Fetal movements:Midwives role

Dr Jane Warland

Can unborn babies let us know they are ok?

•Fetal movement•Fetal growth

Decreased Fetal Movements (DFM)

• A quarter of women who present with DFM have adverse perinatal outcomes such as growth restriction and stillbirth. (Peat et al 2012)

• 42.6% women who experienced a late term stillbirth presented with DFMs at some time in their pregnancy compared to 9% of live born controls. (Stacey et al 2011)

Can awareness of fetal movements be protective against stillbirth?

• Large multi-centred international RCT 68,000 participants

• All risk groups i.e. entire clinics were recruited

• ‘Count to ten’ versus usual care

• No Difference in stillbirth rate between groups

• BUT Stillbirth rate fell , across the cohort , from an expected 4:1000 to 2.8 :1000 ( Grant et al 1989)

BUT

It is normal to feel less movement towards the end of pregnancy

• Fetal movements do not normally decrease close to term. In fact decreased fetal movement at or near term places the pregnancy at substantial increased risk (Dutton et al 2012, O’Sullivan et al 2009 )

Clinical practice guideline• Clinical practice guideline for the management of

women who report decreased fetal movements. (Preston et al 2010)

Summary of Recommendations regarding decreased fetal movement (DFM)(Preston et al 2010 p16-17)

Recommendation 1 Evidence level

All Pregnant women should be routinely provided with verbal and written information regarding normal fetal movements during the antenatal period.

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Recommendation 2

All women should be advised to contact their health care provider if they have any concern about decreased or absent fetal movements and be advised not to wait until the next day to report DFM.

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Recommendation 3

After discussion , women who remain unsure whether movements are decreased should be given guidance on counting. However, maternal concern of DFM overrides any definition of DFM based on numbers of kicks

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STARS study

STARS • Online survey• Cohort study design with nested case-control arm

• Cohort• A total of 1,714 women who had experienced a stillbirth >3 weeks prior to enrolment completed the survey

• Case-control (preliminary)• 132 cases who had a stillbirth ≤ 3 weeks prior and 283 controls who had had a recent livebirth or who were still pregnant.

 

N (%)

N=1,714

No change in fetal movement 480 (28.0%)

A little bit less movement 273 (15.9%)

Significantly less movement 522 (30.5%)

A little bit more movement 136 (7.9%)

Significantly more movement 146 (8.5%)

Don’t remember 103 (6.0%)

Missing 54 (3.2%)

Fetal Movements

46.4%

16.4%

62.8%

Increased Movements

.

she was a little more active in the last two weeks and her pattern was slightly off. Not enough that I was concerned. I thought it was a healthy sign

The week before my baby passed, I recall she was VERY active one night when I was trying to fall asleep, so much that I actually got up out of bed for a while because her movements were keeping me awake

The day before he died he was especially busy and moving like crazy

moved like crazy then nothing

 

Reduced

n=795 (%)

Increased

n=282 (%)Did not worry 51 (6.4%) 39 (13.8%)Mentioned to family and friends but did not worry further

105 (13.2%) 59 (20.9%)

Mentioned to healthcare provider and was reassured 244 (30.7%) 76 (27.0%)

Mentioned to healthcare provider and was told to monitor at home for symptoms and call back if still concerned

65 (8.1%) 21 (7.4%)

Mentioned to healthcare provider and had general evaluation (fetal heart rate, cervical status etc)

59 (7.4%) 16 (5.6%)

Mentioned to healthcare provider and outpatient testing 80 (10.1%) 23 (8.1%)

Mentioned to healthcare provider and was admitted 45 (5.7%) 12 (4.5%)

Went to hospital and was admitted 75 (9.4%) 13 (4.6%)

Went to hospital and was sent home 37 (4.7%) 10 (3.5%)

Did not provide response to question 34 (4.3%) 13 (4.6%)

61%

Australian Women’s knowledge• 526 women 34 weeks gestation or later Mater

Women’s Brisbane.• 67% received information about FM during pregnancy• 80 % said they received this info from a midwife• 2/3 of women agreed it was normal to feel reduced

movements towards the end of pregnancy. Some groups ie ATSI 100% agreed

• 65% would wait longer than 24 hours before seeking advice from a health practitioner about DFMs

• 83% would normalise DFM and not take any action• Only 33% agreed that being aware of fetal

movements could help identify if the fetus was unwell McArdle et al 2015

NZ study• Ninety-seven per cent of women reported that their lead maternity

carer (LMC) regularly asked about fetal movements, • 62% recalled receiving information from their LMC about what to

expect regarding fetal movements in the last three months of pregnancy.

• Thirty-three per cent recalled receiving information from their LMC that their baby’s movements should increase or stay the same and 20% that their baby’s movements may decrease in late pregnancy.

• Forty per cent were advised to contact their LMC if they had any concerns about their baby’s movements, and one-quarter were informed to seek advice if they had fewer than 10 movements in a day.

• Conclusions: Our study suggests a proportion of pregnant women in Auckland do not have optimum information about fetal movements. Strategies to enhance maternal knowledge such as a pamphlet about fetal movements may be helpful. (Peat et al 2012)

How do you ask about FMs?

•Is your baby moving?

•OR

•Tell me about your baby’s movements?

Empowering women to know her baby by asking about FMs:• Be aware of who her baby is, • how her baby is and • Immediately report a change

Phone advice re DFMsWhat have you observed happening if a woman rang concerned about decreased FM?

What would you do?

Preston et al 2010

DFM: flow chart

Preston 2010

ReferencesDutton PJ, Warrander LK, Roberts SA, Bernatavicius G, Byrd LM, Gaze D, et al. (2012)

Predictors of Poor Perinatal Outcome following Maternal Perception of Reduced Fetal Movements – A Prospective Cohort Study. PLoS ONE 7(7): e39784. doi:10.1371/journal.pone.0039784

Grant A, et al (1989) Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet ;2:345-9.

McArdle A, et al (2015) How pregnant women learn about foetal movements: sources and preferences for information. Women Birth. 28(1):54-9.

O’Sullivan O, Stephen G, Martindale E, et al (2009) Predicting poor perinatal outcome in women who present with decreased fetal movements Journal of obstetrics and Gynaecology 29: (8) 705-710

Peat AM, Stacey T, Cronin R, McCowan LM. (2012) Maternal knowledge of fetal movements in late pregnancy. Aust N Z J Obstet Gynaecol. 2012 Oct;52(5):445-9.

Preston S, Mahomed K, Chadha Y, et al for the Australia and New Zealand Stillbirth Alliance (ANZSA). Clinical practice guideline for the management of women who report decreased fetal movements. Brisbane, July 2010.

Sinha D et al. (2007) Obstetric outcome in women complaining of reduced fetal movements. J Obstet Gynaecol 27 (1) 41-43

Stacey T, et al (2011)Maternal perception of fetal activity and late stillbirth risk: findings from the Auckland Stillbirth Study. Birth. 2011 38(4):311-6.

Warland J et al (in press) An International Internet Survey of the Experiences of 1,714 Mothers with a Late Stillbirth: The STARS Cohort Study BMC Pregnancy and Childbirth. Accepted 28th July 2015