Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons

Is it possible to monitor fetal movements with a wearable device? A review of novel technologies

Stillbirth is often preceded by reduced fetal movements and obstetric intervention is necessitated for stillbirth prevention. Yet, despite fetal movements being one of the few tangible ways a pregnant woman and the clinical team can assess the wellbeing of her baby, there are few validated, objective means for pregnant women to quantify the frequency and nature of an unborn baby's movements. Traditional methods of assessing fetal wellbeing such as cardiotocography and fetal movement charts have a lack of diagnostic accuracy, and often lead to false positive intervention. The need for fetal movement counting has led to the development of objective methods to attempt to quantify movements. Some are based on electrocardiography, others on the principles of accelerometery, phonography and optical fibre technology. This review paper not only explores these technologies and evaluates the state-of the-art fetal movement monitoring, but explains the engineering principles underpinning the various technologies, and explores the importance and practice of fetal movement monitoring. To this end, we conclude that there is still a need for the continued development of innovations which will enable a pregnant woman to carry out everyday activities, whilst confident in the knowledge that her unborn child's wellbeing is being accurately monitored, and that feedback from the monitoring device is readily accessible to her.

Connecting with fetus: The use of app-based fetal movement counting and experiences during pregnancy and birth

BACKGROUND

Pregnant people are often introduced to fetal movement counting to monitor the health of their fetus. This study aims to examine the impacts of app-based fetal movement counting on experiences during pregnancy and birth.

METHOD

This study used two types of secondary data including individual user's app use and their end of pregnancy survey data collected on the Count the Kicks (CTK) app. CTK is a free mobile app providing a virtual platform for pregnant people to conduct their daily kick counting. The study sample includes 1,147 pregnant people. Descriptive analyses were used to examine the number of kick counts using CTK and pregnant women's experiences with the app, their pregnancy, and childbirth. Bivariate analyses were used to examine the relationships between the frequency of kick counts and pregnant people's experience with their pregnancy and birth. Logistic regressions were used to model pregnant people's experiences: anxiety level related to their pregnancy and bonding with their baby.

FINDINGS

The study found that there is inadequate compliance with daily fetal movement counting recommendations in third trimester among pregnant people. However, results showed that frequent use of fetal movement counting is associated with lower anxiety level related to their pregnancy, and more bonding with their baby. These positive pregnancy experiences are associated with healthy birth.

CONCLUSION

To benefit from the impacts of fetal movement counting on positive pregnancy and birth experience, the app developers and public health agencies need to develop strategies to increase daily use of fetal movement counting.

[Fetal death: Expert consensus from the College of French Gynecologists and Obstetricians]

Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient's wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it's the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.

Development of core outcome sets for studies relating to awareness and clinical management of reduced fetal movement

OBJECTIVE

This study aimed to create core outcome sets (COSs) for use in research studies relating to the awareness and clinical management of reduced fetal movement (RFM).

DESIGN

Delphi survey and consensus process.

SETTING

International.

POPULATION

A total of 128 participants (40 parents, 19 researchers and 65 clinicians) from 16 countries.

METHODS

A systematic literature review was conducted to identify outcomes in studies of interventions relating to the awareness and the clinical management of RFM. Using these outcomes as a preliminary list, stakeholders rated the importance of these outcomes for inclusion in COSs for studies of: (i) awareness of RFM; and (ii) clinical management of RFM.

MAIN OUTCOME MEASURES

Preliminary lists of outcomes were discussed at consensus meetings where two COSs (one for studies of RFM awareness and one for studies of clinical management of RFM).

RESULTS

The first round of the Delphi survey was completed by 128 participants, 66% of whom (n = 84) completed all three rounds. Fifty outcomes identified by the systematic review, after multiple definitions were combined, were voted on in round one. Two outcomes were added in round one, and as such 52 outcomes were voted on in two lists in rounds two and three. The COSs for studies of RFM awareness and clinical management are comprised of eight outcomes (four maternal and four neonatal) and 10 outcomes (two maternal and eight neonatal), respectively.

CONCLUSIONS

These COSs provide researchers with the minimum set of outcomes to be measured and reported in studies relating to the awareness and the clinical management of RFM.

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.

Pregnancy, birth and neonatal outcomes associated with reduced fetal movements: A systematic review and meta-analysis of non-randomised studies

PROBLEM

Maternal perception of reduced fetal movements (RFM) is identified as an important alarm signal for possible risk of impending adverse perinatal outcomes.

BACKGROUND

Perinatal outcomes associated with RFM are increasingly being investigated in non-randomised studies with several associated outcomes, including stillbirth, preterm birth, fetal growth restriction and neonatal death being reported. Findings from studies, however, are conflicting.

AIM

To synthesise the findings of published studies regarding pregnancy, birth and neonatal outcomes in women who presented with RFM.

METHODS

PubMed, EMBASE, CINAHL complete, Maternity and Infant Care, PsycINFO, and Science Citation Index databases were searched up to 8th July 2021 and updated again on 8th September 2022. Non-randomised studies involving pregnant women ≥24 weeks' gestation, who presented with a primary complaint of RFM compared to women who did not present with RFM were included. Data were meta-analysed using a random-effects model and presented as Odds Ratios (OR) or Standard Mean Differences (SMD) with 95% Confidence Intervals (CI).

FINDINGS

Thirty-nine studies were included. Women with RFM had increased odds of stillbirth (OR 3.44, 95% CI 2.02-5.88) and small for gestational age (OR 1.37, 95% CI 1.16-1.61) when compared with women who did not have RFM. Associations were also found for induction of labor, instrumental birth and caesarean section but not for preterm birth (OR 0.92, 95% CI 0.71-1.19) or neonatal death (OR 0.99; 95% CI 0.52-1.90).

CONCLUSION

This review revealed that RFM is associated with increased odds of stillbirth, small for gestational age, induction of labor, instrumental birth and caesarean section but not preterm birth or neonatal death.

Evaluation of the relationship between reduced fetal movement and obstetric-neonatal outcomes and placental pathologies

BACKGROUND

Fetal movements are one of the simple methods that show the baby's well-being. Conditions associated with decreased fetal movements have not been determined, so it is important to analyze their different aspects. This study aimed to evaluate the relationship between reduced fetal movement and obstetric-neonatal outcomes, and placental pathologies.

METHODS

In this prospective controlled study, laboratory results (blood glucose, hemoglobin, thyroid-stimulating hormone [TSH]), a non-stress test (NST), biophysical profile results, obstetric and neonatal outcomes, and placental pathological results of 74 pregnant women at 35 or more gestational weeks (to exclude the effect of prematurity on obstetric and neonatal outcomes) attending the obstetrics clinic between December 26, 2017 and January 30, 2019 with complaints of reduced fetal movement, were compared with 74 healthy pregnant women. Since prematurity and post-maturity may adversely affect obstetric-neonatal and placental pathology results, term pregnancies between 37^0/7-40^6/7 weeks were evaluated separately.

RESULTS

In the group with reduced fetal movement, the biophysical profile was lower than the controls (P=0.013). Among placental pathologies, chorangiosis and hypercoiled cord were significantly higher in the group with reduced fetal movement than controls (P<0.05). Small for gestational age (SGA) and fetal growth restriction (FGR) in this group had these pathologies. Results of women at 37^0/7-40^6/7 weeks were similar except for the additional finding of chorioamnionitis.

CONCLUSIONS

Reduced fetal movement may be associated with the low biophysical profile. In cases where fetal movement decreases, placental chorangiosis and hypercoiled cord seem to be associated with fetal growth restriction.

Development of a core outcome set (COS) for studies relating to awareness and clinical management of reduced fetal movement: study protocol

BACKGROUND

Concerns regarding reduced fetal movements (RFM) are reported in 5-15% of pregnancies, and RFM are associated with adverse pregnancy outcomes including fetal growth restriction and stillbirth. Studies have aimed to improve pregnancy outcomes by evaluating interventions to raise awareness of RFM in pregnancy, such as kick counting, evaluating interventions for the clinical management of RFM, or both. However, there is not currently a core outcome set (COS) for studies of RFM. This study aims to create a COS for use in research studies that aim to raise awareness of RFM and/or evaluate interventions for the clinical management of RFM.

METHODS

A systematic review will be conducted, to identify outcomes used in randomised and non-randomised studies with control groups that aimed to raise awareness of RFM (for example by using mindfulness techniques, fetal movement counting, or other tools such as leaflets or mobile phone applications) and/or that evaluated the clinical management of RFM. An international Delphi consensus will then be used whereby stakeholders will rate the importance of the outcomes identified in the systematic review in (i) awareness and (ii) clinical management studies. The preliminary lists of outcomes will be discussed at a consensus meeting where one final COS for awareness and management, or two discrete COS (one for awareness and one for management), will be agreed upon.

DISCUSSION

A well-developed COS will provide researchers with the minimum set of outcomes that should be measured and reported in studies that aim to quantify the effects of interventions.

My Baby's Movements: a stepped-wedge cluster-randomised controlled trial of a fetal movement awareness intervention to reduce stillbirths

OBJECTIVE

The My Baby's Movements (MBM) trial aimed to evaluate the impact on stillbirth rates of a multifaceted awareness package (the MBM intervention).

DESIGN

Stepped-wedge cluster-randomised controlled trial.

SETTING

Twenty-seven maternity hospitals in Australia and New Zealand.

POPULATION

Women with a singleton pregnancy without major fetal anomaly at ≥28 weeks of gestation from August 2016 to May 2019.

METHODS

The MBM intervention was implemented at randomly assigned time points, with the sequential introduction of eight groups of between three and five hospitals at 4-monthly intervals. Using generalised linear mixed models, the stillbirth rate was compared in the control and the intervention periods, adjusting for calendar time, study population characteristics and hospital effects.

MAIN OUTCOME MEASURES

Stillbirth at ≥28 weeks of gestation.

RESULTS

There were 304 850 births with 290 105 births meeting the inclusion criteria: 150 053 in the control and 140 052 in the intervention periods. The stillbirth rate was lower (although not statistically significantly so) during the intervention compared with the control period (2.2/1000 versus 2.4/1000 births; aOR 1.18, 95% CI 0.93-1.50; P = 0.18). The decrease in stillbirth rate was greater across calendar time: 2.7/1000 in the first versus 2.0/1000 in the last 18 months. No increase in secondary outcomes, including obstetric intervention or adverse neonatal outcome, was evident.

CONCLUSIONS

The MBM intervention did not reduce stillbirths beyond the downward trend over time. As a result of low uptake, the role of the intervention remains unclear, although the downward trend across time suggests some benefit in lowering the stillbirth rate. In this study setting, an awareness of the importance of fetal movements may have reached pregnant women and clinicians prior to the implementation of the intervention.

TWEETABLE ABSTRACT

The My Baby's Movements intervention to raise awareness of decreased fetal movement did not significantly reduce stillbirth rates.

Antepartum Fetal Surveillance: ACOG Practice Bulletin, Number 229

The goal of antepartum fetal surveillance is to reduce the risk of stillbirth. Antepartum fetal surveillance techniques based on assessment of fetal heart rate (FHR) patterns have been in clinical use for almost four decades and are used along with real-time ultrasonography and umbilical artery Doppler velocimetry to evaluate fetal well-being. Antepartum fetal surveillance techniques are routinely used to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions (eg, diabetes mellitus) as well as those in which complications have developed (eg, fetal growth restriction). The purpose of this document is to provide a review of the current indications for and techniques of antepartum fetal surveillance and outline management guidelines for antepartum fetal surveillance that are consistent with the best scientific evidence.

Optimizing cervical ripening in women presenting with decreased fetal movements

OBJECTIVE

To determine the optimal method for cervical ripening in women presenting with decreased fetal movements at term. We hypothesized that women who undergo induction of labor for decreased fetal movements represent a higher risk group, and will benefit from mechanical intervention with cervical ripening balloon rather than with pharmacological prostaglandin E2 vaginal insert.

STUDY DESIGN

Retrospective cohort study from January 2014 and January 2019. We recommended induction of labor to every woman ≥39 weeks' gestation with complaints of persistent decreased fetal movements. We excluded women with major fetal anomalies, Bishop score of ≥6 on admission, and cases with contraindications to prostaglandins. Women were allocated into one of two groups based on the cervical ripening agent used. In group 1 we introduced the prostaglandin E2 vaginal insert (10 mg dinoprostone in a timed-release formulation). In group 2 we placed the mechanical cervical ripening balloon. The primary outcome of the study, analyzed separately to nulliparous and multiparous women, was the rate of cesarean delivery in each of the groups.

RESULTS

During the 5-years study, 294 women were included in the final analysis, of which 201 were in the prostaglandin E2 vaginal insert group and 93 were in the cervical ripening balloon group. The rate of cesarean delivery was comparable between the groups (nulliparous: 20.8%, 16/77 versus 21.3%, 10/47. multiparous: 16.9%, 21/124 versus 7%, 3/46, respectively). Other maternal and neonatal secondary outcomes, including the induction-to-delivery time (nulliparous: 32.5 ± 25.3 h versus 26.5 ± 12.2 h. multiparous: 24.6 ± 17.2 h versus 21.25 ± 12.3 h, respectively), were also not different between the two induction methods used. A longer induction-to-delivery time was observed in nulliparous women who had repeat prostaglandin E2 vaginal insert compared with the cervical ripening balloon group (74.6 ± 27.3 h versus 26.5 ± 12.2 h, p < .01).

CONCLUSION

Both pharmacological and mechanical methods can safely and efficiently be used for cervical ripening in women presenting with decreased fetal movements at term. With repeat prostaglandin E2 use, nulliparous women may experience a prolong labor compared with the cervical ripening balloon group, but maternal or fetal safety are not compromised.

Foetal cardiac function in third trimester pregnancies with reduced fetal movements

The objective of our study was to investigate the possible relationship between poor perinatal outcome and foetal cardiac functions in pregnant women with reduced foetal movements (RFM). This cross-sectional study included 126 pregnant women with normal foetal movements (Group 1, Controls) and 42 pregnant women over 32 weeks gestation with RFM (Group 2). Group 2 was further divided into two subgroups according to their perinatal outcome: normal perinatal outcome (Group 2a) and poor perinatal outcome (Group 2b). Cardiotocography, the E/A ratio in both atrioventricular valves, myocardial performance index (MPI) and foetal tricuspid annular plane systolic excursion (f-TAPSE) were evaluated. Foetuses with poor perinatal outcome had a higher MPI (p = .003), higher tricuspid and mitral E/A (p < .001), and lower f-TAPSE values (p < .001). In regression analysis, f-TAPSE was the only parameter (p = .04) independently associated with poor perinatal outcome. İn conclusion, examining f-TAPSE may predict adverse perinatal outcome in pregnancies with RFM.IMPACT STATEMENTWhat is already known on this subject? Reduced foetal movement (RFM) is associated with adverse pregnancy outcome. Cardiotocography, amniotic fluid assessment, estimated birthweight, foetal Doppler and formal foetal movement count (kick chart) are generally used in the clinical assessment of pregnancies with reduced foetal movements. These tests, we currently use to assess foetal wellbeing in women with reduced foetal movements, have limited sensitivity in predicting foetal compromise.What do the results of this study add? Foetal cardiac Doppler may potentially be used as an important adjunct to the conventional management of women with a perception of reduced foetal movements.What are the implications of these findings for clinical practice and/or further research? Foetal echocardiographic evaluation, such as f-TAPSE, may influence clinical practice by enabling improved risk stratification for poor perinatal outcome, thus allowing more timely definitive intervention. This could help to decrease the rate of stillbirth related to reduced foetal movements. The few established echocardiographically derived parameters, which can asses global right ventricle function, are not always easy to obtain, however, f-TAPSE is easily obtainable using ultrasound and it appears to be a clinically useful echocardiographic measurement of right ventricular function.

The effect of formal fetal movement counting on maternal psychological outcomes: A systematic review and meta-analysis

INTRODUCTION

Formally counting fetal movements in pregnancy is one of the oldest methods to assess fetal well-being. Although not routinely recommended in contemporary maternity care, due to a lack of evidence of its effectiveness, formal fetal movement counting is still practiced in many birth settings. Requesting women to formally count their fetal movements in a structured, objective way that can potentially improve maternal subjective outcomes such as worry or concern. The aim of this study was to evaluate the effect of formal fetal movement counting versus no formal counting, on maternal worry, concern or anxiety, and maternal-fetal attachment (MFA). Secondary outcomes were compliance with the intervention (counting method) and hospital admission/attendance for fetal activity concerns.

METHODS

CINAHL, MEDLINE and EMBASE were searched systematically for eligible studies from inception dates to June 2020, supplemented by searches of trial databases, grey literature and the reference lists of included studies. Randomized controlled and quasi-randomized trials were included in the review.

RESULTS

Nine studies reported across 15 publications were included involving 70824 pregnant women. The results showed that MFA levels were significantly higher in women who formally counted fetal movements than those who did not (standardized mean difference=0.72; 95% CI: 0.10-1.33, five studies, 1565 women). There were no differences between the groups in maternal anxiety or worry/concern outcomes. Attendance or admission rates for reduced fetal movements, or concern for fetal activity, did not differ between the groups (OR=1.36; 95% CI: 0.97-1.91, three studies, 1947 women). Compliance in completing fetal movement charts varied, ranging 45-90%, although definitions of compliance differed across studies, which may have affected rates.

CONCLUSIONS

This review has found that formal fetal movement counting in pregnancy has no detrimental effects on maternal psychological or emotional status and positively affects maternal-fetal attachment. Although current evidence does not support the use of formal fetal movement counting for improving perinatal outcomes, such as stillbirth and neonatal death, the results of this review are helpful for clinicians in discussing fetal movements in pregnancy and in discussing the optional methods available to women who may be advised to or choose to objectively assess fetal movements using a formal fetal movement counting method.

Midwives' experiences of using the Mindfetalness method when talking with pregnant women about fetal movements

BACKGROUND

Information given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby's fetal movement pattern.

AIM

We aimed to explore midwives' perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work.

METHODS

A web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire.

FINDINGS

The midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task.

CONCLUSION

Mindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.

A Novel Fetal Movement Simulator for the Performance Evaluation of Vibration Sensors for Wearable Fetal Movement Monitors

Fetal movements (FM) are an important factor in the assessment of fetal health. However, there is currently no reliable way to monitor FM outside clinical environs. While extensive research has been carried out using accelerometer-based systems to monitor FM, the desired accuracy of detection is yet to be achieved. A major challenge has been the difficulty of testing and calibrating sensors at the pre-clinical stage. Little is known about fetal movement features, and clinical trials involving pregnant women can be expensive and ethically stringent. To address these issues, we introduce a novel FM simulator, which can be used to test responses of sensor arrays in a laboratory environment. The design uses a silicon-based membrane with material properties similar to that of a gravid abdomen to mimic the vibrations due to fetal kicks. The simulator incorporates mechanisms to pre-stretch the membrane and to produce kicks similar to that of a fetus. As a case study, we present results from a comparative study of an acoustic sensor, an accelerometer, and a piezoelectric diaphragm as candidate vibration sensors for a wearable FM monitor. We find that the acoustic sensor and the piezoelectric diaphragm are better equipped than the accelerometer to determine durations, intensities, and locations of kicks, as they have a significantly greater response to changes in these conditions than the accelerometer. Additionally, we demonstrate that the acoustic sensor and the piezoelectric diaphragm can detect weaker fetal movements (threshold wall displacements are less than 0.5 mm) compared to the accelerometer (threshold wall displacement is 1.5 mm) with a trade-off of higher power signal artefacts. Finally, we find that the piezoelectric diaphragm produces better signal-to-noise ratios compared to the other two sensors in most of the cases, making it a promising new candidate sensor for wearable FM monitors. We believe that the FM simulator represents a key development towards enabling the eventual translation of wearable FM monitoring garments.

Fetal Movement Counting and Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the association of fetal movement counting with perinatal mortality.

DATA SOURCES

Electronic databases (ie, MEDLINE, ClinicalTrials.gov, ScienceDirect, the Cochrane Library at the CENTRAL Register of Controlled Trials) were searched from inception until May 2019. Search terms used were: "fetal movement," "fetal movement counting," "fetal kick counting," "stillbirth," "fetal demise," "fetal mortality," and "perinatal death."

METHODS OF STUDY SELECTION

We included all randomized controlled trials comparing perinatal mortality in those women randomized to receive instructions for fetal movement counting compared with a control group of women without such instruction.

TABULATION, INTEGRATION AND RESULTS

The primary outcome was perinatal mortality. Five of 1,290 identified articles were included, with 468,601 fetuses. Definitions of decreased fetal movement varied. In four of five studies, women in the intervention group were asked to contact their health care providers if they perceived decreased fetal movement; the fifth study did not provide details. Reported reduction in fetal movement usually resulted in electronic fetal monitoring and ultrasound assessment of fetal well-being. There was no difference in the incidence of perinatal outcome between groups. The incidence of perinatal death was 0.54% (1,252/229,943) in the fetal movement counting group and 0.59% (944/159,755) in the control group (relative risk [RR] 0.92, 95% CI 0.85-1.00). There were no statistical differences for other perinatal outcomes as stillbirths, neonatal deaths, birth weight less than 10th percentile, reported decreased fetal movement, 5-minute Apgar score less than 7, neonatal intensive care unit admission or perinatal morbidity. There were weak but significant increases in preterm delivery (7.6% vs 7.1%; RR 1.07, 95% CI 1.05-1.10), induction of labor (36.6% vs 31.6%; RR 1.15, 95% CI 1.09-1.22), and cesarean delivery (28.2% vs 25.3%; RR 1.11, 95% CI 1.10-1.12).

CONCLUSION

Instructing pregnant women on fetal movement counting compared with no instruction is not associated with a clear improvement in pregnancy outcomes. There are weak associations with some secondary outcomes such as preterm delivery, induction of labor, and cesarean delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019123264.

Obstetric Care Consensus #10: Management of Stillbirth: (Replaces Practice Bulletin Number 102, March 2009)

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained, even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

Management of Stillbirth: Obstetric Care Consensus No, 10

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

Mindfetalness to increase women's awareness of fetal movements and pregnancy outcomes: a cluster-randomised controlled trial including 39 865 women

OBJECTIVE

To examine whether a method for raising women's awareness of fetal movements, Mindfetalness, can affect pregnancy outcomes.

DESIGN

Cluster-randomised controlled trial.

SETTING

Sixty-seven maternity clinics in Stockholm, Sweden.

POPULATION

Women with singleton pregnancy with birth from 32 weeks' gestation.

METHODS

Women registered at a clinic randomised to Mindfetalness were assigned to receive a leaflet about Mindfetalness (n = 19 639) in comparison with routine care (n = 20 226). Data were collected from a population-based register.

MAIN OUTCOME MEASURES

Apgar score <7 at 5 minutes after birth, visit to healthcare due to decrease in fetal movements. Other outcomes: Apgar score <4 at 5 minutes after birth, small-for-gestational-age and mode of delivery.

RESULTS

No difference (1.1 versus 1.1%, relative risk [RR] 1.0; 95% CI 0.8-1.2) was found between the Mindfetalness group and the Routine care group for a 5-minute Apgar score <7. Women in the Mindfetalness group contacted healthcare more often due to decreased fetal movements (6.6 versus 3.8%, RR 1.72; 95% CI 1.57-1.87). Mindfetalness was associated with a reduction of babies born small-for-gestational-age (RR 0.95, 95% CI 0.90-1.00), babies born after gestational week 41⁺⁶ (RR 0.91, 95% CI 0.83-0.98) and caesarean sections (19.0 versus 20.0%, RR 0.95; 95% CI 0.91-0.99).

CONCLUSIONS

Mindfetalness did not reduce the number of babies born with an Apgar score <7. However, Mindfetalness was associated with the health benefits of decreased incidence of caesarean section and fewer children born small-for-gestational-age.

TWEETABLE ABSTRACT

Introducing Mindfetalness in maternity care decreased caesarean sections but had no effect on the occurrence of Apgar scores <7.

'InUTERO': The effectiveness of an educational half day stillbirth awareness workshop for maternity care providers

BACKGROUND

There is a disconnect between what maternity care providers consider should be done and what they actually do with respect to talking with their pregnant clients about reducing their risk of stillbirth. This suggests that they would benefit from receiving up-to-date knowledge about stillbirth, alongside education that provides them with strategies for talking about stillbirth with pregnant women.

OBJECTIVES

To gain an understanding of maternity care provider (obstetricians and midwives) knowledge of stillbirth and determine whether delivering a half day workshop improves knowledge and results in intention to change practice.

DESIGN

A pre-post intervention study.

SETTING

Maternity care providers (Obstetricians, Midwives) working in the northern areas of Tasmania, Australia were asked, via questionnaire, about their knowledge of stillbirth both before and after attending a half-day workshop.

PARTICIPANTS

Maternity care providers (n = 51) attended the workshop and 30 (59%) completed both the pre-workshop and post-workshop surveys.

METHODS

A four hour interactive workshop grounded in understanding the stillbirth experience. Participants were given up-to-date information about stillbirth risks and current prevention research as well as provided with an actionable step wise approach to talking about stillbirth prevention in pregnancy.

RESULTS

Stillbirth knowledge scores (total of 8-points) significantly increased following the workshop (pre: mean = 2.9 ± 1.5; post: mean = 4.7 ± 1.4 points, t ₂₉ = 7.9, <0.001). Before the workshop, only 20% of participants responded that they "always" or usually" discussed the possibility stillbirth occurring with pregnant women in their care whereas, after the workshop, nearly all (88%) indicated that they planned to "always" discuss stillbirth with their pregnant clients.

CONCLUSIONS

Attending a stillbirth awareness for prevention education workshop resulted in significant knowledge improvement and self-reported intention to change practice in a group of Australian maternity care providers. While these results are promising, further study is needed to determine the presence and extent of actual practice change following such education.

My Baby's Movements: a stepped wedge cluster randomised controlled trial to raise maternal awareness of fetal movements during pregnancy study protocol

Background

Stillbirth is a devastating pregnancy outcome that has a profound and lasting impact on women and families. Globally, there are over 2.6 million stillbirths annually and progress in reducing these deaths has been slow. Maternal perception of decreased fetal movements (DFM) is strongly associated with stillbirth. However, maternal awareness of DFM and clinical management of women reporting DFM is often suboptimal. The My Baby’s Movements trial aims to evaluate an intervention package for maternity services including a mobile phone application for women and clinician education (MBM intervention) in reducing late gestation stillbirth rates.

Methods/design

This is a stepped wedge cluster randomised controlled trial with sequential introduction of the MBM intervention to 8 groups of 3–5 hospitals at four-monthly intervals over 3 years.

The target population is women with a singleton pregnancy, without lethal fetal abnormality, attending for antenatal care and clinicians providing maternity care at 26 maternity services in Australia and New Zealand. The primary outcome is stillbirth from 28 weeks’ gestation. Secondary outcomes address: a) neonatal morbidity and mortality; b) maternal psychosocial outcomes and health-seeking behaviour; c) health services utilisation; d) women’s and clinicians’ knowledge of fetal movements; and e) cost. 256,700 births (average of 3170 per hospital) will detect a 30% reduction in stillbirth rates from 3/1000 births to 2/1000 births, assuming a significance level of 5%. Analysis will utilise generalised linear mixed models.

Discussion

Maternal perception of DFM is a marker of an at-risk pregnancy and commonly precedes a stillbirth. MBM offers a simple, inexpensive resource to reduce the number of stillborn babies, and families suffering the distressing consequences of such a loss. This large pragmatic trial will provide evidence on benefits and potential harms of raising awareness of DFM using a mobile phone app.

Trial registration

ACTRN12614000291684. Registered 19 March 2014.

Version

Protocol Version 6.1, February 2018.

Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring

Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.

No. 197a-Fetal Health Surveillance: Antepartum Consensus Guideline

OBJECTIVE

This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum care in Canada.

OPTIONS

Consideration has been given to all methods of fetal surveillance currently available in Canada.

OUTCOMES

Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered.

EVIDENCE

A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1).

SPONSOR

This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: FETAL MOVEMENT COUNTING: RECOMMENDATION 2: NON-STRESS TEST: RECOMMENDATION 3: CONTRACTION STRESS TEST: RECOMMENDATION 4: BIOPHYSICAL PROFILE: RECOMMENDATION 5: UTERINE ARTERY DOPPLER: RECOMMENDATION 6: UMBILICAL ARTERY DOPPLER.

The use of actograph in the assessment of fetal well-being

Purpose: Third trimester maternal perception of fetal movements is often used to assess fetal well-being. However, its true clinical value is unknown, primarily because of the variability in subjective quantification. The actograph, a technology available on most cardiotocograph machines, quantifies movements, but has never previously been investigated in relation to fetal health and existing monitoring devices. The objective of this study was to quantify actograph output in healthy third trimester pregnancies and investigate this in relation to other methods of assessing fetal well-being.Methods: Forty-two women between 24 and 34 weeks of gestation underwent ultrasound scan followed by a computerized cardiotocograph (CTG). Post capture analysis of the actograph recording was performed and expressed as a percentage of activity over time. The actograph output results were analyzed in relation to Doppler, ultrasound and CTG findings expressed as z-score normalized for gestation.Results: There was a significant association between actograph output recording and estimated fetal weight Z-score (R = 0.546, p ≤ .005). This activity was not related to estimated fetal weight. Increased actograph activity was negatively correlated with umbilical artery pulsatility index Z-score (R = -0.306, p = .049) and middle cerebral artery pulsatility index Z-score (R = -0.390, p = .011).Conclusion: Fetal movements assessed by the actograph are associated both with fetal size in relation to gestation and fetoplacental Doppler parameters. It is not the case that larger babies move more, however, as the relationship with actograph output related only to estimated fetal weight z-score. These findings suggest a plausible link between the frequency of fetal movements and established markers of fetal health.RATIONALEThe objective of this study was to quantify actograph output in healthy third trimester pregnancies and investigate this in relation to other methods of assessing fetal well-being. This is a widely available method of assessing fetal movements objectively, which has been shown to be an important marker of fetal health. This research is novel in the fact that actograph has never been truly investigated in relation to fetal well-being, despite being available on most cardiotocograph (CTG) machines.Our results show that fetal movements assessed by the actograph are associated both with fetal size in relation to gestation and fetoplacental Doppler parameters. If this proves to be true, smaller babies that move less maybe at particular perinatal risk.

Daily structured approach to awareness of fetal movements and pregnancy outcome - a prospective study

OBJECTIVES

We investigated how women, seeking care due to decreased movements, had paid attention to fetal movements and if the method of monitoring was associated with pregnancy outcome.

METHODS

A questionnaire was distributed to women from gestational week 28, who had sought care due to decreased fetal movements in Stockholm between January 1st and December 31st^, 2014. Women were included in the study if the examination did not reveal any signs of a compromised fetus requiring immediate intervention. Birth outcome and sociodemographic data were collected from the obstetric record register.

RESULTS

There were 29166 births in Stockholm in 2014, we have information from 2683 women who sought care for decreased fetal movements. The majority (96.6%) of the women stated that they paid attention to fetal movements. Some women observed fetal movements weekly (17.2%) and 69.5% concentrated on fetal movements daily (non-structured group). One in ten (9.9%) used counting methods daily for observing fetal movements (structured group). Women in the structured group more often had caesarean section before onset of labor (RR 1.6, 95% CI 1.2-2.2) and a lower risk of their baby being transferred to neonatal nursery (RR 0.25, 95% CI 0.03-0.94) compared to women in the non-structured group.

CONCLUSIONS

Women, who had a daily and structured approach to awareness of fetal movements, were more likely to have a caesarean section but their babies were less likely to be transferred to a neonatal nursery as compared with women who used a non-structured method daily.

Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial

BACKGROUND

2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth.

METHODS

This stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022.

FINDINGS

37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75-1·07; p=0·23).

INTERPRETATION

The RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven.

FUNDING

Chief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.

Features of randomised trials designed by the NPEU Perinatal Trials Service during Adrian Grant's directorship

Adrian Grant pioneered methodological innovations in the randomised trials organised by the Perinatal Trials Service established at the national Perinatal Epidemiology Unit in Oxford, UK. This Commentary discusses these innovations, and shows the wide range of trials designed under his directorship.

Performance of a wearable acoustic system for fetal movement discrimination

Fetal movements (FM) are a key factor in clinical management of high-risk pregnancies such as fetal growth restriction. While maternal perception of reduced FM can trigger self-referral to obstetric services, maternal sensation is highly subjective. Objective, reliable monitoring of fetal movement patterns outside clinical environs is not currently possible. A wearable and non-transmitting system capable of sensing fetal movements over extended periods of time would be extremely valuable, not only for monitoring individual fetal health, but also for establishing normal levels of movement in the population at large. Wearable monitors based on accelerometers have previously been proposed as a means of tracking FM, but such systems have difficulty separating maternal and fetal activity and have not matured to the level of clinical use. We introduce a new wearable system based on a novel combination of accelerometers and bespoke acoustic sensors as well as an advanced signal processing architecture to identify and discriminate between types of fetal movements. We validate the system with concurrent ultrasound tests on a cohort of 44 pregnant women and demonstrate that the garment is capable of both detecting and discriminating the vigorous, whole-body ‘startle’ movements of a fetus. These results demonstrate the promise of multimodal sensing for the development of a low-cost, non-transmitting wearable monitor for fetal movements.

Management and Outcome of Reduced Fetal Movements-is Ultrasound Necessary?

OBJECTIVE

To review the management and outcome of pregnancies of women presenting to obstetrical triage with decreased fetal movements (DFM).

STUDY DESIGN

A retrospective review of women presenting with DFMs to two large Canadian obstetrical centres with a combined 9490 deliveries per year. The charts were reviewed for compliance with the Canadian guidelines for demographics (age, parity, GA, comorbidities, etc.), pregnancy management (admission vs. discharge, need to deliver), and pregnancy outcomes (mortality, morbidity, GA at delivery, Apgar scores, etc.). Patients who did not comply with the Canadian guidelines (requiring the patient to count six movements within two hours) were not excluded.

RESULTS

The charts of 579 patients who self-reported DFMs between January 2012 and December 2012 were reviewed. The distribution of ages was between 18 and 47 year old. The majority of these patients had no comorbidities (454/579). A significant minority of patients had FM in the triage area (231/579). The Canadian guidelines were interpreted differently in the two centres. In one (level 3), the protocol was to have a biophysical profile (BPP) on all patients prior to discharge, whereas in the other (level 2), only patients with a non-reactive non-stress test (NST) and/or oligohydramnios or intrauterine growth restriction (IUGR) underwent a BPP. All patients had an evaluation by an RN and MD and had a NST on arrival. A combination of NST and BPP was performed on 235/579. The frequency of DFM was 6.1% (level 3 centre: 5.6%, level 2 centre: 7.8%). There were 8 stillbirths on arrival. The 187 patients who had a reactive NST and a normal BPP and were sent home did not have a single stillbirth within 2 weeks. In the level 3 centre, 19 patients were sent home without a BPP and one had a stillbirth within 2 days (5%); in the level 2 hospital, there was only one stillbirth among the NST-only group (0.35%). There were 65 admissions; 46 of them (71%) were delivered, and 50% of them had a Caesarean delivery (baseline around 30%).

CONCLUSIONS

This is the first study looking at the performance of the Canadian guidelines of 2007. We found that the DFM rate was compatible with the literature (6.1% vs. 5%). The frequency of stillbirth on arrival was 1.4% (8/579). Patients discharged after normal NST and BPP did extremely well (no stillbirths), whereas those admitted following DFM had a relatively high Caesarean delivery rate (50%). This study was not designed to address changes in stillbirth rate, but it outlines the patients who experience DFM and their eventual outcomes.

Women's attitudes, experiences and compliance concerning the use of Mindfetalness- a method for systematic observation of fetal movements in late pregnancy

Background

Maternal perception of decreased fetal movements and low awareness of fetal movements are associated with a negative birth outcome. Mindfetalness is a method developed for women to facilitate systematic observations of the intensity, character and frequency of fetal movements in late pregnancy. We sought to explore women’s attitudes, experiences and compliance in using Mindfetalness.

Methods

We enrolled 104 pregnant women treated at three maternity clinics in Stockholm, Sweden, from February to July of 2016. We educated 104 women in gestational week 28–32 by providing information about fetal movements and how to practice Mindfetalness. Each was instructed to perform the assessment daily for 15 min. At each subsequent follow-up, the midwife collected information regarding their perceptions of Mindfetalness, and their compliance. Content analyses, descriptive and analytic statistics were used in the analysis of data.

Results

Of the women, 93 (89%) were positive towards Mindfetalness and compliance was high 78 (75%). Subjective responses could be binned into one of five categories: Decreased worry, relaxing, creating a relationship, more knowledge about the unborn baby and awareness of the unborn baby. Eleven (11%) women had negative perceptions of Mindfetalness, citing time, and the lack of need for a method to observe fetal movements as the most common reasons.

Conclusion

Women in late pregnancy are generally positive about Mindfetalness and their compliance with daily use is high. The technique helped them to be more aware of, and create a relationship with, their unborn baby. Mindfetalness can be a useful tool in antenatal care. However, further study is necessary in order to determine whether the technique is able to reduce the incidence of negative birth outcome.

Can promoting awareness of fetal movements and focusing interventions reduce fetal mortality? A stepped-wedge cluster randomised trial (AFFIRM)

BACKGROUND

In 2013, the stillbirth rate in the UK was 4.2 per 1000 live births, ranking 24th out of 49 high-income countries, with an annual rate of reduction of only 1.4% per year. The majority of stillbirths occur in normally formed infants, with (retrospective) evidence of placental insufficiency the most common clinical finding. Maternal perception of reduced fetal movements (RFM) is associated with placental insufficiency and increased risk of subsequent stillbirth.This study will test the hypothesis that the introduction of a package of care to increase women's awareness of the need for prompt reporting of RFM and standardised management to identify fetal compromise with timely delivery in confirmed cases, will reduce the rate of stillbirth. Following the introduction of a similar intervention in Norway the odds of stillbirth fell by 30%, but the efficacy of this intervention (and possible adverse effects and implications for service delivery) has not been tested in a randomised trial.

METHODS

We describe a stepped-wedge cluster trial design, in which participating hospitals in the UK and Ireland will be randomised to the timing of introduction of the care package. Outcomes (including the primary outcome of stillbirth) will be derived from detailed routinely collected maternity data, allowing us to robustly test our hypothesis. The degree of implementation of the intervention will be assessed in each site. A nested qualitative study will examine the acceptability of the intervention to women and healthcare providers and identify process issues including barriers to implementation.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Scotland A Research Ethics Committee (Ref 13/SS/0001) and from Research and Development offices in participating maternity units. The study started in February 2014 and delivery of the intervention completed in December 2016. Results of the study will be submitted for publication in peer-reviewed journals and disseminated to local investigating sites to inform education and care of women presenting with RFM.

TRIAL REGISTRATION NUMBER

www.clinicaltrials.gov NCT01777022.

VERSION

Protocol Version 4.2, 3 February 2017.

Interventions to prevent stillbirth

Stillbirth is one of the most distressing complications of pregnancy and still occurs far too frequently. The rate of stillbirth has been decreasing worldwide but room for improvement remains even in high-income countries. Risk factors for stillbirth have been identified in an effort to detect those women at increased risk. However, risk factors are non-specific and do not identify most stillbirths. Strategies employed to screen the general population such as assessment of fetal activity, fetal growth screening and biomarkers have also been used to identify increased risk for stillbirth. As with clinical risk factors, these methods are non-specific. Interventions to prevent stillbirth include antenatal testing of high-risk women, ultrasonographic assessments of fetal growth and Doppler velocimetry as well as iatrogenic preterm or term delivery. Additional research into the role of these interventions and better identification of those at high risk for stillbirth will help to achieve further stillbirth reduction.

The effect of foetal movement counting on maternal anxiety: A randomised, controlled trial

This study assessed the effect of foetal movement counting on maternal anxiety. In a randomised, controlled trial, 208 primigravida women with a singleton pregnancy were allocated either to perform daily foetal movement counting (n100) from 28 weeks ’ gestation or to follow standard Iranian antenatal care (n108). Maternal anxiety was measured by Spielberger State-Trait Anxiety Inventory. Statistical analysis was performed by SPSS (16.0). There was no significant difference in mean state and trait anxiety scores at 28 weeks ’ gestation; the difference was significant at 37 weeks ’ gestation in state anxiety score between the intervention and control groups (35.34 9.98 vs. 38.25 9.63, respectively, P0.001). A significant difference was found in mean trait anxiety score at 37 weeks ’ gestation between the two groups (35.88 8.19 vs. 39.15 9.25, respectively, P 0.008). Women who performed foetal movement counting from 28 to 37 weeks ’ gestation reported less anxiety compared with those in control group.

Fetal movements as a predictor of health

The key determinant to a fetus maintaining its health is through adequate perfusion and oxygen transfer mediated by the functioning placenta. When this equilibrium is distorted, a number of physiological changes, including reduced fetal growth, occur to favor survival. Technologies have been developed to monitor these changes with a view to prolong intrauterine maturity while reducing the risks of stillbirth. Many of these strategies involve complex interpretation, for example Doppler ultrasound for fetal blood flow and computerized analysis of fetal heart rate changes. However, even with these modalities of fetal assessment to determine the optimal timing of delivery, fetal movements remain integral to clinical decision-making. In high-risk cohorts with fetal growth restriction, the manifestation of a reduction in perceived movements may warrant an expedited delivery. Despite this, there has been little evolution in the development of technologies to objectively evaluate fetal movement behavior for clinical application. This review explores the available literature on the value of fetal movement analysis as a method of assessing fetal wellbeing, and demonstrates how interdisciplinary developments in this area may aid in the improvement of clinical outcomes.

The effect of glucose administration on perceived fetal movements in women with decreased fetal movement, a double-blinded placebo-controlled trial

OBJECTIVE

To assess the effect of maternal glucose administration on perceived fetal movements.

STUDY DESIGN

This was a randomized, double-blinded placebo-controlled trial. Patients 28-41 weeks singleton gestation complaining of decreased fetal movements (DFM) were assigned to receive either 500 cc dextrose 5% (group A) or 500 cc normal saline (group B) intravenously. Primary outcome was number of fetal movements recorded during the following 30 min. Secondary outcomes included need for admission or induction of labor owing to persistent DFM. Maternal glucose levels were taken before and after intervention. A sample size of 50 patients was planned in order to detect a 30% increase in fetal movements in group A.

RESULTS

Between February 2011 and April 2013, 50 patients were recruited. Demographic characteristics were similar among groups. There was no difference in the number of fetal movements recorded (7±6 vs 8.8±6 movements/30 min, group A and B, respectively, P=0.39). Similar number of patients had persistent DFM that required admission (8 vs 10 patients, P=0.77, OR 1.4, confidence interval (CI) 0.38-5.3); of those admitted, similar number of patients had induction of labor (3 vs 6 patients, P=0.64, OR 0.4, CI 0.03-3.8). Maternal glucose levels were similar at recruitment (88±19 vs 83±15 mg dl(-1) P=0.36) but were significantly higher in group A (161±37 vs 75±15 mg dl(-1) P<0.0001) after intervention.

CONCLUSION

In women with DFM, maternal glucose administration has no effect on perceived fetal movement and its clinical use is questionable.

Perinatal outcomes of reduced fetal movements: a cohort study

BACKGROUND

The perception of reduced fetal movement (RFM) is an important marker of fetal wellbeing and is associated with poor perinatal outcome (such as intra-uterine death).

METHODS

We conducted a prospective study of women presenting with RFM over 28 weeks' gestation to a tertiary-level maternity hospital. We examined pregnancy outcomes and compared them to a retrospectively collected control group delivering contemporaneously.

RESULTS

In total, 275 presentations were analysed in the RFM group, with 264 in the control group. Women with RFM were more likely to be nulliparous (p = 0.002) and have an induction of labour (p = 0.0011). 26.5 % (n = 73) of cases were admitted following presentation with RFM, and 79.4 % (n = 58) delivered on primary presentation. Overall, 15.2 % (n = 42) women were induced for RFM specifically.

CONCLUSION

This prospective study shows the increased burden of care required by those with RFM, including increased neonatal unit admission rates, increased induction rates and higher surveillance demands, demonstrating the need for increased attention to this area of practice.

Fetal movement in late pregnancy - a content analysis of women's experiences of how their unborn baby moved less or differently

Background

Pregnant women sometimes worry about their unborn baby’s health, often due to decreased fetal movements. The aim of this study was to examine how women, who consulted health care due to decreased fetal movements, describe how the baby had moved less or differently.

Methods

Women were recruited from all seven delivery wards in Stockholm, Sweden, during 1/1 – 31/12 2014. The women completed a questionnaire after it was verified that the pregnancy was viable. A modified content analysis was used to analyse 876 questionnaires with the women’s responses to, “Try to describe how your baby has moved less or had changes in movement”.

Results

Four categories and six subcategories were identified: “Frequency” (decreased frequency, absence of kicks and movement), “Intensity” (weaker fetal movements, indistinct fetal movements), “Character” (changed pattern of movements, slower movements) and “Duration”. In addition to the responses categorised in accordance with the question, the women also mentioned how they had tried to stimulate the fetus to move and that they had difficulty in distinguishing fetal movements from contractions. Further, they described worry due to incidents related to changed pattern of fetal movements.

Conclusion

Women reported changes in fetal movement concerning frequency, intensity, character and duration. The challenge from a clinical perspective is to inform pregnant women about fetal movements with the goal of minimizing unnecessary consultations whilst at the same time diminishing the length of pre-hospital delay if the fetus is at risk of fetal compromise.

Trial registration

Not applicable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0922-z) contains supplementary material, which is available to authorized users.

The Effects of Fetal Movement Counting on Pregnancy Outcomes

INTRODUCTION

Counting fetal movements may lead to timely assess fetal health and prevent the adverse effects of pregnancy.

AIM

The aim of this study was to determine the effect of fetal movement counting on pregnancy outcomes.

MATERIALS AND METHODS

In a randomized controlled trial, 208 women with singleton pregnancy were randomly divided into two groups of fetal movement counting and control. Pregnancy outcomes were compared between the two groups. Data were analysed with SPSS and p<0.05 was considered significant.

RESULTS

There was no significant difference in the mean maternal concern (p=0.36), admission to hospital due to the decreased fetal movements (p=0.99), birth weight (p=0.21), Apgar score (p=0.51), the mean of gestational age at the time of decreased fetal movements (p=0.49) and mode of delivery (p=0.69) between the two groups. There were no cases of premature labour, intrauterine growth retardation and fetal death in the two groups.

CONCLUSION

Pregnancy outcome was similar in the two groups of fetal movement counting and control. Further studies are needed to evaluate the effect of fetal movement counting on the major outcomes of pregnancy such as intrauterine fetal death.