Date Published: June 12, 2019
Publisher: Public Library of Science
Author(s): Billie F. Bradford, Robin S. Cronin, Christopher J. D. McKinlay, John M. D. Thompson, Edwin A. Mitchell, Peter R. Stone, Lesley M. E. McCowan, Clive J Petry.
Encouraging awareness of fetal movements is a common strategy used to prevent stillbirths. Information provided to pregnant women about fetal movements is inconsistent perhaps due to limited knowledge about normal fetal movement patterns in healthy pregnancies. We aimed to describe maternally perceived fetal movement strength, frequency, and pattern in late pregnancy in women with subsequent normal outcomes.
Participants were ≥28 weeks’ gestation, with a non-anomalous, singleton pregnancy who had been randomly selected from hospital booking lists and had consented to participate. Fetal movement data was gathered during pregnancy via a questionnaire administered face-to-face by research midwives. Participants remained eligible for the study if they subsequently gave birth to a live, appropriate-for-gestational-age baby at ≥37 weeks.
Participants were 274 women, with normal pregnancy outcomes. The majority (59.3%, n = 162) of women reported during antenatal interview that the strength of fetal movements had increased in the preceding two weeks. Strong fetal movements were felt by most women in the evening (72.8%, n = 195) and at night-time including bedtime (74.5%, n = 199). The perception of fetal hiccups was also reported by most women (78.8%). Women were more likely to perceive moderate or strong fetal movements when sitting quietly compared with other activities such as having a cold drink or eating.
Our data support informing women in the third trimester that as pregnancy advances it is normal to perceive increasingly strong movement, episodes of movements that are more vigorous than usual, fetal hiccups, and a diurnal pattern involving strong fetal movement in the evening. This information may help pregnant women to better characterise normal fetal movement and appropriately seek review when concerned about fetal movements. Care providers should be responsive to concerns about decreased fetal movements in the evening, as this is unusual.
Maternal perception of fetal movements is reassuring of fetal wellbeing. It is well established that perception of decreased fetal movements (DFM) is associated with stillbirth and pregnant women are routinely asked about fetal movements during antenatal visits [1,2]. However, association of DFM with stillbirth is only moderately strong (odds ratio 2.4–14.1)[3,4] and the majority of presentations for DFM are followed by a normal pregnancy outcome . A large UK trial has reported that encouraging awareness of fetal movement, coupled with a management protocol involving a low threshold for induction of labour, led to increased intervention and no reduction in stillbirths . Some commentators have concluded that encouraging awareness of fetal movements is harmful and should be discouraged [6,7]. Others have pointed out that maternal concern about DFM remains a risk factor for adverse outcome and argued for renewed focus of researchers’ efforts to understand this important clinical sign .
This cross-sectional study was conducted across seven healthcare regions in New Zealand. Participants were initially recruited as controls in a larger study on late stillbirth and were randomly selected from hospital booking lists based on gestation-matching with stillbirths in that locality . At recruitment eligible participants were ≥28 weeks’ gestation, with a non-anomalous singleton pregnancy, and provided written consent to participate. Women were interviewed antenatally between February 2012 and December 2015. The findings of the stillbirth study have been reported elsewhere [26,27]. Birth outcome data were collected from the medical records following birth. Ethical approval was obtained from the Northern X Region Ethics Committee: NTX/06/05/054.
In total, 274 women met the study inclusion criteria (Fig 1). Mean (SD) maternal age at interview was 29.8 (5.2) years and nulliparous women comprised 42.7% of the sample. Mean (SD) gestation at interview was 36.2 (3.3) weeks with approximately half (44.9%) interviewed between 28+0 and 36+6 weeks’ gestation and the remainder interviewed at ≥37 weeks’ gestation (Table 1). Demographics characteristics were similar in this sub-study to the larger control group (data not shown). Comparison of demographic characteristics between eligible non-participants and recruited participants has already been reported . Briefly, women of high parity were slightly under-represented, whilst women of Indian ethnicity were over-represented and New Zealand Māori women were under-represented in the recruited population.
This cross-sectional study of a representative sample of pregnant women who subsequently gave birth to live appropriate-for-gestational-age babies at term, provides novel quantitative data on aspects of fetal movement that are observed by pregnant women but not currently well described in the literature. We found that women typically perceived fetal movements in the third trimester to be increasingly strong, likely to include fetal hiccups, and exhibiting a clear diurnal pattern involving strong fetal movements in the evening.
Pregnant women have indicated they would like more information about fetal movements. Our data support informing women in the third trimester that as pregnancy advances it is normal to perceive increasingly strong movement, episodes of movements that are more vigorous than usual, fetal hiccups, and a diurnal pattern involving strong fetal movement in the evening. This information may help pregnant women to better characterise normal fetal movement and appropriately seek review when concerned about fetal movements. This study should also inform care providers that it is important to be responsive to reports of fetal movement concerns in the evening as such reports are unusual.