What are normal fetal movements?

There is no universally agreed definition of normal fetal movements. There is no magic number of kicks per hour and there is no particular pattern that every baby should follow. The guidance encourages women to become familiar with what is normal for their own baby. That is one of the reasons the UK no longer recommends counting a particular number of kicks within a certain period of time.

By around 28-32 weeks, most babies have developed a recognisable pattern of movement. Those movements might be kicks, stretches, pushes, rolls, swishes or flutters. One of the most important messages in the guideline is that the frequency of movements should not reduce simply because you are approaching your due date. Many women notice that the nature of movements changes. Sharp kicks may become more rolling or stretching movements as the baby grows, but this is different from a genuine reduction in movement.

Babies have sleep cycles, usually lasting around 20–40 minutes and rarely more than 90 minutes. During these periods they do not generally move, which is one reason there may be short spells where movements are not perceived. It is also worth remembering that you won't perceive every movement your baby makes. Studies suggest women detect somewhere between around 37% and 88% of fetal movements, with longer movements much more likely to be noticed than brief ones.

There are also lots of perfectly normal reasons why movements may feel easier or harder to notice from one day to the next. Lying on your side and quietly focusing on your baby tends to increase awareness. Exercise, anxiety and mealtimes may also increase perception. Being distracted or busy can reduce it. An anterior placenta can make movements harder to feel, particularly before 28 weeks, although a change in movements should never simply be attributed to placental position.

Trust yourself, but don't live in fear

One thing I have become increasingly aware of is how many women spend the last weeks of pregnancy expecting that something is about to go wrong. It is understandable. Stories of tragedy stay with us, and campaigns encouraging women to seek help if movements change are important and have undoubtedly had a positive impact. At the same time, it is equally important to remember that the overwhelming majority of pregnancies end with healthy mothers and healthy babies.

It is also a particularly difficult stage of pregnancy emotionally. By this point you desperately want your baby safely in your arms, and yet one of the only people who can judge whether their movements feel normal is you. I think many women carry quite a heavy burden because of that. They don't want to ignore something important, but equally they don't want to overreact or spend the last weeks of pregnancy in a constant state of anxiety.

My hope would not be that women spend the last weeks of pregnancy constantly monitoring and worrying, but that they gradually become familiar with their own baby's usual pattern and feel confident recognising when something genuinely feels different. I would never want somebody to dismiss a genuine concern. Equally, I would never want somebody to stay at home because they were frightened that seeking assessment would automatically lead to interventions they did not want.

What happens if I go to hospital with reduced fetal movements?

The broad aims of assessment are actually very straightforward:

• To confirm that your baby is alive (overwhelmingly likely!)
• To try and identify any evidence of fetal compromise.
• To try and identify pregnancies that may be at increased risk
• To avoid unnecessary intervention

Interestingly, this fourth aim is one that many women find does not always reflect their own experience of maternity care. I'll come back to that later.

If you are beyond around 26 weeks, this will usually include a CTG (cardiotocograph) to assess your baby's heart rate pattern, together with your routine antenatal observations such as blood pressure and urine testing.

Like every medical test, CTG has limitations and should not be interpreted in isolation. (I would highly recommend reading some of Dr Kirsten Small's work if you are interested in understanding CTG in more depth.)

Will I automatically have a scan?

No.

This was one of the parts of the updated guideline that I thought deserved much more attention. Routine ultrasound for every woman presenting with a single episode of reduced fetal movements is not recommended.

Instead, ultrasound is generally recommended where:

• reduced movements persist despite a normal CTG;
• there are additional risk factors for fetal growth restriction or stillbirth; or
• there are other clinical concerns that make further assessment appropriate. These should be explained to you.

When ultrasound is performed, it should include assessment of fetal growth (abdominal circumference and/or estimated fetal weight), amniotic fluid volume and umbilical artery Doppler.

This selective approach exists for a reason. Studies looking at offering ultrasound routinely to all women with reduced fetal movements have not demonstrated a reduction in stillbirth, while increasing rates of intervention. (I'll link separately to the AFFIRM study for anyone who wants to read more.)

Many women are surprised to learn that routine ultrasound for every first presentation with reduced fetal movements is not what the national guidance recommend. Ultrasound is recommended in particular circumstances, but not simply because somebody has attended once with reduced movements.

Will I be induced if I go to hospital with reduced fetal movements?

There is one sentence in the guideline that I think deserves to be quoted in full:

Where there is no objective evidence of fetal compromise (no CTG abnormalities, no evidence of reduced fetal growth, oligohydramnios or abnormal umbilical artery Doppler), there is no indication for expediting birth.

That is quite an important statement.

It means that a single episode of reduced fetal movements, in the absence of any concerning clinical signs, does not automatically mean that induction is recommended. The purpose of assessment is to identify the babies who need intervention while avoiding intervention for those who do not.

The reality in practice

I also think it is important to acknowledge something that many women will recognise. The guideline itself is measured and repeatedly refers to individualised decision-making and avoiding unnecessary intervention. Real-life experiences can sometimes feel rather different.

Some women are offered investigations that they weren't expecting or that appear to go beyond what is routinely recommended in the national guidance. Some are strongly encouraged towards induction despite reassuring investigations. Others come away feeling that uncertainty has been presented as certainty or that they have not had enough opportunity to understand the evidence behind a recommendation.

One point that I think is worth emphasising is that going into hospital for assessment and agreeing to an induction are two separate decisions. If you are worried about your baby's movements, my advice would always be to seek assessment. If, following that assessment, induction or another intervention is recommended, you are entitled to understand why, what evidence supports that recommendation, whether there are alternatives and what the risks and benefits are in your own particular situation. It is entirely reasonable to ask questions.

For example:

• What exactly is concerning you?
• What is your estimate of the absolute risk in my situation?
• Which findings are you basing this recommendation on?
• Is this recommendation based on national guidance or local policy?
• What evidence is there that induction is likely to improve outcomes in my particular situation?
• What would happen if I chose to wait?
• Is there any additional information that would change your recommendation?

Those are sensible questions, not difficult ones. You do not lose your right to ask questions simply because you have accepted an assessment.

Reduced fetal movements after 39 weeks: what does the guidance say?

The guideline states that, after 39 weeks, expediting birth following reduced fetal movements does not appear to be associated with increased risk to mother or baby. That is not the same thing as saying every woman should be induced.



Nor does it mean induction has no disadvantages or trade-offs. Research findings about induction and women's lived experiences do not always feel aligned, particularly when it comes to induction of labour in first pregnancies. I have written separately about induction because I think it deserves a much fuller discussion than can be given here.

What if everything is normal?

This is another part of the guideline that I find reassuring.

Healthcare professionals can reassure women with a single episode of reduced fetal movements that they are unlikely to experience an adverse perinatal outcome if the basic assessment offered – CTG and routine antenatal checks - is reassuring.

Reduced fetal movements are associated with an increased risk of stillbirth when researchers look across populations as a whole. However, observational studies where women are encouraged to report concerns promptly and are managed according to structured protocols have not demonstrated an increase in stillbirth among those managed women.

This is perhaps the part of the guideline that may surprise you the most. It isn't saying "don't come in". Quite the opposite. It's saying "come in, be assessed, and if everything is reassuring, you should be reassured."

What if I have more than one episode of reduced fetal movements?

Repeated presentations for reduced fetal movements do change the conversation.

The evidence here is much less clear-cut than many people realise. The guideline cites observational studies suggesting that women who present on two or more occasions with reduced fetal movements after 28 weeks appear to have higher rates of adverse outcomes than women who present only once. However, these are observational studies rather than randomised trials, so they can demonstrate an association but cannot tell us with certainty whether one thing causes the other.

The guideline also notes that ultrasound abnormalities are more likely to be found in women with repeated presentations, which is one reason ultrasound assessment is generally indicated in that situation.

For practical purposes, the UK has adopted a consensus definition of recurrent reduced fetal movements as two or more episodes occurring within a 21-day period after 26 weeks of

pregnancy. This definition is based on expert consensus rather than direct evidence that this exact timeframe represents a proven threshold of risk.

Perhaps the biggest uncertainty is what to do if everything is then found to be normal. There are currently no studies demonstrating exactly what the best management is when growth, amniotic fluid volume and CTG remain reassuring. In other words, there is evidence that repeated presentations deserve further assessment, but much less evidence about what should happen if those assessments are all normal.

It is important not to overstate what the evidence actually tells us. Equally, it is important not to minimise recurrent concerns. The fact that we don't have a clear evidence-based answer does not mean they should be dismissed.

The guideline therefore does not recommend a routine approach in this situation. Instead, decisions should be individualised, taking into account the whole clinical picture and the woman's own preferences, rather than assuming there is a single evidence-based answer that applies to everyone.

What is the cerebroplacental ratio (CPR) and why might it be measured?

If you've never heard of this before, don't worry. It isn't something that has traditionally formed part of routine conversations in pregnancy.

One thing I have noticed in recent months is that additional ultrasound measurements, such as the cerebroplacental ratio (CPR), are increasingly becoming part of discussions in some maternity units, particularly when women present with reduced fetal movements.

This is an area of active research and one where the evidence is still evolving.

Recent studies suggest that, in some women presenting at term with reduced fetal movements and an otherwise normally grown baby, using CPR as part of decision-making may reduce

some adverse neonatal outcomes, such as low cord pH, low Apgar scores and emergency delivery for fetal distress.

However, it has not been shown to reduce stillbirth, and it should not be interpreted in isolation. Like every other piece of information in maternity care, it needs to be considered alongside the whole clinical picture and the woman's own circumstances.

For those who enjoy reading the research for themselves, I'll include links to some of the relevant studies below.

Do reduced fetal movements mean I can't have a home birth or use a birth centre?

Many women assume that an episode of reduced fetal movements automatically means they have lost those options.

That is not what the national guidance says. Reduced fetal movements do not, in themselves, automatically mean that a home birth or birth centre birth is no longer possible.

If you are told that you now need continuous fetal monitoring in labour or that your planned place of birth should change, it is entirely reasonable to ask:

• Is this recommendation based on national guidance?
• Is it based on local policy?
• Is it based on my individual clinical circumstances?
• What is it about my individual situation that means you think a different place of birth would be safer?

If this is something you are navigating, I would highly recommend looking into the work of Dr Kirsten Small on CTG monitoring and intrapartum fetal surveillance. It provides a thoughtful and evidence-based perspective on an area that is often presented as much more straightforward than it really is.

Ultimately the decision where you give birth is yours.

Lisa's doula thoughts

One of the reasons I wanted to write this article is I don't think women should have to choose between ignoring their instincts and feeling that seeking assessment means giving up all control over what happens next.

The evidence suggests women should become familiar with their own baby's normal pattern, trust themselves if something genuinely changes and seek assessment promptly - while also remembering that the overwhelming majority of pregnancies end with healthy babies.

Get to know your own baby's normal pattern. Build self-trust and confidence that you know your baby best.

But don't dismiss a genuine change because someone told you babies always move less near the end of pregnancy. And don't avoid assessment because you are frightened that walking into hospital means giving up control over what happens next.

Going in for assessment and agreeing to an induction are two separate decisions.

You can have the CTG. You can ask questions. You can ask what the evidence says and whether a recommendation comes from national guidance or local policy. You can ask for time to think if the situation allows, and you can ask for a second opinion. You can also choose to have monitoring without speaking to a doctor if that is your preference and your clinical situation allows.

And if your assessment is reassuring, it is worth remembering that the current RCOG guidance explicitly states that, in the absence of objective evidence of fetal compromise, there is no indication to expedite birth simply because of a single episode of reduced fetal movements.

Seeking assessment does not take away your right to make informed decisions about your care.

Frequently asked questions about reduced fetal movements

A final thought

If reading this article has made you realise just how nuanced some of these conversations can become, you're not alone.

One of the things I value most about my work as a doula is having the time to sit with families, look carefully at the evidence, acknowledge where there is genuine uncertainty and help them prepare for conversations with their healthcare team.

My aim is never to tell anyone what decision to make or to persuade them down a particular path. It is to help them understand their options, feel confident asking questions and make decisions that genuinely feel right for them and their family.

If you're pregnant in South West London and looking for evidence-based, non-judgemental support throughout your pregnancy and birth, you can read more about my doula services here.

About the author

Lisa Harris is a birth and postnatal doula based in Wimbledon, South West London. She supports families across South West London and has attended births in hospitals, birth centres and homes across the region. She is passionate about helping parents understand the evidence, navigate uncertainty and make informed decisions throughout pregnancy and birth.