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Maternal Perception of Fetal Movements: a Qualitative Description

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Maternal Perception of Fetal Movements: a Qualitative Description View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by ResearchArchive at Victoria University of Wellington MATERNAL PERCEPTION OF FETAL MOVEMENTS: A QUALITATIVE DESCRIPTION BY BILLIE BRADFORD A thesis submitted to the Victoria University of Wellington in fulfilment of the requirements for the degree of Master of Midwifery Victoria University of Wellington 2014 Abstract Background: Maternal perception of decreased fetal movements is a specific indicator of fetal compromise, notably in the context of poor fetal growth. There is currently no agreed numerical definition of decreased fetal movements, with subjective perception of a decrease on the part of the mother being the most significant definition clinically. Both qualitative and quantitative aspects of fetal activity may be important in identifying the compromised fetus.Yet, how pregnant women perceive and describe fetal activity is under-investigated by qualitative means. The aim of this study was to explore normal fetal activity, through first- hand descriptive accounts by pregnant women. Methods: Using qualitative descriptive methodology, interviews were conducted with 19 low-risk women experiencing their first pregnancy, at two timepoints in their third trimester. Interview transcripts were later analysed using qualitative content analysis and patterns of fetal activity identified were then considered along-side the characteristics of the women and their birth outcomes. Results: Fetal activity as described by pregnant women demonstrated a sustained increase in strength, frequency and variation from quickening until 28-32 weeks. Strength of movements continued to increase at term, but variation in movement types reduced. Kicking and jolting movements decreased at term with pushing or stretching movements dominating. In this study increased strength and frequency of movements at term as determined qualitatively by the mother was associated with higher mean customised birthweight of newborns, whilst decreased frequency was in all cases associated with either maternal obesity, customised birthweight under the 20th centile or operative delivery for non-reassuring fetal status. A novel finding of a complex pattern of fetal movements in relation to mealtimes is reported here. More than a third of participants (37%) described marked increases in fetal movements in response to hunger, in many cases subsiding postprandially. The women who described this pattern in response to hunger and eating, subsequently gave birth to infants significantly smaller (mean difference 364gm) than those who did not describe a fetal response to hunger. Patterns of fetal movements were reported to be influenced by time of day, maternal position and ii activity, with an inverse relationship between maternal activity and fetal activity described by all participants. Conclusions: Maternal descriptions of fetal movements with advancing gestation and in relation to time of day are consistent with fetal activity as described in ultrasound studies, lending reliability to the maternal account. Maternal perception of fetal movements in response to environmental stimuli such as maternal meals and maternal position-changes may constitute a maternal-fetal communication in the interests of maintaining the pregnancy. Pregnant women are reassured by fetal movements occurring at a usual time or situation, suggesting that maternal monitoring of fetal movements is a dynamic process taking into account a broad range of fetal functions. Key Words: fetal movements, stillbirth, antenatal care, fetal development. Billie Bradford has asserted her right under the Copyright Act 1994 to be identified as the author of this work. iii Acknowledgements I would like to thank my supervisor Robyn Maude for her encouragement, support, and shared passion for fetal physiology. I would especially like to thank my friend Robin Cronin for her interest in the thesis and for providing moral support during difficult times. I would also like to acknowledge the women who generously shared their pregnancies with me as participants in the research and the midwives who enthusiastically recruited women in their care to the study. Thanks go to my mother Vanessa for instilling early in me a passion for science, research, wondering and discovery. Also to my father Alan and stepmother Rebecca for their enduring belief in me and ever-ready practical and loving support during the many trips to Wellington. Last but not least, thanks to my husband Lee and children Iris, Roland, Gwen and William who have lost so much time with me to this work. Thank you for your patience and your pride in me. iv Table of Contents Contents Abstract................................................................................................................................. ii Acknowledgements............................................................................................................ iv Table of Contents ................................................................................................................ v Tables and figures ............................................................................................................. ix Chapter 1 .............................................................................................................................. 1 Introduction and context..................................................................................................... 1 1.1 Background ............................................................................................................... 1 1.2 The problem of stillbirth ........................................................................................... 4 1.3 Maternal perception of fetal movements and fetal compromise ....................... 6 1.4 Clinical presentations with decreased fetal movements .................................... 7 1.5 Risk of iatrogenic harm ............................................................................................ 9 1.6 Decreased fetal movements at term ................................................................... 10 1.7 Midwifery imperative in antenatal surveillance .................................................. 10 1.8 Aims of research..................................................................................................... 12 1.9 Structure of thesis .................................................................................................. 12 Chapter 2 ............................................................................................................................ 14 Literature review ................................................................................................................ 14 2.1 Introduction .............................................................................................................. 14 2.2 Search strategy....................................................................................................... 14 2.3 Section One: Ultrasound studies of fetal activity ............................................... 15 2.3.1 Fetal movements in early pregnancy ........................................................... 15 2.3.2 Fetal activity in late pregnancy ..................................................................... 17 2.3.3 Temporal patterning of fetal activity ............................................................. 17 2.3.4 Fetal behavioural states ................................................................................. 18 2.3.5 Fetal breathing movements ........................................................................... 18 2.3.6 Ultrasound-observed fetal movements and pathology ............................. 19 2.3.7 Amniotic fluid ................................................................................................... 20 2.3.8 Summary .......................................................................................................... 20 2.4 Section Two: Maternal perception of fetal movements .................................... 20 2.4.1 Correlation between maternally-perceived fetal movements and objective detection .................................................................................................... 21 2.4.2 Parity ................................................................................................................. 23 2.4.3 Placental location ............................................................................................ 23 v 2.4.4 Maternal obesity .............................................................................................. 24 2.4.5 Term gestation................................................................................................. 25 2.4.6 Fetal position ................................................................................................... 26 2.4.7 Smoking ............................................................................................................ 26 2.4.8 Maternal meals ................................................................................................ 27 2.4.9 Amniotic fluid volume ..................................................................................... 27 2.4.10 Time of day .................................................................................................... 28 2.4.11 Maternal position........................................................................................... 28 2.4.12 Summary .......................................................................................................
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