Volume 64, Number 7

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright 2009
by Lippincott Williams & Wilkins

CME REVIEWARTICLE

21

CHIEF EDITORS NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA Category 1 CreditsTM can be earned in 2009. Instructions for how CME credits can be earned appear on the
last page of the Table of Contents.

Factors Affecting Maternal Perception

of Fetal Movement
Zina Rashed Hijazi, MS,* and Christine Elizabeth East, PhD
*Medical Student, Senior Lecturer, Department of Obstetrics and Gynecology, Pregnancy Research Centre,
Department of Perinatal Medicine, Royal Womens Hospital, the University of Melbourne, Melbourne, Australia
Maternal perception of fetal movement is an important screening method for fetal well-being, as
decreased fetal movement is associated with a range of pregnancy pathologies and poor pregnancy outcomes. An understanding of factors that may affect perception could help clinicians to
determine the importance of maternal reports of decreased fetal movement. This review considers
factors that may affect maternal perception of fetal movement and the sensitivity of maternal
perception of fetal movements in comparison with ultrasound and other objective methods of
movement detection. There is conflicting evidence on whether parity, gestational age, overweight
and obesity, and placental location affect perception. This may be related to the small sample sizes
of available studies and lack of consistent definitions of factors that may affect the ability of mothers
to perceive movement. There is some evidence that psychological factors and duration of fetal
movement may affect perception, and that strong movements and those including trunk movement are
more likely to be perceived. The proportion of fetal breathing movements that mothers perceive has not
been investigated. Research is also lacking as to whether there needs to be contact of fetal part(s) with
maternal structures for movement to be perceived, and whether fetal position, amniotic fluid volume,
maternal position, sedatives, or other drugs affect movement perception.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader should be able to define variables that
may affect a mothers ability to perceive fetal movements, describe different methods of fetal movement
counting, and summarize how fetal movements may be related to fetal well-being.

This review outlines the patterns of normal fetal

movement and the importance of decreased fetal
movement in indicating fetal compromise. Factors
The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to
this educational activity.
The Faculty and Staff in a position to control the content of this
CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies
pertaining to this educational activity.
Lippincott Continuing Medical Education Institute, Inc. has
identified and resolved all faculty conflicts of interest regarding
this educational activity.
Reprint requests to: Christine East, PhD, University Department
of Obstetrics and Gynaecology, Royal Womens Hospital, 20
Flemington Rd, Parkville VIC 3052, Australia. E-mail: eastc@
unimelb.edu.au.

that may affect the ability of mothers to perceive fetal

movements are discussed. The sensitivity of maternal
perception of fetal movements in comparison with
ultrasound and other objective methods of movement
detection is also considered.
NORMAL FETAL MOVEMENT
Fetal movements begin at about 7 to 8 weeks
gestation (1). Movements are generally considered to
decrease progressively in the second half of pregnancy (24), although whether this decline actually
occurs has been disputed (5). One longitudinal study
found that fetuses were active about 17% of the time
at 24 weeks, which decreased to 7% near-term (2). In

www.obgynsurvey.com | 489

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Obstetrical and Gynecological Survey

a healthy fetus, it has been suggested that movements

range from 4 to 100 movements per hour (6), but the
range of normal movement incidence is not agreed
upon (79) as there is considerable interfetal, and
possibly intrafetal, variation in amount of movement
(1,2,8).
Fetal movements include general body movements,
isolated limb movements, breathing, and hiccups
(10,11). General movements occur most commonly
and involve trunk, limb, and head movements in a
variable sequence, with intensity fluctuating throughout the movement (12).
Fetal behavioral states mature by 36 weeks (12,13):
state 1F: quiescence, 2F: frequent whole body movements and continuous presence of eye movements, 3F:
continuous eye movements without body movements,
and 4F: vigorous, continuous body movements with
continuous eye movements (14). A diurnal rhythm of
movement also develops in the second trimester (15),
with movements increasing throughout the day (16)
and peaking between the hours of 21:00 and 01:00
(5,17). The issue of whether or not maternal meals
increase fetal general movement remains controversial (4,5,16,18,19).
Women begin to perceive fetal movements at 16 to
20 weeks (20), with multiparae perceiving movements before primigravidae (21). The number of
movements counted by mothers, as distinct from the
actual number of movements, increases with gestational age until 32 weeks, after which the number
decreases (9,22). Maternal concern about decreased
fetal movement is common, particularly with advancing gestation, with as many as half of women
concerned about decreased fetal movements at some
point during the pregnancy (23). Around 7% of pregnant women contact health care providers because of
concerns of decreased fetal movement (24,25).
For normal fetal movement to occur, neuromuscular functions must be intact and an adequate supply
of oxygen and nutrients to the central nervous system
is needed. Normal quantity and quality (8) of fetal
movement therefore suggests a healthy central nervous system (11,26).
THE SIGNIFICANCE OF DECREASED
FETAL MOVEMENT
Decreased fetal movement may occur in healthy
fetuses (6). Causes of decreased movement, which do
not necessarily indicate fetal compromise include
fetal quiescent period (24,27), drugs such as corticosteroids (28,29) or sedatives (30), smoking (31,32),
and maternal exercise (33,34). When mothers report

a decrease in fetal movements it may simply reflect a

reduced perception of movement, rather than an actual decrease in movement (23). This reduced perception may occur when the mother is distracted or
busy (24,35).
Actual decreases in fetal movement may indicate
fetal compromise or predict poor fetal outcome
(6,20,23,24,26,27,3638). Decreased fetal movement
occurs in acute and chronic fetal hypoxia (3942)
and malnutrition (8), which are most commonly due
to placental insufficiency (37). The decrease in
movement may be an adaptive response to reduce
oxygen requirements and conserve energy, but in more
severe stages of placental insufficiency, the decrease in
movement is a sign of impending injury (43).
A reduced number of fetal movements (13,20,4446)
and markedly altered movement quality has been observed in fetal growth restriction, a consequence of
long-term placental insufficiency, with movements being slower and lacking normal strength and variability (8).
Decreased strength (47) and quantity of fetal
movement may be a sign of imminent fetal death
(22,36,44,46,4854), with around 50% of women
reporting decreased fetal movement in the days before fetal death (51). There may be a sufficient window for intervention between the time women
present with reduced fetal movements and fetal
death, with decreased movement occurring days before fetal death, except in cases of sudden fetal death
due to placental abruption or umbilical cord accidents (20,37,54). These and other pregnancy pathologies and poor pregnancy outcomes associated with
decreased fetal movement are listed in Table 1. Maternal monitoring of fetal movement has therefore been
suggested as an important screening test (54) for various fetal complications, possibly allowing intervention
to reduce perinatal morbidity and mortality.
FACTORS AFFECTING MATERNAL
PERCEPTION OF FETAL MOVEMENT
To determine the importance of maternal reports of
decreased fetal movements, there must be an understanding of variables that affect the mothers
ability to perceive movements. There is conflicting
evidence around the effect of a variety of factors
alone or in combination on the sensitivity of maternal perception of fetal movement. Negative
findings reported by small studies may have resulted in some of the disagreement around whether
certain factors affect maternal perception. There is a
possibility for interaction between these factors. For
example, it is possible that placental site influences

Factors Affecting Maternal Perception of FM Y CME Review Article

TABLE 1
Pregnancy pathologies and poor pregnancy outcomes associated
with decreased fetal movement
Pathology or Outcome

References

Perinatal hypoxia/asphyxia/acidemia
Intrauterine fetal death
Low birth weight
Fetal growth restriction
Small for gestational age
Preeclampsia
Premature labor/birth
Neonatal hypoglycemia
Fetomaternal transfusion/fetal
anemia
Intrauterine infections
Umbilical cord complications
Abruptio placentae/placental
insufficiency/severe degenerative
placental changes
Congenital anomalies including
those affecting neurological or
musculoskeletal systems
Perinatal brain injuries/postnatally
diagnosed neurodevelopmental
disability

(39 42, 46,55)

(22,36,37,44,46, 48 54)
(8,13,20, 44 46)
(56 58)
(36)
(46,58)
(58)
(20,59)
(60)
(20)
(20,58)

(56,58, 61 63)

(64,65)

maternal perception of fetal movement at certain

gestational ages but not others (66).
Parity
Although multiparous women perceive fetal movements earlier in gestation than primigravidae (21) it
is unclear whether or not parity influences the sensitivity of maternal perception of movement with advancing gestation, given that 5 studies comparing
maternal perception of fetal movement to ultrasound
for a total of 476 women report conflicting results
(27, 6669). Case-control studies including 2469
women reporting decreased fetal movements also
found conflicting results on whether there is an association between parity and diminished maternal
perception of fetal movement (38,70).
Gestational Age
Women may be increasingly aware of fetal movements with advancing gestation (71). In a study of 50
women, as gestation advanced there was an increase
in sensitivity of maternal perception of fetal movements relative to movements seen with ultrasound
(69). In contrast, there was no effect of gestational
age on maternal perception relative to ultrasound in
other studies with varying degrees of adequate de-

491

scriptions of methodology and a total of 267 women

(27,67,68,72,73).
Overweight and Obesity
Tuffnel et al found that reports of decreased fetal
movement were more likely in mothers weighing
over 80 kg (70). Obesity is associated with an increased risk of pregnancy complications (74), and
decreased fetal movement may be associated with
obesity for this reason. However, the pregnancies in
this study all had a favorable outcome, which suggest
that increasing maternal weight was associated with a
decreased sensitivity of movement perception rather
than an actual decrease in movements. In contrast,
another study found no association between obesity
and the number of movements mothers counted (75).
Lowery et al (73) compared maternal perception
to ultrasound-observed fetal movement and found
that sensitivity of maternal perception decreased
with increasing maternal weight but was not related to maternal abdominal wall thickness. Several further studies comparing maternal perception to
ultrasound have not found an association between
obesity and sensitivity of fetal movement perception
(27, 6769, 72).
Most of these studies either did not define obesity, or measured maternal weight without considering maternal height. Hertogs et al (68) measured
the subscapular skinfold thickness to assess obesity.
No studies used the body mass index, which although
not without limitations (76), takes height as well as
weight into account and is commonly documented
antenatally. There is a need for a better classification
of obesity in studies assessing maternal perception of
fetal movement and body mass index may be a useful
method to define the degree of overweight and obesity in future studies.
Placental Location
It has been reported that women with an anterior
placenta begin to feel fetal movements later than
women with a posterior placenta (21). Fisher (71)
found that 70% of women presenting with a complaint of reduced fetal movements, despite an active
fetus, had an anterior placenta, even although the
prevalence of an anterior or other placental location
is similar (77). These findings suggest that women
with an anterior placenta have a reduced perception
of fetal movements compared with women with other
placental locations. Similarly, another study found
that reports of decreased fetal movements were twice

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Obstetrical and Gynecological Survey

as likely for women with an anterior placenta (70).

However, one study of 66 fetuses at 32 to 36 weeks
gestation found that placental location did not affect
the number of movements mothers reported (75).
In a study with 284 women comparing maternal
perception of fetal movements with movements documented by ultrasound, an anterior placenta reduced perception from weeks 20 to 27 weeks and
36 to 42 weeks, but not at 28 to 35 weeks (66).
Other smaller studies (for a total of 94 women) that
compared maternal perception to ultrasound, conducted mostly in the third trimester, did not find an
effect of placental location on maternal perception
(68,69,72). Further research may determine
whether placental location variably affects maternal perception throughout gestation.

perceived the breathing movements observed on ultrasound (68,69,80). No identified studies investigated the proportion of fetal breathing movements
mothers perceive, despite the fact that perception of
movement that includes breathing may be more indicative of fetal well-being than other types of movement (17). However, Hertogs et al (68) argue that
mothers cannot distinguish between fetal breathing
movement and passive changes in fetal position
caused by maternal movement, and that fetal breathing movement should therefore not be counted by
mothers. This assertion implies that inclusion of
these movements would be invalid, but the investigators offer no guidance as to how to teach women
which movements are valid or not valid. Further
studies may need to address this issue.

Amniotic Fluid Volume

Ahn et al (78) found a greater likelihood of oligohydramnios in women presenting with a decrease in
perceived fetal movements, which may reflect an
actual decrease in fetal movement (79). No studies
have compared the sensitivity of maternal perception
to an objective method of movement detection across
a spectrum of amniotic fluid volumes.
Characteristics of Fetal Movements
There may be an interaction between the characteristics of fetal movement, such as moving fetal
part(s), strength, and duration of movement. For example, movements of the entire fetal body may be
stronger and of longer duration than isolated limb
movement (20) and mothers may be more likely to
perceive these movements.

Strength of Fetal Movement

Decreased strength of fetal movement may indicate
fetal compromise or imminent fetal death (47). It is
therefore important to know how mothers perceive
fetal movements of varying strength. Sadovsky et al
(81) compared maternal perception of fetal movements to those detected by an electromagnetic device, and found that stronger movements were more
accurately perceived by mothers, whereas weaker
movements were often unnoticed. Another study
compared maternal perception of fetal movement to
movements detected by ultrasound and found that
mothers perceived a greater proportion of movements that the investigators rated as strong from
ultrasound examination (72).

Type of Fetal Movement

Duration of Fetal Movement

Several studies comparing maternal perception of

fetal movement to movement detected by ultrasound
found that mothers perceived a higher proportion of
movements that included trunk movement than
movements isolated to a limb (27,69,72,80). In contrast, Hertogs et al (68) did not find a significant
difference between maternal perception of fetal
trunk, limb, and head movement, but did find a
relationship between the number of moving body
parts and maternal perception of the movement.
Few studies consider maternal perception of fetal
breathing movements. One study found that breathing movement was not perceived by mothers (72),
whereas others reported instances where mothers

Sorokin et al (82) found that mothers perceived a

smaller proportion of fetal movements lasting 1
second compared with movements with a duration of
1 to 3 seconds. Perception was greatest for movements lasting 3 seconds. Another study found a
relationship between sensitivity of maternal perception and fetal movement duration, but this was due to
movements of longer duration involving a greater
number of moving body parts (68). In a study comparing maternal perception of fetal movement to a
Doppler actograph, mothers had a decreased perception of movements lasting less than 20 seconds or more
than 60 seconds (83). The investigators did not give an
explanation for this distribution of perception.

Factors Affecting Maternal Perception of FM Y CME Review Article

Contact With Maternal Structures

No studies have investigated whether there needs
to be contact of fetal part(s) with maternal structures
(uterus or placenta) for the mother to perceive movement, and which, if any, structures are responsible
for the perception of movement. Tuffnel et al (70)
reason that if an anterior placenta reduces maternal
perception of movement then it may be transmission
of fetal movement through the uterine wall to the
anterior abdominal wall that leads to perception of
movement. They also suggest that if movement is felt
via the maternal abdominal wall structures, then obesity, with its associated increase in extraperitoneal
fat, should reduce the sensation of movements.
Fetal Position
Fisher found that in 80% of women reporting reduced fetal movement despite the fetus being active,
the fetal spine was anterior (71). However, another
study reported that fetal lie did not affect the number
of fetal movement counts mothers reported (75).
There were no identified reports on the effect of fetal
position on the sensitivity of maternal perception of
movement in comparison with an objective method
of movement detection, such as ultrasound.
Psychological Factors
There is a paucity of research on the influence of
maternal psychological factors on fetal movement
perception. By exclusive reasoning, Hertogs et al
(68) suggested that psychological rather than physical factors influence the sensitivity of maternal perception of fetal movement, because they found no
relationship between physical factors and maternal
perception of movement.
Wenderlein (84) found that both maternal intelligence and neuroticism, determined by Eysencks
Maudsly Personality Inventory (85), influenced perception of fetal movement. The higher the mothers intelligence, the less frequently she experienced the first
fetal movements clearly. In contrast, higher neuroticism in the mother was associated with an increased
likelihood of experiencing the first movements
clearly. Sjostrom et al (50) found no effect of maternal anxiety, measured by The Spielberger State-Trait
Anxiety Inventory (86), on maternal perception of
ultrasound-assessed movement.
It has been suggested that busy mothers may not
perceive as many fetal movements (24,26). Johnson
(35) observed that mothers perceived more move-

493

ments when focusing on fetal movement in a quiet

room. Perception also improves when women are
shown movement on the ultrasound scan (27) (87) or
are instructed about movements in an ultrasound
session (11).
Sedatives and Other Drugs
It is suggested that sedatives and alcohol decrease
maternal perception of fetal movements (24). However, as sedatives and other drugs have been reported
to actually decrease fetal movement (2830), it is
unclear whether, in the face of maternal sedative use,
fetal movement or maternal perception is diminished.
Likely both are, even although we identified no studies that investigated the effect of sedatives or other
drugs on the sensitivity of maternal perception of
fetal movement.
Maternal Position
Studies report that mothers perceive a greater number of fetal movements when in a recumbent position
compared with sitting and standing (16,88). It has
been suggested that this is because the mother focuses more on the movement when lying down
(36,87). However, it is unclear whether there is an
actual increase in fetal movements or an increase in
maternal sensitivity to movement when the mother is
in a recumbent position, or why such an increased
sensitivity would occur.
MATERNAL PERCEPTION OF FETAL
MOVEMENT IN COMPARISON WITH
ULTRASOUND
Several studies have compared the sensitivity of
maternal perception of fetal movements with movement observed with real-time ultrasound. The percentages of movements observed on ultrasound that
are felt by the mother for each study and the details
of the studies are listed in Table 2.
One reason for the disparity in results is the variety
of methods of counting ultrasound observed fetal
movements (90). In one study, a long movement with
various moving body parts might be considered as a
single movement, whereas in another it might be
considered to represent numerous short movements
(90). Some studies use an intermovement interval,
such as 2 seconds of no movement, to define movements as separate (69,72,73,80). Other studies did
not define an intermovement interval (27,67,68,82).

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Obstetrical and Gynecological Survey

TABLE 2
Studies comparing maternal perception with real-time ultrasound detection of fetal movement
Sensitivity
of Maternal
Perception (%)

Definition of Agreement Between Maternally

Perceived and Ultrasound-Observed
Movement

Gettinger et al. (67)

40

Hertogs et al. (68)

33

Neldam and Jessen (89)

Rayburn (27)
Sorokin et al. (82)
Neldam* (66)
Schmidt et al. (69)
Schmidt et al. (80)

88
82
71
87
37
38

Valentin et al. (72)

38

Lowery et al. (73)

38

2 s between movements registered by

mother and US
2 s between movements registered by
mother and US
Not defined
Not defined
Not defined
Not defined
Not defined
Maternally perceived movements coinciding
with US-detected movement
2.4 s between movements registered by
mother and US
Not defined

Investigators

Interval Required to Consider

Ultrasound-Observed Movements
as Separate
Not defined
Not defined
Not defined
Not defined
Not defined
Counted every new trunk movement
2 s
2 s
2.4 s
2 s

*Calculated from available data: number of FM mothers counted and number viewed on US. It may not represent actual correlation
between FM registered by mothers and US. The investigators noted only fetal trunk movement seen on US.
FM indicates Fetal movement; US, Ultrasound; s, second.
TABLE 3
Studies comparing maternal perception of fetal movement with other methods of fetal movement detection

Investigators

Method of Fetal Movement

Detection

Sensitivity of Maternal
Perception Compared
With Movement Detector

Sensitivity of Movement
Detector Compared
With Ultrasound

Sadovsky et al. (81)

Sadovsky et al. (91)
Ehrstrm (9)
Neldam and Jessen (89)

Electromagnetic device
Piezo-electric crystals
Impedance plethysmography
Tocodynamometry

87%
77%
90%
No correlation

Sorokin et al. (82)

Valentin et al. (72)
Johnson et al. (83)

Tocodynamometry
Piezo-electric crystals
Doppler actograph

Not done
Not done
Not done
Tocodynamometry was
not reliable
88%
70%
Not done

Neldam (66) counted every trunk movement as a new

movement.
Some studies did not define how they evaluated
agreement between maternally perceived and ultrasound observed movement (27,66,69,73,82).
Schmidt et al considered maternal registration of
fetal movement to be correct only if it coincided with
fetal movement observed on ultrasound (80). However, this definition may not allow enough time for
mothers to register fetal movement. Hertogs et al
(68) and Gettinger et al (67) defined agreement as
movement registration by the mother 2 seconds
from movement observed on ultrasound. Valentin
et al (72) defined agreement as 2.4 seconds from
movement observed on ultrasound (Table 2).
Furthermore, Sorokin et al (82) and Neldam (66)
counted only trunk movements when observing the
movements on ultrasound. This may explain the high
sensitivity of maternal perception (71%) observed in

82%
39%
16%

the study by Sorokin et al because the mother may

be more likely to perceive movements that involve
trunk movement than isolated limb movements
(27,69,72,80). The inclusion of breathing movement in some studies (72,73,82) but not others (27,
6669,80,89) may also have contributed to the variability of the results. Furthermore, these studies did
not consider all the factors, which may affect maternal perception mentioned earlier and this may have
led to differing results.
MATERNAL PERCEPTION OF FETAL
MOVEMENT COMPARED WITH OTHER
METHODS OF MOVEMENT DETECTION
Besides real-time ultrasound, several objective methods
of fetal movement detection have been compared with
maternal perception of movement, including tocodynamometry, piezo-electric crystals, Doppler actograph,

Factors Affecting Maternal Perception of FM Y CME Review Article

impedance plethysmography, and an electromagnetic

device that detects displacement, that is, a change in
position of structures beneath the device (Table 3). A
tocodynamometer uses a strain gauge to measure
pressure changes caused by fetal movement that are
transmitted to the maternal abdominal wall (20).
Piezo-electric crystals convert perpendicular straining forces to a recordable signal (91). The divergent
results of these studies may reflect either the varying
sensitivities of these devices to detect movement,
different definitions of agreement, or methods of
counting ultrasound-observed movements, or a combination of these.

FORMAL FETAL MOVEMENT COUNTING

A more formal approach to the mothers subjective monitoring of fetal movement involves mothers
counting and recording fetal movement on a chart.
Many formal movement counting methods with
varying quantitative definitions of reduced movement have been devised. The definitions are mostly
arbitrary and there is no general agreement on any
one definition (7,26). Because of the wide range of
normal movement (1,2,8) and wide variability in
maternal perception of movement (67), it has proved
difficult to set a lower normal limit for fetal movements as counted by mothers (26).
Sadovsky and Polishuk (36) described a counting
method in which women count fetal movements for
30 to 60 minutes, 3 times a day. If fewer than 3
movements per hour are noted, counting should continue for 6 to 12 hours. Women are instructed to
report to their health care provider if movements
cease or are reduced to several per day. The count to
10 method involves daily fetal movement counting
and reporting if it takes longer than usual to feel 10
movements, or if fewer than 10 movements are felt in
12 hours (6,22). Moore and Piacquadio devised a
counting method wherein mothers were instructed to
record the time to perceive 10 fetal movements while
at rest and focusing on fetal movement (5,16,17).
The definition of decreased movement used was less
than 10 movements in 2 hours.
It has been suggested that definitions of reduced
fetal movement should be individualized, depending
on the normal number of movements usually registered by each woman (66). This is supported by the
argument that a decline from the previous amount of
movement, rather than the actual number of movements, is the important factor indicating possible
fetal jeopardy (20).

495

There is no evidence that any formal definitions are

more effective than the mothers subjective perception
of reduced fetal movement (23,43), which has been
recommended as the main definition of decreased
fetal movement, with any quantitative definition providing only guidance (48). However, Johnson argues
that the mothers subjective perception of decreased
fetal movement is often incorrect and that a more
objective method to determine whether there is decreased movement is needed (35).
A large randomized control trial of formal fetal
movement counting found that use of formal fetal
movement counting charts did not reduce mortality
(92) and caused a marked decrease in publications
about fetal movement as a means of assessing fetal
health (25). However, recent reviews describe several methodological limitations of the trial and draw
attention to other studies that suggest use of formal
fetal movement counting programs decrease perinatal mortality (25,44,48).

CONCLUSION
Factors affecting maternal perception of fetal
movement are not well understood. There is conflicting or limited evidence on many suggested factors that
may affect perception. Negative findings may be due to
small study sample sizes. Larger studies considering a
variety of factors that may affect perception and
comparing maternal perception to an objective
method of movement detection using rigorous definitions and methodologies are needed. Such studies
may enhance understanding of the potential for maternal monitoring of fetal movements to prevent stillbirth and possibly even perinatal morbidity.

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