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A double tragedy - Inappropriate action after maternal perception of reduced fetal movements
- Alexander E Heazell (6 November 2009)
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Re: A double tragedy - Inappropriate action after maternal perception of reduced fetal movements
- Abhijoy Chakladar, Hazel Adams (10 November 2009)
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Dangers of listening to the fetal heart at home, that may be surmountable, should be weighed against the benefits
- John A Crowe (11 November 2009)
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The dangers of home fetal heart monitoring: a personal perspective
- Amy L Blake (17 November 2009)
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Alexander E Heazell, Clinical Lecturer in Obstetrics Maternal and Fetal Health Research Group, University of Manchester, St Mary's Hospital, M13 9WL, UK
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Chakladar and Adams report a tragic case where a woman has presented with a stillbirth after attempting to auscultate her baby’s heart sounds after perceiving a decrease in fetal movements.1 The outcome of this case not only illustrates the risk of inappropriately used hand-held Doppler ultrasound, but also emphasises the dangers of an inappropriate response to a decrease in fetal movements. Studies over the past 30 years have demonstrated that a decrease in fetal movements is associated with an increased risk of stillbirth and intra-uterine growth restriction.2 The authors incorrectly cite the Cochrane review by Mangesi and Hofmeyr; this actually states that there is no evidence to support formal fetal movement counting, for example, that using count to ten charts.3 Instead we should rely on women’s perceptions of reduced fetal movements. This is recognised by the current NICE guidelines for antenatal care which recommend that women noticing a reduction in their baby’s movements should contact their maternity healthcare provider.4 Recent studies in Norway has shown that the incidence of stillbirth in women attending with reduced fetal movements can be significantly reduced by investigation with cardiotocography and ultrasound measurement of growth and liquor volume.5 Therefore, patients perceiving a sudden reduction in fetal movements should be encouraged to see their maternity service and should be adequately investigated. Thus, this case actually demonstrates two tragedies. Firstly, that the woman was not given the correct advice to attend the obstetric service following a reduction in fetal movements and secondly, in the absence of this advice, she then used equipment that she was not trained to use or interpret. 1. Chakladar A, Adams H. Dangers of listening to the fetal heart at home. BMJ 2009;339:b4308 2. Heazell AEP, Frøen F. Maternal Perception of Fetal Movements and Detection of Fetal Compromise: A Review of the Literature. Journal of Obstetrics and Gynaecology 2008;28(2):147-154. 3. Mangesi L, Hofmeyr GJ. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev 2007;(1):CD004909. 4. National Collaboration Centre for Women's and Children's Health, Antenatal care: routine care for the healthy pregnant woman. 2003, RCOG Press: London. p276. 5. Tveit JV, Saastad E, Stray-Pedersen B, Børdahl PE, Flenady V, Fretts R, Frøen JF. Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth. 2009;9:32. Competing interests: Dr Alexander Heazell is currently developing a guideline for the management of women with reduced fetal movements which has been commissioned by the Royal College of Obstetricians and Gynaecologists (UK). |
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Abhijoy Chakladar, Research Fellow Department of Anaesthesia, Princess Royal Hospital, BSUH NHS Trust, RH16 4EX, Hazel Adams
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In the interest of brevity we kept our summary of the Cochrane review [1] brief and did not refer to the 'counting' of fetal movements - relevant as the woman in question had noticed a reduction in the number of her baby's movements. The review concludes, 'This review does not provide enough evidence to influence practice' and that is what we stated. Mothers do seem to log, perhaps subconsciously, the frequency of their child's movements. Our intention was to illustrate the potential limitations of 'evidence based practice' and, to highlight the importance placed on maternal subjective perception and/or concerns by obstetric services in detecting fetal compromise. We understand that the need to seek advice from maternity services if there is a perceived reduction in fetal movements should be standard advice to all expectant parents. It was not our intention to enter into a discussion on the markers of fetal well being as this falls outside our sphere of experience, but instead to highlight the public availability of fetal heart monitors, their home use and to concentrate on the dangers of their untrained use. Although we are grateful to Dr Heazell for his comments on our article [2] and his summary of the current thinking behind the management of reduced fetal movement, we have not commented on what advice this woman was or was not given. As such, readers should not make assumptions. [1] Mangesi L, Hofmeyr GJ. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev 2007;(1):CD004909. [2] Chakladar A, Adams H. Dangers of listening to the fetal heart at home. BMJ 2009;339:b4308 doi:10.1136/bmj.b4308 Competing interests: AC and HA are the authors of the original article |
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John A Crowe, Professor of Biomedical Engineering University of Nottingham
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Recent correspondence [1-3] has highlighted the potential risks associated with women self-monitoring their own baby’s heart beat. It has been well known for many years [4] that Doppler ultrasound based fetal heart rate monitors (both hand held and incorporated into cardiotocographs) can on occasion misreport the heart rate due to either detecting maternal blood flow or ‘doubling’ the true value. Consequently use of current monitors by untrained staff must be cautioned. However this problem means that the potential benefits of self- monitoring may be overlooked. These could include reassurance, as noted in Coombes’ ‘Feature’ [3], and their potential future use in monitoring at- risk babies such as in cases of obstetric cholestasis. What should be recognised is that the reasons for the problems encountered by Doppler ultrasound fetal heart rate monitors are well understood [5,6] and could potentially be overcome with more sophisticated electronics and data processing. Crucial to understanding the detailed operation of these monitors was the simultaneous recording of the antenatal trans-abdominal fetal electrocardiogram, a signal that offers an alternative means of obtaining the fetal heart rate [7,8] in an unobtrusive manner that is suitable for long-term use. The nature of this signal, and fact that the maternal electrocardiogram is also recorded, means that whilst there may be periods when the fetal heart rate cannot be determined (since the trans-abdominal fetal electrocardiogram is a very small signal) the monitor’s output can clearly indicate this, and reporting of false values should not occur. As noted in the reported cases [1,2] it was most likely the maternal heart that was being monitored which is clear when using the trans-abdominal fetal electrocardiogram. In addition it is also possible to monitor gross fetal movements via the morphology of the fetal electrocardiogram. Consequently it would be unfortunate if examples of the inappropriate self-use of antenatal heart rate monitoring were to dissuade investigations into its potential benefits, and bias users against it for reasons that are essentially non-clinical that may be overcome by technical improvements. 1. Aust T, Ankers D, Famoriyo A. Caution with home fetal Doppler devices. BMJ 2009;339:b3220 2. Chakladar A, Adams H. Dangers of listening to the fetal heart at home. BMJ 2009;339:b4308 3. Coombes R. Don’t try this at home? BMJ 2009;339:b4421 4. Cydney CA, Kopel E. Electronic Fetal Monitoring: Concepts and Applications, ISBN 0781770114, p19 5. Shakespeare S, Crowe JA, Hayes-Gill BR, Bhogal K and James DK. The information content of Doppler ultrasound signals from the fetal heart, Med. Biol. Eng. & Comp., 39, 619-626, 2001 6. Bhogal K, Shakespeare S, Crowe JA, Hayes-Gill B and James DK. Cardiotocographs and the transabdominal fetal electrocardiogram, RCM Midwives Journal, November, 4, 372-375, 2001 7. Crowe JA, Harrsion A and Hayes-Gill BR. The feasibility of long- term fetal heart rate monitoring in the home environment using maternal abdominal electrodes. Physiol. Meas., 16, 195-202, 1995. 8. Pieri JF, Crowe JA, Hayes-Gill BR, Spencer CJ, Bhogal K and James DK. Compact long-term recorder of the transabdominal foetal and maternal electrocardiogram. Med.Biol.Eng. & Comp., 39, 118-125, 2001 john.crowe@nottingham.ac.uk Competing interests: The author has a small shareholding in Monica Healthcare a University of Nottingham spin-out company who sell a long-term electrocardiogram based fetal heart rate recorder |
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Amy L Blake, CT1 Psychiatry The Caludon Centre, Clifford Bridge Road, Coventry, CV2 2TE
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As a junior doctor currently experiencing a complicated pregnancy first hand, I read Abhijot Chakladar and Hazel Adams’ article[1] with unease. A few weeks ago, in a state of significant anxiety about my baby’s health, and before I could feel any fetal movements, I seriously researched buying or hiring a fetal heart monitor in the hope that being able to hear my baby’s heartbeat might allay my fears between visits to the hospital and midwife. Thankfully, I can still remember my brief training in basic midwifery from medical school and the difficulty I had in reliably detecting anything at all with a fetal Doppler, let alone differentiating between fetal and placental blood flow, and so thought better of it. A close friend of mine however, had only the experience of watching her midwife confidently detecting the baby’s heart beat at each consultation. She purchased an amplifying system and has, I am convinced, been contentedly listening to her placenta for the last 6 weeks. On the night I was trawling the internet, I was struggling to decide whether my PV bleeding warranted presenting to hospital. If I had had a Doppler at home and could have heard the heart beat I would probably not, as I later did, have called my consultant and been admitted. The marketing of these devices for the use of untrained individuals is a recipe for disaster. At one end of the spectrum, individuals who are unable to detect anything resembling a fetal heartbeat will flood midwifery clinics and emergency departments unnecessarily. More worrying, however, at the other extreme, is the tragic case described by Chakladar and Adams, where false reassurance through improper interpretation of these sounds results in delayed presentation and, possibly, a still birth and lifetime of guilt for the parent. Pregnant women see these devices being used in clinics at every appointment as a marker of fetal wellbeing. I do not feel that any amount of emphasis on the part of the manufacturers that they are not meant as a substitute for normal antenatal care will suffice. Midwives and obstetricians need to become increasingly aware of the wide availability of fetal heart monitors and counsel all couples, particularly those experiencing complications, against their use. 1.Chakladar A, Adams H. Dangers of listening to the fetal heart at home. BMJ 2009;339:b4308 Competing interests: None declared |
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