kdSRRMAL MOVEMEN AND THEIR RELATIONSH A PILOT TRIAL ■ by S H Irwin-Carruthers Introduction Stu d ies o f fetal m ov em en t pat­ terns have proliferated in the last dec­ ade, the m ost authoritative of these studies having been carried out in the N etherlands.1,2,3 Studies to date can be divided into three categories: • quantitative approaches w ith the aim of m onitoring fetal viability • qualitative studies w ith the aim of classify ing fetal m ovem ent pat­ terns and analysing their develop­ m ental course • studies of fetal biorhythm s and b e ­ havioural states. So far there are no published cross- cultural studies of fetal m ovem ent. De V ries, Visser and Prechtl (1984), classify fetal m ovem ents into 16 cate­ gories, ranging from prim itive m ove­ m ents such as startles and jum ps, through locom otive and propulsive m ovem ents to isolated limb m ove­ m ents.1 Their classification of m ove­ m ents correlates w ell w ith m ov e­ m e n ts d e s c rib e d in e a r lie r stu d ­ ies4,5,6, although the age of onset was often found to be earlier. This could be due to the longer observation time in the latest study, coupled with the use of vid eo -record in gs w hich al­ lowed review of m ovem ents. 3 7 0 9 Several authors ' ' ' d e s c r ib e a specific sequence of em ergence of in­ creasingly selective and com plex pat­ terns of m ovem ent, m ost m ovem ents rem aining consistent in pattern once established. Fetal orientation has also been reported to show developm en- 1 3tal trends ' . Changes in position in­ crease in num ber from 1 -15 weeks, thereafter decreasing in response to the confines which the uterus im ­ poses on the grow ing fetus1. Although d iu m al variations in fe­ tal m ovem ent occur from about 20 w eeks' gestation10, true behavioural states are not found until after 36 w eeks11,12. Pillai and Jam es (1990) found that behavioural states I F and 2F in the full term fetus were com pa­ rable to states S I and S2 in the new ­ born, but did not find any other cor­ relations13. Prechtl (1985) considers that fetal m ovem ent patterns are closely re­ lated to patterns seen in the neonatal n period and in early developm ent . The com plexity of patterns already seen at 20 w eeks' gestation, when the m orphological developm ent of the nervous system is very incom plete, is explained by Touw en (1989)14. He postulates that the generation of m o ­ tor patterns is a prim ary function of the central nervous system even at a very low stage of developm ent, and that this is utilised post-natally when patterns developed in utero becom e linked to specific afferent inform a­ tion in the acquisition of m otor con­ trol and adaptive functions. Only one study has been traced which com pared fetal m ovem ent to m otor activity in the neonatal pe­ rio d 15. In this study 51 patients h os­ pitalised for com plications of preg­ nancy recorded fetal m ovem ents for one hour, twice daily. It is stated that no factors known to affect fetal m ove­ m ent were present in any of the sub­ jects. All infants w ere born healthy and no correlation was found be- SUMMARY The aim of the study was to investigate the relationship between fetal movement and neonatal behaviour, as well as to compare the fetal movement patterns and neonatal competencies of black and white infants. The sample for the pilot trial consisted of 12 mothers and their infants, selected at between 10 and 12 weeks of gestational age. The black sample and part of the white sample was drawn from the low-risk population attending the booking clinic of St Monica’s Hospital; the rest of the white mothers were drawn from the private sec­ tor. Nine mothers satisfied the criteria throughout the trial. Two had to be ex­ cluded when their pregnancies were ter­ minated and a third was excluded due to epilepsy. Fetal movement was recorded by ultra­ sound scanning at 20/52 gestational age, recorded on videotape. All infants were born at full term by normal vertex delivery. The Brazelton neonatal behavioural as­ sessment scale (BNBAS) was performed between 12 and 36 hours post-birth. This assessment was also videotaped. • Test-retest reliability for counting and classifying fetal movements was estab­ lished at 99,45 (SF=1.05). Sequential and isolated movements predominated and the proportion of sequential and isolated movements was related to the total num­ ber of fetal movements. Higher FM scores were also related to more optimal scores on the BNBAS in the neonatal period. The black infants tended to show more mature patterns of fetal movement that the white infants. The black infants also scored bet­ ter on the BNBAS in relation to optimal postural tone, motor maturity and good orientation/alertness. The number of sub­ jects in the pilot trial was too small for statistical analysis, but the results justify ^ continuation of the main trial._________y tween m ean fetal m ovem ent scores and neonatal perform ance on a par­ tial (sic) Brazelton neonatal behav­ ioural assessm ent (BN BA S). There were, how ever, several design faults inherent in this study. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) A further study16 show ed an asso­ ciation betw een the pre- natal rate of habituation to vibrotactile stim ula­ tion and autonom ic stability m eas­ ured with the BN BA S, the fast habi- tuators scoring low er on autonom ic stability post-birth. If the num ber and pattern of fetal m ovem ents can be related to neona­ tal com petency and early m otor de­ velopm ent, im proved know ledge of fetal m ovem ent w ill provide a better basis for identifying infants at risk for developm ental disability. At the sam e tim e this study will c o n trib u te to w ard s fo rm u la tin g a stan d ard ised classificatio n o f fetal m ovem ents, the need for which has been identified by de Vries et al (1982) and Cintas (1987)2'17. W hen evaluating infants for devel­ opm ental delay or signs of cerebral m otor disturbance a sound know l­ edge of the developm ental norm s for the population concerned is essen­ tial. C o n flictin g e v id en ce for and again st ad v anced d ev elo p m en t in black A frican infants has been pub­ lished for over 50 years. Early reports defects in design and m easurem ent, and in p articu lar for the fact that com parisons have been m ade with test norm s established in other coun­ tries instead o f by com paring sam - 2 2 23pies w ithin an A frican country ' . A recent study of W estern Cape infants24'25 involved 681 black and 741 w hite infants, and found South African urban infants to be in ad­ v a n ce o f A m e ric a n in fa n ts w h en tested on the D enver D evelopm ental Screening Test (D D ST)26. Som e sig­ nificant differences in m otor devel­ opm ent w ere also found betw een the black infants and the w hite infants, particularly during the first year of life. D ifferences in m otor abilities ap­ peared to be partially due to child handling practices, supporting the v ie w s o f s o m e e a r lie r r e s e a r c h ­ ers27-28'29'30. The differences in han­ dling practices w ere, how ever, insuf­ ficient to account for the advanced m otor behaviour of the black infants early in the first year of life, support- o i o n O O ing the view s of other w orkers ' ' that the genetic factors may play a role. Should this be so, differences in fetal m ovem ent and neonatal behav­ iour may be expected. The aim of this study is therefore two-fold: • to investigate the relationship b e ­ tween fetal m ovem ent and neona­ tal behaviour • to com pare the fetal m ovem ent patterns and neonatal com peten­ cies o f black and w hite infants. Subjects and method The sam ple for the pilot trial con­ sisted of 12 m others and their infants, selected at betw een 10 and 12 weeks of gestational age. Initial exclusions included m oth­ ers who were aged less than 18 years or m ore than 37 years at the time of conception, those w ith a history of previous caesarian section, perinatal death or pre-eclam psia, know n h e ­ reditary disease, m aternal m alnour- ishm ent, acknow ledge drinkers or sm o k ers, u n m arried m o th ers and those living outside the greater Cape Tow n area. The black sam ple and part of the white sam ple was drawn from the lo w -risk p op ulation attend ing the booking clinic at St M onica's H ospi­ tal; the rest of the white m others were draw n from the private sector. In both groups the first five consecutive mothers satisfying the criteria were accepted. O f the initial 10 m others, two (#1 and #10) had to be excluded w hen their pregnancies had to be ter­ m inated; a further two m others were thus taken into the sample. O ne other m other (#6) had to be excluded due to epilepsy, leaving four black and five w hite m others in the sample. Fetal m ovem ent studies consisted o f so nar scanning at 20/52 gesta­ tional age, recorded on videotape. The scanner used w as an Aloka Echo Cam era M odel SSD -650 w ith convex sector scanner operating at 3,5M H z across 60 degrees. M easurem ents of b ip a rie ta l d iam eter, fem u r le n g th and abdom inal circum ference w ere taken in order to confirm the gesta­ tional age. W ith the m other lying su­ pine, the transducer was then posi­ tioned p arallel to the long axis of the vertebral colum n of the fetus and was held stationary for the duration of the 30 m inute recording, unless the fetus changed its orientation in the uterus (in w hich case the transducer was tu rn e d u n til the fe tu s w as again view ed in sagittal or p arasagittal sec­ tion). A ll recordings w ere m ade b e­ tw een 16h00 and 18h00. Three videotape recordings were m ade on other fetuses at 20 w eeks, under the sam e conditions, in order to establish test-retest reliability for n u m b er and c la ssifica tio n of fetal m ovem ents. R eliab ility w as estab­ lished at 99,45 (SE=1,05) using a Pear­ son correlation coefficient. It w as originally intended to com ­ pare the FH R during periods of gen­ tle and m ore forceful m ovem ent, but w ith the apparatus available it was im possible to record FH R accurately during forceful m ovem ent. During gentle m ovem ent the m ean FH R was 125. T h e B ra z e lto n n e o n a ta l beh av-. io ural assessm ent (B N B A S)34 w as perform ed betw een 12 and 36 hours post-birth, in the neonatal nursery at St M o nica's H ospital or in a private ward in the case o f infants born else­ w h ere. T h is a ss e s s m e n t w as also video recorded. Results C haracteristics o f th e m others The m ean age of the m others at tim e of conception w as 25 years 6 m onths, w ith a range of 20-31. Fifty percent of the m others w ere prim i- gravidas. In all cases except one the foetal m easu rem ents corresponded w ith the gestational age calculated from the last m enstrual period; the m ean gestational age at the tim e of the sonar studies w as 20,2, with a range of 19,4-20,6. The average educational level was standard 10 (range 7-4 year degree) and the fathers' occupations all fell R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) into the so-called b lu e-or W h ite-collar categories. A ll m others w ere non-sm okers. Characteristics of the infants A ll infants w ere born at term by norm al vertex delivery. Duration of labour ranged from 6hr 10 m in to l l h r 35min. There w ere no perinatal com plications and all infants had a five m inute A pgar score of 9. One infant had slight evidence of am niotic bands around one ankle, with no lim itation of m ovem ent. Fetal m ovem ent studies Since studies reported in the literature had found quiet periods during recordings, the period of each recording was divided into 3-m inute w indow s and, in addition to num ber and type of m ovem ent, the strength of m ovem ent was noted as being gentle, forceful or forceful with change of position. H ow ever, no em pty w indow s w ere found in any of the recordings, m ost w indow s containing m ove­ m ents of different strength. Type 3 m ovem ents (forceful with change of position) were also not limited to windows in which a large num ber of m ovem ents were recorded. The final analysis was therefore carried out over the full 30 m inute period. The average total num ber of fetal m ovem ents over the thirty m inute period was 237,88, ranging from 160 to 316. TABLE I: CLASSIFICATION OF FETAL M O V E M E N T TYPE AT 2 0 WEEK GESTATIONAL AGE FM TYPE FETUSES 2 3 4 5 7 8 9 11 12 Startles 4 4 1 4 1 Wriggles 27 45 4 0 3 0 18 29 3 0 35 27 Twitches 17 6 7 3 0 44 37 19 31 16 Clonus 2 5 3 2 Jumping 17 35 39 14 2 0 18 12 10 14 Creeping 7 5 11 2 14 4 3 18 9 Stretching 6 4 3 4 5 Arm movements 24 29 2 8 16 2 2 42 50 4 28 Finger movements 4 2 7 1 3 5 3 • . Hand-to-face 4 8 2 7 2 8 Leg Movements 48 4 0 43 47 1 2 0 53 74 37 65 Foot movements 7 1 3 11 3 14 2 Hond-to-foot 9 1 Retroflexion head 11 2 5 2 0 9 10 16 10 4 23 Anteflexion head 5 6 6 2 2 7 7 9 11 Rotation head 22 2 6 22 12 15 17 19 9 23 Rotation fetus 8 6 7 4 9 6 3 2 7 Somersault 1 3 4 1 Breathing 4 7 5 2 4 1 1 5 Unclassified 3 11 2 6 14 3 TOTAL 2 1 8 2 5 5 2 6 3 1 8 0 3 1 6 251 2 5 5 16 0 2 4 3 M ovem ents w ere classified according to the scheme proposed by de Vries, Visser and Prechtl1 but it was found necessary to add two further types of m ovem ent - isolated foot m ovem ents and hands-to-feet. The incidence of the different types of m ovem ent is show n in Table I. For the purpose of analysis, the individual item s w ere grouped into four clusters - those reflecting im m aturity (startles, w riggles, twitches and clonus), those reflecting locom otion and propulsion (jumping, creeping and stretching), se­ quential and/or isolated m ovem ents (arm, fingers, hand- to-face, leg, foot, hand-to-foot) and head/trunk m ov e­ m ents w hich are the precu rso rs of rig hting reactions (retroflexion, anteversion or rotation o f the head; rotation of the fetus, somersault) (Table II). H iccups, breathing, sucking, sw allow ing and yaw ning w ere excluded from the analysis and a few m ovem ents defied classification. TABLE II: CLUSTERED F M TYPES AT 2 0 WEEK GESTATION Fetus Imm Loco Seg/isol Pre-fight Unclass Breath TOTAL 2 4 8 3 0 87 4 6 3 4 2 1 8 3 57 44 72 64 11 7 2 5 5 4 47 53 9 8 58 2 5 2 6 3 5 65 16 64 27 6 2 1 8 0 7 66 34 158 4 0 14 4 3 1 6 8 6 8 2 6 1 1 0 4 6 - 1 251 9 53 2 0 - 1 43 39 2 5 5 11 66 2 8 41 24 1 1 60 12 44 2 3 1 0 3 65 3 5 2 4 3 TOTAL 5 14 2 7 4 8 7 6 4 0 9 3 9 2 9 2 14 1 TABLE III: F M TYPE AS A PROPORTION OF F M M e a n /3 0 min % Immature movements 5 7 ,1 1 2 4 ,3 4 Loco/propulsion 3 0 ,4 4 1 2 ,9 7 Seguential/isol 9 7 ,3 3 4 1 , 4 8 Pre-righting 4 5 ,4 4 1 9 ,3 6 Unclassified 4 ,3 3 1 ,8 5 TOTAL 1 0 0 W hen expressed as a percentage of total m ovem ents (Table III), it is obvious that sequential and isolated m ov e­ m ents predom inate a 20 w eeks' gestation. The percentage of sequential and isolated m ovem ents also appear related to the total num ber of fetal m ovem ents (Fig 1). ■ 3 16 ■255 ■263 ■255 ■ 243 ■218 " 1 6 0 ■180 10 15 20 25 30 35 40 45 50 55 60 P E RC ENTAG E S/I M O V E M E N T S Figure l : Relationship b e tw e e n s e q u e n tia l/is o la te d F M an d to ta l F M a t 2 0 w e e k s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ gestation_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Neonatal studies The BN BA S scoring is m ore difficult to analyse as, al­ though m ost item s are scored on a scale of 1 -9 , the optim al score is not the sam e for all item s (Table IV). For the purpose of analysis, item s have again been clustered in related item s. The groupings are tone (item 11), habitu­ ation (item s 1,2,3,4), o rien tatio n and alertn ess (item s 5 , 6 , 7 , 8 , 9 , 1 0 , 1 6 ) , m o t o r m a t u r it y (ite m s 12,13,14,15,25,26,27), m otor im m aturity (items 21,22) and em otional responses (item s 17,18,19,24). TABLE IV: BRAZELTCIN NEONATAL BEHAVIOURAL A SSESSM ENT SCALE SCORES Tone M ot.M ot. M ot.lm m . Orient/AI Resp.Dec Emot.Res Optimum 5-6 9 < 5 9 > 5 < 5 2 6 8 ,4 2 3 ,0 0 8 ,4 2 6 ,2 5 3 ,0 0 3 5 8 ,0 0 3 ,0 0 7,71 7 ,7 5 4 ,0 0 4 6 7 ,1 4 3 ,0 0 8 ,5 7 7 ,2 5 2 ,0 0 5 7 4 ,1 2 4 ,0 0 3 ,3 7 6 ,5 0 4 ,2 5 7 6 6 ,2 0 7 ,0 0 5 ,4 3 4 ,5 0 5 ,6 7 8 6 5 ,1 4 3 ,5 0 7,71 6 ,7 5 4 ,0 0 9 6 7 ,4 0 3 ,0 0 6,71 6 .7 5 1 ,0 0 11 4 4 ,0 0 4 ,5 0 3 ,5 7 6 ,2 5 4 ,2 5 12 6 4 ,8 0 4 ,0 0 6 ,5 7 5 ,5 0 4 ,0 0 Fetal m ovem ent c/f BNB AS scores Com parison of the fetal m ovem ent and BNBAS scores (Figs 2 and 3) show s a pattern in w hich higher total FM scores are related to m ore optim al BN BA S scores, whereas low FM scores are associated w ith less optim al BNBA S scores, in p articular w ith poor p ostural tone (high or low )(infants #5 and #11). In addition, a predom inance of m ore m ature types of fetal m ovem ent at 20 weeks appears to be associated in m ost instances w ith m ore optim al BNBA S scores. Figure 2 : Total F M a l 2 0 w e e k g estatio n com pared w ith m o to r m atu rity on the BNBAS C om parative perform ances of black c/f w hite infants A lthough the num bers are sm all, Table V show s a ten­ dency to fewer im m ature fetal m ovem ents and m ore m a­ ture patterns of fetal m ovem ent am ong the black fetuses. Figure 3 : Totol F M at 2 0 w e e k g e s tatio n co m p ared w ith o rie n ta tio n /a le rtn e s s on the BNBAS Com parative analysis of the BN BA S scores show s that the black infants were m ore inclined than the w hite infants to have optim al postural tone, a high degree of m otor m aturity and good orientation/alertness. They could also keep them selves calm , show ing stable em otional respon­ ses and a good response decrem ent to afferent stim uli. TABLE V: COMPARISON OF B U C K AND W H IT E IN FANTS U S IN G M EA N SCORES Black (n = 4 ) White