magicpixie, I believe the current NICE guidelines are:
------
What is the optimal management of women with reduced fetal movements?
The initial goal of antenatal fetal surveillance in cases of reduced fetal movements 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.
What should be included in the clinical history?
Upon presenting with reduced fetal movements, a relevant history should be taken to assess a woman's risk factors for stillbirth and fetal growth restriction (fetal growth restriction).
If after discussion with the clinician it is clear that the woman does not have reduced fetal movements, there are no other risk factors for stillbirth and there is the presence of a fetal heart rate on auscultation, she can be reassured. However, if the woman still has concerns, she should be advised to attend her maternity unit.
A history of reduced fetal movements should be taken, including the duration of reduced fetal movements, whether there has been absence of fetal movements and whether this is the first occasion the woman has perceived reduced fetal movements. 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 reduced fetal movements, known fetal growth restriction, hypertension, diabetes, extremes of maternal age, primiparity, smoking, placental insufficiency, congenital malformation, obesity, racial/ethnic factors, poor past obstetric history (e.g. fetal growth restriction and stillbirth), genetic factors and issues 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. If after discussion with the clinician it is clear that the woman does not have reduced fetal movements, 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.
What should be covered in the clinical examination?
If a woman presents with reduced fetal movements in the community setting with no facility to auscultate the fetal heart, she should be referred immediately to her maternity unit for auscultation.
When a woman presents with reduced fetal movements 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.
Clinical assessment of a woman with reduced fetal movements should include assessment of fetal size with the aim of detecting small for gestational age fetuses.
The key priority when a woman presents with reduced fetal movements 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 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 small for gestational age fetuses include abdominal palpation, measurement of symphysis–fundal height and ultrasound biometry. The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on the investigation and management of the small for gestational age fetus recommend use of a customised fundal height chart. 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 reduced fetal movements.
What is the role of cardiotocography?
After fetal viability has been confirmed and history confirms a decrease in fetal movements, arrangements should be made for the woman to have a cardiotocography to exclude fetal compromise if the pregnancy is over 28+0 weeks of gestation.
What is the role of ultrasound scanning?
Ultrasound scan assessment should be undertaken as part of the preliminary investigations of a woman presenting with reduced fetal movements after 28+0 weeks of gestation if the perception of reduced fetal movements persists despite a normal cardiotocography or if there are any additional risk factors for fetal growth restriction/stillbirth.
Ultrasound scan assessment should include the assessment of abdominal circumference and/or estimated fetal weight to detect the small for gestational age fetus, and the assessment of amniotic fluid volume.
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.
Is there any role for the biophysical profile?
There may be a role for the selective use of biophysical profile in the management or investigation of reduced fetal movements.
*What is the optimal surveillance method for women who have presented with reduced fetal movements in whom investigations are normal?
Women should be reassured that 70% of pregnancies with a single episode of reduced fetal movements are uncomplicated.
There are no data to support formal fetal movement counting (kick charts) after women have perceived reduced fetal movements in those who have normal investigations.
What is the optimal management of the woman who presents recurrently with reduced fetal movements?
When a woman recurrently perceives reduced fetal movements, her case should be reviewed to exclude predisposing causes.
When a woman recurrently perceives reduced fetal movements, ultrasound scan assessment should be undertaken as part of the investigations.
There are no studies to determine whether intervention (e.g. delivery or further investigation) alters perinatal morbidity or mortality in women presenting with recurrent reduced fetal movements. Therefore, the decision whether or not to induce labour at term in a woman who presents recurrently with reduced fetal movements when the growth, liquor volume and cardiotocography appear normal must be made after careful consultant-led counselling of the pros and cons of induction on an individualised basis.