Obgyn · Year 3 · from Obgyn
Case 3: Decreased Fetal Movement with Oligohydramnios
Patient Demographics
- Age: 32 years
- Sex: Female
- Occupation: Nurse
Chief Complaint
"I haven't felt the baby move as much today. Something feels wrong."
History of Present Illness
The patient is G3P2 at 39 weeks 2 days gestation with an uncomplicated pregnancy. She reports that over the past 24 hours, she has noticed significantly decreased fetal movement. She normally feels the baby move vigorously, especially in the evening, but last night and today she has felt only occasional, weak movements. She attempted kick counts this morning but only felt 4 movements in 2 hours (goal is 10 movements in 2 hours). She denies contractions, vaginal bleeding, or leakage of fluid.
Past Medical History
- Two prior uncomplicated term vaginal deliveries
- No chronic medical conditions
Physical Examination
- Vital Signs: BP 118/72 mmHg, HR 78 bpm, afebrile
- Abdomen: Gravid, non-tender, vertex by Leopold maneuvers
- Cervix: Closed, 30% effaced, -3 station
Initial Evaluation: Nonstress Test
NST Results:
- Baseline fetal heart rate: 155 bpm
- Variability: Minimal to absent
- Accelerations: None in 40 minutes
- Decelerations: Two variable decelerations noted
- Interpretation: Non-reactive with variable decelerations
Concern Raised - Proceed to BPP
Biophysical Profile:
| Component | Finding | Score |
|---|---|---|
| NST | Non-reactive | 0 |
| Fetal Breathing | None observed in 30 minutes | 0 |
| Fetal Movement | 2 movements only | 0 |
| Fetal Tone | One extension noted | 2 |
| Amniotic Fluid (MVP) | 1.5 cm (Oligohydramnios) | 0 |
Total BPP Score: 2/10
Diagnosis
Non-reassuring Fetal Status with BPP 2/10
- Critically low BPP score indicating probable fetal asphyxia
- Oligohydramnios suggesting chronic placental insufficiency
- Variable decelerations may indicate cord compression
Management - Emergent Delivery
Immediate Actions:
- Continuous fetal monitoring initiated
- IV access established, type and crossmatch
- Obstetric team and anesthesia notified
- NICU alerted
- Decision: Emergent cesarean delivery
Rationale:
- BPP 2/10 at term is an indication for delivery
- Attempting induction would be inappropriate given the non-reassuring status
- Cesarean provides the most expeditious delivery
Delivery Outcome
- Emergent cesarean delivery performed
- Female infant, 3,020 grams
- Apgars 4/6/8 (1, 5, and 10 minutes)
- Cord gases: pH 7.12, base excess -10 (mild metabolic acidosis)
- Nuchal cord x 2 noted at delivery (likely cause of oligohydramnios from cord compression and variable decelerations)
- NICU observation for 24 hours; discharged to well-baby nursery
Placental Pathology
- Placenta sent for evaluation
- Findings: Small infarcts, accelerated maturation
- Consistent with chronic uteroplacental insufficiency
Teaching Points
- Decreased fetal movement is an important warning sign requiring prompt evaluation
- Low threshold for evaluation when patient reports decreased movement
- BPP ≤4 indicates high probability of fetal asphyxia
- Oligohydramnios at term warrants delivery consideration
- Variable decelerations suggest umbilical cord compression
- Normal testing has high negative predictive value, but abnormal testing requires action
Clinical Image
Image Description: Ultrasound image demonstrating severe oligohydramnios with maximum vertical pocket of less than 2 cm. The fetal structures appear crowded with minimal amniotic fluid surrounding the fetus, consistent with chronic placental insufficiency.
Attribution: Educational illustration. Public domain medical education resource.