What are normal baby movements (and why we bang on about them so much)
Baby movements is your baby’s way of telling you all is well. A healthy baby should move. Imagine if you were really sick, you would still move around the bed and get up several times a day to go the toilet. If you lay in bed for many hours, not moving at all, you would probably be dreadfully ill. A baby that’s doing nothing is not normal.
And why are we so insistent about baby movements? If we look at unexpected stillbirths in the third trimester, an alarming number of those stillbirths are preceded by a couple of days of decreased or absent fetal movements.
Your main defence against this is taking decreased or absent fetal movements very seriously and be focused from about 28 weeks on your baby’s pattern of movement.
What are the main areas you should be looking at?
How picking your baby’s pattern of movement is important
Why we moved away from ‘kick charts’
Never go to sleep on absent fetal movements
What to do if you think you have reduced or absent fetal movements
Why a baby ‘slowing’ down at term is not a sign you are going into labour.
Brigid [00:00:36] So welcome everyone to episode eleven and today we're going to talk about why we get so concerned about monitoring your baby's movements. One of the main reasons we do this is to make sure that your baby is well and healthy. The content that we're going to talk about in this podcast might trigger some listeners because we talk about stillbirth. So what we mostly want you to know is that the pattern is more important than the number or strength of the movement and any changes from the baby's usual pattern are significant and you need to go to your hospital or health care provider to be reassured all is well. And if it's a false alarm your healthcare provider will be as happy as you are that all is well and you can go home to grow your baby. So for everybody else wanting more information about how to monitor your baby then listen on.
Patrick [00:01:24] So today I've just sort of whizzed in here to do this now because we've got a fascinating patient today who's got type 1 diabetes with one of these newfangled insulin pumps and it's a special type of insulin pump that's also got a sensor. So it not only delivers the insulin without her needing to give injections but it senses the blood sugar level in her bloodstream and sort of manages the diabetes for her.
Brigid [00:01:50] Yeah. And what about in the labour situation?
Patrick [00:01:52] Good question. Right, so I've learned a bit today because managing blood sugar level in type 1 diabetics in labour is really complex and we often do it in conjunction with the endocronologists and physicians diabetes specialists because the metabolic demands of labour are very strong and your muscles working hard and we don't want that woman to go too high or too low.
Patrick [00:02:13] So what I'm learning a bit about today is how to use the pump sensor for that for that purpose. And working with the diabetes guys to get that balance as accurate as we can for her labour. So that's been fascinating I found out a lot today.
Brigid [00:02:28] And what a challenge for her and for you. Like you know for her to have a baby when she is type 1 diabetic. You know it's a very different path. And it looks very different from anybody else that's having a baby.
Patrick [00:02:38] Yeah. Just the normal management of the pregnancy itself has been really quite interesting and tricky and you have to do more to get a good outcome for type 1 diabetic.
Brigid [00:02:48] And it's quite unusual to have Type 1 diabetes but it's not unusual to have gestational diabetes and we might do a podcast on that another time as well.
Patrick [00:02:58] Yes. So Gestational diabetes is obviously common and relevant and does need some management but it's nothing compared to the obstetric complexities of getting good results for women and with type 1 diabetes.
Brigid [00:03:10] Yes. All right. So this episode is all about baby movements and the first time we feel our baby move is different for every woman and you know in some cases different for every pregnancy. I can definitely vouch for that. I had two that were gymnasts and I felt like I never got a moment's rest and I had babies that are doing somersaults and flips and and then our fourth, Rex. Oh wow. He did not move. I don't think I felt him till like 25 weeks and you know he used to panic us all the time didn't it? And we were a bit spoilt.
Patrick [00:03:42] We've got our ultrasound machine so we can just just have a look whenever you like.
Brigid [00:03:48] I used to sneak down to the clinic and say ah Pat. I haven't felt Rex move, or this baby move for the whole day please can I jump on the machine?
Patrick [00:03:56] Yeah so that I'm that that's actually illustrates quite well that the main take home message from today and that's that we really need you to keep aware of the pattern of movements. So this is something that's changed a bit in recent years as the science behind this has developed a little bit. There used to be a thing called Kick charts where you would literally count up the number of kicks the baby had done in the day. And sometimes people would look at the strength of the kicks and so forth but it turns out those things don't correlate all that well with problems in the baby. What does correlate pretty well is if the baby has an established pattern that suddenly isn't there. That's a problem. So to know whether your baby has deviated from the established pattern you have to know whether establish pattern is. So roundabout that 20 week mark when women start feeling the baby move, then as soon as possible after, it's really great if we've been watching the baby closely enough, if Mum has, so that she can be quite confident of when the baby typically likes to move. And this works both ways. If the baby always moves during the woman's morning shower, and always does, that's a healthy baby. It'd be nice to feel that baby move a dozen other times during the day, but if the baby always moves in the shower in the morning, and always does, that's a healthy baby. Okay. Similarly if that baby suddenly does not do its thing, a little nice roll while you're in the shower in the morning, and is not being its usual self then that is not cause for alarm but it's cause for you to pay attention. Yes. Then we want women to zoom in on this as a feature and start trying to provoke some movements and the things that work for that are glass of ice cold water. In advance pregnancy the uterus has come all the way up so its next door to your stomach. And if you have some ice cold water a chill will pass through the wall of the stomach into the uterus and the baby will feel that and move. Some babies respond to a hot cup of tea. Poke yourself in the tummy. Yeah do the thing that normally makes the baby move. So if the baby always moves when you get between cool sheets at night-time, go and get between some cool sheets and get the baby to tell you that it's okay. And then of course if that's still not working that's what we need to contact our our obstetric care providers because we need to listen to that baby and have an ultrasound look at what's going on.
Brigid [00:06:30] My queues for the baby to move was definitely at night. If I manage to sit down to watch some telly at night or something like that, that's when the baby would move a lot. And it's that is the time that you really want to just relax as well. You've got this baby that's all of a sudden woken up. Yeah. So it would go from sitting on the couch to bed and that was its most active period for all of them actually you know. And so that was that was my pattern and I always sort of kept an eye on that particular pattern.
Patrick [00:07:01] Yeah well that's another good message because the other take home message - first one being that the pattern is important and the other take home message is don't go to sleep on absent foetal move. Okay so if you've got a baby that moves in the evening. At least you know when you go to bed that was fine. So don't go to sleep on absent foetal movement means exactly that if you haven't had movements all day and you think oh well the baby normally moves when I'm watching the TV at eight thirty PM and then it doesn't. That is not a normal situation. Babies, if we look closely enough for a pattern, they're creatures of habit. I don't think there's much else going on in there in the dark. And so they will follow a pattern if we look closely enough at it. And sometimes people say to me "there's no pattern. I can't see it". And to them I say, well that is a problem for us. That that doesn't mean we can just say "oh don't worry there's no pattern to your baby bad luck". That baby might need some regular foetal monitoring. And occasionally I've encouraged people to attend much more often for foetal monitoring because they have a baby that just doesn't play by those rules.
Brigid [00:08:06] And sometimes we're not really taking the notice that we perhaps think we are. So you have to get a bit more strategic about it don't you. You have to write it down or you have to look at one of those apps to help you monitor your baby's movements. Absolutely. Because that's when you start to see a pattern. So if you did it over a couple of days and then looked back on your notes and then you can see.
Patrick [00:08:28] Yep. So people have to take it more seriously where there's a problem. If baby always move in the morning every single morning you know.
Patrick [00:08:36] But if we've got a baby it really doesn't move according to a pattern or really doesn't move enough then yeah we're to ramp up the surveillance.
Brigid [00:08:42] Hence that's what we used to do for Rex because you know it was so hilarious when he was born and he was he was just an observer of life wasn't he. He just would sit in his bassinet or he would when he was old enough to sit in the high chair we didn't hear boo from him. I think for the first twelve months he was just really observing and not moving much. A lot of things have changed about Rex right now.
Patrick [00:09:03] Yes it all has dramatically changed now but maybe that behaviour as a newborn was just like his foetal behaviour.
Brigid [00:09:11] So you know you've told them to go along to the hospital but you get there and what about if the hospital doesn't believe them or they don't do the monitoring that you think they should be doing.
Patrick [00:09:21] So I want to reassure everybody that we're getting a lot better at this. Okay. So the whole point of monitoring foetal movements is that healthy babies should move. And the other problem is that if we look at unexpected stillbirths in the third trimester an alarming number of those stillbirths are preceded by a couple of days of decreased or absent foetal movements. So we think that our only defence against that is taking decreased or absent foetal movements very seriously. A third trimester pregnancy loss is devastating for people and we haven't made enormous inroads over the last 20 years or so into the rate of stillbirths despite an enormous amount of work done by some very dedicated people to look into the causes and what we could be doing differently. But one of the things we're sure we could be doing differently is education. So in my labour ward there's posters on every door that says decrease foetal movements aren't normal. It's not normal for your baby to move less close to term.
Brigid [00:10:33] Oh right. Because there's there's a lot out there that say the baby does move less. Just before you go into labour.
Patrick [00:10:38] So that's not true and what you might see in the weeks before the last few weeks of the pregnancy is that the movements are less dramatic because the baby can't get a real swing up anymore. Okay enough room for 28 week baby plenty room and they will kick hard. The term baby is bunched up in the foetal position with the knees next to the chin and it's just hard to get a decent kick up but it still has to move. Yeah.
Brigid [00:11:05] And in the later stages the movement, you don't get any kicks but what you do get is a lot of stretching. Yes and pulling and you can feel a lot of pressure down in your pelvis and and it's more of a rolling movement. Yeah. Wriggles and pivots. Yeah. You can feel you. Oh my God. Ha. I just had like a little flashback and a little tingle, the pivoting on my pelvis was quite a disgusting feeling.
Patrick [00:11:33] One of the things I find useful is sometimes I'll say it to some of the women under my care, think about yourself if you were at home from work for a sick day.
Patrick [00:11:41] Even if you were really sick you would still get up several times a day out of your bed and go to the toilet and you would still move around the bed. Yes and you would still be moving.
Brigid [00:11:54] Even if it is to find the TV remote you would be moving. Yes.
Patrick [00:11:57] And if you lay there for many hours awake but not moving at all you would probably be dreadfully ill. Yes. Yes. So a baby that's doing nothing is not normal.
Brigid [00:12:10] All right. So. Oh my gosh that is all pervading on the internet about a baby will slow down just before Labour and some people say that that's a sign that you're going into labour.
Patrick [00:12:20] Yeah it's not true that foetal movements should or are allowed to decrease close to term and I don't think there's any evidence that it's a predictor of Labour in fact people should be alarmed. You should be alarmed at that. Yeah. So what do we do? We try and provoke movements and failing that, we ask for help.
Brigid [00:12:40] Yeah okay okay what about excessive movement like is excessive movement ever a sign that your baby might be in distress.
Patrick [00:12:49] No there's a thing called Foetal Distress which we see in labour but that baby in distress is not one that sort of panic on moving around too much in fact a lot of those babies will be too sick to move if they're in genuine foetal distress. What excessive movements are is usually just a very active baby and the one consolation for the mother is that's usually a healthy baby. Yeah. Okay. People might worry that that baby is more likely to get tangled up in the cord or have the cord around the neck or so forth well that is what it is we'll just keep monitoring that situation but a baby that moves a lot as well.
Brigid [00:13:22] I think it was Sully, the third boy he used to do a very jerky sort of frenetic kind of, felt like I mean he was having like a little shiver or something. You know that's just his movement isn't it.
Patrick [00:13:35] Absolutely. Sometimes people worry that that's epilepsy or foetal seizure and it's not. Yeah okay. And a foetus with problem like a seizure is incredibly uncommon. Yes but babies that have jerky foetal movements are normal. Normal. Yeah. It's like watching a dog sleep. Yeah the dog shivers So she was a normal and jerk and this is normal.
Brigid [00:13:56] Yeah. All right. There was another movement that I wanted to talk to you about. Oh hiccups. Yeah. Yeah it's hilarious when the baby has hiccups.
Patrick [00:14:04] Yeah. And that's it's the same. It's the same phenomenon. Yes. You and I can get hiccups. And it is it is hilarious. Enjoy. Yeah.
Brigid [00:14:11] Yeah. I do love that. I remember an ad from a long time ago where the mother is sitting down on the couch and she's got a Malteser on her belly. It's a great ad. I don't know how they managed to do that. For that to work at that I must have just had a movie camera trained on her for a very long time for that to happen. But the baby kicks her belly and the Malteser pops up into her mouth and I think you know sometimes that's how it feels, like they are really having a dance party in your belly. All right. So what is your gold standard. If I've gone to the hospital what do I expect. How. How are they going to check whether my baby still okay.
Patrick [00:14:47] So what. Pregnant women should be out of expect is that if they speak up because of decreased or absent foetal movements that they will be taken seriously. Okay so a couple of posters on the doors and tell everybody to come in with decreased foetal movements and then make people feel like a goose for turning up. Yeah. Okay. Because of course what happens mostly is you coming on a cold night and in the walk between the car park and the door of the hospital the baby fires up and you turn around and go home. So what I say to people is what you said in the introduction, we will be as happy as you are. If the baby is fine.
Patrick [00:15:22] Has the monitoring, turn around and go home. So the monitoring depends on what happens once you get there. The most common thing to do is a CTG which is that strap around your tummy that will trace out the Foetal heart rate over 20 or 30 minutes. And if that's normal that's great. Sometimes we also use bedside ultrasound to look at the amount of water around the baby and how well the blood is flowing either down the cord or through the baby's brain on ultrasound. And they're really great predictors of well-being. The thing is though that we can't just do some monitoring say Your baby's fine and see you later. All that does is prove that the baby is still alive. Yeah. Which is a great start but it doesn't fix the problem of decreased or absent movements. So you either need a single episode of monitoring followed by a return to normal movements. Or ongoing monitoring and the movement will always come back in a healthy baby they will be back. Yeah. So you just monitor until they do. Yeah.
Brigid [00:16:28] What do you mean, that's you monitoring at home or you're coming back and having another ultrasound?
Patrick [00:16:32] If you've got movements at home you don't need them. Yeah you're fine. The movements are back. No I'm talking about if they stay gone then you need intense monitoring. And of course occasionally because absent foetal movements are so abnormal. Occasionally at full term if the baby's ready to go we'll induce on the basis of absent movement. That's how seriously we take it. Because it's not normal and because we want to get that baby out while while the going's good.
Brigid [00:17:05] All right. So just to recap. Firstly we're monitoring the pattern of our baby's movements. We're never going to bed in the absence of movement. Yep yep. We need to try and get that baby to move. Yes. And if we don't get that baby to move then we need to go to the hospital.
Patrick [00:17:20] Yes. You can't say I'll go in the morning if I don't get the movement in the morning. Yeah. Okay. Every obstetrician has seen that scenario go very badly.
Brigid [00:17:30] Yeah. And then if you do have decreased foetal movements it's not a one off Test. You need to go back if there's no return to normal movements.
Patrick [00:17:41] So you can be confident that your care providers will take it seriously. Yeah that you won't be made to feel like a goose and that some appropriate monitoring will be done and the appropriate monitoring will be continued until the foetal movements return.
Brigid [00:17:56] Yeah great. All right everyone well that's the bottom line of normal baby movements. If you haven't subscribed yet please go to iTunes or wherever you get your podcasts from an hit subscribe and this enables you to get the next episode as it hits and we release an episode every Tuesday. But if you're a subscriber you'll get it on Monday and so we look forward to having your company next time.