Diagnosing the ‘at risk’ fetus: an ethnographic study of practice following women’s reports of altered fetal movement

Poorly-managed episodes of altered fetal movement have been highlighted as a key contributor to avoidable stillbirth. NHS England’s 2016 Saving Babies’ Lives Care Bundle included recommendations for the management of altered fetal movement. Despite a 20% reduction in the stillbirth rate over the period in which the Care Bundle was implemented, the benefits of a policy that promotes awareness of fetal movement remain unproven.This ethnographic study used observation, interviews, and document analysis at two UK maternity units to learn about clinicians’ practice, perspectives and experiences in relation to altered fetal movement. Drawing on work from the sociology of diagnosis, I analysed fieldnotes, interview transcripts, maternity notes and clinical guidelines to identify important influences and themes.Overall, practice relating to fetal movement appeared remarkably consistent and ‘by the book’. However, there were challenges and tensions in this area of care, including doubts about the symptom’s reliability, conflicting evidence of fetal activity and wellbeing, and the uncertain effects of regular monitoring and induction of labour. This account provides novel insight into a range of influences on fetal movement practice, and considers how a high level of adherence to guidelines has been achieved, despite some clinicians’ doubts about the benefits and costs of the current approach. It is proposed that a strong fear of stillbirth can have a facilitative or obstructive effect on clinicians’ adherence to clinical guidelines, depending on whether their content recommends a greater or lesser interventionist approach. There is a clear case for exploring strategies to make clinicians feel personally ‘safe’ as they make important decisions about whether, when and how to intervene in a pregnancy, often working with uncertain data in the notoriously ‘risky’ field of obstetrics.