Assessment of movement is a noninvasive way to monitor the well being of a fetus. Fetal
movement directly reflects the health of central nervous system mechanisms and reflexes.
Near term, 92% of all obvious gross body movement is associated with fetal heart rate
accelerations, and 85% of all accelerations occur in association with fetal movements. Thus,
an assessment of the amount of fetal movement appears to be roughly interchangeable with
monitoring of fetal heart rate accelerations during the last weeks of pregnancy.
Normally a baby spends about 10% of its time making gross body movements during the third
trimester; approximately 30 such movements are made every hour. Periods of active body
movement last around 40 minutes with quiet periods lasting about 20 minutes. The mother is
able to detect 70 to 80% of these movements. Fine movements also occur but are less likely
to be detectable by the mother. Movements lasting 20 to 60 seconds are most likely to be
felt by her. Fetal movement tends to peak between 9 pm and 1 am. It has been found that
fetal movement increases as maternal blood glucose levels fall; movement does not increase
after meals or after maternal glucose ingestion. In a normal fetus, the maximum period
without detectable movement is about 75 minutes.
Fetal motion may change character as term approaches. There is often a change in the
quality, rather than the quantity, of movement. Women may report that the baby is moving
less, but when questioned carefully relate that the baby's pattern is changing from punching,
kicking, and other large movements to rolling, shifting, and more-subtle movements. This
change must be distinguished from a true decrease in fetal movement. Keep in mind that
movement can gradually diminish over time when the fetus is conserving energy because the
mother needs to eat more. If the baby is severely compromised, the movements will diminish
during a period of 3 to 4 days; some time after that, they will stop all together.
- Anne Frye,
Understanding Diagnostic Tests
in the Childbearing Year, Labrys Press 1997
Continuous measurements of fetal heart rate (FHR), gross fetal body movements, fetal
breathing movements, and maternal heart rate (MHR) were made for 24-hour observation
intervals in 11 pregnant women at 38 to 40 weeks. There was a significant positive
correlation between each mother's daily mean MHR and her fetus' daily mean FHR. There
was a trough in mean hourly FHR between 0200 and 0600 hours and a trough in mean hourly
MHR between 2400 and 0700 hours. Mean hourly FHR both during and between times of gross
fetal body movements was significantly correlated to mean hourly MHR. At term, the mean
FHR is strongly influenced by the mean MHR and the presence or absence of gross fetal
-Am J Obstet Gynecol 1982 Nov. 1 144(5) 533-8
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Question of the Week
Q: I am a doula and have a client with pelvic floor
dysfunction (PFD) and interstitial cystitis (IC). She would like to have a natural birth.
She has been told to get an epidural to "quiet the bladder and pelvic nerves." Does anyone
have experience with PFD or IC? Any information would be greatly appreciated.
- Rachel Porter, birth doula
Send your responses to firstname.lastname@example.org with
"Question of the Week" in the subject line.
Question of the Week Responses
Q: Have you successfully delivered a baby when the mother has
a rectocele? I have a mild rectocele and am expecting my ninth baby. I am interested if there
is way to prevent it from worsening during pregnancy and especially during delivery.
A: I work as a midwife in the Philippines, and many women have rectoceles because
their tears have not been repaired. I have seen many babies born over a rectocele. During your
birth I would suggest a lot of breathing your baby down instead of pushing. When you do push
you may want your midwife to put two fingers in your vagina and press down gently on your push
button to give you an urge to push. Many women with rectoceles do not have an urge to push,
and that is one of the difficulties.
A: I'm an on/off student midwife, doula, and just gave birth to my third child, with
a fairly severe rectocele that I developed with pregnancy number two. Anecdotally, I can tell
you that with both my second and third pregnancy and birth it didn't cause any complications—
both births went very smoothly, and the pushing stage was quick. The only real issue I had,
and continue to have with my rectocele, is with bowel movements - having to "splint"
occasionally to help the stool out because the rectocele prevents complete evacuation.
As for remedies, I've been told that for severe rectoceles, surgery is really the only cure.
Midwives promote kegel exercises and also, after breastfeeding, with hormone changes,
supposedly a rectocele can get better. That hasn't been my experience although I have been
continuously breastfeeding for more than four years.
A: Having the same myself after only one baby, I commiserate. What has helped me the
most in general is walking and eating a high-fiber diet. Walking (10-30 minutes, 4-7 days per
week) helps those muscles regain tone. It doesn't "fix" the problem, but it does lessen the
impact. The fiber helps keep everything moving. When I think about birthing my next baby (in
a couple years), I expect I will want to give birth in an upright or forward-leaning position
to take stress off of that part of the perineum and help "aim" the baby better. If I feel I
need it, I will ask someone to put a warm compress over my anus and provide a little
counterpressure to keep things aimed right. We'll see!
- Jennifer Rosenberg
A: I suffered a rectocele in my first pregnancy and home birth. My pelvic floor was
torn about 50%. My son had been hung up somewhat in his long two-day labor and descent, and
when I stood up to pee one time, he changed position and his head came down very hard onto
the pelvic floor. My perineum was intact but I had pain for several weeks postpartum and
couldn't be on my feet for long without feeling pain. A check-up at four weeks revealed
that torn pelvic floor muscles were the source of pain. I did nothing and they healed over
time. I did find that I needed to keep my diet and water consumption in good form so that I
was not constipated, causing the feces and my rectal wall to protrude into my vagina like a
hernia. I did find that hormone levels during my cycles (when not pregnant) could make the
pelvic floor ache some months during my blood flow at times. My second pregnancy was 2 1/2
years later and I had absolutely no problems. I kept up a good diet and water consumption.
The labor was straightforward - about 8 hours total - delivery easy, I pushed two to three
times for delivery over an intact perineum again, and I had no pelvic floor pain afterward.
I still have the rectocele as a crone, but if diet and water consumption are good I have no
- Danette Condon, midwife, Marlinton, WV
More about pregnancy-induced itching [Issue 5:1]:
A: I had the same problem and got
results with oatmeal baths, to which I added about 6–8 drops of tea tree oil. I think my skin
stretching coupled with hard water in the shower was the culprit. When even bathing didn't
help, I used St. Ives lotion. I needed to use a thick layer of it two or three times a day,
but it really relieved the itching.
A: I am concerned about the diagnosis given by the doula to the woman with severe
itching. The woman didn't say she had a rash of papules or plaques, so calling it PUPPS is not
a good idea. It sounds a lot more like cholestasis if she doesn't have a rash, and that is
diagnosed with a blood test for liver enzymes and bile acids. A good summary of PUPPS is
Making a correct diagnosis is important because
PUPPS is benign and cholestasis of pregnancy presents some concerns.
- Lis Worcester, midwife, FNP, San Francisco
EDITOR'S NOTE: Please see Editor's Note 1/7/2005 under Question of the Week Responses in Issue 5:1.
EDITOR'S NOTE: Responses to any Question of the Week may be sent to E-News at any time.
Please indicate the topic of discussion in the subject line or in the message.
Midwifery Today magazine Question of the Quarter
Theme for Issue No. 66: Birth Environment
Question of the Quarter
What do you do to create a positive birth environment? In your experience, what have you seen
that disturbed or facilitated the birth environment?
Please submit your response by March 1, 2003 to
All responses subject to editing for space and style.)
With Woman by Gloria Lemay
Pregnancy is a time when mothers will make changes for the better in their lifestyles
that they might never even have attempted at any other time. All can be mastered for the
good of the baby when it is often impossible to do it for the good of ourselves, especially
in matters of nutrition. Women need practical, workable ideas for improving their diets:
avoid the temptation to cover too much in one sitting. Here's a script for a quick, potent
intervention that produces immediate results. Read it out loud several times:
Every day the following 3 items should be eaten:
- either a baked potato or a bowl of brown rice
- one piece of citrus fruit for vitamin C - e.g., 1/2 grapefruit, l orange, 2 kiwi, a whole
- a large bowl full of raw, green salad
When looking at food, ask yourself: How much has this been bleached, pounded, shredded,
processed, cooked, boiled? The goal is to make what you put in your mouth as close to what
Mother Nature put in the ground as possible. So if it's a potato, it's baked in its skin; if
it's a green vegetable, it's raw in a salad; if it's meat, it's broiled till cooked through
but not roasted to death.
Study nutrition, and remember to tailor your advice to the individual. Be sure to
acknowledge all the smart choices your clients make. The support and encouragement you
give to both mother and father in pregnancy can produce a lifetime of healthy habits.
Read about the Brewer diet here.
Gloria Lemay is a private birth attendant in Vancouver, British Columbia, and is a
contributing expert at BirthLove. Read more from Gloria on
"Pushing for First-Time Moms" on Midwifery Today's Web site.
Note: This article is also published online in French and Spanish.
Exclusively on the BirthLove site:
Gloria Lemay, celebrated midwife and teacher, is offering advanced online
doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes
simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and
professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all
BirthLove members. Check it out!
I am a mother of 9 beautiful children. I am also a labor nurse, and I was a doula for 13
years before I became an RN. My dream is to some day become a certified nurse midwife. I take
care of many patients who are misinformed about the major portion of labor. I would like to
know where to find information about laboring with epidurals, effects of epidurals on
breastfeeding, and so forth. Please let me know about resources that are out there for the
- Carole Jare
Concerning the lack of progress past 5 cm during a previous labour [Issue 5:01]: I
encourage you to consider the thoughts that were going through your mind leading up to that
time of your labour and then those you remember during the plateau period. If you discover
any thoughts that suggested that you should stop progressing (e.g., fears, concerns, worries
about yourself, the baby, your family circumstances, the situation of that labour), they would
be best addressed before the next labour starts. Hypnosis done either alone or guided by a
specialist might be helpful.
- Heather Mains, doula
I am an aspiring midwife and childbirth educator in New Brunswick, Canada, one of Canada's
provinces where midwifery remains unregulated. After much discussion and debate, I am
questioning whether or not to fight for regulation of/legislation for the practice of
midwifery because I do not believe it belongs within the medical system, something that
has happened in our regulated provinces. I would like to network with other women in the
province who can reach me by e-mailing me here.
- Amy Gow
I recently had a lot of pain in my symphisis. An X-ray showed new bone growing over the
pubic symphisis. He is not concerned, but I'm wondering if anyone has dealt with this. I have two children, both very large at birth - the second was 11+ pounds and born a year ago.
The pain just started a month ago. Besides using an anti-inflammatory, which my doctor
recommended, are there any other herbal remedies for pain?
EDITOR'S NOTE: Only letters sent to the E-News official e-mail address,
email@example.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.
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