Europ. J. Obstet. Gynec. reprod. Biol.

, 19 (1985) 133-136 133

Elsevier

EJO 00165

Absence of fetal movements and normal infants

Y. Biale and M. Mazor

Division oj Obstetrics and Gynecolog, Soroka University Hospital and Faculty of Health S&nces,
Ben - Gurion University 01 the Negev, Beer Sheba, Israel

Accepted for publication 5 September 1984

BIALE. Y. and MAZOR, M. (1985): Absence of fetal movements and normal infants. Europ. J. Obster.
C+nec. reprod. Biol., 19, 133-136.
Pregnant women feel movements from about the fifth month of pregnancy. In cases of high-risk
pregnancy daily recording of fetal movements is useful in monitoring fetal well-being. Complete cessation
of fetal movements points to a severely distressed fetus and impending death.
We report here five women in whom failure to experience fetal movements was present from the
beginning of pregnancy. or occurred after fetal movements had been felt for several weeks during the
pregnancy. AH the women delivered normal infants with high Apgar score.

fetal movements; normal infants

Introduction

Pregnant women feel fetal movements from about the fifth month of pregnancy
and sometimes even earlier. Every fetus has its own movement rhythm and the
number of fetal movements daily varies from a few to several hundred (Sadovsky
and Polishuk, 1977).
The daily average number of fetal movements increases during pregnancy with
maximum values between the 29th and 38th wk of pregnancy. Fetal movements are
an expression of fetal well-being and a reduction or cessation of fetal motion may
signify fetal distress (Homburg et al., 1980; Matthews, 1973; Rovinsky and Gutt-
macher, 1965).
In cases of high-risk pregnancy daily recording of fetal movements may be useful
in monitoring fetal well-being. Pronounced reduction in fetal movements from a
high constant or fluctuating levels, to less than 4 per h, or the complete cessation of
movements points to severely distressed fetus and impending death, requiring
prompt delivery (Sadovsky and Polishuk, 1977). On the other hand, it may be
possible that the lack of feeling of fetal movements need not imply fetal distress. We
report here five women who did not experience fetal movements but nevertheless
delivered normal infants.

0028-2243/85/$03.30 0 1985 Elsevier Science Publishers B.V. (Biomedical Division)

134

Patients and results

Five women who complained of the absence of fetal movements were studied
(Table I). Three women had not noticed fetal movements from the beginning of
pregnancy: all had had normal pregnancies with normal fetal movements previously.
In the other two women fetal movements were present initially and disappeared in
the 25th and 28th wk of pregnancy, respectively.
Each woman was hospitalized several times from the 28th wk of pregnancy for
variable periods during which time non-stress tests and urine estriol estimations were
performed on alternate days and ultrasonogram every 5-10 days.
There was no fetal distress as demonstrated by normal repeated non-stress test
recordings and estriol measurements (Table I). There was no meconium and all the
women delivered at term healthy infants of normal weight with high Apgar score
(Table II). Ultrasonograms demonstrated anterior placentas in two women, fundal
placenta in one and higher posterior implanted placenta in the other two. The
quantity of amniotic fluid, fetal breathing movements and fetal muscle tonus were
normal in all cases. In the second case no fetal movements could be demonstrated on
the day of delivery even though estriol level was normal, non-stress test was reactive
and previous repeated ultrasonograms demonstrated fetal movements (Table III).

TABLE I

Pertinent clinical data regarding women with absence of fetal movements

A. abortion; p., spontaneous delivery; C.S., cesarean section.

Age of parturient (yr) 21 18 30 28 25

Initiation of absence of
fetal movements (wk) never 28 never 25 never
Gestational history C.S. none A-2; p.-2 p.-2 P.-l
Weight gain (kg) 8.5 10.5 9.5 12 10
Delivery at (wk) 40 39 40 38 38
Complications during asympt. none none none broncho-
bacteriuria pneumonia
Non-stress tests normal normal normal normal normal
Urine estriol levels (mg/24 h) 18-28 20-34 22-30 20-30 17-26

TABLE II
Details of delivery and fetal condition

Patient

1 2 3 4 5

Mode of delivery Forceps Spont. Spont. Spont. Vacuum extraction

Weight of newborn (g) 3400 2680 3100 3010 3270
Apgar score (5, min) 9 9 10 10 9
Sex Male Male Female Female Male
Meconium None None None None None
Placenta Normal Velementous insertion Normal Normal Normal
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TABLE III

Ultrasonogram data of pregnancies with absence of fetal movements

N. normal

Patient
1 2 3 4 5
--
Placenta localization high anterior low anterior fundal high posterior high postertor
Quantity of amniotic fluid N N N N N
Fetal movements N N N N N
Fetal breathing movements N N N N N
Fetal muscle tonus N N N N N

Discussion

A protocol for detecting deterioration in the chronically distressed fetus was

suggested by Sadovsky (1980). It offers three barriers preceding, fetal death. The first
indication of fetal jeopardy (first barrier) is a pathological oxytocin challenge test
and a non-reactive fetal movement acceleration non-stress test.
The second barrier is represented by absent or decreased fetal movements
indicating further deterioration in fetal well-being. Pathologic non-stress tests con-
stitute the third barrier, indicating a more severely distressed fetus, close to death.
who might have cerebral damage. It is imperative to recognize danger at the first or.
at latest, the second barrier and to deliver the fetus before but not at the third
barrier.
The cases in the present series would fit the second barrier and, were bioelectric
and hormonal tests of fetal well-being not available. early termination of the
pregnancies would be seriously considered. The failure to feel fetal movements was
present from the beginning of pregnancy or occurred after fetal movements had been
felt for several weeks during the pregnancy. In all the patients. however, ultrasono-
grams demonstrated fetal movements.
The lack of maternal feeling of fetal movements has been ascribed to the placenta
being situated on the anterior uterine wall, polyhydramnios or congenital malforma-
tions dampening fetal movements (Sadovsky and Perlman, 1978). In the present
series in three women no anterior placenta was demonstrated and none exhibited
polyhydramnios or congenital fetal malformations.
It could not be argued that these women cannot recognize fetal movements, since
all of them experienced fetal movements in previous gestations and two of them for
several weeks initially during the present pregnancies.
Hysterical patients or women who ‘neglect’ their pregnancy may also report
absence of fetal movements. To our knowledge, the women in our series were not
hysterical and all pregnancies were desired. At their first hospitalization, all women
were worried because of the absence of fetal movements. However, repeated discus-
sions explaining that the non-stress tests, estriol measurements and the ultrasono-
grams all demonstrated normal fetal development and well-being helped in reassur-
ing the women during the pregnancy.
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It is suggested that recording of fetal movements by an electromagnetic or

electronic device will be of great value in confirming the reliability of the patients’
own assessment (Sadovsky and Polishuk, 1977).
In situations where pregnant women fail to detect fetal movements and sophisti-
cated devices are not available, the pregnancy should continue to be managed
according to the results of bioelectric and hormonal determinations.

References

Homburg, R., Matzkel, A., Birger, M. and Insler, V. (1980): Management of patients with a live fetus and
cessation of fetal movements. Brit. J. Obstet. Gynaec., 87, 804.
Mathews, D.D. (1973): Fetal movements and fetal well-being. Lancet, i, 1315.
Rovinsky, J. and Guttmacher, A.P. (1965): Medical, Surgical and Gynecological Complications of
Pregnancy, pp. 805-812. Williams & Wilkins, Baltimore.
Sadovsky, E. (1980): When prompt delivery is indicated. Contemp. Obstet. Gynec., 16, 109.
Sadovsky, E. and Perlman, M. (1978): Decreased fetal movements in polyhydramnios. Acta Obstet.
Gynec. Stand., 57, 177.
Sadovsky, E. and Polishuk, W.Z. (1977): Fetal movements in utero. Obstet. and Gynec., 50, 49.