© Longman Group UK Ltd 1992

Midwifery

An evaluation of the importance of formal, maternal fetal movement counting as a measure of fetal well-being
Andrea Marnoch

M a t e r n a l p e r c e p t i o n o f fetal m o v e m e n t s has, o v e r the years, b e c o m e r e c o g n i s e d as a valuable tool f o r early d e t e c t i o n o f fetal c o m p r o m i s e . Several studies p u b l i s h e d in the m i d - 1 9 7 0 s h a v e d e m o n s t r a t e d that a r e d u c t i o n o r cessation in m a t e r n a l l y p e r c e i v e d fetal m o v e m e n t s m a y p r e c e d e a n t e p a r t u m late fetal d e a t h by a day o r l o n g e r . F r o m these findings f o r m a l fetal m o v e m e n t c o u n t i n g e m e r g e d as a valuable, non-invasive m e t h o d o f assessing fetal well-being; the b e l i e f b e i n g that clinical actions t a k e n o n t h e basis o f r e d u c e d fetal m o v e m e n t c o u n t i n g m a y p r e v e n t a n t e p a r t u m d e a t h o r m o r b i d i t y . C o n v e r s e l y , m o r e r e c e n t studies h a v e failed to d e m o n s t r a t e t h a t t h e r e is a beneficial e f f e c t o f a f o r m a l , fetal m o v e m e n t c o u n t i n g policy o n a n t e p a r t u m d e a t h . It is n o t d i s p u t e d that fetal m o v e m e n t s are o f clinical i m p o r t a n c e b u t it seems t h a t r o u t i n e daily c o u n t i n g o f fetal m o v e m e n t s by w o m e n followed by a p p r o p r i a t e action w h e n m o v e m e n t s a r e r e d u c e d o f f e r s n o a d v a n t a g e s o v e r f o r m a l i n q u i r y a b o u t fetal m o v e m e n t s d u r i n g s t a n d a r d a n t e n a t a l care. T h u s , the a p p l i c a t i o n o f f o r m a l , m a t e r n a l fetal m o v e m e n t c o u n t i n g as a m e t h o d o f fetal surveillance to r e d u c e late a n t e p a r t u m d e a t h m u s t be q u e s t i o n e d .

INTRODUCTION
Since biblical times fetal movements have been viewed as a reassuring sign of a healthy and viable pregnancy: 'And it came to pass that when Elizabeth heard the salutation o f Mary, the babe leaped in her womb' (Holy Bible, St Luke 1 v 41). Despite this knowledge, maternal perception of fetal activity as a measure of fetal well-being in late pregnancy had, up until the last decade, been largely ignored.
Andrea Marnoch RGN, RM, ADM, Midwifery Sister, Queen Alexandra's Royal Army Nursing Corps, 2 Aspen Gardens, Hook, Hants RG27 9RB, UK. Manuscript accepted 5 December 1991 Requests for offprints to AM

Prior to the mid-1970s fetal surveillance was carried out using a wide range of biochemical tests. However, the poor predictive power of these tests at detecting the fetus at risk led Alexander et al (1989) to conclude that 'they serve to be of no benefit for screening purposes in the second half o f pregnancy'. This, coupled with high costs (Alexander et al, 1989) and impracticalities (i.e. hospital based) involved in carrying out biochemical assessment of fetal well-being, clearly demonstrated a need for a simple, low technology, inexpensive, superior method of screening to detect the fetus at risk of late antepartum death. From the mid-1970s maternal fetal movement counting began to emerge and formed the basis of a new format o f antenatal care whereby the

54

MIDWlVEkY 55 woman, rather than the obstetrician, assumed responsibility for monitoring fetal well-being (Oakley, 1986). study clearly emphasises the importance of inquiring about the type of fetal m o v e m e n t perceived by the woman during standard antenatal care.

Fetal movements in late pregnancy
It is recognised that each fetus has its own pattern of daily activity with definite periods of rest and activity (Rayburn, 1982). From the research conducted by Patrick et al (1982) peak activity time is reported to be f r o m 2100 hours to 0100 hours and m i n i m u m activity f r o m 0100 hours to 0500 hours. Gibby (1988) suggests that fetal activity is influenced by maternal activity level. When the woman is active, the fetus is quiet. Conversely, there is an increase in fetal activity when the woman is resting. These findings are also borne out by Rayburn (1982). Clearly these findings have implications for the time period chosen to count movements formally and, more importantly, stress the necessity of distinguising between sleep states and a compromised fetus. Research has shown that fetal movements decrease significantly with increasing gestational age (Mathews, 1978; Sadovsky & Yaffe, 1973). According to Sadovsky and Yaffe (1973) a decrease in fetal movements occurs after the 32nd week of gestation and is accompanied by a reduction in the actual n u m b e r o f quiet-active cycles. T h e reason for the decrease in m o v e m e n t with advancing gestational age is not fully understood (Davies, 1987). Mathews (1978) suggests that it may be a direct result o f the smaller area in which the fetus has to move as well as increasing maturation of the central nervous system. In a study of the different types of fetal movements during late pregnancy, Sadovsky et al (1979) classified the movements into three categories: weak, strong and rolling. T h e y found that the rate of weak movements gradually decreased until the 36th and 37th weeks, whilst the strong and rolling m o v e m e n t s increased from the 36th to 37th weeks until term when weak movements increased again with a decline in strong and rolling movements. O f clinical significance is the assertion that before fetal death or in severe fetal distress the relative rate of weak movements increased significantly. This

Maternal perception of fetal activity
I f fetal movement counting is to be used to assess fetal well-being then maternal perception of fetal activity must be accurate otherwise the method will have little clinical significance. T o assess whether every m o v e m e n t made by a healthy fetus is appreciated by the woman Sadovsky et al (1973) used an electromagnetic device to detect fetal movements and reported that on average women were aware of 87% - but the range was 64% to 100% suggesting relatively poor perception on the part of some women. Hertogs et al (1979), in an albeit small sample of 20 subjects, demonstrated that women differ widely in their ability to perceive movements some notice nearly all of their baby's movements, others only a proportion and some apparently none at all. Furthermore, no correlation was found between movements perceived and parity, obesity, gestational age or placental site. These differences between women and their perception of fetal m o v e m e n t are the major source of variation in fetal movements (Grant & Elbourne, 1989). These findings draw attention to the methods of m o v e m e n t counting employed since many false alarms may occur, together with prolonged counting in pregnancies in which movements are infrequent. An individualised system as described by Grant and H e p b u r n (1984) abolishes these problems and is discussed later. Oakley (1986) feels that pregnant women have always possessed their own knowledge about fetal vitality and that f r o m the interior uterine movements of the fetus women gain a sense of fetal character and well-being. Kitzinger (1988) echoes these statements by stating that women themselves are the best judges of fetal vitality. This intimate maternal knowledge of the fetus provided the bench m a r k from which obstetricians developed fetal m o v e m e n t counting as a method of evaluating the fetal state. However,

56

MIDWIFERY Cardiff 'Count-to-Ten' system for the recording of maternally perceived fetal movements (see Fig. 1). This enabled women's perceptions of their own baby's movements to be used as an index o f fetal well-being.

Oakley (1986) feels that by asking the woman to count fetal movements systematically 'obstetricians are capitalising on pregnant women's own bodily expertise by d e m a n d i n g that maternal experience be translated into technical obstetrical language'.

A golden age of fetal movement counting
Sadovsky and Yaffe (1973) first m a d e the important observations that in cases o f placental insufficiency where the fetus died fetal movements decreased and stopped 12-48 h before the fetal heartbeat finally disappeared. T h e y called this the ' m o v e m e n t alarm signal' and suggested that when this signal became manifest, immediate delivery could prevent late a n t e p a r t u m death. These findings were supported by Mathews (1973) who suggested that a history o f reduced fetal activity in late pregnancy indicated 'serious fetal danger'. In 1976 Pearson and Weaver established that 2.5% of women who subsequently delivered a normal baby recorded fewer than 10 movements in a daily 12h period from 32-40 weeks' gestation. This level was then accepted as the lower limit of normal. From this study Pearson and Weaver established that reduced fetal movements were associated with a high incidence of fetal asphyxia, and when fetal death occurred fetal movements rapidly diminished and stopped 12-48h before death providing further evidence to support Sadovsky and Yaffe's (1973) definition of the ' m o v e m e n t alarm signal'. O f greater clinical importance was Pearson and Weaver's (1976) observation that a normal fetal movement count (i.e. not fewer than 10 movements in 12 h) was normally associated with a good outcome and would thus 'reassure the obstetrician who wishes to defer delivery to gain further fetal maturity'. From this study Pearson and Weaver (1976) advocated fetal m o v e m e n t counting as a useful, universally applicable measure of fetal wellbeing which they found to be at least as reliable as the m e a s u r e m e n t o f 24h urinary oestrogen and very much cheaper. In 1977 Pearson devised the

Methods of fetal movement counting
T h e Cardiff Count-to-Ten system, whereby the m a x i m u m normal time to record 10 fetal movements is set at 12h, is theoretically attractive because women with a vigorous fetus count for m i n i m u m lengths o f time, whereas women with a quiet fetus will count longer (Pearson, 1977). However, the drawback with this 'fixed n u m b e r ' approach is that recording becomes less accurate with longer periods of counting, and an important minority o f women with a normal fetus will feel relatively few movements towards the end of pregnancy - - these women must consistently count for long periods of time (Grant & Elbourne, 1989). Another approach to fetal movement counting approved by Neldam (1980) is the 'fixed time' method whereby the woman counts for one hour and continues for a second hour if the count is low - the normal being a m i n i m u m of four movements per hour. However, T h o m p s o n and Wheeler (1985) state that a high false positive alarm rate remains the chief potential drawback o f fixed-time periods that are sufficiently short to be feasible in practice. Further criticism of both the 'fixed-time' and 'fixednumber' approach is that neither take into acount the normal variation in activity which exists between different fetuses; some are consistently vigorous whilst others are consistently sluggish (Sadovsky & Yaffe, 1973). Grant and H e p b u r n (1984) argue that by applying uniform lower limits of fetal activity to all women, a pathological reduction in movements in a fetus which is usually vigorous may be disguised. Similarly a false alarm may be raised by a fetus which normally moves relatively infrequently. T h e y suggest that these problems are likely to be overcome by using a system of formal fetal m o v e m e n t counting based on individualised normal limits which take into account

MIDWIFERY

57

m

m @

Z

e

................

:!
v~ m I[J i'~ I

E
r.. OD 'u.~5 ~(q Ot Ue~ll $set I'.

~
0 u

o
~ o ' mC

-~ c ~ E l ~ ~ ® >, ~ , ~ O.,..:. E= c I - ~ C @ .
." C 0 u

~' ~ cw

"~" ;

.~

i

~"

.c_ m ~ c: {0 ~ JO

C -- ¢::

~®~.~o~
o8
~,.,~:
~, ~..~.
~E ~..~ ~ ,

a
: _o
>. " "~

,•

.~E
.~ ," ,~ ~ ~ m

(o ~ . c : ~ ~ x . - - - - "

~

E

:

..

58

MIDWIFERY

~U

u~

, ,~-,

ff
u~ O

u~

e-,

,t,

-=
2O e,O

U

O'J

MIDWIFERY

59

both the variation in activity between fetuses and the variation between women in their perception of fetal movements. T h e individualised system proposed by Grant and H e p b u r n (1984) involved asking women at the end of the second trimester o f their pregnancy to count fetal movements for a two-hour period each day for five consecutive days. Based on this, an average n u m b e r of perceived fetal movements per h o u r would be calculated for each woman-fetus pair. T h e time taken to feel this n u m b e r of movements would then be recorded by the woman each day. T h e promising findings f r o m this research suggested that an individualised approach to fetal m o v e m e n t counting is associated with a substantially lower false alarm rate than a system of counting for one hour and continuing for a second hour if the level is low. In comparison with the Cardiff 'Count-to-Ten' method, the amount of time spent counting each day was more uniform and was halved overall (Table 1). However, these findings must be t e m p e r e d by the knowledge that there were only 25 subjects in the sample used by Grant and H e p b u r n (1984). Despite this concern, the clear advantages that this system offers justifies a m o r e extensive trial before its introduction into clinical practice is contemplated.

Fetal movement counting as a valid measure of fetal well-being
Following the pioneering studies previously cited, other researchers (Neldam, 1980; Fischer et al, 1981) have also demonstrated a correlation between reduced fetal movements and perinatal

death and morbidity. Moreover, their findings support the use of a formal m o v e m e n t counting policy as a reliable test o f fetal well-being. In a study of 2250 British women Neldam (1980) found that half o f the g r o u p assigned to a policy of fetal m o v e m e n t counting had a statistically significant reduction in the rate o f late antepartum death as c o m p a r e d with the remaining half of the g r o u p who did not count fetal movements. His conclusions provide evidence for the assertion that clinical action to expedite delivery on the basis of a reduced m o v e m e n t count can prevent mortality. Further studies on support the contention that a reduction in fetal movements is associated with a significant increase in perinatal mortality (Fischer et al, 1981; Robert et al, 1982; Moore & Piacquadie, 1989). T h e y conclude that a policy of fetal m o v e m e n t counting is effective in reducing the incidence of a n t e p a r t u m death. However, the findings of these three studies must be viewed with caution since they all used small, non-randomised samples and thus the potential problems of imprecision and bias cannot be excluded. Despite this, the research suggests that there is a case for considering fetal m o v e m e n t counting as a screening method for all pregnant women to try to prevent late antep a r t u m fetal death. In contrast to these promising findings other reports (Lobb et al 1985; Grant et al, 1989) have found no beneficial effect of a counting policy on a n t e p a r t u m fetal death. It is clear through the work of Lobb et al (1985) that not all a n t e p a r t u m late fetal deaths are potentially preventable by fetal m o v e m e n t m o n i t o r i n g some are not preceded by a reduction in fetal movements (Correspondence, 1981); for others there may

Table 1 Comparison of the effects of three methods of fetal movement counting on false alarm rates, frequency of prolonged counting and the overall time spent counting in 25 women (Grant & Hepburn 1984)
No. of women with No. of women with false Mean time spent

alarms on one or more days Method Fixed
Count-to-10 n = 8 2 0
25

median time to complete counting of > 2 hours
n = 25

counting per day
(Min)
n = 25

Individualised

0 9 3

86 (Min) 159 (Min) 79 (Min)

60

MIDWIFERY in a group presumably volunteering to help (Correspondence, 1981). Clark and Britton's study (1985) of the use of the Cardiff 'Count-to-Ten' chart by a low-risk population supports this contention. T h e i r subjects did not comply adequately with the p r o t o c o l - - 27% filled out the chart less than 50% of the time and the even m o r e disturbing finding was that 65% who experienced a m o v e m e n t alarm signal (i.e. less than 10 movements in 12 h) did not notify anyone. Such findings render 'kick charts' of questionable value in assessing fetal well-being. Conversely, a study by D r a p e r et al (1984) gave a compliance rate of 98% amongst 127 women asked six weeks after delivery whether they 'regularly' filled in their 'kick chart'. However, the charts were not examined which led T h o m p son & Wheeler (1985) to suggest that it is possible that a proportion of these women would not have completed the 'kick chart' 80% of the time and that a figure of 98% compliance is too high. From these findings the individualised approach to fetal m o v e m e n t counting, as described earlier by G r a n t and H e p b u r n (1984) should theoretically ensure greater compliance as the problems inherent in the 'fixed n u m b e r ' method i.e. long periods of counting, correlate with a reduction in compliance. T h o m p s o n and Wheeler (1985) tested an individualised method similar to the Grant and H e p b u r n approach. Using a sample of 83 w o m e n between the 32nd and 36th week of pregnancy a compliance of only 55% was found with no significant differences in the age, parity or social class between the compliers and non-compliers. They suggest this disappointing result could be due to the greater complexity of such methods resulting in reduced rather than increased compliance. Grant and Elbourne's (1989) review of compliance has implications for the midwife. They stress the importance o f attitudes towards fetal m o v e m e n t counting by proposing that unless midwives are convinced that fetal movement counting is useful and valid they are unlikely to motivate women towards compliance. Thus, it is r e c o m m e n d e d that at each antenatal consultation interest must be taken in the types of fetal movements experienced together with

be insufficient time between the reduction and fetal death to allow clinical action (Grant & Elbourne, 1989). More recently Grant et al (1989) conducted a large (68 000 subjects) international randomised controlled trial to assess the impact of routine formal movement counting on a n t e p a r t u m fetal death. T h e y assigned their subjects to either a counting policy or a selective counting policy coupled with informal noting of movements. Within the two groups the a n t e p a r t u m death rate for normally f o r m e d singletons was similar. Moreover, despite the counting policy most of the fetuses were dead by the time the mother received medical attention. T h e researchers do not dispute that maternally perceived fetal movements are of clinical significance - rather routine daily counting by women, followed by appropriate action when movements are reduced, seems to offer no advantages over f o r m a l inquiry about m o v e m e n t during standard antenatal care and selective use of formal counting in women at high obstetric risk. However, this challenging evidence must be viewed with caution since the lack of any beneficial effect of a counting policy is perhaps explained by the poor compliance (46%) for charting and reporting m o v e m e n t alarms amongst women in the counting g r o u p who experienced late fetal death.

Compliance and maternal fetal movement counting
T h e fact that it is the woman rather than the doctor who assumes responsibility when fetal movements are being monitored is an attraction of this method of fetal surveillance, but it has implications for compliance. In a report by Pearson and Weaver (1976) 61 healthy women who subsequently delivered a live, normal baby were asked to record the n u m b e r of movements their fetus made daily between 0900h and 2100 h from 32 weeks' gestation to delivery. This should have yielded at least 3400 records for analysis but only 1654 were reported. This suggests that compliance was relatively low even

MIDWIFERY 61 how they are recorded by the m o t h e r even if they suggest a perfectly normal fetus, repeatedly from studies of consumers' views of maternity care (Oakley, 1980).

Maternal comprehension of fetal movement charts
Studies using the Cardiff 'Count-to-Ten' chart report that this method, by virtue o f its simplicity, is easily understood by the population and thus readily implemented (Pearson & Weaver, 1976; D r a p e r et al, 1986). However, the fact remains that poor understanding correlates with low compliance o f the 'kick-chart' (Grant & Elbourne, 1989). Moreover, women of lower social classes, the uneducated, and women from a multi-racial background who receive charts that are not printed in a language with which they are familiar, seem less likely to complete the chart (Shaft et al, 1989). Shaft et al claim that these women are often at higher than average risk of late fetal death. T o meet the needs of a multi-racial population m o r e closely they devised a simple pictorial kick chart explaining its use and importance. T h e researchers concluded that the pictorial chart is a distinct i m p r o v e m e n t on the Cardiff chart, increasing understanding and, therefore, compliance in a multi-racial population. In an attempt to remedy the problems of comprehension Grant and Elbourne (1989) suggest that time needs to be set aside at each antenatal consultation to teach women how to count and record movements. Clark and Britton (1985) feel that the importance of recognising and reporting m o v e m e n t alarm signals must be more strongly emphasised. These findings have clear implications for the midwife during antenatal consultations. I f fetal m o v e m e n t counting is to be used as a valuable assessment of fetal well-being then it is part of her responsibilities to ensure that the mother fully understands how to use the chart and, m o r e importantly, the significance of a reduced fetal m o v e m e n t count. It is r e c o m m e n d e d that all health care professionals be assessed regularly on their aptitude at conveying this information correctly. It must be r e m a r k e d that women's dissatisfaction with the lack of information given to them emerges

Fetal movement counting: reassuring or stress-inducing for the mother
In 1986 Draper et al addressed the subject of women's views on keeping fetal m o v e m e n t charts. Although more than half of the women in their study (55%) were reassured by filling in a 'kick-chart', 23% felt it caused them to worry about the health o f their baby. Moreover, there was some evidence f r o m this study to support the view of Mcllwaine et al (1980) that there are negative effects o f stress and anxiety induced as a direct effect of fetal m o v e m e n t counting. O f clinical significance is Reading's (1983) assertion that when anxiety during pregnancy is prolonged and severe the outcomes have included low birth weight, fetal distress, prematurity and stillbirth. Conversely, Gibby (1988) found evidence to support her hypothesis that keeping daily fetal m o v e m e n t charts does not significantly increase a woman's anxiety. From her promising results Gibby advocated that fetal m o v e m e n t counting should be used routinely with all women to screen for fetal compromise. However, such generalisations must be reviewed with caution since a small sample (33 subjects) was used. In their large (68000 subjects) international randomised controlled trail Grant et al (1989) found evidence to support routine fetal m o v e m e n t counting as having little, if any, stress inducing effects on women. T h e y suggest that any maternal anxiety experienced is a reflection of more general concern about fetal movements rather than concern p r o m p t e d by formal counting. Grant and Elbourne (1989) argue that stress and anxiety are significantly reduced when feedback of information is given to women regarding the health of their baby. Communication is, therefore, seen as vital between the woman and the providers of antenatal care for anxiety to be successfully allayed in women using a fetal m o v e m e n t counting policy.

62

MIDWIFERY can be justified. Many weeks o f meticulous chart filling is very time c o n s u m i n g particularly for w o m e n with a n o r m a l p r e g n a n c y and active fetus. Poor compliance with such a policy therefore comes as no surprise. It would seem that selective use o f a c o u n t i n g policy in w o m e n at high obstetric risk would perhaps be o f m o r e clinical value (Grant & Elbourne, 1989). However, D r a p e r et al (1986) feel that the informal noting o f fetal m o v e m e n t s such as those described by Sadovsky et al (1979) coupled with p r o m p t r e p o r t i n g o f a b n o r m a l patterns may be m o r e successful in r e d u c i n g unexplained stillbirths than routine filling in o f fetal m o v e m e n t charts. Clearly there is still scope for improving the methods used to r e c o r d fetal movements, and f u r t h e r research into this field may have implications for increasing compliance and achieving better detection o f the fetus at risk o f perinatal morbidity and mortality. Maternal perception o f fetal activity is i m p o r t a n t but for any benefits to accrue f r o m a formal m o v e m e n t c o u n t i n g policy c o m p r e h e n s i o n o f the 'kick-chart' by w o m e n and compliance with its use are vital. Effective communication on the w o r t h o f such a policy which is specific for each w o m a n ' s needs is thus the linchpin o f the matter. With this achieved, fetal m o v e m e n t c o u n t i n g can then be considered an important and valuable tool in assessing fetal well-being.

DISCUSSION
It would a p p e a r that the i m p o r t a n c e o f fetal m o v e m e n t c o u n t i n g in assessing fetal well-being is controversial. Studies have established the value o f fetal m o v e m e n t charts in predicting fetal c o m p r o m i s e and avoiding fetal death(Pearson & Weaver, 1976; Neldam, 1980). However, the fact remains that stillbirths still occur because m a n y w o m e n do not receive a d e q u a t e and precise information about how to c o u n t a n d record fetal m o v e m e n t s coupled with the p u r p o s e and validity o f the method. F u r t h e r m o r e , m a n y midwives a p p e a r unconvinced o f the value o f r e c o r d i n g fetal m o v e m e n t s to assess fetal well-being. F r o m an informal discussion a m o n g s t fellow colleagues it transpired that the principal reasons given for this opinion is that w o m e n do not u n d e r s t a n d the 'kick-chart' and either fill it in incorrectly or not at all. Moreover, it was felt that w o m e n do not appreciate the significance o f a r e d u c e d m o v e m e n t count. T h e s e findings agree with m u c h o f the research that the likelihood o f a w o m a n complying with advice to r e c o r d fetal m o v e m e n t s and r e p o r t r e d u c e d counts is dependent on the attitude and the ability o f those providing her antenatal care to c o m m u n i c a t e information correctly and adequately. Thus, whilst p o o r maternal c o m p r e h e n s i o n and low compliance exist, the use o f a m o v e m e n t counting policy as a m e t h o d o f fetal surveillance is o f questionable value. A f u r t h e r consideration is the resource implication f r o m implementation o f a routine formal c o u n t i n g policy. T e a c h i n g w o m e n the c o u n t i n g p r o c e d u r e and the necessary response to r e d u c e d m o v e m e n t s is time c o n s u m i n g for all health care professionals. Similarly c o u n t i n g and acting on r e d u c e d m o v e m e n t s is also time cons u m i n g for the woman. G r a n t et al (1989) estimates this to represent about 140000 midwifery h o u r s and 90 million h o u r s o f p r e g n a n t women's time over one year. T h e cost o f repeated admissions to hospital t h r o u g h false alarms must also be considered. T a k i n g all these a r g u m e n t s t o g e t h e r it is questionable w h e t h e r this m e t h o d o f screening

Acknowledgement
Figure 1 was originally published in Nursing Mirror and is reproduced here by kind permission of the editor of Nursing Times and Table 1 is reproduced with permission of the editor of the British Journal of Obstetrics and Gynaecology.

References
Alexander S, Stanwell-Smith R, Bueke NS, P et al 1989 Biochemical assessment of fetal wellbeing. In Chalmers I, Enkin M, Keirse M (eds) Effective Care in Pregnancy and Childbirth. Oxford University Press, Oxford Clark J, Britton K 1985 Factors contributing to client nonuse of the Cardiff 'Count-to-Ten' fetal activity chart. Journal of Nurse-Midwifery 30 (6): 320-326 Coleman C 1981 Fetal movement counts: an assessment tool. Journal of Nurse-Midwifery 26 (1): 15-23 Correspondence 1981 Do fetal movements reflect fetal wellbeing? British Medical Journal 282 (i): 588-589

MIDWIFERY Davies L 1987 Daily fetal movement counting. A valuable assessment tool. Journal of Nurse-Midwifery 32 (1): 11-19 Draper J, Field S, Thomas H 1984 An evaluation of a community antenatal clinic: the early parenthood project. Hughes Hall, Cambridge Draper J, Field S, Thomas H, Hare M J 1986 Women's views on keeping fetal movement charts. British .Journal of Obstetrics & Gynaecology 93 (4): 334-338 Fischer S, Fullerton J, Trezise L 1981 Fetal movements and fetal outcome in a low-risk population..Journal of Nurse-Midwifery. 26 (1): 24-30 Gibby N W 1988 Relationship between fetal movement charting and anxiety in low-risk pregnant women. Journal of Nurse-Midwifery 33 (4): 185-188 Grant A, Elbourne D 1989 Fetal movement counting to assess fetal wellbeing. In Chalmers I, Enkin M, Deirse M (eds) Effective Care in Pregnancy and Childbirth. Oxford University Press, Oxford Grant A, Elbourne D, Valentin L e t al 1989 Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. T h e Lancet ii: 345-349 Grant A, Hepburn M 1984 Merits of an individualised approach to fetal movement counting compared with fixed-time and fixed-number methods. British Journal of Obstetrics and Gynaecology 91:1087-1090 Hertogs K, Roberts A B, Cooper D et al 1979 Maternal perception of fetal motor activity. British Medical Journal (2): 1183-1185 Kitzinger S 1988 Freedom and choice in childbirth Penguin Books, England Lobb M O, Beasley J M, Haddad N G 1985 A controlled study of daily fetal movement counts in the prevention of stillbirths. Journal of Obstetrics and Gynaecology 6 : 8 7 - 9 1 Mathews D D 1973 Fetal movements and fetal wellbeing. T h e Lancet i: 135 Mathews D D 1978 Fetal wellbeing in gravidas with diminished fetal activity at term. Obstetrics and Gynecology 51 (3): 281-283 McIlwain G M, Howat R C L, Dun F N e t al 1980 Perinatal practice and compensation handicap. British Medical Journal 281 : 1067 Moore T R, Piacquadio K 1989 A prospective evaluation of fetal movement screening to reduce the

63

incidence of antepartum fetal death. American Journal of Obstetrics & Gynecology 160 (5): 10751080 Neldam S 1980 Fetal movements as an indicator of fetal well-being. The Lancet i: 1222-1224 Oakley A 1980 Women confined: towards a sociology of childbirth. Martin Robertson, Oxford Oakley A 1986 T h e captured womb. Basil Blackwell Ltd., Oxford Patrick J, Campbell K, Carmichael L e t al 1982 Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. American Journal of Obstetrics and Gynecology 142 (4), 363-371 Pearson J F 1977 Fetal movements - a new approach to antenatal care. Nursing Mirror 144:49-51 Pearson.J F, Weaver J 1976 Fetal activity and fetal wellbeing: an evaluation. British Medical Journal i: 1305-1307 Rayburn W F 1982 Antepartum fetal assessment: fetal activity monitoring. Clinical Perinatology 9 (2): 231252 Reading A E 1983 T h e influence of maternal anxiety on the course and outcome of pregnancy. A Review. Health Psychology 2 (2): 187-202 Roberts M, Liston M B, Arnold W e t al 1982 Antepartum fetal evaluation by maternal perception of fetal movement. Obstetrics and Gynecology 60 (4): 424-426 Sadovsky E, Yaffe H 1973 Daily fetal movement recording and fetal prognosis. Obstetrics and Gynecology 41 (6): 845-850 Sadovsky E, Polishuk W Z, Mahler Y e t al 1973 Correlation between electromagnetic recording and maternal assessment of fetal movement. T h e Lancet i: 1141-1143 Sadovsky E, Lauper N, Allen J W 1979 T h e incidence of different types of fetal movements during pregnancy. British Journal of Obstetrics and Gynaecology 8 6 : 1 0 - 1 4 Shaft M I, Dover M S, Dycer D A et al 1989 Pictorial fetal movement charts in a multi-racial antenatal clinic. British Medical Journal 299:1688 T h o m p s o n S L, Wheeler T 1985 Compliance and maternal fetal movement counting. T h e Lancet 2: 1122