Kurdistan Regional Government-Iraq

Ministry of Health

Directory Of Health in Sulaimania

Maternal and Neonatal outcome in term low risk

pregnancy with reduced fetal movement

A Thesis
Submitted to the ministry of health in partial
fulfillment of the requirement for degree of high
diploma in obstetrics & gynecology
Prepared by
HALA ADNAN RASHED
M.B.CH.B.
2014
Supervised by
DR. SUNDUS YOUSIF KELLOW
M.B.CH.B.C.A.B.O.G.
LECTURER IN OBESTETRICS & TNECOLOGY
UNIVERSITY OF SULAIMANIA
2013
 Acknowledgment

Great thanks to GOD for his entire blessing during the pursuit of my
academic and career goals.
First of all I would like to express my deepest gratitude and thanks to
my supervisor Dr. Sundus Yousif Kellow whose patience, suggestions
and invaluable guidance enable me to carryout my present research. I'm
very grateful to her for the constant revision of this thesis which without
it would not have come to its final shape.
I'm grateful as well as to Dr. Shlear Fayek , the manager of ministry
teaching hospital in Sulaimani and Dr. Zhyan Ahmed head of
department of Obstetrics and Gynecology, for their kind help and
support.
My deep gratitude to all who provide me with help support and
encouragement.
I appreciate the cooperation of all Gynecologists and Obstetricians in
Maternity teaching hospital in Sulaimani for their kind help.
Finally, I have to extend my thanks to my family especially my husband
Gailan Ismat for his grateful help and my lovely parents for their
support.
 List of Content

Page
Supervisors Certification I
Committee's Certification II
Acknowledgment III
Dedication IV
List Of Content V
List Of Abbreviation VI
List Of Tables VIII
List Of Figures VIII
Abstract XI
Chapter One: Introduction 1
Path Physiology 1
Definition Of Fetal Movements 3
Definition Of REM 5
Assessment Of Fetal Well-Being 7
Aim Of The Study 13
Chapter Two: Patient And Method 14
Statistical Analysis 15
Chapter Three: Results 16
Chapter Four: Discussion 26
Chapter Five: Conclusion And Recommendation 28
Conclusion 28
Recommendation 29
References 30
Appendix 1: Questionnaire
Abstract In Arabic
Abstract In Kurdish
 List of abbreviations
AC……………………………………………Abdominal circumference
AFI…………………………………………………amniotic fluid index
APH……………………………………………ante partum hemorrhage
BPD…………………………………………….……Biparietal diameter
C/S………………………………………………...……cesarean section
CTG…………………………..………………………cardio tocography
DVP………………………...…………………………deep vertical pool
EFW………………………………………………estimated fetal weight
FGR………………………………...……………fetal growth restriction
FHR………………………………………………………fetal heart rate
FM………………………………………………………fetal movement
FMH………………….………………………feto-maternal hemorrhage
FOP…………………..………………………………failure of progress
1ST……………………………………………………………………first
5TH.…..………………………………………………………………fifth
GA………………….……………………………………gestational age
HR………………………………..…………………………………hour
IUFD……………………………...……………intrauterine fetal demise
IUGR…………………….……………… intrauterine growth restriction
KG……………………………...………………………………kilogram
MINT………………………….……….…………………………minute
MNST…………………………………………… manual non stress test
MCU………………………………………..…………neonatal care unit
NPV…………………………...………………negative predictive value
NST… ……………...…………………………………… non stress test
PPV……………………………………….……positive predictive value
P-value………………………………………………… predictive value
RFM……………………………………………reduced fetal movement
RH……………………………………..…………………………Rhesus
RR……………………………...……………………………relative risk
SFH………………………………….…………symphysis fundal height
SGA…………………………..………………………small for gestation
U/S………………………...……………………………ultrasonography
U/A……………………..………………………………Umbilical artery
UADV……………………...……Umbilical artery Doppler velocimetry
UA …………………………………………………… Umbilical artery
UADV………...…………………Umbilical artery Doppler velocimetry
 List of Tables
No. Title Page
Table (1) Characteristic of the studied groups 16
Table(2) Clinical findings of the studied groups 19
Table(3) U/S Findings of the studied groups 21
Table(4) Intrapartum Outcome 23
Table(5) Neonatal Outcome of the studied groups 25

List Of Figures
No. Title Page
Figure (1) Optimal Management of Reduced FM Beyond 37 6
weeks
Figure (2) Relation of NST to the mode of delivery and neonatal 17
outcome
Figure (3) Increase neonatal complications with decrease fetal 18
movement
Figure (4) Effect of low AFI on pregnancy outcome 20
Figure (5) Liquor color among studied groups 22
Figure (6) 1st Mint APGAR score related to neonatal outcome 24
ABSRTACT
Maternal perception of fetal movement is the most common method
to assess fetal wellbeing in most communities today. It performed as
unstructured screening to which most pregnant woman depend
Significant reduction or sudden alteration in fetal movement is
potentially important sign of impending fetal death. Studies of fetal
physiology using ultrasound have demonstrated an association between
reduced fetal movement and poor perinatal outcome.

Aim
To observe the outcome of low risk pregnancies presented with
reduced fetal movement at term regarding the time, intrapartum
complications, mode of delivery and early neonatal outcome.
Design: a prospective case – control study.
METHODOLOGY
Hundred low risk pregnant women at term were included in the
study; fifty of them with reduced fetal movements and the other fifty
had good fetal movement. After taking full history and examination
including fetal heart rate and non-stress test and sent to ultrasonography
for amniotic fluid index and umbilical artery Doppler velocimetry, we
followed them up until delivery, and then intrapartum complicated for
comparison between the two groups.
RESULTS:
Regarding mode of delivery there was no significant difference
between the two groups, the rate of caesarean section for fetal distress
was more among the cases 45.8% than control 29.4%. Number of still
birth was just 2 babies of case group. These were significant neonatal
complications as birth asphyxia 24% with meconium aspiration
syndrome 16%, seizures 10% and early neonatal 6% in the studies
(case) groups as compared to the control group.
Conclusion:
 Reduced fetal movement is an important symptom that should be
taken seriously and managed accordingly, to reduce perinatal morbidity
and mortality.
- Each maternity hospital should have a protocol to deal with every
pregnant presents with reduced fetal movement.
- All clinicians should be aware of the potential association of
RFM with risk factores as well as growth restriction, small for
GA fetus, placental insufficiency and congenital malformation,
those which could be diagnosed by serial examinations during
follow up and also by availability of the most up to date and
accurate U/S scanning devices in the hospital.
- Fetal scalp blood sampling for PH in order to decrease neonatal
complications or death.
KEY WORDS:
RFM, kick count, Doppler, NST, fetal hypoxia, neonatal outcome.
Introduction
The predominant goal of antenatal fetal monitoring is to reduce
perinatal morbidity and mortality. Daily monitoring of fetal movement
(FM) provides a useful and non-invasive method of assessing fetal well-
being. Pregnant women can fell FM from the month of pregnancy,
something even earlier. (1)
Although fetal movements being as infrequent, weak and
indistinguishable from other abdominal movement such as those in the
intestine, FM gradually becomes stronger and more frequent as
pregnancy progresses.
Routine antenatal evaluation of pregnancy with the use of
ultrasonography and external fetal monitoring would clearly tax limited
resources but maternal assessment of fetal activity is a simple,
inexpensive and probably effective mean of monitoring fetal
condition. (2)
 -Pathophysiology
Mothers usually report fetal movements from around 20 weeks with
peak at 28-34 week gestation. Multiparous women may notice
movement earlier (16-20) weeks gestation than prim parous women
(20-22) weeks gestation. The number of spontaneous movement tends
to increase until 32 weeks of pregnancy from this stage of gestation, the
frequency of fetal movements plateaus until the onset of labor,
however, the fetal movement may change as pregnancy advances in the
third trimester. (3)
A gradual decline during the third trimester is suggested to be due to
improved fetal coordination and reduced amniotic column, coupled with
increase fetal size, so by term the average number of generalized
movement per hour is 31 (range 16-45), with the longest period
between movements ranging from 50 to 75 minutes. (3)
Changes in the number and nature of fetal movement as the fetus
mature are considered to be a reflection of normal neurological
development of the fetus. From as early as 20 weeks of gestation, fetal
movement show diurnal changes, where the afternoon and evening
period are periods of peak activity. FM are usually reduced during
"sleep cycle", which occur regularly throughout the day and the night
usually last for 20-40 minutes rarely exceed 90 minutes in normal,
healthy fetus.(4)
Various method have been described to quantify the fetal movement
to predict fetal well-being, which include the use of CTG, U/S and
maternal subjective perception. Studies of fetal physiology using U/S
have demonstrated an association between reduce fetal movements and
poor perinatal outcome.(5)
As stillbirth remains a significant problem in both the developed
and developing world, it affects approximately 1/200 pregnancies after
24 weeks of gestation. The most common single cause of stillbirth is
fetal growth restriction which has been mostly preceded by diminish or
absence in fetal movement.(6)
The fetus responds to chronic hypoxia by conserving energy &
subsequent reduction of FM is an adaptive mechanism to reduced
oxygen consumption. It's recognized that IUD is preceded by cessation
of FM for at least 24 hours. (7)

 -Definition of fetal movements

Perceived fetal movements are defined as the maternal sensation of
any discrete kick, flutter, swish of roll. Such fetal activity provides an
indication of integrity of the central nervous and musculoskeletal
systems. Maternal perception of fetal movements has been used as an
indicator of fetal well-being at least 500 years ago, being described by
Thomas Ranald in 1535. The normal fetus is active and capable of
physical movement, and goes through periods of both rest and sleep.(8)
Between (20-30) weeks, general body movements become
organized and them fetus starts to show rest-activity cycle in third
trimester, fetal movements maturation continue until about 36 weeks
when 4 behavioral states are established in 80% of normal fetus (9)
 State If/is a quiescent state (quiet sleep) with narrow
oscillatory band width of fetal HR.
 State 2f/includes frequent gross body movements, continuous
eye movements and wider oscillation of fetal HR, this state is
 analogous to REM(rapid eye movements) or active sleep in
the neonate.
 State 3f/ includes continuous eye movements in the absence of
body movements and no acceleration of the fetal heart rate,
the existence of this state is disputed.
 State 4f/ is one of vigorous body movement with continuous
eye movements and fetal heart rate acceleration. This state
corresponds to the awake state.
Fetus spend most of time in state 3f and 2f. these behavioral states,
particularly 1f and 2f corresponding to quit sleep and active sleep, (9)
Studies found that bladder volume increases during quiet sleep(state
1f) while decreases significantly during state 2f. this is due to fetal
voiding as well as decrease urine production. These phenomena were
interpreted to represent reduce rental blood flow during active sleep. (9)
Amniotic fluid volume is another important determinant of fetal
activity. It has been found that there is decrease fetal activity with
diminished amniotic fluid volume, and suggested that restricted
intrauterine space might physically limit FM. (9)
The majority of women (55%) who are experiencing a still birth
perceived a reduction in fetal movements prior to diagnosis. (10)
In contrast, reduction in these perceived movements is associated
with both pathological and non-pathological conditions which may vary
from serious clinical diagnosis such as intrauterine fetal death,
intrauterine fetal growth restriction, polyhydramnios, oligohydramnios
and hydrops fetalis to other benign causes such as fetal sleep, anterior
placental location, increase body mass index and maternal smoking or
when the mother in sitting or standing position as she perceive most
movements when lying down, it is therefore not surprising that pregnant
women who are busy not concentrating on fetal activity often had
misperception of reduced fetal movement. (11)
 -Definition of RFM
Maternal perception of FM range from 4-94% of actual movements
seen on concurrent ultrasound scanning definition of RFM ranged from
less than 10 movements in 2 hours to less than 12 in 24 hours. (12)
Reports on published definition found most midwives and
obstetricians favored the definition of less than 10 movements in 12
hours. This concurs with definition of Pearson and weaver(1976) who
developed "count to 10 kick chart ", using this kick chart women record
their first 10 movements of each day, and if this is not reached after 12
hours, are advised to seek further assessment. A recent prospective
cohort study showed that the mean time to perceive 10 movements is
approximately 10 minutes in normal third trimester pregnancies.(13)
Other studies showed that the meantime perceive 10 movements
varied between 21 minutes to 162 minutes. (13)
There is no evidence that any formal definition of reduced FM is of
greater value than subjective maternal perception in the detection of
fetal compromise. Therefore, maternal perception of reduction or
sudden alteration of FM should be considered clinically important. (11-
13)

 -Management of reduced FM beyond 37 weeks gestation.

Up to 5% of women will present with reduced FM. If the perception
of reduce FM persists, consideration should be given to other causes
such as fetal structural anomalies (4-3%), anemia or feto-maternal
ultrasound assessment to rule out SGA, structural anomalies and oligo
or polyhyraminos and invite the women for daily CTG until mother and
clinicians are reassured. A blood test should ultimately by considered
looking for maternal metabolic disorders or feto-maternal hemorrhage.
Smoking should be discouraged. If concerns persist in later gestation
indication of labor or delivery can be considered.(14)
As in all areas of good clinical practice, meticulous documentation
about the history and duration of the presenting complaint, stillbirth risk
assessment, examination methods, recommendation of follow-up and
advice is essential.(14)
 (Figure 1) optimal management of reduced FM beyond 37 weeks
gestation(14)
 -Assessment of Fetal Well-being
Obstetric care providers have two patients, the mother and the fetus.
Assessment of maternal well-being is relatively easy, but fetal well-
being is far more difficult to assess, several tests have been developed
to confirm fetal well-being prior to labor and delivery.(15)
All antepartum fetal tests should be interpreted in the light of
gestational age, the presence or absence of congenital anomalies and
underlying clinical risk factors. (13)

Clinical application for fetal movement assessment:

a-kick count
kick chart methods used to document fetal activity include use of
tocodynamometer, visualization with real time ultrasound and maternal
subjective perception.
Most investigators have reported excellent correlation between
maternally perceived fetal motion and movement documented by
instrumentation. Fetal motions lasting more than 20sec. were identified
more accurately by the mother than shorter episodes of fetal activity.
(14)
The threshold for decreased fetal movement is defined for each
mother, fetus at a time when activity is typical, and applying time (no
more than 50% longer to reach average count) or number (no fewer
than one-third the number in a given time).(15)
Use of kick chart in high risk pregnancies can decrease perinatal
morality fourfold.(15)

b-Symphysis fundal height measurement (SFH):

A clinical opinion about the size of the baby including abdominal
palpation and the measurement of SFH should be part of every
assessment and is helpful in the management of reduced FM, despite
the fact that abdominal palpation only detects 30% of small for
gestational age fetuses, and the SFH measurement has a positive
predictive value of 60% and a negative predictive value of 76.8%.(16)
This implies that if the SFH is within normal limits, fetal growth
restriction for placental insufficiency is unlikely to be present.(16)
Serial SFH measurement have an increased specificity and
sensitivity as the trend in growth is of more valu than a single
measurement in predicting poor fetal outcome. As 50-70% of fetuses
with a birth weight below 10th centile are constitutionally small, Gardosi
et al suggested that plotting measurement on customized SFH charts
adjusted for maternal weight, height, parity and ethnic group results in
increased detection of growth restriction and fewer hospital referral.(16)
The SFH mean at 36 weeks gestation on drawn charts 34-34.8 cm
which implies that using of "SFH in cm equals gestation age in week"
would lead to significant over-diagnosis of SGA fetuses.(17)
c-Non stress test –(NST):
the classic coupling of fetal heart rate acceleration to fetal
movement is the basis of the non-stress test. This coupling is not
universally apparent until 24-28 weeks gestation. The non-stress test is
primarily a test of fetal condition, and it differs from the contraction
stress test, which is a test of utero placental function.(15-18)
it reflects maturity of the fetal autonomic nervous system. NST is
non-invasive, simple to perform, readily available and inexpensive.
Interpretation is largely subjective.(14-18)
a reactive CTG is defined by two acceleration exceeding 15 bpm.
Sustained for at least 15 sec in a 20mint period. Loss of variability is
associated with fetal sleep, sedation or central nervous system
depression, including fetal acidosis. The absence of acceleration or
appearance of decelerations along with a history of reduced FM may
indicate fetal hypoxia and is associated with fetal demise and caesarean
section delivery. CTG is useful in the detection of acute hypoxia but is a
poor test for chronic hypoxia. (18)
large scale studies showed that CTG does not reduce still birth or
perinatal morbidity. Nevertheless a reactive CTG is significantly more
condition that non-reactive test.(18)

d-Acoustic stimulation test:

Refers to the response of the FHR to a vibroacoustic stimulus
(which is a potent stimulus to elicit changes in fetal movement and
heart rate). An acceleration on NST of more than 15 bpm for equal or
more than 15 sec is a positive result.(14-19)
It is useful adjunct to decrease the time to achieve reactive NST and
to decrease the proportion of non-reactive NST at term (from 14% to
8%) precluding the need for further testing. (14-19)
e-Measurement of amniotic fluid volume:
Ultrasonography is a more accurate method of estimating amniotic
fluid than measurement of fundal height. Several techniques are
described.
 1- Subjective assessment of amniotic fluid volume.
2- Measurement of the single deepest pocket (free of umbilical
cord) normally between 2-8 cm.
3- Amniotic fluid index(AFI) is semi quantitative methods for
estimating amniotic fluid volume, which minimize intra and
intra-observer error. AFI refers to the sum of the maximum
vertical pocket of amniotic fluid (in cm) in each of the four
quadrants of the uterus, ranged between 10-20 cm with 5%
chance of oligohydramnios is 4 days. (19)
In general, if reduced liquor volume is detected, further evaluation
of the fetus is recommended, given the association of oligohydramnios
with placental insufficiency, premature rupture of membranes and fetal
renal abnormality. Lin et al. found that oligohydramnios was in 29% of
growth restrictied fetuses. An AFI or DVP measurement is also
recommended in postdates pregnancies. (14-20)
f- Fetal biometry:
A Cochrane review showed that if reduced FMs are reported, fetal
ultrasound assessment for abdominal circumference (AC) or estimated
fetal weight (EFW) is indicated in case where measurement suggests
SGA, in late gestation, a single AC measurement is more accurate than
head measurement. AC have reported sensitives of 73%-94% and
specifies 51%-91% (RCOG 2002). AC and EFW measurement are
better to predict a small for gestation age fetus under the 10 th centile
than large for date fetuses (RCOG 2002). Similar to SFH, serial
measurement, ideally two weeks apart, are more accurate than single
estimates in prediction of growth restriction. As with SFH measurement
plotted on customized centile charts to increase sensitivity and
specificity. (14-20)
In conclusion, fetal biometry assessment should be performed is
SFH suggest SGA and if there is suspected oligohydramnios, also
should be considered in 2nd and subsequent presentations or if neither
pregnant women nor clinician are reassured by initial assessment.(20)
g- Modified Biophysical Profile:-
because the biophysical profile is labor-intensive and required a
person trained in ultrasonic visualization of the fetus, Clark and
coworker (1989) used an abbreviated BPP as short-term indicator of
fetal acid base status, with the AFI, as indicator of long term placental
function.(14-20)
h-Umbilical Artery (UA) Doppler Velocimetry:-
There is little evidence for the use of UA Doppler velocimetry in the
assessment of reduced FM. UA Doppler is of benefit in high-risk
pregnancies including the assessment of IUGR pregnancies in order to
reduce perinatal mortality. But has not been shown to be of value as
screening test for detecting fetal compromise in the general obstetric
population. (21)
Dubiel et al compared CTG with UA Doppler in the assessment of
low risk pregnancies complaining of reduce FM they found that CTG
seemed to be a better predictor of mortality and infant handicap than
Doppler velocimetry.(22)
Sergent et al report only one highly pathological UA Doppler in
their retrospective review of 160 pregnancies affected by RFM, this
means that UA Doppler is of limited use in the assessment of reduced
FM, it is useful in the assessment of the IUGR fetus.(22)
 Aim of the Study
The aim of the study is to observe the outcome of pregnancies
presented with RFM at term and compare them to the control group
regarding:
1. The mode of delivery.
2. Intrapartum complications.
3. Early neonatal period complications.
Patients and methods
This is a prospective case – control study.
Place of study:
The study had been conducted in Sulaimania Maternity Teaching
Hospital for a period of 6 months from 1 st of September 2012 until 1st of
March 2013.
The study involved 2 groups of pregenant ladies with low risk term
singleton (37 completed weeks – 42 weeks), admitted to emergency
department. The 2 groups which included in the study were: 1 st group of
50 cases who were complaining of reduced fetal movements and the 2 nd
group were 50 women with good fetal movement admitted in early
labour and no history of reduced fetal movement as control group.
Exclusion criteria include:
1. Medical illness with pregnancy (diabetes mellitus,
hypertension, est)
2. Multiple gestation > 37 weeks
3. Previous 2c/s or more.
4. IUGR.
Both groups were oriented to the objectives of the study and verbal
consent was obtained, the committee agreed on the study and a
performed questionnaire organized for collection of data.
For each patient detailed history and examination including FH,
SFH, manual NST was done;(observation fetal movements within (20-
40) mint and counting FHR acceleration after each movements if it was
more than 2 movements/20 mint and FHR acceleration <15 beats/mint
is considered as normal(, then the patient sent for U/S for fetal
biometry, EFW and UAD velocimetry and they were put on kick count
of fetal movements/12hrs.
According to the results of U/S and senior decision whether to
deliver immediately or just observation till delivery all the patients were
followed up.
 Any intrapartum complication meconium stained liquor, fetal
distress and mode of delivery with the indication of C/S were recorded
for each patient.
After delivery neonatal outcome including gender, weight, apgar
score and early neonatal period complications also were recorded and
tabulated for statistical analysis.
Statistical analysis:
Data were collected, coded, tabulated and then analyzed by
computer using SPSS(Statistical Program for Social Science) version 18
as following:
1. Quantitative data described as mean and standard deviation.
2. Qualitative variables described as frequency and percentage.
3. Chi- square test(descriptive statistics) used to compare
parametric and non-parametric variables among the groups.
4. Any P value less than 0.05 were considered statistically
significant.

A total of 83 pregnant ladies with reduced fetal movement at term

were collected:
From them 3 cases had IUFD which diagnosed on admission to
hospital during examination and confirmed by U/S and 13 cases of
IUFD considered as high risk pregnancy were excluded from the study
and managed accordingly.
Also 17 cases were excluded because they did not return for follow
up (missed), so 50 cases only completed the follow up and encountered
in our study and among them 38 patient delivered after admission and
12 patients discharged and followed up till delivery (5days – 3weeks).
Another 50 term pregnant ladies with good fetal movements who
admitted with infrequent uterine contraction and cervical dilatation
>3cm, 42 patient were delivered after admission and the other 8
delivered at second tie admission after follow up, were taken as control
group.
The results are as following:
1- Characteristics of the study groups (table 1):-
Regarding age: most of the patients were in the age group <30
years {24cases (48%) and 22 control (44%), while those age
below 20 year were 5 cases (10%) and control (16%) and the age
between 20-30 were 21 case (42%) and 20 control(40)}

About residency: majority of the patient were from urban areas

34 cases (68%) and 31 cases (62%) while the others from rural
areas.
The occupation of the study groups mostly were housewives 39
cases (78%) and 43 control cases (86%) while 11 case (22%) and
7 control (14%) were employees.

About the gravidity there were 25 primigravida in case group

(50%) while in control group they were 22 (40%) but
multigravida were 25 (50%) in the case and 28 (56%) in controls.

According to the gestation age 38 cases (76%) were between 37-

40 weeks but 12 of cases (24%) were <40 weeks GA while in
control group 32 patient (64%) with GA between 37-40 weeks
and 18 (36%) with <40 weeks gestation.
The majority of patients were RH+ve 82% cases and 90% of
control. There was no statistical significance between both
groups in all above parameters since the calculated P-values were
< 0.05. As shown in Table (1):
 Study Group
Characteristics
P. value
of the studied Classes Cases control
groups
N % N %
1 >20 5 10 8 16
2 20-30 21 42 20 40 Non
1 Age 0.669
3 <30 24 48 22 44 Sig
Total 50 100 50 100
1 Urban 34 68 31 62
Non
2 Residence 2 Rural 16 32 19 38 0.529
Sig
Total 50 100 50 100
1 Housewife 39 78 43 86
Non
3 Occupation 2 Employee 11 22 7 14 0.298
Sig
Total 50 100 50 100
1 Primi 25 50 22 44
Non
4 Gravidity 2 Multi 25 50 28 56 0.548
Sig
Total 50 100 50 100
1 >40 38 74 32 64
Non
5 GA 2 ≤40 12 24 18 36 0.190
Sig
Total 50 100 50 100
1 RH+ 41 82 45 90
Non
6 Blood Group 2 RH- 9 18 5 10 0.249
Sig
Total 50 100 50 100

2. Clinical Findings of the Studies Groups, Table (2):-

Regarding FHR which detected by sonic taken for 1 mint
continuously there were 38 cases (76%) and 46 control (92%) with FHR
(110-160) means normal at time of admission while 12 of the cases
(24%) and 4(8%) of the control had abnormal FHR (<110 - <160) that
needed further interference, this was statistically not significant.
 By abdominal examination, regarding SFH there were 22 of cases
(44%) had smaller for data, while 28(56%) which coincided with
gestation age. Most of control group 43(86%) SFH coincided with
gestation, p-value 0.003 (statistical significant). The study showed that
SFH smaller for date had a relation with increase C/S rate and
meconium aspiration (RR=1.4, sensitivity=44%, specificity =74%,
NPA=80%).
Regarding MNST which done at time of admission there were 29
(58%) of cases and 42 (84%) of control with reactive MNST, while 21
cases (42%) and 8 control (16%) were non-reactive MNST. This show
significant difference between group's. P-value >0.05, and had relation
with increase rat of C/S (RR=1.3)and neonatal complication (RR=1.5,
sensitivity= 48%, specificity=77%).
Kick counting show also statistical significant difference between
the studies groups as it was in 22 cases (44%) and 22 control (64%)
were more than 10/12hrs, while 28 cases (56%) and 18 control (36%)
counting less than 10/12hrs. which has relation with increase rate of
meconium aspiration and birth asphyxia (RR=1.7, sensitivity=32%,
specificity=57%) these are shown in figure (3), and in Table (2):

Figure (3): increase neonatal complication with decrease fetal

movements. No-comp (No complication), BA (Birth asphyxia), S
(Seizures), D(Death)
 Table (2): Clinical Findings of the studies groups:
Study Group
Clinical
P. value
findings of the Classes Cases control
studied groups
N % N %
Normal FHR
1 38 76 46 92
(110-160)
Non
1 FHR Abnormal FHR 0.069
2 12 24 4 8 Sig
(>100 OR <160)
Total 50 100 50 100
1 Smaller for date 22 44 7 14
Non
2 SFH 2 Coincide with GA 28 56 43 86 0.003
Sig
Total 50 100 50 100
1 Reactive 29 58 42 84
Manual non Non
3 2 Non-reactive 21 42 8 16 0.002
Stress test Sig
Total 50 100 50 100
1 >10/12 hr 28 56 18 36
Non
4 Kick Count 2 >10/12 hr 22 44 32 64 0.045
Sig
Total 50 100 50 100

3-U/S finding of studies groups: table (3)

Regarding the presentation there were 47 (94%) of cases and 46 of
control (92%) cephalic presentation while 3 of the cases (6%) and 4 of
the control (8%) were non cephalic presentation .p-value <0.05 so not
significant difference.
About EFW the majority of the fetuses were weighting (2.5-3.7) kg
which was in case {45 (90%) and in control 44 (88%) only 2 cases had
EFW >2.5 (4%) while EFW <3.7 were 3 (6%) among cases and 6(12%)
in control group, again reach not statistical significance.
About AFI, Normal range (6-20) was found in 24(48%) of cases
and 34% (68%) of control, while AFI>=5 was found in 22(44%) of
cases and 16(32%) of control which we found that it was related to
increase C/S rate because of fetal distress (RR+1.5) and also increase
rate of birth asphyxia (RR=1.2) (sensitivity =28%, specificity=69%,
NPV=74%). AFI>20 reported only in 4 cases (8%) the difference
between groups was statistically significant, p-value >0.05, as shown in
the figure (4):

Figure (4): effect of low AFI on pregnancy outcome. VD (Vaginal

Delivery), C/S (caesarean section), No-comp (No complication), BA
(Birth asphyxia), S(Seizures), D(Death).

Regarding UA Doppler velocimetry there were 46(92%) of cases

and 47(94%) of control group who had normal finding, while in 4(8%)
of cases and 3(6%) of control with abnormal UA flow rate, this was
statistically not significant with p-value 0.695, (sensitivity=8%,
specificity=97%. NPV=71%).
The placental site founded by u/s show no significant difference
since there was 24(48%) of cases and 28(56%) of control were
anteriorly located but 24 (48%) cases and 22(44%) control were
placenta posterior only 2 of cases only had low lying placenta. As
shown in table (3):
 Table (3) U/S Findings of the studied groups:
Study Group
U/S Findings
P. value
of the studied Classes Cases control
groups
N % N %
1 Cephalic 47 94 46 92
Non
1 Presentation 2 No-Cephalic 3 6 4 8 0.695
Sig
Total 50 100 50 100
1 >2.5Kg 2 4 0 0
2 (2.5-3.7) Kg 45 90 44 88 Non
2 EFW 0.222
3 <3.7 3 6 6 12 Sig
Total 50 100 50 100
1 ≤5 22 44 16 32
2 6-20 24 48 34 68 Non
3 AFI 0.036
3 <20 4 8 0 0 Sig
Total 50 100 50 100
1 Normal 46 92 47 94
UA Doppler Non
4
Velocimetry
2 Abnormal 4 8 3 6 0.695
Sig
Total 50 100 50 100
1 Anterior 24 48 28 56
2 Posterior 24 48 22 44 Non
5 PL site 0.302
Sig
3 Low-Lying 2 4 0 0
Total 50 100 50 100

4- Intrapartum outcome (table 4):

The liquor colour in 23 (46%) of cases and 31 (62%) of control
was clear, while 27(54%) of cases and 19 (38%) of control were
meconium stained, the majority was grad II meconium 10(20%) of
cases and 8(16%) of control. There was no statistically significant
difference between groups p-value <0.05 in spite that we found
meconium stained liquor was related to increase b=neonatal
complication in those groups (sensitivity =68%, PPV=14%,
specificity=94%, NPV=79%), as shown in figure (5):

Figure (5) liquor colour among studied groups. Mec. (meconium)

The majority of the patient were delivered by vaginal delivery only
have {26(52%) of cases and 33(66%) of control} while those who
delivered by C/S 24(49%) of cases all expect one were delivered by
emergency c/s and similarly 17(34%) of control had emergency C/S and
which show statistically no significant difference between them, from
the collected data there was significant relation of GA <40 and neonatal
out come as it increase rate of meconium aspiration (RR=1.2) and birth
asphyxia (RR=1.3) but the rate of C/S wasn't affected )RR=0.5).
The indication of c/s in case group was for fetal distress 11(45.8%)
while in control only 5(29.4%), for malpresentation (breech) 3(12.5%)
of cases and 4 (23.5%) of control. For APH only 2 cases of placenta
Previa, for FOP 7(29.2%) OF CASES AND 8(47.1%) of control lastly
only one case C/S was done for her on her request at private hospital
(elective C/S).
The reported cases of still birth among all the 100 patients were 2
fetuses both were congenitally abnormal. As shown in table (4).
 Table (4) Intrapartum outcome:
Study Group
Intrapartum P. value
Classes Cases control
Outcome
N % N %
0 Clear liquor 23 46 31 62
1 Grade I mee 9 18 8 16
Non
1 Meconium 2 Grade II mee 10 20 8 16 0.291
Sig
3 Grade III mee 8 16 3 6
Total 50 100 50 100
1 VD 26 52 33 66
Made of Non
2 3 C/S 24 49 17 34 0.155
Delivery Sig
Total 50 100 50 100
1 Fetal distress 11 45.8 5 29.4
2 Malpresentation 3 13.5 4 23.5
3 APH 2 8.3 0 0 Non
3 Indication 0.355
4 FOP 7 29.2 8 47.1 Sig
5 On request 1 4.2 0 0
Total 24 100 17 100
1 Negative 48 96 50 100
Non
4 Still Birth 2 Positive 2 4 0 0 0.153
Sig
Total 50 100 50 100
*All of them breech presentation, expect one of control was shoulder
presentation.
**both of them were congenitally abnormal
5-Neonatal outcome of the study groups (table 5):
The gender of the babies in 27(54%) of cases and 23(46%) of control
were female while in 23(46%) of cases and 27 of control (54%) were
male, p-value was 0.424 (statistically not significant).
The birth weight mostly was between (2.5-3.7)Kg {cases 43(86%)
and control 41(82%) but those who had <3.7kg 5(10%) of cases and
9(18%) of control and only 2 babies of cases with birth wt. >2.5kg were
recorded, p-value 0.203 (statistically not significant).
The Apgar score at 1st mint in 31 (62%) of cases and 16(32%) of
control within (0-6) and in 19(38%) of cases and 34(68%) of control
was within (7-10), p-value 0.003(highly significant) and there was a
relation with increase neonatal complication for these groups (RR=1.2)
(sensitivity =76%, specificity= 73%, PPV=51%, NPV=90%), shown in
figure (7):

Figure (6): 1st mint APGAR score related to neonatal outcome. No-
comp (No complication)., BA (birth asphyxia), S(seizures), D (Death).
While Apgar score at 5th mint was 26(52%) of the cases and
21(42%) of control had (0-6) score count and those with score (7-10)
24(48%) of cases and 29(58%) of control, p-value 0.312 (non-
significant)
Need for admission to NCU counted in the case 27(54%) while in
the control 21(42%), p-value 0.230(not significant)
About early neonatal period complications those with no
complications were {30(60%) of cases and 45(90%) of control}, but
12(24%) of case's babies and 5(10%) of control's babies had birth
asphyxia majority were meconium aspiration syndrome, seizure
recorded in 5 case 3 of them had meconium after follow up one of them
died after 14 days of birth, also there were 3 babies how died during
 first 7 days of birth one because of birth asphyxia and other 2 babies
had congenital anomalies died at first day of life, by comparing between
the two groups in neonatal outcome the p-value was 0.003(highly
significant difference). As shown Table (5):

Table (5) Neonatal Outcome of the study groups:

Study Group
Neonatal
P. value
outcome of the Classes Cases control
study groups
N % N %
1 Male 27 54 23 46
Non
1 Gender 2 Female 23 46 27 54 0.424
Sig
Total 50 100 50 100
1 >2.5Kg 2 4 0 0
2 (2.5-3.7) Kg 43 86 41 82 Non
2 Weight 0.203
3 <3.7 5 10 9 18 Sig
Total 50 100 50 100
1 0-6 31 62 16 32
3 APGAR 1min 2 7-10 19 38 34 68 0.003 Sig
Total 50 100 50 100
1 0-6 26 52 21 42
Non
4 APGAR 5min 2 7-10 24 48 29 58 0.316
Sig
Total 50 100 50 100
1 Yes 27 54 21 42
Admission Non
5 2 No 23 46 29 58 0.230
NCU Sig
Total 50 100 50 100
1 No 30 60 45 90
2 Birth asphyxia 12 24 5 10
Neo.
6 3 Seizure 5 10 0 0 0.003 Sig
Complications
4 Death 3 6 0 0
Total 50 100 50 100
 Fetal movement is the sign of fetal well-being. Mother's awareness
of a loss of or significant decrease of the propulsive fetal movement has
been traditionally regarded as a warning sign. We all accept today fetal
activity expresses fetal condition in utero, daily monitoring of fetal
movement provides good way of assessing fetal well-being. (23)
In this study among 50 cases who presented with reduced fetal
movement 12 cases showed abnormal FHR and 21 case had abnormal
MNST with significant difference between studied groups this result
was agreed with search of Mamata Baral (2002).(22), and N Daly et al
(2011)(18) that there is a significant change in FHR and NST which
may indicate placental insufficiency or fetal hypoxia.
About kick count chart of patient with reduced fetal movement show
statistically significant difference compared with the control this agree
with Unterscheider et al (2010) (14), and Grant et al (1989) (8) who
were able to demonstrate reduction in the incidence of antepartum fetal
death using formal movement counting but not agree with Heazall et all
(2008) (6), Witty et all(1991) (17) and Sinha D et al (2007) (20) who
were against using kick count chart routinely as it is associated with 2.6
fold increase in obstetric interventions and C/S rate.
The study didn't show any relation between fetal presentation and
fetal activity this agree with results of Dr Mamata (2002) (23).
Using AFI for assessment of fetal well being showed significant
association between reduced liquor amount and reduced fetal
movement this agree with Julia Unterscheder and Keeln Donoghue
(2012) (14) who found that oligohydramnios associated with placental
insufficiency in pregnancies presented with RFM.
Regarding UA Doppler study in this agree with Dubiet et al(1997)
(21), Seregnt et al(2005) (15) who reported only one highly
pathological UA Doppler in the retrospective review of 160 pregnant
lady with RFM.
So UA Doppler velocimetry is of limited use in the assessment of
RFM (Unterschrder et al 2009) (14), it is useful in the assessment of
IUGR fetuses.
 About mode of delivery the study didn’t show any significant
difference between the groups and this not agreed with Dr. Mamata
(2002)(23), N. Daly et al (2011)(18) and Unterschrder (2011( (14). Who
found sig. association between RFM and increase rate of C/S.

Regarding neonatal outcome and especially Apgar score of the baby

our results showed significant low Apgar score at first mint. In babies
whose mother presented with RFM, while at 5th mint, there were no
statistical difference amon them this agree with result of Dr, Mamata
(2002)(23), N. Daly et al (2011)(18) of Apgar at 1 st mint, but not agree
with this study regarding 5th mint. Apgar score.
Similarity admission to NCU show no significant difference among
studied groups which agree with results of Dr. Mamata(2002)(23) but
not agree with N. Daly et al (2011)(18).
This study shoed that there is significant association between RFM
and early neonatal period complications by significant difference
between groups, as there were 12 babies of cases with birth asphyxia
and 5 babies with seizure 1 of them died after 14 days while there was
no seizure nor Dr. Mamata (2002)(23) and N. Daly et al (2011) (18)
was against this results.
 Conclusion
In view of our study, we conclude that:

1- There is no f=difference between primgravida and multigravida

in perception of decrease fetal movement.
2- There is increase incidence of RFM in those fetuses who are
smaller than gestation.
3- NST is an important test to determine fetal well-being.
4- Although kick count is a subjective finding but it is an evidence
that we should respect and take it seriously.
5- UA Doppler is of limited use in assessment of RFM; it is useful
in the assessment of IUGR.
6- RFM may lead to low Apgar score at first mint and higher rate of
early neonatal period complication.
 Recommendation
From the outcome of present study, we recommend:

Clear protocols to deal with RFM at term pregnancy include:

1. Clear history and examination.

2. CTG and NST is important test to evaluate fetal well-being.
3. Every woman should know what KICK COUNT is and how to
assess herself as a way to decrease perinatal morbidity and
mortality.
4. If abnormal kick count then send for U/S especially AFI and
EFW.
5. Fetal scalp blood sampling for PH especially for those with
meconium stained liquor or none reassuring CTG to decrease
neonatal complications or death.
Name:
Age: Address; Occupation:
Phone No.:
GPA: GA: BLOOD GROUP:
Duration of reduced fetal movement:
EXAMINATION:
Fetal heart
Manual nst:
SFH:
PAST HISTORY
Medical hx
Drug hx (sedation or steroid)
Smoking
INVESTIGATION:
US presentation Lie: FL: AC: BPD:
FEW
AFI:
DOPPLER US:
PLCENTAL SITE:
COGENITAL ANOMALIES:
Mode of delivery: NVD: CS: indication:
When delivered:
Meconium: Yes No
Sex of baby: WT:
ABGAR SCOR:
Admittion to NCU: Yes No
Early neonatal period complications:
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