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PROSPECTIVE STUDY/AUDIT

2016-2017
ALTERED AND ABNORMAL FETAL
MOVEMENT IN PREGNANT
PATIENTS.
AUDIT
At watford general hospital
Dr harry Nduka
Senior Registrar
Altered or Reduced fetal
movement
Investigation, management and
outcome
AIM
The aim
Find out what local guideline is available.
National guideline
If both were being followed
Standards being met and to extent they were met
Further Aim

Evaluate outcome for these patients


Investigate the interventions
Ctg, ultrasound, monitoring, delivery
what impact regarding better outcome
OBJECTIVES

Hospital paper record to access notes


(electronic record usually does not contain this).
Reduced fetal movement after 28weeks notes for patients july,
august and september 2016upto 2017 for 7months
Initially planned for a year but job duration cut it to those months.
Audit department kindly obtained the notes
Objectives continued

Data extracted from the notes using


RCOG guide, with nice imput and
hospital guide imput..
Altered or Reduced fetal
movement implication
Known to be associated with poorer obstetric and
fetal/neonatal outcome.
Known precursor of fetal demise intra and extra uterine.
Important variable in pregnant patients, fetal wellbeing.
Method
Patients with altered or Reduced fetal movement after 28week second episode
were subject of audit,
Patients with first episode but obstetric /fetal risk factors were included.
The patients were referred by community midwife or were self referral to triage,
MDAU, labour ward.
Neonatal unit of the hospital allows for 27weeks and above hence use of
28weeks
In future another audit could be done to include 24weeks onwards.
Method continued

Eventually 21 patients were found.


STANDARDS
The standard setting used was from
RCOG guide and nice imput with
watford hospital
local policy
Known grey areas in reduced
fetal movement
Though there are many grey areas in
investigation, management and
outcome in reduced fetal movement
Standards are well known.
Standard set
• Patient review
• CTG carried out
• USS growth, liquor,doppler
• Registrar/consultant review
• Intervention and monitoring if abnormality found
• Plan made.
• Decision about delivery if indicated
• Reassurance and continue care if no problem
found.
OUTCOMES Evaluated
• Induction of labour where indicated
• Meconium liquor complication
• Ceasarean section where indicated
• SVD
• Instrumental delivery
• Stillbirth
• FGR
• Admission to NICU
RESULTS

Review , all patients were seen by


midwifes except one ie 95%

One patient that was not seen


appeared to have attended but no
documention in the note

A comprehensive guideline would


be needed to be made by watford
general hospital on reduced fetal
movement
Results on CTG

19 of 21 patients had a CTG ie 92%

2 patients did not have a CTG

3 patients out of the 19 had abnormal


CTG at first review

At least 4 other patients had abnormal


CTG as there monitoring continued due
to RFM
Results on Ultrasound

16 of the 21 patients had USS approx


76%

5 patients not having initial Uss had it


later for other reasons eg suspected
FGR/congenital anommalies

6 patients of the 16 that had USS had


anomalies /fgr/liquor volume
decrease.

1 Patient had fetal demise at


30weeks due to cardiac defect and
bowel atresia.
Registrar/consultant review

15 patients of 21 had review by


Reg/consultant on that day of
attending 72%

6 patients did not get reviewed, seen


only by midwife, this can be made
better

Those 6 patients later had problems.

Reassurance when no problem 67%


expected achieved.
Induction of labour were indicated

9 patients had IOl

1 patient had Iol for PPROM


and RFM at 34 weeks and
baby weighed 1.5kg

Most of the Iol were


appropriate , about 90%
Ceasearean Section where indicated

9 patients of 21
had C/S

4 had EL C/S

5 had EMLSCS
Reasons
for C/s

5 EMLSCS

Fetal demise 30weeks


previous C/S cardiac
anomaly

2 abnormal CTG,
prolonged 1 for maternal 1 for no progress at
decel/bradycardia less pyrexia/fetal sepsis 10cm
than 3cm in labour
EL CS

4 Elective C/S

2 for previous 1 for previous


1 for placenta
C/S greater 3rd degree injury
preavia grade 4
than twice and RFM
Admission to NICU
neonatal intensive unit

1 transfer to
5 admmission 1 out of the 5
tertiary
to NICU for sepsis
hospital

1 out of the 5 1 out of the 5


for 34weeks for thick mec
delivery aspiration
Still born
• There was only one stillbirth, due to cardiac
anomaly, bowel atresia, baby died at 30weeks.
• There was on lost to follow up which I do not
know how the baby has done.
Fetal growth restriction
• 4 patients had verified FGR at birth
• 2 patients had reduced liqour volume.
• EFW was fairly corresponding with birth
weight 1.5kg -2.4kg
• Gestation was between 35weeks and 41
weeks
Recommendations

• It is known that between 50-60% of patients with fetal


demise had altered or reduce fetal movement
• It is known that inappriopriate clinician response occurs in
most of them
• It is known that poor perinatal outcome is associated with
RFM
• In a large study of approx 3500 patients 21% were found to
have problem on CTG or USS at first presentation of RFM,
Just under 5%-10% needed delivery.
• 70% of first episode of decreased fetal movement are going
to be uncomplicated if CTG is normal
• Hence the following possible recommendations are being
suggested
Recommendations
• A comprehensive guideline or protocol would make the
management of RFM better. Grade A
• All patients with RFM after 28weeks should have a
CTG, prefarable computerised CTG. Grade B
• They must all be reviewed by at least Registrar level if
after second episode or first episode with background
risk factors. Grade B recommendation
• USS should be done in all if after second episode or
first episode with risk factors. Grade b
recommendation
• Accurate record keeping is imperative and should be
the norm.
Discussion open.
• Thank you

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