Decreased fetal movements — structured SAQ (15 marks)

(a) Immediate priorities — first ten minutes (4 marks)

One mark per point, maximum four. ^[3][4]

• Confirm fetal viability with handheld Doppler or ultrasound at the bedside; do not proceed without confirming the baby is alive.
• Continuous CTG and interpretation: this trace is abnormal (reduced variability and recurrent late decelerations) and signals fetal compromise.
• Call for help — senior obstetrician, midwifery coordinator, theatre and anaesthetics alert; this is a fetus at risk and a recurrent presentation.
• Focused history and examination — recurrent DFM (second presentation in eight days), smoking, fundal height 34 cm at 37 weeks (small for dates), maternal observations to exclude pre-eclampsia and abruption.

Reasoning mark for stating that this is a compromised fetus with an abnormal CTG in the context of recurrent DFM and suspected fetal growth restriction.

(b) Why a reactive CTG at the first presentation did not exclude compromise (3 marks)

One mark per point. ^[4][5]

• The CTG reflects only the next twenty minutes of fetal oxygenation, not placental function over days to weeks; a reactive trace does not exclude a failing placenta.
• Recurrent DFM up-tiers the risk — the Lu IPD meta-analysis shows recurrent DFM clusters with fetal growth restriction and placental insufficiency, and abnormal fetal heart rate carries an adjusted OR of 3.65 for adverse outcome.^[3]
• At the first presentation, growth on customised charts, amniotic fluid volume and umbilical artery Doppler were required in addition to the CTG, because fetal growth restriction and placental insufficiency are the most common underlying pathology (FGR was the most common complication in the Lu IPD meta-analysis at 4.6%).^[3]

(c) Investigations and thresholds for abnormality (4 marks)

One mark per investigation with threshold. Marks are lost for omitting customised growth or Doppler. ^[4][5]

(d) Management and the role of the awareness trials (4 marks)

One mark per element. ^[1][3]

• This fetus is compromised: an abnormal CTG with recurrent DFM and suspected growth restriction warrants urgent obstetric review and expedited birth, likely by caesarean given the gestation and the abnormal trace, after senior consultation and counselling of the woman.^[3]
• Recurrent DFM mandates a senior decision, not a repeat reassuring CTG and discharge; a third presentation is a near-mandate for a decision about birth.
• Counselling integrates the awareness evidence: the AFFIRM trial (Norman, Lancet 2018) showed that an awareness and standardised-management care package did NOT reduce stillbirth (4.40 vs 4.06 per 1000, aOR 0.90, 0.75 to 1.07); however, the Thompson IPD meta-analysis confirms the association between DFM and stillbirth is real (reduced frequency aOR 2.33).^[1][2]
• Document the assessment, findings, counselling and plan, give written advice, and feed into the Safer Baby Bundle quality-improvement pathway (DFM is one of the five elements).^[6]