The grades of recommendations (A-E and I) and levels of evidence (I, II-1, II-2, II-3, and III) are defined at the end of the "Major Recommendations" field.
Fetal Movement Counting
- Daily monitoring of fetal movements starting at 26 to 32 weeks should be done in all pregnancies with risk factors for adverse perinatal outcome. (I-A)
- Healthy pregnant women without risk factors for adverse perinatal outcomes should be made aware of the significance of fetal movements in the third trimester and asked to perform a fetal movement count if they perceive decreased movements. (I-B)
- Women who do not perceive six movements in an interval of two hours require further antenatal testing and should contact their caregivers or hospital as soon as possible. (III-B)
- Women who report decreased fetal movements (< 6 distinct movements within 2 hours) should have a complete evaluation of maternal and fetal status, including non-stress test and/or biophysical profile. Prior to considering an intervention for fetal well-being, an anatomical scan to rule out a fetal malformation should be done, if one has not already been done. Management should be based upon the following:
- Non-stress test is normal and there are no risk factors: the woman should continue with daily fetal movement counting. (III-B)
- Non-stress test is normal and risk factors or clinical suspicion of intrauterine growth restriction/oligohydramnios is identified: an ultrasound for either full biophysical profile or amniotic fluid volume assessment within 24 hours. The woman should continue with daily fetal movement counting. (III-B)
- Non-stress test is atypical/abnormal: further testing (biophysical profile and/or contraction stress test and assessment of amniotic fluid volume) should be performed as soon as possible. (III-B)
Non-Stress Test
- Antepartum non-stress testing may be considered when risk factors for adverse perinatal outcome are present. (III-B)
- In the presence of a normal non-stress test, usual fetal movement patterns, and absence of suspected oligohydramnios, it is not necessary to conduct a biophysical profile or contraction stress test. (III-B)
- A normal non-stress test should be classified and documented by an appropriately trained and designated individual as soon as possible, (ideally within 24 hours). For atypical or abnormal non-stress tests, the nurse should inform the attending physician (or primary care provider) at the time that the classification is apparent. An abnormal non-stress test should be viewed by the attending physician (or primary care provider) and documented immediately. (III-B)
Contraction Stress Test
- The contraction stress test should be considered in the presence of an atypical non-stress test as a proxy for the adequacy of intrapartum uteroplacental function and, together with the clinical circumstances, will aid in decision making about timing and mode of delivery. (III-B)
- The contraction stress test should not be performed when vaginal delivery is contraindicated. (III-B)
- The contraction stress test should be performed in a setting where emergency Caesarean section is available. (III-B)
Biophysical Profile
- In pregnancies at increased risk for adverse perinatal outcome and where facilities and expertise exist, biophysical profile is recommended for evaluation of fetal well-being. (I-A)
- When an abnormal biophysical profile is obtained, the responsible physician or delegate should be informed immediately. Further management will be determined by the overall clinical situation. (III-B)
Uterine Artery Doppler
- Where facilities and expertise exist, uterine artery Doppler may be performed at the time of the 17 to 22 weeks' gestation detailed anatomical ultrasound scan in women with the following factors for adverse perinatal outcome. (II-A)
- Women with a positive uterine artery Doppler screen should have the following:
- A double marker screen (for alpha-fetoprotein and beta human chorionic gonadotrophin [hCG]) if at or before 18 weeks' gestation. (III-C)
- A second uterine artery Doppler at 24 to 26 weeks. If the uterine artery Doppler is positive at the second scan, the woman should be referred to a maternal-fetal medicine specialist for management. (III-C)
Umbilical Artery Doppler
- Umbilical artery Doppler should not be used as a screening tool in healthy pregnancies, as it has not been shown to be of value in this group. (I-A)
- Umbilical artery Doppler should be available for assessment of the fetal placental circulation in pregnant women with suspected placental insufficiency. (I-A) Fetal umbilical artery Doppler assessment should be considered (1) at time of referral for suspected growth restriction, or (2) during follow-up for suspected placental pathology.
- Depending on other clinical factors, reduced, absent, or reversed umbilical artery end-diastolic flow is an indication for enhanced fetal surveillance or delivery. If delivery is delayed to improve fetal lung maturity with maternal administration of glucocorticoids, intensive fetal surveillance until delivery is suggested for those fetuses with reversed end-diastolic flow. (II-1B)
Definitions:
Levels of Evidence*
I: Evidence obtained from at least one properly randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case–control studies, preferably from more than one center or research group.
II-3: Evidence obtained from comparison between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be regarded as this type of evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.
Grades of Recommendations †
A. There is good evidence to recommend the clinical preventive action
B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive action
I. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making
† Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.
