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

Standardizing Fetal Movement Monitoring using Count the Kicks

ABSTRACT

Stillbirth affects 1 in 175 pregnancies in the United States. There are significant racial and ethnic disparities in rates of stillbirth. Rates of stillbirth are highest among non-Hispanic Native Hawaiian or Other Pacific Islander and non-Hispanic Black women, more than twice the rate of non-Hispanic White women. Stillbirth is a public health crisis that warrants attention as it has significant physical, psychosocial, and economic effects on women and their family. Many stillbirths occur due to placental insufficiency, causing a lack of oxygenation of the fetus, which can result in decreased movement. Pregnant patients who experience stillbirth often observe decreased fetal movement days before birth. Daily fetal movement monitoring has the potential to identify pregnancies at risk so providers can intervene. Count the Kicks is a fetal movement monitoring program that provides standardized education and resources for expectant parents. Increased awareness of providers and childbearing families about the importance of fetal movement monitoring, standardized provision of education on fetal movement counting, and what to do if a baby's normal movement patterns change can be helpful in promoting healthy pregnancy outcomes.

Maternal perception of decreased fetal movements is independent of infant size

OBJECTIVE

Fetal movements are often used as a surrogate for fetal wellbeing. Previous research suggests a link between maternal perception of decreased fetal movements (DFM) and small-for-gestational-age (SGA) infants. The aim of this study was to investigate the association between maternal presentation with DFM and birth-weight centile categories at a large Australian perinatal center.

METHODS

This was a retrospective study of non-anomalous singleton infants born at ≥ 28 + 0 weeks' gestation between January 2016 and October 2020 at the Mater Mothers' Hospital in Brisbane, Australia. The primary outcome was the rate of DFM according to birth-weight centile category. Maternal demographic characteristics included age, body mass index, ethnicity, parity, medical conditions and previous stillbirth. The association between DFM and birth-weight centile was evaluated using adjusted multinomial regression models. Robust standard errors were used to account for clustering at the patient level. Wald tests and Akaike's and Bayesian information criteria were used to evaluate models.

RESULTS

Over the 5-year study period, 45 042 women met the inclusion criteria. Of these, 6690 (14.9%) women presented with DFM. Of the DFM cohort, 80.9% (5411/6690) had only one presentation with DFM, and 19.1% (1279/6690) had two or more presentations. The overall stillbirth rate was similar in women with DFM (0.1% (8/6690)) and those without DFM (0.1% (50/38 352)). There was no association between DFM (either single or multiple) and infant birth-weight centile.

CONCLUSIONS

This study suggests that presentation with DFM is not associated with infant size. Clinicians should consider additional risk factors and the overall clinical context when deciding appropriate management. DFM is not necessarily an indication for an immediate or urgent ultrasound scan to assess fetal size. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Stillbirth: we can do better

Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.

Decreased fetal movements: Report from the International Stillbirth Alliance conference workshop

Maternal reports of decreased fetal movement (DFM) are a common reason to present to maternity care and are associated with stillbirth and other adverse outcomes. Promoting awareness of fetal movements and prompt assessment of DFM has been recommended to reduce stillbirths. However, evidence to guide clinical management of such presentations is limited. Educational approaches to increasing awareness of fetal movements in pregnant women and maternity care providers with the aim of reducing stillbirths have recently been evaluated in a several large clinical trials internationally. The International Stillbirth Alliance Virtual Conference in Sydney 2021 provided an opportunity for international experts in fetal movements to share reports on the findings of fetal movement awareness trials, consider evidence for biological mechanisms linking DFM and fetal death, appraise approaches to clinical assessment of DFM, and highlight research priorities in this area. Following this workshop summaries of the sessions prepared by the authors provide an overview of understandings of fetal movements in maternity care at the current time and highlights future directions in fetal movement research.

Women's perception of fetal movements and perinatal outcomes: results of a prospective cohort study

BACKGROUND

Active fetal movements (AFMs) are a sign of the well-being of the baby during pregnancy and suggests the integrity of the cardiovascular, musculoskeletal, and nervous systems of the fetus. The abnormal perception of AFMs is associated with an increased risk of adverse perinatal outcomes such as stillbirth (SB) and brain damage. Several definitions of " decreased fetal movements" have been proposed, but none of them has been universally accepted. The aim of the study is to investigate the perinatal outcomes in relation to AFMs frequency and perception in term pregnancy with an ad hoc questionnaire administered to the women before delivery.

STUDY DESIGN

This was a prospective case-control study on pregnant women at term referring to the Obstetric Unit of the University Hospital of Modena, Italy, between January 2020 and March 2020. A validated questionnaire was administered to women who agreed to participate in the study. Therefore, women were subdivided into the case and control groups: cases included women who experienced adverse perinatal outcomes (APO) such as perinatal mortality (SB and early neonatal mortality), operative delivery (cesarean section or vacuum) due to fetal distress, Apgar 5' < 7, neonatal resuscitation at birth and NICU Admission, while controls were women who experienced delivery and birth without APO in the same period.

RESULTS

Seventy-seven cases and 178 controls that compiled the questionnaire were included in the analysis. Characteristics significantly associated with APO were low education (OR 1.57, CI 95% 1.11-2.22), nulliparity (OR 1.76, CI 95% 1.20-2.58), obesity (OR 1.55, CI 95% 1.10-2.17), neonatal male gender (OR 1.92 CI95% 1.33-2.78) and centile at birth (< 10° and >90°) (OR 2.77, 95%CI 2.17, 3.55). There was no association between any answer about strengths, frequency and vigor of perceived fetal movements and APO. Even any maternal perception of fetal hiccups or uterine contractions wasn't associated with APO. On the other hand, women who referred to frequent change positions during sleep (OR 1.55 CI95% 1.05-2.30) and women who snore (OR 1.43 CI95% 1.01-2.05) showed a statistically significant increase of APO.

CONCLUSIONS

Our data confirm the significant association between modifiable risk factors (such as obesity and low education) and APO. Thus, healthcare providers should be aware of the importance of intervention in reducing obesity, therefore snoring and related sleep apnea syndrome. Finally, changing position during sleep while not the perception of modified/reduced fetal movements significantly could induce the worst obstetric outcomes.

Risk factors for stillbirth at term: an Italian area-based, prospective cohort study

BACKGROUND

Stillbirth at term has great emotional impact on both parents and professionals. In developed countries, efforts to identify risk factors are mandatory to plan area-specific prevention strategies.

OBJECTIVE

The aim of the study was to identify independent risk factors that contribute to stillbirth at 37 weeks' gestation or later.

STUDY DESIGN

This was an area-based, prospective cohort study on pregnancy at term with enrolled from 2014 to 2021 in Emilia-Romagna, a north Italian region. Data were retrieved from both birth certificates and the Stillbirth Surveillance system database. To identify independent risk factors, a multivariate analysis using logistic regression was performed. A descriptive analysis of the causes of stillbirth is also reported.

RESULTS

In the observation period, 246,437 babies born at term (including 260 stillbirths, giving a rate of 1.06/1000) were considered. The risk factors independently associated with stillbirth were small for gestational age babies (odds ratio, 2.58; 95% confidence interval, 1.88-3.53), pregnancy achieved though fertility treatments (odds ratio, 2.01; 95% confidence interval, 1.15-3.51), and delayed access to pregnancy services (odds ratio, 1.56; 95% confidence interval, 1.10-2.22). In multipara, the presence of a previous stillbirth (odds ratio, 3.91; 95% confidence interval, 1.98-7.72) was also associated with an increased risk for recurrence. Early- rather than late-term was an additional risk factor. The most frequent causes of death were placental and cord disorders (61/260 and 56/260, respectively). However, 28.1% of cases remain unexplained.

CONCLUSION

The risks for stillbirth at term are known early in pregnancy or could be identified through tailored antenatal management, allowing effective preventive strategies to reduce preventable cases.

A wearable fetal movement detection system for pregnant women

A wearable device-based fetal movement detection system for pregnant women is proposed to resolve the problems of low accuracy of fetal movement detection by fetal heart monitor, difficulties of fetal movement monitoring by pregnant women in person, and inability to monitor for long periods of time by ultrasonic Doppler imaging device. The overall software design flow of the system is proposed after determining the overall structure of the system based on symmetric sensor. The application circuit of the three-axis acceleration sensor MC3672 and its supporting sensor data collection program are designed, and the application circuit of the main control chip NRF52840 with Cortex-M4 core is analyzed. The function of data collection and algorithm recognition result transfer to a smartphone is realized through the fetal movement recognition and algorithm design and Bluetooth communication design. Finally, the system test scheme is introduced, which involves performing functional tests on four healthy pregnant volunteers and analyzing the results. The experimental results show that the average recognition rate and correct rate of this system to recognize fetal movement is 89.74% when using the real fetal movement actively perceived by pregnant women as the standard, achieving a domestic and wearable design of fetal movement monitoring device for pregnant women that can be used to analyze and predict the fetal health condition.

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.

Risk factors for late preterm and term stillbirth: A secondary analysis of an individual participant data meta-analysis

OBJECTIVE

Identify independent and novel risk factors for late-preterm (28-36 weeks) and term (≥37 weeks) stillbirth and explore development of a risk-prediction model.

DESIGN

Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors.

SETTING

An IPD database from five case-control studies in New Zealand, Australia, the UK and an international online study.

POPULATION

Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257).

METHODS

Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second-hand smoking, antenatal-care utilisation, and detailed fetal movement and sleep variables.

MAIN OUTCOME MEASURES

Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth.

RESULTS

After model building, 575 late-stillbirth cases and 1541 controls from three contributing case-control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hiccoughs, increasing strength, frequency or vigorous fetal movements) aOR of stillbirth. Poor antenatal-care utilisation increased risk while more-than-adequate care was protective. The area-under-the-curve was 0.84 (95% CI 0.82-0.86).

CONCLUSIONS

Similarities in risk factors for late-preterm and term stillbirth suggest the same approach for risk-assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal-care utilisation could be valuable in late-stillbirth risk assessment.

Expectant management of advanced abdominal pregnancies: Is it justifiable?

OBJECTIVE

To evaluate the outcome of a case series of women with advanced abdominal pregnancies (AAP) who underwent expectant management.

STUDY DESIGN

A retrospective study that utilized prospective data of 46 women who were admitted for expectant management at a tertiary hospital in Durban, South Africa. All data was analyzed descriptively and presented in percentages.

RESULTS

The average period of expectant management was 27 days; thirty-three (72 %) of the 46 women were discharged from the hospital with live babies. There were 11 (24 %) neonatal deaths and two cases of stillbirths. There were no maternal deaths and morbidity was minimal.

CONCLUSION

When diagnosed after the 24th week of gestation, an option is expectant management which includes careful patient selection, prolonged hospitalization, and close antenatal fetal and maternal surveillance to achieve fetal viability. Management by experienced clinicians and a multidisciplinary team in a tertiary institution is recommended. Informed consent needs to take into consideration the risks with interventional laparotomy, social separation from family and friends, and the guarded perinatal outcome.

Maternal perception of fetal movements: Views, knowledge and practices of women and health providers in a low-resource setting

The study assessed perception, knowledge, and practices regarding maternal perception of fetal movements (FMs) among women and their healthcare providers in a low-resource setting. Semi-structured interviews, questionnaires and focus group discussions were conducted with 45 Zanzibar women (18 antenatal, 28 postpartum) and 28 health providers at the maternity unit of Mnazi Mmoja Hospital, Zanzibar, Tanzania. Descriptive and thematic analyses were conducted to systematically extract subthemes within four main themes 1) knowledge/awareness, 2) behavior/practice, 3) barriers, and 4) ways to improve practice. Within the main themes it was found that 1) Women were instinctively aware of (ab)normal FM-patterns and healthcare providers had adequate knowledge about FMs. 2) Women often did not know how to monitor FMs or when to report concerns. There was inadequate assessment and management of (ab)normal FMs. 3) Barriers included the fact that women did not feel free to express concerns. Healthcare providers considered FM-awareness among women as low and unreliable. There was lack of staff, time and space for FM-education, and no protocol for FM-management. 4) Women and health providers recognised the need for education on assessment and management of (ab)normal FMs. In conclusion, women demonstrated adequate understanding of FMs and perceived abnormalities of these movements better than assumed by health providers. There is a need for more evidence on the effect of improving knowledge and awareness of FMs to construct evidence-based guidelines for low resource settings.

Fetal movements: A framework for antenatal conversations

BACKGROUND

Presentations for decreased fetal movements comprise a significant proportion of acute antenatal assessments. Decreased fetal movements are associated with increased likelihood of adverse pregnancy outcomes including stillbirth. Consensus-based guidelines recommend pregnant women routinely receive information about fetal movements, but practice is inconsistent, and the information shared is frequently not evidence-based. There are also knowledge gaps about the assessment and management of fetal movement concerns. Women have indicated that they would like more accurate information about what to expect regarding fetal movements.

DISCUSSION

Historically, fetal movement information has focussed on movement counts. This is problematic, as the number of fetal movements perceived varies widely between pregnant women, and no set number of movements has been established as a reliable indicator of fetal wellbeing. Of late, maternity care providers have also advised women to observe their baby's movement pattern, and promptly present if they notice a change. However, normal fetal movement patterns are rarely defined. Recently, a body of research has emerged relating to maternal perception of fetal movement features such as strength, presence of hiccups, and diurnal pattern as indicators of fetal wellbeing in addition to frequency.

CONCLUSION

Sharing comprehensive and gestation-appropriate information about fetal movements may be more satisfying for women, empowering women to identify for themselves when their baby is doing well, and importantly when additional assessment is needed. We propose a conversational approach to fetal movement information sharing, focusing on fetal movement strength, frequency, circadian pattern, and changes with normal fetal development, tailored to the individual.

Computation of Fetal Kicking in Various Fetal Health Examinations: A Systematic Review

Fetal movement has always been considered an essential indicator to evaluate the health of the unborn fetus. Many factors affect fetal movement. The frequency of fetal kicking is an important measurement of whether fetal development is progressing and healthy. Various instruments and methods of detecting fetal movement have been used and each method has its advantages and disadvantages. Although limited by the fetal environment in utero, the finite element method and musculoskeletal model can be used to calculate fetal lower limb movement. This review aims to summarize the current detection techniques for fetal movement, especially in the lower limbs. These will be outlined by describing the different measurements of fetal movement, and the related biomechanical analyses of fetal lower limb skeletogenesis and the associated muscular development to better evaluate and calculate the movements of the fetus in the womb.

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.

Passive Fetal Movement Recognition Approaches Using Hyperparameter Tuned LightGBM Model and Bayesian Optimization

Fetal movement is an important clinical indicator to assess fetus growth and development status in the uterus. In recent years, a noninvasive intelligent sensing fetal movement detection system that can monitor high-risk pregnancies at home has received a lot of attention in the field of wearable health monitoring. However, recovering fetal movement signals from a continuous low-amplitude background that is heavily contaminated with noise and recognizing real fetal movements is a challenging task. In this paper, fetal movement can be efficiently recognized by combining the strength of Kalman filtering, time and frequency domain and wavelet domain feature extraction, and hyperparameter tuned Light Gradient Boosting Machine (LightGBM) model. Firstly, the Kalman filtering (KF) algorithm is used to recover the fetal movement signal in a continuous low-amplitude background contaminated by noise. Secondly, the time domain, frequency domain, and wavelet domain (TFWD) features of the preprocessed fetal movement signal are extracted. Finally, the Bayesian Optimization algorithm (BOA) is used to optimize the LightGBM model to obtain the optimal hyperparameters. Through this, the accurate prediction and recognition of fetal movement are successfully achieved. In the performance analysis of the Zenodo fetal movement dataset, the proposed KF + TFWD + BOA-LGBM approach's recognition accuracy and F1-Score reached 94.06% and 96.85%, respectively. Compared with 8 existing advanced methods for fetal movement signal recognition, the proposed method has better accuracy and robustness, indicating its potential medical application in wearable smart sensing systems for fetal prenatal health monitoring.

A better understanding of the association between maternal perception of foetal movements and late stillbirth-findings from an individual participant data meta-analysis

BACKGROUND

Late stillbirth continues to affect 3-4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings. Reduced foetal movements are frequently reported by women prior to foetal death, but there remains a poor understanding of the reasons and how to deal with this symptom clinically, particularly during the preterm phase of gestation. We aimed to determine which women are at the greatest odds of stillbirth in relation to the maternal report of foetal movements in late pregnancy (≥ 28 weeks' gestation).

METHODS

This is an individual participant data meta-analysis of all identified case-control studies of late stillbirth. Studies included in the IPD were two from New Zealand, one from Australia, one from the UK and an internet-based study based out of the USA. There were a total of 851 late stillbirths, and 2257 controls with ongoing pregnancies.

RESULTS

Increasing strength of foetal movements was the most commonly reported (> 60%) pattern by women in late pregnancy, which were associated with a decreased odds of late stillbirth (adjusted odds ratio (aOR) = 0.20, 95% CI 0.15 to 0.27). Compared to no change in strength or frequency women reporting decreased frequency of movements in the last 2 weeks had increased odds of late stillbirth (aOR = 2.33, 95% CI 1.73 to 3.14). Interaction analysis showed increased strength of movements had a greater protective effect and decreased frequency of movements greater odds of late stillbirth at preterm gestations (28-36 weeks' gestation). Foetal hiccups (aOR = 0.45, 95% CI 0.36 to 0.58) and regular episodes of vigorous movement (aOR = 0.67, 95% CI 0.52 to 0.87) were associated with decreased odds of late stillbirth. A single episode of unusually vigorous movement was associated with increased odds (aOR = 2.86, 95% CI 2.01 to 4.07), which was higher in women at term.

CONCLUSIONS

Reduced foetal movements are associated with late stillbirth, with the association strongest at preterm gestations. Foetal hiccups and multiple episodes of vigorous movements are reassuring at all gestations after 28 weeks' gestation, whereas a single episode of vigorous movement is associated with stillbirth at term.

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.

Fetal movement counting is associated with the reduction of delayed maternal reaction after perceiving decreased fetal movements: a prospective study

Maternal perception of decreased fetal movement is associated with adverse perinatal outcomes. Although there have been several studies on interventions related to the fetal movements count, most focused on adverse perinatal outcomes, and little is known about the impact of the fetal movement count on maternal behavior after the perception of decreased fetal movement. We investigated the impact of the daily fetal movement count on maternal behavior after the perception of decreased fetal movement and on the stillbirth rate in this prospective population-based study. Pregnant women in Shiga prefecture of Japan were asked to count the time of 10 fetal movements from 34 weeks of gestation. We analyzed 101 stillbirths after the intervention compared to 121 stillbirths before the intervention. In multivariable analysis, maternal delayed visit to a health care provider after the perception of decreased fetal movement significantly reduced after the intervention (aOR 0.31, 95% CI 0.11–0.83). Our regional stillbirth rates in the pre-intervention and post-intervention periods were 3.06 and 2.70 per 1000 births, respectively. Informing pregnant women about the fetal movement count was associated with a reduction in delayed maternal reaction after the perception of decreased fetal movement, which might reduce stillbirths.

Evaluation of Pregnancy Outcomes Among Women With Decreased Fetal Movements

IMPORTANCE

Stillbirth is a devastating pregnancy outcome with far-reaching economic and psychosocial consequences, but despite significant investment, a screening tool for identifying those fetuses at risk for stillbirth remains elusive. Maternal reporting of decreased fetal movements (DFM) has been found to be associated with stillbirth and other adverse perinatal outcomes.

OBJECTIVE

To examine pregnancy outcomes of women presenting with DFM in the third trimester at a tertiary Australian center with a clear clinical management algorithm.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data on all births meeting the inclusion criteria from 2009 through 2019 at Mater Mothers' Hospital in Brisbane, Australia. This is a tertiary center and Australia's largest maternity hospital. All singleton births without a known congenital anomaly after 28 weeks' gestation were included. Among 203 071 potential participants identified from the hospital database, 101 597 individuals met the eligibility criteria. Data analysis was performed from May through September 2020.

EXPOSURE

Presentation to hospital with DFM after 28 weeks gestation.

MAIN OUTCOMES AND MEASURES

The primary outcome of this study was the incidence of stillbirth. Multivariate analysis was undertaken to determine the association between DFM and stillbirth, obstetric intervention, and other adverse outcomes, including being born small for gestational age (SGA) and a composite adverse perinatal outcome (at least 1 of the following: neonatal intensive care unit admission, severe acidosis [ie, umbilical artery pH <7.0 or base excess -12.0 mmol/L or less], 5-minute Apgar score <4, or stillbirth or neonatal death). The hypothesis being tested was formulated prior to data collection.

RESULTS

Among 101 597 women with pregnancies that met the inclusion criteria, 8821 (8.7%) presented at least once with DFM and 92 776 women (91.3%) did not present with DFM (ie, the control population). Women presenting with DFM, compared with those presenting without DFM, were younger (mean [SD] age, 30.4 [5.4] years vs 31.5 [5.2] years; P < .001), more likely to be nulliparous (4845 women [54.9%] vs 42 210 women [45.5%]; P < .001) and have a previous stillbirth (189 women [2.1%] vs 1156 women [1.2%]; P < .001), and less likely to have a previous cesarean delivery (1199 women [13.6%] vs 17 444 women [18.8%]; P < .001). During the study period, the stillbirth rate was 2.0 per 1000 births after 28 weeks' gestation. Presenting with DFM was not associated with higher odds of stillbirth (9 women [0.1%] vs 185 women [0.2%]; adjusted odds ratio [aOR], 0.54; 95% CI, 0.23-1.26, P = .16). However, presenting with DFM was associated with higher odds of a fetus being born SGA (aOR, 1.14; 95% CI, 1.03-1.27; P = .01) and the composite adverse perinatal outcome (aOR, 1.14; 95% CI, 1.02-1.27; P = .02). Presenting with DFM was also associated with higher odds of planned early term birth (aOR, 1.26; 95% CI, 1.15-1.38; P < .001), induction of labor (aOR, 1.63; 95% CI, 1.53-1.74; P < .001), and emergency cesarean delivery (aOR, 1.18; 95% CI, 1.09-1.28; P < .001).

CONCLUSIONS AND RELEVANCE

The presence of DFM is a marker associated with increased risk for a fetus. This study's findings of a nonsignificantly lower rate of stillbirth among women with DFM may be reflective of increased community awareness of timely presentation to their obstetric care clinician when concerned about fetal movements and the benefits of tertiary level care guided by a clear clinical management protocol. However, DFM was associated with increased odds of an infant being born SGA, obstetric intervention, early term birth, and a composite of adverse perinatal outcomes.

Assessing fetal movements in pregnancy: A qualitative evidence synthesis of women's views, perspectives and experiences

Background

Raising awareness of the importance of fetal movements (FMs) and advising women on the appropriate action to take if they experience reduced FMs, is important for minimising or avoiding adverse perinatal outcomes. To gain insight and understanding of women’s perspectives of assessing FMs in pregnancy, we conducted a qualitative evidence synthesis.

Methods

A qualitative evidence synthesis using thematic synthesis was conducted. Studies were eligible if they included pregnant women who were at least 20 weeks gestation and reported qualitative data from women on assessing FMs in pregnancy. MEDLINE, CINAHL, EMBASE, PsycINFO and Social Science Citation Index, from inception to July 2020, were searched. The methodological quality of included studies was assessed by at least two reviewers using an Evidence for Policy and Practice Information (EPPI)-Centre quality assessment tool. Data synthesis, using the Thomas and Harden framework, involved line by line coding of extracted data, establishing descriptive themes, and determining analytical themes. Confidence in the findings was assessed using GRADE CER-Qual.

Results

Nine studies, involving 2193 women, were included in the review. The methodological quality of the studies was overall generally high. The synthesis revealed three dominant themes, and seven sub-themes that reflected women’s perspectives of assessing FMs in pregnancy. These were; 1) How women engage with FMs, with subthemes of informal engagement, formal engagement, and strategies to stimulate FMs; 2) ‘ … like a feather inside my belly’ - articulating and describing FMs, with sub-themes of sensations associated with FMs and timing and frequency of FMs; and 3) FMs and help/health seeking, with sub-themes of information sources and interacting with healthcare professionals. Confidence in the findings was either high or moderate, although two findings were rated low confidence and one very low.

Conclusion

This qualitative evidence synthesis reveals that women informally engage with FMs during pregnancy. Women commonly adopt strategies to stimulate FMs when concerned. The use of the internet was a common source of obtaining information regarding FMs. Women require better support when contacting healthcare professionals about FMs. As only three of the nine included studies were exclusively qualitative in design, further qualitative studies exploring women’s perspective of assessing FMs in pregnancy are required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03667-y.

Potentially preventable antepartum stillbirths in a high-resource setting: a prospective audit-based study

OBJECTIVES

The primary objective was the identification of sub-standard care in antepartum stillbirths in Emilia-Romagna Region (Italy), hence the number of potentially preventable cases. Secondly, we seek to evaluate any association between inadequate care and either risk factors for stillbirth or causes of death.

STUDY DESIGN

This study was based on prospectively-collected data in an institutional stillbirth audit project, involving all 29 hospital with a maternity unit in Emilia-Romagna Region. For each stillbirth occurred in the area from 2014 to the first semester of 2019 the same diagnostic workup was performed and a clinical record with data about mother and stillborn was completed. Every case was discussed in a multidisciplinary local audit to assess both the cause of death and the quality of care. Two aspects of care quality were evaluated: clinical management and women's access to care. Data were then reviewed by the Regional Audit Group.

RESULTS

Elements of inadequate care were identified in 56 out of 524 (10.7 %) fetal deaths. Non-Italian women and pregnancies with fetal growth restriction had double the risk of having received inadequate care during pregnancy, compared to Italian women (aOR 2.0, 95 % CI 1.1-3.6) and a normally developing fetus (aOR 2.0, 95 % CI 1.1-4.1), respectively. Women whose stillbirth was caused by maternal disorders were at higher risk for inadequate care compared to women who had stillbirth explained by other cause (aOR 5.89, 95 %CI 2.2-15.4). Sub-optimal clinical management and barriers to access to care were observed to equal extents. Inappropriate ultrasound monitoring was the most frequent suboptimal care element.

CONCLUSIONS

About one out of ten stillbirths was potentially preventable. Interventions to reduce stillbirth occurrence in our high-resource setting should focus on appropriate diagnosis and management of maternal disorders and fetal growth restriction, as well as improving access to antenatal care.

Current Resources for Evidence-Based Practice, November 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of diversity in the maternity care workforce and commentaries on reviews focused on burnout in midwifery and a cross-national comparison of guidelines for uncomplicated childbirth.

A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method

Background

Maternal perception of decreased fetal movements is commonly used to assess fetal well-being. However, there are different opinions on whether healthcare professionals should encourage maternal observation of fetal movements, as researchers claim that raising awareness increases unnecessary interventions, without improving perinatal health. We aimed to investigate whether cesarean sections and labor induction increase by raising women’s awareness of fetal movements through Mindfetalness. Further, we aimed to study perinatal health after implementing Mindfetalness in maternity care.

Methods

In a cluster randomized controlled trial, 67 maternity clinics were allocated to Mindfetalness or routine care. In the Mindfetalness group, midwives distributed a leaflet telling the women to focus on the character, strength and frequency of the fetal movements without counting each movement. The instruction was to do so for 15 min daily when the fetus was awake, from gestational week 28 until birth. In this sub-group analysis, we targeted women born in Sweden giving birth from 32 weeks’ gestation. We applied the intention-to-treat principle.

Results

The Mindfetalness group included 13,029 women and the Routine-care group 13,456 women. Women randomized to Mindfetalness had less cesarean sections (18.4% vs. 20.0%, RR 0.92, CI 0.87–0.97) and labor inductions (19.2% vs. 20.3%, RR 0.95, CI 0.90–0.99) compared to the women in the Routine-care group. Less babies were born small for gestational age (8.5% vs. 9.3%, RR 0.91, CI 0.85–0.99) in the Mindfetalness group. Women in the Mindfetalness group contacted healthcare due to decreased fetal movements to a higher extent than women in the Routine care group (7.8% vs. 4.3%, RR 1.79, CI 1.62–1.97). The differences remain after adjustment for potential confounders.

Conclusions

Raising awareness about fetal movements through Mindfetalness decreased the rate of cesarean sections, labor inductions and small-for-gestational age babies.

Trial registration

ClinicalTrials.gov (NCT02865759). Registered 12 August 2016, www.clinicaltrials.gov.