British Journalof Obstetrics and Gynaecofogy January 1979. Vol. 86. pp 10-14

THE INCIDENCE OF DIFFERENT TYPES OF FETAL MOVEMENTS DURING PREGNANCY BY

E. SADOVSKY N. LAUFER AND

J. W. ALLEN Department of Obstetrics and Gynaecology, High Risk Pregnancy Unit Hadassah University Hospital, Jerusalem, Ein Kerem, Israel Summary In high risk pregnancies with severe fetal distress, a reduction of fetal movements may take place before fetal death occurs. This decrease is accompanied by a weakening of the fetal movements. One hundred and twenty pregnant women (310 recordings) between 20 and 41 weeks gestation recorded fetal movements and classified them into weak, strong, and rolling. The movements noted by the woman were correlated to those recorded by a fetal movements recorder. The rate of weak movements gradually decreased until the 36 to 37th week, while the strong and rolling movements increased. From the 36 to 37th week till term weak movements increased again with a decline in strong and rolling movements. Before fetal death, or in severe fetal distress with decreased total movements, the relative rate of weak movements increased. Reduction in daily total movements without a change in the distribution of the type of movement may not indicate fetal distress.

DAILYfetal movement recording has been suggested as useful in the evaluation of the fetal state (Mathews, 1972; Sadovsky and Yaffe, 1973; Pearson and Weaver, 1976). In high risk pregnancies, pronounced reduction or cessation of fetal movements while heart sounds are still audible has been referred to as the movement alarm signal (Sadovsky et al, 1974). This sign may be a warning of severe distress and impending fetal death, and serves as an indication for immediate delivery (Pearson and Weaver, 1976; Sadovsky et al, 1974; Sadovsky and Polishuk, 1977). A reduced intensity in fetal activity concomitant with a decrease in fetal movement count has been observed by women prior to cessation of movements and fetal death, a

phenomenon described by Rovinsky and Gutmacher (1965) as '. . . a decrease in vigour of fetal movements'. Using a pressure transducer and simple palpation, Timor-Tritsch et a1 (1976) classified fetal movements between 26 weeks gestation and term, on the basis of duration, shape and amplitude into four categories : rolling, simple, high frequency, and respiratory movements. The aim of this work was to study the different types of fetal movements and their distribution pattern during pregnancy. PATIENTS AND

METHODS

A total of 120 pregnant women, between 20 and 41 weeks gestation, without intrauterine fetal growth retardation, was asked to record 10

TYPES OF FETAL MOVEMENT

about 50 fetal movements and classify them subjectively. The majority had an uncomplicated pregnancy (Table I). Seven patients with slight vaginal bleeding, six patients with mild preeclampsia and two patients with well-controlled diabetes mellitus gave birth to healthy wellgrown infants ; they were not therefore excluded TABLEI Complications in 120 pregnant women who recorded fetal movements

Diagnosis

No. of women

Normal pregnancy Uterine scar Uterine contractions Slight vaginal bleeding Mild pre-eclampsia Mild diabetes mellitus

89 8 8

7 6

2

Total

I 20

-_

11

from the study group. All patients attended the antenatal clinic and the Department of Obstetrics at the Hadassah University Hospital. All women recorded the fetal movements for two hours after breakfast. In a preliminary study, it had been observed that most women described three main types of fetal activity: (a) weak movements or kicks, either solitary or in repetitive bursts; (b) strong movements or kicks, either singly or repetitively (a burst was counted as one movement only); (c) rolling or rotating movements, sometimes interpreted as change in position of the fetus. This is clearly visible to the observer who sees a slow, wavy movement of the abdominal wall. The types of fetal movement described by eight women were correlated with recording of a fetal movement recorder (Sadovsky et a/, 1977). This device, fitted with a piezoelectric transducer, is sensitive to rapid straining forces such as fetal movements, and relatively insensitive to steady or

i

-

I I FIG.1 A weak movement followed by a strong one, immediately followed by a rolling movement, longer in duration (6 seconds) and biphasic or "'-shaped (paper speed 1 mm/second). 1

12 SADOVSKY, LAUFER AND ALLEN slowly changing motions such as uterine contractions or maternal respiratory movements (Sadovsky et al, 1977). There was good correlation between subjective observations and the recordings obtained. Weak movement appeared as single spikes of short duration (1 second) and low amplitudes above and below the baseline. Strong movements showed as spikes of short duration (1 second) and greater amplitude; rolling movements were biphasic, 'N' or 'W' shaped and of longer duration (3 to 10 seconds) (Figure 1). The recorded amplitude did not specifically identify the type of fetal movement, but in all women the shorter spikes were identified with a weak, and the greater amplitudes with strong movements.

RESULTS Figure 2, based on 310 readings, shows the

1 WEAK

MOVEMEMENTS

1 - 1 "

2

u

2

STRONG MOVEMENTS

60

1

ROLLING MOVEMENTS

-

10

20 0

.-*e€?%€

20- 22- 21- 26- za- 30- 32- 31- 36- 38- 1021 23 25 27 29 31 33 35 37 39 (1 \'JYIKY

OF GESTP.TION

FIG.2 The incidence of each type of movement expressed as a percentage (mean & 1 SD) of the total movement count, according to the week of gestation.

incidence of each movement type expressed as a percentage (mean+ 1 SD) of the total count. Each bi-weekly sub-division comprises approximately 30 recordings from between 8 and 14 women. The upper graph depicts the change in weak fetal movements, the percentage gradually decreasing from 100 per cent during the 20 to 21st week of gestation to 38 per cent 2 17 per cent at 36 to 37 weeks, and increasing again to 68 per cent k 6 per cent towards term. The middle graph shows that strong movements first appear in the 22 to 23 weeks, steadily increasing 12 per cent of the to a peak of 27 per cent total count during 36 to 37 weeks and then decreasing towards term. The rolling movements appeared at 26 to 27 weeks, reached a peak of 35 per cent I 18 per cent of the total count at 36 to 37 weeks, and then decreased towards term. Patients with abnormal changes in the pattern of fetal movement Patient 1. A 32-year-old woman in her fourth pregnancy had been admitted a t 34 weeks gestation. A week before admission she had noted a decrease in fetal movements and, concomitantly, a disappearance of the strong and rolling movements; she only felt weak kicks. The day before her admission, she had ceased to feel any fetal movements and upon examination no fetal heart sounds were heard. Three days later she was delivered of a macerated fetus, weighing 1200g, with a 200 g placenta. Patient 2. A 38-year-old woman was admitted in her 32nd week of pregnancy, because of essential hypertension, latent diabetes and intrauterine growth retardation. Fetal movements were between 80 to 130/day, and the pattern showed a gradual increase in weak movements with a parallel decrease in rolling and strong kicks (Fig. 3). A day before delivery, at 38 weeks, fetal movements decreased to 7/day and a Caesarean section was performed. An infant weighing 2380 g, with an Apgar score of 9, was delivered. Patient 3. A 32-year-old woman was admitted at 30 weeks gestation because of a decrease in fetal movements to 20 to 40/day, which did not vary until term. The movement pattern was normal (Fig. 3). She gave birth at term to a

-

TYPES OF FETAL MOVEMENT

h x q ROLLING STRONG WEAK

I

"

NORMAL

PATIENT

2

13

MOVEMENT II

I1

PATIENT

3

32-33 34-35 36-37 32-33 34-35 36-37 32-33 34-35 36-37 WEEKS O F GESTATION FIG.3

The distribution of the type of movement in patients 2 and 3, as compared with the distribution of movement types in normal patients.

normal infant, weighing 2900 g, with an Apgar score O f 9. DISCUSSION A correlation was found between the three types of fetal movement (weak kicks, strong kicks, and rolling movements) as felt by the woman and those recorded by a fetal movement recorder. At 20 weeks of gestation all movements are perceived as weak, and their percentage in the total count decreases towards 36 to 37 weeks. Concomitantly, the strong and rolling movements, which appear two to three weeks later in pregnancy, increase. As others have shown (Pearson and Weaver, 1976), a decrease in fetal movements in patients with pre-eclampsia and intrauterine fetal growth retardation indicates the likelihood of severe fetal distress and impending fetal death. A number of patients stated that before the fetal movements ceased, there was a change in type of fetal activity with the weaker movements predominating. This is

illustrated in patient 1, where only weak movements were felt before their disappearance and subsequent intrauterine fetal death. It seems to us that an increased incidence of weak movements may be an additional sign of fetal distress. In patient 2, the decrease in total movements was preceded by a few weeks by an increased incidence of weak movements. Patient 3 shows that when there is a sudden decrease in fetal movements (to not lower than lO/day), the pattern may be used to distinguish between low but normal daily fetal movement counts and a low fetal movement count which is ominous because of the predominance of weak movements. Daily fetal movement recording is important and useful in the evaluation of the fetal state, especially in patients with suspected intrauterine fetal growth retardation. Our preliminary study indicates that a decrease in fetal movement with an increased incidence of weak movements may be important signs heralding fetal death.

14

SADOVSKY, LAUFER AND ALLEN

ACKNOWLEDGEMENT This work was supported by a grant from the Chief Scientists Office, Ministry of Health, Israel. REFERENCES Mathews, D. D. (1972): British Medical Journal, 1,439. Pearson, J. F., and Weaver, J. B. (1976): British Medical Journal, 1,1305. Rovinsky, J. J., and Guttmacher, A. P. (1965): Medical, Surgical and Gynecological Complications of Pregnancy. Williams & Wilkins Company, Baltimore, p 805.

Sadovsky, E., and Polishuk, W. Z. (1977): Obstetrics and Gynecology, 50,49. Sadovsky, E., Polishuk, W. Z., Yaffe, H., Adler, D., Pachys, F., and Mahler, Y. (1977): International Journal of Gynaecology and Obstetrics, 15,20. Sadovsky, E., and Yaffe, H. (1973): Obstetrics and Gynecology, 41,845. Sadovsky, E., Yaffe, H., and Polishuk, W. Z. (1974): International Journal of Gynaecology and Obstetrics, 12,75. Timor-Tritsch, I., Zador, I., Hertz, R. H., and Rosen, M. G . (1976): American Journal of Obstetrics and Gynecology, 126,70.

The incidence of different types of fetal movements during pregnancy.

British Journalof Obstetrics and Gynaecofogy January 1979. Vol. 86. pp 10-14 THE INCIDENCE OF DIFFERENT TYPES OF FETAL MOVEMENTS DURING PREGNANCY BY...
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