Episode 226 - Is my baby moving normally during pregnancy?
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey.
[0:24] Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and I'm a midwife and part of my job is to help women understand the sensations in their body during pregnancy and what they're trying to tell them in their everyday life. Being pregnant is this brand new event for some women. They've never been pregnant before. Maybe you have, but every pregnancy is different. You get these new sensations, and we're not sure if they're normal or abnormal. And so part of my job as a midwife is to say to women, oh, yeah, a lot of women feel that that's really normal or to say, oh, I'm glad you reported that. That seems unusual. And one of the things we talk to women about is the movement of their baby and what the movements mean. Are they normal, abnormal? So that is the whole topic of today's episode is how to understand your baby's movements and also how to use your intuition and your own knowledge to work out on a day-to-day basis, is my baby okay?
[1:29] Now, I'm sitting here in my podcast studio. There is actually chaos all around me. There is mess everywhere. And I just want to acknowledge that when you're pregnant and even through life, but particularly when you're pregnant, life can be thrown into absolute chaos around you can be wild, mess, just disorganized, everything. But there is a way that you can work out in your internal peace or to find some internal peace if your baby is okay amongst that chaos. So let's talk about that today.
[2:06] So what I'm going to do is share some of the research with you about fetal movement, what we call fetal movement or the movement of your baby in pregnancy, and answer some of those questions like, how many movements is normal? Do we still have to count the kicks of your baby? How many kicks are you doing every day? How will you know if your baby's not okay? And I'd like to give you a little bit of information about what to do if you feel like your baby's moving less, but also if your baby's moving more. Hello, beautiful listeners. before we go any further in this podcast episode, I want to tell you a little something about me and my parenting journey. Part of one of my core philosophies in life is to not be wasteful, care for the environment, care for our bodies, and make wise purchases around those principles. And that's why I endorse the products made by UgoPouch.
[2:58] Ergo Pouch uses organic cotton and they're committed to the longevity of their products, which means you can buy well and buy one and it will last through all of your children. We still have the Ergo Pouch that we use for both our children and they're all grown up now. I also love that Ergo Pouch has an interest in sustainability in their second hand store where you can recycle used Ergo Pouches. The ergo pouch speaks to every part of my parenting and lifestyle philosophies and I have no hesitation in recommending the ergo pouch products to you my absolute favorite ergo pouch product is the, the sleeping sacks which I love because your kids arms can be free, and the ergo pouch travels so easily it becomes like the staple part of your sleeping journey with your baby On those cold nights when you're feeding, you don't have to unwrap your baby. The zip function means that you don't have to completely unravel them for nighttime nappy changes. We found the Ergo Pouch to be an invaluable part of our parenting journey. With our children, it made sleep and comfort so much easier. It traveled easily and just gave us freedom with our sleeping routines.
[4:13] If you love the thought of low-tox, easy travel, and sustainable items for your babies, use the link below in the show notes to grab your ErgoPouch products. I really, really love the sleep pouch. I would like to personally thank the sponsor of this podcast because that means that you get to listen for free. Poppy Child from Pop That Mama is a doula and hypnobirth practitioner, and she's a sponsor for today's podcast. Poppy has an online course, hypnobirthing course. It's called the Birth Box and it's already helped thousands of women. I get behind the work that Poppy is doing in the Birth Box. It's practical strategies to help you get ready for labor and birth, but also the challenges of parenting. And with my code, if you type Melanie in at the cart, you'll get 25% off. So if you're preparing for birth, go check it out. you will be so glad you did. The link is in the show notes. Type Melanie at the cart and get 25% off. Thank you Poppy for sponsoring this podcast so that everybody else gets to listen completely free.
[5:23] Okay, let's talk about today's topic, your baby's movements during pregnancy.
[5:28] And I want to first start by sharing the generic information on the topic. So there's a few organizations who've created educational tools for women and for maternity care providers to help set the standard for understanding and monitoring the movement of your baby. So the general message from organizations such as Safer Baby, the Stillbirth Centre for Research Excellence and the Perinatal Society of Australia and New Zealand are these things. So firstly, they say you will feel your baby start moving anywhere between 16 and 24 weeks.
[6:04] A pattern of movement starts to become obvious around 24 to 28 weeks.
[6:11] And that's what's important. The pattern of movement, not the number of movements. What they're saying is that we don't count kicks anymore as a measurement and that the number of movements is not important. The important part is the usual patterns of movements and if that's changed. Every baby is different. They have rest times and active times just like a newborn. That will wake and sleep. So it's easier to feel your baby's movements when you're sitting down or you're lying on your side, especially in the evening. And that listening to your intuition about the well-being of your baby is important. These organizations will also say that your baby's movements don't slow down towards the end of pregnancy. Your baby should move with a regular pattern until the day it's born. And the recommendation is that if you notice a change in the pattern of the movement of your baby, don't wait a day to contact your care provider. You will never be bothering them. If you feel like your baby's movements have changed and you're worried about your baby, don't worry about bothering your care provider. They will not be bothered. It's more important that you have this checked sooner rather than waiting.
[7:22] And also, hiccups don't count as movements. If your baby is hiccupping but not moving according to its normal pattern. Don't count the hiccups as movements. Hiccups are a sign of development, but they're not a sign of health and wellbeing. So don't count them as movements if you're concerned about the wellbeing of your baby.
[7:43] So now let's talk about reduced fetal movements. This is what the research calls it, reduced fetal movements. But if you notice that your baby's moving less. So reduced fetal movement is typically defined as a decrease in the mother's perception, your perception of the movements of your baby or a change in the pattern of normal movement. It's not about the number of kicks. You don't have to count how many kicks your baby's doing each day and use that as a measurement of normal or reduced or increased movements. They used to tell us to do that, and apparently every baby was supposed to kick the same amount, but that's not how it works. So it's about recognizing your baby's usual pattern of movements.
[8:23] And that advice that I just gave you is part of the Movements Matter campaign. So let's have a look at why movements matter.
[8:31] So the reason your baby's movements matter is that for women who have very sadly experienced a loss of their baby before it's born, where their baby has died in utero before labor and birth, one of the things that they reflect on is that in the days prior, they noticed a reduction in their baby's movements. And this prompted researchers and clinicians to explore fetal movement as a subjective way of monitoring the health and well-being of your baby. You'll only have a few appointments with your care provider through your pregnancy. The day-to-day understanding of how well your baby is really is up to you to explore and monitor and so working out your baby's usual pattern of movement and being alert to that is one way that you can work out if your baby's still okay. If you perceive that your baby is moving less than you feel is normal, this could be a sign, not that your baby is close to a lethal event, but perhaps that something else is wrong for your baby or the placenta that could be discovered by exploring things with things like an ultrasound, for example. So reduced fetal movement in itself isn't the issue. It's a symptom of a possible issue. And that's the instigating factor that takes women and their care providers on a journey of discovering.
[9:54] The reason, why is your baby moving less? The idea is that this is a symptom and now it's your job with your clinician to determine if your baby is okay or if something is wrong. And the most likely scenario is that everything is just fine. We don't really have great research about the normal ebbs and flows of how a baby usually moves and still stays healthy. And you'll see through this episode that we're all really taking an educated guess at this point about what is normal fetal movement and what is abnormal fetal movement.
[10:32] But I will say here that the findings from a report about decreased fetal movements, and this is a report from the International Stillbirth Alliance Conference. They did a big workshop and they summarized some of the big studies about fetal movement monitoring and its correlation to stillbirth. And this is what the report said, and I'm reading this verbatim. This is a quote and it says, trials of fetal movement awareness interventions have yet to demonstrate a significant impact on stillbirth rates. However, large-scale trials of complex educational interventions are problematic and it should be noted that existing trials have all compared fetal movement awareness interventions with routine care that usually also involves fetal movement awareness strategies and this makes it difficult to measure the effects. So promoting fetal movement awareness may yet prove beneficial, although caution is required to avoid the harm associated with unnecessary intervention. Determining optimal approaches to education around fetal movements and assessments of such cases remains a research priority. Basically, what they're saying is we actually don't have great research to suggest that telling women to be aware of the movements of their babies will actually have an impact on stillbirth rates.
[11:55] Mostly because it's difficult to study that kind of thing. Also, what they found and what they reported in their report was that when women come to their clinicians and report reduced fetal movements...
[12:07] The clinicians tend to intervene sooner, potentially bringing the date of the birth sooner through induction or cesarean section through a concern that maybe there's something wrong with the baby. And so what they've suggested here in this report is that, we have to still be cautious because this could have the unintended effect of giving unnecessary interventions if we are asking women to use fetal movement awareness strategies to help prevent stillbirth. So just straight up, the research is not solid on this.
[12:42] And some of the research that they looked at for this report showed that for women who experienced a reduction in fetal movements, they could be inadvertently exposed to more interventions, as I said, including induction and caesarean, without a corresponding improvement in stillbirth rates. So what the report is saying that there haven't really been very conclusive studies done on fetal movement awareness and how this impacts stillbirth rates. But what the research also said is that maternity care providers have to and do educate women about fetal movements. So we're required to educate you, but the research is out on exactly what the impact of that will be. But measurement of fetal movements, it is a subjective experience and it's open to interpretation. And so there hasn't yet been convincing evidence to suggest that conscious fetal movement monitoring will produce a change in stillbirth rates. It's still an under-researched area and so we just have to do that the best we can with what we have, with the information that we have at the moment.
[13:50] And all we have at the moment is that as clinicians we are required to encourage you to monitor the movement of your baby and follow up with your care provider if you think they've reduce if the patterns changed. But we aren't sure yet from the evidence if this is a clear way to reduce stillbirth rates. But stick with me because there is a good reason to be.
[14:13] Aware of how your baby is moving, particularly of the pattern. Now, we don't really know exactly why babies will reduce their movement. Some plausible suggestions include that reduced fetal activity represents like a compensatory measure to save energy at a time of oxygen or nutrient stress for the baby, which might resolve or not resolve. And then due to a persistent shortage of oxygen on nutrients for the baby could lead to absent fetal movement. So basically, the baby stops moving to save energy in a time of stress. But if the stress persists, this could lead to a poor outcome for the baby. So there are known events in pregnancy that can lead to reduced movement, including substance use in pregnancy. So there's some research that correlates with the reduced oxygenation through the placenta after smoking or vaping, for example, in pregnancy. And this has been documented to reduce the baby's movements as a result. So this observation might support the idea that reduced oxygenation to the baby, in this case, which was caused by smoking, will change the activity of the baby. So potentially you could transfer that knowledge to other scenarios where the baby is deprived of oxygen. Could this be a reason why they stop moving so much?
[15:35] And there have been research projects which examined the role, for example, of placental function and how this correlates to fetal movements. So applying this theory where decreased fetal movement is a fetal response to reduced oxygen or reduced nutrition, it can be hypothesized that evidence of placental dysfunction, should be more prevalent in cases where the baby is not moving as in a usual pattern.
[16:04] So there was a study by Waranda et al. All of these papers are in the resource folder for anyone who's on the mailing list. You can get access to all the research papers that are used for each episode, including this one. So Waranda conducted a case-controlled study. They looked at 36 placentas from women who gave birth within seven days of reporting decreased fetal movement. And then they also compared 36 placentas from women who had never reported reduced fetal movements. So the placentas from the women who did report reduced movement of their baby, they were smaller, they were more likely to have an off-center cord insertion. So the umbilical cord is typically inserted in the middle, but there are cord insertions that are more towards the side of the placenta. So they were more likely to be smaller, more likely to have an off-center cord insertion. And then when they look at them microscopically, under a microscope, placentas from women with decreased fetal movements often had signs of what we call maternal vascular malperfusion, which means from the maternal side, reduced.
[17:17] Blood flow through the placenta. So they had more knots in their blood vessels, fewer fetal blood vessels. So there's maternal blood vessels and fetal blood vessels in the placenta. And theirs had fewer blood vessels.
[17:33] And a smaller area of attachment. So further analysis of these samples also showed increased inflammatory cells in those placentas. So quick stop here, all of those terms basically mean that the function and attachment of the placenta was substandard, which created abnormal placentation and abnormal placental function. So maternal vascular malperfusion is a condition where the mother's blood flow, to the placenta is inadequate, and that leads to placental dysfunction. And it's usually caused by abnormalities in the mother's blood vessels or improper placental implantation or damage to the placenta after implantation. So maternal vascular malperfusion is linked to adverse pregnancy outcomes, such as reduced fetal growth, so fetal growth restriction, preeclampsia and fetal death.
[18:32] So this study is linking the possibility of poor placental function to decrease fetal movement. And these changes are similar to those that were observed in pregnancies with what we call overt fetal growth restriction. So from that study, we can see that reduced fetal movements could have actually been related to substandard placental function. And this is what I was saying before is that reduced fetal movements isn't the problem itself. It says to you as the parent hey we might have a problem that warrants some investigation and potentially one of those problems could be with the placenta, and this also correlates with findings that the babies who are more likely to be stillborn just generally, are also more likely to be growth restricted and smaller so possibly fetal movement stillbirth and growth restriction could go together. So with some individual clinical reasoning, you and your practitioner could start to connect some of the dots of how carefully you need to monitor for the well-being of your baby. So if you're experiencing reduced fetal movements and there's ultrasound evidence of impaired placental function or a condition such as preeclampsia or growth issues for the baby, or potentially your PAP-A measurement that you got if you had a nuchal translucency blood result.
[19:56] If all of those start to correlate with reduced placental function, and you've got decreased fetal movements and a smaller baby, now we're starting to put together a picture of.
[20:07] If your baby is at more risk than a baby that doesn't have those correlating factors.
[20:12] Now, there are two more studies that examined what we call the histopathological features of placentas for women whose babies had decreased fetal movement. So this is the actual microscopic appearance of the placental tissue. And that's what we mean by histopathological. So Winji et al. Studied 129 women who had decreased fetal movement and compared them to 191 controls. So they found that decreased fetal movement was not linked to the presence of any placental pathology. So the actual cells of the placenta were normal, but it was associated with the maternal vascular malperfusion that I described in the earlier study. So actually it's about how much blood flow is getting through and the blood vessel structure and placentation is more important than the microscopic part of the placenta. And there was another researcher, Levi et al, who examined placentas from 203 women who had decreased fetal movements, and that was within two weeks or less of the birth, and 203 women who didn't have decreased fetal movements. And they found that a greater proportion of women who had decreased movements also had small placentas and the maternal vascular malperfusion. They also noted the inflammatory response on the maternal side of the placenta. So similar findings to that first study that I talked to you about. So this association...
[21:40] Was confirmed when they examined cases of stillbirth in a retrospective study. So they looked back on cases of stillbirth and found that pregnancies with reduced fetal movement prior to the diagnosis of stillbirth were independently associated with placental insufficiency. So the bigger problem here is not that your baby is moving less. The bigger problem is that there's a problem behind the baby not moving as much, if that's what you're feeling. So what this says is if your baby is reducing their fetal movement pattern and you're concerned, this is an opportunity to explore and discover why. Why is your baby not moving as well? Is there a problem with the placenta?
[22:23] So if we take all these studies together, all these placental studies, they provide a little of a biological basis to understand the association between decreased fetal movement, and adverse outcomes and how they relate to things like asphyxia or deoxygenation. And is this attributable to placental insufficiency? So for this reason, part of the clinical assessment, if you're experiencing reduced fetal movement, could be an ultrasound that assesses the blood flow through the placenta and the placental health. And they can do this with an ultrasound technique called Doppler flow of the blood through the placenta and the cord. So, of course, not all placental pathologies can be detected by ultrasound, but that's what we've got. It's certainly what you'll be offered is an ultrasound, a CTG.
[23:13] Doppler flow checks of the blood flow. Over time, there's other tools that will be developed, but this is what we've got at the moment.
[23:21] So it has been established that decreased fetal movement can be associated with stillbirth and with fetal growth restriction. However, there is a lack of high quality evidence to guide best practice around this area because many of the interventions around counting kicks and monitoring movements, they still haven't.
[23:41] Been shown to directly correlate to actually reducing the statistical chance or the incidence of stillbirth. Nonetheless, maternity care providers are encouraged to inform pregnant women about the importance of being aware of the movement of your baby. Yet, studies suggest that information that's often shared is not evidence-based. And so women would like more information about what's normal fetal movements and what to expect. Because about 15% of women will contact their care provider throughout pregnancy with concerns about their baby's movements and the perception that their movements have reduced. It's a common reason why women go to hospital or why they contact their care provider. And thankfully, the vast majority of these encounters show that there's nothing wrong with your baby, but also there isn't really scientific consensus on how best to measure and manage circumstances of reduced fetal movement.
[24:38] So it's definitely an understudied area. Nonetheless, there are a few things that you have as a woman and a mother that you can consciously or subconsciously use to determine the well-being of your baby. One of the ways of knowing if your baby is well is your intuition and your inner knowledge and connection with your baby. So put simply, you might just feel really confident that everything is completely fine.
[25:07] Alternatively, your intuition might be setting off alarm bells, asking you to pay attention to something that you can't quite put your finger on and that you can't put down or dismiss. So intuition is a powerful way of knowing. And some women trust the intuition and some have not honed the ability to trust their intuition. And if that's you, you might be feeling a bit nervous and worried if you can't get confirmation from your health provider that your baby is well. And I've certainly looked after those clients before that just constantly feel concerned that the baby's not well and they make contact a lot, just not sure if their intuition is sending them the right messages. And this is where sometimes medical knowledge can help. Some women might need to combine their own experience and knowledge with that of their care provider and with medical technology in order to feel confident.
[26:02] And if that's you, that's okay. But know that there are two ways of knowing. Your care provider has one way and you have another way. They're both unique in nature. So some women are really comfortable in their intuition. They trust it. They know it. They listen to it. They don't question it. Your inner knowledge and intuition is something that no one else can have on your behalf. So your care provider can give you some objective knowledge about your pregnancy using tools such as ultrasound and CTGs and Dopplers, but these are not necessarily superior to your own knowledge. So I've had clients tell me that something just does not feel right, and I always take that seriously, even if everything seems okay from my end, from what I can gather. So I've got some knowledge and skills, but it's not superior to the woman. So if they say, if you say something doesn't feel right, I will always believe them and take action from there with what's going on. It almost doesn't matter what I find. If a woman says to me, something does not feel right, my next response is, okay, let's go see what else we can discover to see if there is something wrong.
[27:13] Right, I could talk about the power of your intuition forever, but here we're talking about baby's movements and there's other ways of knowing if your baby is well. But I mentioned your intuition and your inner knowledge because I do believe that fetal movement monitoring and your intuition go hand in hand. And this is the same messaging from the organizations that I mentioned earlier. So the question I ask women if they call me and report a change in their movements is do you feel like something is wrong? They might say hey I think my baby's moving less. And I'll say, do you feel like something is wrong? And if they're immediately feeling concerned, I don't even have to ask about the baby's movements. If you feel something is not right, that is a legitimate and an immediate reason to seek other ways of knowing, including your care provider and pursuing some medical monitoring. To combine with your own knowledge and with your care provider's knowledge. So there's medical ways and there's your own intuition. So that's the first thing. So even if your baby's movements are normal, but you have a sense that something is not right, don't brush that feeling off. Seek care. And if they don't take you seriously, keep pushing for reassurance and keep asking for the time that you need. Don't let them make you doubt your own intuition.
[28:35] So the first trigger of assessing the well-being of your baby between appointments is your intuition and your interpretation of your baby's movements. And then if you're concerned, your care provider can assist with the use of ultrasound and fetal heart rate monitoring. And babies who are compromised could be detected by either one of these methods. But evidence on how good they are and how accurate they are is a little bit, uncertain. So that's the first thing.
[29:02] Now let's take a look at what exactly are normal and healthy fetal movements. Currently, what we tell women is that, firstly, you will feel your baby moving at its own unique time. So somewhere between 16 and 24 weeks is a professional opinion about when you might start feeling your baby move. But if you've had babies before, you might know what it feels like to have a human wriggling around in your uterus. So personally, I felt movements from around 14 weeks. So you could also, but sometimes if your placenta is positioned at the front and that your ultrasound report will say that your placenta is anterior, if this is the case, you might feel your baby moving a little bit later because the movements are a little bit muffled by the placenta at the front, but your baby's still moving. You might just not feel it as early as another woman. But typically between 16 and 24 weeks, you'll start to feel the movements of the baby and.
[29:59] And really, from about 20 weeks onwards, your care provider will start asking you, hey, have you started to feel movements yet? And what we currently know about fetal movement features that are associated with an ongoing and healthy pregnancy, so what we conclude might be normal fetal movement patterns include so increasing strength of movements as the pregnancy goes on, the presence of occasional or daily hiccups, a pattern of moderate or strong movements, particularly in the evening, that seems to be a really common time when babies move. And a healthy baby near full term will have longer periods of time when they're quiet due to reduced intrauterine space and differing neurological development. But they'll still have a pattern of strong or moderate movement in the evening, and they'll move at various times through the day. So alternatively fetal movement features that are associated with stillbirth include decreased frequency, decreased strength and a baby that is quiet in the evening. So a healthy baby can be felt moving every day, the absence of movement for a day or a significant reduction in the strength or frequency of movements for a day.
[31:15] Or more, warrants a checkup. So if it's the evening and you've not noticed that your baby's moving or there's been a noticeable change in the pattern, don't put off attending or calling your care provider until the day after. Do it that day. So that's normal fetal movements. So we can see that the monitoring of this is subjective and it does have to combine your own individual and internal wisdom with what you've already experienced as normal for your baby. And the thing to remember here is that every baby is different. You can't expect your next babies to move as your first babies. My first baby felt like it moved all the time. I was never concerned for his well-being. He constantly was moving. My second was not at all generous with fetal movements and I had to pay very close attention to even notice if she had been moving that day. That required a lot more of my intentional monitoring than my first baby. So every baby will be different They're both well and healthy, but moved very differently and I had to be aware in a different way.
[32:20] Now, if you've gotten to this point in the podcast episode and you are listening because you feel like your baby's movements have reduced, you feel like your baby's moving less than you would expect. If you think that they have deviated from their usual pattern or you're perceiving something that might be unusual, the advice is to have a conversation with your care provider, yes, or with your maternity care services to determine next step. Don't wait till the next day. But also consider the possibility that your baby has been moving, but perhaps you've had a busy day. You're feeling stressed. If you're feeling overwhelmed and distracted, if you've got other children, you may not have noticed. Maybe your baby's moving, but you didn't notice. Certainly women with busy lives and like me, just surrounded by clutter at the moment, Women will often remark that sometimes they even forget that they are pregnant. So ask yourself, did my baby move today?
[33:20] Is it reducing its movements or have I been so busy that I didn't notice? And if that's you, this is your opportunity now to lay down on your side or sit somewhere quiet and comfortable, slow down for a minute and check in with your baby. It might not be that your baby is moving less. It's possible that you've been paying less attention. So the only cure for that is to make conscious effort to internally check in with your baby. Listen to what your intuition is telling you. Is your baby moving okay? Is this how it normally moves at this time of the day? A lot of women have concerns for the well-being of their baby. They'll call their care provider and then when they're in the hospital having all their checks, they all of a sudden notice their baby moving heaps. Maybe they just took a moment to pay attention.
[34:11] And when I was a student midwife, if women would ring into the hospital and say, you know, I don't know if my baby's moving that well. We used to tell women to sit quietly, eat something sweet and have a cold drink to wake up the baby, but that's not part of what we recommend anymore. Of course, you're welcome to snack and drink.
[34:30] But these things aren't considered part of the advice anymore, the usual management plan, but you can. It's completely fine. But the sitting or laying down and checking on your baby as an activity, it is the part of the current recommendations. And women report that the evening and night time to be particularly active times for the baby.
[34:51] So, you know, if you're lying down at night and you're thinking, gosh, my baby's not moving, consider if that's normal or not. But I do wonder if the research has noticed or women often report that their baby moves more at night, just because this could be the time of quiet when they're able to pay attention and slow down so they actually notice the movements more. That's just a thought of my own. I don't have a research paper on that, just my own personal thoughts. So before I move on to some information about increased fetal movements, I want to read you the conclusion of the report from the International Stillbirth Alliance Conference, which is currently the most authoritative research or resource that we have on fetal movements. And it says, Research trials of fetal movement awareness interventions have yet to demonstrate a significant impact on stillbirth rates. However, demonstrating benefits for fetal movement awareness in clinical trials is difficult due to the risk of contamination such as fetal movement awareness among control groups and variation of guidelines for the management of decreased fetal movements.
[36:00] Policy makers should be made aware that decreased fetal movement remains an indicator of possible fetal compromise and clinical evaluation is warranted, which is what we said. If the baby's moving less, it's not time to intervene. It's time to check why is the baby moving less. So, they go on and say, mounting evidence from placental studies supports a physiological basis for the association of.
[36:25] Decreased fetal movements and placental insufficiency as a causative mechanism for stillbirth. And so, clinical assessment protocols should account for this. And they say that promoting fetal movement awareness may yet prove beneficial, although caution is required to avoid harm associated with unnecessary intervention. So they advised that we share information with pregnant women about the importance of the perception of regular daily fetal movements in the third trimester as a sign of well-being. So really these patterns only start to develop possibly after 28 weeks. So the clinical practice guideline that was developed by the Stillbirth Centre of Research Excellence in Australia provides the most current and comprehensive evidence-based guide to clinical management of decreased fetal movements. So, we do proactively ask women about fetal movement strength, frequency, and pattern for antenatal care. And this allows women to interpret for themselves how well their baby is.
[37:33] Okay, that's what we've got from the most recent research minds. And I've included that report and the resources from that in the resource folder for this podcast. And you can get access to that at melaniethemidwife.com. It's all in the show notes.
[37:48] All right, so that's what I have to say about normal fetal movement and decreased fetal movement. So now let's have a look at increased fetal movement because there is some little bits of attention that's being given to this. So I'm drawing from a research paper here that brings together a collection of research about increased fetal movements or the perception of increased fetal movements. And this study is called The Association Between Increased Fetal Movements in the Third Trimester and Perinatal Outcomes. And it's a systematic review and meta-analysis, which means they did all the hard work and brought together the studies on this. So this means that we can read this one and get the overall feel for the current, research on this subject. So the paper was published 2024, which means it's pretty well up to date. And the summary of this study is that they found seven studies examining the association between increased third trimester fetal movement and various perinatal outcomes. So what did the fetal movements mean in regards to what the final outcomes were?
[38:53] And when they combined all the findings from all the studies, the meta-analysis revealed a significant reduction in the risk of cesarean section among women who had increased fetal movements compared to the control groups. So it seems like clinicians were less concerned about increased fetal movements, because fewer of these women had cesarean sections. So they kind of suggested that there was a potential protective factor for having increased fetal movements against cesarean sections. Now, something that kicked off this interest in increased fetal movements was a study done in 1977.
[39:33] By Sadwowski, which initially identified that sudden excessive movement of a baby was a potential sign of acute fetal distress, like something was majorly wrong at that point. So, since then, numerous studies have been conducted to explore and better understand this phenomenon. And as part of the STARS study, S-T-E-R-S study, which was based on a web-based survey which had 1,714 women who had experienced a stillbirth after 28 weeks of pregnancy, among them 39% experienced unusual fetal movements, with 30% of them reporting significantly less movement and 8.5 reporting significantly more movement. And the group described increased fetal movements.
[40:28] And then decreased movement and the subsequent death of their baby. So it sounded like this acute event which suddenly caused the baby to move a lot and then become quieter and eventually pass away. A similar finding was found in a Swedish study where 10% of women described abnormally vigorous activity before stillbirth. There was a sudden increase in the movement, which was followed by limited or no movement and then fetal death. So this is what led some researchers to suspect that increased fetal movement is like an acute sudden event due to a baby being in distress. It's very sad.
[41:09] And based on the Auckland stillbirth study, so women who experienced a single episode of these vigorous movements had a sevenfold increase in the risk of stillbirth. However, if these vigorous movements happened often and repeatedly, it wasn't the same correlation. It seems to be a single significant event that maybe increased fetal movement, is an indicator of an issue. So these findings from the Auckland study were replicated in the UK MIND study, M-I-N-E-S study, in which women with a single episode of increased fetal movements had twofold risk of stillbirth, but a reduced risk if the episodes were reoccurring. So maybe that Their baby just had very vigorous movements often, but a single event seemed to demonstrate that this could have been an acute damaging event.
[42:05] So this team, this study, he did the UK MIND study, also demonstrated that women who reported increased strength of movement in the last two weeks had a decreased risk of late stillbirth compared to those who were not changed. So it's still unclear what the underlying mechanism is that leads to excessive movements in the baby, which could create a bad outcome. It could be asphyxia, so oxygen deprivation and infection. Maybe the baby's attempting to release its own cord or, you know, it could be something from the outside, you know, a substance or an issue that caused it. Now, despite these studies that I just talked about, the evidence regarding excessive fetal movement is considered really sparse. And there's no clinical guidance that we've been given as care providers regarding how you should report this symptom to your care providers. So given that the reports from women of these increased fetal movements seem to represent end stages of a health issue for a baby, the question is how do you get this managed in a timely manner? So it's an internal thought of mine. What do women do if they feel a sudden, event of increased fetal movements? Do they race off immediately or could this be a normal occurrence for your baby? We don't have the answers to that yet, unfortunately.
[43:27] So just please don't feel scared by these studies about increased fetal movement. The field of study is still in its infancy, and we're yet to really understand.
[43:37] We don't understand it enough to make any clinical recommendations. So still, your intuition is the most powerful thing here. Your own understanding of your baby's normal movement pattern is what's important.
[43:51] If you're going to report reduced fetal movements or increased fetal movements, or if you're just going to use your intuition on your own to detect if there's an issue with your baby.
[44:02] So the authors from this study about the meta-analysis from all increased fetal movements, they say and they conclude that.
[44:10] Due to the limited number of studies available to include in the metasynthesis itself, the current findings should be interpreted with caution and additional research is critical to strengthen the evidence base in this area. So for now, there's no universally accepted strategy that we use to educate women about what to do if they sense increased fetal movement. Or even what this means for pregnancy.
[44:34] Okay, so that's what I'm going to say about increased fetal movement. So today we spoke about normal fetal movements, decreased fetal movement and increased fetal movement. So let's cover off a bit of a summary of what normal movements are and when might be a good idea to contact your care provider if you deviate from this. So firstly, It's normal. You will feel your baby start moving anywhere between 16 and 24 weeks. That's a normal pattern. The pattern of movement, so a reliable pattern of movement usually starts to become obvious between 24 and 28 weeks. And the pattern of movement, not the number of movements, is what's important. We don't kick count anymore. We don't count kicks. We don't count the number of movements and we don't tell you how many movements per hour is normal. It's all about the pattern and your understanding of your baby's usual pattern.
[45:32] Every baby is different. They'll have rest times and active times just like newborns. And it's easier to notice your baby's movements if you're sitting quietly or laying down to your side. Consider that maybe your baby is moving, but you haven't been paying attention. So an initial strategy can be to sit down, pay attention. And also listening to your intuition about the well-being of your baby is important. Trusting your intuition to tell you if something is right or not goes hand in hand with understanding your baby's own normal movements. Your baby's movements will also not slow down towards the end of pregnancy. Your baby should move with the same regular pattern until it's born. And if you notice a change in the usual pattern or movement of your baby, don't wait a day to contact your care provider. If you feel concerned about your baby's movements or your intuition is pinging that something is not right, don't delay. You will not be bothering your care provider by calling them with this. Contact them to discuss next steps. Also, hiccups don't count as fetal movements. They are a sign of development of your baby but not an indicator of well-being.
[46:46] So reduced fetal movements is typically defined as a decrease in your perception of the movements of your baby. Is there a change in the pattern and normal movement pattern? It's not about the number of kicks. You don't have to count kicks. I won't say that anymore, but you don't have to count kicks. It's about recognizing your baby's usual pattern and if they seem like they're moving less or if you feel worried. You don't even have to have a reason to call. And if your care provider dismisses your concerns, that is a major red flag with regards to how invested they are in you and how much they believe in your knowledge. So if you go to your care provider and report decreased fetal movements or that you intuitively feel like something is not right with your baby and they dismiss your concerns, don't accept dismissive care. Ask them to please give you the details of someone who would take your concerns seriously.
[47:40] Sleep. That has been today's episode of the Great Birth Rebellion podcast about what's normal and abnormal when it comes to understanding the wellbeing of your baby. I'm your host, Dr. Melanie Jackson, and I will see you in the next episode of The Great Birth Rebellion. To get access to the resources for each podcast episode, join the mailing list at melanethemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
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