View of Recommendations for fetal movement monitoring and assesment

(1)

1 Department of Perinatology, Division of Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia

2 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Correspondence/

Korespondenca:

Tanja Premru Sršen, e:

tanja.premru@gmail.com Key words:

antenatal care; fetal movement; fetal movement counting;

reduced fetal movements;

stillbirth Ključne besede:

spremljanje plodovega stanja; gibi ploda; štetje plodovih gibov; zmanjšano število plodovih gibov;

mrtvorojenost Received: 20. 11. 2017 Accepted: 16. 7. 2018

eng slo element

en article-lang

10.6016/ZdravVestn.2671 doi

20.11.2017 date-received

16.7.2018 date-accepted

Human reproduction Reprodukcija človeka discipline

Professional article Strokovni članek article-type

Recommendations for fetal movement moni-

toring and assesment Priporočila za spremljanje plodovih gibov v nosečnosti z navodili za nosečnice

article-title Recommendations for fetal movement moni-

toring and assesment Priporočila za spremljanje plodovih gibov v nosečnosti z navodili za nosečnice

alt-title antenatal care, fetal movement, fetal move-

ment counting, reduced fetal movements, stillbirth

spremljanje plodovega stanja, gibi ploda, štetje plodovih gibov, zmanjšano število plodovih gibov, mrtvorojenost

kwd-group

The authors declare that there are no conflicts

of interest present. Avtorji so izjavili, da ne obstajajo nobeni

konkurenčni interesi. conflict

year volume first month last month first page last page

2019 88 9 10 479 490

name surname aff email

Tanja Premru Sršen 1,2 tanja.premru@gmail.com

name surname aff

Vid Janša 1

Gabrijela Bržan Šimenc 1

eng slo aff-id

Department of Perinatology, Division of Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia

Porodnišnica Ljubljana - Klinični oddelek za perinatologijo, Ginekološka klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija

1

Faculty of Medicine, University

of Ljubljana, Ljubljana, Slovenia Medicinska fakulteta, Univerza v Ljubljani, Ljubljana, Slovenija 2

Recommendations for fetal movement monitoring and assesment

Priporočila za spremljanje plodovih gibov v nosečnosti z navodili za nosečnice

Vid Janša,¹ Gabrijela Bržan Šimenc,¹ Tanja Premru Sršen^1,2

Abstract

Reduced foetal movements or a change in the pattern of foetal movements may be associated with a poor perinatal outcome. In case of reduced foetal movements, inadequate response of physician -gynecologist and obstetrician is a factor that contributes to stillbirth. All pregnant women should be given information about the normal foetal movement. We recommend uniform instructions about fetal movement monitoring, a uniform method of foetal movement monitoring (modified “count to ten” method) and the use of a uniform table/chart for foetal movement recording. In case of maternal perception of less than ten movements within 2 hours, women should contact their maternity unit. Appointment is also necessary in case of changes in the pattern of foetal movements or a sudden significant prolongation of time to 10 moves count that persist over several days. The history and clinical examination help us detect high risk pregnancies. At every appointment we should monitor blood pressure and test urine for proteinuria.

Clinical assessment of women with reduced foetal movements should include assessment of foetal size with the aim of detecting foetuses small for gestational age. CTG is needed to exclude foetal compromise if the pregnancy is over 28 weeks of gestation. Ultrasound scan assessment should be done if there are any additional risk factors for stillbirth, in case of pathological CTG and if the perception of reduced fetal movements persists despite a normal CTG.

Izvleček

Zmanjšana plodova aktivnost ali sprememba vzorca plodovega gibanja je lahko povezana s sla- bim perinatalnim izidom. Ugotaljali so, da je neustrezen odziv zdravnika ginekologa in porod- ničarja ob srečanju z nosečnico, ki poroča o zmanjšanem gibanju ploda, dejavnik, ki prispeva k mrtvorojenosti. Vse nosečnice bi morale dobiti informacije o normalnem gibanju ploda. Pri- poročamo enotno podajanje informacij o spremljanju plodovih gibov, enotno metodo spreml- janja gibov ploda (modificirano metodo »štej do deset«) in uporabo enotne tabele za beleženje plodovih gibov, namenjene nosečnicam. Če je nosečnica v dveh urah naštela manj kot 10 gibov, naj ne čaka in naj se takoj dogovori za pregled. Z izbranim ginekologom naj se dogovori za pregled tudi v primeru spremembe vzorca gibanja ploda in nenadnega pomembnega podaljšanja časa do naštetih 10 gibov, ki, tako podaljšan, vztraja več dni. Z anamnezo in kliničnim pregle- dom moramo odkriti nosečnice z večjim tveganjem za zaplete. Ob vsakem pregledu je potrebno izmeriti krvni tlak in izključiti proteinurijo. V nadaljevanju pregleda je potrebno ugotoviti, ali je rast ploda primerna gestacijski starosti. Po 28. tednu nosečnosti je potrebno s pomočjo CTG ugotavljati ogroženost ploda. V primeru dejavnikov tveganja za smrt ploda v maternici ali za zas- toj rasti ploda, v primeru nenavadnega zapisa CTG ter v primeru normalnega zapisa CTG ob vztra- janju slabšega gibanja ploda je potrebna ultrazvočna preiskava.

Slovenian Medical

Journal

(2)

1 The objective

The objective of these recommendations is to present the clinical significance of reduced foetal movement, give practical instructions for providing advice so pregnant women about monitoring the foetus’s movements, and to present the recommendations on how to respond in case of reduced foetal movement.

2 Introduction

For pregnant women detecting foetal movements is one of the first signs the foetus is alive (1). A pregnant woman first detects movements between the 18th and the 20th week of pregnancy, and foetal activity soon stabilizes in a recurring time pattern (2). Reduced foetal activity or changes to the pattern of foetal movements can have clinical significance. Several studies have shown a link between reduced foetal movement and low birth weight (3- 10), oligohydramnios, premature birth (3,11), developmental and chromosome irregularities (12), fetomaternal haemor- rhage (12), irregular development of the central nervous system (13,14), intrauterine infection (15), low Apgar score and perinatal acidosis (5,7), hypoglycaemia (3), placental insufficiency (4,10), labour induction, urgent caesarean, stillbirth and neonatal mortality (16,17). Even for pregnant women with a low risk for complications and adverse perinatal outcome a correlation was established between intrauterine growth restriction, premature birth and perinatal mortality (3,4,18-20).

Cite as/Citirajte kot: Janša V, Bržan Šimenc G, Premru Sršen T. Recommendations for fetal movement monitoring and assesment. Zdrav Vestn. 2019;88(9–10):479–90.

DOI: https://doi.org/10.6016/ZdravVestn.2671

The Norwegian study put the perinatal mortality rate at 8.2 per 1,000 for pregnant women who conducted an extra check- up because of reduced foetal movement at a time when the foetus was still alive, while in general population the perinatal mortality rate is at 2.9 per 1,000 (17). The research group from the United Kingdom published a case-control study, and established that in 11% of intrauterine growth restriction was in the group of pregnant women with reduced foetal movement, while in the control group there were 0 cases of intrauterine growth restriction (21).

Reduced number of foetal movements can be a warning signal of imposing perinatal mortality and an adverse perinatal outcome (22,23). Detecting foetal movements is variable (24) and depends on numerous factors (position of the placenta, the amount of amniotic fluid, smoking, pari- ty, the pregnant woman’s habitus) (24-26).

Reduced foetal movement is a frequent reason for visiting a gynaecologist. 4–15%

of pregnant women come for an extra exam in the third trimester because of reduced foetal movement (20,27-29). 55%

of pregnant women with a stillborn child reported reduced foetal movement before neonatal mortality was established (30).

Doctors have been cautioning pregnant women to monitor foetal movement; however, they often receive unclear and con- flicting instructions about how to monitor foetal movements.

Several studies have found that an inappropriate response from the physician-gy-

(3)

naecologist and obstetrician seeing a pregnant woman reporting on reduced foetal movement is a factor that contributes to a stillbirth (31,32). Pregnant women who detect reduced foetal movement sooner are a sensitive group with whom preven- tive strategies and recommendations for activities in the event of reduced foetal movement can prevent stillbirth.

3 Identification and assessment of evidence

The main recommendations are taken from the Royal College of Obstetricians and Gynaecologists (RCOG): Reduced foetal movements (2), The Australian and New Zealand Stillbirth Alliance (ANZ- SA): Clinical Practice Guideline for the Management of Women who report De- creased Fetal Movements (33) and Soci- ety of Obstetricians and Gynaecologists of Canada (SOGC): Fetal Health Surveil- lance: Antepartum and Intrapartum Con- sensus Guideline (34). Data from newer publications has been added.

Individual recommendations are eval- uated using a scale, i.e. with regard to available studies or the opinions of expert groups (Table 1).

Recommendation with the booklet for counting foetal movements was adopt- ed as professionally accurate and recommended for general use by the Slovenian Association for Perinatal Medicine and the Main Expert Council of the Slovenian Medical Association of 8 October 2019.

The booklet was published in the online edition of the Slovenian Medical Journal as a separate file.

4 What is normal foetal movement?

Recommendation C

Most pregnant women begin noticing foetal movement by the 20th week of pregnancy.

Recommendation B

The gynaecologist should explain to the pregnant woman that foetal movements plateau at 32 weeks, however, the third trimester should not have any reduction in foetal movement.

All pregnant women should receive verbal and written information on normal foetal movement. They should be informed of the changes to foetal movement during the development of the foetus in the womb, about the cycles of activity and sleep/rest, and the factors that can influence foetal movement detection.

Foetal movement is defined as any kind of movement, stretching, kicking or turn- ing by the foetus that is detected by the pregnant woman (35). Movement is an indicator of the integrity of the central nervous and muscular-skeletal system. When the foetus is in an active phase, movement is present, while during rest and sleep it is normal that there are no movements.

A lot of pregnant women will detect the first movements between the 18th and 20th week of pregnancy. Multiparae detect foetal movement before the 18th week, while primiparae can detect it even after the 20th week of pregnancy (36). The number of foetal movements increases until the 32nd week of pregnancy (37), then plateaus, and after that the method of the foetus’s movements changes as the result of the foetus’s neurological development (17,37,38-40). There is no evidence that the number of movements would de- crease in the third trimester or at the start of delivery (29,33). From the 20th week of pregnancy the foetus’s movements have a diurnal rhythm. The periods with highest activity levels are afternoons and evenings (41,42). When the foetus sleeps or rests,

(4)

there is no movement, and this occurs reg- ularly and at night, and usually lasts 20–40 minutes (23,43), and with a healthy foetus rarely more than 90 minutes (43-45),

Numerous factors affect foetal movements and how the mother detects them.

Before the 28th week of pregnancy the placenta – located on the front wall of the uterus – can make it more difficult to detect foetal movement (46). Alcohol, ben- zodiazepine, methadone and other opiates can temporarily reduce foetal movement (47,48). We often advise pregnant women who are worried about reduced foetal movement to eat something sweet or have a very cold drink, and then to expect foetal movement in 20 minutes. Some studies have shown that there is increased foetal movement when the pregnant woman’s blood glucose levels rise, however, many studies have also not supported this con- nection (49-51). From the 30th week of pregnancy onward the concentration of carbon dioxide effects the foetus’s breathing paths, and it has been described in studies that smoking lowers foetal movement (47,52,53). Taking corticosteroids (maturation therapy) lowers the number of foetus’s movements and the variability of foetus’s heart rate in the CTG, and is supposed to result in reduced foetal movement for 2 days (54-56). The position of the foetus does not affect the detection of foetal movement (57). It has been established that when the foetus’s back is facing the front wall of the uterus the pregnant women did not detect any foetal movement, even though it was visible when conducting an ultrasound (US) (58).

5 How should a pregnant woman monitor foetal movement?

The pregnant woman should monitor foetal movement through subjective detection of movement.

It has been established that 37–88%

of movements that are noticeable on an US are also detected by a pregnant woman. Most pregnant women detect major movements and those lasting longer than 7 seconds (59-65). Detecting movement with a Doppler ultrasound is a somewhat more sensitive method than a mother’s subjective movement detection (66,67), and it is possible also that there are false positives in movement detection (68).

There is no published data to demonstrate that recording movement with a Doppler US lowers the risk for stillbirth.

It is recommended that the pregnant woman monitors the number of foetus’s movements.

If there is a reduction or a complete absence of foetal movement after the 28th week of pregnancy, the pregnant woman should visit a gynaecologist and obstetrician.

If after the 28th week a pregnant woman is not certain whether the foetus is moving correctly, we advise to lie on her left side and monitor foetal movement for two hours. If there are fewer than 10 movements in the two hours, she should immediately contact her selected or on-call gynaecologist and obstetrician.

We should advise pregnant women not to wait until the next day if they are concerned about a reduction in or an absence of foetal movement, and to contact their selected or the on-call gynaecologist and obstetrician immediately.

However, the problem with monitoring foetal movement is that the definition of

(5)

the normal number of foetus’s movements is unclear. The currently most broadly ad- opted definition says that fewer than 10 movements in 2 hours in the active part of the foetus’s cycle counts as reduced foetal movement (44). This limit was also adopt- ed by the American Academy of Pediatrics in American College of Obstetricians and Gynaecologists (69).

The latest study by Cochrane favours formally quantifying foetal movement by using tables/spreadsheets to keep track of the number of foetus’s movements (70), however, there is little data on this. Formal quantification helps recognize the foetuses with a higher risk for stillbirth. It has been established that perinatal mortality did not decline when formal quantification of movements was introduced, as we would expect, however, this has been at- tributed to inappropriate measures taken by healthcare workers when meeting pregnant women who noted a lower number of foetus’s movements.

Higher awareness about monitoring foetal movement did bring down the level of stillborn babies by more than 50%

(20,22,29,71). Moor at al. discovered that using the count-to-ten method of monitoring movement the perinatal mortality declined from 8.7/1,000 to 3.6/1,000, however, they also noted there was a higher rate of induced labour and urgent caesarean deliveries (44).

Gradual increase in between movements until the 10th movement have been noted to be clinically significant, pointing to a chronic endangerment of the foetus (72). They also noted a relation between the gradual decline of foetal movement and the intrauterine growth restriction, and thereby related adverse perinatal outcome (20,70,73,74)

A doctor who advises a pregnant woman to monitor foetal movement should be aware that unclear and inappropriate information can increase a pregnant woman’s anxiety and lead to more unnecessary examinations and procedures.

Opponents of formally monitoring the number of foetus’s movements (using tables to count the number of foetus’s movements) warn that this amounts to a psy- chological stress for the pregnant woman (70,75,76), and can lead to an increased number of unnecessary medical examinations and procedures (70). Even though the recommendations from foreign as- sociations (2,33) do not take a position for or against formally monitoring foetal movement because of the lack of evidence, some studies that have shown beneficiary effects of providing advice to do so. It has been established that encouraging counting movements and using a table leads to a sense of empowerment among pregnant women (72). Pregnant women who were provided with correct instructions on monitoring foetal movement and who used a uniform table to mark the number of movements had fewer worries related to the course of their pregnancy, they were more confident, and unprofessional information (social networks, forums, etc.) had less of an effect on their well-being (77).

Using tables to mark the number of movements was defined as positive by most pregnant women (77).

It is the general conviction of healthcare workers that the introduction of formal monitoring of foetal movement would cause a greater strain on the healthcare

(6)

system and more unnecessary medical examinations (76). Studies have shown that encouraging pregnant women to count foetal movement does not cause a greater strain on the healthcare network, and is not connected to a significant increase in the number of unnecessary medical examinations (72).

Recommendation D

We recommend providing uniform information on foetal movement monitoring, a uniform method for monitoring foetal movement (a modified count-to-ten method) and the use of a uniform table for marking foetal movement for pregnant women (the booklet for monitoring foetal movement was published in the online edition of the Medical Journal as a separate file).

Providing uniform information and systematic foetal movement monitoring improve the capability of pregnant women to recognize change in foetal movement and lowers the pregnant woman’s psy- chological distress (72). We believe that in Slovenia it makes sense to unify what pregnant women are advised regarding foetal movement monitoring. We recommend a modified count-to-ten method.

We advise that foetal movement is mon- itored from the 28th week of pregnancy and until delivery. A pregnant woman should count with the aim to make sure that there are at least 10 movements within 2 hours. She should pick a time of day when the foetus is usually active the most.

She should strive to count the movements every day at about the same time. First, she should lie or sit down comfortably. Next, put both hands on her stomach, check the time and begin counting. If she does not feel any movement, she should try to wake up the foetus by walking around for a few minutes, having something sweet to eat or a very cold drink. It is important to count the movements every time she knows that

the foetus is awake. Every move counts!

When there is a series of movements, she should count each one of them. When she gets to ten, she should check how much time has passed since she began counting. In the table that has days marked with dates, she should enter the time taken from when she began counting movements and until she counted the tenth one (the attachment on the Slovenian Medical Journal’s website at https://vestnik.szd.si/

index.php/ZdravVest/article/view/2671).

She should count movements every day.

She should count for up to two hours at most. She should stop counting when she gets to 10 movements.

If a pregnant woman counts fewer than 10 movements in 2 hours, she should not wait, but schedule an examination immediately. She should also schedule an examination with her gynaecologist if there is a change to the pattern of the foetus’s movements or a sudden significant prolongation of the time until she counts 10 movements that persists for several days. It is important to emphasize the positive as- pects when advising to monitor the number of foetal movements (71). We should emphasize that counting movements can be a wonderful way of establishing a bond with the child, while also a simple method that helps the doctor check foetus’s condi- tion, and the pregnant woman can do it by herself, at home. We should explain when giving advise that not every reduction in the number of foetus’s movements is a sign of an adverse perinatal outcome, but it does call for additional examinations. It is important to often encourage pregnant women (at every examination) to count foetal movement, as this improves their cooperation (77).

Counting foetal movements provides support to the general clinical practice and diagnostic procedures.

Recommendation and the booklet for counting foetal movement were adopt- ed as professionally accurate and recommended for general use by the Slovenian Association for Perinatal Medicine and

(7)

the Slovenian Medical Association of 25 October 2017.

6 What action to take if a pregnant woman notices reduced foetal movement?

A pregnant woman with reduced foetal movement should be examined as soon as possible.

It is recommended that a pregnant woman with no foetal movement be examined within 2 hours, and those with reduced foetal movement within 12 hours (33).

The pregnant woman should first be consoled by explaining to her that in 70% of pregnancies with one episode of reduced foetal movement there are no complications and the outcome is good.

During the examination we should first exclude foetus’s death, then continue to establish whether the foetus is endangered, and provide an estimate as to whether this is a high-risk pregnancy. It is important for the physician to be aware that reduced foetal movement could be related to intrauterine growth restriction, placental insufficiency or developmental irregularities.

Recommendation B By setting an anamnesis we first establish the risk factors for intrauterine foetal death and growth restriction.

It is important to establish whether this is the first experience of reduced foetal movements, and for how long the pregnant woman has been noticing reduced

foetal movement. Factors related to higher risk for intrauterine foetal death are recurring episodes of reduced foetal movement, intrauterine growth restriction, hyperten- sion, diabetes, the mother’s age, primipara, smoking, placental insufficiency, developmental irregularities, obesity, past high- risk pregnancy, and past adverse perinatal outcome (78).

A clinical examination is required to confirm the presence of foetus’s heartbeat.

First the viability of the foetus has to be confirmed. At every examination blood pressure is taken and proteinuria has to be excluded, so that pre-eclampsia and other hypertensive pregnancy diseases can be recognized. Next it has to be established whether the foetus’s growth is appropriate for its gestation age (the symphsis-fundus distance, US measurements of the foetus) (79). Previous measurements of the symphsis-fundus distance should be re- viewed (79).

After the 28th week of pregnancy the endangerment of the foetus should be established using CTG.

A normal CTG record is an indicator that the foetus is doing well and that the autonomous nervous system works normally (80). In the prospective study it was established that the rate of stillbirth (when excluding developmental irregularities leading to death) with a normal CTG record was 1.9/1,000 births, while with a suspicious and pathological CTG record it stood at 26/1,000 births. An older study showed that the CTG record was pathological with 56% of pregnant women who came in for an examination because of reduced foetal movement, and in 9 out of 10 cases this was related to an adverse peri-

(8)

natal outcome (62). CTG is a justifiable examination for a pregnant woman with decreased foetal movement after 28 weeks of pregnancy (2,33,81).

If there are risk factors for intrauterine foetal death or growth restriction and with a suspicious CTG record, and in the event of normal CTG record but with increasingly slower foetal movement an US examination is required.

Taking a US measurement of the abdominal circumference and the US weight estimate of the foetus to establish, whether the foetus is too small for its gestation age. Using a US examination is needed to assess the amount of placenta fluid.

Recommendation A

If the pregnant woman has not conducted her regular morphological US examination, the foetus’s

morphology must be assessed.

There is not enough data supporting US examination for every pregnant woman

Table 1: Recommendation evaluation (84).

Strength level, i.e. the weight of the recommendation

A the recommendation is supported by at least one meta-analysis or with a range of evidence from experimental studies (controlled randomized studies) or systematic reviews of experimental studies with a very low bias, with consistent results and a direct usability for the target population

B recommendation is supported with high-quality systematic reviews of case-control studies or cohort studies or with case-control studies and cohort studies with a very low bias risk

C recommendation is supported with high-quality case-control studies or cohort studies with a very low bias risk

D recommendation is supported with evidence from cases or groups of cases or with expert opinions

with reduced foetal movement, however, US can be used to establish some reasons for reduced foetal movement. The major Norwegian study (29,40,82) established that by monitoring foetal movement and using an appropriate protocol for pregnant women with reduced foetal movement (CTG and US) has a significant impact on the reduction of intrauteral foetal deaths, and no increase in the number of early deliveries or the need for intensive care of new-borns. The number of conducted USs was doubled, however, it was also found that the increased US examinations were compensated with fewer control examinations.

Recommendation D

We should advise the pregnant woman that in the case of repeated reduction in foetal movement another examination is needed (RCOG’s recommendation based on best clinical practice).

In the event of another episode of reduced foetal movement the perinatal outcome is worse (83), and consequently another examination is needed, includ- ing CTG and US. There is no published research that would make the decision easier as to whether delivery should be induced at the planned date of delivery, if

(9)

the episodes of reduced foetal movement are recurring, while foetal growth remains appropriate, CTG normal and the amount of placental fluid appropriate. In such cases the decision on induced delivery should be on a case-by-case basis and taken by an experienced obstetrician.

7 Conclusion

Reduced foetal movement is clinically significant and can forecast an adverse

perinatal outcome. We recommend providing uniform information on foetal movement monitoring, a uniform method for monitoring foetal movement (modified count-to-ten method) and the use of a uniform table for marking foetal movement for pregnant women. Appropriate action during contact with the pregnant woman who reports on reduced foetal movement can help recognize the more endangered pregnant women and foetuses.

References

1. Malm MC, Lindgren H, Rådestad I. Losing contact with one’s unborn baby—mothers’ experiences prior to receiving news that their baby has died in utero. Omega (Westport). 2010-2011;62(4):353-67. DOI: 10.2190/

OM.62.4.c PMID: 21661539

2. Royal College of Obstetricians and Gynaecologists. Reduced Fetal Movements (Green-top Guideline No.

27). London: RCOG; 2011 [cited 2014 Dec 01]. Available from: https://www.rcog.org.uk/en/guidelines- research-services/guidelines/gtg57/.

3. Valentin L, Marsál K. Pregnancy outcome in women perceiving decreased fetal movement. Eur J Obstet Gynecol Reprod Biol. 1987;24(1):23-32. DOI: 10.1016/0028-2243(87)90033-5 PMID: 3817269

4. Whitty JE, Garfinkel DA, Divon MY. Maternal perception of decreased fetal movement as an indication for antepartum testing in a low-risk population. Am J Obstet Gynecol. 1991;165(4 Pt 1):1084-8. DOI:

10.1016/0002-9378(91)90476-8 PMID: 1951519

5. Bekedam DJ, Visser GH. Effects of hypoxemic events on breathing, body movements, and heart rate variation: a study in growth-retarded human fetuses. Am J Obstet Gynecol. 1985;153(1):52-6. DOI:

10.1016/0002-9378(85)90589-7 PMID: 4036999

6. Gagnon R, Hunse C, Fellows F, Carmichael L, Patrick J. Fetal heart rate and activity patterns in growth- retarded fetuses: changes after vibratory acoustic stimulation. Am J Obstet Gynecol. 1988;158(2):265-71.

DOI: 10.1016/0002-9378(88)90135-4 PMID: 3341405

7. Ribbert LS, Nicolaides KH, Visser GH. Prediction of fetal acidaemia in intrauterine growth retardation:

comparison of quantified fetal activity with biophysical profile score. Br J Obstet Gynaecol.

1993;100(7):653-6. DOI: 10.1111/j.1471-0528.1993.tb14233.x PMID: 8369249

8. Sival DA, Visser GH, Prechtl HF. The effect of intrauterine growth retardation on the quality of general movements in the human fetus. Early Hum Dev. 1992;28(2):119-32. DOI: 10.1016/0378-3782(92)90107-R PMID: 1587224

9. Vindla S, James DK, Sahota DS, Coppens M. Computerised analysis of behaviour in normal and growth- retarded fetuses. Eur J Obstet Gynecol Reprod Biol. 1997;75(2):169-75. DOI: 10.1016/S0301-2115(97)00131- 0 PMID: 9447370

10. Vindla S, James D, Sahota D. Computerised analysis of unstimulated and stimulated behaviour in fetuses with intrauterine growth restriction. Eur J Obstet Gynecol Reprod Biol. 1999;83(1):37-45. DOI: 10.1016/

S0301-2115(98)00238-3 PMID: 10221608

11. Sherer DM, Spong CY, Minior VK, Salafia CM. Decreased amniotic fluid volume at < 32 weeks of gestation is associated with decreased fetal movements. Am J Perinatol. 1996;13(8):479-82. DOI: 10.1055/s-2007- 994431 PMID: 8989478

12. Lin CC, Adamczyk CJ, Sheikh Z, Mittendorf R. Fetal congenital malformations. Biophysical profile evaluation. J Reprod Med. 1998;43(6):521-7. PMID: 9653699

13. Naeye RL, Lin HM. Determination of the timing of fetal brain damage from hypoxemia-ischemia. Am J Obstet Gynecol. 2001;184(2):217-24. DOI: 10.1067/mob.2001.108996 PMID: 11174505

14. James DK, Telfer FM, Keating NA, Blair ME, Wilcox MA, Chilvers C. Reduced fetal movements and maternal medication - new pregnancy risk factors for neurodevelopmental disability in childhood. J Obstet Gynaecol. 2000;20(3):226-34. DOI: 10.1080/01443610050009494 PMID: 15512540

(10)

15. Goldstein I, Romero R, Merrill S, Wan M, O’Connor TZ, Mazor M, et al. Fetal body and breathing movements as predictors of intraamniotic infection in preterm premature rupture of membranes. Am J Obstet Gynecol.

1988;159(2):363-8. DOI: 10.1016/S0002-9378(88)80085-1 PMID: 3407694

16. Sadovsky E, Yaffe H. Daily fetal movement recording and fetal prognosis. Obstet Gynecol. 1973;41(6):845- 50. PMID: 4196643

17. Tveit JV, Saastad E, Bordahl PE, Stray-Pedersen B, Frøen JF. The epidemiology of decreased fetal movements. Proceedings of the Norwegian Perinatal Society Conference. 1996;6:161-4.

18. Rayburn WF, McKean HE. Maternal perception of fetal movement and perinatal outcome. Obstet Gynecol.

1980;56(2):161-4. PMID: 7393504

19. Fischer S, Fullerton JT, Trezise L. Fetal movement and fetal outcome in a low-risk population. J Nurse Midwifery. 1981;26(1):24-30. DOI: 10.1016/0091-2182(81)90203-2 PMID: 6907301

20. Frøen JF. A kick from within—fetal movement counting and the cancelled progress in antenatal care. J Perinat Med. 2004;32(1):13-24. DOI: 10.1515/JPM.2004.003 PMID: 15008381

21. Sinha D, Sharma A, Nallaswamy V, Jayagopal N, Bhatti N. Obstetric outcome in women complaining of reduced fetal movements. J Obstet Gynaecol. 2007;27(1):41-3. DOI: 10.1080/01443610601016909 PMID:

17365457

22. Grant A, Elbourne D, Valentin L, Alexander S. Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet. 1989;2(8659):345-9. DOI: 10.1016/S0140- 6736(89)90535-7 PMID: 2569550

23. Harrington K, Thompson O, Jordan L, Page J, Carpenter RG, Campbell S. Obstetric outcome in women who present with a reduction in fetal movements in the third trimester of pregnancy. J Perinat Med.

1998;26(2):77-82. DOI: 10.1515/jpme.1998.26.2.77 PMID: 9650126

24. Johnson TR, Jordan ET, Paine LL. Doppler recordings of fetal movement: II. Comparison with maternal perception. Obstet Gynecol. 1990;76(1):42-3. PMID: 2193268

25. Tuffnell DJ, Cartmill RS, Lilford RJ. Fetal movements; factors affecting their perception. Eur J Obstet Gynecol Reprod Biol. 1991;39(3):165-7. DOI: 10.1016/0028-2243(91)90052-M PMID: 2032586 26. Hijazi ZR, East CE. Factors affecting maternal perception of fetal movement. Obstet Gynecol Surv.

2009;64(7):489-97. DOI: 10.1097/OGX.0b013e3181a8237a PMID: 19545457

27. Frøen JF, Saastad E, Tveit JV, Børdahl PE, Stray-Pedersen B. Clinical practice variation in reduced fetal movements. Tidsskr Nor Laegeforen. 2005;125(19):2631-4. PMID: 16215607

28. Sergent F, Lefèvre A, Verspyck E, Marpeau L. Decreased fetal movements in the third trimester: what to do?

Gynécol Obstét Fertil. 2005;33(11):861-9. DOI: 10.1016/j.gyobfe.2005.07.041 PMID: 16243568

29. Tveit JV, Saastad E, Stray-Pedersen B, Børdahl PE, Flenady V, Fretts R, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth. 2009;9(1):32. DOI: 10.1186/1471-2393-9-32 PMID: 19624847

30. Efkarpidis S, Alexopoulos E, Kean L, Liu D, Fay T. Case-control study of factors associated with intrauterine fetal deaths. MedGenMed. 2004;6(2):53. PMID: 15266278

31. Fossen D, Silberg IE. [Perinatal deaths in the county of Ostfold 1989-97]. Tidsskr Nor Laegeforen.

1999;119(9):1272-5. PMID: 10327848

32. Saastad E, Vangen S, Frøen JF. Suboptimal care in stillbirths - a retrospective audit study. Acta Obstet Gynecol Scand. 2007;86(4):444-50. DOI: 10.1080/00016340701207724 PMID: 17486466

33. Australian and New Zealand Stillbirth Association. Clinical Practice Guideline for the Management of Women who report Decreased Fetal Movements. First edition, Version 1.1. Woolloongabba: ANZSA; 2010 [cited 2013 Jun 01]. Available from: https://sanda.psanz.com.au/assets/Uploads/FINAL-DFM-guideline- Ed1V1-1-16Sept2010.pdf.

34. Liston RM, Sawchuck D, Young DC. Fetal health surveillance: antepartum and intrapartum consensus guideline. SOGC Clinical Practice Guideline No. 197, September 2007. J Obstet Gynaecol Can.

2007;[suppl]:29.

35. Neldam S. Fetal movements as an indicator of fetal well-being. Dan Med Bull. 1983;30(4):274-8. PMID:

6872585

36. Marsál K. Ultrasonic assessment of fetal activity. Clin Obstet Gynaecol. 1983;10(3):541-63. PMID: 6360464 37. D’Elia A, Pighetti M, Moccia G, Santangelo N. Spontaneous motor activity in normal fetuses. Early Hum Dev.

2001;65(2):139-47. DOI: 10.1016/S0378-3782(01)00224-9 PMID: 11641034

38. Natale R, Nasello-Paterson C, Turliuk R. Longitudinal measurements of fetal breathing, body movements, heart rate, and heart rate accelerations and decelerations at 24 to 32 weeks of gestation. Am J Obstet Gynecol. 1985;151(2):256-63. DOI: 10.1016/0002-9378(85)90022-5 PMID: 3881962

39. Eller DP, Stramm SL, Newman RB. The effect of maternal intravenous glucose administration on fetal activity. Am J Obstet Gynecol. 1992;167(4 Pt 1):1071-4. DOI: 10.1016/S0002-9378(12)80040-8 PMID: 1415393 40. Cito G, Luisi S, Mezzesimi A, Cavicchioli C, Calonaci G, Petraglia F. Maternal position during non-stress

test and fetal heart rate patterns. Acta Obstet Gynecol Scand. 2005;84(4):335-8. DOI: 10.1111/j.0001- 6349.2005.00644.x PMID: 15762962

(11)

41. Patrick J, Fetherston W, Vick H, Voegelin R. Human fetal breathing movements and gross fetal body movements at weeks 34 to 35 of gestation. Am J Obstet Gynecol. 1978;130(6):693-9. DOI: 10.1016/0002- 9378(78)90330-7 PMID: 637085

42. Minors DS, Waterhouse JM. The effect of maternal posture, meals and time of day on fetal movements. Br J Obstet Gynaecol. 1979;86(9):717-23. DOI: 10.1111/j.1471-0528.1979.tb11273.x PMID: 497144

43. Patrick J, Campbell K, Carmichael L, Natale R, Richardson B. Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. Am J Obstet Gynecol.

1982;142(4):363-71. DOI: 10.1016/S0002-9378(16)32375-4 PMID: 7058842

44. Moore TR, Piacquadio K. A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol. 1989;160(5 Pt 1):1075-80. DOI: 10.1016/0002-9378(89)90164- 6 PMID: 2729383

45. Velazquez MD, Rayburn WF. Antenatal evaluation of the fetus using fetal movement monitoring. Clin Obstet Gynecol. 2002;45(4):993-1004. DOI: 10.1097/00003081-200212000-00006 PMID: 12438877

46. Neldam S, Jessen P. Fetal movements registered by the pregnant woman correlated to retrospective estimations of fetal movements from cardiotocographic tracings. Am J Obstet Gynecol. 1980;136(8):1051-4.

DOI: 10.1016/0002-9378(80)90636-5 PMID: 7369257

47. Richardson BS, O’Grady JP, Olsen GD. Fetal breathing movements and the response to carbon dioxide in patients on methadone maintenance. Am J Obstet Gynecol. 1984;150(4):400-5. DOI: 10.1016/S0002- 9378(84)80147-7 PMID: 6435452

48. Castillo RA, Devoe LD, Ruedrich DA, Gardner P. The effects of acute alcohol intoxication on biophysical activities: a case report. Am J Obstet Gynecol. 1989;160(3):692-3. DOI: 10.1016/S0002-9378(89)80061-4 PMID: 2929694

49. Robertson SS, Dierker LJ. Fetal cyclic motor activity in diabetic pregnancies: sensitivity to maternal blood glucose. Dev Psychobiol. 2003;42(1):9-16. DOI: 10.1002/dev.10045 PMID: 12471632

50. Zisser H, Jovanovic L, Thorsell A, Kupperman A, Taylor LJ, Ospina P, et al. The fidgety fetus hypothesis: fetal activity is an additional variable in determining birth weight of offspring of women with diabetes. Diabetes Care. 2006;29(1):63-7. DOI: 10.2337/diacare.29.01.06.dc05-1369 PMID: 16373897

51. Birkenfeld A, Laufer N, Sadovsky E. Diurnal variation of fetal activity. Obstet Gynecol. 1980;55(4):417-9.

PMID: 7189265

52. Manning F, Wyn Pugh E, Boddy K. Effect of cigarette smoking on fetal breathing movements in normal pregnancies. BMJ. 1975;1(5957):552-3. DOI: 10.1136/bmj.1.5957.552 PMID: 1139146

53. Ritchie K. The fetal response to changes in the composition of maternal inspired air in human pregnancy.

Semin Perinatol. 1980;4(4):295-9. PMID: 6776632

54. Magee LA, Dawes GS, Moulden M, Redman CW. A randomised controlled comparison of betamethasone with dexamethasone: effects on the antenatal fetal heart rate. Br J Obstet Gynaecol. 1997;104(11):1233-8.

DOI: 10.1111/j.1471-0528.1997.tb10968.x PMID: 9386022

55. Mulder EJ, Derks JB, Visser GH. Antenatal corticosteroid therapy and fetal behaviour: a randomised study of the effects of betamethasone and dexamethasone. Br J Obstet Gynaecol. 1997;104(11):1239-47. DOI:

10.1111/j.1471-0528.1997.tb10969.x PMID: 9386023

56. Jackson JR, Kleeman S, Doerzbacher M, Lambers DS. The effect of glucocorticosteroid administration on fetal movements and biophysical profile scores in normal pregnancies. J Matern Fetal Neonatal Med.

2003;13(1):50-3. DOI: 10.1080/jmf.13.1.50.53 PMID: 12710857

57. Kean LH, Suwanrath C, Gargari SS, Sahota DS, James DK. A comparison of fetal behaviour in breech and cephalic presentations at term. Br J Obstet Gynaecol. 1999;106(11):1209-13. DOI: 10.1111/j.1471-0528.1999.

tb08150.x PMID: 10549969

58. Fisher ML. Reduced fetal movements: a research-based project. Br J Midwifery. 1999;7(12):733-7. DOI:

10.12968/bjom.1999.7.12.8208

59. Gettinger A, Roberts AB, Campbell S. Comparison between subjective and ultrasound assessments of fetal movement. BMJ. 1978;2(6130):88-90. DOI: 10.1136/bmj.2.6130.88 PMID: 667573

60. Hertogs K, Roberts AB, Cooper D, Griffin DR, Campbell S. Maternal perception of fetal motor activity. BMJ.

1979;2(6199):1183-5. DOI: 10.1136/bmj.2.6199.1183 PMID: 519353

61. Neldam S. Fetal movements as an indicator of fetal wellbeing. Lancet. 1980;1(8180):1222-4. DOI: 10.1016/

S0140-6736(80)91681-5 PMID: 6104039

62. Rayburn WF. Clinical significance of perceptible fetal motion. Am J Obstet Gynecol. 1980;138(2):210-2. DOI:

10.1016/0002-9378(80)90037-X PMID: 7424986

63. Sorokin Y, Pillay S, Dierker LJ, Hertz RH, Rosen MG. A comparison between maternal, tocodynamometric, and real-time ultrasonographic assessments of fetal movement. Am J Obstet Gynecol. 1981;140(4):456-60.

DOI: 10.1016/0002-9378(81)90045-4 PMID: 7246664

64. Schmidt W, Cseh I, Hara K, Kubli F. Maternal perception of fetal movements and real-time ultrasound findings. J Perinat Med. 1984;12(6):313-8. DOI: 10.1515/jpme.1984.12.6.313 PMID: 6533277

(12)

65. Valentin L, Marsál K, Lindström K. Recording of foetal movements: a comparison of three methods. J Med Eng Technol. 1986;10(5):239-47. DOI: 10.3109/03091908609022914 PMID: 3537300

66. Besinger RE, Johnson TR. Doppler recording of fetal movement: clinical correlation with real-time ultrasound. Obstet Gynecol. 1989;74(2):277-80. PMID: 2664613

67. Lowery CL, Russell WA, Baggot PJ, Wilson JD, Walls RC, Bentz LS, et al. Time quantified detection of fetal movements using a new fetal movement algorithm. Am J Perinatol. 1997;14(1):7-12. DOI: 10.1055/s-2007- 994088 PMID: 9259889

68. Melendez TD, Rayburn WF, Smith CV. Characterization of fetal body movement recorded by the Hewlett-Packard M-1350-A fetal monitor. Am J Obstet Gynecol. 1992;167(3):700-2. DOI: 10.1016/S0002- 9378(11)91574-9 PMID: 1530026

69. The American College of Obstetricians and GynecologistsGuidelines for perinatal care. 5th ed. Washington DC: The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Paediatrics; 2002.

70. Mangesi L, Hofmeyr GJ, Smith V, Smyth RM. Fetal movement counting for assessment of fetal wellbeing.

Cochrane Database Syst Rev. 2015;10(10):CD004909. DOI: 10.1002/14651858.CD004909.pub3 PMID:

26467769

71. Saastad E, Tveit JV, Flenady V, Stray-Pedersen B, Fretts RC, Børdahl PE, et al. Implementation of uniform information on fetal movement in a Norwegian population reduced delayed reporting of decreased fetal movement and stillbirths in primiparous women - a clinical quality improvement. BMC Res Notes.

2010;3(1):2. DOI: 10.1186/1756-0500-3-2 PMID: 20044943

72. Saastad E, Israel P, Ahlborg T, Gunnes N, Frøen JF. Fetal movement counting—effects on maternal-fetal attachment: a multicenter randomized controlled trial. Birth. 2011;38(4):282-93. DOI: 10.1111/j.1523- 536X.2011.00489.x PMID: 22112328

73. Olesen AG, Svare JA. Decreased fetal movements: background, assessment, and clinical management.

Acta Obstet Gynecol Scand. 2004;83(9):818-26. DOI: 10.1111/j.0001-6349.2004.00603.x PMID: 15315592 74. Heazell AE, Sumathi GM, Bhatti NR. What investigation is appropriate following maternal perception of

reduced fetal movements? J Obstet Gynaecol. 2005;25(7):648-50. DOI: 10.1080/01443610500278303 PMID:

16263536

75. Flenady V, MacPhail J, Gardener G, Chadha Y, Mahomed K, Heazell A, et al. Detection and management of decreased fetal movements in Australia and New Zealand: a survey of obstetric practice. Aust N Z J Obstet Gynaecol. 2009;49(4):358-63. DOI: 10.1111/j.1479-828X.2009.01026.x PMID: 19694688

76. Heazell AE, Green M, Wright C, Flenady V, Frøen JF. Midwives’ and obstetricians’ knowledge and management of women presenting with decreased fetal movements. Acta Obstet Gynecol Scand.

2008;87(3):331-9. DOI: 10.1080/00016340801902034 PMID: 18307074

77. Saastad E, Winje BA, Israel P, Frøen JF. Fetal movement counting—maternal concern and experiences: a multicenter, randomized, controlled trial. Birth. 2012;39(1):10-20. DOI: 10.1111/j.1523-536X.2011.00508.x PMID: 22369601

78. Confidential Enquiry into Stillbirths and Deaths in InfancyShaw RW, Maternal and Child Health Research Consortium. Confidential Enquiry into Stillbirths and Deaths in Infancy: 8th Annual Report. London: CESDI National Advisory Body; 2001.

79. Royal College of Obstetricians and GynaecologistsGreentop. Small-for-Gestational-Age Fetus, Investigation and Management (Green-top Guideline No. 31). London: RCOG; 2002.

80. Keegan KA, Paul RH. Antepartum fetal heart rate testing. IV. The nonstress test as a primary approach. Am J Obstet Gynecol. 1980;136(1):75-80. DOI: 10.1016/0002-9378(80)90568-2 PMID: 6444346

81. Malcus P. Antenatal fetal surveillance. Curr Opin Obstet Gynecol. 2004;16(2):123-8. DOI: 10.1097/00001703- 200404000-00005 PMID: 15017340

82. Freeman RK, Anderson G, Dorchester W. A prospective multi-institutional study of antepartum fetal heart rate monitoring. Am J Obstet Gynecol. 1982;143(7):771-7. DOI: 10.1016/0002-9378(82)90008-4 PMID:

7102744

83. O’Sullivan O, Stephen G, Martindale E, Heazell AE. Predicting poor perinatal outcome in women who present with decreased fetal movements. J Obstet Gynaecol. 2009;29(8):705-10. DOI:

10.3109/01443610903229598 PMID: 19821662

84. Geršak K, Fras Z, Rems M. Ali vemo, kakšne morajo biti dobre klinične smernice? Zdrav Vestn. 2016;85(1):6- 14.