Launceston General Hospital Clinical Guideline WACSClinProc1.

12/10 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: The rationale for maternal monitoring of fetal movement is based on the assumption that early recognition of decreased fetal movement makes it possible for the clinician to intervene at a stage when the fetus is still compensated, and thus prevent progression to fetal or neonatal death. Women should be advised to contact their antenatal care provider if they feel a major and persistent decrease in usual activity, or if there are fewer than 10 movements over two hours at times when the fetus is usually active and the mother is focusing upon counting. Maternal concern of decreased fetal movement overrides any definition based on the number of kicks. The recommended time frame for initiation of clinical assessment is within 2 hours if fetal movements are absent and within 12 hours if they are decreased. The prevalence and significance of reduced fetal movement in the second trimester are largely unknown, while third trimester reduced fetal movement has been linked with adverse pregnancy outcomes related to fetal hypoxia and malnutrition. Women with third trimester reduced fetal movement are more likely to have pregnancies complicated by impaired fetal growth, preterm birth, and fetal or neonatal death than women with normal fetal movement. A decrease in perceived fetal movement does not necessarily mean the fetus is compromised. The perception of low fetal activity may be due to early gestational age, decreased amniotic fluid, maternal drug ingestion, fetal position, or a fetal sleep pattern. Fetal activity may be reduced with maternal illness or when amniotic fluid volume is decreased. The prevalence of perceived reduced fetal movement increases with nulliparity, obesity and smoking. Assessment of reduced fetal movement less than 24 weeks gestation: Review antenatal record for risk factors Auscultate fetal heart with doppler Provide reassurance, education and document in antenatal record and hand held record Discharge, after consultation with the senior midwife/registrar, for follow up with usual antenatal care provider. If fetal heart unable to be detected, the registrar, consultant or trained provider should then perform an ultrasound scan to visual the fetal heart
1 Decreased Fetal Movement Feb-11 WACSClinProc1.12/10

Decreased Fetal Movement Reduced Fetal Movement WACSClinProc1.12/07 Management of women with reduced fetal movement Midwives and medical officers, QVMU Reduced fetal movement

Assessment of reduced fetal movement greater than 24 weeks gestation: Review antenatal record for risk factors Maternal observations Abdominal palpation and symphysis fundal height (SFH) measure Auscultate fetal heart rate with a doppler. If over 30 weeks gestation perform an antenatal cardiotocograph (CTG). Consider antenatal CTG if less than 30 weeks gestation and risk factors present. Antenatal CTG only provides an assessment of immediate fetal condition Ultrasound scan assessment of fetal biometry, amniotic fluid volume and morphology (preferably within 24 hours) should be performed where maternal perception of decreased fetal movement persists despite a normal CTG For women with their first presentation, no risk factors and a reassuring CTG, consult with the senior midwife/registrar, provide education and complete documentation. Where concern remains over decreased fetal movement in the presence of normal clinical assessment (CTG and ultrasound) women should be advised to return for follow-up assessment within 24 hours. If recurrent presentation, with or without risk factors, SFH not within 2cm or CTG not reassuring then formal ultrasound scan (preferably within 24 hours) required for growth, AFI and UA dopplers. Registrar or Consultant to review and develop management plan. If fetal heart rate unable to be located then ultrasound scan to be performed by the registrar or consultant. If CTG is non-reassuring then referral to the registrar or consultant is required. Testing for fetal maternal haemorrhage is recommended. Fetal Movement Chart There is not enough evidence to recommend or not recommend formal fetal movement counting at present. There is indirect evidence that fetal movement counting may be beneficial. Limited data suggests that women prefer daily counting to repeated counting periods during the day.

2 Decreased Fetal Movement Feb-11 WACSClinProc1.12/10

Attachments Attachment 1 Performance Indicators: Review Date: Stakeholders: Developed by:

Reduced Fetal Movement Algorithm Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Annually verified for currency or as changes occur, and reviewed every 3 years Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _15 June 2010_____

REFERENCES Froen, J 2006, Evaluation of decreased fetal movement, UpToDate, Online: http://uptodateonline.com/utd/content/topic.do?topicKey=antenatl/24547&selectedTitle=1~ 39&source=search_result Mangesi, L & Hofmeyr, G 2006, Fetal movement counting for assessment of fetal wellbeing, Cochrane Review, Online: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004909/frame.html Olesen, A & Svare, J 2004, Decreased fetal movements: background, assessment, and clinical management, Acta Obstetrics and Gynecology Scandinavia, vol. 83, pp.818-826. Preston, S, Mahomed, K, Chadha, Y, Flenady, V, Gardener, G, Macphail, J, Conway, L, Koopmans, L, Stacey, T, Heazell, A, Fretts, R and Froen, F for the Fetal Movement Study Group and the International FEMINA collaboration. Clinical practice guidelines for management of decreased fetal movements. Consultation edition. Brisbane, August 2009. www.stillbirthalliance.org.au

3 Decreased Fetal Movement Feb-11 WACSClinProc1.12/10

ATTACHMENT 1 Algorithm for Women with Reduced Fetal Movement Review antenatal history for risk factors

Discuss with the Arrange USS for > 24 weeks gestation senior AFI, UA doppler, midwife/registrar growth within 24 CTG if over 30 weeks gestation hours. (as per Antenatal Electronic Fetal Documentation Monitoring Guideline Encourage WACSClinProc1.7) woman Review and to return ASAP if management plan perception of DFM developed Consider CTG if under 30 weeks by persists registrar or

< 24 weeks gestation Auscultate FH with doppler. If fetal heart reassuring: Reassure, document and discharge to usual antenatal care provider USS by consultant if unable to locate FHR with doppler.

First presentation No risk factors SFH within 2 cm Reassuring CTG

Repeat presentation
&/or

FH not detected

Non reassuring CTG

Risk factors
&/or

SFH not within 2 cm

&/or

CTG non reassuring Real time USS by registrar or consultant Urgent referral to registrar or consultant

4 Decreased Fetal Movement Feb-11 WACSClinProc1.12/10