Del Mar, Chris

O'Connor, Vivienne

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Should we stop telling well pregnant women to monitor fetal movements? How to use and interpret guidelines

[Extract] THE confusion articulated in the commentary by Hill-Smith1 is interesting on several levels. Is this an example of the mess that evidence-based medicine (EBM) can get us into? It certainly raises the thorny issue of how research conducted in one place and time could usefully assist us in clinical practice in another setting. It also calls into question what good guidelines should look like.Hill-Smith wonders whether we should ask women to routinely keep a fetal movement diary (‘kick chart’). The NICE (National Institute of Clinical Excellence) guidelines suggest not — kick charts make no difference to infant mortality.2 But there is a rider: one baby may be saved for every 1250 women routinely using kick charts. These two statements appear contradictory

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Bond UniversityResearch RepositoryShould we stop telling well pregnant women to monitor fetal movements? How to use andinterpret guidelinesDel Mar, Chris; O'Connor, ViviennePublished in:British Journal of General PracticePublished: 01/11/2004Document Version:Publisher's PDF, also known as Version of recordLink to publication in Bond University research repository.Recommended citation(APA):Del Mar, C., & O'Connor, V. (2004). Should we stop telling well pregnant women to monitor fetal movements?How to use and interpret guidelines. British Journal of General Practice, 54(508), 810-811.General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.For more information, or if you believe that this document breaches copyright, please contact the Bond University research repositorycoordinator.Download date: 06 Nov 2019Bond UniversityePublications@bondFaculty of Health Sciences & Medicine Publications Faculty of Health Sciences & MedicineNovember 2004Should we stop telling well pregnant women tomonitor fetal movements? How to use andinterpret guidelines.Chris Del MarBond University, chris_del_mar@bond.edu.auVivienne O'ConnorUniversity of QueenslandFollow this and additional works at: http://epublications.bond.edu.au/hsm_pubsThis Editorial is brought to you by the Faculty of Health Sciences & Medicine at ePublications@bond. It has been accepted for inclusion in Faculty ofHealth Sciences & Medicine Publications by an authorized administrator of ePublications@bond. For more information, please contact BondUniversity's Repository Coordinator.Recommended CitationDel Mar, Chris and O'Connor, Vivienne, "Should we stop telling well pregnant women to monitor fetal movements? How to use andinterpret guidelines." (2004). Faculty of Health Sciences & Medicine Publications. Paper 7.http://epublications.bond.edu.au/hsm_pubs/7Editorials810 British Journal of General Practice, November 2004Should we stop telling well pregnantwomen to monitor fetal movements? How to use and interpret guidelinesTHE confusion articulated in the commentary by Hill-Smith1 is interesting on several levels. Is this an exampleof the mess that evidence-based medicine (EBM) can get usinto? It certainly raises the thorny issue of how research con-ducted in one place and time could usefully assist us in clin-ical practice in another setting. It also calls into questionwhat good guidelines should look like. Hill-Smith wonders whether we should ask women to rou-tinely keep a fetal movement diary (‘kick chart’). The NICE(National Institute of Clinical Excellence) guidelines suggestnot — kick charts make no difference to infant mortality.2 Butthere is a rider: one baby may be saved for every 1250women routinely using kick charts. These two statementsappear contradictory.To understand them we have to go back past the NICEguidelines and read the original trial on which they arebased, published in The Lancet 15 years ago.3 It was a wellconducted multicentre study in the United Kingdom (UK),United States (US), Ireland, Sweden, and Belgium of 68 654women in a cluster randomised trial in which 33 clusters (atotal of 31 993 women) were randomised to keep routinekick charts, and 33 clusters (of 36 661 women) were not.The principal outcome was unexplained late fetal death.There were 59 fetal deaths in the kick chart groups com-pared with 58 in the controls, which can be expressed as 2.9per 1000 births for the formal counting compared with 2.7 forthe controls. No differences were significant. So far it seemspretty clear that formal movement charts confer no benefit. So where does the 1:1250 babies saved come from? Itcomes from the lower 95% confidence interval for the estimateof odds for the intervention groups compared with the control.The explanation between these apparently incompatible state-ments represents the gap between ‘no evidence of effect’ and‘evidence of no effect’ — not the same thing by any means. There are other considerations. Would pregnant womenagree that it is worth undertaking a non-invasive test if itsaved one baby in 1250? This is a question of values, a‘what is it worth?’ question. We suspect that most womenwould say they would willingly invest the time. But not nec-essarily all. How many would in practice? The Lancet trialpartly answers this: only about 50% of those women whosebabies died had made use of the kick charts.3But then, what should be done if women report decreasedfetal movements even if not asked to do so? The NICE guide-lines suggest that they should report to their midwife or hos-pital (another apparent contradiction). What then? Of the 17women randomised to kick charts who did sound the alarmbecause of decreased movements and went on to have still-born babies, none had an emergency delivery: every one wasgiven false reassurance (as it turned out) following diagnostictesting (principally cardiotocography).2 We now know thatcardiotocography has unacceptably high false-positive rates,insufficient for its use antenatally for fetal assessment.4 Buttimes have changed. There are now other methods to assessfetal wellbeing (including biophysical profile and Dopplerultrasound of umbilical arterial flow) although even these havenot been helpful in the low-risk population.5 Perhaps the inter-vention failed not because of the insensitivity of women todecreased fetal movements, but because of inadequacies inthe next stage of the clinical pathway. If this is the case, thenwe might expect things to improve if and when effective testsfor fetal wellbeing are developed — presumably the hope onwhich this NICE recommendation is based. Hill-Smith’s careful analysis of the NICE guidelines showhow hard they are to use. In particular, the apparent contra-dictions are likely to confuse clinicians. What would makethem easier? Perhaps guidelines should adhere better to thedefinition ‘systematised review of the evidence’6 (rather thanto inconsistent recipe-like instruction), enabling us to decidehow good the information is, and giving us the flexibility toadapt the information for an individual patient — even at thecost of making us have to work it out. Finally, how is the world reacting to this information? Arefetal wellbeing kick charts being abandoned wholesale foruncomplicated pregnancy across the globe? A quick look atthe repository at The National Guideline Clearinghouse in theUS (www.guideline.gov) yielded 19 hits for ‘fetal movements’,of which two guidelines were still recommending them for nor-mal pregnancy. Clearly — as the trial was published so longago — the information can be interpreted very differently!And for the future, although the intervention might be help-ful one day, the problem area is with finding the appropriatemode to further evaluate the fetus. Perhaps a Cochrane pro-tocol under development might throw further light on the cur-rent situation by evaluating any newer studies.7 Or perhaps itis timely to review all the current methods developed toassess fetal wellbeing. Perhaps a fresh new study is required.CHRIS DEL MAR, Dean Health Science and Medicine, Bond University, Gold Coast, AustraliaVIVIENNE O’CONNORSenior Lecturer in Obstetrics and Gynaecology, University of Queensland, Mater Hospital, Brisbane, AustraliaReferences1. Hill-Smith I. Professional and patient perspectives of NICEguidelines to abandon maternal monitoring of fetal movements. Br J Gen Pract 2004; 54: 858-861.2. National Institute for Clinical Effectiveness. CG6 — Antenatal care— Routine care for health pregnant women, full guideline.www.nice.org.uk/page.aspx?o=93992 (accessed 8 Oct 2004).3. Grant A, Elbourne D, Valentin L, Alexander S. Routine formal fetalmovement counting and risk of antepartum late death in normallyformed singletons. Lancet 1989; 2(8659): 345-349.4. Pattison N, McCowan L. Cardiotocography for antepartum fetalEditorialsBritish Journal of General Practice, November 2004 811assessment (Cochrane Review). The Cochrane Library, Issue 3.Chichester: John Wiley & Sons Ltd, 2004.5. Chan FY, Shub A. Assessment of fetal well being. In: O’Connor V,Kovacs G (eds). Obstetrics, gynaecology and women’s health.Cambridge: Cambridge University Press, 2003.6. Jackson R, Feder G. Guidelines for clinical guidelines. BMJ 1998;317(7156): 427-428.7. Mangesi L, Hofmeyr GJ. Fetal movement counting for assessmentof fetal well-being (Protocol for a Cochrane Review). The CochraneLibrary, Issue 3. Chichester: John Wiley & Sons Ltd, 2004.Address for correspondenceChris Del Mar, Dean Health Science and Medicine, Bond University,Gold Coast, 4299 Queensland, Australia.E-mail: cdelmar@bond.edu.au 

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Should we stop telling well pregnant women to monitor fetal movements? How to use and interpret guidelines

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