AUDIT

Altered or Reduced fetal movements investigation, management and outcome

Watford general hospital

Audit 2016-2017

Aim

The aim is to find out what local guideline was available, the national guideline and if both were
being followed and standards met,

The aim also included evaluating the outcome for these patients , and thereby find out if the
interventions ie monitoring, ultrasound, ctg and delivery made an impact leading to better
outcome.

Objectives

The hospital paper record was assessed to obtain the patients that had decreased fetal
movement after 28weeks as it is not usually in the electronic record , this was obtained for the
months of july, august and septmeber of 2016. it was initially planned for a year but due to
certain matters I have done it for those months due to job duration.

The notes were then obtained through the audit department system and data extracted .

The RCOG guide was used and nice imput added to set and evaluate standards.

Altered or reduced fetal movement has a well known association with poorer obstetric and
fetal/neonatal outcome and is a known precursor of intrauterine fetal death hence it is an
important variable to be considered in all pregnant patients.

Methods
Patients that had hospital attendance for altered or decreased fetal movement after 28 weeks
were the subject of the audit, the audit was done retrospectively, the patients were either
referred fom community midwife or were walk into , triage, MDAU or labour ward.

Data was collected based on the clinical assessment they had, what staff reviewed them, actions
and intervention, and eventual outcome including obstetric and immediate neonatal outcome.

The neonatal unit of the hospital allows from 27weeks hence the 28week gestation
used,however in future a larger audit including from 24weeks can be done.

The audit department supported espiecially finding note which is not always easy .

eventually 21 patients notes were found

patients with first episode but having obstetric risk factors were included same as second
episode.

Standard

The standard setting was based on the RCOG guide and imput from nice and hospital .

It would be needed that the watford hospital makes a comprehensive formal guide eventually
for the management of reduced fetal movement, at the time of the audit this appeared to be in
the plan.

It has to be noted that the audit was important and standard used are well known but it must be
remembered that there are lots of grey area in the recommendation.

The following standards were set

All patients with significant history of decreased/altered fetal movement should have at referral
to hospital

1,Review

2,CTG

3,ultrasound growth, liquor and dopplers if the second episode or first episode with risk factors

4,registrar or consultant review if second episode or above,

5 INTERVENTION OR MONITORING if abnormal findings/CTG problem or ultrasound abnormality

6,A plan of action or decision made and documented about further management, including
sweep if term, IOL IF more than three episode and term pregnancy.

7,DECISION ABOUT DELIVERY IF ABNORMAL CTG

8, reasurance and continue care if no problem found at first episode.

The following outcomes were evaluated

number that had

IOL

MECONIUM

CEASAREAN SECTION

INSTRUMENTAL DELIVERY FORCEPS OR VENTOUSE

SVD

STILLBIRTH

FGR

ADMMISSION TO NICU.

RESULTS

Review all the patients were seen by midwife except one where all I found in the note was
attended MDAU,

CTG

19 PATIENTS Had CTG of the 21 at at second episode of altered and RFM

of that 19 three patients had abnormal CTG at between 28weeks and term

The two patients that did not have CTG one was thought to be normal on sonic aid, the other
patient was not reviewed or it was not documented

ULTRASOUND after second episode

16 patients had ultrasound of the 21 patients

5 patients were not arranged for scan, 3 later had a scan through other problems coming up ie ?
SFD .

of the 16 that had scan 6 had abnormal scan from various congenital anomalies including FGR,
cardiac defect, bowel atresia, talipes and abnormal liquor

there was one fetal demise intra uterine 30 weeks but it was patient with congenital heart
defect

Registrar and or consultant review

15 patients had registrar/consultant review

6 did not get the review,were seen only by midwife

this would need to be better as some of them later had problems.

IOL

9 patients were induced at between 37 and 41 weeks, they all had other risk factors as well. this
was appropriate

1 patient had IOL at 34weeks due to prolonged SROM in addition to decreased fetal movement
at least thwo episodes, the baby was small 1.5kg.

Ceasarean Section

9 patients had ceasarean section

5 had emergency C/S , 2 for abnormal ctg/bradycardia prolonged decel in early labour, 1 for
maternal pyrexia/fetal sepsis and one for
4 had ELCS, one patient had cardiac anomaly/fetal demise

2 previous C/S more than twice

one placenta preavia grade four

one previous third degree injury but deceleration on CTG category three C/S

Admission to NICU