What is Going on with the Foetus?

Question 1

What does Reduced Foetal movements represent?

Answer 1

• Less than 10 movements within 2 hours in pregnancies past 28-week gestation is an indication for further assessment.
• Can represent foetal distress as method of foetal compensation to reduce oxygen consumption as reponse to chronic hypoxia in utero.
• Reflects increased risk of stillbirth and foetal growth restriction. Also a link between reduced foetal movement and placental insufficiency

Question 2

What is Quickening?

Answer 2

• Quickening is the first onset of recognized foetal movement and occur between 18-20 weeks’ gestation and increases until 32 weeks’ gestation where frequency of movement tends to plateau.
• Multiparous women will usually experience foetal movement sooner from 16-18 weeks gestation. Towards the end of pregnancy, foetal movements should not reduce
• Nature of movement can be variable.

Question 3

What are risk factors for reduced foetal movements?

Answer 3

• Posture: There can be positional changes in foetal movement awareness, generally being more prominent during lying down and less when sitting and standing
• Distraction: Awareness of foetal movements can be distractable. If a woman is busy or concentrating on something else, these can be less prominent
• Placental position: Patient with anterior placentas prior to 28 weeks’ gestation may have lesser awareness of foetal movements
• Medication: Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced foetal movements
• Foetal position: Anterior foetal position means movements are less noticeable
• Body habitus: Obese patients less likely to feel prominent foetal movements
• Amniotic fluid volume: Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
• Foetal size: Up to 29% of women presenting with RFM have a SGA foetus

Question 4

What are investigations for Reduced Foetal movements after 28 weeks?

Answer 4

>28 weeks’ gestation

• Handheld doppler should be used to confirm foetal heartbeat. If foetal heartbeat is undetectable, immediate ultrasound should be offered
• If foetal heartbeat present, CTG used for at least 20 minutes to monitor foetal heart rate to assist in excluding foetal compromise
• If concern remains, despite normal CTG, urgent ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated foetal weight (to exclude SGA) and amniotic fluid volume measurement

Question 5

What are investigations for Reduced Foetal Movements occuring before Week 28?

Answer 5

24 to 28 weeks’ gestation

• Handheld doppler used to confirm presence of foetal heartbeat

<24 weeks’ gestation

• If foetal movements have previously been felt, a handheld doppler should be used.
• If foetal movement have not yet been felt by 24 weeks, referral should be made to maternal foetal medicine unit.

Question 6

How is recurrent Reduced Foetal Movements managed?

Answer 6

• Further investigations also required to consider structural or genetic foetal abnormalities

Question 7

What are types of Foetal Lie?

Answer 7

• Longitudinal lie (99.7% of foetuses at term)
• Transverse lie (<0.3% of foetuses at term)
• Oblique (<0.1% of foetuses at term)

Incidence of transverse lie is slightly higher than oblique lie. The causes and management options are the same for both. Oblique lie is easier to correct because the foetus is closer to longitudinal lie.

Question 8

What is a Transverse Lie?

Answer 8

Abnormal foetal presentation whereby the foetal longitudinal axis lies perpendicular to the long axis of the uterus.

• This means the foetal head is on the lateral side of the pelvis and the buttocks are opposite. When in transverse lie, the foetus can be either ‘scapulo-anterior’ (most common) where the foetus faces towards the mother’s back or ‘scapulo-posterior’ where the foetus faces towards the mother’s front.

Question 9

What are risk factors for Transverse Lie?

Answer 9

• Most commonly occurs in women who have had previous pregnancies
• Fibroids and other pelvic tumours
• Pregnant with twins or triplets
• Prematurity
• Polyhydramnios
• Foetal abnormalities

Question 10

What are investigations for Transverse Lie?

Answer 10

Detected during routine antenatal appointments with a midwife during abdominal examination.

• Abdominal examination: the head and buttocks are not palpable at each end of the uterus. The foetus can be felt to be lying directly across the uterus.
• Ultrasound scan: allows direct visualisation of the foetal lie. Foetal heart rate is also auscultated to assess for distress.

Question 11

What is the managment for Transverse lie?

Answer 11

• <36 weeks’ gestation: No management required. Most foetuses will spontaneously move into longitudinal lie during pregnancy
• >36 weeks’ gestation:
  
  • ​Active management: perform external cephalic version (ECV) of the foetus. Contraindications include maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormality. Success rate is around 50%
  • Elective caesarean section if patient opts for it section or ECV has been unsuccessful or is contraindicated.

Question 12

What are complications of Transverse Lie?

Answer 12

• Pre-term rupture of membranes
• Cord prolapse
• Compound presentation may occur if allowed to progress to vaginal delivery