Reduced Fetal Activity And Assessing For Poor Pregnancy Outcome

Main Category: Pregnancy / Obstetrics
Article Date: 19 Oct 2009 - 3:00 PDT

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A paper published in TOG: The Obstetrician & Gynaecologist today recommends discontinuing the traditional practice of monitoring how well your baby is doing by counting the number of kicks felt over a set period, cross-referenced with fetal kick charts.

Fetal kick charts, developed in the 1970s, are still used in some countries to help determine if the pregnancy is progressing well. Pregnant women are asked to count the number of kicks felt in the womb per day. The general rule of thumb is that they should have felt at least up to ten kicks within the space of 12 hours. If this number is not reached in that time, they should seek help.

Most women report feeling fetal movements from 20 weeks gestation, though some may experience them earlier. The peak occurs around 28 to 34 weeks, after which, sensations of movement change as a result of fetal development. Previous research has shown that mothers who had reported reduced fetal movement had babies that were small-for-gestational-age (SGA) or had severe growth restriction (IUGR). Around 15% of women feel reduced movement during their pregnancy. Decreased fetal movements for more than 24 hours could indicate that the baby is unwell and may result in fetal death, which is why mothers are so concerned if they have not felt the baby kicking or moving over an extended period of time.

Irish researchers from the Cork University College Maternity Hospital believe that this method may not be accurate as women are relying on unreliable perceptions which may result in under or over counting. Previous studies show that there is also a lack of clear agreement among midwives and obstetricians over the numbers determining abnormal movement requiring immediate attention. These range from <10 movements in two hours, to 12 and 24 hours.

The authors of the paper suggest that obstetricians identify women who are at-risk through a standard assessment, where the mother's previous medical history is considered alongside information such as levels of alcohol consumption and smoking. After which, further investigations using ultrasound scanning and cardiotocography (CTG) to measure the fetus' progress should be used.

Dr Julia Unterscheider, from the Anu Research Centre, Department of Obstetrics and Gynaecology at the University of Cork said, "Around 15% of pregnancies are assessed in hospitals because the mother is concerned that her baby is not moving well.

"Obstetricians are often faced with the dilemma of not knowing what is best for mother and baby, as clinical guidance is inconsistent and management varies. Unnecessary investigation in an otherwise healthy pregnancy can lead to increased intervention such as caesarean delivery. In contrast, reduced fetal movements can represent a warning sign that the baby is small for gestation or unwell.

"We suggest that a careful history and examination together with a CTG (cardiotocograph) are used to confirm fetal wellbeing at a given time. Ultrasound evaluation is recommended when babies are at and beyond their due date, or when examination of the mother's abdomen suggests that the baby is small. Kick-charts, which are in use in many maternity units worldwide, are of no benefit to reducing poor outcomes in low-risk pregnant women. A mother's subjective perception of diminished movements is a better predictor of problems."

Jason Waugh, TOG editor-in-chief said, "Understandably, mothers get very anxious when they haven't felt the baby kicking for a while and think there may be something amiss. There are several plausible reasons why this may be, including the fetus being in a state of sleep, the mother being on a course of sedatives, or even the mother being too busy to focus on fetal activity. Because these sensations are so subjective, and the circumstances are different from mother-to-mother, the authors of this paper are advising healthcare professionals not to rely on fetal kick-charts alone.

"Indeed NICE have already recommended that routine fetal movement counting should not be offered in antenatal care since their predictive value is low. Based on the evidence, we shouldn't just count on the 'count-to-ten' method."

Notes

The Obstetrician & Gynaecologist (TOG) is published quarterly and is the Royal College of Obstetricans and Gynaecologists' (RCOG) medical journal for continuing professional development. TOG is an editorially independent, peer-reviewed journal aimed at providing health professions with updated information about scientific, medical and clinical developments in the specialty of obstetrics and gynaecology.

Reference

Unterscheider J, Horgan R, O'Donoghue K, Greene R. Reduced fetal movements. The Obstetrician & Gynaecologist 2009;11:245-251.

Source
The Obstetrician & Gynaecologist