The issue is what harm might be caused to healthy women and babies if we intervene every time a woman reports reduced fetal movements. Reduced fetal movements/slow growth are not a cause of stillbirth, they are symptom of an underlying problem. Only a minority of those with the symptom actually have a pathology.  The problem is that we don’t know which small babies/babies with slow growth are pathologically affected, and which are just exhibiting something that is physiological for them. The risk is that we cause more risk to healthy women and babies than we prevent harm to those that are truly at risk if we only have very blunt diagnostic instruments/techniques, that, themselves, cause harm.

For me, the parallel  is with the Wax study, that concluded (based on midwife led care and home birth) that ‘less medical intervention in home birth is associated with a tripling in the neonatal death rate’. What sane woman would choose a home birth based on this finding?

However, (and apart from the critique of the design of the Wax study – just taking it on its own terms) if you look at the data, the following is also true:

-for every 1000 healthy women who choose midwife-led care / hospital over home for birth, 1 less baby will die:

but there will be:

 40 more preterm babies

9 more low birth weight babies

67 more operative vaginal births

43 more cesarean sections

30 more episiotomies

13 more third degree tears

19 more maternal infections

An individual woman looking at these data doesn’t know if her baby will be the 1:1000 that might be saved, or if the baby, or her, will be in the list of complications as a consequence of not having antenatal care with a midwife/ or of having a baby in hospital. A health service may look at that list of complications and consider the cost implications for whole populations. And if the data are inversely correlated (that is, proportionally more women and babies need to be exposed to the adverse outcomes of interventions as proportionally fewer babies die) at what point does one side of the equation outweigh the other side?

There is no easy answer to this, of course, because for each parent who loses a baby, percentages don’t matter – it is 100% for them. But this is also true for each parent with a very preterm baby with all the complications that may bring, or for a woman who cannot have a much wanted second baby because of secondary infertility following a caesarean section. It  seems to me that the least we can do is to subject any intervention done for the excellent cause of reducing stillbirth to rigorous research, assessing both short and long term physical, emotional and psychosocial outcomes,  to make sure that we don’t run into the same long term cross-generational risks as we did, for example, with thalidomide or DES – we really need to know the consequences of our genuinely well-intentioned efforts to improve outcomes for women and babies. As WHO said twenty years or more ago:

•         ….The uncritical adoption of a range of unhelpful, untimely, inappropriate and/or unnecessary interventions, all too frequently poorly evaluated, is a risk run by many who try to improve the maternity services…..

WHO http://www.who.int/reproductivehealth/publications/MSM_96_24/MSM_96_24_Chapter1.en.html

it would be great to have some debate about these points!

all the best

Soo

Has it been established that the drop in the stillbirth rate is causal? Can you please give us the references?

Thanks, Alison

Here in England, we are seeing a substantial increase in induction and caesarean section rates. Soo, can you please tell us more about the projects which are evaluation these policies for reduced fetal movements? If everyone is changing their policies an just doing more inductions and caesareans, might it be too late?

 

Alison Macfarlane

 

From: Laura Iannuzzi [mailto:[log in to unmask]]
Sent: 10 January 2017 02:34
To: [log in to unmask]
Subject: Re: protocols/guidelines for women's perception of reduced fetal movement

 

Thank you, 

(And thanks to all who replied so far) This is all really helpful! I feel this is a very grey area at the moment ... to date the management even in our hospital is really variable and I can see the attitude to the problem has changed (for many this has become a reason to admit the women to hospital for surveillance , where before it was more accepted the time for counselling and that after an assessment women could return home). I can see also that our concerns as clinicians in society have ended with more concerns (that does not mean necessarily the right awareness of the problem) amongst women. A clearer guidance in

The multitude of views is really needed, certainly those studies can help

 

Best wishes

Laura 

 

 

 

 

 

Inviato da iPhone

Il giorno 09 gen 2017, alle ore 11:11, Soo Downe <[log in to unmask]> ha scritto:

Laura, there is no good evidence either way on what to do in these circumstances as far as Im aware, in terms of reducing adverse outcome for the baby, but, of course, we know that routine interventions in large numbers of healthy women and babies can have adverse consequences. There are a couple of large on-going studies in the UK that should be completed soon about management of reduced fetal movements, and I would suggest that any change in practice should really wait for these studies to be complete.

 

The website for the AFFIRM study is here: http://www.crh.ed.ac.uk/affirm/

 

The intervention is:

 

Single episode of presenting with decreased fetal movement.

i. 39 weeks gestation or more

a. Perform CTG within 2 h and LV within 12 hours. Perform USS for EFW /AC next working day. If all normal

AND fetal movements have returned to normal, discharge back to routine care.

If AC or EFW less than 10th centile or LV abnormal (deepest pool ≤ 3cm) consider delivery with input from

senior obstetrician.

ii. If 37 to 39 weeks:

Perform CTG within 2 h and LV within 12 hours. Perform USS for EFW /AC next working day.

If all are normal and fetal movements have returned to normal, the woman can be discharged to routine care.

If all are normal but decreased fetal movements persist, manage the following day as for repeat episode of

decreased FM (see below)

If AC OR EFW are less than 10th centile and fetal movements have returned to normal refer to senior

obstetrician for review, consider delivery if fetal growth restriction is suspected.

If LV abnormal (deepest pool < 3 cm) consider delivery.

iii If 28 - 37 weeks

Perform CTG within 2 h and LV within 12 hours. Perform USS for EFW /AC next working day.

If all are normal and fetal movements have returned to normal, the woman can be discharged to routine care.

If all are normal but decreased fetal movements persist, manage the following day as for repeat episode of

decreased FM (see below)

If AC OR EFW are less than 10th centile or LV abnormal (deepest pool < 3 cm) perform umbilical artery

Doppler and review by senior obstetrician as per local protocol for suspected IUGR. The revised RCOG

guidelines for SGA (currently out for consultation at http://www.rcog.org.uk/womens-health/consultationdocuments)

should be also be consulted. Consider delivery by 37 weeks for women with suspected fetal

growth restriction.

Recurrent episodes of reduced fetal movements

Perform CTG and LV within 2 h

(i) If more than 38 weeks gestation consult with senior obstetrician and consider delivery within 24 h

(ii) If more than 14 days since previous scan repeat USS and manage accordingly.

Page 31 of 30

(iii) If less than 14 days since previous scan, schedule repeat scan for 2 weeks after first scan and perform

twice weekly CTG monitoring and weekly LV until then. Thereafter, manage according to scan results. Centile

crossing could prompt Doppler, otherwise ignore unless no growth since previous scan.

 

 

Note that referral back to usual care in the absence of any increased markers of complications is part of this protocol. They are also looking for possible unintended adverse consequences at the population level , so the fact that this is being introduced in a trial means that both benefits and harms can be assessed.

 

The full protocol is here: http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/7%20AFFIRM%20PROTOCOL.pdf

 

All the best

 

Soo

 

 

 

 

From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Laura Iannuzzi
Sent: 08 January 2017 22:05
To: [log in to unmask]
Subject: protocols/guidelines for women's perception of reduced fetal movement

 

Dear all

in our hospital we are working on a document (protocol) for the care of women reporting a reduction of fetal movements antenatally (especially at term) In Italy there is an increasing concern about the topic and here in Florence some doctors are proposing various management e.g that everytime a woman reports a reduction of fetal movement she has to be admitted to hospital (so without the possibility of councelling and going back home if fine) or needs to have a computerised monitoring of FHR, a scan with a doppler.

 

the current management is variable, and there have been debates regarding the management that should be performed in our AMU. As we have CTG monitors it could be reasonable the discussion and proposal could be to offer councelling in case of reduced fetal movement and have a first level of monitoring  within the AMU without this being a ordinary reason for transfer and admission to the maternity department/traditional pathway (this would keep the focus on staying with women and use all the possibilities to empower and reassure her, while offering a safe care) . computerised monitoring and US could be thus offered in case of risk factors or a non-convicing first level assessment.

 

I saw the RCOG guidelines of 2011, but having attended some conference here I'm conscious that there is a big push towards a different approach more US-scan based..

 

 

have you got any thoughts on the topic, suggestions or reference that you feel I should consider while working on this document and, most importantly, in order to offer a safe care but avoiding unhelpful interventionism ?

 

 

thanks 

Laura Iannuzzi

 

RM. BMid. PG Cert, MSCi, PhD

Margherita Birth Centre, Careggi University Hospital, Florence, Italy