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

The association between increased fetal movements in the third trimester and perinatal outcomes; a systematic review and meta-analysis

BACKGROUND

Fetal movement monitoring is one of the strategies used to assess the fetus's health. Until now, most studies focused on the decreased fetal movement and neonatal outcome, although this systematic review and meta-analysis is designed to assess the association between increased fetal movements (IFM) with perinatal outcomes.

METHOD

The electronic databases including PubMed, Scopus, Web of Science, and EMBASE were systematically searched for studies investigating the perinatal outcome of women with increased fetal movements from inception to July 2023. Following that, a random-effect meta-analysis model was used to obtain the combined diagnostic and predictive parameters including perinatal mortality (still birth and early neonatal mortality), operative delivery, Apgar score, neonatal resuscitation at birth and NICU Admission.

RESULTS

After the initial screening, seven studies examining the association between increased third trimester fetal movement and various perinatal outcomes were included. Meta-analysis revealed a significant reduction in the risk of cesarean delivery among patients with IFM compared to controls, suggesting a potential protective effect during childbirth. However, no statistically significant difference was observed in birth weight, small or large for gestational age births, neonatal intensive care unit admission, maternal age, umbilical cord around the neck, gestational diabetes mellitus, and hypertension, indicating that IFM may not be a major predictor of adverse perinatal outcomes or maternal conditions. Notably, IFM was significantly associated with a higher likelihood of labor induction.

CONCLUSION

The findings suggest that IFM may have a protective effect against cesarean delivery. Additionally, IFM does not appear to be significantly associated with maternal age, umbilical cord around the neck, gestational diabetes mellitus and hypertension. However, the observed significant association with labor induction warrants further investigation.

Obstetric outcomes and uptake of care among 149 non-Swedish speaking migrant women attending a birth preparation visit during pregnancy - An observational study from Sweden

Introduction

In Sweden almost one third of the population is born in another country and a large number of the women who do not speak Swedish are of reproductive age. Women migrating from low-income countries have higher risks for poor obstetric outcomes than receiving country-born citizens. INFOR (a Swedish word for "before" or "ahead of") is an intervention offering language-assisted, individual birth preparation for non-Swedish speaking pregnant women unfamiliar with the maternity care system. The aim of this study was to describe the uptake of care and obstetric outcomes among non-Swedish speaking migrant women attending INFOR.

Methods

A descriptive study of the obstetric outcomes and uptake of care was conducted of the 149 non-Swedish speaking pregnant women who participated in INFOR between 2016 and 2020. The data were accessed retrospectively from the medical record system Obstetrix and the population-based Swedish Pregnancy Registry and analysed descriptively.

Results

Women participating in INFOR originated from 44 countries and spoke 35 different languages. During late pregnancy, 20 percent of the women sought care for decreased fetal movements and 80 percent of the women attended the postpartum visit. While the majority of the participants were offered professional language support during pregnancy, almost none had a professional interpreter present during labour and birth. After birth, 80 percent of the primiparous women were asked to rate their birth experience, but only half of the multiparous women were asked. Further, only half of the primiparous women attending the postpartum visit were asked about their self-rated health.

Conclusion

INFOR may increase uptake of some important aspects of care during pregnancy, birth and postpartum among migrants of diverse backgrounds. The findings raise concerns however about communication support for migrant women, especially during labour and birth. The offer of professional interpreting as part of standard maternity care for women who need it is essential and must be improved in order to provide equitable care for all.

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.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS AND CONCLUSIONS

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

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

PROBLEM

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

BACKGROUND

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

AIM

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Outpatient labour induction

The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18 h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.

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.

Pregnancy outcomes among women born in Somalia and Sweden giving birth in the Stockholm area - a population-based study

Background

Studies report that women born in some African countries, after migrating to the Nordic countries, have worse pregnancy outcomes than women born in the receiving countries. With the aim of identifying unmet needs among Somali-born women, we here study this subgroup.

Objective

We compared pregnancy outcomes among women born in Somalia to women born in Sweden. Further, we investigated whether the proactive maternal observation of fetal movements has effects on birth outcomes among women born in Somalia.

Methods

In Stockholm, half of the maternity clinics were randomized to intervention, in which midwives were instructed to be proactive towards women by promoting daily self-monitoring of fetal movements. Data for 623 women born in Somalia and 26 485 born in Sweden were collected from a population-based register.

Results

An Apgar score below 7 (with stillbirth counting as 0) at 5 minutes was more frequent in babies of women born in Somalia as compared to babies of women born in Sweden (RR 2.17, 95% CI 1.25–3.77). Babies born small for gestational age were more common among women born in Somalia (RR 2.22, CI 1.88–2.61), as were babies born after 41 + 6 gestational weeks (RR 1.65, CI 1.29–2.12). Somali-born women less often contacted obstetric care for decreased fetal movements than did Swedish-born women (RR 0.19, CI 0.08–0.36). The differences between women born in Somalia and women born in Sweden were somewhat lower (not statistically significant) among women allocated to proactivity as compared to the Routine-care group.

Conclusions

A higher risk of a negative outcome for mother and baby is seen among women born in Somalia compared to women born in Sweden. We suggest it may be worthwhile to investigate whether a Somali-adapted intervention with proactivity concerning self-monitoring of fetal movements may improve pregnancy outcomes in this migrant population.

Do fertility treatments affect labor induction success rate? A retrospective cohort study

Purpose: To evaluate labor induction success rate by Foley catheter (FC) on patients who conceived spontaneously, as compared to those who underwent fertility treatments.Materials and methods: This retrospective cohort study included all pregnant women hospitalized at a single tertiary care center between January 2011 and May 2018 for induction of labor with FC. The study groups included patients with a singleton pregnancy who conceived after fertility treatments: controlled ovarian hyperstimulation (COH) or in vitro fertilization (IVF), while control group included patients who conceived spontaneously. Our primary outcome was the rate of cesarean deliveries. Regression analysis was conducted on the following parameters: age, gravidity, parity, the gestational week, and IVF.Results: The study groups included 59, 321, and 3159 patients who conceived following COH, IVF, or spontaneously, respectively. While 72.1% of patients who conceived spontaneously had a vaginal delivery, only 62.7% and 58% of patients who conceived by COH and IVF had successful labor induction (respectively, p < .01). Similarly, significantly higher cesarean section (CS) rates were demonstrated by patients who conceived by COH and IVF (28.8% and 30%, respectively), compared to the control group (18.7%, p < .01). Regression analysis demonstrated that although age, parity, and the gestational week were significantly related to cesarean sections, no statistically significant association was found regarding fertility treatments (p = .050).Conclusions: The possible association between fertility treatments and cesarean delivery remains an important dilemma for obstetricians and fertility experts. While unadjusted analysis demonstrated such association among patients who undergo labor induction by FC, adjusted analysis has not supported that finding. Further studies focusing on the causes of failed vaginal delivery are needed to further expand our knowledge and to improve patient consultation.

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

OBJECTIVES

Reduced fetal movement (RFM) is a commonly presenting worrisome complaint, both for mothers and attending clinicians. The aim of this study was to review the management of RFM before and following the implementation of new hospital guideline and to determine pregnancy outcomes following single vs repeated consultations with complaints of RFM. We also compared the standards in our old and new trust guidelines against published guidance from the Royal College of Obstetricians and Gynaecologists (RCOG).

STUDY DESIGN

This retrospective cohort study was conducted between June -November 2016 (audit 1) and July- December 2018 (audit 2). All women with a non-anomalous singleton pregnancy, attending the Day Assessment Unit of the Jessop Wing Hospital Sheffield UK with a primary presentation of perceived RFM after 24 weeks of gestation were included. The electronic maternity database was used to collect information regarding their presentations and pregnancy outcomes. Adherence to the old and the new local guidelines for the respective epochs of the assessment were reviewed by two independent observers using the Appraisal of Guidelines for Research and Evaluation (AGREE) 11 tool.

RESULTS

A total of 1775 women presented with RFM during the two study periods. Of these, 632 attended with more than 1 presentation of RFM (35.6 %). There were 3 stillbirths; all diagnosed at the first presentation with RFM. In the second audit, prevalence of RFM increased by 10 %, CTG documentation improved by 1% and ultrasound scan requests decreased by 6.6 %. Women with more than one episode of RFM were more likely to be younger, smokers, nulliparous, have raised BMI, had a higher IOL rate and had more ultrasound scans compared to those with one episode. However, neonatal outcome, onset of labour and mode of delivery remained unchanged between the two groups. While the RCOG guideline was superior to both (old and new) guidelines, the overall scores increased in the new guideline by 22 %.

CONCLUSION

After implementing the new guideline, the re-audit demonstrates a reduction in the number of requested ultrasound scans without any compromise on the perinatal outcome.