Clinical Inquiries

Do abnormal fetal kick counts predict intrauterine death in average-risk pregnancies?

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EVIDENCE-BASED ANSWER

No. Structured daily monitoring of fetal movement doesn’t decrease the rate of all-cause antenatal death in average-risk pregnancies (strength of recommendation [SOR]: B, single good-quality, randomized controlled trial [RCT]). Although maternal perception of decreased fetal movement may herald fetal death, it isn’t specific for poor neonatal outcome (SOR: B, single good-quality, diagnostic cohort study). Monitoring fetal movement increases the frequency of non-stress-test monitoring (SOR: B, single good-quality RCT).

Clinical commentary

A rare tragedy that monitoring can’t prevent
Johanna Warren, MD
Oregon Health and Sciences University, Portland

Fetal movement is a marker of well-being. We draw on our experience with fetal monitoring to know that in healthy fetuses, movement increases sympathetic response and accelerates heart rate. Fetuses with severe acid-base disorders can’t oxygenate their muscles adequately and don’t move. Fetal movement, therefore, is a relatively simple indirect means of fetal assessment that indicates a lack of significant acidosis.

Intrauterine fetal demise (IUFD) is a rare but devastating event in an uncomplicated term pregnancy; it occurs in about 5000 of nearly 4 million us births each year (0.125). As the authors of this Clinical Inquiry state, nearly half of term IUFDs are unexpected and unexplained. Although it may be a logical extension to apply our knowledge of fetal physiology in an attempt to prevent IUFD, no conclusive evidence suggests that daily monitoring of fetal movement improves fetal or neonatal outcomes. We can hope that, with more accurate dating methods and more aggressive control of hypertension, diabetes, and anemia in pregnancy, the number of term IUFDs will continue to fall.

Evidence summary

Nearly 50% of late-pregnancy IUFDs have no associated risk factors. Fetal demise, however, may be heralded by decreased fetal movement followed by cessation of movement at least 12 hours before death.1 Maternal monitoring of fetal movement by kick counts has been proposed as a method to verify fetal well-being and decrease the rate of IUFD in the general obstetric population.

Counting doesn’t reduce antenatal death, large study shows

A well-done RCT randomized 68,654 women to either usual care or structured, daily monitoring of fetal movement using the count-to-10 method—daily maternal documentation of the amount of time it takes to perceive 10 fetal movements. Usual care was comprised of a query about fetal movement at antenatal visits and instruction to perform fetal movement monitoring at the provider’s discretion. Mothers were told to visit their health-care provider for evaluation if they felt no movement in 24 hours or fewer than 10 movements in 10 hours during a 48-hour period. The trial showed no benefit from monitoring in reducing the rate of antenatal death from all causes.

The rate of all fetal deaths in the counting group was 2.9 per 1000 normally formed, live, singleton births; the rate in the control group was 2.67 (absolute risk reduction=0.24; 95% confidence interval [CI], –0.5 to 0.98). Women in the counting group spent an average of 160 hours counting during pregnancy and had a statistically significant increase in fetal non-stress-test (NST) monitoring (odds ratio [OR]=1.39; 95% CI, 1.31-1.49; number needed to harm [NNH]=50 to cause 1 additional NST). A statistically insignificant trend toward increased antepartum admissions was also noted in the counting group.2

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