Stillbirths: Discussion About Fetal Movement

I’ve recently read a ProPublica article on stillbirths. Officially a stillbirth is the death of an unborn child after more than 20 weeks of gestation, or halfway through the pregnancy. ProPublica has done a good job reporting on stillbirth, preterm birth, and maternal mortality. Every year, according to ProPublica, 20,000 pregnancies end in stillbirths.

This number represents more deaths than the infant mortality rate for each of the last 10 years. According to the Centers for Disease Control, and Prevention (CDC), this number is 15 times greater than for sudden infant death syndrome (SIDS). We are also failing in preventing preterm delivery and maternal mortality.

Get to Know the Three Tests for Fetal Well-Being

There are ways women can monitor the health of their babies in the last three months of pregnancy. Women need to discuss with their doctor how they can take part in this monitoring along with their doctor.

There are three tests for fetal well-being:

1. the home kick test,

2. the non-stress test (NST) performed in hospitals or clinics, and

3. the biophysical profile (BPP).

The home kick test is one the pregnant patient can do at home. The NST and BPP tests are done in a clinic or hospital. The results should always be discussed with your doctor, not left to nurses or other hospital caregivers.

1. The Home Kick Test

The ProPublica article mentions the fetal kick test, but indicates that there is some question or confusion about how to do the test and what the test means. Believe it or not, as I’ve indicated above, there are people who object to the fetal kick test, also called the home non-stress test, because the test is considered to not be scientific or because it can produce false positive results which require the effort and money to do an NST in a clinic or hospital. The important point here is the charge for an NST test is a very small amount of money to avoid a stillbirth.

How to Do a Home Stress Test

There are a number of ways to do a home stress test. I have read many studies of various options and the following is my favorite:

1. a half hour after you finish eating lunch (if you eat at 12:30, do this test from 1:00 to 1:30 pm).

2. lie on a comfortable place such as a bed or recliner midway between your left side and your back (called the left decubitus position).

3. in this position count your baby’s kicks.

4. you will usually get about ten kicks in 20 minutes, but you may take another ten minutes.

5. if your baby extends it’s legs and returns to it’s previous position, that is considered to be two movements, or “kicks.”

Know Your Baby’s Movements

This test worked 100 percent of the time for the 6000 births I did. I like the test for several reasons. First, there is no cost to the patient or the insurance company. Secondly, it’s an opportunity for my patient to know on a daily basis the normal activity of the baby in her uterus. This allows women to become comfortable with their baby’s normal movement and provides the opportunity for women to know when the movement is increasing or decreasing. 

It is fairly commonly accepted knowledge that babies who are in trouble go through an episode of violent movement before they die. So an episode of violent movement is one that the mom should recognize. But perhaps the best reason to do a home fetal kick test is the discussion that you should have between your provider and yourself, which is part of forming your patient provider partnership. This communication will serve as a conduit between you and your provider to communicate in terms understood by both of you regarding the status of your unborn baby. Your concerns about your baby’s movement should be communicated directly to your provider and not through the nurses. Moreover, your concern should not be delayed from Sunday till Monday. Any deviation from your baby’s normal movement is an emergency. You need to go to the emergency room or the labor and delivery floor immediately and get the movement variation checked.

Besides preventing stillbirths and establishing a conduit for discussion between patient and provider, there is a third very good reason to do the home fetal kick test. That is for the patient to understand exactly how her baby moves so she can determine easily what is different. For example, if mom usually experiences 10 kicks in 20 minutes and then goes to two kicks in 20 minutes that’s a big change and a cause for concern and a reason to get to labor and delivery.

The organization Push for Empowered Pregnancy was founded by women who wanted to understand why they had lost a baby to stillbirth. At their site women can find information about the value of the home kick test, and even an application to keep track of the results of your home kick tests.

2. The NST Test

In general, providers should not ignore what patients tell them and specifically, they certainly should not ignore mother’s complaints about too little or too much fetal movement. Such a complaint requires at least a valid NST, which is conducted with fetal monitors of the baby’s heart rate, heart rate variability, and for the mother’s uterine contractions.

If the NST shows the baby is well, the test is considered valid for three days. In my experience, if I were really concerned about a mother and a baby, I would do an NST twice a week just to make sure that everything looked good on the monitor strip. I trained my patients to kept track of their fetal movements with the home fetal kick test.

3. The BPP Test

Of the three common tests for determining fetal well-being, the fetal BioPhysical Profile (BPP) is the most complex, and in theory has the highest best value. It is a non-invasive, an easily learned and performed by ultrasound. The BPP measures five separate parameters, including fetal body or limb movement, fetal tone, fetal breathing, fetal heart rate and amniotic fluid volume. I like to combine this test with an NST. The BPP is usually performed after the 28th week, although it may be used in unusual cases before the 28th week.

The BPP test is most commonly done after 32 weeks for high risk health conditions in pregnancy. The following elements are tested.

• NST (Non-Stress Test): The heart rate should vary between 120 and 160 with an average of about 140 and should increase with fetal movement. The heart rate should be variable, meaning that it increases and decreases several times a minute. The presence of variability implies that all the neurologic connections which regulate heart rate are intact. A flat baseline is ominous and implies that the control of the heart rate by the nervous system has been compromised. An increase in the baby’s heart rate in this test is similar to your heart rate increase in healthy adults whose heart rate would increase walking up the steps ot going for a jog. There should be two or more heart rate accelerations at more than 15 bpm in the 20 minutes that a test should take.

• Muscle tone: This includes one or more episodes of active extension (straightening ) and flexion (bending) of an arm or a leg or the opening and closing of a hand in 30 minutes.

• Fetal Gross Body movement: Three or more separate fetal movements of limbs or body.

• Breathing movements: The fetus has continuous, rhythmic breathing episodes of continuous breathing lasting 30 seconds during the 30 minute test

• Amniotic fluid volume There’s a pocket of amniotic fluid that measures at least 1 cm across (horizontally) and 2 cm vertically.

The Patient-Doctor Relationship

ProPublica tells the story of Amanda, a 31-year-old woman pregnant at 39 weeks who presented to labor and delivery with a stillborn female. At 39 weeks, she was awakened at 3:00 a.m. with a huge kick. Unfortunately, Amanda didn’t immediately go to the hospital for an NST, but waited until the next day. That 3:00 a.m. movement was the last Amanda felt from her baby. Amanda went about her day reminding herself that the nurses had told her she would feel less movement with the polyhydramnios (too much amniotic fluid in the amniotic sac during pregnancy). First, too much amniotic fluid sometimes has significance and sometimes it does not, but when it’s combined with other warning signs such as an abnormal BPP or the mother’s concern about too little movement, too much amniotic fluid probably shouldn’t be ignored.

I have always recommended the home fetal kick test. This is for every mother. It brings into the discussion the importance of fetal well-being and provides the patient and doctor a basis for meaningful dialogue.

With Amanda, the nurses made the decision about whether or not Amanda’s fetal movement was O.K.  She actually should have been talking with her doctor about fetal movement. This brings up a topic which I harp on fairly regularly. That is the deterioration of the relationship or the partnership between the patient and the provider.

According to the ProPublica article, Amanda was told by the nurses that she would feel less movement with excess amniotic fluid. First, this is not true and secondly, it’s placation, something the nurses say to end the discussion and send the patient home with an answer that appears to have some meaning or significance, but doesn’t.

According to the ProPublica article, Amanda had a BPP the next day. The BPP produced one baby hand movement after 30 minutes. According to the story, we don’t know how much time lapsed between the biophysical profile and the last kick. But I can say with some certainty that this baby did not score well on the BPP, and therefore should have been delivered at that time or had very significant monitoring which probably would have most likely led to a delivery.

Become Familiar With Your Baby’s Movements

There are several very good reasons for patients to learn how to monitor their baby’s movements at home during the last three months of their pregnancy. Becoming comfortable with knowing your baby’s movements is something every woman should do. The home fetal kick test allows a woman to track that movement for no cost.  Knowing your baby’s movements and the history of them provides you with the confidence to advocate for your baby if you have to go to the emergency room for an NST. You will also have the confidence to ask to speak with your doctor about the hospital NST.

From my experience, I believe that women learning to do a home fetal kick test is crucial to decreasing the number of stillbirths.