Reduced Fetal Movements

Green-top Guideline No. 57

February 2011
Reduced Fetal Movements
This is the first edition of this guideline.

1. Purpose and scope

The purpose of this guideline is to provide advice to guide clinicians, based on the best evidence where
available, regarding the management of women presenting with reduced fetal movements (RFM) during
pregnancy.This guideline reviews the risk factors for RFM in pregnancy and factors influencing maternal
perception. It provides recommendations as to how women presenting in both the community and
hospital settings should be managed. This guideline excludes the management of RFM in multiple
pregnancy. As is apparent from the low grading of the evidence for many of the recommendations, they
have been developed to provide a broad practical guide for midwives and obstetricians in clinical practice.
However, it is recognised that in individual women alternative approaches may be reasonable

1.1 Population and setting

Pregnant women in community or hospital settings reporting RFM in singleton pregnancies.

1.2 Interventions to be studied

Comparison of modalities to detect and manage women perceiving RFMs.

2. Background
Maternal perception of fetal movement is one of the first signs of fetal life and is regarded as a manifes-
tation of fetal wellbeing.1,2 Movements are first perceived by the mother between 18 and 20 weeks of
gestation and rapidly acquire a regular pattern. Fetal movements have been defined as any discrete kick,
flutter, swish or roll.3 A significant reduction or sudden alteration in fetal movement is a potentially
important clinical sign. It has been suggested that reduced or absent fetal movements may be a warning
sign of impending fetal death. Studies of fetal physiology using ultrasound have demonstrated an
association between RFM and poor perinatal outcome.4,5 The majority of women (55%) experiencing a
stillbirth perceived a reduction in fetal movements prior to diagnosis.6 A number of studies of fetal deaths
in Norway and the UK identified that an inappropriate response by clinicians to maternal perception of
RFM was a common contributory factor in stillbirth.7,8

3. Identification and assessment of evidence

This guideline was developed in accordance with standard methodology for producing RCOG Green-top
Guidelines. Medline, Pubmed, all EBM reviews (Cochrane CRCT, Cochrane Database of Systematic Reviews,
Methodology register, ACP journal club, DARE, HTA, Maternity and Infant Care), EMBASE and TRIP were
searched for relevant randomised controlled trials, systematic reviews and meta-analyses, cohort studies
and case studies.The search was restricted to articles published between 1980 and November 2008. Search
words included ‘fetal activity’, ‘fetal movement + detection’, ‘reduced fetal movement’, ‘fetal cardio-
tocography’, ‘fetal heart auscultation’ and ‘umbilical artery Doppler’, including all relevant MeSH terms.The
search was limited to humans and the English language.The National Library for Health and the National
Guidelines Clearing House were also searched for relevant guidelines. Where possible, recommendations
are based on available evidence; areas where evidence is lacking are annotated as good practice points
(designated by a tick).

3.1 Limitations of data used in this guideline

Interpreting studies of women perceiving RFM is complicated by multiple definitions of normal and
abnormal fetal movements (discussed in detail in section 5 of this guideline) and a paucity of large-scale

RCOG Green-top Guideline No. 57 2 of 16 © Royal College of Obstetricians and Gynaecologists

(over 1000 participants) descriptive or intervention studies. There are no randomised controlled trials
addressing the management of RFM.The main outcome of interest – stillbirth – is relatively uncommon and
adequately powered studies of different management protocols would require large numbers of partic-
ipants. Consequently, many studies have limitations in terms of definition of RFM and outcomes,
ascertainment bias and selection bias.

4. What are considered normal fetal movements during pregnancy?

Most women are aware of fetal movements by 20 weeks of gestation.
C
Clinicians should be aware (and should advise women) that although fetal movements tend to plateau
at 32 weeks of gestation, there is no reduction in the frequency of fetal movements in the late third
B
trimester.

Perceived fetal movements are defined as the maternal sensation of any discrete kick, flutter, swish or roll.3
Such fetal activity provides an indication of the integrity of the central nervous and musculoskeletal
systems. The normal fetus is active and capable of physical movement, and goes through periods of both
rest and sleep.The majority of women perceive fetal movements and intuitively view their experience of
fetal activity as normal.

From 18–20 weeks of gestation, most pregnant women become aware of fetal activity, although
some multiparous women may perceive fetal movements as early as 16 weeks of gestation and
some primiparous women may perceive movement much later than 20 weeks of gestation.1
The number of spontaneous movements tends to increase until the 32nd week of pregnancy.9–
11
From this stage of gestation, the frequency of fetal movements plateaus until the onset of
labour; however, the type of fetal movement may change as pregnancy advances in the third
trimester.9–13 By term, the average number of generalised movements per hour is 31 (range 16– Evidence
45),with the longest period between movements ranging from 50 to 75 minutes. Changes in the level 2–

number and nature of fetal movements as the fetus matures are considered to be a reflection
of the normal neurological development of the fetus. From as early as 20 weeks of gestation, fetal
movements show diurnal changes. The afternoon and evening periods are periods of peak
activity.14,15 Fetal movements are usually absent during fetal ‘sleep’ cycles, which occur regularly
throughout the day and night and usually last for 20–40 minutes.5,16 These sleep cycles rarely
exceed 90 minutes in the normal, healthy fetus.16–18

Because of the paucity of robust epidemiological studies on fetal activity patterns and maternal perception
of fetal activity in normal pregnancies, there is currently no universally agreed definition of RFM.

5. Are there factors which influence a woman’s perception of this activity?

P
Women should be advised of the need to be aware of fetal movements up to and including the onset of
labour and should report any decrease or cessation of fetal movements to their maternity unit.

Fetal activity is influenced by a wide variety of factors.There is some evidence that women perceive most
fetal movements when lying down, fewer when sitting and fewest while standing.15 It is therefore not
surprising that pregnant women who are busy and not concentrating on fetal activity often report a misper-
ception of a reduction of fetal movements.12,17 Johnson demonstrated that when attention is paid to fetal
activity in a quiet room and careful recordings are made, fetal movements that were not previously
perceived are often recognised clearly.19,20

Prior to 28+0 weeks of gestation, an anteriorly positioned placenta may decrease a woman’s Evidence
perception of fetal movements.21 level 2–

RCOG Green-top Guideline No. 57 3 of 16 © Royal College of Obstetricians and Gynaecologists

Sedating drugs which cross the placenta such as alcohol, benzodiazepines, methadone and other Evidence
level 3
opioids can have a transient effect on fetal movements.22,23

Several observational studies have demonstrated an increase in fetal movements following the elevation
of glucose concentration in maternal blood, although other studies refute these findings.24,25 From 30
weeks of gestation onwards, the level of carbon dioxide in maternal blood influences fetal respiratory
movements, and some authors report that cigarette smoking is associated with a decrease in fetal
activity.22,26,27

The administration of corticosteroids to enhance fetal lung maturation has been reported by
some authors to decrease fetal movements and fetal heart rate variability detected by
Evidence
cardiotocography (CTG) over the 2 days following administration.28–30 The pathophysiology of level 2–
corticosteroid changes in fetal movement and fetal heart rate variability is still unclear and has
not been definitely proven.28–31 Evidence level 2-

Fetuses with major malformations are generally more likely to demonstrate reduced fetal activity.31
However, normal or excessive fetal activity has been reported in anencephalic fetuses.32,33 A lack of vigorous
motion may relate to abnormalities of the central nervous system, muscular dysfunction or skeletal
abnormalities.34

Fetal presentation has no effect on perception of movement.35 Evidence

level 2+

Fetal position might influence maternal perception: 80% of fetal spines lay anteriorly in women
Evidence
who were unable to perceive fetal movements despite being able to visualise them when an level 2–
ultrasound scan was performed.36

6. How can fetal movements be assessed?

Fetal movements should be assessed by subjective maternal perception of fetal movements.
C
Fetal movements are most commonly assessed by maternal perception alone. Studies on the
correlation between maternal perception of fetal movements and fetal movements concurrently
detected on ultrasound scans show wide variation, with correlation ranging from 37 to 88%
and large body movements and those lasting more than 7 seconds most likely to be felt.37–43 The Evidence
greatest number of fetal movements are noted when the mother is lying down, and the number level 2–

appears to be greatest in the evening.12 This may be an effect of concentrating on fetal

movements.The difference in mean time to perceive 10 movements varied between 21 minutes
for focused counting to 162 minutes with unfocused perception of fetal movements.4,17

Objective assessments of fetal movements use Doppler or real-time ultrasound to detect fetal
movement. These studies report slightly increased sensitivity for fetal movements recorded by
ultrasound, with 31.4–57.2% of all movements recorded compared with 30.8% for maternally
perceived fetal movements.44,45 However, the duration of recording is restricted to 20–30
Evidence
minutes with the mother in a semi-recumbent position. There are no studies which have level 2–
evaluated the use of longer periods of fetal movement counting by Doppler ultrasound or
whether this method can detect fetuses at risk of stillbirth. Given the potential detection of
false-positive signals from maternal abdominal wall movements such as coughing, this may not
be a useful means to objectively measure fetal movements in all pregnant women.46

RCOG Green-top Guideline No. 57 4 of 16 © Royal College of Obstetricians and Gynaecologists

7. Should fetal movements be counted routinely in a formal manner?
There is insufficient evidence to recommend formal fetal movement counting using specified alarm limits.
B
Women should be advised to be aware of their baby’s individual pattern of movements. If they are
concerned about a reduction in or cessation of fetal movements after 28+0 weeks of gestation, they should
C
contact their maternity unit.

P
Women who are concerned about RFM should not wait until the next day for assessment of fetal
wellbeing.

If women are unsure whether movements are reduced after 28+0 weeks of gestation, they should be
advised to lie on their left side and focus on fetal movements for 2 hours. If they do not feel 10 or more
C
discrete movements in 2 hours, they should contact their midwife or maternity unit immediately.

Clinicians should be aware that instructing women to monitor fetal movements is potentially associated
with increased maternal anxiety.
B

Formal fetal movement counting relies on a woman counting fetal movements and, if she perceives fewer
movements than a specified alarm limit, contacting her care provider. There are a number of problems
with this strategy. First, there is a wide range of ‘normal’ fetal movements, leading to wide variability among
mothers. Second, the most frequently used alarm limit was developed in high-risk patients who counted
fetal movements while hospital inpatients; therefore, these observations may not be applicable to a general
population.47 Ideally, an alarm limit would be developed using the whole obstetric population and then
be proved to reduce stillbirth rates in a prospective study.48

There have been five studies evaluating maternal assessment of fetal movements. Grant et al.
published a multicentre study randomising women (n=68 654) to counting fetal movements
using the count-to-ten chart or a non-counting group. These groups were contaminated as
women in the non-counting group were also instructed to count fetal movements if they were
deemed high risk.4 There was no reduction in perinatal mortality in the group randomised to
counting fetal movements, although the number of women presenting initially with a live fetus Evidence
level 2–
that was subsequently stillborn was greater in the counting cohort (11 versus six).The study’s
authors acknowledged that these intrauterine deaths may have been preventable, resulting from
false reassurance from CTG and clinical error. Importantly, the perinatal mortality rate for the
whole study population fell to 2.9 per 1000 compared with 4.0 per 1000 reported prior to the
study, suggesting that participation in the trial may have been beneficial (the Hawthorne
effect).49

In a smaller randomised trial (n=2250), patients were randomised to focus on fetal movements
for 2 hours three times a week or given no information.3 There were eight intrauterine deaths, Evidence
all in the control group, leading to a significant decrease in perinatal mortality in women who level 2+

formally counted fetal movements. Over 75% of this study population were classified as high risk.

Moore and Piacquadio used a retrospective case–control design.17 In a period when women
counted fetal movements for 2 hours a day but were not given any alarm limits, the perinatal
mortality rate was 8.7 per 1000 (n=2519). The study was then extended to 5758 women who
were instructed to present for further investigation if they had not felt 10 movements after 2 Evidence
level 2–
hours of focused counting.50 During this period the perinatal mortality rate was 3.6 per 1000.
This extension of the study was associated with increased hospital attendances, rates of
induction of labour (7.9% versus 4.4%) and emergency caesarean birth for fetal distress (2.4%
versus 0.8%).

RCOG Green-top Guideline No. 57 5 of 16 © Royal College of Obstetricians and Gynaecologists

Westgate and Jamieson compared the rates of stillbirth before and after the introduction of the
count-to-ten charts in New Zealand.51 They describe a significant reduction in the stillbirth rate Evidence
from 10.8 to 8.2 per 1000 total births. Other service improvements introduced over this period level 2–

may also have had an impact on the perinatal mortality rate.

In Norway, a comparison was made between the incidence of stillbirth before and after women
were given written information about decreased fetal movements and a standard protocol for
Evidence
the management of RFM was introduced.52 The incidence of stillbirth fell from 3.0 to 2.0 per level 2+
1000 during the intervention period. In women perceiving RFM, the rate dropped from 42 to
24 per 1000.

While normal perception of fetal movements is associated with a positive effect on maternal–
fetal attachment,52,53 the effect of monitoring fetal movements is equivocal. Two studies
(including one randomised controlled trial) reported no adverse effects.54,55 A small retrospective
cohort found that 23% of women reported anxiety and a further 16% felt that monitoring fetal
Evidence
movements was useless and a nuisance.56 Perception of RFM itself is associated with increased level 2+
maternal anxiety.57,58 Clinicians should be aware that the risk of stillbirth (in the absence of
congenital anomaly) in the UK is less than one in 250 births. Any study of the utility of fetal
movements as a screening test must take account of the potentially deleterious effects of
maternal stress and anxiety.

8. What is the optimal management of women with RFM?

The initial goal of antenatal fetal surveillance in cases of RFM is to exclude fetal death. Subsequent to this,
the aim is to exclude fetal compromise and to identify pregnancies at risk of adverse pregnancy outcome
while avoiding unnecessary interventions. A large cross-sectional survey revealed wide variations in
knowledge and practice among both obstetricians and midwives with regard to management of women
presenting with RFM. Although most clinicians recognised the association with fetal growth restriction
(FGR), this did not translate into practice as professionals seldom undertook further assessment to identify
FGR.59

8.1 What should be included in the clinical history?

Upon presenting with RFM, a relevant history should be taken to assess a woman’s risk factors for
stillbirth and FGR.
B

P
All clinicians should be aware of the potential association of decreased fetal movements with key risk
factors such as FGR, small-for-gestational-age (SGA) fetus, placental insufficiency and congenital malfor-
mations.

If after discussion with the clinician it is clear that the woman does not have RFM, there are no other risk
factors for stillbirth and there is the presence of a fetal heart rate on auscultation, she can be reassured.
C
However, if the woman still has concerns, she should be advised to attend her maternity unit.

P
Women noticing a sudden change in fetal activity or in whom other risk factors for stillbirth are identified
should report to their maternity unit for further investigation (see section 6.3).

A history of RFM should be taken, including the duration of RFM, whether there has been absence of fetal
movements and whether this is the first occasion the woman has perceived RFM.The history must include
a comprehensive stillbirth risk evaluation, including a review of the presence of other factors associated
with an increased risk of stillbirth, such as multiple consultations for RFM, known FGR, hypertension,
diabetes, extremes of maternal age, primiparity, smoking, placental insufficiency, congenital malformation,
obesity, racial/ethnic factors, poor past obstetric history (e.g. FGR and stillbirth), genetic factors and issues

RCOG Green-top Guideline No. 57 6 of 16 © Royal College of Obstetricians and Gynaecologists

with access to care. Clinicians should be aware that a woman’s risk status is fluid throughout pregnancy
and that women should be transferred from low-risk to high-risk care programmes if complications occur.60
If after discussion with the clinician it is clear that the woman does not have RFM,in the absence of further
risk factors and the presence of a normal fetal heart rate on auscultation, there should be no need to follow
up with further investigations.

8.2 What should be covered in the clinical examination?

If a woman presents with RFM in the community setting with no facility to auscultate the fetal heart, she
B
should be referred immediately to her maternity unit for auscultation.

When a woman presents with RFM in the community or hospital setting, an attempt should be made to
auscultate the fetal heart using a handheld Doppler device to exclude fetal death.
B

P
Clinical assessment of a woman with RFM should include assessment of fetal size with the aim of
detecting SGA fetuses.

The key priority when a woman presents with RFM is to confirm fetal viability. In most cases,
a handheld Doppler device will confirm the presence of the fetal heart beat. This should be
available in the majority of community settings in which a pregnant woman would be seen by
a midwife or general practitioner. The fetal heart beat needs to be differentiated from the
maternal heart beat.This is easily done in most cases by noting the difference between the fetal Evidence
level 2+
heart rate and the maternal pulse rate. If the presence of a fetal heart beat is not confirmed,
immediate referral for ultrasound scan assessment of fetal cardiac activity must be undertaken.
If the encounter with the woman has been over the telephone and there is thus no additional
reassurance of auscultation of the fetal heart, the woman should be advised to report for further
assessment.

Methods employed to detect SGA fetuses include abdominal palpation, measurement of symphysis–fundal
height and ultrasound biometry. The RCOG guidelines on the investigation and management of the SGA
fetus recommend use of a customised fundal height chart.61 Consideration should be given to the judicious
use of ultrasound to assess fetal size in women in whom clinical assessment is likely to be less accurate,
for example those with a raised body mass index. As pre-eclampsia is also associated with placental
dysfunction, it is prudent to measure blood pressure and test urine for proteinuria in women with RFM.

8.3 What is the role of CTG?

After fetal viability has been confirmed and history confirms a decrease in fetal movements,
B
arrangements should be made for the woman to have a CTG to exclude fetal compromise if the pregnancy
is over 28+0 weeks of gestation.

CTG monitoring of the fetal heart rate, initially for at least 20 minutes, provides an easily
accessible means of detecting fetal compromise. The presence of a normal fetal heart rate
pattern (i.e. showing accelerations of fetal heart rate coinciding with fetal movements) is
indicative of a healthy fetus with a properly functioning autonomic nervous system. Interpre-
tation of the CTG fetal heart rate pattern is assisted by adopting the National Institute for Health
Evidence
and Clinical Excellence classification of fetal heart rate patterns.62 The fetal heart rate accelerates level 3
with 92–97% of all gross body movements felt by the mother.63,64 Computer systems for interpre-
tation of CTG provide objective data, reduce intra- and inter-observer variation and are more
accurate than clinical experts in predicting umbilical acidosis and depressed Apgar scores.
However, further evaluation of this technology is required before clinical recommendations can
be made.65

RCOG Green-top Guideline No. 57 7 of 16 © Royal College of Obstetricians and Gynaecologists

Several studies have concluded that if the term fetus does not experience a fetal heart rate
acceleration for more than 80 minutes, fetal compromise is likely to be present.66–68 However, a
systematic review in the Cochrane Database of Systematic Reviews did not confirm or refute
Evidence
any benefits of routine CTG monitoring of ‘at risk’ pregnancies.69 The authors acknowledged level 2–
several limitations, including limited numbers of women (four trials and 1588 women) and
serious methodological concerns, such as the fact that the trials were conducted in the early
1980s when CTG monitoring was just being introduced into routine clinical practice.

In a Norwegian study of 3014 women who presented with RFM, a CTG was performed in 97.5%
of cases, with an abnormality such as FGR, fetal distress, oligohydramnios or malformations
detected in 3.2% of cases.58 In a different observational study of women presenting with RFM
who had an initial CTG and an ultrasound scan, 21% had an abnormality detected that required
Evidence
action and 4.4% were admitted for immediate delivery.70 Another study showed that stillbirth level 2+
rates (corrected for lethal congenital anomalies) after a reactive or non-reactive CTG were 1.9
and 26 per 1000 births,respectively.71 Lastly, a relatively small study reported that 56% of women
with a high-risk pregnancy who reported RFM had an abnormal CTG.This was associated with
an unfavourable perinatal outcome in nine out of ten cases.40

8.4 What is the role of ultrasound scanning?

Ultrasound scan assessment should be undertaken as part of the preliminary investigations of a woman
presenting with RFM after 28+0 weeks of gestation if the perception of RFM persists despite a normal
B
CTG or if there are any additional risk factors for FGR/stillbirth.

P
If an ultrasound scan assessment is deemed necessary, it should be performed when the service is next
available – preferably within 24 hours.

Ultrasound scan assessment should include the assessment of abdominal circumference and/or
estimated fetal weight to detect the SGA fetus, and the assessment of amniotic fluid volume.
C

Ultrasound should include assessment of fetal morphology if this has not previously been performed
and the woman has no objection to this being carried out.
A

There are no randomised controlled trials of ultrasound scan versus no ultrasound scan in
women with RFM. Froen et al. conducted a prospective population-based cohort study of 46 132
births in eastern Norway and Bergen over a 17-month period from 2006 to 2007.57 In the
Evidence
prospective cohort of 3014 women presenting with RFM, ultrasound scanning was performed level 2+
in 94% of cases and detection of an abnormality such as FGR, reduced amniotic fluid volume
and abnormal fetal morphology or Doppler of the umbilical artery was reported in 11.6% of
cases. Umbilical artery Doppler alone did not provide uniquely valuable information in any case.

In a recent quality improvement programme in Norway, a prospective ‘before and after’ study
design was used to evaluate the combined impact of providing women with information on
RFM and clinicians with clinical practice guidelines.13,34,72 After an initial period of study (n=19
407), an investigation protocol of CTG and ultrasound scan was introduced in the management
of women with RFM (n=46 143). The guideline recommended that both investigations be
performed within 2 hours if women reported no fetal movements, and within 12 hours if they Evidence
reported RFM.The ultrasound scan was conducted to assess amniotic fluid volume, fetal size and level 2–

fetal anatomy; the addition of Doppler studies to the investigation protocol did not show any
additional benefit. There was a significant reduction in all stillbirths from 3.0 to 2.0 per 1000,
and from 4.2% to 2.4% of women presenting with RFM. The study reported no increase in the
number of preterm births, infants requiring transfer to neonatal care or infants with severe
neonatal depression or FGR.There was more than a doubling in the number of ultrasound scans

RCOG Green-top Guideline No. 57 8 of 16 © Royal College of Obstetricians and Gynaecologists

(OR 2.64; 95% CI 2.02–3.45), but this seemed to be compensated by a reduction in additional Evidence
follow-up consultations and admissions for induction of labour. level 2–

In a study of 489 women with RFM, Ahn et al. demonstrated that women with RFM but no
additional pregnancy risk factors did not require further follow-up once the CTG and the Evidence
amniotic fluid volume were confirmed to be normal.73 However, the study found a 3.7 times level 2–

greater likelihood of diminished amniotic fluid volume on scan in their study population.

8.5 Is there any role for the biophysical profile (BPP)?

There may be a role for the selective use of BPP in the management or investigation of RFM.
B
The basis of the BPP is the observed association between hypoxia (low levels of oxygen) and
alterations of measures of central nervous system performance such as fetal heart rate patterns,
fetal movement and fetal tone, which have been observed in both human and animal fetuses.74
A systematic review of the use of BPP in women with high-risk pregnancies, including women
with RFM, included five poor-quality studies with fewer than 3000 patients.75 The systematic Evidence
review concluded that the available evidence from randomised controlled trials does not level 1–

support the use of BPP as a test of fetal wellbeing in high-risk pregnancies. It should be noted,
however, that there is evidence from uncontrolled observational studies that BPP in high-risk
women has good negative predictive value; that is, fetal death is rare in women in the presence
of a normal BPP.76

9. What is the optimal surveillance method for women who have presented with RFM in
whom investigations are normal?
Women should be reassured that 70% of pregnancies with a single episode of RFM are uncomplicated.
C
There are no data to support formal fetal movement counting (kick charts) after women have perceived
RFM in those who have normal investigations.
C

P
Women who have normal investigations after one presentation with RFM should be advised to contact
their maternity unit if they have another episode of RFM.

The majority of women (approximately 70%) who perceive a reduction in fetal movements will
have a normal outcome to their pregnancy.77–79 There are no studies of the follow-up of women
who have normal investigations. Some practitioners advocate commencing formal fetal Evidence
level 2–/+
movement counting in this situation.57 There is no evidence to support this strategy. Formal
fetal movement counting in this situation is subject to the same difficulties as in the general
obstetric population.

In a single retrospective cohort study, perinatal outcome was worse in women who had
presented on more than one occasion with RFM.79 If a woman experiences a further episode Evidence
of definite RFM, she should be referred for hospital assessment to exclude signs of compromise level 2–

through the use of CTG and ultrasound, as outlined in section 8.

10. What is the optimal management of the woman who presents recurrently with reduced
RFM?
When a woman recurrently perceives RFM, her case should be reviewed to exclude predisposing causes.
C
When a woman recurrently perceives RFM, ultrasound scan assessment should be undertaken as part of
the investigations.
B

RCOG Green-top Guideline No. 57 9 of 16 © Royal College of Obstetricians and Gynaecologists

 P
Caregivers should be aware of the increased risk of poor perinatal outcome in women presenting with
recurrent RFM.

Women who present on two or more occasions with RFM are at increased risk of a poor
perinatal outcome (stillbirth, FGR or preterm birth) compared with those who attend on only
one occasion (OR 1.92; 95% CI 1.21–3.02).79 There are no studies to determine whether
intervention (e.g. delivery or further investigation) alters perinatal morbidity or mortality in Evidence
women presenting with recurrent RFM.Therefore,the decision whether or not to induce labour level 2–

at term in a woman who presents recurrently with RFM when the growth, liquor volume and
CTG appear normal must be made after careful consultant-led counselling of the pros and cons
of induction on an individualised basis.

11. What is the optimal management of RFM before 24+0 weeks of gestation?

P
If a woman presents with RFM prior to 24+0 weeks of gestation, the presence of a fetal heartbeat should
be confirmed by auscultation with a Doppler handheld device.

P
If fetal movements have never been felt by 24 weeks of gestation, referral to a specialist fetal medicine
centre should be considered to look for evidence of fetal neuromuscular conditions.

There are no studies looking at the outcome of women who present with RFM before 24+0 weeks of
gestation.While placental insufficiency rarely presents before the first trimester, the fetal heartbeat should
be auscultated to exclude fetal demise.There is limited evidence from a number of case reports that women
who present having failed to feel fetal movements at all may have a fetus with an underlying neuromuscular
condition.80–84 A routine full antenatal check-up should be carried out, including listening to the fetal heart.

12. What is the optimal management of RFM between 24+0 and 28+0 weeks of gestation?

P
If a woman presents with RFM between 24+0 and 28+0 weeks of gestation, the presence of a fetal heartbeat
should be confirmed by auscultation with a Doppler handheld device.

There are no studies looking at the outcome of women who present with RFM between 24+0 and 28+0
weeks of gestation. The fetal heartbeat should be confirmed to check fetal viability. History must include
a comprehensive stillbirth risk evaluation, including a review of the presence of other risk factors
associated with an increased risk of stillbirth. Clinicians should be aware that placental insufficiency may
present at this gestation. There is no evidence to recommend the routine use of CTG surveillance in this
group. If there is clinical suspicion of FGR, consideration should be given to the need for ultrasound
assessment.There is no evidence on which to recommend the routine use of ultrasound assessment in this
group.

13. What should we document in the maternal records?

It is important that full details of assessment and management are documented. It is also important to
record the advice given about follow-up and when/where to present if a further episode of RFM is
perceived. Accurate record keeping is needed in sufficient detail to ensure that the consultation and
outcome can be easily audited and continuity of care provided.

14. Suggested audit topics

● Existence of a guideline on RFM.
● Percentage of women over 28+0 weeks of gestation in whom history confirms RFM having a CTG to
exclude fetal compromise.

RCOG Green-top Guideline No. 57 10 of 16 © Royal College of Obstetricians and Gynaecologists

● Percentage of women having ultrasound scan assessment as part of the preliminary investigation of
women presenting with confirmed RFM if the perception of RFM persists despite a normal CTG or
if there are any additional risk factors for FGR/stillbirth.
● Percentage of women presenting with recurrent RFM referred for a growth scan and liquor volume
assessment.

References

1. Marsál K. Ultrasonic assessment of fetal activity. Clin Obstet 18. Velazquez MD, Rayburn WF.Antenatal evaluation of the fetus
Gynaecol 1983;10:541–63. using fetal movement monitoring. Clin Obstet Gynecol
2. Rayburn WF. Fetal body movement monitoring. Obstet 2002;45:993–1004.
Gynecol Clin North Am 1990;17:95–110. 19. Johnson TR, Jordan ET, Paine LL. Doppler recordings of fetal
3. Neldam S. Fetal movements as an indicator of fetal movement: II. Comparison with maternal perception.
well-being. Dan Med Bull 1983;30:274–8. Obstet Gynecol 1990;76:42–3.
4. Grant A, Elbourne D, Valentin L, Alexander S. Routine formal 20. Johnson TR. Maternal perception and Doppler detection of
fetal movement counting and risk of antepartum late death fetal movement. Clin Perinatol 1994;21:765–77.
in normally formed singletons. Lancet 1989;2:345–9. 21. Neldam S, Jessen P. Fetal movements registered by the
5. Harrington K,Thompson O, Jordan L, Page J, Carpenter RG, pregnant woman correlated to retrospective estimations of
Campbell S. Obstetric outcome in women who present with fetal movements from cardiotocographic tracings. Am J
a reduction in fetal movements in the third trimester of Obstet Gynecol 1980;136:1051–4.
pregnancy. J Perinat Med 1998;26:77–82. 22. Richardson BS, O’Grady JP, Olsen GD. Fetal breathing
6. Efkarpidis S, Alexopoulos E, Kean L, Liu D, Fay T. Case-control movements and the response to carbon dioxide in patients
study of factors associated with intrauterine fetal deaths. on methadone maintenance. Am J Obstet Gynecol
MedGenMed 2004;6:53. 1984;150:400–5.
7. Fossen D, Silberg IE. Perinatal deaths in the county of Ostfold 23. Castillo RA, Devoe LD, Ruedrich DA, Gardner P.The effects of
1989–97. Tidsskr Nor Laegeforen 1999;119:1272–5.Article acute alcohol intoxication on biophysical activities: a case
in Norwegian. report. Am J Obstet Gynecol 1989;160:692–3.
8. Saastad E, Vangen S, Frøen JF. Suboptimal care in stillbirths – 24. Robertson SS, Dierker LJ. Fetal cyclic motor activity in
a retrospective audit study. Acta Obstet Gynecol Scand diabetic pregnancies: sensitivity to maternal blood glucose.
2007;86:444–50. Dev Psychobiol 2003;42:9–16.
9. Natale R, Nasello-Paterson C,Turliuk R. Longitudinal 25. Zisser H, Jovanovic L,Thorsell A, Kupperman A,Taylor LJ,
measurements of fetal breathing, body movements, Ospina P , et al.The fidgety fetus hypothesis: fetal activity is
heart rate, and heart rate accelerations and decelerations at an additional variable in determining birth weight of
24 to 32 weeks of gestation. Am J Obstet Gynecol offspring of women with diabetes. Diabetes Care
1985;151:256–63. 2006;29:63–7.
10. Eller DP, Stramm SL, Newman RB.The effect of maternal 26. Manning F, Wyn Pugh E, Boddy K. Effect of cigarette smoking
intravenous glucose administration on fetal activity. on fetal breathing movements in normal pregnancies.
Am J Obstet Gynecol 1992;167:1071–4. Br Med J 1975;1:552–3.
11. D’Elia A, Pighetti M, Moccia G, Santangelo N. Spontaneous 27. Ritchie K.The fetal response to changes in the composition
motor activity in normal fetuses. Early Hum Dev of maternal inspired air in human pregnancy. Semin
2001;65:139–47. Perinatol 1980;4:295–9.
12. Cito G, Luisi S, Mezzesimi A, Cavicchioli C, Calonaci G, 28. Magee LA, Dawes GS, Moulden M, Redman CW.
Petraglia F. Maternal position during non-stress test and fetal A randomised controlled comparison of betamethasone with
heart rate patterns. Acta Obstet Gynecol Scand dexamethasone: effects on the antenatal fetal heart rate.
2005;84:335–8. Br J Obstet Gynaecol 1997;104:1233–8.
13. Tveit JV, Saastad E, Bordahl PE, Stray-Pedersen B, Frøen JF.The 29. Mulder EJ, Derks JB, Visser GH. Antenatal corticosteroid
epidemiology of decreased fetal movements. Proceedings of therapy and fetal behaviour: a randomised study of the
the Norwegian Perinatal Society Conference. Oslo, Norway; effects of betamethasone and dexamethasone. Br J Obstet
2006. Gynaecol 1997;104:1239–47.
14. Patrick J, Fetherston W, Vick H, Voegelin R. Human fetal 30. Jackson JR, Kleeman S, Doerzbacher M, Lambers DS.The
breathing movements and gross fetal body movements at effect of glucocorticosteroid administration on fetal
weeks 34 to 35 of gestation. Am J Obstet Gynecol movements and biophysical profile scores in normal
1978;130:693–9. pregnancies. J Matern Fetal Neonatal Med 2003;13:50–3.
15. Minors DS, Waterhouse JM.The effect of maternal posture, 31. Christensen FC, Rayburn WF. Fetal movement counts. Obstet
meals and time of day on fetal movements. Br J Obstet Gynecol Clin North Am 1999;26:607–21.
Gynaecol 1979;86:717–23. 32. Visser GH, Laurini RN, de Vries JI, Bekedam DJ, Prechtl HF.
16. Patrick J, Campbell K, Carmichael L, Natale R, Richardson B. Abnormal motor behaviour in anencephalic fetuses. Early
Patterns of gross fetal body movements over 24-hour Hum Dev 1985;12:173–82.
observation intervals during the last 10 weeks of pregnancy. 33. Baskett TF, Liston RM. Fetal movement monitoring: clinical
Am J Obstet Gynecol 1982;142:363–71. application. Clin Perinatol 1989;16:613–25.
17. Moore TR, Piacquadio K. A prospective evaluation of fetal 34. Tveit JV, Saastad E, Stray-Pedersen B, Børdahl PE, Flenady V,
movement screening to reduce the incidence of antepartum Fretts R, et al. Reduction of late stillbirth with the
fetal death. Am J Obstet Gynecol 1989;160:1075–80. introduction of fetal movement information and guidelines –

RCOG Green-top Guideline No. 57 11 of 16 © Royal College of Obstetricians and Gynaecologists

 a clinical quality improvement. BMC Pregnancy Childbirth 56. Draper J, Field S,Thomas H, Hare MJ.Womens’ views on
2009;9:32. Erratum in: BMC Pregnancy Childbirth keeping fetal movement charts. Br J Obstet Gynaecol
2010;10:49. 1986;93:334–8.
35. Kean LH, Suwanrath C, Gargari SS, Sahota DS, James DK.A 57. Frøen JF,Tveit JV, Saastad E, Børdahl PE, Stray-Pedersen B,
comparison of fetal behaviour in breech and cephalic Heazell AE, et al. Management of decreased fetal movements.
presentations at term. Br J Obstet Gynaecol Semin Perinatol 2008;32:307–11.
1999;106:1209–13. 58. Saastad E, Ahlborg T, Frøen JF. Low maternal awareness of
36. Fisher ML. Reduced fetal movements: a research-based fetal movement is associated with small for gestational age
project. Br J Midwifery 1999;7:733–7. infants. J Midwifery Womens Health 2008;53:345–52.
37. Gettinger A, Roberts AB, Campbell S. Comparison between 59. Heazell AE, Green M, Wright C, Flenady V, Frøen JF. Midwives’
subjective and ultrasound assessments of fetal movement. and obstetricians’ knowledge and management of women
Br Med J 1978;2:88–90. presenting with decreased fetal movements. Acta Obstet
38. Hertogs K, Roberts AB, Cooper D, Griffin DR, Campbell S. Gynecol Scand 2008;87:331–9.
Maternal perception of fetal motor activity. Br Med J 60. Confidential Enquiry into Stillbirths and Deaths in Infancy
1979;2:1183–5. (CESDI). 8th Annual Report. London: Maternal and Child
39. Neldam S. Fetal movements as an indicator of fetal wellbeing. Health Research Consortium; 2001.
Lancet 1980;315:1222–4. 61. Royal College of Obstetricians and Gynaecologists. Green-
40. Rayburn WF. Clinical significance of perceptible fetal motion. top Guideline No. 31: The Investigation and Management
Am J Obstet Gynecol 1980;138:210–2. of the Small-for-gestational-age Fetus. London: RCOG; 2002
41. Sorokin Y, Pillay S, Dierker LJ, Hertz RH, Rosen MG.A [http://www.rcog.org.uk/files/rcog-corp/uploaded-
comparison between maternal, tocodynamometric, and real- files/GT31SmallGestationalAgeFetus.pdf].
time ultrasonographic assessments of fetal movement. 62. National Collaborating Centre for Women’s and Children’s
Am J Obstet Gynecol 1981;140:456–60. Health. Intrapartum care. Care of healthy women and
42. Schmidt W, Cseh I, Hara K, Kubli F. Maternal perception their babies during childbirth. London: RCOG Press; 2007
of fetal movements and real-time ultrasound findings. [http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.
J Perinat Med 1984;12:313–8. pdf].
43. Valentin L, Marsál K, Lindström K. Recording of foetal 63. Rabinowitz R, Persitz E, Sadovsky E.The relation between
movements: a comparison of three methods. J Med Eng fetal heart rate accelerations and fetal movements. Obstet
Technol 1986;10:239–47. Gynecol 1983;61:16–8.
44. Besinger RE, Johnson TR. Doppler recording of fetal 64. Patrick J, Carmichael L, Chess L, Staples C. Accelerations of
movement: clinical correlation with real-time ultrasound. the human fetal heart rate at 38 to 40 weeks’ gestational age.
Obstet Gynecol 1989;74:277–80. Am J Obstet Gynecol 1984;148:35–41.
45. Lowery CL, Russell WA Jr, Baggot PJ, Wilson JD, Walls RC, 65. Grivell RM, Alfirevic Z, Gyte GM, Devane D.Antenatal
Bentz LS, et al.Time quantified detection of fetal movements cardiotocography for fetal assessment. Cochrane Database
using a new fetal movement algorithm. Am J Perinatol Syst Rev 2010;(1):CD007863.
1997;14:7–12. 66. Lee CY, Drukker B.The nonstress test for the antepartum
46. Melendez TD, Rayburn WF, Smith CV. Characterization of fetal assessment of fetal reserve. Am J Obstet Gynecol
body movement recorded by the Hewlett-Packard M-1350-A 1979;134:460–70.
fetal monitor. Am J Obstet Gynecol 1992;167:700–2. 67. Brown R, Patrick J.The non-stress test: how long is enough?
47. Pearson JF, Weaver JB. Fetal activity and fetal wellbeing: an Am J Obstet Gynecol 1981;141:646–51.
evaluation. Br Med J 1976;1:1305–7. 68. Leveno KJ, Williams ML, DePalma RT, Whalley PJ. Perinatal
48. Heazell AE, Frøen JF. Methods of fetal movement counting outcome in the absence of antepartum fetal heart rate
and the detection of fetal compromise. J Obstet Gynaecol acceleration. Obstet Gynecol 1983;61:347–55.
2008;28:147–54. 69. Pattison N, McCowan L. Cardiotocography for antepartum
49. Roethlisberger FJ, Dickson WJ. Management and the worker. fetal assessment. Cochrane Database Syst Rev
An account of a research program conducted by the 2000;(2):CD001068.
Western electric company, Hawthorne works, Chicago. 70. Whitty JE, Garfinkel DA, Divon MY. Maternal perception of
Cambridge, MA: Harvard University Press; 1939. decreased fetal movement as an indication for antepartum
50. Elbourne D, Grant A. Study results vary in count-to-10 testing in a low-risk population. Am J Obstet Gynecol
method of fetal movement screening. Am J Obstet Gynecol 1991;165:1084–8.
1990;163:264–5. 71. Freeman RK, Anderson G, Dorchester W.A prospective multi-
51. Westgate J, Jamieson M. Stillbirths and fetal movements. institutional study of antepartum fetal heart rate monitoring.
N Z Med J 1986;99:114–6. I. Risk of perinatal mortality and morbidity according to
52. Lerum CW, LoBiondo-Wood G.The relationship of maternal antepartum fetal heart rate test results. Am J Obstet Gynecol
age, quickening, and physical symptoms of pregnancy to the 1982;143:771–7.
development of maternal-fetal attachment. Birth 72. Saastad E,Tveit JV. Uniform information on fetal activity is
1989;16:13–7. associated with reduction of stillbirth rates among
53. Liston RM, Bloom K, Zimmer P.The psychological effects of primiparous mothers: An intervention study from Norway.
counting fetal movements. Birth 1994;21:135–40. International Stillbirth Alliance Annual Conference; 2007.
54. Mikhail MS, Freda MC, Merkatz RB, Polizzotto R, Mazloom E, 73. Ahn MO, Phelan JP, Smith CV, Jacobs N, Rutherford SE.
Merkatz IR.The effect of fetal movement counting on Antepartum fetal surveillance in the patient with decreased
maternal attachment to fetus. Am J Obstet Gynecol fetal movement. Am J Obstet Gynecol 1987;157:860–4.
1991;165:988–91. 74. Manning FA, Lange IR, Morrison I, Harman CR. Fetal
55. Smith CV, Davis SA, Rayburn WF. Patients’ acceptance of biophysical profile score and the nonstress test: a
monitoring fetal movement. A randomized comparison of comparative trial. Obstet Gynecol 1984;64:326–31.
charting techniques. J Reprod Med 1992;37:144–6. 75. Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile

RCOG Green-top Guideline No. 57 12 of 16 © Royal College of Obstetricians and Gynaecologists

 for fetal assessment in high risk pregnancies. Cochrane 80. Rayburn WF, Barr M. Activity patterns in malformed fetuses.
Database Syst Rev 2008;(1):CD000038. Am J Obstet Gynecol 1982;142:1045–8.
76. Dayal AK, Manning FA, Berck DJ, Mussalli GM, Avila C, 81. Stoll C, Ehret-Mentre MC,Treisser A,Tranchant C. Prenatal
Harman CR, et al. Fetal death after normal biophysical diagnosis of congenital myasthenia with arthrogryposis
profile score: An eighteen-year experience. Am J Obstet in a myasthenic mother. Prenat Diagn 1991;11:17–22.
Gynecol 1999;181:1231–6. 82. Hoffmann R, Lohner M, Böhm N, Leititis J, Helwig H.
77. Heazell AE, Sumathi GM, Bhatti NR. What investigation is Restrictive dermopathy: a lethal congenital skin disorder.
appropriate following maternal perception of reduced Eur J Pediatr 1993;152:95–8.
fetal movements? J Obstet Gynaecol 2005;25:648–50. 83. Hsu CD, Feng TI, Crawford TO, Johnson TR. Unusual fetal
78. Sinha D, Sharma A, Nallaswamy V, Jayagopal N, Bhatti N. movement in congenital myotonic dystrophy. Fetal Diagn
Obstetric outcome in women complaining of reduced Ther 1993;8:200–2.
fetal movements. J Obstet Gynaecol 2007;27:41–3. 84. Chen H, Blackburn WR, Wertelecki W. Fetal akinesia
79. O’Sullivan O, Stephen G, Martindale E, Heazell AE. Predicting and multiple perinatal fractures. Am J Med Genet
poor perinatal outcome in women who present with 1995;55:472–7.
decreased fetal movements. J Obstet Gynaecol
2009;29:705–10.

RCOG Green-top Guideline No. 57 13 of 16 © Royal College of Obstetricians and Gynaecologists

Appendix 1

Attends with first presentation of reduced fetal movements (RFM) at >28+0 weeks of gestation

Detailed clinical history including risk factors for stillbirth and fetal growth restriction (FGR)

History confirms RFM History does not confirm RFM

Auscultate with handheld Doppler to exclude Offer to auscultate fetal heart (FH)
intrauterine fetal death (IUFD) Routine antenatal assessment
Give advice re: further episodes of RFM
If unsure whether fetal movements are reduced, focus on fetal
movements for 2 hours
FH not present on FH present on If they do not feel more than 10 movements in 2 hours, contact
auscultation auscultation healthcare provider

Immediate Cardiotocograph to exclude imminent fetal

ultrasound to compromise
exclude/diagnose
IUFD

Suspicious or pathological fetal Normal fetal heart rate pattern

heart rate pattern

IUFD Manage as per unit Continue with RFM or risk factors Perception of RFM resolved and no risk
protocol for FGR/stillbirth factors for FGR/stillbirth

Ultrasound for amniotic fluid Reassure

volume/abdominal Give advice re: further episodes of RFM
circumference/estimated fetal If unsure whether fetal movements are
weight reduced, focus on fetal movements for
2 hours
If they do not feel more than 10
movements in 2 hours, contact
maternity unit
Abnormality detected on scan Normal scan

RCOG Green-top Guideline No. 57 14 of 16 © Royal College of Obstetricians and Gynaecologists

Appendix 2
Clinical guidelines are:‘systematically developed statements which assist clinicians and patients in making
decisions about appropriate treatment for specific conditions’. Each guideline is systematically developed
using a standardised methodology. Exact details of this process can be found in Clinical Governance Advice
No.1: Development of RCOG Green-Top Guidelines (available on the RCOG website at http://www.rcog.
org.uk/womens-health/clinical-guidance/development-rcog-green-top-guidelines-policies-and-processes).
These recommendations are not intended to dictate an exclusive course of management or treatment.
They must be evaluated with reference to individual patient needs, resources and limitations unique to the
institution and variations in local populations. It is hoped that this process of local ownership will help to
incorporate these guidelines into routine practice. Attention is drawn to areas of clinical uncertainty where
further research may be indicated.

The evidence used in this guideline was graded using the scheme below and the recommendations
formulated in a similar fashion with a standardised grading scheme.

Classification of evidence levels Grades of recommendations

1++ High-quality meta-analyses, systematic At least one meta-analysis, systematic review or
reviews of randomised controlled trials A randomised controlled trial rated as 1++ and
or randomised controlled trials with a directly applicable to the target population; or
very low risk of bias
A systematic review of randomised controlled
1+ Well-conducted meta-analyses, systematic trials or a body of evidence consisting
reviews of randomised controlled trials principally of studies rated as 1+ directly
or randomised controlled trials with a applicable to the target population and
low risk of bias demonstrating overall consistency of results
1– Meta-analyses, systematic reviews of A body of evidence including studies rated as
randomised controlled trials or B 2++ directly applicable to the target
randomised controlled trials with a high population, and demonstrating overall
risk of bias consistency of results; or
2++ High-quality systematic reviews of case– Extrapolated evidence from studies rated as
control or cohort studies or high-quality 1++ or 1+
case–control or cohort studies with a
very low risk of confounding, bias or A body of evidence including studies rated as
C 2+ directly applicable to the target population
chance and a high probability that the
relationship is causal and demonstrating overall consistency of
results; or
2+ Well-conducted case–control or cohort
studies with a low risk of confounding, Extrapolated evidence from studies rated as
bias or chance and a moderate 2++
probability that the relationship is causal Evidence level 3 or 4; or
D
2- Case–control or cohort studies with a Extrapolated evidence from studies rated as 2+
high risk of confounding, bias or chance
and a significant risk that the
relationship is not causal Good practice point

P
3 Non-analytical studies, e.g. case reports,
Recommended best practice based on the
case series
clinical experience of the guideline
4 Expert opinion development group

RCOG Green-top Guideline No. 57 15 of 16 © Royal College of Obstetricians and Gynaecologists

 This guideline was produced on behalf of the Guidelines Committee of the Royal College of Obstetricians and Gynaecol-
ogists by:
Dr MK Whitworth MRCOG, Manchester, Professor M Fisher, Exeter and Dr A Heazell MRCOG, Manchester

and peer-reviewed by: the British Maternal and Fetal Medicine Society (BMFMS); RCOG Consumers’ Forum; Professor Sir
S Arulkumaran FRCOG, London; Mrs A Diyaf MRCOG, Birmingham; Mr D Fraser FRCOG, Norfolk; Dr T Kay MRCOG, Exeter;
Mr TG Overton FRCOG, Bristol; Dr S Yong MRCOG, Hong Kong.

The Guidelines Committee lead reviewers were: Mr M Griffiths FRCOG, Luton and Dr P Owen MRCOG, Glasgow.

The final version is the responsibility of the Guidelines Committee of the RCOG.

The guideline review process will commence in 2014 unless evidence requires earlier review.

DISCLAIMER

The Royal College of Obstetricians and Gynaecologists produces guidelines as an educational aid to good clinical practice.
They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by
obstetricians and gynaecologists and other relevant health professionals.The ultimate judgement regarding a particular
clinical procedure or treatment plan must be made by the doctor or other attendant in the light of clinical data presented
by the patient and the diagnostic and treatment options available.

This means that RCOG guidelines are unlike protocols or guidelines issued by employers, as they are not intended to be
prescriptive directions defining a single course of management. Departure from the local prescriptive protocols or
guidelines should be fully documented in the patient’s case notes at the time the relevant decision is taken.

RCOG Green-top Guideline No. 57 16 of 16 © Royal College of Obstetricians and Gynaecologists