A 27-year old primigravid woman at 37 weeks' gestation comes to the emergency department because of frequent contractions for 4 hours. Her pregnancy has been complicated by hyperemesis gravidarum which subsided in the second trimester. The contractions occur every 10–15 minutes and have been increasing in intensity and duration since onset. Her temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/85 mm Hg. Uterine contractions are felt on palpation. Pelvic examination shows clear fluid in the vagina. The cervix is 50% effaced and 3 cm dilated. After 4 hours the cervix is 80% effaced and 6 cm dilated. Pelvic examination is inconclusive for the position of the fetal head. The fetal heart rate is reassuring. Which of the following is the most appropriate next step?

Perform external cephalic version

Perform Mauriceau-Smellie-Veit maneuver

A 15-month-old boy is brought to the pediatrician’s office by his mother due to abnormal muscle tone and an inability to walk. He was able to control his head at 5 months of age, roll at 8 months of age, sit at 11 months of age, and develop hand preference at 13 months of age. On physical exam, he is observed to asymmetrically crawl. He has a velocity-dependent increase in tone and 3+ biceps and patellar reflexes. His startle, asymmetric tonic neck, and Babinski reflexes are present. Which of the following is the most common risk factor for developing this patient’s clinical presentation?

Intrauterine growth restriction

A 24-year-old primigravida at 28 weeks gestation presents to the office stating that she “can’t feel her baby kicking anymore.” She also noticed mild-to-moderate vaginal bleeding. A prenatal visit a few days ago confirmed the fetal cardiac activity by Doppler. The medical history is significant for GERD, hypertension, and SLE. The temperature is 36.78°C (98.2°F), the blood pressure is 125/80 mm Hg, the pulse is 70/min, and the respiratory rate is 14/min. Which of the following is the next best step in evaluation?

Confirmation of cardiac activity by Doppler

Order platelet count, fibrinogen, PT and PTT levels

A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?

Placement of fetal scalp electrode

Fetal movement monitoring for USMLE Step 3: High-Yield OB/GYN Lessons

Fetal Movement - Feeling the Kicks

Quickening: First maternal perception of fetal movement.
- Primigravida: 18-20 weeks
- Multigravida: 16-18 weeks
Perception is subjective and can be affected by anterior placenta, amniotic fluid index (AFI), and maternal BMI.
Decreased Fetal Movement (DFM): Subjective reduction in activity from the fetus's established baseline.

First Fetal Movement by Gestation Week

⭐ A key screening approach is the "count to 10" (Cardiff method): feeling 10 distinct movements within 2 hours is considered reassuring.

Kick Count Methods - Counting the Wiggles

Formal fetal movement assessment, or 'kick counts,' is a key method for monitoring fetal well-being, typically initiated around 28 weeks of gestation. The mother quantifies fetal movements to detect potential hypoxia early.

Method	Procedure	Alarm Threshold
Cardiff ("Count to 10")	Time how long it takes to feel 10 distinct fetal movements.	> 2 hours to feel 10 movements.
Sadovsky	Count movements for 1 hour, three times per day, usually after meals.	< 4 movements per hour.

*   Perform counts at the same time each day, when the baby is typically active.
*   Lie on the left side to enhance uterine perfusion.

⭐ A maternal report of Decreased Fetal Movement (DFM) always warrants further investigation, starting with a Non-Stress Test (NST).

DFM Workup - When Kicks Quiet Down

Reactive NST strip with normal accelerations

Initial management for decreased fetal movement (DFM) is a stepwise process to assess for fetal hypoxia and prevent stillbirth. The primary goal is to rule out acidosis.

Umbilical Artery (UA) Doppler: Crucial in fetal growth restriction (IUGR) cases to assess placental perfusion. Absent or reversed end-diastolic flow is an ominous sign.

⭐ The Biophysical Profile (BPP) is an "ultrasound Apgar." It assesses 5 components, each getting a score of 0 or 2: Fetal breathing, Gross body movements, Fetal tone, Amniotic fluid index (AFI), and the NST itself.

Etiology of DFM - The Silent Culprits

Fetal
- Benign: Normal sleep-wake cycles (most common, up to 40 min).
- Pathologic: CNS depression (hypoxia, acidosis), congenital anomalies, infection, demise.
Placental
- Insufficiency (leading to IUGR), abruption.
Maternal
- Medications: CNS depressants like sedatives, opioids.
- Substances: Smoking, alcohol.
- Conditions: Obesity, dehydration.

⭐ An anterior placenta can mask fetal movements, making it a frequent cause for benign maternal concern.

High‑Yield Points - ⚡ Biggest Takeaways

Decreased fetal movement (DFM) is a critical sign requiring immediate evaluation to rule out fetal compromise.

Maternal monitoring ("kick counts") typically starts at 28 weeks; a normal count is ≥10 movements in 2 hours.

The first step for reported DFM is a Nonstress Test (NST).

A non-reassuring NST prompts a Biophysical Profile (BPP) or Contraction Stress Test (CST).

Underlying causes often relate to uteroplacental insufficiency, leading to fetal hypoxia.

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