Research Article|Articles in Press

Fetal movements: A framework for antenatal conversations

Published:September 22, 2022DOI:



      Presentations for decreased fetal movements comprise a significant proportion of acute antenatal assessments. Decreased fetal movements are associated with increased likelihood of adverse pregnancy outcomes including stillbirth. Consensus-based guidelines recommend pregnant women routinely receive information about fetal movements, but practice is inconsistent, and the information shared is frequently not evidence-based. There are also knowledge gaps about the assessment and management of fetal movement concerns. Women have indicated that they would like more accurate information about what to expect regarding fetal movements.


      Historically, fetal movement information has focussed on movement counts. This is problematic, as the number of fetal movements perceived varies widely between pregnant women, and no set number of movements has been established as a reliable indicator of fetal wellbeing. Of late, maternity care providers have also advised women to observe their baby’s movement pattern, and promptly present if they notice a change. However, normal fetal movement patterns are rarely defined. Recently, a body of research has emerged relating to maternal perception of fetal movement features such as strength, presence of hiccups, and diurnal pattern as indicators of fetal wellbeing in addition to frequency.


      Sharing comprehensive and gestation-appropriate information about fetal movements may be more satisfying for women, empowering women to identify for themselves when their baby is doing well, and importantly when additional assessment is needed. We propose a conversational approach to fetal movement information sharing, focusing on fetal movement strength, frequency, circadian pattern, and changes with normal fetal development, tailored to the individual.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women and Birth
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bradford B.
        • Maude R.
        Maternal perception of fetal movements in the third trimester: a qualitative description.
        Women Birth. 2018; 31: e287-e293
        • Raynes-Greenow C.H.
        • Gordon A.
        • Li Q.
        • Hyett J.A.
        A cross-sectional study of maternal perception of fetal movements and antenatal advice in a general pregnant population, using a qualitative framework.
        BMC Pregnancy Childbirth. 2013; 13: 32
        • Smyth R.M.D.
        • Taylor W.
        • Heazell A.
        • Furber C.
        • Whitworth M.
        • Lavender T.
        Women’s and clinicians perspectives of presentation with reduced fetal movements: a qualitative study.
        BMC Pregnancy Childbirth [Internet]. 2016; 16
        • Malm M.C.
        • Hildingsson I.
        • Rubertsson C.
        • Rådestad I.
        • Lindgren H.
        Prenatal attachment and its association with foetal movement during pregnancy – a population based survey.
        Women Birth. 2016; 29: 482-486
        • Saastad E.
        • Ahlborg T.
        • Frøen J.F.
        Low maternal awareness of fetal movement is associated with small for gestational age infants.
        J. Midwifery Women’s. Health. 2008; 53: 345-352
        • Efkarpidis S.
        • Alexopoulos E.
        • Kean L.
        • Liu D.
        • Fay T.
        Case-control study of factors associated with intrauterine fetal deaths.
        Medscape Gen. Med. 2004; 6: 53
        • O’Sullivan O.
        • Stephen G.
        • Martindale E.
        • Heazell A.E.P.
        Predicting poor perinatal outcome in women who present with decreased fetal movements.
        J. Obstet. Gynaecol. 2009; 29: 705-710
        • James D.K.
        • Telfer F.M.
        • Keating N.A.
        • Blair M.E.
        • Wilcox M.A.
        • Chilvers C.
        Reduced fetal movements and maternal medication - new pregnancy risk factors for neurodevelopmental disability in childhood.
        J. Obstet. Gynaecol. J. Inst. Obstet. Gynaecol. 2000; 20: 226-234
        • Warrander L.
        • Batra G.
        • Bernatavicius G.
        • Greenwood S.L.
        • Dutton P.
        • Jones R.L.
        • et al.
        Maternal perception of reduced fetal movements is associated with altered placental structure and function.
        PLoS ONE. 2012; 7e34851
        • Pagani G.
        • D’Antonio F.
        • Khalil A.
        • Papageorghiou A.
        • Bhide A.
        • Thilaganathan B.
        Association between reduced fetal movements at term and first trimester markers of impaired placental development.
        Placenta. 2014; 35: 606-610
        • Pagani G.
        • D’Antonio F.
        • Khalil A.
        • Akolekar R.
        • Papageorghiou A.
        • Bhide A.
        • et al.
        Association between reduced fetal movements at term and abnormal uterine artery Doppler indices.
        Ultrasound Obstet. Gynecol. 2014; 43: 548-552
        • Dutton P.J.
        • Warrander L.
        • Roberts S.A.
        • Bernatavicius G.
        • Byrd L.M.
        • Gaze D.
        • et al.
        Predictors of poor perinatal outcome following maternal perception of reduced fetal movements – A prospective cohort study. Baradaran HR, editor.
        PLoS ONE. 2012; 7e39784
        • Norman J.E.
        • Heazell A.E.P.
        • Rodriguez A.
        • Weir C.J.
        • Stock S.J.E.
        • Calderwood C.J.
        • et al.
        Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): A stepped wedge, cluster-randomised trial.
        Lancet. 2018; 392: 1629-1638
        • Flenady V.
        • Gardener G.
        • Ellwood D.
        • Coory M.
        • Weller M.
        • Warrilow K.
        • et al.
        My Baby’s Movements: a stepped‐wedge cluster‐randomised controlled trial of a fetal movement awareness intervention to reduce stillbirths.
        BJOG Int J. Obstet. Gynaecol. 2021;
        • Thompson J.M.D.
        • Wilson J.
        • Bradford B.F.
        • Li M.
        • Cronin R.S.
        • Gordon A.
        • et al.
        A better understanding of the association between maternal perception of foetal movements and late stillbirth—findings from an individual participant data meta-analysis.
        BMC Med. 2021; 19: 267
        • Bellussi F.
        • Poʼ G.
        • Livi A.
        • Saccone G.
        • De Vivo V.
        • Oliver E.A.
        • et al.
        Fetal movement counting and perinatal mortality: a systematic review and meta-analysis.
        Obstet. Gynecol. 2020; 135: 453-462
        • Akselsson A.
        • Lindgren H.
        • Skokic V.
        • Rådestad I.
        A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method.
        BMC Pregnancy Childbirth. 2020; 20: 577
        • Saastad E.
        • Vangen S.
        • Frøen J.F.
        Suboptimal care in stillbirths – a retrospective audit study.
        Acta Obstet. Gynecol. Scand. 2007; 86: 444-450
        • Hofmeyr G.J.
        • Novikova N.
        Management of reported decreased fetal movements for improving pregnancy outcomes.
        (Cochrane Database of Systematic Reviews [Internet])in: Hofmeyr G.J. The Cochrane Collaboration. John Wiley & Sons, Ltd, Chichester, UK2012
        • Rådestad I.
        • Lindgren H.
        Women’s perceptions of fetal movements in full-term pregnancy.
        Sex. Reprod. Health. 2012; 3: 113-116
        • Bradford B.
        • Cronin R.S.
        • McKinlay C.J.D.
        • Thompson J.M.D.
        • Mitchell E.A.
        • Stone P.R.
        • et al.
        A diurnal fetal movement pattern: Findings from a cross-sectional study of maternally perceived fetal movements in the third trimester of pregnancy. Petry CJ, editor..
        PLOS ONE. 2019; 14e0217583
        • Sadovsky E.
        • Yaffe H.
        Daily fetal movement recording and fetal prognosis.
        Obstet. Gynecol. 1973; 41: 845-850
        • Pearson J.
        • Weaver J.
        Fetal activity and fetal wellbeing: an evaluation.
        Br. Med. J. 1976; 1: 1305-1307
        • Leader L.
        • Baillie P.
        • Van
        • Schalkwyk D.
        Fetal movements and fetal outcome: a prospective study.
        Obstet. Gynecol. 1981; 57: 431-436
        • Neldam S.
        Fetal movements as an indicator of fetal wellbeing.
        Lancet. 1980; 315: 1222-1224
        • Liston R.
        • Cohen A.
        • Mennuti M.
        • Gabbe S.G.
        Antepartum fetal evaluation of maternal perception of fetal movements.
        Obstet. Gynecol. 1982; 60: 424-426
        • Grant A.
        • Elbourne D.
        • Valentin L.
        • Alexander S.
        Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons.
        Lancet. 1989; 2: 346-349
        • Patrick J.
        • Campbell K.
        • Carmicheal L.
        • Natale R.
        • Richardson B.
        Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy.
        Am. J. Obstet. Gynecol. 1982; 142: 363-371
        • Moore T.
        • Piacquadio K.
        A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death.
        Am. J. Obstet. Gynecol. 1989; 160: 1075-1080
        • Tveit J.V.H.
        • Saastad E.
        • Stray-Pedersen B.
        • Børdahl P.E.
        • Flenady V.
        • Fretts R.
        • et al.
        Reduction of late stillbirth with the introduction of fetal movement information and guidelines – a clinical quality improvement.
        BMC Pregnancy Childbirth. 2009; 9: 32
        • Akselsson A.
        • Lindgren H.
        • Georgsson S.
        • Pettersson K.
        • Steineck G.
        • Skokic V.
        • et al.
        Mindfetalness to increase women’s awareness of fetal movements and pregnancy outcomes: a cluster‐randomised controlled trial including 39 865 women.
        BJOG Int J. Obstet. Gynaecol. 2020; 127: 829-837
        • Winje B.A.
        • Wojcieszek A.
        • Gonzalez-Angulo L.
        • Teoh Z.
        • Norman J.
        • Frøen F.
        • et al.
        Interventions to enhance maternal awareness of decreased fetal movement: a systematic review.
        BJOG Int J. Obstet. Gynaecol. 2016; 123: 886-898
        • Warland J.
        • Glover P.
        Fetal movements: What are we telling women?.
        Women Birth. 2016; 30: 23-28
        • Berndl A.M.L.
        • O’Connell C.M.
        • McLeod N.L.
        Fetal movement monitoring: How are we doing as educators?.
        J. Obstet. Gynaecol. Can. 2013; 35: 22-28
        • Pollock D.
        • Ziaian T.
        • Pearson E.
        • Cooper M.
        • Warland J.
        Breaking through the silence in antenatal care: Fetal movement and stillbirth education.
        Women Birth. 2020; 33: 77-85
        • McArdle A.
        • Flenady V.
        • Toohill J.
        • Gamble J.
        • Creedy D.
        How pregnant women learn about foetal movements: Sources and preferences for information.
        Women Birth. 2015; 28: 54-59
        • Peat A.M.
        • Stacey T.
        • Cronin R.
        • McCowan L.M.E.
        Maternal knowledge of fetal movements in late pregnancy.
        Aust. N. Z. J. Obstet. Gynaecol. 2012; 52: 445-449
        • Olagbuji B.
        • Igbarumah S.
        • Akintayo A.
        • Olofinbiyi B.
        • Aduloju P.
        • Alao O.
        Maternal understanding of fetal movement in third trimester: A means for fetal monitoring and reducing stillbirth.
        Niger. J. Clin. Pr. 2014; 17: 489
        • Heazell A.E.P.
        • Warland J.
        • Stacey T.
        • Coomarasamy C.
        • Budd J.
        • Mitchell E.A.
        • et al.
        Stillbirth is associated with perceived alterations in fetal activity – findings from an international case control study.
        BMC Pregnancy Childbirth. 2017; 17: 369
      1. NHS England. Saving babies lives: A care bundle o reduce stillbirths [Internet]. NHS England; 2016. Available from: 〈〉.

        • Malm M.C.
        • Lindgren H.
        • Rådestad I.
        Losing contact with one’s unborn baby—mothers’ experiences prior to receiving news that their baby has died in utero.
        OMEGA-J. Death Dying. 2010; 62: 353-367
        • Georgsson S.
        • Linde A.
        • Pettersson K.
        • Nilsson R.
        • Rådestad I.
        To be taken seriously and receive rapid and adequate care – Womens’ requests when they consult health care for reduced fetal movements.
        Midwifery. 2016; 40: 102-108
        • Hoffmann D.E.
        • Tarzian A.J.
        The girl who cried pain: a bias against women in the treatment of pain.
        SSRN Electron J. [Internet]. 2003; (Available from)
        • Walker K.F.
        • Thornton J.G.
        Encouraging awareness of fetal movements is harmful.
        Lancet. 2018; 392: 1601-1602
        • Linde A.
        • Rådestad I.
        • Pettersson K.
        • Hagelberg L.
        • Georgsson S.
        “Better safe than sorry”—Reasons for consulting care due to decreased fetal movements.
        Women Birth. 2017; 30: 376-381
        • Mikhail M.
        • Freda M.
        • Merkatz R.
        • Polizzotto R.
        • Mazloom E.
        • Merkatz I.
        The effect of fetal movement counting on maternal attachment to fetus.
        Am. J. Obstet. Gynecol. 1991; 165: 988-991
        • Hijazi Z.R.
        • Callan S.E.
        • East C.E.
        Maternal perception of foetal movement compared with movement detected by real-time ultrasound: An exploratory study.
        Aust. N. Z. J. Obstet. Gynaecol. 2010; 50: 144-147
        • Brown R.
        • Higgins L.E.
        • Johnstone E.D.
        • Wijekoon J.H.
        • Heazell A.E.P.
        Maternal perception of fetal movements in late pregnancy is affected by type and duration of fetal movement.
        J. Matern Fetal Neonatal Med. 2016; 29: 2145-2150
        • Degani S.
        • Leibovitz Z.
        • Shapiro I.
        • Ohel G.
        Twins’ temperament: Early prenatal sonographic assessment and postnatal correlation.
        J. Perinatol. 2009; 29: 337-342
        • Groome L.J.
        • Swiber M.J.
        • Holland S.B.
        • Bentz L.S.
        • Atterbury J.L.
        Spontaneous motor activity in the perinatal infant before and after birth: Stability in individual differences.
        Dev. Psychobiol. 1998; 35: 15-24
        • Gillieson M.
        • Dunlap H.
        • Nair R.
        • Pilon M.
        Placental site, parity, and date of quickening.
        Obstet. Gynecol. 1985; 64: 44-45
        • Hertogs K.
        • Roberts A.
        • Cooper D.
        • Griffen D.
        Maternal perception of fetal motor activity.
        Br. Med J. 1979; 2: 1183-1185
        • Tuffnell D.
        • Cartmill R.
        • Lilford R.
        Fetal movements: Factors affecting their perception.
        Eur. J. Obstet. Gynecol. Reprod. Biol. 1991; 39: 165-167
        • Bradford B.
        • Thompson J.M.D.
        • Heazell A.E.P.
        • Mccowan L.M.E.
        • McKinlay C.J.D.
        Understanding the associations and significance of fetal movements in overweight or obese pregnant women: A systematic review.
        Acta Obstet. Gynecol. Scand. 2018; 97: 13-24
        • Bradford B.
        • Cronin R.
        • McKinlay C.
        • Thompson J.
        • McCowan L.
        Maternally perceived fetal movement patterns: The influence of body mass index.
        Early Hum. Dev. 2020; 140104922
        • Winje B.A.
        • Røislien J.
        • Frøen J.F.
        Temporal patterns in count-to-ten fetal movement charts and their associations with pregnancy characteristics: A prospective cohort study.
        BMC Pregnancy Childbirth [Internet]. 2012; 12 ([cited 2017 Apr 26])
        • de Vries J.
        • Visser G.
        • Mulder E.
        • Prechtl H.
        Diurnal and other variations in fetal movements and heart rate patterns at 20-22 weeks.
        Early Hum. Dev. 1987; 15: 333-348
        • Mangesi L.
        • Hofmeyr G.J.
        • Smith V.
        • Smyth R.M.
        Fetal movement counting for assessment of fetal wellbeing.
        (Cochrane Database of Systematic Reviews [Internet])The Cochrane Collaboration. John Wiley & Sons, Ltd, Chichester, UK2015
        • Pillai M.
        • James D.
        Hiccups and breathing in human fetus.
        Arch. Dis. Child. 1990; 65: 1072-1075
        • Goldkrand J.W.
        • Farkouh L.
        Vibroacoustic stimulation and fetal hiccoughs.
        J. Perinatol. J. Calif. Perinat. Assoc. 1991; 11: 326-329
        • D’Elia A.
        • Pighetti M.
        • Moccia G.
        • Santangelo N.
        Spontaneous motor activity in normal fetuses.
        Early Hum. Dev. 2001; 65: 139-147
        • Hayat T.T.
        • Nihat A.
        • Martinez-Biarge M.
        • McGuinness A.
        • Allsop J.M.
        • Hajnal J.V.
        • et al.
        Optimization and initial experience of a multisection balanced steady-state free recession cine sequence for the assessment of fetal behavior in utero.
        Am. J. Neuroradiol. 2011; 32: 331-338
        • Nijhuis J.
        Fetal behavior.
        Neurobiol. Aging. 2003; 24: S41-S46
        • Pillai M.
        • James D.
        Human fetal mouthing movements: a potential biophysical variable for distinguishing state 1F from abnormal fetal behaviour; report of 4 cases.
        Eur. J. Obstet. Gynecol. Reprod. Biol. 1991; 38: 151-156
        • Kamata H.
        • Ryo E.
        • Seto M.
        • Morita M.
        • Nagaya Y.
        Counting fetal hiccups using a fetal movement acceleration measurement recorder.
        J. Matern Fetal Neonatal Med. 2016; : 1-4
        • Goodlin R.
        History of fetal monitoring.
        Am. J. Obstet. Gynecol. 1979; 133: 323-351
        • Heazell A.
        • Stacey T.
        • O’Brien L.M.
        • Mitchell E.A.
        • Warland J.
        Excessive fetal movements are a sign of fetal compromise which merits further examination.
        Med Hypotheses. 2018; 111: 19-23
        • Sharp I.
        • Adeyeye T.
        • Peacock L.
        • Mahdi A.
        • Farrant K.
        • Sharp A.N.
        • et al.
        Investigation of the outcome of pregnancies complicated by increased fetal movements and their relation to underlying causes – A prospective cohort study.
        Acta Obstet. Gynecol. Scand. 2021; 100: 91-100
        • Huang C.
        • Han W.
        • Fan Y.
        Correlation study between increased fetal movement during the third trimester and neonatal outcome.
        BMC Pregnancy Childbirth. 2019; 19: 467
        • Bradford B.
        • Cronin R.S.
        • McCowan L.M.E.
        • McKinlay C.J.D.
        • Mitchell E.A.
        • Thompson J.M.D.
        Association between maternally perceived quality and pattern of fetal movements and late stillbirth.
        Sci. Rep. 2019; 9: 9815
        • Warland J.
        • Heazell A.E.P.
        • Mitchell E.A.
        The STARS Consortium. An international internet survey of the experiences of 1,714 mothers with a late stillbirth: The STARS cohort study.
        BMC Pregnancy Childbirth [Internet]. 2015; 15 (Available from)
        • Scala C.
        • Bhide A.
        • Familiari A.
        • Pagani G.
        • Khalil A.
        • Papageorghiou A.
        • et al.
        Number of episodes of reduced fetal movement at term: Association with adverse perinatal outcome.
        Am. J. Obstet. Gynecol. 2015; 213: 678.e1-678.e6
        • Warland J.
        • Heazell A.E.P.
        • Stacey T.
        • Coomarasamy C.
        • Budd J.
        • Mitchell E.A.
        • et al.
        They told me all mothers have worries, stillborn mother’s experiences of having a ‘gut instinct’ that something is wrong in pregnancy: Findings from an international case–control study.
        Midwifery. 2018; 62: 171-176
        • Linde A.
        • Pettersson K.
        • Rådestad I.
        Women’s experiences of fetal movements before the confirmation of fetal death - contractions misinterpreted as fetal movement.
        Birth. 2015; 42: 189-194
        • Stanger J.J.
        • Horey D.
        • Hooker L.
        • Jenkins M.J.
        • Custovic E.
        Fetal movement measurement and technology: a narrative review.
        IEEE Access. 2017; 5: 16747-16756
        • Daly L.
        • Gardener G.
        • Bowring V.
        • Burton W.
        • Chadha Y.
        • Ellwood D.
        • et al.
        Care of pregnant women with decreased fetal movements: Update of a clinical practice guideline for Australia and New Zealand.
        Aust N Z J Obstet Gynaecol [Internet]. 2018
        • Nijhuis J.G.
        Fetal behaviour.
        Neurobiology of Aging. 2003; 24: S41-S46
        • Brown R.
        • Higgins L.
        • Johnstone E.
        • Wijekoon J.
        • Heazell A.
        Maternal perception of fetal movements in late pregnancy is affected by type and duration of fetal movement.
        Journal of Maternal-Fetal and Neonatal Medicine. 2015; 29: 2145-2150