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Commentary on: T Stacey, JM Thompson, EA Mitchell, et al.. Maternal perception of fetal activity and late stillbirth risk: findings from the Auckland Stillbirth Study. Birth2011;38:311–16.

Aim To access information given to pregnant women regarding fetal movement. Type of audit Prospective. Settings Three hospitals (1 tertiary referral university hospital+2 district hospitals) Background Maternal perception of decreased fetal activity is one of the most common complaint and also a common reason for frequent hospital visits in pregnancy. There is no universally acceptable definition of fetal movement. Women presenting with decreased fetal movements do have a higher risk of still birth, intra uterine growth restriction, preterm birth and other related outcomes. Very little research has been conducted to identify optimal management. Methods Questionnaire given to pregnant women attending antenatal clinics. Results The mothers believed that it was normal for their baby to move less often at the end of pregnancy. Many of them had waited 24–48 h before contacting a health professional. There is no evidence that fetal movement decreases in the third trimester. In few still births we had, the mother did not contact health professional upto 48 h thinking it might be normal for fetus to move less nearer to expected date of delivery. Conclusion More than third of the women had not received information on the importance of reporting decreased fetal movements. There is no evidence that fetal movements reduce in third trimester. Increased maternal awareness to interpret fetal activity may produce better pregnancy outcomes. Information should promote high awareness of fetal activity. Giving misleading information regarding recution in fetal movements poses threat to fetus.

Selected anti-epileptic drugs have been associated with higher risk of congential anomalies and with impaired cognitive development. To date, no study has examined the effects of anti-epileptic drug therapy on fetal behaviour. Purpose To examine movements in fetuses of women taking the anti-epileptic drugs carbamazepine, valporate and lamotrigine and to compare them to unaffected fetuses. Method Fetuses of thirty women taking three anti-epileptic drugs (carbamazepine: n=10; valporate: n=10; lamotrigine: n=10) and of 20 women unaffected by epilepsy were studied. Fetal movements were observed by ultrasound for 30 min at 12–15 weeks gestation. The number of arm, leg, startle and head movements was recorded off-line for each fetus. Results Results revealed more movement by fetuses in the carbamazepine group (M=9.62 +/−3.15 (SD)) and less movement by fetuses in the valporate group (M=6.06 +/−2.37) than by those in the control group (M=6.96 +/−3.01, n=20). Movement scores of fetuses in the lamotrigine group (M=7.75 +/−3.03, n=7) were similar to those in the control group. Fetal activity is affected by anti-epileptic drugs, and these effects are drug-specific. Anti-epileptic medications have been associated with cognitive delay in children. Observation of fetal behaviour reveals the effect of these medications on central nervous system functioning during the prenatal period. Evaluation of fetal behaviour may enable the mechanisms by which anti-epileptic drugs exert their long term neurodevelopmental consequences to be determined.

A 27 year old presented to our labour ward at 8 pm, 32 weeks into her first pregnancy with reduced fetal movements. She had first noted a reduction in fetal activity two days earlier but had used her own Doppler device to listen to the fetal heartbeat and reassured herself that everything was normal. A fetal cardiotocograph was not reassuring and showed reduced variability for over an hour. Steroids were given to enhance fetal lung …

Fetal behavioural patterns were examined to test whether they could be used to localise sites of brain damage antenatally. Decreased fetal movement, persistent nonreactive fetal heart rate (FHR) pattern, and/or central nervous system malformation were used as indicators of possible neurological impairment. Ten fetuses tested in this way underwent further ultrasound examination observing movement of the extremities, chest wall (breathing), and eye and mouth, and active/quiet FHR patterns. Eight of these 10 fetuses were found on postnatal examination to have a brain impairment. The fetuses having potential in utero brain impairment were divided into four groups: those with (1) lesion sites at, or caudal to, the pons-medulla that were specifically identified by fetal behaviour, (2) diffuse lesions in the brain which, although resulting in abnormal behaviour, could not be localised by this behaviour, (3) lesions localised in the cerebral hemisphere(s) but with no abnormal behaviour and (4) temporally abnormal behaviour in utero, finally changing over to a normal pattern with no neonatal neurological abnormality. A screening system for the antenatal assessment of brain impairment is thus proposed.

A randomised and double blind study of 100 subjects and 50 controls was performed to confirm or refute a report from Cardiff in 1975 that continuous Doppler ultrasound, as used in fetal heart rate monitoring, increases fetal movement by over 90%. The results showed such an effect to be most unlikely (power greater than 0.99). A total of 150 pregnant mothers recorded fetal movements for 30 minutes while connected to a specially modified cardiotocograph, the ultrasound being switched on at random for either the first or second 15 minutes in 100 of the patients. The mean difference in 15 minute movement count, with and without ultrasound, among the 100 patients was 0.2 of a movement (SD 12.7; p greater than 0.6 by two tailed Wilcoxon matched pairs signed ranks test). The control group showed a mean difference of 2.6 movements (SD 12.1; p greater than 0.2). Results of a pilot study suggested that the observations in the earlier report may have been influenced by mechanisms unrelated to ultrasound.

The possibility that Doppler ultrasound, as used in routine fetal monitoring by external cardiotocography, might stimulate fetal activity was investigated. A mean increase in fetal activity of over 90% was found, as judged by the fetal movement count.

Forty pregnant women participated in a study to compare subjective with ultrasound assessments of fetal movements. A real-time ultrasound scanner was used. Movements were recorded for 45 minutes in all cases. There was a significant positive correlation between the number of movements recorded by the two methods, but the 95% confidence limits were wide and no correlation was found in those patients who recorded fewer than 20 movements in the study period. Thus "false-positive" information may be obtained from purely subjective data, and in patients reporting low "kick counts" fetal activity should be assessed from real-time ultrasound recordings.