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. 2015 Oct 15;2015(10):CD004909.
doi: 10.1002/14651858.CD004909.pub3.

Fetal movement counting for assessment of fetal wellbeing

Lindeka Mangesi  1 , G Justus Hofmeyr, Valerie Smith, Rebecca M D Smyth
Affiliations

Fetal movement counting for assessment of fetal wellbeing

Lindeka Mangesi et al. Cochrane Database Syst Rev. .

Abstract

Background: Fetal movement counting is a method by which a woman quantifies the movements she feels to assess the condition of her baby. The purpose is to try to reduce perinatal mortality by alerting caregivers when the baby might be compromised. This method may be used routinely, or only in women who are considered at increased risk of complications affecting the baby. Fetal movement counting may allow the clinician to make appropriate interventions in good time to improve outcomes. On the other hand, fetal movement counting may cause unnecessary anxiety to pregnant women, or elicit unnecessary interventions.

Objectives: To assess outcomes of pregnancy where fetal movement counting was done routinely, selectively or was not done at all; and to compare different methods of fetal movement counting.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) and cluster-RCTs where fetal movement counting was assessed as a method of monitoring fetal wellbeing.

Data collection and analysis: Two review authors assessed studies for eligibility, assessed the methodological quality of included studies and independently extracted data from studies. Where possible the effects of interventions were compared using risk ratios (RR), and presented with 95% confidence intervals (CI). For some outcomes, the quality of the evidence was assessed using the GRADE approach.

Main results: Five studies (71,458 women) were included in this review; 68,654 in one cluster-RCT. None of these five trials were assessed as having low risk of bias on all seven risk of bias criteria. All included studies except for one (which included high-risk women as participants) included women with uncomplicated pregnancies.Two studies compared fetal movement counting with standard care, as defined by trial authors. Two included studies compared two types of fetal movement counting; once a day fetal movement counting (Cardiff count-to-10) with more than once a day fetal movement counting methods. One study compared fetal movement counting with hormone assessment.(1) Routine fetal movement counting versus mixed or undefined fetal movement countingNo study reported on the primary outcome 'perinatal death or severe morbidity'. In one large cluster-RCT, there was no difference in mean stillbirth rates per cluster (standard mean difference (SMD) 0.23, 95% CI -0.61 to 1.07; participants = 52 clusters; studies = one, low quality evidence). The other study reported no fetal deaths. There was no difference in caesarean section rate between groups (RR 0.93, 95% CI 0.60 to 1.44; participants = 1076; studies = one,low quality evidence). Maternal anxiety was significantly reduced with routine fetal movement counting (SMD -0.22, 95% CI -0.35 to -0.10; participants = 1013; studies = one, moderate quality evidence). Maternal-fetal attachment was not significantly different (SMD -0.02, 95% CI -0.15 to 0.11; participants = 951; studies = one, low quality evidence). In one study antenatal admission after reporting of decreased fetal movements was increased (RR 2.72, 95% CI 1.34 to 5.52; participants = 123; studies = one). In another there was a trend to more antenatal admissions per cluster in the counting group than in the control group (SMD 0.38, 95% CI -0.17 to 0.93; participants = 52 clusters; studies = one, low quality evidence). Birthweight less than 10th centile was not significantly different between groups (RR 0.98, 95% CI 0.66 to 1.44; participants = 1073; studies = one, low quality evidence). The evidence was of low quality due to imprecise results and because of concerns regarding unclear risk of bias. (2) Formal fetal movement counting (Modified Cardiff method) versus hormone analysisThere was no difference between the groups in the incidence of caesarean section (RR 1.18, 95% CI 0.83 to 1.69; participants = 1191; studies = one). Women in the formal fetal movement counting group had significantly fewer hospital visits than those randomised to hormone analysis (RR 0.26, 95% CI 0.20 to 0.35), whereas there were fewer Apgar scores less than seven at five minutes for women randomised to hormone analysis (RR 1.72, 95% CI 1.01 to 2.93). No other outcomes reported showed statistically significant differences. 'Perinatal death or severe morbidity' was not reported. (3) Formal fetal movement counting once a day (count-to-10) versus formal fetal movement counting method where counting was done more than once a day (after meals)The incidence of caesarean section did not differ between the groups under this comparison (RR 2.33, 95% CI 0.61 to 8.99; participants = 1400; studies = one). Perinatal death or severe morbidity was not reported. Women were more compliant in using the count-to-10 method than they were with other fetal movement counting methods, citing less interruption with daily activities as one of the reasons (non-compliance RR 0.25, 95% CI 0.19 to 0.32).Except for one cluster-RCT, included studies were small and used different comparisons, making it difficult to measure the outcomes using meta-analyses. The nature of the intervention measured also did not allow blinding of participants and clinicians..

Authors' conclusions: This review does not provide sufficient evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Only two studies compared routine fetal movements with standard antenatal care, as defined by trial authors. Indirect evidence from a large cluster-RCT suggested that more babies at risk of death were identified in the routine fetal monitoring group, but this did not translate to reduced perinatal mortality. Robust research by means of studies comparing particularly routine fetal movement counting with selective fetal movement counting is needed urgently, as it is a common practice to introduce fetal movement counting only when there is already suspected fetal compromise.

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Conflict of interest statement

None known.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 1 Caesarean section.
1.2
1.2. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 2 Maternal anxiety.
1.3
1.3. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 3 Maternal‐fetal attachment.
1.4
1.4. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 4 Antenatal hospital admission rate per cluster (mean).
1.5
1.5. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 5 Antenatal Admission after reporting DFM.
1.6
1.6. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 6 Other fetal testing (cardiotocogram) on presentation with DFM rate per cluster (mean).
1.7
1.7. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 7 Other fetal testing (cardiotocogram) on presentation with DFM.
1.8
1.8. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 8 Other fetal testing (ultrasound) on presentation with DFM.
1.9
1.9. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 9 Stillbirth rate per cluster (mean).
1.10
1.10. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 10 Premature birth.
1.11
1.11. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 11 Low birthweight (< 2500 g or < 10th centile).
1.12
1.12. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 12 Assisted birth (vaginal).
1.13
1.13. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 13 5 minute Apgar score < 4.
1.14
1.14. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 14 Neonatal ICU admission.
1.15
1.15. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 15 Perinatal death.
1.16
1.16. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 16 Consultation for DFM.
1.17
1.17. Analysis
Comparison 1 Routine fetal movement counting versus mixed or undefined fetal movement counting, Outcome 17 Use of ultrasound (for foetal growth, amniotic fluid and foetal activity).
2.1
2.1. Analysis
Comparison 2 Fetal movement counting versus hormonal analysis, Outcome 1 Caesarean section.
2.2
2.2. Analysis
Comparison 2 Fetal movement counting versus hormonal analysis, Outcome 2 Maternal anxiety/Created insecurity.
2.3
2.3. Analysis
Comparison 2 Fetal movement counting versus hormonal analysis, Outcome 3 Antenatal hospital admissions.
2.4
2.4. Analysis
Comparison 2 Fetal movement counting versus hormonal analysis, Outcome 4 Stillbirths.
2.5
2.5. Analysis
Comparison 2 Fetal movement counting versus hormonal analysis, Outcome 5 Apgar score < 7 in 5 minutes.
2.6
2.6. Analysis
Comparison 2 Fetal movement counting versus hormonal analysis, Outcome 6 Assisted birth.
2.7
2.7. Analysis
Comparison 2 Fetal movement counting versus hormonal analysis, Outcome 7 Number of hospital visits (not pre‐specified).
3.1
3.1. Analysis
Comparison 3 'count‐to‐10' method versus 'count three (Sadovsky) or four (CLAP) times daily method", Outcome 1 Caesarean section due to absent FM (not pre‐specified).
3.2
3.2. Analysis
Comparison 3 'count‐to‐10' method versus 'count three (Sadovsky) or four (CLAP) times daily method", Outcome 2 Maternal anxiety.
3.3
3.3. Analysis
Comparison 3 'count‐to‐10' method versus 'count three (Sadovsky) or four (CLAP) times daily method", Outcome 3 Maternal fetal attachment.
3.4
3.4. Analysis
Comparison 3 'count‐to‐10' method versus 'count three (Sadovsky) or four (CLAP) times daily method", Outcome 4 Other tests of fetal wellbeing.
3.5
3.5. Analysis
Comparison 3 'count‐to‐10' method versus 'count three (Sadovsky) or four (CLAP) times daily method", Outcome 5 Premature birth.
3.6
3.6. Analysis
Comparison 3 'count‐to‐10' method versus 'count three (Sadovsky) or four (CLAP) times daily method", Outcome 6 Perinatal death.
3.7
3.7. Analysis
Comparison 3 'count‐to‐10' method versus 'count three (Sadovsky) or four (CLAP) times daily method", Outcome 7 Non‐compliance (not pre‐specified).
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References

References to studies included in this review

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