times calls will be directed to ABC) The community midwife should inform ABC at the first appropriate opportunity and provide an up to date telephone number in case the woman does not self refer. Time frame for review in hospital Women with RFM should be seen at the earliest opportunity within 4 hours. Women with no fetal movements should be given an appointment within 1 hour. She should be urged to attend as soon as possible although we recognise that this may not always be achievable for the woman. Second or subsequent presentations. A significant number of women will re-present with reduced fetal movements and if there is persistence in the perception of a reduction in movements despite investigation then consideration should be given to other causes such as fetal structural abnormality, anaemia or feto-maternal haemorrhage. Women who present on more than one occasion with RFM are at increased risk of a poor perinatal outcome when compared with those who attend on only one occasion.

6 There is a move to offer women with recurrent RFM an induction of labour at 39 weeks gestation. This should be discussed with the woman by an experienced registrar or consultant obstetrician The following management may be appropriate: CTG analysis until reassurance is provided. Whether repeated CTG monitoring will be required will depend on assessment of clinical need, including assessment of risk factors. Ultrasound assessment to identify growth restriction, structural abnormalities and reduced liquor volume should be performed. If an ultrasound scan has been performed in the preceding two weeks a further scan is not necessary. Blood tests to identify maternal metabolic disorder or fetal haemorrhage weeks gestation There are no studies looking at the outcome of RFM between weeks gestation. There is no evidence to recommend the routine use of CTG surveillance in this group. If there is a clinical suspicion of a small for gestational age fetus consideration should be given to the need for ultrasound assessment. Routine ultrasound assessment is not indicated in this group. Optimal management before 24 weeks of gestation. The fetal heart beat should be auscultated to exclude fetal demise and a full antenatal assessment should be carried out to include urinalysis and blood pressure measurement. The woman should have felt some fetal movements by 24 weeks and the absence of any sensation of fetal movements may need investigation. As there is limited evidence to show that women who have never felt fetal movements at all may have a fetus with an underlying neuromuscular condition, referral to a specialist fetal medicine centre should be considered. (RCOG 2011, reviewed 2014) REFERENCES Alfirevic Z, Neilson J. (1995) Doppler Ultrasonography in high-risk pregnancies; systematic review with meta-analysis. Am J Obstet Gynecol; 172;

7 Duttan PJ, et al (2012) Predictors of Poor Perinatal Outcome following Maternal Perception of Reduced Fetal Movements A Prospective Cohort Study. DOI: /journal.pone Grant E, et al (1989) Routine formal fetal movement counting and the risk of antepartum late death in normally formed singletons. Lancet 1989:2: Harrington K, Thompson O, Jordan L et al (1998). Obstetric outcome in women who present with a reduction in fetal movements in the third trimester of pregnancy. Journal of Perinatal Medicine Vol 26, No2 pp Heazell AP, Sumanathi GM, Bhatti NR. (2005) What investigation is appropriate following maternal perception of reduced fetal movements? Journal of Obstetrics and Gynaecology, Vol 25, no 7, October 2005, pp Heazell AP, Froen JF. (2008) methods of fetal movement counting and the detection of fetal compromise. J Obstet Gynaecol 28: National Institute for Health and National Collaborating Centre for Women s and Childrens Health. (2008) Antenatal Care: Routine care for the healthy pregnant Woman. Guideline CG62.l National Institute for Health and National Collaborating Centre for Women s and Childrens Health. (20014) intrapartum care: Pattinson N, McCowan L. Cochrane systematic Review (2000) :2. RCOG green topped Guideline No 57. (2011, reviewed 2014) Royal college of obstetricians and Gynaecologists. Sergent F (2005) Decreased fetal movements in the third trimester; what to do? Gynecol Obstet Fertil 2005: Sinha D, Sharma A, Nallaswamy V et al (2007) Obstetric outcome in women complaining of reduced fetal movements. Journal of Obstetrics and Gynaecology, Vol 27, no 1 pp41-43 Tveit JV, Saastad E, et al (2008) Reduction of late stillbirth with the introduction of fetal movement information and Guidelines for fetal assessment in high risk pregnancies. Cochrane database syst rev(1) : CD Unterscheider J eta al (2009) Reduced Fetal Movements. The Obstetrician and Gynaecologist 2009:11:

8 Unterscheider J, et al (2008) How do Irish Obstetricians manage reduced fetal movements in an uncomplicated pregnancy at term? Velazquez MD, Rayburn WE (2002) Antenatal evaluation of the fetus using fetal movement monitoring. Clinical Obstet Gynecol, 45:

9 Appendix: Management of the fetus with reduced fetal movements First presentation with reduced fetal movements after 24/40 Detailed history, risk factors, check EDD, Maternal observations, Abdominal palpation, SFH measurement in centimetres, Auscultation/CTG/maternal pulse recording Investigations reassuring Abnormal findings First occurrence Second or subsequent occurrence Assessment by an experienced registrar or consultant Reassure, educate Transfer home if no other reason for admission. Advise to refer again if further episodes of reduced/changed pattern of fetal movements or any other concerns. Review by SpR or Consultant and transfer to Consultant-led care. Individualise management depending on gestation and risk factors.

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