Your baby’s movements during pregnancy are a good indication of their health and wellbeing, with studies showing that a reduction or absence of fetal movements is linked with an increased risk of poorer health outcomes.
- Giving birth to poorly grown (smaller) babies i.e. ‘intrauterine growth restriction’ (IUGR)
- An increased risk of preterm birth
- And in the worst cases, intrauterine death and stillbirth.
Reduced fetal movements have also been found to be associated with congenital fetal abnormalities, where the baby’s nerves, muscular and skeletal systems do not develop as they should.
NICE Guidelines currently advise that midwives do not listen for the baby’s heart beat at routine antenatal appointments. This is because the presence of the fetal heart rate does not a guarantee the baby is healthy and well. Instead, monitoring the baby’s activity and their pattern of movements is better at assessing fetal health and wellbeing.
Routine antenatal assessments
Assessing fetal movements is an important aspect of the regular antenatal care that your midwife provides during pregnancy. Your midwife/doctor should inform you early on about the importance of feeling for your baby’s movements, or kicks. This is a very simple way that mums-to-be can assess their baby’s health and wellbeing without needing to receive training or use specialist equipment. It is very important that you take time out of your daily routines, no matter how hectic they might be, to focus on your baby’s movements inside the womb.
How many movements?
Research shows there is no set number of movements that babies should make over a 24 hour-period because each baby is individual – some babies will be more active than others; in the same way as some mums-to-be will be more aware of their baby’s movements than others. The important point to highlight here is that all pregnant women should be encouraged to recognise their baby’s normal level of movements and peak times of activity. When this is done, any reduction in movements or changes to the pattern of activity can be identified and promptly referred to a midwife or doctor for assessment and treatment, as needed.
Normal fetal movements
The first time you feel your baby move inside the womb is often a really exciting moment. In the early weeks of pregnancy, fetal movements often tend to be felt as a slight ‘fluttering’, ‘swishing’, ‘kicking’ or ‘rolling’ sensation. However, as the pregnancy advances and the baby develops, movements become more pronounced and a pattern of activity quickly develops. Studies that have looked at fetal movement patterns show that afternoons and evenings tend to be the peak times of activity.
The majority of pregnant women feel their baby’s distinct movements in the womb by around 18-20 weeks’ gestation; however, this can vary between women:
- Women expecting their first baby often start to notice fetal movements by 20 weeks’ gestation
- Those expecting their second or subsequent baby may notice fetal movements at a much earlier gestation – often around 16 weeks.
As pregnancy advances fetal movements continue to increase and will peak at around 32 weeks’ gestation, after which time, they plateau out. However, there should be no reduction in the frequency of fetal movements in the late third trimester.
From 32 weeks’ gestation, the fetus usually develops a pattern of movement and sleep that the pregnant woman tends to get accustomed to.
The type of fetal movements felt will change around this time, as the available space in the womb becomes increasingly limited. However, as already mentioned, their frequency should not and mums-to-be should continue to feel their baby moving right up to, and throughout labour.
Factors affecting fetal movements
Just like the rest of us, babies also need rest and sleep. Their times of peak activity will be punctuated by sleep time when fetal movements subside and will often stop altogether. On average babies sleep for around 20 – 40 minutes at a time and seldom for longer than 90 minutes. These ‘sleep cycles’ occur regularly throughout both the day and night.
Anything that enters the mother’s body can cross the placenta and enter the unborn baby’s blood circulatory system, causing them to become sleepy and have reduced fetal movements. Substances that can affect fetal movements include:
- Tobacco smoke
- Medications (including sedatives and strong pain-killing drugs)
- Illness or congenital abnormality
There are also certain congenital conditions that affect the central nervous system, muscles and skeleton of the unborn baby, which leads to reduced fetal movements. This doesn’t mean you should assume your baby has a congenital abnormality, there are a variety of reasons for reduced fetal movements, that we discuss in this article.
Factors that make it more difficult to recognise fetal movements?
Fetal movements in the early weeks of pregnancy are not always noticeable and, in first-time pregnancies, can easily be mistaken for wind or indigestion. If women lead very hectic lives work, daily responsibilities, chores, and the care needs of any other children can all impact on a woman’s ability to keep track of her baby’s movements and activity patterns.
There is also some research that suggests a woman’s posture can affect her perception of fetal movements. It suggests that most fetal movements are felt when women are lying down with fewer movements felt when sitting and fewest while standing upright.
If the placenta is in an anterior (at the front of the womb) position, particularly before 28 weeks’ gestation, it can often cushion the baby’s movements or kicks so that women are less aware of them. The baby’s position inside the womb and the direction in which they are lying can also affect the extent to which fetal movements are felt. For instance, if the baby is lying with its spine against the mother’s spine (occipito-posterio position), women are more likely to feel fetal movements than when the baby’s back is facing towards the front of the womb (occipito-anterior position). However, whether the baby is presenting head first (cephalic) or bottom first (breech) has been shown not to affect how fetal movements are felt.
Adolescents and women with strong abdominal muscles may also be less aware of fetal movements.
What to do when you are unsure of your baby’s movements
We have previously mentioned how easy it can be for women with hectic lifestyles to lose track of their baby’s movements. When this happens, it is recommended that women take themselves to a quiet room and lie down on their left side, in a relaxed and comfortable position. They should stay there for two hours and focus solely on their baby’s movements – resting a hand on their abdomen can help with this. It is advised that women need to feel for ten distinct individual fetal movements or kicks. Having a glass of cold water or fruit juice can sometimes help, but a woman should never feel tempted to poke or prod their ‘bump’ in order to elicit fetal movements. Most women find that once they have laid-down for a couple of hours, their baby’s movements can be easily felt and there are no further concerns.
The legacy of the kick chart
Contrary to what some women believe, UK maternity services stopped routinely using pregnancy ‘kick charts’ some time ago, because research showed there was insufficient evidence to support their use. Other studies have found that women received conflicting and vague guidance on their use, so instead it is advised that women focus on their baby’s movements at regular intervals throughout the day. These studies have shown the woman’s recognition of any reduction and/or alteration to her baby’s usual pattern of movements is key to improving fetal health outcomes.
Management of reduced fetal movements
If you think that your baby is moving less than normally or you have not felt any movements, it is important that you contact your local maternity hospital without delay and go in to be assessed – regardless of the time, day or night. Women should never leave reduced fetal movements until the morning, because reduced activity can be a sign that the baby is unwell and their health might deteriorate quickly with potentially terrible consequences.
Under 24 weeks’ gestation
If you are under 24 weeks’ the midwife or doctor will listen to your baby’s heart rate with a hand-held doptone. This enables both you and your health care professional to listen to the baby’s heartbeat, which normally ranges from 110 – 160 beats per minute. The doctor may also recommend that you have an Ultrasound scan to check fetal movements. In some circumstances, where any risk factors for stillbirth are identified, women may be referred to a specialist Fetal Medicine Unit so that their baby’s wellbeing can be closely monitored more regularly.
24 – 28 weeks’ gestation
The midwife or doctor will take a full history about how you are feeling and your pregnancy to date. They will also perform a full antenatal check – this includes recording your temperature, pulse, blood pressure and respiratory rate, and testing a urine sample for protein (proteinuria) to make sure that all is as it should be and there is no underlying illness or condition that might be affecting your baby.
The midwife will palpate your womb, measuring its height to ensure the size of the womb equates with the number of weeks’ pregnant you are. Abdominal palpation enables the midwife or doctor to identify the baby’s position inside the womb. They will check your baby’s heart beat with a hand-held Doptone or by using an electronic fetal heart rate monitor called a ‘cardiotocograph’ (CTG). The CTG records your baby’s heart beat and its pattern, and can also record the presence of any womb tightening’s or contractions.
Whenever the baby moves there should be a corresponding increase in their heart rate – these are displayed as spikes on the paper print-out and are called fetal heart rate accelerations. Any contractions present will show up as wave-like patterns on the CTG printout.
Should their assessment raise any concerns about the baby’s size and health, the doctor will recommend a scan to check fetal growth and development.
For further information, see Pregnancy conditions explained: Pre-eclampsia.
28 weeks or more
You will be given a full antenatal check-up as detailed previously and will be advised to have electronic fetal heart rate monitoring using a CTG. Your baby’s heart rate will be monitored for at least 20 minutes to ensure their heart rate and pattern is within the expected range. Many expectant parents find it very reassuring to listen to their baby’s heart beat and to see it on the print out.
If there are any concerns regarding the baby’s heart rate or pattern the midwife or doctor will advise that the CTG is left on for longer. This may also include asking you to adjust your position – to sit up more or to lie on one side and see whether this wakes the baby up. Once the midwife or doctor is happy with the fetal heart rate trace, the CTG monitoring can be stopped.
If there are any concerns about the baby’s movements, their size, or the volume of amniotic fluid (waters) surrounding them; the doctor will usually recommend a scan to assess the baby’s growth and development. Similarly, if there are any underlying medical or obstetric (pregnancy) factors that are associated with the pregnancy being at a higher risk of stillbirth, the doctors will always advise closer, specialist monitoring.
If these investigations show there is no cause for concern, you will be allowed to go home. However, you will always be advised to continue monitoring fetal movements and to return to hospital if there are any further concerns. It does not matter how many times you might need to return to be checked over; the important thing is that you are assessed each time.
If there are concerns about you and/or your baby’s health and the doctor is concerned that continuing the pregnancy is placing your baby at risk, you may be advised to deliver early. This decision is never taken lightly and will depend on the stage of the pregnancy and individual circumstances. The doctor and midwife will explain the concerns fully, so that you understand the reasons behind their recommendations and are able to make an informed decision.
Reading around this topic may leave you feeling a little anxious, so it is important that you also discuss any queries or concerns with your own midwife. It is also important to highlight that research demonstrates that the majority of women who experience one episode of reduced fetal movements go on to enjoy a straightforward pregnancy and give birth to a healthy baby.
For more information visit the Kicks Count website.