Sands calls for improved patient information and triage response to reduced fetal movements in pregnancy

Leading UK stillbirth and neonatal death charity, Sands, has called for improvements in the information and maternity triage responses that pregnant women and birthing people receive in relation to reduced fetal movements in pregnancy.

Fetal movement not only provides reassurance to the expectant mother and a sense of connection with her baby, but is also a vital indicator of the unborn baby’s health. Reduced or absent movements require urgent recognition and antenatal checks for abnormalities in the fetal heart rate, growth and amniotic fluid and, if necessary, the expedited delivery of the baby.

Sands’ report on the charity’s recent research with Dr Tomasina Stacey (King’s College, London) , Improving information and guidance about fetal movements: a horizon scanning project, highlights the challenges faced by pregnant patients and maternity staff in communicating about fetal movements, and calls for professional consensus and priority action to reduce the harm suffered by babies.

Maternity safety watchdog, MNSI, welcomed the publication of Sands' report, which closely aligns with recurring safety themes including consistent communication, accessible information and the need for standardised triage which MNSI have repeatedly identified in their maternity investigations and national learning reports.

Why are fetal movements in pregnancy so important?

Raising awareness of the importance of reduced fetal movements in pregnancy is thought to be one of the keys to reducing avoidable stillbirth. Whilst formal, maternal, daily counting of fetal movements (kick counting) is no longer advised during pregnancy, various research and initiatives (aimed at reducing stillbirth) have shown that increasing awareness of reduced fetal movements combined with appropriate maternity care may be associated with a reduction in poor outcomes for babies. 

Most women and birthing people start feeling their unborn baby moving between 16 and 24 weeks of pregnancy. Whilst there isn’t an ideal number of movements that should be felt each day,  the NHS advises that movements should gradually increase until 32 weeks then stay roughly the same until the baby’s birth. It is a dangerous but commonly held myth that unborn babies move less towards the end of pregnancy or in labour.

Any reduction or change in fetal movements can be a warning sign that the baby is compromised (or suffering fetal distress). For that reason, pregnant mothers who are worried about their unborn baby’s movements must call their maternity unit immediately, at any time of night or day. They will usually be asked to go to the maternity unit straight away for checks, which may involve a full antenatal check-up, CTG fetal heart-rate monitoring and, if necessary, an ultrasound scan to check on the baby’s growth and amniotic fluid. If these investigations identify that the baby’s health is at risk, a decision may be made to deliver the baby urgently.

The NHS advises that parents who are worried about reduced fetal movements should never hesitate to contact their midwife for advice, even if they have done so before and were reassured. They should not rely on home Dopplers, hand-held monitors or phone apps, but must seek professional maternity healthcare advice. Parents are reminded that swift action could save their baby’s life.

Failure to advise, warn or ask a pregnant mother about their unborn baby’s fetal movements during their antenatal care, or to act on a pregnant mother’s concerns about reduced fetal movements (such as by fetal heart-rate monitoring), and delays in expediting the delivery of a compromised baby are common allegations of negligence in hypoxic  birth injury (HIE) and stillbirth claims. 

Sands’ Fetal Movement Report - findings

Between July and September 2024, Sands listened to 35 bereaved and non-bereaved parents and healthcare staff who had received or provided UK NHS maternity care since 2016, to identify challenges in sharing information and guidance about fetal movements and agree on what needs to change to help maternity staff provide all parents with detailed, accurate,  accessible information and advice about babies’ movements in pregnancy.

Parents’ experiences

Sands found that there is a lack of detailed, personalised information about ‘normal’ fetal movements, underlying physiology and related risks. Parents told them that they needed more information from healthcare staff to understand what type, frequency or ‘pattern’ of movements should be considered ‘normal’ across different gestations and pregnancies. Some mothers also wanted more information about the relationship between fetal movements, placental function and important risks, including stillbirth. Some felt that a certain minimum amount of information was required for parents to be able to make informed choices and help keep their babies safe.

Fetal movement concerns were often ‘explained away’, with explanations given by midwives or doctors for why a mother might have felt less movement  including that the baby is probably ‘a night owl’ like their mother, or ‘a bit lazy’ or that ‘it’s getting cramped in there’. Mothers were also told that their anterior placenta, high BMI, distractions or feeling anxious could prevent them from feeling their baby’s movements. They felt their concerns were dismissed, potentially causing them to doubt their own experience and putting them off seeking help in future. 

Many mothers felt that their midwives’ closed (yes or no) questions didn’t leave room for detailed communication or understanding, leaving healthcare staff with incomplete or inaccurate information about fetal movements. In addition, mothers found it unhelpful to be told, ‘if you are worried, come in’. They did not have enough information to know how worried they should be and some mothers are naturally more optimistic or anxious than others.  Sands noted that ‘worry’ is too subjective to be a useful benchmark, whilst also noting the stressful combination of having an awareness of risk but in a way that was coupled with ‘vague’ information and lack of action by maternity staff.

Healthcare staff’s experiences

Forty five healthcare staff including midwives, student midwives, obstetricians and a clinical midwife academic, told Sands that common challenges in communications with pregnant women about fetal movements included:

• a lack of detail in current information, which varies depending on the clinician providing it, further confused by the mother’s exposure to conflicting or contradictory information shared online or from family and friends;
• many parents (including English and non-English speakers) struggle to understand information they are given about fetal movements in pregnancy;
• families face barriers when trying to access care for reduced fetal movements, including busy phone lines, limited language options, hostile staff attitudes, costs of travel, lack of community-based services and continuity of carer;
• staff do not have enough time for detailed, personalised conversations about fetal movements, particularly when working with families with complex needs or limited English;
• increased maternal anxiety making it difficult to identify changes in fetal activity, exacerbated by ‘generalised’ advice, being responsible for monitoring movements and fear of medical intervention. 

Common themes in communication and awareness around fetal movements in maternity care

Overall, Sands identified common themes in communication and awareness around fetal movements in maternity care.

The first related to poor sharing of important information in routine antenatal care, with the lack of accessible, detailed, gestation-specific information about fetal movements leaving women not understanding the risks related to reduced fetal movements or the importance of promptly sharing their concerns, and not feeling confident that they can identify and call for help when fetal movements change. Sands noted that a focus on raising awareness of fetal movements coupled with ‘vague’ information may increase maternal anxiety, which, in turn, makes it harder for pregnant mothers to know when to seek help.

A second theme was the barriers faced by women and birthing people when trying to access care. This prevents them from sharing concerns about their baby’s movements or causes them to wait until their next routine appointment, particularly if they are being (falsely) reassured by information online or by family and friends.  

The third common theme was the off-putting nature of the response that pregnant mothers who report changes in fetal movements receive from maternity staff. This included experiences, which are all too common in birth injury negligence claims, such as unhelpful initial (triage) telephone conversations (often with an unknown midwife) or being discharged with false reassurance and lack of safety-netting information after attending the maternity unit about their concerns.

Sands pointed out that if women and birthing people feel dismissed, uncertain or overly-reassured following their initial contact with staff, they are less likely to attend for care or seek help in the future.

Sands’ Fetal Movement Report – recommendations 

Sands’ report,  Improving information and guidance about fetal movements: a horizon scanning project, calls for priority actions for improvement in the way maternity services communicate with women and birthing people about fetal movements in pregnancy. The charity’s recommendations include:

• the development of a national triage policy, which includes fetal movement, and evidence-based recommendations for telephone access;
• distilling the currently available evidence base into clinical guidelines and developing the evidence base relating to placental factors and identifying babies most at risk;
• introducing guidance on the information and advice to be given during ‘the fetal movement care encounter’ as well as developing training and guidance for healthcare staff, including on how they approach communication;
• the development of clear, consistent, detailed fetal movement information in multiple formats including digital communication, such as apps, and wearable devices and trackers to enable remote care.

Sands emphasised that to be effective, solutions must lead to improvements at each of the ‘information-sharing’, ‘accessing care’ and ‘response’ stages, with accessibility, equity and trust being important considerations throughout.

We welcome Sands’ valuable work and wholeheartedly support their call for improvements in the information, advice and care given to pregnant women and birthing people in maternity care, to reduce the unacceptable level of avoidable harm from birth injury. 

If your child has cerebral palsy or neurological disability as a result of medical negligence, or you have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.