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1.  A cross-sectional study of maternal perception of fetal movements and antenatal advice in a general pregnant population, using a qualitative framework 
Background
Maternal perception of fetal movements has been used as a measure of fetal well-being. Yet a Cochrane review does not recommend formal fetal movement counting compared to discretional fetal movement counting. There is some evidence that suggests that the quality of fetal movements can precede quantitative changes however there has been almost no assessment of how women describe movements and whether these descriptions may be useful in a clinical setting. Therefore we aimed to examine maternal perception of fetal movements using a qualitative framework.
Methods
Using a cross-sectional design we identified women during routine antenatal care at a tertiary referral hospital, in Sydney, Australia. Eligible women were pregnant ≥ 28 weeks, carrying a single child, > 18 years old, and with sufficient English literacy to self-complete a questionnaire. Post-natally the medical records were reviewed and demographic, pregnancy and fetal outcome data were extracted. Text responses to questions regarding maternal descriptions of fetal movements throughout pregnancy, were analysed using thematic analysis in an explicit process.
Results
156 women participated. There was a general pattern to fetal movement descriptions with increasing gestation, beginning with words such as “gentle”, to descriptions of “strong” and “limb” movements, and finally to “whole body” movements. Women perceived and described qualitative changes to fetal movements that changed throughout gestation. The majority (83%) reported that they were asked to assess fetal movements in an implicit qualitative method during their antenatal care. In contrast, only 16% regularly counted fetal movements and many described counting as confusing and reported that the advice they had received on counting differed.
Conclusions
This is the first study to use qualitative analysis to identify that pregnant women perceive fetal movements and can describe them in a relatively homogenous way throughout pregnancy that follow a general pattern of fetal growth and development. These findings suggest that women’s perception of fetal wellbeing based on their own assessment of fetal movement is used in an ad hoc method in antenatal care by clinicians.
doi:10.1186/1471-2393-13-32
PMCID: PMC3572429  PMID: 23383737
Pregnancy; Fetal movement; Qualitative analysis; Cross-sectional study
2.  Predictors of Poor Perinatal Outcome following Maternal Perception of Reduced Fetal Movements – A Prospective Cohort Study 
PLoS ONE  2012;7(7):e39784.
Background
Maternal perception of reduced fetal movement (RFM) is associated with increased risk of stillbirth and fetal growth restriction (FGR). RFM is thought to represent fetal compensation to conserve energy due to insufficient oxygen and nutrient transfer resulting from placental insufficiency.
Objective
To identify predictors of poor perinatal outcome after maternal perception of reduced fetal movements (RFM).
Design
Prospective cohort study.
Methods
305 women presenting with RFM after 28 weeks of gestation were recruited. Demographic factors and clinical history were recorded and ultrasound performed to assess fetal biometry, liquor volume and umbilical artery Doppler. A maternal serum sample was obtained for measurement of placentally-derived or modified proteins including: alpha fetoprotein (AFP), human chorionic gonadotrophin (hCG), human placental lactogen (hPL), ischaemia-modified albumin (IMA), pregnancy associated plasma protein A (PAPP-A) and progesterone. Factors related to poor perinatal outcome were determined by logistic regression.
Results
22.1% of pregnancies ended in a poor perinatal outcome after RFM. The most common complication was small-for-gestational age infants. Pregnancy outcome after maternal perception of RFM was related to amount of fetal activity while being monitored, abnormal fetal heart rate trace, diastolic blood pressure, estimated fetal weight, liquor volume, serum hCG and hPL. Following multiple logistic regression abnormal fetal heart rate trace (Odds ratio 7.08, 95% Confidence Interval 1.31–38.18), (OR) diastolic blood pressure (OR 1.04 (95% CI 1.01–1.09), estimated fetal weight centile (OR 0.95, 95% CI 0.94–0.97) and log maternal serum hPL (OR 0.13, 95% CI 0.02–0.99) were independently related to pregnancy outcome. hPL was related to placental mass.
Conclusion
Poor perinatal outcome after maternal perception of RFM is closely related to factors which are connected to placental dysfunction. Novel tests of placental function and associated fetal response may provide improved means to detect fetuses at greatest risk of poor perinatal outcome after RFM.
doi:10.1371/journal.pone.0039784
PMCID: PMC3394759  PMID: 22808059
3.  Screening and triage of intrauterine growth restriction (IUGR) in general population and high risk pregnancies: a systematic review with a focus on reduction of IUGR related stillbirths 
BMC Public Health  2011;11(Suppl 3):S1.
Background
There is a strong association between stillbirth and fetal growth restriction. Early detection and management of IUGR can lead to reduce related morbidity and mortality. In this paper we have reviewed effectiveness of fetal movement monitoring and Doppler velocimetry for the detection and surveillance of high risk pregnancies and the effect of this on prevention of stillbirths. We have also reviewed effect of maternal body mass index (BMI) screening, symphysial-fundal height measurement and targeted ultrasound in detection and triage of IUGR in the community.
Methods
We systematically reviewed all published literature to identify studies related to our interventions. We searched PubMed, Cochrane Library, and all World Health Organization Regional Databases and included publications in any language. Quality of available evidence was assessed using GRADE criteria. Recommendations were made for the Lives Saved Tool (LiST) based on rules developed by the Child Health Epidemiology Group. Given the paucity of evidence related to the effect of detection and management of IUGR on stillbirths, we undertook Delphi based evaluation from experts in the field.
Results
There was insufficient evidence to recommend against or in favor of routine use of fetal movement monitoring for fetal well being. (1) Detection and triage of IUGR with the help of (1a) maternal BMI screening, (1b) symphysial-fundal height measurement and (1c) targeted ultrasound can be an effective method of reducing IUGR related perinatal morbidity and mortality. Pooled results from sixteen studies shows that Doppler velocimetry of umbilical and fetal arteries in ‘high risk’ pregnancies, coupled with the appropriate intervention, can reduce perinatal mortality by 29 % [RR 0.71, 95 % CI 0.52-0.98]. Pooled results for impact on stillbirth showed a reduction of 35 % [RR 0.65, 95 % CI 0.41-1.04]; however, the results did not reach the conventional limits of statistical significance. This intervention could be potentially recommended for high income settings or middle income countries with improving rates and standards of facility based care. Based on the Delphi, a combination of screening with maternal BMI, Symphysis fundal height and targeted ultrasound followed by the appropriate management could potentially reduce antepartum and intrapartum stillbirth by 20% respectively. This estimate is presently being recommended for inclusion in the LiST.
Conclusion
There is insufficient evidence to recommend in favor or against fetal movement counting for routine use for testing fetal well being. Doppler velocimetry of umbilical and fetal arteries and appropriate intervention is associated with 29 % (95 % CI 2% to 48 %) reduction in perinatal mortality. Expert opinion suggests that detection and management of IUGR with the help of maternal BMI, symphysial-fundal height measurement and targeted ultrasound could be effective in reducing IUGR related stillbirths by 20%.
doi:10.1186/1471-2458-11-S3-S1
PMCID: PMC3231882  PMID: 21501426
4.  Diagnostic Value of Fetal Movement Counting by Mother and the Optimal Recording Duration 
Journal of Caring Sciences  2013;2(2):89-95.
Introduction: Fetal movement counting is a method used by mother to quantify her baby's movements. However, the optimal number of movements and the ideal duration of counting them have not been recognized. The aim of this study was to determine the diagnostic value of the two common fetal movements counting methods by mother including "ten fetal movements counting in two hours" and "three fetal movements counting in one hour" and to compare the required mean time for counting fetal movements in the two methods. Methods: 300 subjects were selected by random sampling among clients with complains of decreased fetal movements referring to AL-Zahra teaching hospital in Tabriz, Iran. Full training about how to perform the two methods of fetal movements counting and how to record in related tables was instructed by researcher. Immediately after counting movements, biophysical profile test was performed. Results: Among 291 mothers in the two groups, 99.7% had active fetuses based on both methods of fetal movement counting. 96.9% of these active fetuses obtained score of 10 in biophysical profile. There was a statistically significant relation between the results of both two methods of fetal movement counting and the biophysical profile as the gold standard. Sensitivity, specificity, positive and negative predictive values of both methods were equally 100%, 96%, 10% and 100%, respectively.Mean time (SD) for ten movement counting was 22.1(4.6) and for three movementcounting was 8.0(2.8) minutes Conclusion: The findings of this study showed that fetal movement counting test can be used as an initial screening method in predicting fetal health.
doi:10.5681/jcs.2013.011
PMCID: PMC4161098  PMID: 25276714
Biophysical profile; Fetal movements; Diagnostic value
5.  Acetylcholine receptor δ subunit mutations underlie a fast-channel myasthenic syndrome and arthrogryposis multiplex congenita 
Journal of Clinical Investigation  2001;108(1):125-130.
Limitation of movement during fetal development may lead to multiple joint contractures in the neonate, termed arthrogryposis multiplex congenita. Neuromuscular disorders are among the many different causes of reduced fetal movement. Many congenital myasthenic syndromes (CMSs) are due to mutations of the adult-specific ε subunit of the acetylcholine receptor (AChR), and, thus, functional deficits do not arise until late in gestation. However, an earlier effect on the fetus might be predicted with some defects of other AChR subunits. We studied a child who presented at birth with joint contractures and was subsequently found to have a CMS. Mutational screening revealed heteroallelic mutation within the AChR δ subunit gene, δ756ins2 and δE59K. Expression studies demonstrate that δ756ins2 is a null mutation. By contrast, both fetal and adult AChR containing δE59K have shorter than normal channel activations that predict fast decay of endplate currents. Thus, δE59K causes dysfunction of fetal as well as the adult AChR and would explain the presence of joint contractures on the basis of reduced fetal movement. This is the first report of the association of AChR gene mutations with arthrogryposis multiplex congenita. It is probable that mutations that severely disrupt function of fetal AChR will underlie additional cases.
PMCID: PMC209343  PMID: 11435464
6.  Development of Fetal Movement between 26 and 36-Weeks’ Gestation in Response to Vibro-Acoustic Stimulation 
Background: Ultrasound observation of fetal movement has documented general trends in motor development and fetal age when motor response to stimulation is observed. Evaluation of fetal movement quality, in addition to specific motor activity, may improve documentation of motor development and highlight specific motor responses to stimulation. Aim: The aim of this investigation was to assess fetal movement at 26 and 36-weeks gestation during three conditions (baseline, immediate response to vibro-acoustic stimulation (VAS), and post-response). Design: A prospective, longitudinal design was utilized. Subjects: Twelve normally developing fetuses, eight females and four males, were examined with continuous ultrasound imaging. Outcome Measures: The fetal neurobehavioral coding system (FENS) was used to evaluate the quality of motor activity during 10-s epochs over the three conditions. Results: Seventy-five percent of the fetuses at the 26-week assessment and 100% of the fetuses at the 36-week assessment responded with movement immediately following stimulation. Significant differences in head, fetal breathing, general, limb, and mouthing movements were detected between the 26 and 36-week assessments. Movement differences between conditions were detected in head, fetal breathing, limb, and mouthing movements. Conclusion: Smoother and more complex movement was observed with fetal maturation. Following VAS stimulation, an immediate increase of large, jerky movements suggests instability in fetal capabilities. Fetal movement quality changes over gestation may reflect sensorimotor synaptogenesis in the central nervous system, while observation of immature movement patterns following VAS stimulation may reflect movement pattern instability.
doi:10.3389/fpsyg.2011.00350
PMCID: PMC3245669  PMID: 22207855
motor development; fetal programming; prenatal; pregnancy; fetal movement
7.  Fetal Movement Counting Improved Identification of Fetal Growth Restriction and Perinatal Outcomes – a Multi-Centre, Randomized, Controlled Trial 
PLoS ONE  2011;6(12):e28482.
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.
Trial Registration
ClinicalTrials.gov NCT00513942
doi:10.1371/journal.pone.0028482
PMCID: PMC3244397  PMID: 22205952
8.  Maternal perception of decreased fetal movements from maternal and fetal perspectives, a cohort study 
Background
Maternal counting of fetal movement is a popular and valuable screening tool of fetal wellbeing, however it is still not known what percentage of healthy pregnant women who gave birth to healthy term newborns had experienced decreased fetal movements during gestation and what maternal and fetal factors are associated with this maternal perception of decreased fetal movements. The aim of this study was to assess the associations between maternal perception of decreased fetal movements and maternal and fetal factors in normotensive singleton pregnancies with good pregnancy outcome.
Methods
This study was conducted on 729 normotensive singleton pregnant women who had referred for prenatal visit and on follow up gave birth to healthy term newborns. A questionnaire was completed for the participants and ultrasound imaging was performed. Participants were asked to count their fetal movements for one hour/3times/day. Participants were followed till delivery to exclude mothers with preterm and/or small for gestational age delivery from the study.
Results
Perception of decreased fetal movement was independently associated with maternal employment (Odds Ratio (OR), 2.66; 95% Confidence Interval (95% CI), 1.35–5.23), not having daily exercise (OR, 4.38; 95% CI, 1.56-8.08) and maternal supine position (OR, 3.85; 95% CI, 1.71–8.83).
Conclusions
8.1% of healthy pregnant women who have good pregnancy outcome report perception of decreased fetal movement when asked to count their fetal movement in third gestational trimester which is independently associated with maternal employment, supine position on counting and not having daily exercise.
doi:10.1186/1471-2393-14-286
PMCID: PMC4148945  PMID: 25148850
Feeling; Fetus; Movement; Pregnancy; Sensation
9.  Women with bleeding in the first 20 weeks of pregnancy: value of general practice ultrasound in detecting fetal heart movement. 
BACKGROUND: Real-time ultrasound scanning has made it possible to ascertain whether the fetus is alive in women who have bleeding in early pregnancy. Portable ultrasound machines are capable of detecting fetal heart movement reliably after the ninth week of pregnancy, and can be used in a general practice setting. An ultrasound clinic was set up in a health centre and 22 general practitioners in the local area could refer women patients with bleeding in early pregnancy. AIM: A study was carried out among women with bleeding in early pregnancy to compare the presence of fetal heart movement detected at the initial ultrasound scan with subsequent fetal survival during the first 20 weeks of pregnancy. METHOD: Data were collected during a three-year period on women referred opportunistically by their general practitioners. An abdominal scan was performed on the same day or the day after presentation and the presence or absence of fetal heart movement recorded. Diagnoses and outcome at 20 weeks were ascertained from patients' health centre records. RESULTS: A total of 240 women with bleeding in early pregnancy were scanned and at the first examination fetal heart movement was detected in 115 of the fetuses (48%). Three fetuses were subsequently miscarried spontaneously while 109 of the 115 continued to the 20th week (95%). Three fetuses had gross abnormalities and these pregnancies were subsequently terminated. No heart movement was detected in 117 fetuses (49%); all were subsequently miscarried. For eight women scanned it was not clear whether fetal heart movement was present. Three of these eight pregnancies survived to the 20th week. Predictive values of fetal survival to the 20th week of pregnancy from fetal heart movement detected by general practice ultrasound scan for women with bleeding in early pregnancy showed a sensitivity of 97% and a specificity of 98%. CONCLUSION: If fetal heart movement is detected at the initial scan, approximately 19 out of every 20 viable pregnancies (those in which the fetus appears normal) will not miscarry before the 20th week. Using ultrasound in general practice it was possible to identify promptly those women with bleeding whose fetus was alive. For those women found to have a non-viable pregnancy, appropriate arrangements could be made at an early stage in the knowledge that a miscarriage was inevitable, thus avoiding unnecessary bed rest for the patient. Where fetal heart movement was detected, there was a good prognosis and thus women could be given strong reassurance.
PMCID: PMC1239503  PMID: 8745844
10.  Maternal Perception of Reduced Fetal Movements Is Associated with Altered Placental Structure and Function 
PLoS ONE  2012;7(4):e34851.
Background
Maternal perception of reduced fetal movement (RFM) is associated with increased risk of stillbirth and fetal growth restriction (FGR). DFM is thought to represent fetal compensation to conserve energy due to insufficient oxygen and nutrient transfer resulting from placental insufficiency. To date there have been no studies of placental structure in cases of DFM.
Objective
To determine whether maternal perception of reduced fetal movements (RFM) is associated with abnormalities in placental structure and function.
Design
Placentas were collected from women with RFM after 28 weeks gestation if delivery occurred within 1 week. Women with normal movements served as a control group. Placentas were weighed and photographs taken. Microscopic structure was evaluated by immunohistochemical staining and image analysis. System A amino acid transporter activity was measured as a marker of placental function.
Placentas from all pregnancies with RFM (irrespective of outcome) had greater area with signs of infarction (3.5% vs. 0.6%; p<0.01), a higher density of syncytial knots (p<0.001) and greater proliferation index (p<0.01). Villous vascularity (p<0.001), trophoblast area (p<0.01) and system A activity (p<0.01) were decreased in placentas from RFM compared to controls irrespective of outcome of pregnancy.
Conclusions
This study provides evidence of abnormal placental morphology and function in women with RFM and supports the proposition of a causal association between placental insufficiency and RFM. This suggests that women presenting with RFM require further investigation to identify those with placental insufficiency.
doi:10.1371/journal.pone.0034851
PMCID: PMC3327709  PMID: 22523561
11.  Maternal perception of fetal motor activity. 
British Medical Journal  1979;2(6199):1183-1185.
A technique using real-time ultrasound for comprehensive recording of fetal motor activity was used in 20 subjects in the third trimester of pregnancy. Maternal awareness of fetal movement correlated with the number of fetal parts contributing to the movement but not with maternal parity or obesity, gestational age, placental site, or duration of the fetal movement. Some subjects recorded fetal breathing, passive fetal displacement, and Braxton Hicks's contractions as fetal movement. Most of our subjects were consistent and accurate in their perception of major fetal movements, but a few were inconsistent and one was completely unaware of major fetal movements. These results suggest that kick counts kept by most mothers will be accurate. Low counts of fetal movement should be an indication for fetal monitoring by other means and not, unconfirmed, for intervention.
PMCID: PMC1597230  PMID: 519353
12.  Fetal response to maternal hunger and satiation – novel finding from a qualitative descriptive study of maternal perception of fetal movements 
Background
Maternal perception of decreased fetal movements is a specific indicator of fetal compromise, notably in the context of poor fetal growth. There is currently no agreed numerical definition of decreased fetal movements, with the subjective perception of a decrease on the part of the mother being the most significant definition clinically. Both qualitative and quantitative aspects of fetal activity may be important in identifying the compromised fetus. Yet, how pregnant women perceive and describe fetal activity is under-investigated by qualitative means. The aim of this study was to explore normal fetal activity, through first-hand descriptive accounts by pregnant women.
Methods
Using qualitative descriptive methodology, interviews were conducted with 19 low-risk women experiencing their first pregnancy, at two timepoints in their third trimester. Interview transcripts were later analysed using qualitative content analysis and patterns of fetal activity identified were then considered along-side the characteristics of the women and their birth outcomes.
Results
This paper focuses on a novel finding; the description by pregnant women of fetal behaviour indicative of hunger and satiation. Full findings will be presented in later papers. Most participants (74% 14 of 19) indicated mealtimes were a time of increased fetal activity. Eight participants provided detailed descriptions of increased activity around meals, with seven (37% 7 of 19) of these specifying increased fetal activity prior to meals or in the context of their own hunger. These movements were interpreted as a fetal demand for food often prompting the mother to eat. Interestingly, the women who described increased fetal activity in the context of hunger subsequently gave birth to smaller infants (mean difference 364 gm) than those who did not describe a fetal response to hunger.
Conclusions
Food seeking behaviour may have a pre-birth origin. Maternal-fetal interaction around mealtimes could constitute an endocrine mediated communication, in the interests of maintaining optimal intrauterine conditions. Further research is warranted to explore this phenomenon and the potential influence of feeding on the temporal organisation of fetal activity in relation to growth.
doi:10.1186/1471-2393-14-288
PMCID: PMC4152596  PMID: 25154868
Fetal development; Fetal movement; Maternal-fetal exchange; Hunger
13.  Temporal patterns in count-to-ten fetal movement charts and their associations with pregnancy characteristics: a prospective cohort study 
Background
Fetal movement counting has long been suggested as a screening tool to identify impaired placental function. However, quantitative limits for decreased fetal movement perform poorly for screening purposes, indicating the need for methodological refinement. We aimed to identify the main individual temporal patterns in fetal movement counting charts, and explore their associations with pregnancy characteristics.
Methods
In a population-based prospective cohort in Norway, 2009–2011, women with singleton pregnancies counted fetal movements daily from pregnancy week 24 until delivery using a modified "count-to-ten” procedure. To account for intra-woman correlation of observations, we used functional data analysis and corresponding functional principal component analysis to identify the main individual temporal patterns in fetal movement count data. The temporal patterns are described by continuous functional principal component (FPC) curves, with an individual score on each FPC for each woman. These scores were later used as outcome variables in multivariable linear regression analyses, with pregnancy characteristics as explanatory variables.
Results
Fetal movement charts from 1086 pregnancies were included. Three FPC curves explained almost 99% of the variation in the temporal data, with the first FPC, representing the individual overall counting time, accounting for 91% alone. There were several statistically significant associations between the FPCs and various pregnancy characteristics. However, the effects were small and of limited clinical value.
Conclusions
This statistical approach for analyzing fetal movement counting data successfully captured clinically meaningful individual temporal patterns and how these patterns vary between women. Maternal body mass index, gestational age and placental site explained little of the variation in the temporal fetal movement counting patterns. Thus, a perceived decrease in fetal movement should not be attributed to a woman’s basic pregnancy characteristics, but assessed as a potential marker of risk.
doi:10.1186/1471-2393-12-124
PMCID: PMC3542088  PMID: 23126608
Fetal movement; Kick counting; Decreased fetal movement; Functional data analysis; Principal components; Temporal pattern
14.  Do Facial Expressions Develop before Birth? 
PLoS ONE  2011;6(8):e24081.
Background
Fetal facial development is essential not only for postnatal bonding between parents and child, but also theoretically for the study of the origins of affect. However, how such movements become coordinated is poorly understood. 4-D ultrasound visualisation allows an objective coding of fetal facial movements.
Methodology/Findings
Based on research using facial muscle movements to code recognisable facial expressions in adults and adapted for infants, we defined two distinct fetal facial movements, namely “cry-face-gestalt” and “laughter- gestalt,” both made up of up to 7 distinct facial movements. In this conceptual study, two healthy fetuses were then scanned at different gestational ages in the second and third trimester. We observed that the number and complexity of simultaneous movements increased with gestational age. Thus, between 24 and 35 weeks the mean number of co-occurrences of 3 or more facial movements increased from 7% to 69%. Recognisable facial expressions were also observed to develop. Between 24 and 35 weeks the number of co-occurrences of 3 or more movements making up a “cry-face gestalt” facial movement increased from 0% to 42%. Similarly the number of co-occurrences of 3 or more facial movements combining to a “laughter-face gestalt” increased from 0% to 35%. These changes over age were all highly significant.
Significance
This research provides the first evidence of developmental progression from individual unrelated facial movements toward fetal facial gestalts. We propose that there is considerable potential of this method for assessing fetal development: Subsequent discrimination of normal and abnormal fetal facial development might identify health problems in utero.
doi:10.1371/journal.pone.0024081
PMCID: PMC3164123  PMID: 21904607
15.  Werdnig-Hoffmann disease. The effects of intrauterine onset on lung growth. 
Archives of Disease in Childhood  1978;53(12):921-925.
Thoracic gas volume (TGV), resting lung volume at end expiration, was measured by the plethysmographic technique in 9 infants with Werdnig-Hoffmann disease. Five of these infants were considered to have intrauterine onset of the disease; the mother in each case had reported a pronounced reduction in fetal activity during the last trimester of pregnancy, and 4 were found to be hypotonic at birth. The remaining 4 infants appeared normal at birth and did not develop any signs of the disease until between 2 and 12 weeks postnatally. Those with intrauterine onset of disease had a significantly reduced TGV (mean 20.8 ml kg(-1)), whereas those with postnatal onset had normal lung volumes (means 36.1 ml kg(-1)). The reduction in lung volume correlated only with intrauterine onset of disease, and was not related to either the degree of muscle weakness or the duration of disease. There is increasing evidence that fetal breathing movements may be one of the essential prerequisites for normal fetal lung development. It is therefore possible that diminished fetal breathing movements, resulting from weakness of the respiratory musculature in utero, could be responsible for the reduction in lung volume found in those infants with intrauterine onset of the disease.
PMCID: PMC1545162  PMID: 747396
16.  Reduction of late stillbirth with the introduction of fetal movement information and guidelines – a clinical quality improvement 
Background
Women experiencing decreased fetal movements (DFM) are at increased risk of adverse outcomes, including stillbirth. Fourteen delivery units in Norway registered all cases of DFM in a population-based quality assessment. We found that information to women and management of DFM varied significantly between hospitals. We intended to examine two cohorts of women with DFM before and during two consensus-based interventions aiming to improve care through: 1) written information to women about fetal activity and DFM, including an invitation to monitor fetal movements, 2) guidelines for management of DFM for health-care professionals.
Methods
All singleton third trimester pregnancies presenting with a perception of DFM were registered, and outcomes collected independently at all 14 hospitals. The quality assessment period included April 2005 through October 2005, and the two interventions were implemented from November 2005 through March 2007. The baseline versus intervention cohorts included: 19,407 versus 46,143 births and 1215 versus 3038 women with DFM, respectively.
Results
Reports of DFM did not increase during the intervention. The stillbirth rate among women with DFM fell during the intervention: 4.2% vs. 2.4%, (OR 0.51 95% CI 0.32–0.81), and 3.0/1000 versus 2.0/1000 in the overall study population (OR 0.67 95% CI 0.48–0.93). There was no increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care or severe neonatal depression among women with DFM during the intervention. The use of ultrasound in management increased, while additional follow up visits and admissions for induction were reduced.
Conclusion
Improved management of DFM and uniform information to women is associated with fewer stillbirths.
doi:10.1186/1471-2393-9-32
PMCID: PMC2734741  PMID: 19624847
17.  The Role of 4D Ultrasound in the Assessment of Fetal Behaviour 
Mædica  2011;6(2):120-127.
ABSTRACT
Fetal behavior is defined as any fetal action seen by the mother or fetus diagnosed by objective methods such as cardiotocography (CTG) or ultrasound. Analysis of the dynamics of the fetal behavior with morphological studies has lead to the conclusion that fetal behavior patterns are directly reflecting development and maturation of the central nervous system. The assessment of fetal behavior by 4D ultrasound could allow distinction between normal and abnormal fetal behavior patterns which might make possible the early recognition of fetal brain impairment.
Aim: Assessment of fetal movements throughout the pregnancy using 4D ultrasound.
Material and Method: The study group included 144 healthy pregnant women with single pregnancies between 7-38 weeks of gestation. For the first trimester of pregnancy we assessed eight types of fetal movements and for the second and third trimesters 14 types of fetal movements and facial expressions. The analyzed parameters for each trimester of pregnancy can be used for performing antenatal neurodevelopment test, used the first time by Professor Kurjak.
Results: After 15-20 minutes 4D ultrasound examination, we found a pattern of fetal behavior for each trimester of pregnancy.
Conclusions: Dynamic evaluation of fetal behavior reflects directly the processes of maturation and development of the central nervous system. This can make the difference between normal and abnormal brain development and may be used for early diagnosis of neurological disorders that become manifest in perinatal and postnatal periods.
PMCID: PMC3239390  PMID: 22205894
fetal behavior; 4D ultrasound; fetal movements
18.  Fetal Eye Movements on Magnetic Resonance Imaging 
PLoS ONE  2013;8(10):e77439.
Objectives
Eye movements are the physical expression of upper fetal brainstem function. Our aim was to identify and differentiate specific types of fetal eye movement patterns using dynamic MRI sequences. Their occurrence as well as the presence of conjugated eyeball motion and consistently parallel eyeball position was systematically analyzed.
Methods
Dynamic SSFP sequences were acquired in 72 singleton fetuses (17–40 GW, three age groups [17–23 GW, 24–32 GW, 33–40 GW]). Fetal eye movements were evaluated according to a modified classification originally published by Birnholz (1981): Type 0: no eye movements; Type I: single transient deviations; Type Ia: fast deviation, slower reposition; Type Ib: fast deviation, fast reposition; Type II: single prolonged eye movements; Type III: complex sequences; and Type IV: nystagmoid.
Results
In 95.8% of fetuses, the evaluation of eye movements was possible using MRI, with a mean acquisition time of 70 seconds. Due to head motion, 4.2% of the fetuses and 20.1% of all dynamic SSFP sequences were excluded.
Eye movements were observed in 45 fetuses (65.2%). Significant differences between the age groups were found for Type I (p = 0.03), Type Ia (p = 0.031), and Type IV eye movements (p = 0.033). Consistently parallel bulbs were found in 27.3–45%.
Conclusions
In human fetuses, different eye movement patterns can be identified and described by MRI in utero. In addition to the originally classified eye movement patterns, a novel subtype has been observed, which apparently characterizes an important step in fetal brainstem development. We evaluated, for the first time, eyeball position in fetuses. Ultimately, the assessment of fetal eye movements by MRI yields the potential to identify early signs of brainstem dysfunction, as encountered in brain malformations such as Chiari II or molar tooth malformations.
doi:10.1371/journal.pone.0077439
PMCID: PMC3806733  PMID: 24194885
19.  Fetal Cardiac Autonomic Control during Breathing and Non-Breathing Epochs: The Effect of Maternal Exercise 
Early human development  2012;88(7):539-546.
We explored whether maternal exercise during pregnancy moderates the effect of fetal breathing movements on fetal cardiac autonomic control assessed by metrics of heart rate (HR) and heart rate variability (HRV). Thirty women were assigned to Exercise or Control group (n=15/group) based on the modifiable physical activity questionnaire (MPAQ). Magnetocardiograms (MCG) were recorded using a dedicated fetal biomagnetometer. Periods of fetal breathing activity and apnea were identified using the fetal diaphragmatic magnetomyogram (dMMG) as a marker. MCG R-waves were marked. Metrics of fetal HR and HRV were compared using 1 breathing and1 apneic epoch/fetus. The main effects of group (Exercise vs. Control) and condition (Apnea vs. Breathing) and their interactions were explored. Fetal breathing resulted in significantly lower fetal HR and higher vagally-mediated HRV. Maternal exercise resulted in significantly lower fetal HR, higher total HRV and vagally-mediated HRV with no difference in frequency band ratios. Significant interactions between maternal exercise and fetal breathing were found for metrics summarizing total HRV and a parasympathetic metric. Post hoc comparison showed no group difference during fetal apnea. Fetal breathing was associated with a loss of Total HRV in the Control group and no difference in the Exercise group. Both groups show enhanced vagal function during fetal breathing; greater in the Exercise group. During in utero breathing movements, the fetus of the exercising mother has enhanced cardiac autonomic function that may give the offspring an adaptive advantage.
doi:10.1016/j.earlhumdev.2011.12.017
PMCID: PMC3753784  PMID: 22264436
Exercise; Autonomic Nervous System; Magnetocardiogram; Fetal Biomagnetometry; Diaphragm Activation
20.  Characterization of the Fetal Diaphragmatic Magnetomyogram and the Effect of Breathing Movements on Cardiac Metrics of Rate and Variability 
Early human development  2011;87(7):467-475.
Breathing movements are one of the earliest fetal motor behaviors to emerge andare ahallmark of fetal well-being. Fetal respiratory sinus arrhythmia (RSA) has been documented but efforts to quantify the influence of breathing on heart rate (HR) and heart rate variability (HRV) are difficult due to the episodic nature of fetal breathing activity. We used a dedicated fetal biomagnetometer to acquire the magnetocardiogram (MCG) between 36-38 weeks gestational age (GA). We identified and characterized a waveform observed in the raw data and independent component decomposition that we attribute to fetal diaphragmatic movements during breathing episodes. RSA and increased high frequency power in a time-frequency analysis of the IBI time-series was observed during fetal breathing periods. Using the diaphragmatic magnetomyogram (dMMG) as a marker, we compared time and frequency domain metrics of heartrate and heart rate variability between breathing and non-breathing epochs. Fetal breathing activity resulted in significantly lower HR, increased high frequency power, greater sympathovagal balance, increased short-term HRV andgreater parasympathetic input relative to non-breathing episodesconfirming the specificity of fetal breathing movements on parasympathetic cardiac influence. No significant differences between breathing and non-breathing epochs were found in two metrics reflecting total HRVor very low, low and intermediate frequency bands. Using the fetal dMMG as a marker, biomagnetometry can help to elucidate the electrophysiologic mechanisms associated with diaphragmatic motor function and may be used to study the longitudinal development of human fetal cardiac autonomic control and breathing activity.
doi:10.1016/j.earlhumdev.2011.03.012
PMCID: PMC3114157  PMID: 21497027
Autonomic Nervous System; Magnetocardiogram; Fetal Biomagnetometry; Diaphragm Activation
21.  A Novel Approach to Track Fetal Movement Using Multi-sensor Magnetocardiographic Recordings 
Annals of biomedical engineering  2010;39(3):964-972.
Changes in fetal magnetocardiographic (fMCG) signals are indicators for fetal body movement. We propose a novel approach to reliably extract fetal body movements based on the field strength of the fMCG signal independent of its frequency. After attenuating the maternal MCG, we use a Hilbert transform approach to identify the R-wave. At each R-wave, we compute the center-of-gravity (cog) of the coordinate positions of MCG sensors, each weighted by the magnitude of the R-wave amplitude recorded at the corresponding sensor. We then define actogram as the distance between the cog computed at each R-wave and the average of the cog from all the R-waves in a 3-min duration. By applying a linear de-trending approach to the actogram we identify the fetal body movement and compare this with the synchronous occurrence of the acceleration in the fetal heart rate. Finally, we apply this approach to the fMCG recorded simultaneously with ultrasound from a single subject and show its improved performance over the QRS-amplitude based approach in the visually verified movements. This technique could be applied to transform the detection of fetal body movement into an objective measure of fetal health and enhance the predictive value of prevalent clinical testing for fetal wellbeing.
doi:10.1007/s10439-010-0231-z
PMCID: PMC3037432  PMID: 21140290
Center-of-gravity; Hilbert transform; Fetal magenetocardiogram; Fetal body movement; Ultrasound
22.  Fetal breathing movements and other tests of fetal wellbeing: a comparative evaluation. 
British Medical Journal  1979;2(6190):577-579.
Sixty pregnant women whose fetuses were considered to be at high risk were intensively studied with fetal and placental function tests. Fetal breathing movements were studied with real-time ultrasound and the amount of time spent breathing and the variability of the breath-to-breath interval were measured. A reduction in the amount of time the fetus spent making breathing movements and decreased variability were indicative of fetal compromise. When these results were compared with those of other tests of fetal wellbeing measurement of fetal breathing movements and ultrasound assessment of growth were more sensitive tests of fetal wellbeing than the biochemical measures (urinary oestrogen, human placental lactogen, pregnancy-specific beta-1-glycoprotein, and unconjugated oestriol concentrations) or fetal heart rate. The predictive value was highest with serum unconjugated oestriol but the results of other tests were similar. Study of fetal breathing movements or an ultrasonic assessment of growth may provide a better screening test for fetal compromise than biochemical estimations.
PMCID: PMC1596521  PMID: 315254
23.  A randomised controlled trial comparing standard or intensive management of reduced fetal movements after 36 weeks gestation-a feasibility study 
Background
Women presenting with reduced fetal movements (RFM) in the third trimester are at increased risk of stillbirth or fetal growth restriction. These outcomes after RFM are related to smaller fetal size on ultrasound scan, oligohydramnios and lower human placental lactogen (hPL) in maternal serum. We performed this study to address whether a randomised controlled trial (RCT) of the management of RFM was feasible with regard to: i) maternal recruitment and retention ii) patient acceptability, iii) adherence to protocol. Additionally, we aimed to confirm the prevalence of poor perinatal outcomes defined as: stillbirth, birthweight <10th centile, umbilical arterial pH <7.1 or unexpected admission to the neonatal intensive care unit.
Methods
Women with RFM ≥36 weeks gestation were invited to participate in a RCT comparing standard management (ultrasound scan if indicated, induction of labour (IOL) based on consultant decision) with intensive management (ultrasound scan, maternal serum hPL, IOL if either result was abnormal). Anxiety was assessed by state-trait anxiety index (STAI) before and after investigations for RFM. Rates of protocol compliance and IOL for RFM were calculated. Participant views were assessed by questionnaires.
Results
137 women were approached, 120 (88%) participated, 60 in each group, 2 women in the standard group did not complete the study. 20% of participants had a poor perinatal outcome. All women in the intensive group had ultrasound assessment of fetal size and liquor volume vs. 97% in the standard group. 50% of the intensive group had IOL for abnormal scan or low hPL after RFM vs. 26% of controls (p < 0.01). STAI reduced for all women after investigations, but this reduction was greater in the standard group (p = 0.02). Participants had positive views about their involvement in the study.
Conclusion
An RCT of management of RFM is feasible with a low rate of attrition. Investigations decrease maternal anxiety. Participants in the intensive group were more likely to have IOL for RFM. Further work is required to determine the likely level of intervention in the standard care arm in multiple centres, to develop additional placental biomarkers and to confirm that the composite outcome is valid.
Trial registration
ISRCTN07944306
doi:10.1186/1471-2393-13-95
PMCID: PMC3640967  PMID: 23590451
Reduced fetal movements; Randomised controlled trial; Human placental lactogen; Feasibility; Maternal anxiety
24.  Management of reported decreased fetal movements for improving pregnancy outcomes 
Background
Clinical observations indicate that mothers commonly perceive a reduction in, or absence of, the baby’s movements for some days preceding a baby’s death. For this reason, fetal movement monitoring is advised by caregivers and used spontaneously by mothers to assess the baby’s well-being. However, it is possible that the harmful effects of interventions may outweigh the benefits of such testing. Evidence of effectiveness of fetal movement screening to improve outcomes is limited, though indirect evidence suggests a potential benefit. A secondary question is whether any specific management response to perceived decreased fetal movements (DFM) improves clinical outcome.
Objectives
To determine, from the best available evidence, the effectiveness of various management strategies for DFM.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (28 February 2012) and bibliographies of included studies.
Selection criteria
Randomised clinical trials comparing various management strategies for DFM, including delivery, expectant management, cardiotocography (visual and computerised), ultrasound examination including Doppler ultrasound, and fetal arousal tests (cardiotocographic or clinical).
Data collection and analysis
Two assessors evaluated potentially eligible trials for inclusion, and extracted data onto a purpose-designed form. Where DFM was one among a number of inclusion criteria for the trial, we contacted trial authors for information on outcomes specific to the DFM subgroups.
Main results
No randomised trials of management of DFM were found. Of 13 randomised trials of management strategies for pregnancies with risk factors for fetal compromise including DFM, data on the DFM subgroups could only be provided by the authors of one trial. The numbers were too small for meaningful analysis (there were 28 cases of DFM).
Authors’ conclusions
There are insufficient data from randomised trials to guide practice regarding the management of DFM. Based on the results of other systematic reviews of management strategies for women whose babies are thought to be at risk of compromise for various reasons, the following strategies show promise and may be prioritised for further research: Doppler ultrasound studies, computerised cardiotocography, and fetal arousal to facilitate cardiotocography.
For settings where electronic fetal assessment methods are not available, clinical fetal arousal tests should be investigated.
doi:10.1002/14651858.CD009148.pub2
PMCID: PMC4058897  PMID: 22513971
*Fetal Movement; *Pregnancy Outcome; Fetal Distress [*therapy]; Fetal Monitoring; Female; Humans; Pregnancy
25.  Women’s experiences of two different self-assessment methods for monitoring fetal movements in full-term pregnancy - a crossover trial 
Background
Low maternal awareness of fetal movements is associated with negative birth outcomes. Knowledge regarding pregnant women’s compliance with programs of systematic self-assessment of fetal movements is needed. The aim of this study was to investigate women’s experiences using two different self-assessment methods for monitoring fetal movements and to determine if the women had a preference for one or the other method.
Methods
Data were collected by a crossover trial; 40 healthy women with an uncomplicated full-term pregnancy counted the fetal movements according to a Count-to-ten method and assessed the character of the movements according to the Mindfetalness method. Each self-assessment was observed by a midwife and followed by a questionnaire. A total of 80 self-assessments was performed; 40 with each method.
Results
Of the 40 women, only one did not find at least one method suitable. Twenty of the total of 39 reported a preference, 15 for the Mindfetalness method and five for the Count-to-ten method. All 39 said they felt calm, relaxed, mentally present and focused during the observations. Furthermore, the women described the observation of the movements as safe and reassuring and a moment for communication with their unborn baby.
Conclusions
In the 80 assessments all but one of the women found one or both methods suitable for self-assessment of fetal movements and they felt comfortable during the assessments. More women preferred the Mindfetalness method compared to the count-to-ten method, than vice versa.
doi:10.1186/1471-2393-14-349
PMCID: PMC4286931  PMID: 25288075
Self-assessment; Fetal movements; Pregnancy; Crossover trial

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