Baby gerak ok? (Approach to Reduced Fetal Movement)

Very often reduced fetal movement causes anxiety to mothers. They are often worried something might have gone wrong to their child. Let's us dive into this topic to understand more about it and hopefully may help future mothers to alleviate their anxiousness.

So, how do we define fetal movement? Fetal movement, defined as any discrete kick, flutter, swish or roll, is very subjective. It is usually based on maternal perception and varies according to individual. Most mothers will be able to feel the movement by 20 weeks of gestation (primiparous:18-20 weeks or later than 20 weeks, multiparous: ~16 weeks onward). These movements would increase until 32nd week and will then be plateau. During afternoon and evening periods, the fetal movement is at its peak. After moving much, there will of course be a sleeping period, which could last for 20-40 minutes, rarely exceeding 90 minutes, and occur throughout day and night.

Presence of fetal movement symbolises the maturity of central nervous system and musculoskeletal system.

Factors affecting fetal movement
1. Maternal

•  Position of mother (best when lying down > sitting > standing) 
•  Sedatives which cross placenta (alcohol, benzodiazepines, methadone, opioids)
•  Timing (busy = less perception)
•  Toxins (smoking, sedative eg: cough syrup)
•  Trauma/massage
•  Infection
• Hypoglycemia (fasting?)

2. Placental

• Position of placenta (Anteriosly placed placenta may reduce the sensation)
• Retroplacental clot
• Placental insufficiency

3. Fetal

• Malformation
• Position (spine on the anterior masks the movements)
• Intrauterine death
• Excessive/reduced liquor volume
• Engagement

How do we assess patient presented with reduced fetal movement (RFM)?

History

- First episode or reccurent of RFM?

- The various factors affecting fetal movement stated above

- Any risk factor of stillbirth?

1. Maternal factors

• Previous history of RFM
• Known fetal growth restriction (FGR)
• Medical problems: hypertension, diabetes
• Extremes maternal age
• Primiparity
• Smoking
• Obesity
• Racial/ethnic factors
• Poor past obstetric history (FGR and stillbirth)
• Genetic factors
• Problems with access to care

2. Placental factor

• Placental insufficiency

3. Fetal factors

• Congenital malformation

Clinical Examination + Investigations

Aim: To confirm FETAL VIABILITY

1. Hand held Doppler device to confirm the presence of fetal heart beat

2. Ultrasound scan assessment for fetal cardiac activity, fetal parameters (TRO FGR) - done if hand held Doppler is not available

- assess abdominal circumference, estimated fetal weight (TRO small for gestational age, SGA), and amniotic fluid volume

Basic bedside palpation (to detect smaller for gestation fetus)

1. Abdominal palpation, measurement of symphysis-fundal height

TRO pre eclampsia

1. Blood pressure

2. Urine albumin

CTG

1. For at least 20 minutes

2. To rule out fetal compromise

Biophysical profile (BPP), is it useful?

It is used in selective cases due to its good negative predictive value (good BPP --> rare risk of fetal death)

Treatment

1. Assess the fetal movement

• Subjective: Encourage mother to lie down and focus of counting the number of fetal kicks to be recorded in a chart, usually from 9am-9pm or whichever convenient for the mother, until 10 kicks is achieved (for 2 hours in RCOG GTG 57)
• Objective: Doppler/ Ultrasound (but may give rise to false positive signals from maternal abdominal wall eg: cough)

2. Reassurance if fetal viability is confirmed and CTG is reactive 

    (NOTE: 70% of pregnancies with single episode of RFM is uncomplicated)

3. To inform mother to return if she perceive reduced fetal movement

Summary from RCOG GTG 57 Appendix 1

Reference:

RCOG Green Top Guideline 57 on Reduced Fetal Movement (click here)

Cheers~

Till the next article :D

Signing out,

J&Fi