Hospital Monitoring Rarely Changes Care When Fetal Movements Reduce Without Pathology

When a pregnant woman reports that her baby has been moving less than usual, the response of maternity services varies enormously, and in Germany many hospitals respond by admitting her for around twenty-four hours of continuous fetal monitoring. A new retrospective study from a university-based tertiary referral maternity hospital now suggests that, for a carefully defined group of women, this practice may add remarkably little. Among 78 patients who presented with a first episode of reduced fetal movements and showed entirely physiological fetal parameters at their initial assessment, inpatient monitoring with repeated cardiotocography failed to yield any new findings or change management in 74 cases, or 94.87 percent of the cohort.

The study, published in Archives of Gynecology and Obstetrics, examined women treated between January 2017 and December 2025 at a hospital handling approximately 2,000 deliveries per year. The researchers searched their internal clinical database for cases coded under ICD-10-GM O36.8, maternal care for other specified fetal problems, involving at least one overnight inpatient stay. From 263 initially identified cases, 154 women had actually presented with reduced fetal movements, and after applying strict inclusion and exclusion criteria, 78 patients remained for analysis. Forty patients, or 51.28 percent, were assigned to a cohort without maternal risk factors, while 38 patients, or 48.72 percent, formed a second cohort that included women with risk factors such as a body mass index above 30, age above 40, preeclampsia, hypertension, small-for-gestational-age status, fetal growth restriction, diabetes, intrahepatic cholestasis of pregnancy, or a previous intrauterine fetal death.

The inclusion criteria were deliberately narrow. Women had to present with a first episode of reduced fetal movements, defined as a maternal subjective perception of decreased or absent fetal activity prompting clinical evaluation, together with a physiological initial fetal assessment comprising cardiotocography, measurement of the single deepest vertical pocket of amniotic fluid, estimated fetal weight, and umbilical artery Doppler assessment. Gestational age had to fall between 24 plus 0 and 39 plus 0 weeks. Excluded were women with evidence of fetal pathology at the initial assessment, multiple gestation, recurrent presentations with reduced fetal movements, premature rupture of membranes or onset of labor before the clinical visit, and those beyond 39 weeks, where induction is more routinely performed for independent reasons. Patients with more than 30 percent missing data were also excluded.

The clinical workup at presentation was thorough. Board-certified obstetricians or experienced residents evaluated each woman with a comprehensive medical and obstetrical history, urine analysis for proteinuria, blood pressure measurement with assessment for hypertension above 140 over 90 millimeters of mercury, cardiotocography, and an ultrasound examination covering fetal biometry within the normal range of the 10th to 95th percentile, a single deepest vertical pocket between 2 and 8 centimeters, and umbilical artery Doppler with a pulsatility index below the 95th percentile. If the patient had attended the clinic within the preceding 14 days, previously recorded biometry values were used and only the cardiotocogram, amniotic fluid measurement, and Doppler assessment were repeated.

The results were striking in their consistency. The median gestational age at presentation was 36 weeks and 2 days, with an interquartile range from 33 weeks to 37 weeks and 5 days, and the median hospital stay lasted 1.5 days. Across 74 patients, repeated cardiotocographic evaluations during hospitalization revealed no new findings and prompted no modification of treatment. Only four patients, or 5.13 percent, experienced changes in their clinical status requiring individualized management, and crucially, none of these changes were attributable to the reduced fetal movements themselves. Three of the four belonged to the cohort with pre-existing maternal risk factors.

The four exceptional cases illustrate the point. One patient, aged 39 and in her second pregnancy at 38 weeks and 3 days, developed premature rupture of membranes the day after admission and subsequently delivered. Another, a 41-year-old first-time mother at 38 weeks and 2 days, underwent induction of labor because of poorly controlled pre-existing hypertension that had already been evident at admission with blood pressure readings of approximately 150 over 100 millimeters of mercury. A third, aged 35 and in her fifth pregnancy at 35 weeks and 4 days, required delivery due to suspected impending uterine rupture in the context of a prior cesarean section. The fourth patient, a 21-year-old first-time mother from the low-risk cohort, had a prolonged hospital stay of four days due to recurrent reduced fetal movements and was transferred to another hospital for further observation because of internal capacity constraints. In other words, clinical worsening occurred only through the physiological progression of pregnancy or through independent maternal conditions that would have warranted intervention regardless of the movement complaint.

The comparison with a control cohort reinforced the impression that these pregnancies generally fared well. Controls were drawn retrospectively at random from a comprehensive delivery database covering the same period, using a systematic sampling approach that selected every fifth entry and included both low- and high-risk pregnancies. Among individual clinical characteristics, only body mass index differed significantly, with the reduced fetal movement group showing a higher median of 29.19 kilograms per square meter compared with controls, a finding consistent with a systematic review by Bradford and colleagues linking maternal body size to increased presentation with reduced fetal movements. Although the five-minute Apgar scores differed statistically between the groups, the direction of the difference did not indicate poorer neonatal condition, with both groups showing a median score of 10. Other parameters, including preterm delivery, mode of birth, birth weight, umbilical artery pH, and the ten-minute Apgar score, did not differ significantly. Birth data were available for 59 patients in the reduced fetal movement cohort.

The context behind this question is clinically weighty. Reduced fetal movements are extremely common, with up to 40 percent of pregnancies reporting the perception at some point, and they account for roughly 6.1 to 22.6 percent of the caseload in acute maternity assessment settings. The symptom matters because women reporting it demonstrate substantially higher odds of stillbirth, with an odds ratio of 3.44 and a 95 percent confidence interval of 2.02 to 5.88, alongside an increased likelihood of delivering small-for-gestational-age infants. Yet the evidence base for managing women whose initial assessment is normal is thin. The current Royal College of Obstetricians and Gynaecologists guidelines explicitly note a distinct lack of studies examining the follow-up of women with normal findings, and a Cochrane systematic review identified the distinction between women with and without antecedent risk factors as a key consideration. In Germany, the rationale for admitting women solely for reduced fetal movements in the absence of abnormal cardiotocographic or ultrasound findings rests largely on clinical experience rather than robust scientific evidence, and no distinct evidence-based national recommendations exist.

International guidance takes a risk-stratified approach, incorporating gestational age and coexisting risk factors for stillbirth, and advocates cardiotocography alongside ultrasonographic evaluation of fetal biometry, amniotic fluid, and umbilical artery Doppler in women beyond 28 weeks presenting with reduced movements. Current routine pathways may nonetheless involve hospital admission, induction of labor, and prelabor cesarean delivery, and substantial variability in clinical practice across providers and maternity units persists, meaning a significant proportion of women may not receive care consistent with evidence-based guidelines. Clinicians therefore face a genuine dilemma: minimizing unnecessary tests and interventions while still identifying in time those fetuses genuinely at risk of stillbirth or adverse perinatal outcomes.

The authors are careful to frame their findings as hypothesis-generating rather than definitive. This was a retrospective study with a relatively small, highly selected cohort, and the sample size was determined by the extent of accessible routine hospital records rather than an a priori calculation. Residual confounding cannot be fully excluded despite stringent criteria, and placental histology, which would be of particular interest given the known association between reduced fetal movements and placental pathology, was available for only one patient. A formal comparison of inpatient versus outpatient management would additionally require a control group of women with reassuring initial assessments managed as outpatients, which lay beyond the scope of this analysis. The authors also situate their work within a broader landscape: the widely recognized AFFIRM trial did not demonstrate a reduction in stillbirth rates following a structured care package for reduced fetal movements, while stillbirth rates have declined in countries such as the United Kingdom and Norway but have remained stable or increased in Germany, partly reflecting changing maternal characteristics and documentation practices. With those caveats in place, the conclusion is measured: in women presenting with reduced fetal movements and no evidence of fetal compromise, inpatient monitoring rarely influenced clinical management, and outpatient follow-up with appropriate counselling on fetal movement patterns may be a feasible alternative, pending confirmation in larger prospective studies.

Subject of Research: Retrospective study of inpatient monitoring for reduced fetal movements without fetal pathology

Article Title: Clinical utility of inpatient monitoring for reduced fetal movements in the absence of fetal pathology

Article References: Klamminger, G. G., Hässlin, F., Stewen, K., Eser, B., Hasenburg, A., Degirmenci, Y., & Steetskamp, J. (2026). Clinical utility of inpatient monitoring for reduced fetal movements in the absence of fetal pathology. Archives of Gynecology and Obstetrics, 313(1), Article 276. https://doi.org/10.1007/s00404-026-08579-w

Image Credits: AI Generated

DOI: 10.1007/s00404-026-08579-w

Keywords: reduced fetal movements, fetal monitoring, cardiotocography, obstetrics, pregnancy, stillbirth, outpatient care, retrospective study, maternal care, neonatal outcomes, Clinical, utility