daily fetal movement counting a valuable assessment tool

DAI’LY FETAL MOVEMENT COUNTING A Valuable Assessment Tool

Laurie Davis, CNM, MS, MAJ

ABSTRACT

Fetal movements, since biblical times, have been viewed as a reassuring sign of a healthy pregnancy. If the fetus was active, both mother and the health care provider knew that the fetus was at least alive. It was not until the last 15 years that the obstetric community began to place greater emphasis on the importance of the fetal movements. At present, not only an absence of movement, but also a decrease or sudden change in the number or quality of movements should create alarm. This article reviews the growth in the usage of the fetal movement count through a review of the literature. Recommendations on choosing and/or modifying a counting method to fit your clien- tele also are presented.

Since its beginning, nurse-midwifery has focused on noninvasive ways to detect potentially high-risk situations and to ensure fetal well-being. One such technique that has been receiving attention in the obstetric field during the last 15 years is daily fetal movement counting.

Since biblical times, the mother’s perception of fetal movement has been regarded as a sign of well- being, whereas an absence of fetal movement is frequently reported immediately before intrauterine death. The use of fetal movement counting can prevent a large number of these intrauterine deaths from occurring. This is especially true since approximately 70% of all stillboms weighing more than 1000 g come from other- wise seemingly normal pregnancies. 1

Now, many health care providers are using fetal movement informa- tion as a screening tool as well as a means of identifying the potential

Address correspondence to Laurie Davis, CNM, MS, MAJ, 516 Highpoint Road, Clarks- ville, TN 37040.

fetus at risk. Since the promising findings by Matthews* in 1972 and Sadovsky and Yaffe3 in 1973, various other researchers have devised fetal movement criteria. This paper is designed to focus on the research that has promoted the use of the daily fetal movement count as well as stress the contribution it can make in decreasing the stillborn rate.

VARIOUS FACTORS AFFECTING FETAL MOVEMENT There are various external and internal factors and individual variations that affect the amount and type of fetal movement. It has been demonstrated by several researchers that fetal movement varies with gestational age. A decrease in fetal movement occurs after the 32nd week of gestation according to Sadovsky4 or a decrease after the 38th week according to Ehrostrom.5

Dierken et al6 in 1982 studied the number of quiet-active cycles in re- gard to advancing gestational age. They found that the actual number of cycles showed a significant de-

Journal of Nurse-Midwifery ??Vol. 32, No. 1, January/February 1987

Copyright 0 1987 by the American College of Nurse-Midwives

crease with increasing gestational age. The premature group averaged 6.6 different activity periods per hour as compared with 2.2 per hour of the mature group.

The reasons for the decrease in movement with advancing gestational age is not fully understood at present. It may be a direct result of the smaller area the fetus has to move about in as well as a result of increasing maturation of the central nervous system.7

According to a study carried out with rhesus monkeys,* fetal activity changes from a predominently active fetal pattern to a less active neonatal pattern with increasing maturation of the central nervous system. At present, not all researchers have arrived at the same conclusions. Several studies were unable to observe any decrease in fetal movement with advancing gestation.gJO

A wide range of individual variations of daily fetal movement has been observed. Daily fluctuations ranged from 200 to 700 movements per day according to a study by

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Sadovsky.4 In a 1982 study, Patrick et allo noted a range of 0 to 130 gross fetal movements per hour that accounted for 0 to 50% of the total time. Daily fluctuations in individual cases range from 30 to 40 movements according to Sadovsky and Yaffe.3

In 1977, a range between 4 and 1440 movements per day was observed in 50 pregnant women in another study by Sadovsky and Poli- shuk.rl This wide range of variation of individual fetal movement indicates that no absolute number of daily fetal movements exists. It is thought that as long as fetal movement does not drastically decrease or cease for a X&hour period, a wide range of daily fluctuations can be considered normal. l1

There are conflicting reports concerning diurnal variation of fetal movement. In 1982, Patrick et alI* studied 11 pregnant women between 38 and 40 weeks’ gestation with the use of a real-time ultrasound scanner. Their study revealed that the fetal movement peaked between 10 PM and 2 AM. These results supported the 1973 findings of Spellacy et al, showing a significant increase in fetal movement during the evening hours with 37 pregnant women who counted the movements they felt.

Goodwin and Lower4 also observed diurnal variation. Their study, using a variety of recording devices,

Ms. Laurie Davis obtained her Bachelor

of Science Degree at California State University of Fresno in 1976 and her

Master’s Degree in Nurse Midwifery and Education at the Uniuersity of Kentucky in December 1983. In 1978 she accepted a commission into the Army

Nurse Corps as a Maternal-Child Health Nurse. Currently she is on active duty as

a Major practicing as a Staff Certified Nurse-Midwife at Fort Campbell,

Kentucky. She also is an adjunct faculty member for the Graduate Nursing School at Vanderbilt University, as well as being inuolued in other areas of both patient and staff education.

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noted a peak in movements in the majority of subjects between 7 PM and 9 PM with a second peak occurring between 11 PM and 1 AM. These findings conflict with those of Birken- field et alI5 in which 110 women as- sessed their fetal movements three times a day. Of these women only 18% showed any significant diurnal variation. The majority of research reveals the existence of diurnal variation. Some of the conflicting findings may reflect more of how the movement was recorded than an actual difference. When one uses maternal perception of movement there may be times of the day that the women are more attuned to the movements, such as during periods of rest in the evening. Variations in fetal movements may be more reflective of the variation in life styles than the actual number of movements.

The effects of smoking on fetal movements have been studied by Kelly et all6 on 75 pregnant smokers. Their results show that the nicotine content of the cigarette can decrease fetal movement up to 80 minutes after smoking two cigarettes. These findings are in agreement with a study by Quigley et all7 in 1979.

The effects of blood sugar levels or the ingestion of glucose on fetal movement has yielded conflicting findings by various researchers. Among those studies demonstrating an increase in fetal movement after maternal glucose ingestion is one conducted by Aladjem et alal8 The study population consisted of 39 low-risk and 54 high-risk pregnant patients from 30 to 42 weeks’ gestation. The researchers divided their population into two groups based on whether or not an increase in fetal movement was noted after a glucose ingestion. The group that showed an increase in fetal movement after the glucose ingestion also showed a significantly lower morbidity when compared with those fetuses that failed to demonstrate any increase. The researchers postulated that a glucose loading test could possibly be used to screen fetuses at risk.


Gelmen et all9 also were able to elicit an increase in f&al movement following the ingestion of a glucose solution. In their 1979 study, an intravenous dose of 25 g of glucose was randomly injected into the sample group of 21 low-risk pregnant women. Fetal movement was observed under real-time ultrasound to significantly increase 60 minutes after the glucose was administered. Unfortunately, this study did not continue on to observe what, if any, relation this had to fetal outcome.

Fetal breathing movements were shown under real-time ultrasound to increase after a glucose ingestion in a study conducted by Natale et a120 in 1978. This peak was seen approximately 1 hour after the peak maternal plasma glucose concentration was reached. An increase in fetal breathing was also demonstrated by Lewis et a121 in 1978. Their study showed fetal breathing movements increased from 9.9% to 48% within 1 hour after their sample population of 22 pregnant women drank a 50-g glucose drink. Their study also pointed out that fetal body movements were unaffected by the glucose ingestion.

Although Gelman et all9 were able to demonstrate a definite increase in fetal movement after a glucose load, this finding is not widely supported in the literature. In fact, these findings are in direct contrast to research done by Minors and Water- house22 in 1979, Patrick et allo in 1982, Roederburg and Walde- mirofP3 in 1981, Lewis et a121 in 1978, and Natale, et a120 in 1978. The majority of research findings indicate little to no effect of maternal glucose ingestion on fetal movement.

It is possible that fetal movement also may be affected by the use of ultrasound. The study of David et al24 of 36 pregnant women demonstrated a 90% increase in fetal movement when Doppler ultrasound was applied over the fetal heart for 30- minute periods.

Phillips and Powell25 in 1979 also

studied the effects of a Doppler ultrasound placed over the fetal heart for periods of 15 minutes. Their findings failed to reveal any increase in fetal movement associated with the use of ultrasound. Several other investigators have attempted to elicit an increase in fetal movement with the use of ultrasound but have failed to show any association.26*27

Increased fetal movement had consistently been shown to result from sound and vibration.28929 Grim- wald et aP” in 1971 studied 46 pregnant women near or at term. They found that 83% of the patients experienced a significant increase in fetal movement when sound was applied to the maternal abdomen adjacent to the fetal head. The stimuli used were a 20-second duration pure-tone sound between 500 and 1000 Hz from loudspeakers. Using this technique a intrauterine sound pressure of 80 dB was obtained.

External mechanical stimulus, such as shaking, has, in the past, generally been associated with a fetal response of increased movement31v32 Some studies have used this infor- mation to suggest that an absence of fetal response may indicate a pathological state.ss

Ron et alX in 1976 demonstrated that an increase in fetal movement after amniocentesis was associated with favorable fetal outcome in 93% of the cases. Of those fetuses failing to show a response of increased movement to the amniocentesis, 67% exhibited fetal distress at a later point in their gestation. Is~el,~ Rich- ardson et al,36 and Goodwin and LoweI all studied the effect of external stimuli on fetal movement. All three of these studies failed to elicit any increase in fetal movement after the application of an external stimulus. The external stimulus utilized consisted of either shaking and/or rocking the maternal abdomen.

The application of an external light stimulus has been observed by Poli- shuk et aP7 to increase fetal movement. This increase was noted in 66% of the population of 110 low-

risk pregnancies under study and 50% of the 73 high-risk pregnancies.

As one can note, there are a multitude of both internal and external factors that have the potential to effect the rate of fetal movement. Re- search has examined several of these factors but conflicting reports exist with the majority of those studied. An endless number of stimuli still have not been researched. Some factors such as exercise, working habits, nutritional intake, psycholog- ical well-being, stress, age, inter- course, and maternal health status may have the potential to effect the amount of movement a fetus will ex- hibit. Clearly, additional research in this area is needed for us to gain a fuller understanding.

MATERNAL PERCEPTION OF FETAL MOVEMENT

The accuracy of maternal perception of fetal movement has been the focus of various studies. Leader and Baille38 explored this topic on a study population of 20 antepartum women, from 32 to 39 weeks gestation. The study population on the average was able to detect 80% of the fetal activity that a cardiotoco- graph and a two-channel recorder detected.

They also noted that there is a “safety value” in daily fetal movement counting due to the finding that the majority of women under-counted movement, thus giving an earlier warning than if the movements were fully or over-counted. The per- centage of fetal movement perceived by pregnant women has been observed to range in various research studies from 75.7%3g to 87%40 to 90.3%.5

Another interesting study under- taken by Neldam and Jessen41 in 1980 focused on how fetal movement was recorded on the uterine contraction part of the fetal monitor. Fetal movement has been assumed to cause small spikes on the uterine portion of the monitor strip.42943 This assumption was shown to be inaccu-


rate when compared with maternal perception of fetal movement. This study found no correlation between maternal perception and the spikes registered on the uterine portion of the monitor. Ninety percent of the fetal movement perceived by the women were overlooked on the uterine strip.

DIFFERENT WAYS OF COUNTING FETAL MOVEMENT

Mon-Yosef et ala conducted daily fetal movement counting in sus- pected intrauterine growth retardation (IUGR) cases by instructing the patient to lie on her left side for 30 minutes after meals and record all fetal movements felt. This study, conducted on 34 IUGR patients, was compared with their previous study in 1981 on low-risk patientszs Their study demonstrated that decreased fetal movement has a high association with small-for-dates infants. This research confirmed previous findings of Jarvis and MacDonald& in 1979. Jarvis found that less than 21 movements in 12 hours was strongly associated with small-for-gestational-age (SGA) infants.

Neldam& in 1983 conducted a prospective clinical trial of fetal movement on 3111 pregnant women. Oral and written instructions were given to 1562 women and the results compared with a control group of 1549 women. The control group was questioned regarding fetal movement but no instructions were given for actually counting the number of movements perceived. The experimental group was instructed to count fetal movement while lying down for 1 to 2 hours after meals one time a week until their 32nd week. After their 32nd week they counted fetal movement in the same manner three times a week. The results of their study demonstrated that through the use of fetal movement counting the number of stillbirths can be significantly reduced. In the control group, there

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were 12 stillbirths compared with three in the treatment group.

Fetal movement counting was studied by Pearson and WeaveP7 on 122 pregnant women. These women were instructed to count the number of fetal movements from 9 AM to 9 PM from the 32nd week of gestation until delivery. The study divided the women into four groups based on: 1) Normal daily fetal movement counts, normal 24-hour urinary estrogen excretion; 2) normal daily fetal movement counts with low estrogen values; 3) low daily fetal movement counts with normal estrogen values; and 4) low estrogen values and low daily fetal movements. The study’s findings revealed that a low fetal movement count was associated with a high incidence of fetal asphyxia and that daily fetal movement counting was more predictive of fetal risk than the more expensive placental function test.

In 1980, Neldam& studied 2250 pregnant subjects’ daily fetal movement. Half of the patients were given instructions to count fetal movement for 2 hours after each meal once a week until the 32nd week, then three times a week until delivery. Eight fetal deaths occurred in the control group, those without specific instructions of fetal movement counting. No deaths occurred in the group given instructions on counting. The fetal movement of all those eight patients with stillborns was low or absent from 2 to 5 days before con- tacting the hospital. Results of this study reemphasized the high predictive value of daily fetal movement counting.

Liston et al’ studied the reliability of the Cardiff fetal movement counting on 150 high-risk obstetric patients. The Cardiff fetal movement count consists of having the patient note fetal movement beginning at 9 AM until the 10th movement is felt. The time at which the 10th movement is felt is then charted on a graph. The recordings were then divided into two groups: 1) Those patients having 10 or more fetal move-

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ments in a 12-hour period; and 2) those recordings having less than 10 movements in a 12-hour period. This study had two antepartal fetal deaths, both of which occurred in the group with the lower daily fetal movements. The researchers concluded that the daily fetal movement count is at least as reliable as the nonstress test in predicting those fetuses at risk.

Other methods of recording fetal movement include counting for 60 minutes three times a day,48,49 20 to 30 minutes twice a day,50 30 minutes twice a day,38 and 10 minutes once a day,51 as well as various other counting methods.52

Another currently common practice is to simply ask the patient if the baby is “moving well” without ever explaining how many movements are needed to fit the definition. This method has been shown to result in increased numbers of stillbirths and poor fetal outcome.46 The patient needs to understand that a decrease in movement needs to be evaluated immediately by her health care provider in order for corrective action to be carried out.

Unfortunately, there is no universally accepted fetal movement counting criterium as of yet. Re- search done thus far can only agree on the fact that daily fetal movement counting has been shown to decrease fetal death and poor outcome.

PREDICTIVE VALUE OF DAILY FETAL MOVEMENT COUNTING

The value of daily fetal movement counting in predicting a high-risk situation for the fetus has been exten- sively researched. Harper et a149 in 1981 conducted a study of 101 pregnant women in the third trimester. They tested daily fetal movement counting, weekly nonstress testing, and biweekly serum esteriol levels on the study population. Four women of the study population experienced a decrease in fetal movement. Three of these four women

also had a nonreactive nonstress test and a positive or suspicious oxytocin challenge test. The four women were delivered within 24 hours with favorable outcomes. Among the remaining subjects, there were two neonatal deaths, both attributed to congenital abnormalities incompatible with ex- trauterine life, and one stillbirth due to abruptio placentae. These deaths were preceded by a normal fetal movement count. In all of the subjects, the serum estriols remained within normal limits.

The above study showed that daily fetal movement counts can detect physiologic but not anatomic alterations in enough time for a satisfac- tory outcome to be attained through an expedient delivery. The researchers suggest that with a noted decrease in fetal movement, nonstress testing and an oxytocin challenge test, if necessary, should follow promptly.49 Timing of delivery is based on the results of the nonstress test and oxytocin challenge test findings. The study agreed with Pearson and Weaver in their conclusion that daily fetal movement counts were definitely more predictive than the serum esteriol.

Leader et a15* asked 264 antepartum patients to count fetal movement for 30 minutes four times a day. The daily fetal movement charts kept by the study population were not considered when the researchers made their decision regarding timing and mode of delivery. The study group experienced 15 stillborns, all of which reported a decrease in fetal movements before delivery. Fetal outcome was poor in only 1.3% of the patients with normal fetal movement counts. In comparison, 46% of those women experiencing decreased fetal movements had a poor outcome. A poor outcome was defined in this study as a stillbirth, a 5- minute Apgar score of 6 or less, plus a concordant maternofetal arterial base deficit difference of 5 mEq/L or more. There were two neonatal deaths in the study. One death was due to hydrocephaly and the other


was due to prematurity from fulmi- nating preeclampsia. Neither of these deaths had an abnormal fetal movement count. Based on these results, the researchers concluded the following: 1) Fetal movement counting is a useful indicator of impending fetal death; 2) fetal movement counting is of no value in predicting acute events; and 3) decreased fetal movement may indicate fetal com- promise and demands further inves- tigation by the health care provider responsible.

Liston et all used the Cardiff method of daily fetal movement counting on 150 antepartal patients to study its predictive value. The study population was divided into those having greater than 10 fetal movements in a 12-hour period and those with less than 10 fetal movements in 12 hours. Morbidity, mortality, and fetal distress were significantly higher in the group with low fetal movement. Also, they noted that only 2% of the population that reported a decrease in fetal movement had no associated fetal com- promise. Based on their findings, the researchers concluded that fetal movement counting may be effective on a wide scale in decreasing perinatal mortality.

Real-time B scan was utilized by Manning et a153 in 1979 to study fetal movement in 50 women in the third trimester. Of these 50 women, four experienced a cessation of fetal movement before delivery. Three of the four delivered stillborns with the fourth having a positive contraction stress test. The fourth patient had labor induced and delivered a normal infant. They concluded that a minimum of one fetal movement in 20 minutes was a reassuring sign of a normal fetus as long as there was no acute change in maternal status, or the fetus was not under intrapartum stress or manipulation.

Mathews54 observed 50 obstetric patients in the last month of pregnancy, diagnosed antenatally as SGA. Their findings showed a significant increase in fetal distress in labor

and/or a low Apgar score 5 minutes postbirth in those patients experiencing decreased fetal movement. They concluded that a history of vig- orous fetal movement after the 37th week of gestation is less likely to result in either stillbirth or fetal jeop- ardy as compared with those patients with decreased fetal movements.

The fetal movements of 2250 pregnant women were studied by Neldam& in 1980. Half the study population was given specific instructions on counting of fetal movements while the other half were not. There were eight intrauterine deaths in the group with no instructions as compared with none in the group given instructions. All of the women who experienced intrauterine deaths had from 1 to 6 days in which fetal movement was totally absent. Neldam concluded that all women, especially those with a high-risk pregnancy, should be instructed on daily fetal movement counting. He found that daily fetal movement counting was a reliable screen for fetal well-being as well as being useful in deciding the timing of delivery.

Neldam% was able to arrive at the same conclusion when he performed another study on 3111 pregnant women in 1983. This study was carried out in a similar manner with approximately half the population given written and oral instructions on fetal movement counting and the other half serving as a control. The control group experienced 12 stillbirths of fetuses weighing over 1500 g and without major congenital abnormalities, compared with three in the experimental group. Ten (0.6%) of the women in the experimental group underwent acute cesarean sections due to low fetal activity and delivered healthy babies. The researchers noted an 80% compliance rate.

Rayburn and McKean55 in 1980 also found a high association of decreased fetal movement with nonreactive nonstress tests and poorer fetal outcome on their study popula-


tion of 306 antepartum women. They noted that a decrease in fetal movement in the last week before delivery only occurred in cases that experienced subsequent fetal distress. All three antepartum deaths encountered in this study had decreased fetal movement. The only intrapartal death in this study was due to a complete placental abrup- tion and associated mild toxemia. This death was not associated with decreased fetal movement.

Raybum et a156 in 1980 had similar results when they compared daily fetal movement counting with antepartum fetal heart rate testing. They concluded that daily fetal movement counting by a compliant patient is a reliable alternative to antepartum fetal heart rate testing for the initial screening of fetal well- being. Active fetuses had a normal heart rate tracing 97% of the time in this study.

Sadovsky et a157 studied six definitions found in the literature of decreased fetal movement. The study population consisted of 6161 high- risk patients. Two of the six definitions were associated with a high predictive value for fetal compro- mise. The most sensitive definition was the movement alarm signal. It is defined as no fetal movement for at least 12 hours with audible fetal heart beats. This definition had the lowest false-positive cases and 78.4% of the patients experiencing movement alarm signals had a poor outcome. The second definition of 10 or fewer fetal movements in 12 hours also was able to distinguish fetal outcome but was not quite as specific. The movement alarm signal has been used by a variety of researchers and its predictive value re- peatedly demonstrated.3,47,58

Sadovsky5g in 1978 defined movement alarm signal as a signal pointing to a “severely distressed fetus and indicates impending intrauterine fetal death.” They go on to say it is “an indication for immediate delivery of the fetus, provided it is viable.“ll

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One of the advantages to the use of the daily fetal movement counts as a screening tool is that its warning signal of decreased movement occurs in enough time for life-saving action to be carried out in most cases. Sadovsky et a159 in 1978 noted that fetal movement decreased from 1 to 12 days before intrauterine death occurred. Eighteen out of the 19 women in this study had decreased fetal movement from 1 to 3 days before death occurred. The remaining women experienced decreased movement for 12 days before death occurred.

Pearson and Weavefir noted that fetal movement decreased for 3 to 4 days then ceased for another 12 to 48 hours before intrauterine death. Neldam& in 1983 found in his study of 2000 deliveries that all the women with stillborns, excluding those with acute abruptio placentae, experienced a decrease in fetal movement for 2 to 9 days, then a cessation of movement for another 1 to 5 days before diagnosis of fetal death.

Sadovsky and Polishuk” found in 1977 that fetal heart rate changes will appear 1 to 4 days after movement alarm signal has occurred. They also pointed out that fetal movement monitoring was a more reliable tool in predicting impending intrauterine fetal death than urinary esteriols.

APPROPRIATE FOLLOW-UP AFTER A REPORTED DECREASE IN FETAL MOVEMENT

No lower limit of normal concerning individual fetal movement has been agreed upon yet. Decreased fetal movement has been defined as less than five movements for 1 hour,sc’ to as little as no fetal movements for 24 hours,1v47 with a large variety of ranges between these two definitions. It is likely that there will never be a lower limit of normal due to the wide variety of individual fetal movements reported in the literature.

Many health care providers are currently using the definition of move-

ment alarm signal by Sadovsky and Polishukr’ on which to base their management decisions. Movement alarm signal is defined as a decrease in fetal movement to three or less in a 12-hour period with an audible fetal heart rate. Once a decrease in fetal movement is reported by the patient, most authorities agree that external fetal monitoring is the next step in determining the condition of the fetus ‘Ws,Wse

Other tests include nonstress testing, oxytocin challenge test, lung maturation studies, esteriols, and human placental lactogen.29,46 If these tests show a deteriorating condition and the fetus is shown to be viable, delivery is recommended. Sadovsky59 recommends prompt delivery when a definite decrease in fetal movement is followed by total cessation for at least 1 day with viability and fetal heart rate present.

BENEFITS OF DAILY FETAL MOVEMENT COUNTS

There are a multitude of benefits that can be gained from the routine use of the daily fetal movement counts. The rising cost of health care has cre- ated much public attention and outcry. Use of the daily fetal movement counts as a screening tool re- quires minimal time and monetary outlay by the patient. Not only is the initial cost low, but the potential to further decrease cost by avoiding more expensive testing could result in substantial savings.

The reliability of this method has been demonstrated to range from 82%63 to 88%*l with a patient acceptance of approximately 83% when limiting counting to 60 minutes three times a day.49 Pearson and Weave@ have shown patient acceptance to drop to around 50% when a 12-hour continuous fetal movement count was required.

Daily fetal movement counts are a simple, safe, noninvasive technique that can be used by almost all patients. There is no wait for results to return with this test since it assesses

the fetus at the time of the observation.

Movement counting has been shown to be a significant indicator of neonatal outcome as well as a ca- pable method of identifying the fetus at risk.52 Sadovsky and Polishukl’ have demonstrated fetal movement counting to be more reliable than urinary esteriols, while results from Liston et al’ point to fetal movement counting as being as reliable as the nonstress test.

Several researchers have agreed upon the daily fetal movement counts as a more accurate index of fetal well-being than the currently used placental function studies.2,3*54 Ac- cording to Sadovsky’sl’ movement alarm signal definition, there is a significant time interval after receiving poor results for necessary interven- tion to occur to ensure good fetal outcome.

As daily fetal movement counts become routine as a screening tool worldwide and further research is carried out, more benefits will continue to emerge.

RECOMMENDATION

I strongly recommend that all nurse- midwives incorporate a daily fetal movement count system into their clinical practice. As stated previously, the benefits are multiple while the cost minimal. Charlyn Coleman, CNM, aptly describes a midwifery philosophy as one that does not inter- fere with, but supports, the normal pregnancy and its outcome.64 This philosophy is supported through the consistent use of fetal movement counting.

At present, unfortunately, there are no set counting criteria nor set values that can be universally applied to all antepartum patients when evaluating fetal movement. I recommend that the movement alarm signal be used for basing management decisions. The definition of the movement alarm signal can be adopted from either Sadovsky & Polishuk (three or less movements in

16 Journal of Nurse-Midwifery ??Vol. 32, No. 1, January/February 1987

12 hours)ll or from Pearson (less than 10 .moviments in 12 hour$.65 Both these definitions are supported in the literature. Bear in mind that the exact number of movements is not as crucial as any change in the patient’s pattern of movement.

In my practice, I request my patients to show me their movement charts at each visit once the charting has been initiated. In this way I can quickly see if an ominous pattern is developing as well as ensure that the chart is being used appropriately. Compliance in keeping the chart has improved since I began requesting to see them. If the practitioner does not concern herself with the movement pattern on a consistent basis, then neither can we expect it of the client. Valuable and oftentimes life-saving informatioti will be lost if the counting is not kept current. We spur motivation in our clients through consistent and repeated education.

The choice of which counting method to use must also be an individual decision. To reach that decision you must first ask yourself if your clients will realistically be both able and willing to complete it. This will depend on a variety of factors to include work and sleep schedule, other duties and obligations, intelli- gence, motivation, etc. You must adapt a method that best fits their schedule and not expect them to make alterations in their daily routine to fit the counting method. Several modifications will probably occur before coming up with a count that can be used with ease by both client and care provider. I utilized a variety of methods before deciding on the Car- diff and a modified Cardiff counting chart. The modifications I made to the Cardiff method was done to as- sist my clients on active duty. These women work long and varied hours. Instead of having them begin their counting at the usual 8 or 9 AM, I have them begin when it is most convenient. Once the patient per- ceives the usual 10 movements, they then mark the time it took (ie, l/2 hour, 1 hour, 1% hour1 on the chart.

The feedback I have received on this has all been positive. Other counting techniques have been utilized for the occasional client who for one reason or another had difficulty with the Cardiff method. An example of this was one patient of mine who com- plained that the chart was too small and therefore too difficult to use. The problem was easily solved by en- larging the boxes of the chart. She was then able and willing to keep a daily count.

At what gestation to begin the daily fetal movement count will also need to be individualized to your client’s situation. Studies have sug- gested starting at the age of viability and anytime thereafter up to 36 weeks of gestation. If you begin too soon, motivation and therefore compliance may be lessened. If you begin too late, problems and an ade- quate baseline may not be estab- lished. Obviously, those clients with complications and risk factors need to be started earlier than those without. Careful explanation of the importance of counting, especially in the presence of risk factors, is vital. This explanation may need to be reinforced frequently to ensure compliance. Also, daily fetal movement counts are recommended for all postdate pregnancies.&

A 14.2% movement alarm signal rate was reported in a 1981 study by Fisher et al.67 This study began Car- diff counts in 664 low-risk women at 36 weeks’ gestation. The rate of reported movement alarm signal was far higher than that previously reported in Pearson and Weaver’s study.47 Pearson reported a movement alarm signal rate of 2.5% in a sample size of 1654 women. These findings point to the possibility that patients may use the counting method to manipulate the obstetric staff. This manipulation may be aimed at receiving more attention, having their labor induced, or for various other reasons. We must, nevertheless, follow-up every reported movement alarm signal, even when dealing with a possible mani-


pulator. Oftentimes, the patient may just be unaware of how fetal movement is perceived and a little education is all that is necessary.

Finally, further research in this area is strongly recommended. Set- ting standards and monitoring techniques will only evolve from con- tinued research. These standards are essential to promote universal acceptance and utilization of this vital screening technique.

REFERENCES

1. Liston RM, Cohen AW, Mennuti MT, et al: Antepattum fetal evaluation by maternal perception of fetal movement. Obstet Gynecol 60(4):424-426, 1982.

2. Mathews DD: Measuring placental function. Br Med J 1:439-44-O, 1972.

3. Sadovsky E, Yaffe H: Daily fetal movement recording and fetal prognosis. Obstet Gynecol41:845-850, 1973.

4. Sadovsky E: Monitoring fetal movement: A useful screening tool. Con- temp Obstet Gynecol 123-131, 1985.

5. Ehrstrom C: Fetal movement monitoring in normal and high risk pregnancy. Acta Obstet/Gynecol8O(suppl): 1, 1979.

6. Dierken L, Rosen M, Pillaty S, et al: Correlation between gestation age and fetal activity periods. Biol Neonate 42:66-72, 1982.

7. Mathews DD: Fetal well-being in gravidas with diminished fetal activity at term. Obstet Gynecol 51(3):281-282, 1978.

8. Martin CB, Murata Y, Petrie RH: Respiratory movements in fetal rhesus monkeys. Am J Obstet Gynecol 119(7): 939-948,1974.

9. Manning F, Platt L, Sipos L: Fetal movement in human pregnancy in the third trimester. Obstet Gynecol 54(6): 699-702,1979.

10. Patrick J, Campbell K, Carmi- chael L, et al: Patterns of gross fetal body movements over 24 hours observation interval during the last 10 weeks of pregnancy. Am J Obstet Gynecol 142(4): 363, 1982.

11. Sadovsky E, Polishuk W: Fetal movement in utero. Obstet Gynecol 50(1):49-55, 1977.

12. Patrick J, Campbell K, Carmi-

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chael L, et al: Influence of maternal RH and gross fetal body movement on the daily pattern of fetal heart rates near term. Am J Obstet Gynecol 144(5):537- 538, November 1, 1982.

13. Spellacy WN, Cruz AC, Gelman SR, et al: Fetal movement and placental lactogen levels for fetal-placental evaluation. Obstet Gynecol 49(1):113-115, 1977.

14. Goodwin R, Lowe E: Multiphasic fetal monitoring. Am J Obstet Gynecol 119(3):341-357, 1974.

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daily fetal movement counting a valuable assessment tool

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