Loss of  fetal movements

PROBLEM

• Fetal movements are not felt after 22 weeks of gestation or during labour.

GENERAL MANAGEMENT

• Reassure the woman and provide emotional support.

• Check the fetal heart rate:

- If the mother has had sedatives, wait for the effect of the drugs to wear off and then recheck;

- If the fetal heart cannot be heard, ask several other persons to listen or use a Doppler stethoscope, if available. 

DIAGNOSIS

Table S-19

Diagnosis of loss of fetal movements 

FETAL DEATH

Intrauterine death may be the result of fetal growth restriction, fetal infection, cord accident or congenital anomalies. Where syphilis is prevalent, a large proportion of fetal deaths are due to this disease.

• If x-ray is available, confirm fetal death after 5 days. Signs include overlapping skull bones, hyper flexed spinal column, gas bubbles in heart and great vessels and oedema of the scalp.

• Alternatively, if ultrasound is available, confirm fetal death. Signs include absent fetal heart activity, abnormal fetal head shape, reduced or absent amniotic fluid and doubled-up fetus.

• Explain the problem to the woman and her family. Discuss with them the options of expectant or active management. 

• If expectant management is planned: 

- Await spontaneous onset of labour during the next 4 weeks;

- Reassure the woman that in 90% of cases the fetus is spontaneously expelled during the waiting period with no complications. 

• If platelets are decreasing or 4 weeks have passed without spontaneous labour, consider active management.

• If active management is planned, assess the cervix: 

- If the cervix is favourable (soft, thin, partly dilated), induce labour using oxytocin or prostaglandins; 

- If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins or a Foley catheter;

Note: Do not rupture the membranes due to risk of infection.

- Deliver by caesarean section only as a last resort.

• If spontaneous labour does not occur within 4 weeks, platelets are decreasing and the cervix is unfavourable (firm, thick, closed), ripen the cervix using misoprostol:

- Place misoprostol 25 μcg in the upper vagina. Repeat after 6 hours if required;

- If there is no response after two doses of 25 μcg, increase to 50 μcg every 6 hours;

Note: Do not use more than 50 μcg at a time and do not exceed 4 doses.

Do not use oxytocin within 8 hours of using misoprostol. Monitor uterine contractions and fetal heart rate of all women undergoing induction of labour with prostaglandins. 

• If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics as for metritis.

• If a clotting test shows failure of a clot to form after 7 minutes or a soft clot that breaks down easily, suspect coagulopathy.

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