Fetal movement counting improved identification of fetal growth restriction and perinatal outcomes--a multi-centre, randomized, controlled trial

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.

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).

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fetal Wellbeing Monitoring – A Review Article

While assessing maternal health is relatively easy, assessing fetal well-being has always been tricky. This has led to tremendous technological development in fetal well-being assessment, thus bridging the gap between biotechnology and antenatal medicine. It is broadly divided into early pregnancy, late pregnancy, and during labour assessment. While the early assessment involves genetic check-ups and malformations, the late pregnancy check-ups aim at delivering a healthy fetus at term by normal vaginal delivery. The early tests can be invasive or non-invasive. Non-invasive include cell-free fetal DNA assessment and fetal cell-based assessment. Invasive tests include amniocentesis and chorionic villous sampling. These are followed by chromosomal microarray and next-generation sequencing. Under this procedure, exome sequencing is done, which is either clinical or whole. Sequencing of the whole genome can also be done. A recent advancement is pre-implantation genetic testing. These are mainly useful in identifying monogenic disorders for which the locus causing disease is identified beyond any doubt. In late pregnancy, the most commonly used test is biophysical. It works on the principle that an increase in the fetal heart rate occurs in conjugation with fetal movements. The next widely employed technology is Doppler, which is used to know fetal heart rates, valve timing intervals, and umbilical artery waveforms. Cardiotocography is also widely used both during pregnancy and during labour. It measures the fetal heart rate while correlating it with uterine contractions. Wireless fetal and maternal heart monitoring and telemonitoring are recent upcoming fields.

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.

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.

Novel non-invasive in-house fabricated wearable system with a hybrid algorithm for fetal movement recognition

Fetal movement count monitoring is one of the most commonly used methods of assessing fetal well-being. While few methods are available to monitor fetal movements, they consist of several adverse qualities such as unreliability as well as the inability to be conducted in a non-clinical setting. Therefore, this research was conducted to design a complete system that will enable pregnant mothers to monitor fetal movement at home. This system consists of a non-invasive, non-transmitting sensor unit that can be fabricated at a low cost. An accelerometer was utilized as the primary sensor and a micro-controller based circuit was implemented. Clinical testing was conducted utilizing this sensor unit. Two phases of clinical testing procedures were done and during the first phase readings from 120 mothers were taken while during the second phase readings from 15 mothers were taken. Validation was done by conducting an abdominal ultrasound scan which was utilized as the ground truth during the second phase of the clinical testing procedure. A clinical survey was also conducted in parallel with clinical testings in order to improve the sensor unit as well as to improve the final system. Four different signal processing algorithms were implemented on the data set and the performance of each was compared with each other. Out of the four algorithms three algorithms were able to obtain a true positive rate around 85%. However, the best algorithm was selected on the basis of minimizing the false positive rate. Consequently, the most feasible as well as the best performing algorithm was determined and it was utilized in the final system. This algorithm have a true positive rate of 86% and a false positive rate of 7% Furthermore, a mobile application was also developed to be used with the sensor unit by pregnant mothers. Finally, a complete end to end method to monitor fetal movement in a non-clinical setting was presented by the proposed system.

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.

The prevalence and risk factors of depression in prenatal and postnatal women in China with the outbreak of Corona Virus Disease 2019

BACKGROUND

The prevalence of depression increase with the outbreaks of epidemic disease. The prevalence of depression during the outbreak of Corona Virus Disease 2019 (COVID-19) in prenatal and postnatal women was examined in China.

METHODS

2201 prenatal and postnatal women in mainland China were recruited in this cross-sectional study from February 28^th to April 26^th, 2020. The Patient Health Questionnaire (PHQ-9) was used to assess depression in prenatal and postnatal women.

RESULTS

The prevalence rate of depression was 35.4%. The risk factors for depression included drinking (p = 0.04; adjusted OR = 2.81, 95%CI: 1.26~6.24), nausea and vomiting during pregnancy (p < 0.001; adjusted OR = 3.54, 95%CI: 1.10~11.44), pregnancy's influence on mobility (p = 0.02; adjusted OR = 1.42, 95%CI: 1.11~1.83), anxiety (p < 0.001; adjusted OR = 1.66, 95%CI: 1.57~1.75), insomnia (p < 0.001; adjusted OR = 1.17, 95%CI: 1.14~1.21) and daily attention to fetal movement (p < 0.001; adjusted OR = 0.41, 95%CI: 0.31~0.56).

LIMITATIONS

This study used a cross-sectional design, and cannot compare changes in the incidence of depression before and after the COVID-19 outbreak.

CONCLUSIONS

During the COVID-19 outbreak, the prevalence rate of depression among Chinese prenatal and postnatal women was 35.4%. Moreover, anxiety, insomnia, drinking, nausea and vomiting during pregnancy, as well as the impaired movement and less daily monitoring of fetal movement were risk factors for depression.

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.

Breaking the silence: Determining Prevalence and Understanding Stillbirth Stigma

BACKGROUND

The 2011 and 2016 Stillbirth Lancet series made a call to action to identify mechanisms to reduce stillbirth stigma. This research answers that call, investigating the extent and dimensions of stillbirth stigma experienced by an international sample of mothers bereaved by stillbirth.

OBJECTIVE

To determine the prevalence and type as well as explore explanatory variables associated with higher levels of stillbirth stigma with bereaved mothers in high-income countries (Australia, United Kingdom, The United States of America and New Zealand).

METHOD

An international survey of 889 bereaved mothers was conducted utilising the recently developed Stillbirth Stigma Scale to explore the extent and types of stigma experienced, as well as the association between stigma and self-esteem (Rosenberg Self- Esteem Scales), perinatal grief (Perinatal Grief Scale), and perceived social support (Perceived Social Support Scale). Demographic information (e.g. age, education, stillbirth history, sexual orientation and mental health) were collected to determine the association between individual demographic factors and stillbirth stigma.

RESULTS

Results of the Stillbirth Stigma Scale indicated that a majority (54%) of bereaved mothers experienced stigma. Self-stigma was the predominant type of stigma experienced (80%), followed by perceived devaluation (64.9%). Bereaved mothers also experienced discrimination (29.1%) and issues with disclosing their stillbirth to their community (36.7%). Stillbirth stigma scores were higher in bereaved mothers who had experienced the loss of their first child. High scores were associated with the mother's mental health status (diagnoses prior to stillbirth, and/or after stillbirth (p<.05)).The other scales used indicated that higher stillbirth stigma scores were also associated with lower self-esteem (r (877) =-.304, p<.001), lower perceived social support (r (871) =-.448, p<.001) and higher levels of grief (r (829) =.609, p<.001).

CONCLUSION

The current research was the first to identify that 54% of bereaved mothers experienced stigma, with self-stigma being the most prominent. Bereaved mothers endured discriminating experiences and had trouble disclosing their stillbirth to others within their community. The first-time mother with a self- reported history of mental illnesses appears to be the most at-risk of higher levels of stigma. Future longitudinal research needs to be conducted to determine the direction of the explanatory variables i.e. mental health, self-esteem and social support and develop interventions, which support the bereaved mother and reduce stillbirth stigma.

RELEVANCE

This study is the first to demonstrate the prevalence, extent, type and explanatory variables of stigma reported by bereaved mothers and the association between this and poorer outcomes including increased grief and decreased self-esteem. This study begins a dialogue about prevalence and explanatory variables of stillbirth stigma and its impact, to inform future prevention and support potential stigma reduction programs for community and bereaved mothers.

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

OBJECTIVE

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

DATA SOURCES

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

METHODS OF STUDY SELECTION

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

TABULATION, INTEGRATION AND RESULTS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019123264.

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 is twin pregnancies and the association with adverse neonatal outcomes

OBJECTIVE

Reduced fetal movements (RFM) is an obstetric complaint known to be associated with adverse neonatal outcomes and should serve as an alarming sign in obstetric triage. Whether this assumption holds for twin pregnancies, is still an obstetric enigma, and this complaint is sometimes overlooked in twins. We, therefore, aimed to study neonatal outcomes in twin pregnancies complicated by RFM. We hypothesised that in twin pregnancy, maternal ability to perceive RFM will be limited, and therefore, will not be associated with adverse neonatal outcome.

STUDY DESIGN

Included were all dichorionic twin pregnancies between 2009-2019 who presented to our obstetric triage at a gestational age >34 weeks with an isolated complaint of RFM and delivered during the subsequent two weeks (RFM group). The control group included patients with twin pregnancies (matched for gestational age and maternal age) who presented for routine assessment and reported regular fetal movements throughout pregnancy (no RFM group). Data regarding pregnancy, delivery, and neonatal outcomes were compared between the groups. The primary outcome was a composite of adverse neonatal outcomes, which included one or more of the following: neonatal hypoglycemia, respiratory morbidity, cerebral morbidity, phototherapy, neonatal sepsis, blood transfusions, necrotizing enterocolitis, or neonatal death. Multivariable regression analysis was used to identify independent associations with adverse neonatal outcomes.

RESULTS

Maternal demographics and gestational age at delivery did not differ between the RFM group (n = 83 pregnancies and 166 neonates) and the no RFM group (n = 83 pregnancies and 166 neonates). Neonatal birthweights, as well as the rate of birthweights <10th centile, did not differ between the groups. There were 2 cases of fetal demise diagnosed at triage in the RFM group. The rate of the primary outcome, as well as NICU admissions, were significantly higher in the RFM group compared to the no RFM group (29.5 % vs. 19.2 %, p = 0.01 and 32.5 % vs. 19.2 %, p = 0.001). In multivariable analysis RFM (aOR = 1.18, 95 % CI = 1.06-2.73), and GA at delivery (aOR = 0.88, 95 % CI = 0.67-0.97) were associated with adverse neonatal outcome-independent from background confounders.

CONCLUSION

Patients presented to obstetric triage with twin pregnancies and isolated RFM had higher rates of adverse neonatal outcomes and NICU admissions compared to twin pregnancies without RFM.

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.

Decreased fetal movements: Perinatal and long-term neurological outcomes

BACKGROUND

While maternal perception of decreased fetal movements during advanced stages of pregnancy may be an indicator for adverse perinatal outcome, the long-term neurological outcome of offspring of affected pregnancies remains largely unknown.

OBJECTIVE

To examine whether maternal complaint of decreased fetal movements is associated with adverse perinatal outcomes, and to assess the implications of decreased fetal movements on long-term neurological morbidity of the offspring.

STUDY DESIGN

A single center cohort analysis including deliveries between the years 1991-2014 was conducted. The association between decreased fetal movements and adverse perinatal outcome was evaluated using a general estimation equation (GEE) multivariable analyses. Incidence of hospitalizations (up to age 18 years) due to various neurological conditions was compared between offspring of affected pregnancies, and those who were not, using a Kaplan-Meyer survival curve. A Cox proportional hazards model was used to control for confounders.

RESULTS

439 (0.18%) of 242,342 deliveries included in this study were accompanied by maternal complaint of decreased fetal movements. Perinatal outcome was comparable between the groups, with no cases of perinatal mortality observed among the exposed group. Total neurological-related hospitalization rate of the offspring, as well as hospitalizations due to movement disorders, were higher among the exposed group (Kaplan-Meyer log-rank test P < 0.05). This association between decreased fetal movements and increased long-term neurological hospitalization proved to be independent of potential confounders with an adjusted hazard ratio of 1.54 (95% CI 1.0-2.37).

CONCLUSION

Maternal complaint of decreased fetal movements does not predict adverse perinatal outcome but is associated with an elevated risk for long-term neurological morbidity of the offspring.

Measurement of Maternal Mindful Awareness of Fetal Movement

INTRODUCTION

Decreased fetal movement is a common concern late in pregnancy that may be associated with increased fetal morbidity and mortality. Limited research suggests a relationship between maternal psychological factors and perception of fetal movement. The goal of this study was to test the reliability and external validity of a novel self-report instrument for maternal mindful awareness of fetal movement.

METHODS

Pregnant women who were at 20 weeks' gestation or later and feeling regular fetal movement (N = 497) were recruited online through a commercial pregnancy website to complete an internet survey from April to May 2016. The online survey included demographic and pregnancy characteristics, psychological and mindfulness measures, and investigator-developed items on mindful awareness of fetal movement. Reliability and validity of the instrument were tested with exploratory factor analysis, correlations with psychological variables, and hierarchical linear regression.

RESULTS

Exploratory factor analysis of mindful awareness of fetal movement items using principal components analysis showed a 2-factor structure, noticing and distracted, with internal consistency of α equal to .69 and .57, respectively. Hierarchical multiple regression analysis showed that noticing was associated with increased gestational age, mindfulness (observing facet), and maternal-fetal attachment. Distracted was associated with increased education level and prenatal anxiety and with decreased mindfulness (nonjudging facet).

DISCUSSION

There was moderate internal consistency in the items measuring mindful awareness of fetal movement. Findings suggest relationships between mindful awareness of fetal movement and state mindfulness, maternal-fetal attachment, and prenatal anxiety. More research is needed to further develop items for a mindful awareness of fetal movement scale suitable for research and clinical practice.

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.

Counting fetal movements of small-for-gestational infants using a fetal movement acceleration measurement recorder

Background: Our purpose was to clarify whether small-for-gestational (SGA) infants is associated with a decrease in fetal movements (FMs) even in the absence of hypoxia. We used a fetal movement acceleration measurement (FMAM) recorder, which enabled counting gross FMs for hours at a time.Methods: (1) Parameters of FMs for 13 women who delivered SGA infants were plotted over normal reference value curves made from 64 normal pregnant women in another study. (2) Linear regression analysis was conducted for the women with SGA infants and the normal pregnant women.Results: Thirty-eight data recordings were available in the SGA group. (1) For the ratio of movement positive 10-s epoch, 14 recordings (36.8%) were below 10% of the normal values. For an average number of movements, 13 (34.2%) were below 10%. Regarding average number, average duration, and longest duration of non-movement period, 12 (31.6%), 13 (34.2%), and 15 records (39.4%) were above 90% of the normal values, respectively. (2) SGA was a factor that decreased the positive epoch ratio and the average movements number, and increased the average number and duration, and the longest duration of non-movement period.Conclusions: SGA is associated with decreased movements even in the absence of hypoxia.

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.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

www.clinicaltrials.gov NCT01777022.

VERSION

Protocol Version 4.2, 3 February 2017.

[Use of fetal movements counting for prolonged pregnancy: A comparative preliminary cohort study before and after implementation of an information brochure]

OBJECTIVES

Compare the number of consultations with the consultation's delay in relation with the sensation of decrease active fetal movements (AFM) in case of late pregnancy, according to the fact if the patients use or not the AFM's count.

MATERIALS AND METHODS

We have compared a "control" group made up of 160 patients who received a classic information and observation (from December 18th, 2013 to February 28th, 2014) versus an "educated" group made up of 160 patients who have been educated to the AFM count (from March 1st, 2014 to August 12th, 2014).

RESULTS

The consultations for AFM decrease, were significantly more frequent in the "control" group than in the "educated" group (36 versus 8, P=0.0009). Inducing labor due to AFM reduction was not statistically different between both groups (13 patients in the "educated group" versus 7 patients in the "control" group P=0.97).

CONCLUSION

Learning a count method seems to decrease the number of consultations for AFM reduction without increasing the perinatal morbidity but maybe at the cost of an increase of obstetric interventions.

Perinatal outcomes of reduced fetal movements: a cohort study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Fetal movements: What are we telling women?

PROBLEM

Information that women receive about the importance of monitoring fetal movements and what to do if there are changes is inconsistent and may not be evidence based.

BACKGROUND

This paper reports a summary of the kind of messages a group of South Australian midwives (n=72) currently give pregnant women.

METHODS

Comment data from two questions in a larger survey asking (1) what information midwives routinely provide to women about fetal movements and (2) their practice regarding advice they give to women reporting reduced fetal movements. Data were analysed using summative content analysis.

FINDINGS

Four main recurring words and phrases were identified. With respect to information midwives give all women about monitoring fetal movements, recurring words were "10", "normal", "kick charts" and "when to contact" their care-provider. Recurrent words and phrases arising from answers to the second question about advice midwives give to women reporting reduced fetal movement were "ask questions," "suggest fluids," "monitor at home and call back" or "come in for assessment".

DISCUSSION

These findings suggest that a group of South Australian midwives are providing pregnant women with inconsistent information, often in conflict with best practice evidence.

CONCLUSION

As giving correct, evidence based information about what to do in the event of an episode of reduced fetal movement may be a matter of life or death for the unborn baby it is important that midwives use existing guidelines in order to deliver consistent information which is based on current evidence to women in their care.

To be taken seriously and receive rapid and adequate care - Womens' requests when they consult health care for reduced fetal movements

BACKGROUND

decreased fetal movement is a reason for women to seek health care in late pregnancy.

OBJECTIVE

to examine what pregnant women who present with decreased fetal movements want to communicate to health care professionals and to other women in the same situation.

DESIGN

a qualitative descriptive study.

SETTING AND PARTICIPANTS

questionnaires were distributed in all seven labour wards in Stockholm from 1 January to 31 December 2014 to women who consulted care due to decreased fetal movements. In total, 3555 questionnaires were completed of which 1 000 were included in this study. The women's responses to the open ended question: "Is there something you want to communicate to health care professionals who take care of women with decreased fetal movement or to women who experience decreased fetal movements?", were analysed with manifest content analysis.

FINDING

three categories were revealed about requests to health care professionals: Pay attention to the woman and take her seriously, Rapid and adequate care and Improved information on fetal movements. Regarding what the women want to communicate to other pregnant women, four categories were revealed: Contact health care for check-up, Pay attention to fetal movement, Recommended source of information and Practical advice.

CONCLUSION

pregnant women who consult health care due to decreased fetal movements want to be taken seriously and receive rapid and adequate care with the health of the infant as the primary priority. The women requested uniform information about decreased fetal movements. They wished to convey to others in the same situation the importance of consulting care once too often rather than one time too few.

What is my Baby Like? Representations Concerning the Baby in the Third Trimester of Pregnancy

Aim

To investigate if during the third trimester of pregnancy fantasies emerge in the baby representations based on the information that pregnant women have on their real babies through ultrasound techniques.

Method

A qualitative, descriptive and exploratory research based on a sample of 30 pregnant Portuguese women, whose average age is 32 years old, was developed. A socio-demographic questionnaire and a semi-directive interview entitled "Interview of Maternal Representations During Pregnancy – Revised Version" (IRMAG-R, Ammaniti & Tambelli, 2010) were employed.

Results

Baby representations are immersed in a fantasy dimension, which means that the imaginary baby is quite present in this phase of pregnancy. Pregnant women mainly attribute psychological characteristics to the babies, rather than physical characteristics. Regardless of the type of characteristics analysed, the preference for these characteristics emerges based on their wishes. Secondly, characteristics of the parents may also emerge. Fetal movements and information from ultrasound have no significant influence on the characterization of the baby.

Conclusion

Despite the development of ultrasound techniques, the imaginary baby defines parents representations about the baby on the third trimester of pregnancy. Consequently, a new understanding of how pregnant women experience the transition to the postnatal phase has to be considered.

Fetal movement counting for assessment of fetal wellbeing

BACKGROUND

Fetal movement counting is a method by which a woman quantifies the movements she feels to assess the condition of her baby. The purpose is to try to reduce perinatal mortality by alerting caregivers when the baby might be compromised. This method may be used routinely, or only in women who are considered at increased risk of complications affecting the baby. Fetal movement counting may allow the clinician to make appropriate interventions in good time to improve outcomes. On the other hand, fetal movement counting may cause unnecessary anxiety to pregnant women, or elicit unnecessary interventions.

OBJECTIVES

To assess outcomes of pregnancy where fetal movement counting was done routinely, selectively or was not done at all; and to compare different methods of fetal movement counting.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-RCTs where fetal movement counting was assessed as a method of monitoring fetal wellbeing.

DATA COLLECTION AND ANALYSIS

Two review authors assessed studies for eligibility, assessed the methodological quality of included studies and independently extracted data from studies. Where possible the effects of interventions were compared using risk ratios (RR), and presented with 95% confidence intervals (CI). For some outcomes, the quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Five studies (71,458 women) were included in this review; 68,654 in one cluster-RCT. None of these five trials were assessed as having low risk of bias on all seven risk of bias criteria. All included studies except for one (which included high-risk women as participants) included women with uncomplicated pregnancies.Two studies compared fetal movement counting with standard care, as defined by trial authors. Two included studies compared two types of fetal movement counting; once a day fetal movement counting (Cardiff count-to-10) with more than once a day fetal movement counting methods. One study compared fetal movement counting with hormone assessment.(1) Routine fetal movement counting versus mixed or undefined fetal movement countingNo study reported on the primary outcome 'perinatal death or severe morbidity'. In one large cluster-RCT, there was no difference in mean stillbirth rates per cluster (standard mean difference (SMD) 0.23, 95% CI -0.61 to 1.07; participants = 52 clusters; studies = one, low quality evidence). The other study reported no fetal deaths. There was no difference in caesarean section rate between groups (RR 0.93, 95% CI 0.60 to 1.44; participants = 1076; studies = one,low quality evidence). Maternal anxiety was significantly reduced with routine fetal movement counting (SMD -0.22, 95% CI -0.35 to -0.10; participants = 1013; studies = one, moderate quality evidence). Maternal-fetal attachment was not significantly different (SMD -0.02, 95% CI -0.15 to 0.11; participants = 951; studies = one, low quality evidence). In one study antenatal admission after reporting of decreased fetal movements was increased (RR 2.72, 95% CI 1.34 to 5.52; participants = 123; studies = one). In another there was a trend to more antenatal admissions per cluster in the counting group than in the control group (SMD 0.38, 95% CI -0.17 to 0.93; participants = 52 clusters; studies = one, low quality evidence). Birthweight less than 10th centile was not significantly different between groups (RR 0.98, 95% CI 0.66 to 1.44; participants = 1073; studies = one, low quality evidence). The evidence was of low quality due to imprecise results and because of concerns regarding unclear risk of bias. (2) Formal fetal movement counting (Modified Cardiff method) versus hormone analysisThere was no difference between the groups in the incidence of caesarean section (RR 1.18, 95% CI 0.83 to 1.69; participants = 1191; studies = one). Women in the formal fetal movement counting group had significantly fewer hospital visits than those randomised to hormone analysis (RR 0.26, 95% CI 0.20 to 0.35), whereas there were fewer Apgar scores less than seven at five minutes for women randomised to hormone analysis (RR 1.72, 95% CI 1.01 to 2.93). No other outcomes reported showed statistically significant differences. 'Perinatal death or severe morbidity' was not reported. (3) Formal fetal movement counting once a day (count-to-10) versus formal fetal movement counting method where counting was done more than once a day (after meals)The incidence of caesarean section did not differ between the groups under this comparison (RR 2.33, 95% CI 0.61 to 8.99; participants = 1400; studies = one). Perinatal death or severe morbidity was not reported. Women were more compliant in using the count-to-10 method than they were with other fetal movement counting methods, citing less interruption with daily activities as one of the reasons (non-compliance RR 0.25, 95% CI 0.19 to 0.32).Except for one cluster-RCT, included studies were small and used different comparisons, making it difficult to measure the outcomes using meta-analyses. The nature of the intervention measured also did not allow blinding of participants and clinicians..

AUTHORS' CONCLUSIONS

This review does not provide sufficient evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Only two studies compared routine fetal movements with standard antenatal care, as defined by trial authors. Indirect evidence from a large cluster-RCT suggested that more babies at risk of death were identified in the routine fetal monitoring group, but this did not translate to reduced perinatal mortality. Robust research by means of studies comparing particularly routine fetal movement counting with selective fetal movement counting is needed urgently, as it is a common practice to introduce fetal movement counting only when there is already suspected fetal compromise.

[Maternal knowledge of fetal movements in late pregnancy]

OBJECTIVES

Evaluate knowledge of patients with late pregnancy on active foetal movements.

PATIENTS AND METHOD

This prospective study has been carried out with volontary patients during the 41-week of gestation term consultation, with a questionnaire, at the obstetric gynecology departments of St-Etienne Hospital (CHU), Clermont-Ferrand Hospital (CHU), Roanne Hospital (CH) and Firminy Hospital (CH), from July 22nd, 2013 to September 14th, 2014.

RESULTS

Few patients (17%) have been seen urgently by an obstetrician or a midwife in case of a decrease of the active foetal movements. Most patients (73.6%) wait 24hours to consult. More than 50% of women have not been informed on this topic before the birth. However, 86.84% of the patients are interested in being informed when they see their doctor. The easiest way would be to count the active foetal movements 3 times a day on a short period.

CONCLUSION

There is still a lack of information on the active foetal movements. It remains a difficult topic because its definition is still subjective and the information has no protocol.

Pregnancy outcomes with a primary complaint of perception of reduced fetal movements

Reduced fetal movement is a worrisome common complaint, not only for mothers but also for the attending medical personnel. The aim of this study was to analyse the pregnancy outcomes of women who presented primarily with reduced fetal movements (RFM). A retrospective study was performed based on patients' perception alone. Obstetric, past medical history, current presentation and outcomes of pregnancy were analysed. A total of 230 case notes were reviewed, with the majority being primigravidae. Less than half (48.7%) of the women had spontaneous labour, 45.7% had induction and 5.6% had elective caesarean section. There were no maternal complications in 97.4% (n = 224) of them. About 0.9% (n = 2) and 1.7% (n = 4) had primary postpartum haemorrhage and extended perineal tear, respectively. Although there was no major neonatal mortality and morbidity, until a randomised trial with a significant sample is conducted in the management of RFM, careful selections for elective delivery or conservative management would prevent untoward complications.

MANAGEMENT OF REDUCED FETAL MOVEMENTS

Reduced fetal movement (RFM) is commonly defined as any reduction in maternal perception of fetal activity. Perceived fetal activity may be movement of limbs, trunk or head movement, but excludes fetal hiccoughs (as this is involuntary movement). The perception of fetal movement by an expectant mother is the first, and ongoing, non-sonographic indicator of fetal viability. The “normal” pattern of fetal movements varies from pregnancy to pregnancy, and often does not become established until 28 weeks’ gestation. Many babies have particularly active periods of the day, usually corresponding to periods of maternal rest and inactivity (which may in itself reflect increased maternal awareness of fetal movement). A variable percentage of sonographically observed fetal movements are perceived by prospective mothers (commonly 30–40%, although some studies report rates as high as 80%).

Wavelet principal component analysis of fetal movement counting data preceding hospital examinations due to decreased fetal movement: a prospective cohort study

Background

Fetal movement (FM) counting is a simple and widely used method of assessing fetal well-being. However, little is known about what women perceive as decreased fetal movement (DFM) and how maternally perceived DFM is reflected in FM charts.

Methods

We analyzed FM counting data from 148 DFM events occurring in 137 pregnancies. The women counted FM daily from pregnancy week 24 until birth using a modified count-to-ten procedure. Common temporal patterns for the two weeks preceding hospital examination due to DFM were extracted from the FM charts using wavelet principal component analysis; a statistical methodology particularly developed for modeling temporal data with sudden changes, i.e. spikes that are frequently found in FM data. The association of the extracted temporal patterns with fetal complications was assessed by including the individuals’ scores on the wavelet principal components as explanatory variables in multivariable logistic regression analyses for two outcome measures: (i) complications identified during DFM-related consultations (n = 148) and (ii) fetal compromise at the time of consultation (including relevant information about birth outcome and placental pathology). The latter outcome variable was restricted to the DFM events occurring within 21 days before birth (n = 76).

Results

Analyzing the 148 and 76 DFM events, the first three main temporal FM counting patterns explained 87.2% and 87.4%, respectively, of all temporal variation in the FM charts. These three temporal patterns represented overall counting times, sudden spikes around the time of DFM events, and an inverted U-shaped pattern, explaining 75.3%, 8.6%, and 3.3% and 72.5%, 9.6%, and 5.3% of variation in the total cohort and subsample, respectively. Neither of the temporal patterns was significantly associated with the two outcome measures.

Conclusions

Acknowledging that sudden, large changes in fetal activity may be underreported in FM charts, our study showed that the temporal FM counting patterns in the two weeks preceding DFM-related consultation contributed little to identify clinically important changes in perceived FM. It thus provides insufficient information for giving detailed advice to women on when to contact health care providers. The importance of qualitative features of maternally perceived DFM should be further explored.

A randomised controlled trial comparing standard or intensive management of reduced fetal movements after 36 weeks gestation--a feasibility study

Background

Women presenting with reduced fetal movements (RFM) in the third trimester are at increased risk of stillbirth or fetal growth restriction. These outcomes after RFM are related to smaller fetal size on ultrasound scan, oligohydramnios and lower human placental lactogen (hPL) in maternal serum. We performed this study to address whether a randomised controlled trial (RCT) of the management of RFM was feasible with regard to: i) maternal recruitment and retention ii) patient acceptability, iii) adherence to protocol. Additionally, we aimed to confirm the prevalence of poor perinatal outcomes defined as: stillbirth, birthweight <10^th centile, umbilical arterial pH <7.1 or unexpected admission to the neonatal intensive care unit.

Methods

Women with RFM ≥36 weeks gestation were invited to participate in a RCT comparing standard management (ultrasound scan if indicated, induction of labour (IOL) based on consultant decision) with intensive management (ultrasound scan, maternal serum hPL, IOL if either result was abnormal). Anxiety was assessed by state-trait anxiety index (STAI) before and after investigations for RFM. Rates of protocol compliance and IOL for RFM were calculated. Participant views were assessed by questionnaires.

Results

137 women were approached, 120 (88%) participated, 60 in each group, 2 women in the standard group did not complete the study. 20% of participants had a poor perinatal outcome. All women in the intensive group had ultrasound assessment of fetal size and liquor volume vs. 97% in the standard group. 50% of the intensive group had IOL for abnormal scan or low hPL after RFM vs. 26% of controls (p < 0.01). STAI reduced for all women after investigations, but this reduction was greater in the standard group (p = 0.02). Participants had positive views about their involvement in the study.

Conclusion

An RCT of management of RFM is feasible with a low rate of attrition. Investigations decrease maternal anxiety. Participants in the intensive group were more likely to have IOL for RFM. Further work is required to determine the likely level of intervention in the standard care arm in multiple centres, to develop additional placental biomarkers and to confirm that the composite outcome is valid.

Trial registration

ISRCTN07944306

Temporal patterns in count-to-ten fetal movement charts and their associations with pregnancy characteristics: a prospective cohort study

BACKGROUND

Fetal movement counting has long been suggested as a screening tool to identify impaired placental function. However, quantitative limits for decreased fetal movement perform poorly for screening purposes, indicating the need for methodological refinement. We aimed to identify the main individual temporal patterns in fetal movement counting charts, and explore their associations with pregnancy characteristics.

METHODS

In a population-based prospective cohort in Norway, 2009-2011, women with singleton pregnancies counted fetal movements daily from pregnancy week 24 until delivery using a modified "count-to-ten" procedure. To account for intra-woman correlation of observations, we used functional data analysis and corresponding functional principal component analysis to identify the main individual temporal patterns in fetal movement count data. The temporal patterns are described by continuous functional principal component (FPC) curves, with an individual score on each FPC for each woman. These scores were later used as outcome variables in multivariable linear regression analyses, with pregnancy characteristics as explanatory variables.

RESULTS

Fetal movement charts from 1086 pregnancies were included. Three FPC curves explained almost 99% of the variation in the temporal data, with the first FPC, representing the individual overall counting time, accounting for 91% alone. There were several statistically significant associations between the FPCs and various pregnancy characteristics. However, the effects were small and of limited clinical value.

CONCLUSIONS

This statistical approach for analyzing fetal movement counting data successfully captured clinically meaningful individual temporal patterns and how these patterns vary between women. Maternal body mass index, gestational age and placental site explained little of the variation in the temporal fetal movement counting patterns. Thus, a perceived decrease in fetal movement should not be attributed to a woman's basic pregnancy characteristics, but assessed as a potential marker of risk.

Fetal movement counting for assessment of fetal wellbeing

BACKGROUND

Fetal movement counting is a method by which a woman quantifies the movements she feels to assess the condition of the baby. The purpose is to try to reduce perinatal mortality by alerting caregivers when the baby might have become compromised. This method may be used routinely, or only in women who are considered at increased risk of complications in the baby. Some clinicians believe that fetal movement counting is a good method as it allows the clinician to make appropriate interventions in good time. On the other hand, fetal movement counting may cause anxiety to women.

OBJECTIVES

To assess outcomes of pregnancy where fetal movement counting was done routinely, selectively or was not done at all; and to compare different methods of fetal movement counting.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library) and the reference lists of relevant papers.

SELECTION CRITERIA

Randomised controlled trials. Trials were excluded where allocation concealment was inadequate and no measures were taken to prevent bias were excluded. The interventions included routine fetal movement counting, selective fetal movement counting, and studies comparing different fetal assessment methods.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of included studies and extracted data from studies.

MAIN RESULTS

Four studies, involving 71,370 women, were included in this review; 68,654 in one cluster-randomised trial. All four trials compared formal fetal movement counting. Two trials compared different types of counting with each other; one with no formal instruction, and one with hormonal analysis. Women in the formal fetal movement counting group had significantly fewer visits to the hospital antenatally than those women randomised to hormone analysis (relative risk (RR) 0.26, 95% confidence interval (CI) 0.20 to 0.35), whereas there were fewer Apgar scores less than seven in five minutes for women randomised to hormone analysis (RR 1.72, 95% CI 1.01 to 2.93). There was a significantly higher compliance with the Cardiff 'count to ten' method than with the formal fetal movement counting method (RR 0.25, 95% CI 0.19 to 0.32).All other outcomes reported were non significant.

AUTHORS' CONCLUSIONS

This review does not provide enough evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Robust research is needed in this area.