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It is also important not to look at stillbirth alone as some of these babies who are born alive, will unfortunately not make it though the neonatal period. Louise Louise Silverton CBE Director for Midwifery The Royal College of Midwives 15 Mansfield Street London W1G 9NH Tele: 0300 303 0444 Fax: 020 7312 3536 Web: www.rcm.org.uk Facebook: www.facebook.com/MidwivesRCM<http://www.facebook.com/MidwivesRCM> Twitter: www.twitter.com/MidwivesRCM<http://www.twitter.com/MidwivesRCM> [cid:image001.png@01D25C78.1BD0DEF0]<https://www.rcog.org.uk/en/guidelines-research-services/audit-quality-improvement/third--and-fourth-degree-tears-project/>[cid:image002.png@01D25C78.1BD0DEF0] [Description: Description: Flu Fighter] Supporting seasonal flu vaccine for midwives and pregnant women The Royal College of Midwives. A company limited by guarantee. Registration number 30157. Registered in England and Wales at the above address. The Royal College of Midwives Trust. A company limited by guarantee. 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From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Soo Downe Sent: 10 January 2017 10:54 To: [log in to unmask] Subject: Re: protocols/guidelines for women's perception of reduced fetal movement no, as far as `im aware it has not been established that this is a causal relationship. I think there is a study in this area going on in London? Jane, are you involved in this ? All the best Soo From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Macfarlane, Alison Sent: 10 January 2017 10:26 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: protocols/guidelines for women's perception of reduced fetal movement Has it been established that the drop in the stillbirth rate is causal? Can you please give us the references? Thanks, Alison From: Annie Burrin [mailto:[log in to unmask]] Sent: 10 January 2017 10:23 To: A forum for discussion on midwifery and reproductive health research.; Macfarlane, Alison Subject: Re: protocols/guidelines for women's perception of reduced fetal movement Is it not inevitable that this happens upon introduction of surveillance programmes such as the perinatal institute's GAP programme or the RCOG equivalent? Most stillbirths are related to reduced movements and fetal growth restriction. As you educate more women about fetal movements an increase in IOL and C/S is seen. As the stillbirth rate drops as a consequence what British woman would disagree with this? Sent from my iPhone On 10 Jan 2017, at 10:12, Macfarlane, Alison <[log in to unmask]<mailto:[log in to unmask]>> wrote: 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]<mailto:[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]<mailto:[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]<mailto:[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