What is this Guideline for and Who should use it?



Greater Manchester & Eastern Cheshire (GMEC)Strategic Clinical NetworksReduced Fetal Movement (RFM)in Pregnancy GuidelinesFinal version 2.01 May 2020Document ControlOwnershipRoleDepartmentContactProject Clinical LeadManchester Academic Health Science Centre, Division of Developmental Biology and Medicine Faculty of Biology, Medicine and Health, The University of Manchester.alexander.heazell@manchester.ac.ukProject ManagerGMEC SCNJoanne.langton@Guideline Group MembershipContributorDesignationOrganisationSyma AhmedConsultant ObstetricainWigan, Wrightington, Leigh NHS FTKaren CloughSBLCB LeadPennine Acute Trust NHS FTHelen DaviesSBLCB LeadManchester Foundation TrustNatalie HayesSBLCB LeadBolton NHS FTSarah HowardBereavement MidwifeWigan, Wrightington, Leigh NHS FTChloe HughesSBLCB LeadMacclesfield NHS FTHelen HurrenSBLCB LeadStockport NHS FTMandy PlattSBLCB LeadTameside NHS FTKayleigh RobjohnsMidwife Ultrasound PractitionerPennine Acute Trust NHS FTEileen StringerClinical Lead MidwifeGMEC SCNVersion controlV1.0Ratified by the GMEC Maternity Steering Group19/02/19V1.1RFM Meeting held and revisions discussed06/11/19V1.2Amended by Prof Alex Heazell & circulated to RFM group for comments30/11/19V1.3Comments reviewed by Prof Alex Heazell & amended06/01/20V1.4Further review following & circulation to maternity steering group 24/01/20V1.5Comments reviewed & guideline amended – For steering group ratification20/02/20V2.0Ratified by GMEC SCN Maternity Steering Group 01/05/20Endorsement ProcessApplicationAll Staff CirculationIssue Date:01/05/2020 Circulated byGMEC SCNReviewReview Date: 01/05/2022Responsibility of: GMEC SCN Date placed on the Intranet:Contents TOC \o "1-3" \h \z \u 1What is this Guideline for and Who should use it? PAGEREF _Toc39242532 \h 42What do I need to know? PAGEREF _Toc39242533 \h 43What is the Guideline? PAGEREF _Toc39242534 \h 53.1Physiology PAGEREF _Toc39242535 \h 53.2Definition of RFM PAGEREF _Toc39242536 \h 53.3Advice PAGEREF _Toc39242537 \h 63.4Ask PAGEREF _Toc39242538 \h 63.5Assess PAGEREF _Toc39242539 \h 63.6Act PAGEREF _Toc39242540 \h 73.7Advise PAGEREF _Toc39242541 \h 83.8Act again PAGEREF _Toc39242542 \h 84How will we know that Regional RFM Guidance is being used effectively? PAGEREF _Toc39242543 \h 95Abbreviations & Definitions of terms used PAGEREF _Toc39242544 \h 106Appendices PAGEREF _Toc39242545 \h 11Appendix 1 - Quick Reference Sheet for Reduced Fetal Movements (RFM) PAGEREF _Toc39242546 \h 12Appendix 2 - Equality Impact Assessment PAGEREF _Toc39242547 \h 13Appendix 3 - Checklist for Required Management of Reduced Fetal Movements (RFM) PAGEREF _Toc39242548 \h 14Appendix 4 - Information Leaflet PAGEREF _Toc39242549 \h 15Appendix 5 – Proposed Reduced Fetal Movements Audit Proforma PAGEREF _Toc39242550 \h 17Appendix 6 – Discussion Aid PAGEREF _Toc39242551 \h 187References and Bibliography PAGEREF _Toc39242552 \h 207.1Supporting References PAGEREF _Toc39242553 \h 20What is this Guideline for and Who should use it?The purpose of this guideline is to provide a standardized pathway across GM&EC for pregnant women presenting to maternity services after perceiving reduced fetal movements (RFM). It also aims to standardize information given to women about fetal movements.This guideline is intended to be used by maternity care professionals including obstetricians, midwives, and ultrasonographers.What do I need to know?Maternal perception of fetal movement is one of the first signs of fetal life and is regarded as a manifestation of fetal wellbeing. A significant reduction or sudden alteration in fetal movements is a potentially important clinical sign and can be a concern for both the mother and those providing care for her pregnancy. It has been suggested that reduced or absent fetal movements may be a warning sign of fetal compromise, which if not investigated may lead to fetal death. The significance of exaggerated fetal movements is currently less clear. The importance of providing accurate information for mothers about fetal movements and acting upon RFM has been highlighted by two Confidential Enquiries into antepartum stillbirth conducted 15 years apart ADDIN EN.CITE <EndNote><Cite><Author>Draper</Author><Year>2015</Year><RecNum>333</RecNum><DisplayText>(Confidential Enquiry into Stillbirths and Deaths in Infancy 2001, Draper, Kurinczuk et al. 2015)</DisplayText><record><rec-number>333</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="1475072722">333</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Draper, E.S.</author><author>Kurinczuk, J.J.</author><author>Kenyon, S.</author><author>on behalf of MBRRACE-UK.</author></authors></contributors><titles><title>MBRRACE-UK Perinatal Confidential Enquiry: Term, singleton, normally formed, antepartum stillbirth.</title></titles><dates><year>2015</year></dates><pub-location>Leicester</pub-location><publisher>The Infant Mortality and Morbidty Studies, Department of Health Sciences, University of Leicester</publisher><urls></urls></record></Cite><Cite><Author>Confidential Enquiry into Stillbirths and Deaths in Infancy</Author><Year>2001</Year><RecNum>113</RecNum><record><rec-number>113</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">113</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Confidential Enquiry into Stillbirths and Deaths in Infancy,</author></authors></contributors><titles><title>8th Annual Report, 1 January–31 December 1999</title></titles><dates><year>2001</year></dates><pub-location>London</pub-location><publisher>Maternal and Child Health Research Consortium</publisher><urls></urls></record></Cite></EndNote>(Confidential Enquiry into Stillbirths and Deaths in Infancy 2001, Draper, Kurinczuk et al. 2015). 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ADDIN EN.CITE.DATA (Hofmeyr and Novikova 2012, Mangesi, Hofmeyr et al. 2015). However, current management is based on the best-available evidence synthesized in RCOG guideline ADDIN EN.CITE <EndNote><Cite><Author>Royal College Of Obstetricians and Gynaecologists</Author><Year>2011</Year><RecNum>153</RecNum><DisplayText>(Royal College Of Obstetricians and Gynaecologists 2011)</DisplayText><record><rec-number>153</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">153</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Royal College Of Obstetricians and Gynaecologists, </author></authors></contributors><titles><title>Management of Reduced Fetal Movements</title></titles><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>RCOG</publisher><urls></urls></record></Cite></EndNote>(Royal College Of Obstetricians and Gynaecologists 2011). This guidance is based upon the evidence reviewed in that guideline.Maternal perception of RFM affects up to 15% of pregnancies ADDIN EN.CITE <EndNote><Cite><Author>Sergent</Author><Year>2005</Year><RecNum>28</RecNum><DisplayText>(Sergent, Lefevre et al. 2005)</DisplayText><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">28</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sergent, F.</author><author>Lefevre, A.</author><author>Verspyck, E.</author><author>Marpeau, L.</author></authors></contributors><titles><title>Decreased fetal movements in the third trimester: what to do?</title><secondary-title>Gynecol Obstet Fertil</secondary-title></titles><periodical><full-title>Gynecol Obstet Fertil</full-title></periodical><pages>861-9.</pages><volume>33</volume><number>11</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Cesarean Section</keyword><keyword>English Abstract</keyword><keyword>Female</keyword><keyword>*Fetal Movement</keyword><keyword>Fetoscopy</keyword><keyword>Fetus/physiology</keyword><keyword>*Gestational Age</keyword><keyword>Heart Rate, Fetal</keyword><keyword>Hospitalization</keyword><keyword>Humans</keyword><keyword>Labor, Induced</keyword><keyword>Pregnancy</keyword><keyword>Retrospective Studies</keyword><keyword>Risk Factors</keyword><keyword>Umbilical Arteries/ultrasonography</keyword></keywords><dates><year>2005</year><pub-dates><date>Nov</date></pub-dates></dates><urls></urls></record></Cite></EndNote>(Sergent, Lefevre et al. 2005). Importantly, the majority (70%) of these mothers will have a normal pregnancy outcome ADDIN EN.CITE <EndNote><Cite><Author>O&apos;Sullivan</Author><Year>2009</Year><RecNum>95</RecNum><DisplayText>(O&apos;Sullivan, Stephen et al. 2009)</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">95</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>O&apos;Sullivan, O.</author><author>Stephen, G.</author><author>Martindale, E.A.</author><author>Heazell, A. E.</author></authors></contributors><titles><title>Predicting Poor Perinatal Outcome in Women who Present with Decreased Fetal Movements - A Preliminary Study</title><secondary-title>Journal of Obstetrics and Gynaecology</secondary-title></titles><periodical><full-title>Journal of Obstetrics and Gynaecology</full-title></periodical><pages>705-710</pages><volume>29</volume><number>8</number><dates><year>2009</year></dates><urls></urls></record></Cite></EndNote>(O'Sullivan, Stephen et al. 2009). Up to 29% of the women complaining of Reduced Fetal Movements (RFM) have a small-for- gestational-age baby and there is an increased risk of subsequent stillbirth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EdXR0b248L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (O'Sullivan, Stephen et al. 2009, Dutton, Warrander et al. 2012, Scala, Bhide et al. 2015).Randomized controlled trial evidence does not support the routine use of formal fetal movement counting ADDIN EN.CITE <EndNote><Cite><Author>Grant</Author><Year>1989</Year><RecNum>5</RecNum><DisplayText>(Grant, Elbourne et al. 1989)</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grant, A.</author><author>Elbourne, D.</author><author>Valentin, L.</author><author>Alexander, S.</author></authors></contributors><titles><title>Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons</title><secondary-title>Lancet</secondary-title></titles><periodical><full-title>Lancet</full-title></periodical><pages>345-9.</pages><volume>2</volume><number>8659</number><keywords><keyword>Belgium</keyword><keyword>Comparative Study</keyword><keyword>Evaluation Studies</keyword><keyword>False Positive Reactions</keyword><keyword>Female</keyword><keyword>Fetal Death/epidemiology/*prevention &amp; control</keyword><keyword>*Fetal Monitoring</keyword><keyword>*Fetal Movement</keyword><keyword>Gestational Age</keyword><keyword>Great Britain</keyword><keyword>Human</keyword><keyword>Infant, Newborn</keyword><keyword>Ireland</keyword><keyword>Multicenter Studies</keyword><keyword>Patient Compliance</keyword><keyword>Pregnancy</keyword><keyword>Random Allocation</keyword><keyword>Risk Factors</keyword><keyword>Space-Time Clustering</keyword><keyword>Support, Non-U.S. Gov&apos;t</keyword><keyword>Sweden</keyword><keyword>United States</keyword></keywords><dates><year>1989</year><pub-dates><date>Aug 12</date></pub-dates></dates><urls></urls></record></Cite></EndNote>(Grant, Elbourne et al. 1989); women should be made aware of the importance of becoming familiar with their baby’s pattern of moving, and to report any change as soon as possible.What is the Guideline?63500246380? Intrauterine death? Fetal sleep? Congenital fetal malformations (e.g. neurological, musculoskeletal)? Fetal anaemia or hydrops? Acute or chronic fetal compromise resulting from placental insufficiency leading to:-Oligohydramnios-Fetal growth restriction? Polyhydramnios? Anterior placenta (before 28/40)? Maternal sedating drugs that cross the placenta (e.g. alcohol, benzodiazepines, barbiturates, methadone, narcotics)? Smoking? Administration of corticosteroids for enhancement of lung maturity? A busy mother who is not concentrating on fetal activity? Acute or chronic fetomaternal haemorrhage00? Intrauterine death? Fetal sleep? Congenital fetal malformations (e.g. neurological, musculoskeletal)? Fetal anaemia or hydrops? Acute or chronic fetal compromise resulting from placental insufficiency leading to:-Oligohydramnios-Fetal growth restriction? Polyhydramnios? Anterior placenta (before 28/40)? Maternal sedating drugs that cross the placenta (e.g. alcohol, benzodiazepines, barbiturates, methadone, narcotics)? Smoking? Administration of corticosteroids for enhancement of lung maturity? A busy mother who is not concentrating on fetal activity? Acute or chronic fetomaternal haemorrhageA wide range of conditions are associated with maternal perception of RFM:PhysiologyFetal movements are generally perceived by the mother from 16-24 weeks of gestation. Multiparous women may notice movements earlier (16 weeks); primiparous women later (20-24 weeks). From 16-24 weeks onwards, a pregnant woman should feel the baby move more and more up until 32 weeks, then stay roughly the same until she gives birth. The mother should CONTINUE to feel her baby move right up to the time she goes into labour and fetal movements may continue to be perceived whilst she is in labour too.RFM is a marker for fetal compromise, this is thought to represent a fetal response to chronic hypoxia by conserving energy, with the subsequent reduction of fetal movements is an adaptive mechanism to reduce oxygen consumption ADDIN EN.CITE <EndNote><Cite><Author>Maulik</Author><Year>1997</Year><RecNum>92</RecNum><DisplayText>(Maulik 1997)</DisplayText><record><rec-number>92</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">92</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Maulik, D.</author></authors><secondary-authors><author>Maulik, D.</author></secondary-authors></contributors><titles><title>Doppler velocimetry for fetal surveillance: Adverse perinatal outcome and fetal hypoxia.</title><secondary-title>Doppler ultrasound in Obstetrics and Gynecology </secondary-title></titles><dates><year>1997</year></dates><pub-location>New York</pub-location><publisher>Springer-Verlag</publisher><urls></urls></record></Cite></EndNote>(Maulik 1997). It is recognised that intrauterine death is preceded by cessation of fetal movements for ≥24 hours PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZWF6ZWxsPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48

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ADDIN EN.CITE.DATA (Stacey, Thompson et al. 2011, Heazell, Budd et al. 2018). Between 40-55% women with stillbirth experience RFM prior to diagnosis of intrauterine fetal death ADDIN EN.CITE <EndNote><Cite><Author>Efkarpidis</Author><Year>2004</Year><RecNum>62</RecNum><DisplayText>(Efkarpidis, Alexopoulos et al. 2004)</DisplayText><record><rec-number>62</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">62</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Efkarpidis, S.</author><author>Alexopoulos, E.</author><author>Kean, L.</author><author>Liu, D.</author><author>Fay, T.</author></authors></contributors><titles><title>Case-control study of factors associated with intrauterine deaths</title><secondary-title>Med Ged Med</secondary-title></titles><periodical><full-title>Med Ged Med</full-title></periodical><pages>53-58</pages><volume>6</volume><number>2</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>(Efkarpidis, Alexopoulos et al. 2004).Definition of RFMHere RFM is defined as maternal perception of reduced or absent fetal movements. There is no set number of normal movements. Usually a fetus will have its own pattern of movements that the mother should be advised to get to know.There is no established definition of recurrent episodes of RFM. For the purposes of this guideline, a consensus of 2 or more episodes of RFM occurring within a 21-day period after 26 weeks’ gestation was agreed. AdviceWomen should be informed about fetal movements during their pregnancy. An example of advice given in pregnancy may be:left39370There is no set number of normal movements and every pregnancy is different- usually your baby will have their own pattern of movements that you should get to know.It is NOT TRUE that babies move less often towards the end of pregnancy.From 16-24 weeks on you should feel the baby move more and more up until 32 weeks then movements should stay roughly the same until you give birth.Later on in pregnancy it is really important to be aware of the baby’s activity. You should CONTINUE to feel your baby move right up to the time you go into labour.A change, especially a reduction in movements, may be a warning sign that the baby is not well and needs checking. You must NOT WAIT until the next day to seek advice if you are worried about your baby’s movements. HYPERLINK \l "_Appendix_4_-" Refer to NHSE RFM Leaflet00There is no set number of normal movements and every pregnancy is different- usually your baby will have their own pattern of movements that you should get to know.It is NOT TRUE that babies move less often towards the end of pregnancy.From 16-24 weeks on you should feel the baby move more and more up until 32 weeks then movements should stay roughly the same until you give birth.Later on in pregnancy it is really important to be aware of the baby’s activity. You should CONTINUE to feel your baby move right up to the time you go into labour.A change, especially a reduction in movements, may be a warning sign that the baby is not well and needs checking. You must NOT WAIT until the next day to seek advice if you are worried about your baby’s movements. HYPERLINK \l "_Appendix_4_-" Refer to NHSE RFM LeafletAll women should be given the NHSE Leaflet before 24 completed weeks’ gestation, the leaflet should be easily accessible in women’s hand –held notes.AskAt relevant antenatal contacts professionals should ask women and document whether they have normal perception of fetal movements. Women should be advised to be aware of their baby’s individual pattern of movements. If they experience reduced or cessation of fetal movements they should contact their midwife or the maternity unit immediately (explain it is staffed 24 hrs. 7 days a week).AssessAll reports of reduced/absent fetal movements should be taken seriously and explored. If a woman reports reduced/absent movement she should not be told to wait for two hours and monitor movements before presenting.Women reporting no fetal movements should be seen as soon as possible.Basic assessment on first presentation should include:A detailed historyAssessment of risk factors for Fetal Growth Restriction or Stillbirth in this or previous pregnancy – e.g. consider women eligible for the SGA pathway (smoking, previous stillbirth, previous SGA baby, SFH <10th centile, maternal medical conditions, raised uterine artery PI in second trimester)Record maternal blood pressure, pulse rate, temperature and urinalysis.Abdominal palpation and measurement of symphysis fundal height (SFH) and plotting on a customised SFH chart if not done in the last two weeks unless on SBL scan pathway and scans have started.Fetal heart assessment (auscultation less or equal to 25+6 weeks gestation and for CTG if 26 weeks or over)Table 1 – Risk factors for adverse outcome after maternal presentation with RFMFactorOdds RatioReferenceCigarette smoking2.0Dutton et al. 2012Past Obstetric History of SGA baby or stillbirth2.1O’Sullivan et al. 2009Past Medical History (e.g. Diabetes/Hypertension)3.0O’Sullivan et al. 2009Recurrent presentation with RFM (≥2)1.9O’Sullivan et al. 20098.0Scala et al. 2015Symphysis-fundal height <10th centile19.5O’Sullivan et al. 2009Raised uterine artery PI in 2nd trimester5.7Scala et al. 2015* Some risk factors for stillbirth in the general population e.g. nulliparity are not included in this list because they were not associated with increased risk of adverse outcome after RFM. Professionals should still assess each case individually.Please use the Reduced Fetal Movement proforma and manage according to the flow chart as found on page 1 and Appendix 1.ActAll patients with RFM should be seen in a place where suitable management can be given. Women with abnormal results should be reviewed promptly by a senior obstetrician or midwife and a plan discussed with the mother.NB. If a woman presents at any outlying ANDUs/ANCs and states whilst she is present there that she has Reduced Fetal Movements (RFM) – staff should perform a CTG. If the CTG shows any abnormality, the woman should be transferred to a main hospital unit with obstetric and neonatal care.If there is any contact with a midwife or a woman telephones before arrival and RFM is discussed, the woman should attend an appropriate unit or satellite site where a CTG can be performed and protocols are in place for any abnormality to be acted upon promptly.Management is dependent upon gestation at presentationAuscultate fetal heart (using hand-held Doppler/Pinard)Perform cardiotocograph (CTG) if 26 weeks or over, to assess fetal heart rate in accordance with national guidelines. Ideally, this should be a computerized CTG using Dawes-Redman criteria ADDIN EN.CITE <EndNote><Cite><Author>Grivell</Author><Year>2012</Year><RecNum>306</RecNum><DisplayText>(Grivell, Alfirevic et al. 2012)</DisplayText><record><rec-number>306</rec-number><foreign-keys><key app="EN" db-id="tr9xzwdf5fda99erxs55w0zvav5v2e5avawp" timestamp="0">306</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grivell, R. M.</author><author>Alfirevic, Z.</author><author>Gyte, G. M.</author><author>Devane, D.</author></authors></contributors><auth-address>Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women&apos;s and Children&apos;s Hospital, 72 King William Road, Adelaide, Australia, SA 5006.</auth-address><titles><title>Antenatal cardiotocography for fetal assessment</title><secondary-title>Cochrane Database Syst Rev</secondary-title><alt-title>The Cochrane database of systematic reviews</alt-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD007863</pages><number>1</number><keywords><keyword>Cardiotocography/*methods</keyword><keyword>Female</keyword><keyword>Fetal Monitoring/methods</keyword><keyword>Humans</keyword><keyword>Pregnancy</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2012</year></dates><isbn>1469-493X (Electronic)&#xD;1361-6137 (Linking)</isbn><accession-num>20091654</accession-num><urls><related-urls><url> </url></related-urls></urls><language>eng</language></record></Cite></EndNote>(Grivell, Alfirevic et al. 2012)If >26 weeks’ gestation and risk factors are present for FGR/Stillbirth (See Table 1) or women are already on the SGA pathway then an ultrasound scan for assessment of fetal biometry, liquor volume and umbilical artery Doppler should be performed unless it has been performed in the preceding 3 weeksIf the mother has had a normal growth scan in the preceding 3 weeks a growth scan repeated 3 weeks from the previous scan. If this scan is normal and FM are normal, no further scans are indicated to evaluate RFM. If the preceding growth scan was abnormal then an individualized care plan should be made following discussion with a senior obstetricianExamples of indications for ultrasound assessment are:SFH < 10th centile (or decreasing fetal growth on customised growth chart)Oligohydramnios is suspected on abdominal palpation)1st episode and identified risk factor for FGR/Stillbirth (see Table 1)Recurrent RFM (i.e. 2nd episode within 21 days) if less than 39/40 The mother is over 39/40 gestation and the mother declines IOL or IOL will be delayed by >24 hours.Neither the midwife, obstetrician or woman herself are reassured by the initial assessmentPerform Ultrasound scan for growth, liquor volume assessment and umbilical artery Doppler on the day of referral unless out of hours and then on the next working day.If on a bank holiday weekend extra surveillance with CTG might be considered. If abnormalities are identified on CTG or ultrasound scan an individualized management plan should be developed following discussion with a senior obstetrician. Steroids should be given when preterm delivery is considered. The AFFIRM study found that standardised management for RFM including ultrasound scan for fetal biometry, liquor volume and umbilical artery Doppler and planned delivery (by induction of labour or Caesarean section) for women with recurrent RFM after 37 weeks increased obstetric intervention and admission to neonatal unit, but did not reduce perinatal mortality. (Norman JE et al. Sep 2018).?Prior to 39 weeks gestation, induction of labour or operative delivery is associated with small increases in fetal morbidity. Thus, a decision for delivery needs to be based upon evidence of fetal compromise (e.g. abnormal CTG, estimated fetal weight <10th centile or oligohydramnios) or other concerns (e.g. concomitant maternal medical disease such as hypertension or diabetes) in addition to RFM. After 39 weeks gestation, induction of labour is not associated with an increase in Caesarean section, instrumental vaginal delivery, fetal morbidity or admission to the neonatal intensive care unit. Therefore, if the mother has recurrent RFM at or after 39 weeks, IOL should be offered if vaginal delivery is appropriate. If a mother has a single episode of RFM at or after 39 weeks, IOL could be offered if vaginal delivery is appropriate. In all where IOL is discussed women should be made aware of the process and the possible benefits and risks of IOL in that context. Information to aid this discussion is contained in Appendix 6.AdviseConvey results of investigations to the mother. Record all advice given. Women should be asked to re-attend if further reductions in fetal movements at any time.Act againCheck that the woman still has the RFM leaflet for future reference.How will we know that Regional RFM Guidance is being used effectively?There should be an annual audit of the regional RFM guideline to evaluate compliance. This will be augmented by an annual survey of women’s views about the information they receive.The audit should be undertaken on a minimum of 2 weeks cases or 20 case notes, whichever is the smaller number. The audit findings should be reported to the local governance meeting and to the SCN Saving Babies Lives’ group. An example audit proforma is shown in Appendix 5.The audit standards are:1. Fetal movements leaflet to be given to women by 24 weeks’ gestation2. Fetal movements to be discussed at every subsequent contact3. Management of RFM is in accordance with the checklist, specifically:Was a computerised CTG performed?Was an ultrasound scan for growth, liquor volume and Doppler performed if the mother had risk factors?Was induction of labour (IOL) or delivery offered according to the guideline? Process measures are:1. Proportion of women who present with RFM >24 hours2. Proportion of women who have IOL (or delivery) for RFM as sole indicationOutcome measures:1. Neonatal outcome (Live birth, Stillbirth, Neonatal Death)2. NICU admission3. Mode of deliveryAbbreviations & Definitions of terms usedAbbreviationsDefinition<Less than>More than≥More than or equal toACAbdominal circumferenceAFFIRMAwareness of Fetal movements and Focusing Interventions Reduce Fetal MortalityAFIAmniotic Fluid IndexRFMReduced Fetal Movements (RFM)ANAntenatalANCAntenatal clinicANDUAntenatal Day UnitCESDIConfidential Enquiry into Stillbirths and Deaths in InfancyCTGCardiotocographDVPDeepest Vertical PoolEWSEarly Warning ScoreFGRFetal Growth RestrictionIOLInduction of LabourIUGRIntra Uterine Growth RestrictionLVLiquor VolumeNHSENHS EnglandOutlyingRemote from centrePAPP Pregnancy-associated plasma proteinPETPre-eclampsiaSBLSaving Babies’ LivesSFHSymphysis Fundal HeightSGASmall for Gestational AgeUSSUltrasound-1558290-7270686500 AppendicesAppendix 1:- Quick Reference Sheet for RFM GuidelineAppendix 2:- Equality Impact AssessmentAppendix 3:- Checklist for Required Management of Reduced Fetal Movements (RFM)Appendix 4:-Patient Information LeafletAppendix 5:-Proposed Reduced Fetal Movements Audit ProformaAppendix 6:-Information to Assist Discussion about IoL for Women with RFMAcknowledgementsOn behalf of the Greater Manchester and Eastern Cheshire and Strategic Clinical Networks, I would like to take this opportunity to thank the contributors for their enthusiasm, motivation and dedication in the development and updating of Reduced Fetal Movements (RFM) guidelines.Miss Karen BancroftClinical Lead for the Greater Manchester & Eastern Cheshire SCN Appendix 1 - Quick Reference Sheet for Reduced Fetal Movements (RFM)1956407120622At presentationTake history/identify risk factors for adverse outcome after RFM (See Table 1)Maternal observationsPalpate, measure and plot SFH on customized growth chart (if ≥26w and not measured for 3 weeks and not being scanned on SBL pathway)00At presentationTake history/identify risk factors for adverse outcome after RFM (See Table 1)Maternal observationsPalpate, measure and plot SFH on customized growth chart (if ≥26w and not measured for 3 weeks and not being scanned on SBL pathway)71499353329682914311319600439132926946-131207173776>24 weeks - ≤25+6Auscultate with Doppler for 1 minIf FM NEVER felt by 24 weeks check anomaly scan performed and normal, if not arrange anomaly USS and consider referral to fetal medicine clinic for assessment of neuromuscular condition if no movements seen on USS.If all well reassure and resume normal antenatal care00>24 weeks - ≤25+6Auscultate with Doppler for 1 minIf FM NEVER felt by 24 weeks check anomaly scan performed and normal, if not arrange anomaly USS and consider referral to fetal medicine clinic for assessment of neuromuscular condition if no movements seen on USS.If all well reassure and resume normal antenatal care704935717938739+Perform CTG*If abnormal CTG refer to senior Obstetrician If single episode of RFM then considerOffering cervical assessmentOffering induction of labour (unless vaginal delivery inappropriate)If recurrent RFM then should:Offer cervical assessmentOffer induction of labour (unless vaginal delivery inappropriate)Use Appendix 6 to guide discussionPerform ultrasound scan if IOL not indicated or not taking place for >24h#Offer IOL at any time if FM remain reduced0039+Perform CTG*If abnormal CTG refer to senior Obstetrician If single episode of RFM then considerOffering cervical assessmentOffering induction of labour (unless vaginal delivery inappropriate)If recurrent RFM then should:Offer cervical assessmentOffer induction of labour (unless vaginal delivery inappropriate)Use Appendix 6 to guide discussionPerform ultrasound scan if IOL not indicated or not taking place for >24h#Offer IOL at any time if FM remain reduced178735019060526+0 - 38+6Perform CTG*If normal CTG and no other risk factors (Table 1) resume planned antenatal careIf abnormal CTG refer to senior Obstetrician If risk factors for stillbirth or FGR present (or women on SGA pathway) perform ultrasound scan # on day of referral and review by senior Obstetrician unless there has been a normal scan within 3 weeks.If normal growth scan in the preceding 3 weeks, growth scan can be repeated 3 weeks from the previous scan.If a prior scan was abnormal (e.g. SGA baby) then perform scan for liquor volume and umbilical artery Doppler with review by senior Obstetrician.If presentation with RFM is out of hours/ at the weekend/ bank holiday, consider additional CTG’s until scan performed if persistent concerns regarding fetal activity or maternal wellbeingIf abnormalities identified on investigations women should be reviewed and individualized management plan madeEnsure woman has information about presentation with further concerns0026+0 - 38+6Perform CTG*If normal CTG and no other risk factors (Table 1) resume planned antenatal careIf abnormal CTG refer to senior Obstetrician If risk factors for stillbirth or FGR present (or women on SGA pathway) perform ultrasound scan # on day of referral and review by senior Obstetrician unless there has been a normal scan within 3 weeks.If normal growth scan in the preceding 3 weeks, growth scan can be repeated 3 weeks from the previous scan.If a prior scan was abnormal (e.g. SGA baby) then perform scan for liquor volume and umbilical artery Doppler with review by senior Obstetrician.If presentation with RFM is out of hours/ at the weekend/ bank holiday, consider additional CTG’s until scan performed if persistent concerns regarding fetal activity or maternal wellbeingIf abnormalities identified on investigations women should be reviewed and individualized management plan madeEnsure woman has information about presentation with further concerns*Ideally Computerised CTG should be performed # for fetal biometry (if not done within preceding 21 days), liquor volume and umbilical artery Doppler, otherwise do liquor volume and umbilical artery Doppler. Appendix 2 - Equality Impact AssessmentEquality Impact Assessment for Reduced Fetal Movements (RFM) GuidelineTo be completed by the Lead Author (or a delegated staff member)For each of the Protected Characteristics & equality & diversity streams listed answer the questions below usingY to indicate yes andN to indicate no:AgeDisabilityEthnicity / RaceGenderGenderReassignmentMarriage & Civil PartnershipPregnancy & MaternityReligion/beliefSexual orientationHuman RightsCarersPlease explain your justification1. Does the practice covered have the potential to affect individuals or communities differently or disproportionately, either positively or negatively (including discrimination)?NNNYNNYNNNNPositive effect – for pregnant women2. Is there potential for, or evidence that, the proposed practice will promote equality of opportunity for all and promote good relations with different groups?YYYYNNYYYYNAll women will receive this management3. Is there public concern (including media, academic, voluntary or sector specific interest) in the document about actual, perceived or potential discrimination about a particular community?NNNYNNYNNNNMedia interest in Saving Babies’ LivesYour Name: Your Designation:Signed*: Date: To be completed by the relevant Equality Champion following satisfactory completion & discussion of answers above with authorEquality Champion: Directorate: Signed*: Date: Appendix 3 - Checklist for Required Management of Reduced Fetal Movements (RFM)Attendance with Reduced Fetal Movements (RFM)Please initial and date when complete1 Ask5750560-5461000Is there maternal perception of Reduced Fetal Movements (RFM)?2 Assess5750560444500Are there risk factors for Fetal Growth Restriction or Stillbirth? (see section 3.5)If low-risk for FGR or stillbirth measure fundal height an plot on chart.Consider – women eligible for SGA pathway and issues with access to careRisk factors include: Cigarette smoking, Past Obstetric History of SGA baby or stillbirth, Past Medical History (e.g. Diabetes/Hypertension), Recurrent presentation with RFM (≥2), Symphysis-fundal height <10th centile, Raised uterine artery PI in 2nd trimester (if measured).3 Act5762625-762000Auscultate fetal heart (hand-held Doppler / Pinard)57505604318000If ≥26 weeks’ gestation perform cardiotocograph to assess fetal heart rate in accordance with national guidelines.57505601397000 If risk factors for FGR/Stillbirth, perform ultrasound scan for fetal growth, liquor volume and umbilical artery Doppler on the day of referral unless out of hours and then on the next working day. If on a bank holiday weekend extra surveillance with CTGs might be considered.See Flow Chart on in Appendix 1.4 Advise57505602286000Convey results of investigations to the mother. Mother should re-attend if further reductions in fetal movements at any time.5750560127000005 Act againCheck that the woman still has the RFM leaflet for future reference in an appropriate languageASK ALL WOMEN TO ATTEND TRIAGE FOR ASSESSMENT AND FOLLOW THE CARE PATHWAYIf a woman presents at an outlying ANDUs/ANC, and states whilst she is present there that she has Reduced Fetal Movements (RFM) – staff will perform a CTG. However, if there is any contact with a midwife or telephone before arrival and Reduced Fetal Movements (RFM) are discussed, the woman should attend the main unit Assessment unit to allow for any CTG abnormality to be acted upon promptly.IN THE EVENT OF ABSENT FETAL ACTIVITYAdmit immediately for assessment / reassuranceAppendix 4 - Information LeafletAppendix 5 – Proposed Reduced Fetal Movements Audit ProformaHow long did the mother have RFM for? HoursWhat was the gestation at presentation?Yes/NoWas this the second (or more) episode of RFM within 21 days?Yes/NoDid the mother have any known Risk Factors?Yes/Noe.g. Smoker, previous SGA, previous FDIU, hypertension, symphysis fundal height below the 10th centile. Did this woman have a computerised CTG?Yes/Non-computerised/No CTG Was this CTG within 2 hours of the woman arriving?Yes/NoWas the CTG pathologicalYes/NoDid this woman receive a scan for liquor volume and umbilical artery Doppler (and growth if less than 21 days since previous scan)Yes/NoWas the scan before the end of the next working dayYes/NoWas the ultrasound scan normal?Yes/NoWas this woman offered IOL?Yes/NoIf yes, what was the indication for IOL (please state)Was offer of IOL accepted?Yes/NoWas induction commenced within 48hours?Yes/NoWhat was mode of birth?Spontaneous vaginal delivery/Instrumental vaginal delivery/Caesarean sectionWhat was the neonatal outcomeLive birth/Stillbirth/Neonatal DeathWas the baby admitted to NICU?Yes / No / UnknownAppendix 6 – Discussion AidInformation to Assist Discussion about Induction of Labour for Women with Reduced Fetal MovementsInvestigations following maternal presentation with reduced fetal movements aim to detect acute fetal compromise (by cardiotocography) or evidence of placental dysfunction (by ultrasound scan). If these test results indicate an abnormality an appropriate plan should be made with the mother following consultation with a senior obstetrician.When the results of investigations are normal the consequences of intervention need to be balanced against risks of stillbirth or perinatal death at that stage of pregnancy. Some relevant statistics are presented below to assist with discussions with mothers to plan their management. These statistics must be placed in the context of other risk factors for stillbirth e.g. maternal age >35, smoking, maternal medical conditions etc. The risks of stillbirth (per 1,000 live births) are shown below for specific stages of late pregnancy (data taken from MBRRACE perinatal surveillance report, 2016). This shows that the risk of stillbirth at term is approximately 1 in 666 live births. Gestation Rate of StillbirthRate of Perinatal Death28 weeks 0 days – 31 weeks 6 days 77 per 1,000 live births1 in 13 live births97 per 1,000 live births1 in 10 live births32 weeks 0 days – 36 weeks 6 days16 per 1,000 live births1 in 63 live births20 per 1,000 live births1 in 50 live births37 weeks 0 days – 41 weeks 6 days1.5 per 1,000 live births1 in 666 live births2 per 1,000 live births1 in 500 live births42 weeks 0 days +1 per 1,000 live births1 in 1000 live births1.5 per 1,000 live births1 in 666 live birthsData suggest that a single episode of reduced fetal movements increases the risk of stillbirth by approximately 2-fold. Recurrent reduced fetal movements increase this risk further to over 5-fold.The risk of a stillbirth following a single episode of reduced fetal movements after 28 weeks’ gestation is 0.6% (1in 166 pregnancies); this increased to 1.4% if women presented more than twice with RFM (1 in 71 pregnancies) (Scala et al. Am JOG 2015).The risk of having a small for gestational age baby is 9.8% following a single episode of reduced fetal movements after 28 weeks’ gestation (1 in 10 pregnancies); this increased to 44.2% if women presented more than twice with RFM to 1.4% (2 in 5 pregnancies) (Scala et al. Am JOG 2015).The short-term benefits and risks of induction of labour also varying according to gestation. In general, the risk of perinatal mortality (the baby being stillborn or dying within seven days of birth) decreases with induction of labour (Stock et al. BMJ 2012).Gestation Expectant ManagementInduction of Labour37 weeks0.23%1 in 4350.09%1 in 111138 weeks0.20%1 in 5000.08%1 in 125039 weeks0.19%1 in 5260.06%1 in 166640 weeks0.18%1 in 5550.08%1 in 125041 weeks 0.22%1 in 4540.07%1 in 1428However, at earlier stages of pregnancy the risk of Caesarean section increases. This is not the case after 39 weeks’ gestation.Gestation Expectant ManagementInduction of Labour37 weeks8.3%1 in 12 women9.9%1 in 10 women38 weeks8.0%1 in 12 women8.8%1 in 11 women39 weeks8.4%1 in 12 women9.3%1 in 11 women40 weeks10.8%1 in 9 women8.4%1 in 12 women41 weeks 14.1%1 in 7 women10.7%1 in 9 womenSimilarly, there is a higher risk of baby being admitted to NICU/SCBU following intervention at an earlier stage of pregnancy. This is not the case after 39 weeks’ gestation.Gestation Expectant ManagementInduction of Labour37 weeks7.8%1 in 13 babies17.6%1 in 6 babies38 weeks7.4%1 in 14 babies11.3%1 in 9 babies39 weeks7.3%1 in 14 babies9.3%1 in 11 babies40 weeks7.3%1 in 14 babies8.0%1 in 12 babies41 weeks 8.4%1 in 12 babies6.6%1 in 15 babiesThe lack of evidence for short term harms following IOL after 39 weeks’ gestation is also supported by evidence from the ARRIVE trial of IOL at 39 weeks ‘in low risk women which showed no different in Caesarean section (IOL 18.6% vs. Expectant 22%) and NICU admission (IOL 11.7% vs. Expectant 13.0%).References and BibliographySupporting References ADDIN EN.REFLIST Confidential Enquiry into Stillbirths and Deaths in Infancy (2001). 8th Annual Report, 1 January–31 December 1999. London, Maternal and Child Health Research Consortium.Draper, E. S., J. J. Kurinczuk, S. Kenyon and o. b. o. MBRRACE-UK. (2015). MBRRACE-UK Perinatal Confidential Enquiry: Term, singleton, normally formed, antepartum stillbirth. Leicester, The Infant Mortality and Morbidty Studies, Department of Health Sciences, University of Leicester.Dutton, P. J., L. K. Warrander, S. A. Roberts, G. Bernatavicius, L. M. Byrd, D. Gaze, J. Kroll, R. L. Jones, C. P. Sibley, J. F. Froen and A. E. Heazell (2012). "Predictors of poor perinatal outcome following maternal perception of reduced fetal movements--a prospective cohort study." PLoS One 7(7): e39784.Efkarpidis, S., E. Alexopoulos, L. Kean, D. Liu and T. Fay (2004). "Case-control study of factors associated with intrauterine deaths." Med Ged Med 6(2): 53-58.Grant, A., D. Elbourne, L. Valentin and S. Alexander (1989). "Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons." Lancet 2(8659): 345-349.Grivell, R. M., Z. Alfirevic, G. M. Gyte and D. Devane (2012). "Antenatal cardiotocography for fetal assessment." Cochrane Database Syst Rev(1): CD007863.Heazell, A. E. P., J. Budd, M. Li, R. Cronin, B. Bradford, L. M. E. McCowan, E. A. Mitchell, T. Stacey, B. Martin, D. Roberts and J. M. D. Thompson (2018). "Alterations in maternally perceived fetal movement and their association with late stillbirth: findings from the Midland and North of England stillbirth case-control study." BMJ Open 8(7): e020031.Hofmeyr, G. J. and N. Novikova (2012). "Management of reported decreased fetal movements for improving pregnancy outcomes." Cochrane Database Syst Rev 4: CD009148.Mangesi, L., G. J. Hofmeyr, V. Smith and R. M. Smyth (2015). "Fetal movement counting for assessment of fetal wellbeing." Cochrane Database Syst Rev(10): CD004909.Maulik, D. (1997). Doppler velocimetry for fetal surveillance: Adverse perinatal outcome and fetal hypoxia. Doppler ultrasound in Obstetrics and Gynecology D. Maulik. New York, Springer-Verlag.O'Sullivan, O., G. Stephen, E. A. Martindale and A. E. Heazell (2009). "Predicting Poor Perinatal Outcome in Women who Present with Decreased Fetal Movements - A Preliminary Study." Journal of Obstetrics and Gynaecology 29(8): 705-710.Royal College Of Obstetricians and Gynaecologists (2011). Management of Reduced Fetal Movements. London, RCOG.Scala, C., A. Bhide, A. Familiari, G. Pagani, A. Khalil, A. Papageorghiou and B. Thilaganathan (2015). "Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome." Am J Obstet Gynecol 213(5): 678 e671-676.Sergent, F., A. Lefevre, E. Verspyck and L. Marpeau (2005). "Decreased fetal movements in the third trimester: what to do?" Gynecol Obstet Fertil 33(11): 861-869.Stacey, T., J. M. Thompson, E. A. Mitchell, A. Ekeroma, J. Zuccollo and L. M. McCowan (2011). "Maternal Perception of Fetal Activity and Late Stillbirth Risk: Findings from the Auckland Stillbirth Study." Birth 38(4): 311-316.Norman JE et al. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial. Lancet. 2018 Sep 27. pii: S0140-6736(18)31543-5. ................
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