Citation:

Bellussi, F., Poʼ, G., Livi, A., Saccone, G., Vivo, V. D., Oliver, E. A., & Berghella, V. (2020). Fetal Movement Counting and Perinatal Mortality. Obstetrics & Gynecology, 135(2), 453–462. doi: 10.1097/aog.0000000000003645

Abstract:

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.

Citation:

Saastad, E., Winje, B. A., Stray Pedersen, B., & Frøen, J. F. (2011). Fetal movement counting improved identification of fetal growth restriction and perinatal outcomes–a multi-centre, randomized, controlled trial. PloS one, 6(12), e28482. https://doi.org/10.1371/journal.pone.0028482

Abstract:

 BACKGROUND:

Fetal movement counting is a method used by the mother to quantify her baby’s movements, and may prevent adverse pregnancy outcome by a timely evaluation of fetal health when the woman reports decreased fetal movements. We aimed to assess effects of fetal movement counting on identification of fetal pathology and pregnancy outcome.

METHODOLOGY:

In a multicentre, randomized, controlled trial, 1076 pregnant women with singleton pregnancies from an unselected population were assigned to either perform fetal movement counting from gestational week 28, or to receive standard antenatal care not including fetal movement counting (controls). Women were recruited from nine Norwegian hospitals during September 2007 through November 2009. Main outcome was a compound measure of fetal pathology and adverse pregnancy outcomes. Analysis was performed by intention-to-treat.

PRINCIPAL FINDINGS:

The frequency of the main outcome was equal in the groups; 63 of 433 (11.6%) in the intervention group, versus 53 of 532 (10.7%) in the control group [RR: 1.1 95% CI 0.7-1.5)]. The growth-restricted fetuses were more often identified prior to birth in the intervention group than in the control group; 20 of 23 fetuses (87.0%) versus 12 of 20 fetuses (60.0%), respectively, [RR: 1.5 (95% CI 1.0-2.1)]. In the intervention group two babies (0.4%) had Apgar scores <4 at 1 minute, versus 12 (2.3%) in the control group [RR: 0.2 (95% CI 0.04-0.7)]. The frequency of consultations for decreased fetal movement was 71 (13.1%) and 57 (10.7%) in the intervention and control groups, respectively [RR: 1.2 (95% CI 0.9-1.7)]. The frequency of interventions was similar in the groups.

CONCLUSIONS:

Maternal ability to detect clinically important changes in fetal activity seemed to be improved by fetal movement counting; there was an increased identification of fetal growth restriction and improved perinatal outcome, without inducing more consultations or obstetric interventions.

Delaram, M., & Jafarzadeh, L. (2016). The Effects of Fetal Movement Counting on Pregnancy Outcomes. Journal of clinical and diagnostic research : JCDR, 10(2), SC22–SC24. https://doi.org/10.7860/JCDR/2016/16808.7296

INTRODUCTION:

Counting fetal movements may lead to timely assess fetal health and prevent the adverse effects of pregnancy.

AIM:

The aim of this study was to determine the effect of fetal movement counting on pregnancy outcomes.

MATERIALS AND METHODS:

In a randomized controlled trial, 208 women with singleton pregnancy were randomly divided into two groups of fetal movement counting and control. Pregnancy outcomes were compared between the two groups. Data were analysed with SPSS and p<0.05 was considered significant.

RESULTS:

There was no significant difference in the mean maternal concern (p=0.36), admission to hospital due to the decreased fetal movements (p=0.99), birth weight (p=0.21), Apgar score (p=0.51), the mean of gestational age at the time of decreased fetal movements (p=0.49) and mode of delivery (p=0.69) between the two groups. There were no cases of premature labour, intrauterine growth retardation and fetal death in the two groups.

CONCLUSION:

Pregnancy outcome was similar in the two groups of fetal movement counting and control. Further studies are needed to evaluate the effect of fetal movement counting on the major outcomes of pregnancy such as intrauterine fetal death.

Mangesi, L., Hofmeyr, G. J., Smith, V., & Smyth, R. M. (2015). Fetal movement counting for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.cd004909.pub3

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.

(# of subjects/ studies, cohort definition etc. )

Emily A. Oliver, MD, and Vincenzo Berghella, MD

• Electronic databases (ie, MEDLINE,

ClinicalTrials.gov, ScienceDirect, the Cochrane Library

at the CENTRAL Register of Controlled Trials) were searched from inception until May 2019

• 5 RCT was chosen from were chosen from 1,290 identified article and 468,601 fetuses were part of the subject group
• Intervention group= women instructed

to monitor fetal movement during pregnancy

• control group = women did not receive

instruction regarding fetal movement

monitoring

• One of the primary outcome measure = incidence perinatal mortality, stillbirths and neonatal deaths
• Secondary outcome measure=

• small for gestational age (birth weight less than the 10^th percentile)
• 5-minute Apgar score less than 7
• admission to the neonatal ICU decreased fetal movement
• admission to hospital for reduced fetal movement,
• elective or emergent delivery (cesarean or induction of labor) after decreased fetal movement,
• preterm birth
• induction of labor, and cesarean delivery.

• association of fetal movement counting with perinatal mortality

• In this systematic review and meta-analysis, there were no difference between the control and intervention group meaning the women who were instructed on fetal movement counting had no difference in perinatal mortality compared with those who did not receive instructions
• The only statistically significant results in this meta-analysis are small increased rates of preterm birth, induction of labor and cesarean delivery
• Fetal movement counting were not associated with clear improvement in pregnancy outcome
• It is not possible to

know whether the clinical interventions prevented

a stillbirth, neonatal death, or neonatal morbidity

• 82% of the subjects of the study are from one study therefore other studies had little contribution to he conclusion of this meta-analysis
• Most of RCT in this meta-analysis were conducted in high income countries where pre-natal death is rare so it might not be generalized in the low-income population. However, USA is considered high income country so it could be generalized among American populations.
• The sample size might not be large enough to detect a small risk reduction
• The instruction to the patient regarding fetal count movements, the management of decreased fetal movement and the definition of stillbirth might differ based on the provider.

Multi-Centre, Randomized, Controlled Trial

• 1076 pregnant women with singleton pregnancies were assigned to either perform fetal movement counting from gestational week 28, or to receive

standard antenatal care not including fetal movement counting

• fetal growth restriction <2.5th centile
•  emergency Caesarean section on fetal indication
• Oligohydramnios
• pathological blood flow in arteria umbilicalis
• maternal perception of absent fetal movements for more than 24 hours before admission to hospital
• perinatal death

Secondary outcomes

• Apgar scores <4 at 1 and 5 minutes
• fetal growth restriction <2.5th centile unidentified prior to birth
• the total number of consultations for decreased fetal activity
•  use of health resources in evaluation of these pregnancies
•  interventions prior to or during delivery.

• There was an increased identification of fetal growth restriction and improved perinatal outcomes
• There were less adverse outcomes in the intervention group than in the control group
•  decreased fetal movements, more often a fetus with a <-10% weight estimate was identified in the Intervention versus the control group
•  Further research is needed to assess the effects of fetal movement counting on hard outcomes such as stillbirth rates.

• The sample was only representative pregnant patient from Norway and small number of sample size had characteristic of smoking which may indicate a bias towards healthier pregnancies.
• The sample size were predominantly employed, cohabiting, white, and well-educated; a typical Scandinavian population. Therefore, it can not be generalized rather need to be districted to  similar population
• The intervention group received additional information about fetal activity and how to register and interpret the fetal movement pattern, but this information may also have reached the women in the control group.

• 208 women with singleton pregnancy were randomly divided into two groups of fetal movement counting and control
• randomly assigned to the intervention group (n = 100) and control group (n = 108)
• Exclusion criteria included oligohydramnios, multifetal pregnancy, fetal abnormalities and maternal smoking.

• Maternal concern about reduced fetal movements
• Admission to hospital due to maternal concern
• Birth weight
• Apgar score
• preterm delivery
• intrauterine growth retardation
•  mode of delivery

• There were no significant difference between the intervention and control group regarding hospital admission due to decrease fetal movements, birth weight, Apgar score
• There were no significant difference between the mode of delivery between two groups
• There were no case of premature labor, intra-uterine growth retardation and fetal death between the two groups
• Pregnancy outcome was similar in the two groups of fetal movement counting and control.
• Further studies are needed to evaluate the effect of fetal movement counting on the major outcomes of pregnancy such as intrauterine fetal death

• The most women participating in the study were more employed and educated. Therefore, the finding scan not be generalized and should be limited to the same population.

G Justus Hofmeyr,

Valerie Smith,

Rebecca MD Smyth

Pregnant women who reached the gestational age 28 to 32 weeks

Three Intervention group

Routine fetal movement      counting versus mixed    or undefined fetal  movement             counting

Formal fetal movement  counting (Modified Cardiff method) versus hormone analysis

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)

Primary outcomes

Perinatal death or severe morbidity (neonatal intensive care unit admission, neonatal encephalopathy)

Caesarean section

Secondary outcomes

Maternal outcomes

Maternal satisfaction as defined by trial authors

Maternal anxiety as defined by trial authors

Maternal‐fetal attachment as defined by trial authors

Non‐compliance (not pre‐specified)

Pregnancy complications

Antenatal hospital admission

Other fetal testing

Stillbirths

Premature birth

Birthweight; less than 2500 g or less than 10th centile (not pre‐specified)

Assisted birth

Operative birth

Number of hospital visit (not pre‐specified)

Consultation for decreased fetal movements (not pre‐specified)

Neonatal outcomes

Five‐minute Apgar score less than seven

Umbilical arterial pH less than 7.2

Neonatal intensive care unit admission

Respiratory distress syndrome

Neonatal encephalopathy

Early neonatal death

Perinatal death

Childhood disability

Routine fetal movement  counting lead to reduced maternal anxiety

There were no significant difference between the intervention vs control     regarding Maternal-fetal attachment

Intervention group had  increased hospital admission     as the mother reported decreased fetal movements

Birthweight less than 10th   centile was not significantly different between groups

Intervention#2

Formal fetal movement   counting versus hormone  analysis

There was no difference       between the groups in        regard to incidence of    c- section

Women in the fetal movement counting had significantly fewer.              hospital visits than  hormone analysis

Hormone analysis group had fewer Apgar scores less than seven at five minutes

Perinatal death or severe.        morbidity’ was not reported.

Intervention#3

Formal fetal movement                 counting once a day versus formal fetal movement counting  method

The incidence of caesarean section did not differ between the two groups

Perinatal death or severe morbidity was not reported

Meta‐analysis was not performed because of the degree of heterogeneity

The nature of the intervention measured also did not allow blinding of participants and clinicians.

All five studies were conducted in high income countries (Norway, United Kingdom, Ireland, Sweden, Belgium and the USA)