Reduced Fetal Movements Research Articles

Continuous objective recording of fetal heart rate and fetal movements could reliably identify fetal compromise, which could reduce stillbirth rates by facilitating timely management

Stillbirth currently affects approximately 1 in every 200 pregnancies in the United Kingdom. Fetuses may exhibit signs of compromise as part of a stress response before stillbirth, including reduced fetal movements (RFM) and fetal heart rate (FHR) alterations. At present, and despite widespread use, current fetal monitoring is not associated with a reduction in perinatal mortality rate (PMR) as signs of fetal compromise are not adequately detected. This may be attributed to inaccuracies resulting from manual interpretation of results or subjective assessment of fetal activity. In addition, signs of compromise often occur only hours or days before fetal death, so may be missed by current monitoring methods, which are performed intermittently. A significant consideration is that correct identification of these signs and consequent intervention can result in the delivery of a healthy baby, thus preventing stillbirth. A hypothesis is presented, proposing prompt detection of fetal compromise with the use of 24-hour continuous objective fetal monitoring. With focus placed on obtaining long-term FHR and fetal movement data, prior interest has been found in developing devices for this purpose. However, introduction into clinical practice has not been achieved. Investigation of the hypothesis will begin with the design of a device to record the mentioned parameters, followed by an appropriate validation process. Should development and testing be successful, an eventual comparison in PMR with the use of continuous fetal monitoring vs current monitoring would address the hypothesis. It is suggested that a timely yet reliable indication of fetal wellbeing obtained via long-term monitoring would allow prompt and appropriate obstetric intervention and consequently reduce PMR.

Pregnancy outcomes with a primary complaint of perception of reduced fetal movements

Reduced fetal movement is a worrisome common complaint, not only for mothers but also for the attending medical personnel. The aim of this study was to analyse the pregnancy outcomes of women who presented primarily with reduced fetal movements (RFM). A retrospective study was performed based on patients’ perception alone. Obstetric, past medical history, current presentation and outcomes of pregnancy were analysed. A total of 230 case notes were reviewed, with the majority being primigravidae. Less than half (48.7%) of the women had spontaneous labour, 45.7% had induction and 5.6% had elective caesarean section. There were no maternal complications in 97.4% (n = 224) of them. About 0.9% (n = 2) and 1.7% (n = 4) had primary postpartum haemorrhage and extended perineal tear, respectively. Although there was no major neonatal mortality and morbidity, until a randomised trial with a significant sample is conducted in the management of RFM, careful selections for elective delivery or conservative management would prevent untoward complications.

Studies on the teratogenicity of anabasine in a rat model

A number of plant toxins have been shown to be teratogenic to livestock. The teratogenic action of some of these alkaloids is mediated by nicotinic acetylcholine receptors (nAChR). However, for many of these alkaloids it is difficult to obtain sufficient quantities of individual alkaloids to perform teratology studies in livestock species. Therefore the objective of this study was to determine if a rat model can be utilized to characterize the teratogenic nature of individual plant toxins that are nAChR agonists. In this study, we evaluated the teratogenicity of anabasine by feeding pregnant rats anabasine-containing rodent chow from gestational day (GD) 6–21. On GD21, the dams were euthanized and the gravid uteri were removed. The gravid uteri and individual pups were weighed. The pups were evaluated for bone malformations including cleft palate and scoliosis. Overall, the results of this study suggest that the rat is not a good model to study the teratogenicity of plant toxins that are nAChR agonists. It is possible that in the rat model, anabasine administered orally via the chow may not result in sufficient reduction in fetal movement to cause the significant malformations observed in livestock species.

PPO.54 Reduced Fetal Movements (RFM) at Term – are we getting it right?

BackgroundRFM is associated with increased risk of stillbirth and small for gestational age babies.1,2 Notwithstanding the Royal College of Obstetricians and Gynaecologists’ guidelines, clinical practice varies due to individual circumstances...

Circulating cytokines and alarmins associated with placental inflammation in high-risk pregnancies.

ProblemInflammation during pregnancy has devastating consequences for the placenta and fetus. These events are incompletely understood, thereby hampering screening and treatment.Method of studyThe inflammatory profile of villous tissue was studied in pregnancies at high-risk of placental dysfunction and compared to uncomplicated pregnancies. The systemic inflammatory profile was assessed in matched maternal serum samples in cases of reduced fetal movements (RFM).ResultsPlacentas from RFM pregnancies had a unique inflammatory profile characterized by increased interleukin (IL)-1 receptor antagonist and decreased IL-10 expression, concomitant with increased numbers of placental macrophages. This aberrant cytokine profile was evident in maternal serum in RFM, as were increased levels of alarmins (uric acid, HMGB1, cell-free fetal DNA).ConclusionThis distinct inflammatory profile at the maternal-fetal interface, mirrored in maternal serum, could represent biomarkers of placental inflammation and could offer novel therapeutic options to protect the placenta and fetus from an adverse maternal environment.

Association between reduced fetal movements at term and abnormal uterine artery Doppler indices

To evaluate the association between second-trimester uterine artery (UtA) Doppler pulsatility index (PI) with reduced fetal movements (RFM) and adverse pregnancy outcome at term. This was a retrospective cohort study of all singleton pregnancies referred for routine antenatal care at a fetal medicine unit over a 5-year period. UtA Doppler indices were obtained at the time of the routine anomaly scan between 19 and 23 weeks' gestation to assess the risk for pre-eclampsia. All episodes of RFM within 1 month of the expected date of delivery were recorded. Regression and sensitivity analyses were used to assess the relationship between UtA-PI with RFM, small-for-gestational-age (SGA) fetuses and stillbirth after 36 weeks' gestation. Overall, 17, 649 pregnancies were included in the analysis, of which 742 presented with RFM, 1494 gave birth to an SGA newborn and 53 were complicated by stillbirth after 36 weeks' gestation. Logistic regression analysis showed a significant and independent association between UtA-PI and RFM (odds ratio (OR), 5.03 (95% CI, 4.21-6.01); P < 0.001), SGA (OR 2.41 (95% CI, 2.09-2.79); P < 0.001) and stillbirth (OR 1.55 (95% CI, 1.21-1.98); P< 0.001). The association between UtA-PI and SGA was significantly stronger in women presenting with RFM than in the rest of the cohort (P < 0.001). Similarly the association between UtA-PI and RFM was significantly stronger in those pregnancies complicated by stillbirth (P < 0.001). Compared with normal pregnancies, those complicated by RFM, SGA and stillbirth at term had higher UtA-PI at 19-23 weeks' gestation. These findings support the assertion that RFM at term is independently related to placental dysfunction and subsequent risk for SGA and stillbirth.

MANAGEMENT OF REDUCED FETAL MOVEMENTS

Reduced fetal movement (RFM) is commonly defined as any reduction in maternal perception of fetal activity. Perceived fetal activity may be movement of limbs, trunk or head movement, but excludes fetal hiccoughs (as this is involuntary movement). The perception of fetal movement by an expectant mother is the first, and ongoing, non-sonographic indicator of fetal viability. The “normal” pattern of fetal movements varies from pregnancy to pregnancy, and often does not become established until 28 weeks’ gestation. Many babies have particularly active periods of the day, usually corresponding to periods of maternal rest and inactivity (which may in itself reflect increased maternal awareness of fetal movement). A variable percentage of sonographically observed fetal movements are perceived by prospective mothers (commonly 30–40%, although some studies report rates as high as 80%).

A randomised controlled trial comparing standard or intensive management of reduced fetal movements after 36 weeks gestation-a feasibility study

BackgroundWomen presenting with reduced fetal movements (RFM) in the third trimester are at increased risk of stillbirth or fetal growth restriction. These outcomes after RFM are related to smaller fetal size on ultrasound scan, oligohydramnios and lower human placental lactogen (hPL) in maternal serum. We performed this study to address whether a randomised controlled trial (RCT) of the management of RFM was feasible with regard to: i) maternal recruitment and retention ii) patient acceptability, iii) adherence to protocol. Additionally, we aimed to confirm the prevalence of poor perinatal outcomes defined as: stillbirth, birthweight <10th centile, umbilical arterial pH <7.1 or unexpected admission to the neonatal intensive care unit.MethodsWomen with RFM ≥36 weeks gestation were invited to participate in a RCT comparing standard management (ultrasound scan if indicated, induction of labour (IOL) based on consultant decision) with intensive management (ultrasound scan, maternal serum hPL, IOL if either result was abnormal). Anxiety was assessed by state-trait anxiety index (STAI) before and after investigations for RFM. Rates of protocol compliance and IOL for RFM were calculated. Participant views were assessed by questionnaires.Results137 women were approached, 120 (88%) participated, 60 in each group, 2 women in the standard group did not complete the study. 20% of participants had a poor perinatal outcome. All women in the intensive group had ultrasound assessment of fetal size and liquor volume vs. 97% in the standard group. 50% of the intensive group had IOL for abnormal scan or low hPL after RFM vs. 26% of controls (p < 0.01). STAI reduced for all women after investigations, but this reduction was greater in the standard group (p = 0.02). Participants had positive views about their involvement in the study.ConclusionAn RCT of management of RFM is feasible with a low rate of attrition. Investigations decrease maternal anxiety. Participants in the intensive group were more likely to have IOL for RFM. Further work is required to determine the likely level of intervention in the standard care arm in multiple centres, to develop additional placental biomarkers and to confirm that the composite outcome is valid.Trial registrationISRCTN07944306

PP.67 Survey of Current Management of Reduced Fetal Movements in Scotland

Maternal perception of fetal movements is the oldest and most commonly used method to evaluate fetal wellbeing. The investigation and management of reduced fetal movements (RFM) is complicated by a...

PP.66 An Audit of Reduced Fetal Movements in a District General Hospital in Lanarkshire

BackgroundFetal movements are perceived as a sign of a fetal wellbeing, with reduced fetal movements (RFM) associated with poor perinatal outcome. Antenatal investigation of RFM aims to exclude fetal death...

PP.35 A Feasibility Study For a Randomised Controlled Trial of Management of Reduced Fetal Movements After 36 Weeks Gestation

ObjectivePoor perinatal outcome after reduced fetal movements (RFM) is related to smaller fetal size on ultrasound scan, oligohydramnios and lower human placental lactogen (hPL) in maternal serum. We performed a...

Inflammation as a cause of placental dysfunction in high-risk pregnancies

Event Abstract Back to Event Inflammation as a cause of placental dysfunction in high-risk pregnancies Sylvie Girard1, 2*, Alexander E. Heazell1, Hayley Derricott1, Colin P. Sibley1, Stuart M. Allan2 and Rebecca L. Jones1 1 University of Manchester, Maternal and Fetal Health Research Centre, United Kingdom 2 University of Manchester, Faculty of Life Sciences, United Kingdom Inflammation during pregnancy is associated with stillbirth and life-long diseases in surviving newborns. The mechanism underlying this association is mostly unknown. We hypothesize that cytokines induce placental dysfunction, resulting in fetal nutrient/oxygen deprivation. To test this hypothesis we determined the inflammatory profile in human placentas from high-risk pregnancy associated with reduced fetal movements (RFM) and investigated the effects of identified cytokines on placental function. Methods: Term placentas were collected from women experiencing RFM and compared with uncomplicated pregnancies. ELISA and immunohistochemistry were used to determine cytokine levels in placental lysates and assess their localization respectively. Placental explants from normal pregnancies were treated with interleukin (IL)-1β and the effects on inflammation, hormone production and cell turnover were determined. Results: Levels of IL-1β and IL-1 receptor antagonist (IL-1Ra) were increased in RFM pregnancies, while levels of IL-6 and TNF-α remained unchanged. Placentas from pregnancies with RFM also showed a decreased expression of IL-10, suggesting a pro-inflammatory imbalance within the tissue. RFM placentas also had elevated numbers of CD45+ cells within placental parenchyma, which were highly positive for IL-1Ra. Treatment of placental explants with IL-1β led to decreased secretion of hormone (hCG) and immune activation. Conclusion: This study identifies a pro-inflammatory profile in high-risk pregnancies associated with RFM, characterized by a predominant involvement of the IL-1 system and decreased anti-inflammatory IL-10. IL-1β-treated placental explants showed altered function. These results emphasize the importance of inflammation-induced placental dysfunction in human high-risk pregnancies and subsequent fetal mortality and morbidity. Acknowledgements The authors would like to acknowledge funding from Tommy's the baby charity and the Canadian Institute of Health Research. Keywords: Placenta, prenatal inflammation, IL-1beta, Placental dysfunction, IL-1 receptor antagonist, High risk pregnancy Conference: 15th International Congress of Immunology (ICI), Milan, Italy, 22 Aug - 27 Aug, 2013. Presentation Type: Abstract Topic: Translational immunology and immune intervention Citation: Girard S, Heazell AE, Derricott H, Sibley CP, Allan SM and Jones RL (2013). Inflammation as a cause of placental dysfunction in high-risk pregnancies. Front. Immunol. Conference Abstract: 15th International Congress of Immunology (ICI). doi: 10.3389/conf.fimmu.2013.02.00066 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 08 Mar 2013; Published Online: 22 Aug 2013. * Correspondence: Dr. Sylvie Girard, University of Manchester, Maternal and Fetal Health Research Centre, Manchester, United Kingdom, sylvie.girard@recherche-ste-justine.qc.ca Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Sylvie Girard Alexander E Heazell Hayley Derricott Colin P Sibley Stuart M Allan Rebecca L Jones Google Sylvie Girard Alexander E Heazell Hayley Derricott Colin P Sibley Stuart M Allan Rebecca L Jones Google Scholar Sylvie Girard Alexander E Heazell Hayley Derricott Colin P Sibley Stuart M Allan Rebecca L Jones PubMed Sylvie Girard Alexander E Heazell Hayley Derricott Colin P Sibley Stuart M Allan Rebecca L Jones Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Reduced fetal movements

The association between a reduction in fetal movements (RFM) and stillbirth has been noted for at least 450 years. This was formalised from the 1970s onwards in a series of studies that noted the increased incidence of stillbirth and FGR in women presenting with RFM, which in some cases preceded intrauterine fetal death by several days. Interpretation of the literature relating RFM to stillbirth and FGR is complicated by differences in studies’ definitions of RFM and FGR [1]. Nevertheless, the association between RFM and stillbirth remains, irrespective of the definitions used. Recently, the Auckland Stillbirth Study confirmed that women who had a RFM were 2.4 times (95% CI 1.29-4.35) more likely to have a late stillbirth [2], which is strikingly similar to a UK-based study which found a 3-fold increase in stillbirth after one presentation with RFM [3]. RFM, FGR and stillbirth are thought to be related by placental insufficiency, with RFM representing fetal compensation to restriction of nutrients and oxygen in utero [4,5]. This hypothesis is supported by evidence of abnormal placental structure and amino acid transport in women with RFM, even in the absence of a small-for-gestational age fetus [6]. Despite the association between RFM and stillbirth, RFM is frequently suboptimally managed clinically. Of 422 stillbirths reviewed in a confidential enquiry, 16.4% of cases had suboptimal care related to RFM, including: not communicating the importance of RFM to mothers and a failure to act on RFM [7]. Reasons for clinicians’ behaviour have been explored by two related questionnaire studies, one in the UK and one in Australia and New Zealand. Both of these studies found significant variations in the definitions of RFM applied to clinical practice and varied knowledge of the association between RFM, FGR and stillbirth. As a consequence clinical management of women with RFM varied significantly, with cardiotocography being used in 80-90% of cases and ultrasound assessment of fetal growth, liquor volume and umbilical artery Doppler in approximately 20% of cases [8,9]. Due to the association between RFM, FGR and stillbirth, ultrasound assessment of fetal growth, liquor volume and umbilical artery Doppler may be useful screening tests to identify placental insufficiency [10]. Norwegian studies have suggested that asking women to be more aware of fetal movements did not increase the number of attendances with RFM. Importantly, the implementation of an associated quality-improvement programme was associated with increased use of ultrasound, but a reduction of stillbirth from 4.2% to 2.4% [11], strongly suggesting that appropriate identification of, and intervention following, RFM may decrease the incidence of stillbirth. The management of RFM may be improved by more sensitive tests to specifically identify placental dysfunction, including measurement of placentally-derived factors such as human placental lactogen or placental growth factor [12,13]. The use of RFM as a screening tool for stillbirth prevention needs to be developed; it has the advantages that it is free and does not significantly increase the burden on the antenatal service. However, the best management protocol after women present with RFM has yet to be determined. To date there have been no randomised controlled trials of the management of RFM, despite calls from the World Health Organisation to improve the quality of evidence regarding stillbirth prevention [14]. Therefore, a high-quality trial is needed to evaluate whether intervention (delivery) directed by appropriate investigations after RFM can reduce the incidence of late stillbirth, without significantly increasing maternal and perinatal morbidity.

Predictors of Poor Perinatal Outcome following Maternal Perception of Reduced Fetal Movements – A Prospective Cohort Study

BackgroundMaternal perception of reduced fetal movement (RFM) is associated with increased risk of stillbirth and fetal growth restriction (FGR). RFM is thought to represent fetal compensation to conserve energy due to insufficient oxygen and nutrient transfer resulting from placental insufficiency.ObjectiveTo identify predictors of poor perinatal outcome after maternal perception of reduced fetal movements (RFM).DesignProspective cohort study.Methods305 women presenting with RFM after 28 weeks of gestation were recruited. Demographic factors and clinical history were recorded and ultrasound performed to assess fetal biometry, liquor volume and umbilical artery Doppler. A maternal serum sample was obtained for measurement of placentally-derived or modified proteins including: alpha fetoprotein (AFP), human chorionic gonadotrophin (hCG), human placental lactogen (hPL), ischaemia-modified albumin (IMA), pregnancy associated plasma protein A (PAPP-A) and progesterone. Factors related to poor perinatal outcome were determined by logistic regression.Results22.1% of pregnancies ended in a poor perinatal outcome after RFM. The most common complication was small-for-gestational age infants. Pregnancy outcome after maternal perception of RFM was related to amount of fetal activity while being monitored, abnormal fetal heart rate trace, diastolic blood pressure, estimated fetal weight, liquor volume, serum hCG and hPL. Following multiple logistic regression abnormal fetal heart rate trace (Odds ratio 7.08, 95% Confidence Interval 1.31–38.18), (OR) diastolic blood pressure (OR 1.04 (95% CI 1.01–1.09), estimated fetal weight centile (OR 0.95, 95% CI 0.94–0.97) and log maternal serum hPL (OR 0.13, 95% CI 0.02–0.99) were independently related to pregnancy outcome. hPL was related to placental mass.ConclusionPoor perinatal outcome after maternal perception of RFM is closely related to factors which are connected to placental dysfunction. Novel tests of placental function and associated fetal response may provide improved means to detect fetuses at greatest risk of poor perinatal outcome after RFM.

Maternal Perception of Reduced Fetal Movements Is Associated with Altered Placental Structure and Function

BackgroundMaternal perception of reduced fetal movement (RFM) is associated with increased risk of stillbirth and fetal growth restriction (FGR). DFM is thought to represent fetal compensation to conserve energy due to insufficient oxygen and nutrient transfer resulting from placental insufficiency. To date there have been no studies of placental structure in cases of DFM.ObjectiveTo determine whether maternal perception of reduced fetal movements (RFM) is associated with abnormalities in placental structure and function.DesignPlacentas were collected from women with RFM after 28 weeks gestation if delivery occurred within 1 week. Women with normal movements served as a control group. Placentas were weighed and photographs taken. Microscopic structure was evaluated by immunohistochemical staining and image analysis. System A amino acid transporter activity was measured as a marker of placental function.Placentas from all pregnancies with RFM (irrespective of outcome) had greater area with signs of infarction (3.5% vs. 0.6%; p<0.01), a higher density of syncytial knots (p<0.001) and greater proliferation index (p<0.01). Villous vascularity (p<0.001), trophoblast area (p<0.01) and system A activity (p<0.01) were decreased in placentas from RFM compared to controls irrespective of outcome of pregnancy.ConclusionsThis study provides evidence of abnormal placental morphology and function in women with RFM and supports the proposition of a causal association between placental insufficiency and RFM. This suggests that women presenting with RFM require further investigation to identify those with placental insufficiency.

Cardiotocography as a predictor of fetal outcome in women presenting with reduced fetal movement

ObjectiveTo examine the obstetric and perinatal outcomes of women presenting with reduced fetal movement (RFM) during the third trimester, specifically in relation to the diagnostic capacity of non-stress cardiotocography (CTG) used as the primary investigation in this clinical scenario. Study designThis was a retrospective population-based cohort study of pregnancy outcomes of all women ≥28 weeks’ gestation with singleton pregnancies presenting during one calendar year with maternal perception of RFM, all of whom underwent CTG at presentation. Main outcome measures included: obstetric intervention (induction of labour, spontaneous vaginal delivery, operative vaginal delivery, emergency caesarean section), and perinatal outcome (subsequent perinatal death, low Apgar scores (<75), neonatal resuscitation and NICU admission). ResultsIn all, 524 women presented with RFM and a live fetus, representing 7% of the antenatal obstetric population; 284 women (54%) were nulliparous. The reassuring CTG group comprised 482 (92%) women in whom initial CTG was reassuring and 15 (3%) where a repeat tracing within 1h was reassuring. The non-reassuring/abnormal CTG group (n=27, 5%) either underwent emergency delivery or comprehensive serial fetal assessment; this group had significantly higher rates of emergency caesarean delivery, neonatal resuscitation and NICU admission; the incidence of small-for-gestational-age infants did not differ significantly. No perinatal death occurred in either group following CTG. ConclusionNormal non-stress CTG is a reliable screening indicator of fetal wellbeing in women presenting with perception of RFM in the third trimester; abnormal pregnancy outcomes were more common when initial CTG was abnormal or persistently non-reassuring.

Reduced fetal movements are associated with significant changes in placental structure and function

IntroductionThe presence of reduced fetal movements (RFM) is associated with increased incidence of fetal growth restriction (FGR) and stillbirth. RFM is thought to represent fetal compensation to nutrient and oxygen...

Placentally-derived factors may be used to predict poor pregnancy outcome in reduced fetal movements

Introduction5% of women present with reduced fetal movements (RFM) in the third trimester and 20% of these will have poor pregnancy outcome defined as preterm birth <37 weeks, birthweight below...

Pregnancy outcome following induction of labor with intravaginal misoprostol for decreased fetal movements at term

Objective. To determine the outcome of labor induction with intravaginal misoprostol among women with perception of persistent decrease in fetal movements at term.Method. The study group comprising 107 women who had induction of labor at term for primary complaint of decreased fetal movements (DFM) were compared with equal number of women who had induction for prolong pregnancy in a university teaching hospital.Results. Caesarean section rate (39.3% vs. 22.4%, P < 0.001) and birthweight less than 2500 g (11.2% vs. 2.8%, P = 0.02) were significantly higher in the DFM group with the leading indication for caesarean delivery being nonreassuring fetal heart rate. Also, the incidence of 5-min Apgar score <7 were significantly lower among women in the DFM group. However, there was no difference in neonatal unit admission. There was no case of early neonatal death in both groups of women.Conclusion. Intravaginal misoprostol for labor induction is a safe delivery option for women with perception of DFM with reassuring nonstress test. Since all cases with persistent decrease in fetal movements had reassuring nonstress test, the reduction in fetal movements was most likely due to altered perception.

Legal Briefs

A 2,980-g 35-weeks' gestation female infant is delivered to a 30-year-old woman whose pregnancy was complicated by chronic hypertension. Four days before delivery she had a clinic visit, and fetal ultrasonography performed at that time was read as normal. Two days later (2 days before delivery), the woman called the clinic because she began experiencing chills, a “crampy feeling,” and loose stools. She reported good fetal movement. Several hours later, she visited the emergency department because of additional symptoms of nausea, myalgia, back pain, and vomiting. During this visit, her temperature was 38.9°C. The long-term variability on a nonstress test (NST) was reported as fair, but one spontaneous deceleration was noted. The woman reported that fetal movements decreased from earlier in the day. (The monitoring strip was missing and unavailable for review at the time of litigation.) Complete blood count findings were unremarkable, and urinalysis showed 0 to 3 red blood cells and a large amount of hemoglobin. The plaintiff experts said the physician caring for the woman should have considered a transfusion reaction from the fetus because of the hemoglobinuria, the woman's symptoms, and the report of decreased fetal movement. A more detailed evaluation should have been performed, including a biophysical profile (BPP) and a Kleihauer-Betke test (KB). The box on the paperwork for “fetal movement” was left blank. The woman said in her deposition that she shared with the nurses that fetal movement was reduced. The plaintiff experts said this was the fetus' attempt to conserve energy because of the anemia. The defense experts said that the reduction in fetal movement meant that the damage already had occurred. The mother was discharged. Later that day, the woman visited her obstetrician and had a repeat NST. The obstetrician read the NST as reactive, although he stated on his deposition …