Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement

[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.

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.

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.

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.

The effects of lockdown during the COVID-19 pandemic on fetal movement profiles

PURPOSE

The current study investigated the direct impact of the COVID-19 lockdown on fetal movements, addressing a critical research gap. While previous research has predominantly examined the effects of lockdown on maternal health and postnatal outcomes, little attention has been paid to the direct consequences on fetal well-being as indicated by their movement profile.

METHODS

We conducted analysis of movement profiles in 20 healthy fetuses during the COVID-19 pandemic lockdown (third national UK lockdown period between January and March 2021) and compared them with 20 healthy fetuses from pre-covid pregnancies, all at 32 weeks gestation. We controlled for maternal stress, depression, and anxiety.

RESULTS

Pregnant mothers during pre-covid compared with those during the COVID-19 lockdown reported similar levels of stress (p = 0.47), depression (p = 0.15), and anxiety (p = 0.07). Their fetuses, however, differed in their movement profiles with mouth movement frequencies significantly higher during COVID-19 lockdown (COVID-19 lockdown: mean of 5.909) compared to pre-Covid pregnancies (mean of 3.308; p = 0.029). Furthermore, controlling for maternal anxiety a regression analysis indicated that frequency of fetal mouth movements (p = 0.017), upper face movements (p = 0.008), and touch movements (p = 0.031) were all significantly higher in fetuses observed during lockdown compared to fetuses before the Covid period.

CONCLUSION

Fetuses show an effect of lockdown independent of maternal anxiety, stress, or depression. These findings contribute to our understanding of fetal development during extraordinary circumstances, raising questions about the potential effects of having to stay indoors during lockdowns.

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.

Diminution des mouvements actifs fœtaux: Profil épidémiologique et issue de la grossesse

INTRODUCTION

Decreased fetal movement is a common reason for consultation. It can reveal an intrauterine death or fetal distress.

AIM

To evaluate the epidemiological profile of decreased fetal movement and to identify the predictive factors of poor pregnancy outcome.

METHODS

We performed a retrospective and descriptive study in the department of Maternity between January 2015 and December 2019 including patients hospitalized for decreased fetal movements.

RESULTS

The study included 150 patients with a mean age of 30.7±5.8 years. The patients were primiparous in 45.3% of cases. The mean term of pregnancy was 37.17±2.97 weeks. Cardiotocography was pathological in 22.7% of patients. The delivery rate during the hospitalization was 87.3% with a mean term of 37.9±2.5 SA. Poor pregnancy outcome was noted in 22.1% of cases. The identified predictive factors of poor pregnancy outcome were: gestational term less than 37 weeks (ORa=9.42), insufficient prenatal care (ORa=2.85), delayed maternal reporting of decreased fetal movement (ORa=1.29), complications during pregnancy (ORa=3.01), small symphysiofundal height for gestational age (ORa=6.17), pathological cardiotocography (ORa=1.66), fetal growth restriction (ORa=6.17), abnormal Umbilical Artery Doppler (ORa=6.51).

CONCLUSION

Decreased fetal movement can be a false alarm but it is important to identify predictive factors of poor pregnancy outcome to recognize patients at increased risk and optimize their management.

A systematic review of behaviour change techniques used in the context of stillbirth prevention

BACKGROUND

Stillbirth is one of the most devastating pregnancy outcomes that families can experience. Previous research has associated a wide range of risk factors with stillbirth, including maternal behaviours such as substance use, sleep position and attendance and engagement with antenatal care. Hence, some preventive efforts have been focused on tackling the behavioural risk factors for stillbirth. This study aimed to identify the Behaviour Change Techniques (BCTs) used in behaviour change interventions tacking behavioural risk factors for stillbirth such as substance use, sleep position, unattendance to antenatal care and weight management.

STUDY DESIGN

A systematic review of the literature was conducted in June 2021 and updated in November 2022 in five databases: CINHAL, Psyhinfo, SociIndex, PubMed and Web of Science. Studies published in high-income countries describing interventions designed in the context of stillbirth prevention, reporting stillbirth rates and changes in behaviour were eligible for inclusion. BCTs were identified using the Behaviour Change Technique Taxonomy v1.

RESULTS

Nine interventions were included in this review identified in 16 different publications. Of these, 4 interventions focused on more than one behaviour (smoking, monitoring fetal movements, sleep position, care-seeking behaviours), one focused on smoking, three on monitoring fetal movements and one on sleep position. Twenty-seven BCTs were identified across all interventions. The most commonly used was "Information about health consequences" (n = 7/9) followed by "Adding objects to the environment" (n = 6/9). One of the interventions included in this review has not been assessed for efficacy yet, of the remaining eight, three showed results in the reduction of stillbirth rates. and four interventions produced behaviour change (smoking reductions, increased knowledge, reduced supine sleeping time).

CONCLUSIONS

Our findings suggest that interventions designed to date have limited effects on the rates of stillbirth and utilise a limited number of BCTs which are mostly focused on information provision. Further research is necessary to design evidence base behaviour change interventions with a greater focus to tackle all the other factors influencing behaviour change during pregnancy (e.g.: social influence, environmental barriers).

Guideline No. 441: Antenatal Fetal Health Surveillance

OBJECTIVE

To summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality.

TARGET POPULATION

Pregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation.

OPTIONS

To use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation.

OUTCOMES

Early identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery.

BENEFITS, HARMS, AND COSTS

Antenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm.

EVIDENCE

Medline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. This document represents an abstraction of the evidence rather than a methodological review.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique no 441 : Surveillance prénatale du bien-être fœtal

OBJECTIF

Résumer les données probantes actuelles et formuler des recommandations pour la surveillance prénatale du bien-être fœtal afin de détecter les facteurs de risque périnatal et toute potentielle décompensation fœtale et de permettre une intervention rapide en prévention de la morbidité et la mortalité périnatales.

POPULATION CIBLE

Personnes enceintes avec ou sans facteurs maternels, fœtaux ou gravidiques associés à des risques périnataux et à la décompensation fœtale.

OPTIONS

Utiliser des examens prénataux par technologie de base et/ou avancée en fonction des facteurs de risque de décompensation fœtale. RéSULTATS: La reconnaissance précoce de toute décompensation fœtale potentielle permet d'intervenir de façon à favoriser l'adaptation fœtale pour maintenir le bien-être ou à accélérer l'accouchement. BéNéFICES, RISQUES ET COûTS: Chez les personnes enceintes ayant des facteurs de risque périnatal confirmés, la surveillance du bien-être fœtal contribue à réduire le risque d'issue défavorable. Compte tenu du taux élevé de faux positifs, la surveillance du bien-être fœtal peut augmenter le risque d'interventions inutiles, ce qui peut avoir des effets nuisibles, dont l'anxiété parentale, l'accouchement prématuré ou assisté et l'utilisation accrue des ressources de soins de santé. L'optimisation des protocoles de surveillance d'après des pratiques fondées sur des données probantes peut améliorer les issues périnatales et réduire les effets nuisibles. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à janvier 2022, à partir de termes MeSH et de mots clés liés à la grossesse, à la surveillance fœtale, aux mouvements fœtaux, à la mortinaissance, aux complications de grossesse et à l'échographie fœtale. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les membres de l'équipe de soins qui prodiguent des soins ou donnent de l'information aux patientes en obstétrique, notamment les spécialistes en médecine fœto-maternelle, les obstétriciens, les médecins de famille, les sages-femmes, les infirmières, les infirmières praticiennes et les radiologistes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

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.

Fetal Movement Counting in Prolonged Pregnancies: The COMPTAMAF Prospective Randomized Trial

In prolonged pregnancies, the risks of neonatal morbidity and mortality are increased. The aim of this trial was to assess the benefits of maternal information about fetal movement (FM) counting on neonatal outcomes in prolonged pregnancy. It was a prospective, single center, randomized, open-label study conducted from October 2019 to March 2022. Intention-to-treat analyses were performed on 278 patients randomized into two 1:1 groups (control group and FM counting group). The primary outcome was a composite score of neonatal morbidity (presence of two of the following items: fetal heart rate abnormality at delivery, Apgar score of <7 at 5 min, umbilical cord arterial pH of <7.20, and acute respiratory distress with mutation in neonatal intensive care unit). There was no significant difference between the two groups in the rate of neonatal morbidity (14.0% in the FM counting group versus 22.9% in the standard information group; p = 0.063; OR 0.55, 95% CI 0.29−1.0). In this study, fetal movement counting for women in prolonged pregnancy failed to demonstrate a significant reduction in adverse neonatal outcomes.

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.

Facility-based stillbirth surveillance review and response: an initiative towards reducing stillbirths in a tertiary care hospital of India

OBJECTIVES

India has the highest number of stillbirths in the world in 2019, with an estimated stillbirth rate of 13.9 per 1,000 births. Towards better identification and documentation, a stillbirth surveillance pilot was initiated with the World Health Organization Southeast Asia collaboration in Northern India in 2014. This study aimed to assess whether stillbirth surveillance is feasible and whether this approach provides sufficient information to develop strategies for prevention.

METHODS

This study followed the framework provided in "WHO Making Every Baby Count" in which mortality audit is conducted in six steps; (1) identifying cases; (2) collecting information; (3) analysis; (4) recommending solutions; (5) implementing solutions; and (6) evaluation.

RESULTS

A total of 5,284 births were examined between December 2018 and November 2019; 266 stillbirths were identified, giving a stillbirth rate of 50.6 per 1,000 births in a tertiary care referral hospital of northern India. Out of 266 stillbirths, 223 cases were reviewed and recommendations were formulated to strengthen obstetric triage, implementing fetal growth charts, strengthen the existing referral system and improve the communication skills of health care providers for better compliance with clinical practice guidelines.

CONCLUSIONS

Conducting stillbirth surveillance review and the response of cases in low-middle income countries setting is feasible. As countries progress towards ending preventable mortality, this has the potential to serve as a key process in improving evidence-based and context-specific planning and preventive strategies towards improving the quality of care.

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.

Cerebroplacental ratio and neonatal outcome in low-risk pregnancies with reduced fetal movement: A prospective study

Objective

To evaluate the effectiveness of the cerebroplacental ratio (CPR) in predicting poor outcomes in low-risk pregnancies with reduced fetal movements (RFMs).

Study Design

This prospective study included singleton pregnancies at 28–40 weeks, presenting with RFM but no additional risk factors. Sub analysis was performed for pregnancies between 36 and 40 weeks. Umbilical artery (UA) and middle cerebral artery (MCA) pulsatility indices (PIs) were measured, and the MCA-PI to UA-PI ratio (CPR) was calculated. Mode of delivery, gestational age, fetal monitoring category, Apgar score at 1 and 5 min, birth weight, presence of meconium, umbilical artery pH, and neonatal intensive care unit (NICU) admission were recorded. Women with good and poor outcomes were compared with doppler indices and pregnancy characteristics.

Results

Of 96 women, 86 had good outcomes. There was no significant difference in UA-PI (0.871 ± 0.171 vs. 0.815 ± 0.179, P = 0.446), MCA-PI (1.778 ± 0.343 vs. 1.685 ± 0.373, P = 0.309), or CPR (2.107 ± 0.635 vs. 2.09 ± 0.597, P = 0.993) between the poor and good outcome groups. No difference was found in the location of the placenta, biophysical profile (BPP) score, fetal sex, or amniotic fluid index (AFI) at the time of presentation. The proportion of nulliparous patients in the poor outcome group was higher than that of multiparous patients. Sub analysis for 36–40 weeks revealed the same results; no significant difference in UA-PI (0.840 ± 0.184 Vs 0.815 ± 0.195, P = 0.599), MCA-PI (1.724 ± 0.403 vs. 1.626 ± 0.382, P = 0.523), or CPR (2.14 ± 0.762 vs. 2.08 ± 0.655, P = 0.931) between poor and good outcome groups.

Conclusions

CPR is not predictive of neonatal outcome in low-risk pregnancies with RFM. However, a higher proportion of poor outcomes in nulliparous women warrants further investigation.

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.

How and when to recommend delivery of a growth-restricted fetus: A review

Clinicians consider a range of variables when formulating decisions regarding the diagnosis, monitoring plan, and ultimately the decision to recommend the delivery of a growth-restricted fetus. The differential diagnosis of a pathological fetal growth pattern is initially considered via the history, a physical and laboratory examination of the pregnant person, as well as a comprehensive fetal ultrasound examination. These factors allow a broad distinction between pre-existing disease in the pregnant person, constitutionally small normal growth, placenta-mediated Fetal Growth Restriction (FGR), and intrinsic fetal disease. Most commonly, pathological growth restriction is mediated by underlying placental diseases, of which maternal vascular malperfusion is the most common, and often results in co-existent hypertension. A program of combined monitoring of the pregnant person and fetus, comprising hypertension assessment, and serial fetal ultrasound, including Doppler studies is then instituted, and may be combined with biochemical markers, such as Placental Growth Factor, for greater clinical precision. Recommendations on timing to deliver the growth-restricted fetus worldwide are converging, with similar guidance from clinical practice guidelines informed by high-quality Randomized Controlled Trials (RCTs) and large cohort studies. In most instances, it is reasonable to recommend delivery of all growth-restricted fetuses by approximately 38 weeks. Timing of delivery should take into consideration both short-term neonatal outcomes and long-term outcomes at school age. Mode of delivery is based on many factors, and induction of labor is a safe approach, especially after 34 weeks. Mechanical methods of induction may be preferred to pharmacologic methods, although both have a role and the choice of method is based on individualized assessment. Elective Cesarean birth thereby bypassing fetal stress during labor, is recommended in preterm growth-restricted fetuses with signs of adaptive fetal compromise, especially when ductus venosus flow is abnormal, or a contraction stress test is positive.

Doppler Ultrasonography of the Fetal Tibial Artery in High-Risk Pregnancy and Its Value in Predicting and Monitoring Fetal Hypoxia in IUGR Fetuses

Background and Objectives: Intrauterine growth restriction (IUGR) is the term used to describe a fetus whose estimated weight is less than the 10th percentile of its age growth curve. IUGR is the second most common cause of perinatal death. In many cases there is a deficiency in the standardization of optimal management, prenatal follow-up and timing of delivery. Doppler examination is the most sensitive test that can assess the condition of the fetus and indicate fetal intrauterine hypoxia. Numerous studies of the fetal intrauterine state focus on the umbilical artery and the fetal cerebral blood vessels, while the peripheral arteries have so far received insufficient attention. Materials and Methods: We present a case of an IUGR fetus monitored with a non-stress test (NST) and a Doppler examination of the fetal arteries (tibial, umbilical, middle cerebral and uterine) and the ductus venosus. In this case the first early sign of fetal hypoxia was revealed by blood flow changes in the tibial artery. Results: We hypothesize that peripheral vascular changes (in the tibial artery) may more accurately reflect the onset of deterioration in the condition of the IUGR fetus, such that peripheral blood flow monitoring ought to be employed along with other techniques already in use. Conclusion: This paper describes the clinical presentation of an early detection of late IUGR hypoxia and claims that blood flow changes in the tibial artery signal the worsening of the fetus’s condition.

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.

Knowing your audience: Investigating stillbirth knowledge and perceptions in the general population to inform future public health campaigns

BACKGROUND

The prevalence of stillbirth in many high income countries like Australia has remained unchanged for over 30 years. The 2018 Australian government Senate Select Committee on Stillbirth Research and Education highlighted the need for a public health campaign to encourage public conversations and increase awareness. However, there is little evidence about the community's knowledge and perceptions towards pregnancy and stillbirth, nor their aspirations for a public health campaign.

AIMS

To assess the general knowledge, perceptions, myths and attitudes towards stillbirth to inform future public health campaigns.

METHODS

Australian participants (n = 344; predominately women n = 294 (85.5%)) were recruited via Facebook.com. They completed a cross-sectional online survey designed to assess their knowledge of pregnancy and stillbirth, with additional questions on socio-demographic characteristics.

RESULTS

Stillbirth knowledge and awareness of incidence was low in this sample. Prominent myths, such as baby runs out of room in the uterus (n = 112, 33%) and baby slows down when preparing for labour (n = 24, 27%) were endorsed. Only 25% (n = 85) knew the prevalence of stillbirth in Australia (six per day). Almost two-thirds (n = 205; 62%) agreed that there needs to be a public health campaign, however one in five (n = 65; 20%) were concerned that talking about stillbirth with pregnant women may cause them to worry.

DISCUSSION AND CONCLUSION

Our findings reinforce the need for a targeted campaign, which educates the general population about the definition and prevalence of stillbirth, stillbirth risks and modifiable health behaviours. Appropriate messaging should target pregnant women during antenatal care as well as their support and care systems (family, friends, and care providers).

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

OBJECTIVES

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

DESIGN

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

SETTING

67 maternity clinics and 6 obstetrical clinics in Sweden.

PARTICIPANTS

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

METHODS

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

OUTCOME MEASURES

Predictors for contacting healthcare due to decreased fetal movements.

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

NCT02865759.

Evaluation of Movements Matter: A social media and hospital-based campaign aimed at raising awareness of decreased fetal movements

BACKGROUND

The Movements Matter campaign aimed to raise awareness of decreased fetal movements (DFM) among pregnant women and inform clinicians of best practice management.

AIM

To conduct a process evaluation of campaign implementation, and an impact evaluation of the campaign's effects on knowledge and experiences of pregnant women, and attitudes and practices of clinicians in relation to DFM.

METHODS

This study used a cross-sectional before-after design. Pregnant women and clinicians were sampled at five hospitals. Women were surveyed about their knowledge of DFM, and actions to take if they noticed DFM. Clinicians were asked about their current practices and attitudes about informing women about DFM. Logistic regression was used to calculate campaign effects on outcome measures.

RESULTS

The Movements Matter campaign reached 653 262 people on social media, as well as being covered on news media and popular women's websites. The evaluation surveyed 1142 pregnant women pre-campaign and 473 post-campaign, and 372 clinicians pre-campaign and 149 post-campaign. Following the campaign, women were more likely to be aware that babies should move the same amount in late pregnancy (adjusted odds ratio (aOR) 1.81, 95% CI 1.43-2.27), and were more likely to contact their health service immediately if their baby was moving less (aOR 1.52, 95% CI 1.22-1.91). Clinicians were 2.84 times more likely to recommend women should come in for assessment if they experience DFM (95% CI 1.35-5.97).

CONCLUSIONS

This evaluation has shown that a campaign using social media and in-hospital education materials led to some increases in knowledge about fetal movements among pregnant women.

FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

Fetal Movement Counting Using Optical Fibre Sensors

Daily fetal movement counting based on maternal perception is widely deployed to monitor fetal wellbeing. However, the counting performed by the mother is prone to errors for various reasons. There are limited devices on the market that can provide reliable and automatic counting. This paper presents a prototype of a novel fetal movement monitoring device based on fibre Bragg grating sensors. Deformation of the skin caused by a fetal movement can lead to a change of the strain and stress on the optical fibre sensors, therefore can induce distortions to the breathing pattern of the mother. In the study data was gathered by the sensors through strain measurement and was post-processed using independent component analysis (ICA) and high-pass filtering to show the instances of the fetal movements. Information gathered during user trials with the prototype suggests that the system detects significantly higher numbers of fetus movements than that observed based on the mother's perception. Among the various techniques available for fetal movement monitoring, fibre optic sensing provides many advantages including multiplex capability, flexibility and minimal size, making the concept an attractive solution for reliable monitoring of antenatal fetal movements.

Could a multidisciplinary regional audit identify avoidable factors and delays that contribute to stillbirths? A retrospective cohort study

Background

The annual rate of stillbirth in Sweden has remained largely unchanged for the past 30 years. In Sweden, there is no national audit system for stillbirths. The aim of the study was to determine if a regional multidisciplinary audit could help in identifying avoidable factors and delays associated with stillbirths.

Methods

Population-based retrospective cohort study.

Settings: Six labour wards in Stockholm County.

Participants: Women delivering a stillbirth > 22 weeks of gestation in Stockholm during 2017.

Intervention: A multidisciplinary team was convened. Each team member independently assessed the medical chart of each case of stillbirth regarding causes and preventability, level of delay, the standard of healthcare provided, the investigation of maternal/foetal diseases and if any recommendations were given for the next pregnancy. A decision was based on the agreement of all five members. If no agreement was reached, a reassessment of the case was done and the medical record was scrutinized again until a mutual decision was made.

Primary outcomes: The frequency of probably/possibly preventable factors associated with a stillbirth and the level of delay (patient/caregiver).

Secondary outcomes: The causes of death, the standard of antenatal/intrapartum/postpartum care, whether a summary of possible causes of the stillbirth was made and if any plans for future pregnancies were noted.

Results

Thirty percent of the stillbirths were assessed as probably/possibly preventable. More frequent ultrasound/clinical check-ups, earlier induction of labour and earlier interventions in line with current guidelines were identified as possibly preventable factors. A possibly preventable stillbirth was more common among non-Swedish-speaking women (p = 0.03). In 15% of the cases, a delay by the healthcare system was identified. Having multiple caregivers, absence of continuity in terms of attending the antenatal clinic and not following the basic monitoring program for antenatal care were also identified as risk factors for a delay.

Conclusion

A national/regional multidisciplinary audit group retrospectively identified factors associated with stillbirth. Access to good translation services or a more innovative approach to the problem regarding communication with mothers could be an important factor to decrease possible patient delays contributing to stillbirths.

Trial registration

NCT04281368.

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 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.

Risk factors for poor neonatal outcome in pregnancies with decreased fetal movements

INTRODUCTION

The incidence of Swedish stillbirths has varied little in the past 40 years, with a reported frequency of 400-450 stillbirths/y (approximately 4‰), despite increased information about fetal movement in the media and awareness among healthcare providers. The objectives of this project were to describe the outcome of pregnancies with reduced fetal movement in a Swedish context and to investigate factors associated with poor neonatal outcome in this group.

MATERIAL AND METHODS

A retrospective cohort study was performed at Soder Hospital, Stockholm, Sweden. All single pregnancies at the hospital from January 2016 to December 2017 presenting with reduced fetal movement after 22 gestational weeks were included in the study. A composite neonatal outcome was constructed: 5-minute Apgar score ≤7, arterial pH in the umbilical cord ≤7.10, transfer to neonatal care unit for further care or intrauterine fetal death.

RESULTS

For women seeking care for reduced fetal movement, the occurrence of composite poor neonatal outcome ranged from 6.2% to 18.4% within different groups. The highest risk for poor neonatal outcome (18.4%) was found in the group of women with a small-for-gestational-age fetus. Another high-risk group (12.8%) was the one comprising women with normal birthweight/large-for-gestational-age fetuses with an in vitro fertilization pregnancy.

CONCLUSIONS

The highest incidence of poor neonatal outcome among women with reduced fetal movement was found in the groups with small-for-gestational-age fetuses in nulliparous and multiparous women. A routine ultrasound assessment for fetal growth in third trimester is supposedly most efficient to identify undiagnosed small for gestational age.

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.

Reduced Fetal Movements and Perinatal Mortality

Introduction:

Counting of fetal movement (FM) during pregnancy is believed to be a method by which a woman estimates the fetal well-being. In 2015, it was estimated that 2.6 million babies had died in utero. A percentage of 30-55% of women who experience an episode of reduced fetal movement (RFM) within a week may face stillbirth.

Aim:

The aim of this review was to assess the impact of reduced fetal movements and of educational interventions on maternal counting of fetal movements on perinatal mortality, perinatal outcome and mode of delivery.

Methods:

A search of electronic databases was conducted for detecting studies that examine the coincidence of reduced fetal movements (RFM) in combination with stillbirth and perinatal morbidity.

Results:

The findings of this review suggest that there is an association between the incidence of stillbirth and the experience of alterations in fetal movements’ quantity and quality in the preceding weeks. Interventions on fetal movement counting, concerning both the number and the density of fetal movements, may reduce the adverse perinatal outcomes to an extent, after informing and making aware of the pregnant women for their meaning.

Conclusion:

Maternity care professionals should: a) inform pregnant women about the importance of FM counting, b) encourage pregnant women to be familiarized on the recognition of theirs’ baby normal pattern of fetal movements and c) alarm women when this pattern changes. Care professionals should emphasize that counting of fetal movements is not related only to movements’ quantity (number) but also to movements’ quality (density).

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.

The outcomes of pregnancies with reduced fetal movements: A retrospective cohort study

INTRODUCTION

The objective of this study was to examine the outcomes and interventions in pregnant women presenting with a perception of reduced fetal movements (RFM), and to determine if repeated episodes of RFM increase the risk of adverse outcomes.

MATERIAL AND METHODS

This was a retrospective cohort study conducted in six NHS hospitals within the Thames Valley network region, UK and one neighboring hospital, an area with approximately 31 000 births annually. All women with a primary presentation of perceived RFM after 24 completed weeks of gestation during the month of October 2016 were included in the study. Prospective records in all units were examined and individual case-notes were reviewed. Pregnancy and neonatal outcomes and their relation with recurrent presentations with RFM were examined using relative risks with 95% CI. The main outcome measures are described. Neonatal outcomes measured were perinatal mortality, neonatal unit admission, abnormal cardiotocography at presentation, a composite severe morbidity outcome of Apgar <7 at 5 minutes or arterial pH <7.0 or encephalopathy, and birthweight. Pregnancy outcomes measured were induction of labor, cesarean section, admission and ultrasound usage rates.

RESULTS

In all, 591 women presented with RFM during the month; using annual hospital birth figures, the incidence of RFM was estimated at 22.6% (range 14.9%-32.5%). More than 1 presentation of RFM occurred in 273 (46.2%). All 3 deaths (0.5%) were at the first presentation. More than 1 presentation was associated with higher induction rates (56.0% vs 31.9%), but no increase in any adverse outcomes including small-for-gestational-age.

CONCLUSIONS

Reduced fetal movements, and recurrent episodes, are common, and lead to considerable resource usage and obstetric intervention. We found no evidence to suggest that recurrent episodes increase pregnancy risk.

Association between maternally perceived quality and pattern of fetal movements and late stillbirth

We investigated fetal movement quality and pattern and association with late stillbirth in this multicentre case-control study. Cases (n = 164) had experienced a non-anomalous singleton late stillbirth. Controls (n = 569) were at a similar gestation with non-anomalous singleton ongoing pregnancy. Data on perceived fetal movements were collected via interviewer-administered questionnaire. We compared categorical fetal movement variables between cases and controls using multivariable logistic regression, adjusting for possible confounders. In multivariable analysis, maternal perception of the following fetal movement variables was associated with decreased risk of late stillbirth; multiple instances of 'more vigorous than usual' fetal movement (aOR 0.52, 95% CI 0.32-0.82), daily perception of fetal hiccups (aOR 0.28, 95%CI 0.15-0.52), and perception of increased length of fetal movement clusters or 'busy times' (aOR 0.23, 95%CI 0.11-0.47). Conversely, the following maternally perceived fetal movement variables were associated with increased risk of late stillbirth; decreased frequency of fetal movements (aOR 2.29, 95%CI 1.31-4.0), and perception of 'quiet or light' fetal movement in the evening (aOR 3.82, 95%CI 1.57-9.31). In conclusion, women with stillbirth were more likely than controls to have experienced alterations in fetal movement, including decreased strength, frequency and in particular a fetus that was 'quiet' in the evening.

A diurnal fetal movement pattern: Findings from a cross-sectional study of maternally perceived fetal movements in the third trimester of pregnancy

BACKGROUND AND OBJECTIVES

Encouraging awareness of fetal movements is a common strategy used to prevent stillbirths. Information provided to pregnant women about fetal movements is inconsistent perhaps due to limited knowledge about normal fetal movement patterns in healthy pregnancies. We aimed to describe maternally perceived fetal movement strength, frequency, and pattern in late pregnancy in women with subsequent normal outcomes.

METHODS

Participants were ≥28 weeks' gestation, with a non-anomalous, singleton pregnancy who had been randomly selected from hospital booking lists and had consented to participate. Fetal movement data was gathered during pregnancy via a questionnaire administered face-to-face by research midwives. Participants remained eligible for the study if they subsequently gave birth to a live, appropriate-for-gestational-age baby at ≥37 weeks.

RESULTS

Participants were 274 women, with normal pregnancy outcomes. The majority (59.3%, n = 162) of women reported during antenatal interview that the strength of fetal movements had increased in the preceding two weeks. Strong fetal movements were felt by most women in the evening (72.8%, n = 195) and at night-time including bedtime (74.5%, n = 199). The perception of fetal hiccups was also reported by most women (78.8%). Women were more likely to perceive moderate or strong fetal movements when sitting quietly compared with other activities such as having a cold drink or eating.

CONCLUSIONS

Our data support informing women in the third trimester that as pregnancy advances it is normal to perceive increasingly strong movement, episodes of movements that are more vigorous than usual, fetal hiccups, and a diurnal pattern involving strong fetal movement in the evening. This information may help pregnant women to better characterise normal fetal movement and appropriately seek review when concerned about fetal movements. Care providers should be responsive to concerns about decreased fetal movements in the evening, as this is unusual.

Increased labor induction and women presenting with decreased or altered fetal movements - a population-based survey

Introduction

Women’s awareness of fetal movements is important as perception of decreased fetal movements can be a sign of a compromised fetus. We aimed to study rate of labor induction in relation to number of times women seek care due to decreased or altered fetal movements during their pregnancy compared to women not seeking such care. Further, we investigated the indication of induction.

Material and methods

A prospective population-based cohort study including all obstetric clinics in Stockholm, Sweden. Questionnaires were distributed to women who sought care due to decreased or altered fetal movements ≥ 28 week’s gestation in 2014, women for whom an examination did not indicate a compromised fetus that required induction of labor or cesarean section when they sought care. Women who gave birth at ≥ 28 weeks’ gestation in 2014 in Stockholm comprises the reference group.

Results

Labor was induced more often among the 2683 women who had sought care due to decreased or altered fetal movements (RR 1.4, 95% CI 1.3–1.5). In women who presented with decreased or altered fetal movements induction of labor occurred more frequently for fetal indication than those with induction of labor and no prior fetal movement presentation (RR 1.6, 95% CI 1.4–1.8). The rate of induction increased with number of times a woman sought care, RR 1.3 for single presentation to 3.2 for five or more.

Conclusions

We studied women seeking care for decreased or altered fetal movements and for whom pregnancy was not terminated with induction or caesarean section. Subsequent (median 20 days), induction of labor and induction for fetal indications were more frequent in this group compared to the group of women with no fetal movement presentations. Among women seeking care for altered or decreased fetal movements, the likelihood of induction of labor increased with frequency of presentation.

Electronic fetal monitoring characteristics of a patient with sudden onset of placental abruption and intrauterine fetal demise: A case report

INTRODUCTION

Placental abruption (PA) is a serious complication of pregnancy, associated with significant perinatal complications, including intrauterine fetal demise (IUFD). Continuous electronic fetal monitoring (EFM) has been widely applied in China in recent decades. Exploration of potentially PA-specific patterns of EFM contributes to early detection of PA occurrence.

PATIENT CONCERNS AND DIAGNOSIS

A 33-year-old woman (gravida 3, para 1) was referred to our hospital at 33 weeks gestation due to non-reassuring fetal heart rate (FHR) pattern, and suffered sudden onset of severe PA and subsequent intrauterine fetal demise.

INTERVENTIONS

We analyzed the characteristics of her non-stress tests (NSTs) 1 day and 10 min before the detection of PA, aiming to explore potentially PA-specific patterns of EFM and provide reference for early detection of asymptomatic PA occurrence in obstetric practice.

OUTCOMES

Unfavored characteristics of FHR patterns before PA onset are analyzed.

CONCLUSION

For those who sense decreased fetal movements (DFMs), a NST and a biophysical profile (BPP) are recommended for exclusion of potential adverse maternal and fetal complications.

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.