Management of reduced fetal movement: A comparative analysis of two audits at a tertiary care clinical service

"Smoking during pregnancy - Perinatal outcomes, financial implications, and tobacco treatment services"

Objective

Smoking in pregnancy is the leading modifiable risk factor for poor pregnancy outcomes. A sample population from United Lincolnshire Hospital NHS Trust (ULHT), with the highest prevalence of smoking at the time of delivery (SATOD) in England from April 2020 to March 2021 was studied. The project mapped the journey of women who smoked during pregnancy until birth and compared with a non-smoking cohort. In addition, it explored the options for possible changes to the current tobacco treatment service and importance of catering to the population demographics.

Methods

Data was analysed using Chi-squared or Mann Whitney and student T-test for categorical and continuous variables respectively. A p-value of < 0.05 was considered statistically significant.

Results

All women who smoked during pregnancy were referred to the stop smoking service. However, only 34.9 % accessed the service. Smoking mothers were younger (P = 0.001), had more complex obstetric history (P = 0.044), required increased fetal surveillance (P=<0.001), delivered at an earlier gestation (P = 0.033), and had babies with lower birth-weight (P=<0.001) compared to non-smokers. In addition, women who smoked demonstrated a downward trend in breast feeding their babies at birth and on discharge (P=<0.001 and P=<0.001 respectively).

Conclusions

Findings from the study informed a successful business case for improvements to the current tobacco treatment service and the development of in-house maternity model for pregnant smokers at ULHT.

Decreased fetal movements - An audit of predictors and an evaluation of management based on a locally developed flow chart

OBJECTIVES

Decreased fetal movements (DFM) is associated with adverse pregnancy outcomes. We aimed to look at the risk factors associated with DFM and outcomes of women who presented with and without DFM and outcomes before and after the implementation of a locally developed flow chart based on an evidence-based guideline.

STUDY DESIGN

This was a retrospective audit of 1165 women ≥ 28 weeks' gestation with a singleton pregnancy who presented with concerns regarding DFM. We compared labor and neonatal outcomes to 4706 in a control group who did not present with concerns regarding FM. We also compared the same pregnancy outcomes before and after the implementation of hospital guidelines on the management of DFM. Statistical analyses were performed primarily using Chi square analysis and relative risk.

RESULTS AND CONCLUSIONS

1165 women presented 1645 times with DFM. Women presenting with DFM were younger, (82.8% vs 79.0%, p= <0.01 were 20 to 34-years old), tended to have a higher BMI (42.9% vs 34.4%, p=<0.001 with BMI ≥ 30) and were more likely to have mental health conditions (31.1% vs 24.2%, p=<0.01). There was no difference in the composite neonatal outcome including stillbirth, 5 min APGAR < 7 and Special Care Nursery (SCN) admission between DFM and control (22.9 vs 24.8% respectively, P = 0.18). There was no difference in perinatal outcomes pre- and post-implementation of the hospital guidelines on DFM management. Women presenting with DFM were more likely to have an induction (40.7% vs 29.9% p=<0.01) but not more likely to have a caesarean section (30.9% vs 28.8% respectively, p = 0.16). There were increasing rates of IOL with increasing number of presentations for DFM. Adoption of and adherence to locally developed guidelines was an opportunity to ensure all clinicians provide consistent advice on management and timing of birth for women presenting with DFM.

Effect of encouraging awareness of reduced fetal movement and subsequent clinical management on pregnancy outcome: a systematic review and meta-analysis

OBJECTIVE

Reduced fetal movement, defined as a decrease in the frequency or strength of fetal movements as perceived by the mother, is a common reason for presentation to maternity care. Observational studies have demonstrated an association between reduced fetal movement and stillbirth and fetal growth restriction related to placental insufficiency. However, individual intervention studies have described varying results. This systematic review and meta-analysis aimed to determine whether interventions aimed at encouraging awareness of reduced fetal movement and/or improving its subsequent clinical management reduce the frequency of stillbirth or other important secondary outcomes.

DATA SOURCES

Searches were conducted in MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, and Google Scholar. Guidelines, trial registries, and gray literature were also searched. Databases were searched from inception to January 20, 2022.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials and controlled nonrandomized studies were eligible if they assessed interventions aimed at encouraging awareness of fetal movement or fetal movement counting and/or improving the subsequent clinical management of reduced fetal movement. Eligible populations were singleton pregnancies after 24 completed weeks of gestation. The primary review outcome was stillbirth; a number of secondary maternal and neonatal outcomes were specified in the review.

METHODS

Risk of bias was assessed using the Cochrane Risk of Bias 2 and Risk of Bias in Non-Randomized Studies I tools for randomized controlled trials and nonrandomized studies, respectively. Variation caused by heterogeneity was assessed using I². Data from studies employing similar interventions were combined using random effects meta-analysis.

RESULTS

A total of 1609 citations were identified; 190 full-text articles were evaluated against the inclusion criteria, 18 studies (16 randomized controlled trials and 2 nonrandomized studies) were included. The evidence is uncertain about the effect of encouraging awareness of fetal movement on stillbirth when compared with standard care (2 studies, n=330,084) with a pooled adjusted odds ratio of 1.19 (95% confidence interval, 0.96-1.47). Interventions for encouraging awareness of fetal movement may be associated with a reduction in neonatal intensive care unit admissions and Apgar scores of <7 at 5 minutes of age and may not be associated with increases in cesarean deliveries or induction of labor. The evidence is uncertain about the effect of encouraging fetal movement counting on stillbirth when compared with standard care with a pooled odds ratio of 0.69 (95% confidence interval, 0.18-2.65) based on data from 3 randomized controlled trials (n=70,584). Counting fetal movements may increase maternal-fetal attachment and decrease anxiety when compared with standard care. When comparing combined interventions of fetal movement awareness and subsequent clinical management with standard care (1 study, n=393,857), the evidence is uncertain about the effect on stillbirth (adjusted odds ratio, 0.86; 95% confidence interval, 0.70-1.05).

CONCLUSION

The effect of interventions for encouraging awareness of reduced fetal movement alone or in combination with subsequent clinical management on stillbirth is uncertain. Encouraging awareness of fetal movement may be associated with reduced adverse neonatal outcomes without an increase in interventions in labor. The meta-analysis was hampered by variations in interventions, outcome reporting, and definitions. Individual studies are frequently underpowered to detect a reduction in severe, rare outcomes and no studies were included from high-burden settings. Studies from such settings are needed to determine whether interventions can reduce stillbirth.

Country of birth, educational level and other predictors of seeking care due to decreased fetal movements: an observational study in Sweden using data from a cluster-randomised controlled trial

OBJECTIVES

To identify predictors of seeking care for decreased fetal movements and assess whether care-seeking behaviour is influenced by Mindfetalness.

DESIGN

Observational study with data from a cluster-randomised controlled trial.

SETTING

67 maternity clinics and 6 obstetrical clinics in Sweden.

PARTICIPANTS

All pregnant women with a singleton pregnancy who contacted the obstetrical clinic due to decreased fetal movements from 32 weeks' gestation of 39 865 women.

METHODS

Data were collected from a cluster-randomised controlled trial where maternity clinics were randomised to Mindfetalness or routine care. Mindfetalness is a self-assessment method for women to use daily to become familiar with the unborn baby's fetal movement pattern.

OUTCOME MEASURES

Predictors for contacting healthcare due to decreased fetal movements.

RESULTS

Overall, 5.2% (n=2059) of women contacted healthcare due to decreased fetal movements, among which 1287 women (62.5%) were registered at a maternity clinic randomised to Mindfetalness and 772 women (37.5%) were randomised to routine care. Predictors for contacting healthcare due to decreased fetal movements were age, country of birth, educational level, parity, prolonged pregnancy and previous psychiatric care (p<0.001). The main differences were seen among women born in Africa as compared with Swedish-born women (2% vs 6%, relative risk (RR) 0.34, 95% CI 0.25 to 0.44) and among women with low educational level compared with women with university-level education (2% vs 5.4%, RR 0.36, 95% CI 0.19 to 0.62). Introducing Mindfetalness in maternity care increased the number of women seeking care due to decreased fetal movements overall.

CONCLUSION

Women with country of birth outside Sweden and low educational level sought care for decreased fetal movements to a lesser extent compared with women born in Sweden and those with university degrees. Future research could explore whether pregnancy outcomes can be improved by motivating women in these groups to contact healthcare if they feel a decreased strength or frequency of fetal movements.

TRIAL REGISTRATION NUMBER

NCT02865759.