Alterations in maternally perceived fetal movement and computerized cardiotocography parameters: what's the link? A multicentre pilot study on Fetal Health.

Alterations in maternally perceived fetal movement and computerized cardiotocography parameters: what's the link? 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A multicentre pilot study on Fetal Health. Marco La Verde, Marco Torella, Davide Pisani, Lorenza Driul, Mario Fordellone, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9012661/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Maternal perception of the fetal movement (FM) is an indirect indicator of fetal well-being. The aim was to investigate the relationship between computerized cardiotocography (cCTG) and maternal perception of FM. Methods We conducted a multicentric prospective observational study, including two tertiary referral hospitals. After cCTG, all women completed a questionnaire regarding the maternal FM and fetal hiccups perception. The primary outcome was the relation between integrate multiple cCTG parameters and maternal perceptions of FM. Results We included 419 patients. Women reporting two times less FM from 26 weeks of pregnancy, had a high long-term variability (p = 0.032). Increased FM frequency perception in the last two weeks had and increased number of accelerations (p = 0.0099). The Dawson–Redman criteria need more time to be satisfied in pregnant with no hiccup perception (p = 0.0063). No other statistical correlation were found. Conclusions This pilot multicenter study found that cCTG-assessed fetal well-being was associated with more frequent FM and the presence of fetal hiccups. In future phases, this research will integrate the maternal FM perception, cCTG, prenatal ultrasound, and the neonatal outcomes to provide a comprehensive evaluation of the subjective evaluation of the maternal perception of FM. Health sciences/Health care Health sciences/Medical research Pregnancy Fetal movement Computerized Cardiotocography Cardiotocography Maternal perception Active fetal movements Fetal Health Monitoring Prenatal Care Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 1. Introduction Prenatal care based on patient's history, physical examination, ultrasound, laboratory analysis, and cardiotocography (CTG), represents critical ways of monitoring fetal well-being [ 1 , 2 ]. CTG recorded the fetal heart rate (FHR) and contractions of the uterus [ 3 ]. Variability is a marker of fetal well-being, reflecting the sympathetic and parasympathetic nervous systems balance [ 4 ]. On the basis of FHR, CTG identifies fetal hypoxemia and supports obstetrics management [ 5 , 6 ]. The principal CTG limit is the subjective interpretation, with an elevated intra- and inter-observer variability [ 7 ]. Computerized CTG (cCTG) was introduced to perform an objective FHR analysis [ 8 ]. cCTG analyzes FHR with advanced algorithms, providing a detailed analysis of the different FHR parameters [ 9 ]. The cCTG quantifies the beat-to-beat changes, the short-term variability (STV), supporting the fetal growth restriction (FGR) management [ 10 ]​​. The cCTG systematic fetal evaluation through different FHR parameters include a composite index, the Dawes-Redman criteria, which support the [ 11 , 12 ]. This integration reduces diagnostic variability and CTG subjective evaluation [ 13 ]. There is still debate on whether computerized methods are superior in improving perinatal outcomes [ 14 , 15 ]. Maternal perception of fetal movements (FM) is a non-invasive, intuitive and cost-effective measure of fetal health evaluation, reflecting the integrity of the central nervous system and well-being [ 16 ]. Decreased FM are normally an antecedent to serious fetal complications [ 17 ]. Indeed, maternal perception of FM has long represented one of the oldest modalities for prenatal non-invasive fetal well-being monitoring. A decrease in fetal activity has been well documented in several studies to precede adverse pregnancy outcomes [ 18 ]. This fetal assessment had an overtly subjective basis with regard to perception and interpretation by the mothers [ 19 ]. On the other hand, cCTG is more standardized tool for fetal monitoring [ 20 ]. Using advanced algorithms to analyze FHR patterns, cCTG has shown promise in reducing inter- and intra-observer variability associated with traditional visual interpretation of CTG [ 21 ]. The is studied relationship between maternal perception of FM and cCTG. This lacuna needs to be filled, as the integration of these approaches may offer a more complete understanding of fetal well-being [ 22 ]. This study has attempted to bridge this important lacuna and integrate the subjective (maternal perception of the FM) and objective monitoring techniques (cCTG) into combined cohesive evidence-based practice. We will explore for the first time the relation between cCTG parameters and the maternal FM perception to improve the prenatal care and to better understand the real impact of the maternal perception on the cCTG parameters. Our pilot study provides the basis for further research, in which the maternal perception of FM associated with the cCTG parameters will be compared with other methods of FM evaluation. In future research, we will incorporate the maternal FM perception and cCTG parameters with the neonatal outcomes (Apgar scores or NICU admission) and the ultrasound exams (through amniotic fluid, fetal Doppler velocimetry, and fetal biophysical profile score evaluation). All these analysis aims to improve interpretation of the maternal FM perception. 2. Materials and Methods This prospective multicentric observational study was conducted at the Gynecology and Obstetrics Unit of the University of Campania "Luigi Vanvitelli" of Naples and at the University Study of Pavia. The protocol design, collection, analysis, and interpretation of data, as well as drafting, and subsequent revisions followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines for reporting observational studies. All pregnancies, between 01.08.2024 and 20.08.2025, admitted to our institution's cardiotocography ambulatory were invited to participate. We excluded the following obstetric and fetal conditions: preterm gestation or premature rupture of membranes, multiple pregnancies and fetuses with malformations. Those conditions were excluded to reduce their influence on the maternal perception of FM or on cardiotocography parameters. Upon their first access to the cardiotocography ambulatory, the participants were registered and given written informed consent. Socio-demographic characteristics (gestational age, weight gain, pre-gestational BMI, age, smoker, maternal ethnic group) and obstetric data (gravidity, parity, previous cesarean section, induced abortion or miscarriage, diseases observed during the pregnancy, and fetal gender) were collected for each enrolled pregnant. Maternal perception of fetal movements (frequency and strength of FM) was recognized by a physician (D.P. or L.M.) who administered the fetal movements questionnaire (Table 1). Changes in strength and frequency in the last 2 weeks of the maternal FM perception categorized as increased, decreased, or remained the same (Table 1). Unusual baby’s movements from 26 weeks and vigorous movement in the last two weeks also were explored (Table S1). All questions were adopted in accordance with previous studies that explore the alterations in maternally perceived fetal movement [ 23 ]. Parameters evaluated in Computerized CTG: Fetal movement per hour, accelerations, decelerations, high and low episodes, LTV, and STV were registered for each pregnancy. The primary outcome was the relationship between integrate multiple parameters of computerized CTG and the different maternal perceptions of FM. Continuous variables were reported as either means and standard deviation or median and interquartile ranges (IQRs) according to their distribution, as assessed by the Shapiro-Wilk normality test. Categorical variables were reported as absolute frequencies and percentages. For multiple comparison between response classes, ANOVA test was performed and pairwise t-test with p-value adjusted by Holm approach. All the statistical values equal to or smaller the 0.05 were considered statistically significant. The analysis was conducted using the R statistical software (version 4.1.3; 10-03-2022). This study was carried out with full respect for international standards of good clinical practice regarding the Helsinki Declaration and national and local regulations. This study was registered on ClinicalTrial.gov (identifier: NCT04397874). Appropriate approval was taken from the Ethics Committee of the University of Campania "Luigi Vanvitelli" (protocol number 0020184/i; date: 23/07/2024). 3. Results A total of 419 women were identified as eligible participants. Sixty-three women were excluded based on the exclusion criteria (Fig. 1 ). The demographic characteristics of the study population have been presented in detail in Table 1. The mean gestational age at the cardiotocography was 38.2 weeks (SD 1.0) in a population that was mainly term. Mean gestational weight gain was 10.4 kg (SD 6.1), and the mean body mass index (BMI) before pregnancy was 25.6 kg/m² (SD 6.1). Of these participants, a majority were Caucasian at 83%, followed by South Asians at 8.4%, Black at 4.1%, Afro-Caribbeans at 3.3%, and East Asians at 1.4%. The mean maternal age was 32.1 (SD 5.5) years. The obstetric history revealed that 40% were primigravidas (Table 1). Previous cesarean section was in 16% of the study population. History of one or more miscarriages was in 23% of the study population. History of abortion was in 9% of the study population. The fetal sex is 52% male and 48% female. 13% of pregnant reported smoking during pregnancy. The 33.8% of the pregnant were affected by gestational diabetes and the 11,2% had gestational hypertension or fetal growth restriction (Table 1). Figure 2 's correlation matrix illustrates correlations between principal computerized cardiotocography parameters. Positive correlations were observed between cCTG Duration and High Episodes (0.40, p-value 0.0001), and between LTV and STV (0.86, p-value 0.0001), one variable increasing coincide with increases in the other variable. Negative correlations were found in cCTG duration and STV (-0.26, p-value 0.001) or between Low Episodes and LTV (-0.58, p-value 0.0001), showing an inverse correlation. Figure 3 showed the boxplots of eight parameters (Accelerations, Dawson–Redman, FHR baseline, High Episodes, Low Episodes, LTV, MAF per hour, and STV) stratified on the responses to "Was there any time from 26 weeks of pregnancy that your baby’s movements were less than usual?" (No, One time, Two times, Three or more times). All the parameters had no statistically significant differences, except the LTV (p = 0.032) between the four categories of responses, suggesting a correlation between LTV levels and women’s perceptions of decreased fetal movements (Fig. 3 ). Women who reported less movement from 26 weeks of pregnancy than usual “Two times” displayed high LTV values from those who did report one reduction (Fig. 4 ). Considering the last 2 weeks the frequency of the baby’s movements, categorized as Equal, Decreased, or Increased, the boxplots of eight parameters, Accelerations, Dawson–Redman, FHR baseline, High Episodes, Low Episodes, LTV, MAF per hour, and STV, showed significant differences across these three groups (Fig. 5 ). Accelerations show a statistically significant difference (p = 0.0099) and reflects that increased fetal movement frequency is related to an increased accelerations number. In contrast, Dawson–Redman (p = 0.82), FHR baseline (p = 0.78), High Episodes (p = 0.19), Low Episodes (p = 0.30), LTV (p = 0.69), and MAF per hour (p = 0.57) showed no statistical differences between the groups (Fig. 5 ). The Boxplot of Accelerations about the last 2 weeks the frequency of the baby’s movements, showed more accelerations in the group of mothers with an increased baby’s movement perception (Fig. 6 ). Across all cCTG parameters (Accelerations: p = 0.14, Dawson–Redman: p = 0.65, FHR baseline: p = 0.58, High Episodes: p = 0.76, Low Episodes: p = 0.22, LTV: p = 0.10, MAF per hour: p = 0.33, STV: p = 0.38), none showed a statistical significative (p < 0.05) (Figure S1). These findings suggest no association between the perceived strength of fetal movements and changes in these cCTG parameters (Figure S1). Considering the fetal hiccups perception in the last 2 weeks, Dawson–Redman criteria were satisfied less rapidly in the group of patients with no hiccups perception (p = 0.0063) (Figure S2), suggesting that no perceived hiccup is associated with more to time to reach the Dawson–Redman criteria respect to pregnant with hiccups (Fig. 7 ). 4. Discussion This study explores for the first time the relationship between the maternally perceived fetal movement alterations and computerized cardiotocography parameters. The present study identified significant correlations between cCTG parameters like LTV, Dawson-Redman criteria, and accelerations with maternal-reported changed FM. These associations suggest that cCTG parameters can objective quantify subjective maternal observations, bridging qualitative to quantitative assessment of fetal well-being. Our findings indicate a correlation between maternal perception of reduced fetal movement from 26 weeks of gestation and long-term variability (LTV). Women with a history of two episodes of reduced fetal movement after 26 weeks presented with higher values of LTV compared with pregnant with a single episode of reduced fetal movement. High values of LTV typically reflect heightened autonomic nervous system activity, which may be indicative of transient compensatory mechanisms by the fetus in response to intermittent mild stress or mild fetal hypoxias [ 24 ]. This result agrees with other papers showing that transient change in the pattern of fetal activity may indicate compensatory mechanisms by the fetus in response to intermittent stress [ 25 , 26 ]. Our study revealed a correlation between the increased frequency of maternal perception of FM during the last 2 weeks and the increased accelerations of reduced fetal movement. Accelerations are an indicator of fetal well-being, reflecting intact autonomic control. The link between the increased frequency and higher number of accelerations suggests that maternal perception is a good indirect sign of adequate physiological fetal status. At least, our research showed a significant correlation between the fetus's hiccups and Dawson–Radman criteria. Dawson–Redman criteria is a computerized cCTG parameter for the holistic evaluation of the fetal well-being. We evidenced that mothers with no fetal hiccups perception need longer times to obtain Dawson–Redman criteria. These findings suggest that fetal hiccups may serve as a marker of fetal neurodevelopmental integrity s, and their absence may suggest subtle changes in the behavioural states of the fetus or autonomic stability [ 27 ]. Maternal perception of FM has long been considered as an important indicator of fetal well-being [ 28 ]. This is emphasized by Heazell et al., who established that changes in FM perception are strongly associated with adverse perinatal outcomes, including late stillbirth [ 29 ]. Daly et al. evidenced an association between reduced maternal FM perception and increased cCTG tests as a first-line diagnostic tool, underlining its value in high-risk pregnancies [ 22 ]. Our findings for the first time highlights the link between maternal fetal observations with cCTG parameters, thereby enabling a multidimensional assessment of fetal well-being [ 30 ]. This dual approach offers a more nuanced status of fetal well-being, particularly when traditional CTG parameters such as STV and episodes of high variability show a moderate correlation with FM perception [ 31 ]. Various studies have outlined the inadequacy of the visual analysis of CTG [ 32 ], particularly the inter- and intra-observer variability, such as Imane et al. who explored algorithms and machine-learning improvements, which support the cCTG sensibility to the fetal hypoxia detection [ 14 ]. Future study are needed to explore the relationship between the maternal perception of FM, cCTG and the delivery outcomes [ 33 ]. In addiction technological advancements, as artificial intelligence and machine-learning algorithms, could improve our sensibility analysis [ 34 , 35 ]. Different studies explored the AI sensibility CTG data evaluation [ 36 , 37 ]. Considering the literature, few studies evaluated the predictive value of combined FM perception plus cCTG [ 38 ]. Bailey et al. showed that reduced FM, when combined with normal CTG, may reflect underlying conditions that may develop later in pregnancy [ 39 ]. Maternal FM perception clinical applicability remains ambiguous. First, maternal FM perception is subjective and several factors such as BMI, smoking habits, and placental position, potentially influence the maternal perception [ 40 , 41 ]. Second, signal loss in patients with higher BMI or CTG subjective evaluation add additional limits [ 42 ]. Also, as Alakananda et al. have pointed out, due to the lack of uniform criteria for assessing the outcomes of FM and cCTG, comparisons among different studies become difficult [ 2 ]. Our original article presented several strengths: no previous study associated the maternal FM perception with the cCTG evaluation, the multicentric prospective design of this study, with its different populations and clinical settings, gives generalizability to the study results and supports the integration of maternal FM perception across clinical settings. Thirdly, the population included is adequate to support our conclusion and the exclusion of pregnancy complicated by other comorbidities could ensure homogeneity in the samples. Lastly, the cCTG parameters offer an objective evaluation and analysis of the fetal status, reducing the intra and inter-observer variability, and a physician administered the questionnaire. Different limitations are present. Maternal perception of the FM remains a subjective evaluation that could be influenced by BMI or maternal emotional status [ 21 ]. Concluding, this research supports a multidimensional approach to fetal monitoring using technology and FM during pregnancy. The promotion of such integration can help clinicians identify earlier fetal compromise and intervene appropriately to achieve better fetal care in individualized antenatal settings. This is a multicenter pilot study. The data here is preliminary and only concerned the maternal perception of fetal movements with the cCTG parameters. Further stages in this project, will use numerous and quantitative methods, like ultrasound evaluation for amniotic fluid and fetal doppler. This comprehensive approach will allow the maternal perception of FM to be compared with more objective endpoints and outcome-based thresholds. 5. Conclusions Increased FM frequency in the last two weeks and maternal perception of fetal hiccups are associated with objective sign of fetal well-being supported by the cCTG evaluation. These findings should support clinicians during prenatal care. Abbreviations FM Fetal Movements CTG Cardiotocography cCTG Computerized cardiotocography AI Artificial Intelligence LTV Long-term variability STV Short-term variability FHR Fetal heart rate Declarations Conflicts of Interest: The authors declare that they have no conflict of interest. Funding: This study was not supported by any sponsor or funder. Informed Consent Statement: Written informed consent was obtained from all individual participants included in the study. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of University of Campania “L. Vanvitelli” of Naples (protocol code 0020184/i and date of approval: 23/07/2024). Data Availability Statement: Data are not publicly available due to privacy or ethical restrictions. Data will be made available on reasonable request. Further enquiries can be directed to the corresponding author. Author Contributions: Conceptualization, M.L.V.; methodology, P.H. and B.G.; validation, M.D., and P.D.F.; formal analysis, M.F.; investigation and data curation, D.P. and L.M.; writing—original draft preparation, D.P. and L.M.; writing—review and editing, M.L.V.; visualization, L.P.; supervision, D.L. and B.G.; All authors have read and agreed to the published version of the manuscript. All authors read and approved the final manuscript. Acknowledgments: The authors thank the AI-RITM interdepartmental project for its support in this research and the Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli". References Sandall, J. et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 392 (10155), 1349–1357 (2018). DAS, A. & MAJUMDAR, M. K. DEY AK. 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Today . 30 (1), 19–22 (2018). Bailey, D. Assessment of reduced fetal movements with cardiotocography. J. Obstet. Gynaecol. 23 (sup1), S32–S (2003). Tveit, J. V. H. Decreased fetal movements in late pregnancy-importance today? (2011). La Verde, M. et al. Impact of Braxton-Hicks contractions on fetal wellbeing; a prospective analysis through computerised cardiotocography. J. Obstet. Gynaecol. 42 (4), 569–573 (2022). Kodkin, V. Cardiotocography in obstetrics: New solutions for routine technology. Sensors 22 (14), 5126 (2022). Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table 1. Baseline characteristics of patients included. TableS1.docx Table S1. Questionary for the maternal fetal movements evaluation. FigureS1.docx Figure S1. Boxplots of computerized cardiotocography parameters stratified pregnant’ responses to the question “In the last 2 weeks, did the strength of your baby’s movements…? (Equal, Decreased, or Increased)”. FigureS2.docx Figure S2. Boxplots of computerized cardiotocography parameters stratified pregnant’ responses to the question “During the last 2 weeks, did you feel your baby having hiccups?”. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9012661","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":619173450,"identity":"fae46751-6f2d-489c-a45b-8d2c9c521b3f","order_by":0,"name":"Marco La 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Vanvitelli\"","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"Torella","suffix":""},{"id":619173455,"identity":"ecddaf9f-d6b8-451a-9ba6-dbc73f4c25cd","order_by":2,"name":"Davide Pisani","email":"","orcid":"","institution":"University of Campania \"Luigi Vanvitelli\"","correspondingAuthor":false,"prefix":"","firstName":"Davide","middleName":"","lastName":"Pisani","suffix":""},{"id":619173456,"identity":"83c16a8f-af6a-46c8-8d4a-a9bae5fe0b2d","order_by":3,"name":"Lorenza Driul","email":"","orcid":"","institution":"Ospedale Santa Maria della Misericordia di Udine","correspondingAuthor":false,"prefix":"","firstName":"Lorenza","middleName":"","lastName":"Driul","suffix":""},{"id":619173458,"identity":"9803ae71-bb31-46af-8bc9-a5e08c7b7e3a","order_by":4,"name":"Mario Fordellone","email":"","orcid":"","institution":"University of Campania \"Luigi Vanvitelli\"","correspondingAuthor":false,"prefix":"","firstName":"Mario","middleName":"","lastName":"Fordellone","suffix":""},{"id":619173459,"identity":"fdd5e6cf-b7bc-45b9-b236-7a7a782f506f","order_by":5,"name":"Petra Hanulìková","email":"","orcid":"","institution":"Charles University","correspondingAuthor":false,"prefix":"","firstName":"Petra","middleName":"","lastName":"Hanulìková","suffix":""},{"id":619173462,"identity":"90bd500d-8228-40b6-8cf4-bd346e4bb4e1","order_by":6,"name":"Lucia Pasquini","email":"","orcid":"","institution":"Azienda Ospedaliero-Universitaria Careggi","correspondingAuthor":false,"prefix":"","firstName":"Lucia","middleName":"","lastName":"Pasquini","suffix":""},{"id":619173463,"identity":"d3ba363a-339c-4177-ba60-9409bc32d130","order_by":7,"name":"Liliana Mariani","email":"","orcid":"","institution":"University of Pavia","correspondingAuthor":false,"prefix":"","firstName":"Liliana","middleName":"","lastName":"Mariani","suffix":""},{"id":619173466,"identity":"a28d65a7-056b-4de7-8df9-e28a866c09f8","order_by":8,"name":"Mattia Dominoni","email":"","orcid":"","institution":"University of Pavia","correspondingAuthor":false,"prefix":"","firstName":"Mattia","middleName":"","lastName":"Dominoni","suffix":""},{"id":619173470,"identity":"2877648e-5715-4997-85c5-fa5bf615425e","order_by":9,"name":"Barbara Gardella","email":"","orcid":"","institution":"University of Pavia","correspondingAuthor":false,"prefix":"","firstName":"Barbara","middleName":"","lastName":"Gardella","suffix":""}],"badges":[],"createdAt":"2026-03-02 17:25:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9012661/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9012661/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106596454,"identity":"857d884c-4809-4241-8586-e8b256474a03","added_by":"auto","created_at":"2026-04-10 09:36:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44504,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Flowchart.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/63a72bfc4eb5d50b31fd5533.png"},{"id":106726378,"identity":"349f32ec-7197-4aba-9aff-bd70a4705027","added_by":"auto","created_at":"2026-04-12 18:35:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":88335,"visible":true,"origin":"","legend":"\u003cp\u003ePairs plot of multiple computerized cardiotocography (cCTG) parameters.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/b96aaa365d6f56ddfdb1bca1.png"},{"id":106596455,"identity":"72454812-b860-451a-abcd-335c0a273a46","added_by":"auto","created_at":"2026-04-10 09:36:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34584,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplots of computerized cardiotocography parameters stratified pregnant’ responses to the question “Was there any time from 26 weeks of pregnancy that your baby’s movements were less than usual?”.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/86abb46c98af4164a57bfcdb.png"},{"id":106728612,"identity":"77ce4936-2df5-4fe9-9178-ba578550c143","added_by":"auto","created_at":"2026-04-12 18:43:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":37252,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot of LTV values across four groups of participants who responded “No,” “One time,” “Two times,” or “Three or more times” to the question, “Was there any time from 26 weeks of pregnancy that your baby’s movements were less than usual?”\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/a5e1c185415c818cb111711a.png"},{"id":106596466,"identity":"5f71712c-80af-4390-9181-46b1f3f4358f","added_by":"auto","created_at":"2026-04-10 09:36:57","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":33372,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplots of computerized cardiotocography parameters stratified pregnant’ responses to the question “In the last 2 weeks, did the frequency of your baby’s movements…? (categorized as Equal, Decreased, or Increased)”.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/c2c479fd301232983d9f5938.png"},{"id":106725254,"identity":"8582758c-a179-4f04-9e9f-346b17d327b8","added_by":"auto","created_at":"2026-04-12 18:32:04","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot of Accelerations across three groups Equal, Decreased, or Increased of participants who responded to the question “In the last 2 weeks, did the frequency of your baby’s movements…?”.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/52c51fef530ab0586615485d.png"},{"id":106727244,"identity":"a0de85b4-6ff2-4b60-a9ac-2b96e10af178","added_by":"auto","created_at":"2026-04-12 18:38:26","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":19275,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot of Dawson-Redman across three groups No, Rarely, or Occasionally Hiccups perception.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/e2fde1882c1ae9b168b2fe31.png"},{"id":108699383,"identity":"69e2ca56-ac5f-4ac9-b33a-7638adf060a3","added_by":"auto","created_at":"2026-05-07 12:27:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":411297,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/75fe8c6a-c5e3-4ed5-9a31-6f8f66712187.pdf"},{"id":106726354,"identity":"d09c124d-02f6-42ed-92f1-5518f5bf908b","added_by":"auto","created_at":"2026-04-12 18:35:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16466,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Baseline characteristics of patients included.\u003c/p\u003e","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/94fd0f356bf2ed963464df6d.docx"},{"id":106726216,"identity":"84bd6b00-3ea5-42ca-b897-2f550bd205dd","added_by":"auto","created_at":"2026-04-12 18:35:38","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15101,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable S1.\u003c/strong\u003e Questionary for the maternal fetal movements evaluation.\u003c/p\u003e","description":"","filename":"TableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/08a334d1d3e5dadc1ef47f14.docx"},{"id":106728701,"identity":"7b6d0e1a-628a-47a8-9da6-94fd301227ee","added_by":"auto","created_at":"2026-04-12 18:43:59","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":33368,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure S1. \u003c/strong\u003eBoxplots of computerized cardiotocography parameters stratified pregnant’ responses to the question “In the last 2 weeks, did the strength of your baby’s movements…? (Equal, Decreased, or Increased)”.\u003c/p\u003e","description":"","filename":"FigureS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/a86024e5fe85a824dd6f43f6.docx"},{"id":106726107,"identity":"c439d8ca-369d-4901-8304-686028d6f21a","added_by":"auto","created_at":"2026-04-12 18:35:21","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":33481,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure S2. \u003c/strong\u003eBoxplots of computerized cardiotocography parameters stratified pregnant’ responses to the question “During the last 2 weeks, did you feel your baby having hiccups?”.\u003c/p\u003e","description":"","filename":"FigureS2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9012661/v1/2c7fb7d68cbb27e4e5aa6788.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Alterations in maternally perceived fetal movement and computerized cardiotocography parameters: what's the link? A multicentre pilot study on Fetal Health.","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePrenatal care based on patient's history, physical examination, ultrasound, laboratory analysis, and cardiotocography (CTG), represents critical ways of monitoring fetal well-being [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. CTG recorded the fetal heart rate (FHR) and contractions of the uterus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Variability is a marker of fetal well-being, reflecting the sympathetic and parasympathetic nervous systems balance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. On the basis of FHR, CTG identifies fetal hypoxemia and supports obstetrics management [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The principal CTG limit is the subjective interpretation, with an elevated intra- and inter-observer variability [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Computerized CTG (cCTG) was introduced to perform an objective FHR analysis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. cCTG analyzes FHR with advanced algorithms, providing a detailed analysis of the different FHR parameters [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The cCTG quantifies the beat-to-beat changes, the short-term variability (STV), supporting the fetal growth restriction (FGR) management [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]​​. The cCTG systematic fetal evaluation through different FHR parameters include a composite index, the Dawes-Redman criteria, which support the [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This integration reduces diagnostic variability and CTG subjective evaluation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. There is still debate on whether computerized methods are superior in improving perinatal outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Maternal perception of fetal movements (FM) is a non-invasive, intuitive and cost-effective measure of fetal health evaluation, reflecting the integrity of the central nervous system and well-being [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Decreased FM are normally an antecedent to serious fetal complications [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Indeed, maternal perception of FM has long represented one of the oldest modalities for prenatal non-invasive fetal well-being monitoring. A decrease in fetal activity has been well documented in several studies to precede adverse pregnancy outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This fetal assessment had an overtly subjective basis with regard to perception and interpretation by the mothers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the other hand, cCTG is more standardized tool for fetal monitoring [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Using advanced algorithms to analyze FHR patterns, cCTG has shown promise in reducing inter- and intra-observer variability associated with traditional visual interpretation of CTG [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The is studied relationship between maternal perception of FM and cCTG. This lacuna needs to be filled, as the integration of these approaches may offer a more complete understanding of fetal well-being [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has attempted to bridge this important lacuna and integrate the subjective (maternal perception of the FM) and objective monitoring techniques (cCTG) into combined cohesive evidence-based practice. We will explore for the first time the relation between cCTG parameters and the maternal FM perception to improve the prenatal care and to better understand the real impact of the maternal perception on the cCTG parameters. Our pilot study provides the basis for further research, in which the maternal perception of FM associated with the cCTG parameters will be compared with other methods of FM evaluation. In future research, we will incorporate the maternal FM perception and cCTG parameters with the neonatal outcomes (Apgar scores or NICU admission) and the ultrasound exams (through amniotic fluid, fetal Doppler velocimetry, and fetal biophysical profile score evaluation). All these analysis aims to improve interpretation of the maternal FM perception.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eThis prospective multicentric observational study was conducted at the Gynecology and Obstetrics Unit of the University of Campania \"Luigi Vanvitelli\" of Naples and at the University Study of Pavia. The protocol design, collection, analysis, and interpretation of data, as well as drafting, and subsequent revisions followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines for reporting observational studies. All pregnancies, between 01.08.2024 and 20.08.2025, admitted to our institution's cardiotocography ambulatory were invited to participate.\u003c/p\u003e \u003cp\u003eWe excluded the following obstetric and fetal conditions: preterm gestation or premature rupture of membranes, multiple pregnancies and fetuses with malformations. Those conditions were excluded to reduce their influence on the maternal perception of FM or on cardiotocography parameters.\u003c/p\u003e \u003cp\u003e Upon their first access to the cardiotocography ambulatory, the participants were registered and given written informed consent. Socio-demographic characteristics (gestational age, weight gain, pre-gestational BMI, age, smoker, maternal ethnic group) and obstetric data (gravidity, parity, previous cesarean section, induced abortion or miscarriage, diseases observed during the pregnancy, and fetal gender) were collected for each enrolled pregnant. Maternal perception of fetal movements (frequency and strength of FM) was recognized by a physician (D.P. or L.M.) who administered the fetal movements questionnaire (Table\u0026nbsp;1). Changes in strength and frequency in the last 2 weeks of the maternal FM perception categorized as increased, decreased, or remained the same (Table\u0026nbsp;1). Unusual baby\u0026rsquo;s movements from 26 weeks and vigorous movement in the last two weeks also were explored (Table S1). All questions were adopted in accordance with previous studies that explore the alterations in maternally perceived fetal movement [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Parameters evaluated in Computerized CTG: Fetal movement per hour, accelerations, decelerations, high and low episodes, LTV, and STV were registered for each pregnancy. The primary outcome was the relationship between integrate multiple parameters of computerized CTG and the different maternal perceptions of FM. Continuous variables were reported as either means and standard deviation or median and interquartile ranges (IQRs) according to their distribution, as assessed by the Shapiro-Wilk normality test. Categorical variables were reported as absolute frequencies and percentages. For multiple comparison between response classes, ANOVA test was performed and pairwise t-test with p-value adjusted by Holm approach. All the statistical values equal to or smaller the 0.05 were considered statistically significant. The analysis was conducted using the R statistical software (version 4.1.3; 10-03-2022). This study was carried out with full respect for international standards of good clinical practice regarding the Helsinki Declaration and national and local regulations. This study was registered on ClinicalTrial.gov (identifier: NCT04397874). Appropriate approval was taken from the Ethics Committee of the University of Campania \"Luigi Vanvitelli\" (protocol number 0020184/i; date: 23/07/2024).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 419 women were identified as eligible participants. Sixty-three women were excluded based on the exclusion criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The demographic characteristics of the study population have been presented in detail in Table\u0026nbsp;1. The mean gestational age at the cardiotocography was 38.2 weeks (SD 1.0) in a population that was mainly term. Mean gestational weight gain was 10.4 kg (SD 6.1), and the mean body mass index (BMI) before pregnancy was 25.6 kg/m\u0026sup2; (SD 6.1). Of these participants, a majority were Caucasian at 83%, followed by South Asians at 8.4%, Black at 4.1%, Afro-Caribbeans at 3.3%, and East Asians at 1.4%. The mean maternal age was 32.1 (SD 5.5) years. The obstetric history revealed that 40% were primigravidas (Table\u0026nbsp;1). Previous cesarean section was in 16% of the study population. History of one or more miscarriages was in 23% of the study population. History of abortion was in 9% of the study population. The fetal sex is 52% male and 48% female. 13% of pregnant reported smoking during pregnancy. The 33.8% of the pregnant were affected by gestational diabetes and the 11,2% had gestational hypertension or fetal growth restriction (Table\u0026nbsp;1). Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e's correlation matrix illustrates correlations between principal computerized cardiotocography parameters. Positive correlations were observed between cCTG Duration and High Episodes (0.40, p-value 0.0001), and between LTV and STV (0.86, p-value 0.0001), one variable increasing coincide with increases in the other variable. Negative correlations were found in cCTG duration and STV (-0.26, p-value 0.001) or between Low Episodes and LTV (-0.58, p-value 0.0001), showing an inverse correlation. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e showed the boxplots of eight parameters (Accelerations, Dawson\u0026ndash;Redman, FHR baseline, High Episodes, Low Episodes, LTV, MAF per hour, and STV) stratified on the responses to \"Was there any time from 26 weeks of pregnancy that your baby\u0026rsquo;s movements were less than usual?\" (No, One time, Two times, Three or more times). All the parameters had no statistically significant differences, except the LTV (p\u0026thinsp;=\u0026thinsp;0.032) between the four categories of responses, suggesting a correlation between LTV levels and women\u0026rsquo;s perceptions of decreased fetal movements (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Women who reported less movement from 26 weeks of pregnancy than usual \u0026ldquo;Two times\u0026rdquo; displayed high LTV values from those who did report one reduction (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Considering the last 2 weeks the frequency of the baby\u0026rsquo;s movements, categorized as Equal, Decreased, or Increased, the boxplots of eight parameters, Accelerations, Dawson\u0026ndash;Redman, FHR baseline, High Episodes, Low Episodes, LTV, MAF per hour, and STV, showed significant differences across these three groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Accelerations show a statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.0099) and reflects that increased fetal movement frequency is related to an increased accelerations number. In contrast, Dawson\u0026ndash;Redman (p\u0026thinsp;=\u0026thinsp;0.82), FHR baseline (p\u0026thinsp;=\u0026thinsp;0.78), High Episodes (p\u0026thinsp;=\u0026thinsp;0.19), Low Episodes (p\u0026thinsp;=\u0026thinsp;0.30), LTV (p\u0026thinsp;=\u0026thinsp;0.69), and MAF per hour (p\u0026thinsp;=\u0026thinsp;0.57) showed no statistical differences between the groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The Boxplot of Accelerations about the last 2 weeks the frequency of the baby\u0026rsquo;s movements, showed more accelerations in the group of mothers with an increased baby\u0026rsquo;s movement perception (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Across all cCTG parameters (Accelerations: p\u0026thinsp;=\u0026thinsp;0.14, Dawson\u0026ndash;Redman: p\u0026thinsp;=\u0026thinsp;0.65, FHR baseline: p\u0026thinsp;=\u0026thinsp;0.58, High Episodes: p\u0026thinsp;=\u0026thinsp;0.76, Low Episodes: p\u0026thinsp;=\u0026thinsp;0.22, LTV: p\u0026thinsp;=\u0026thinsp;0.10, MAF per hour: p\u0026thinsp;=\u0026thinsp;0.33, STV: p\u0026thinsp;=\u0026thinsp;0.38), none showed a statistical significative (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Figure S1). These findings suggest no association between the perceived strength of fetal movements and changes in these cCTG parameters (Figure S1). Considering the fetal hiccups perception in the last 2 weeks, Dawson\u0026ndash;Redman criteria were satisfied less rapidly in the group of patients with no hiccups perception (p\u0026thinsp;=\u0026thinsp;0.0063) (Figure S2), suggesting that no perceived hiccup is associated with more to time to reach the Dawson\u0026ndash;Redman criteria respect to pregnant with hiccups (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study explores for the first time the relationship between the maternally perceived fetal movement alterations and computerized cardiotocography parameters. The present study identified significant correlations between cCTG parameters like LTV, Dawson-Redman criteria, and accelerations with maternal-reported changed FM. These associations suggest that cCTG parameters can objective quantify subjective maternal observations, bridging qualitative to quantitative assessment of fetal well-being. Our findings indicate a correlation between maternal perception of reduced fetal movement from 26 weeks of gestation and long-term variability (LTV). Women with a history of two episodes of reduced fetal movement after 26 weeks presented with higher values of LTV compared with pregnant with a single episode of reduced fetal movement. High values of LTV typically reflect heightened autonomic nervous system activity, which may be indicative of transient compensatory mechanisms by the fetus in response to intermittent mild stress or mild fetal hypoxias [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This result agrees with other papers showing that transient change in the pattern of fetal activity may indicate compensatory mechanisms by the fetus in response to intermittent stress [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Our study revealed a correlation between the increased frequency of maternal perception of FM during the last 2 weeks and the increased accelerations of reduced fetal movement. Accelerations are an indicator of fetal well-being, reflecting intact autonomic control. The link between the increased frequency and higher number of accelerations suggests that maternal perception is a good indirect sign of adequate physiological fetal status. At least, our research showed a significant correlation between the fetus's hiccups and Dawson\u0026ndash;Radman criteria. Dawson\u0026ndash;Redman criteria is a computerized cCTG parameter for the holistic evaluation of the fetal well-being. We evidenced that mothers with no fetal hiccups perception need longer times to obtain Dawson\u0026ndash;Redman criteria. These findings suggest that fetal hiccups may serve as a marker of fetal neurodevelopmental integrity s, and their absence may suggest subtle changes in the behavioural states of the fetus or autonomic stability [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Maternal perception of FM has long been considered as an important indicator of fetal well-being [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This is emphasized by Heazell et al., who established that changes in FM perception are strongly associated with adverse perinatal outcomes, including late stillbirth [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Daly et al. evidenced an association between reduced maternal FM perception and increased cCTG tests as a first-line diagnostic tool, underlining its value in high-risk pregnancies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings for the first time highlights the link between maternal fetal observations with cCTG parameters, thereby enabling a multidimensional assessment of fetal well-being [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This dual approach offers a more nuanced status of fetal well-being, particularly when traditional CTG parameters such as STV and episodes of high variability show a moderate correlation with FM perception [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Various studies have outlined the inadequacy of the visual analysis of CTG [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], particularly the inter- and intra-observer variability, such as Imane et al. who explored algorithms and machine-learning improvements, which support the cCTG sensibility to the fetal hypoxia detection [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Future study are needed to explore the relationship between the maternal perception of FM, cCTG and the delivery outcomes [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In addiction technological advancements, as artificial intelligence and machine-learning algorithms, could improve our sensibility analysis [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Different studies explored the AI sensibility CTG data evaluation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Considering the literature, few studies evaluated the predictive value of combined FM perception plus cCTG [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Bailey et al. showed that reduced FM, when combined with normal CTG, may reflect underlying conditions that may develop later in pregnancy [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Maternal FM perception clinical applicability remains ambiguous. First, maternal FM perception is subjective and several factors such as BMI, smoking habits, and placental position, potentially influence the maternal perception [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Second, signal loss in patients with higher BMI or CTG subjective evaluation add additional limits [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Also, as Alakananda et al. have pointed out, due to the lack of uniform criteria for assessing the outcomes of FM and cCTG, comparisons among different studies become difficult [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur original article presented several strengths: no previous study associated the maternal FM perception with the cCTG evaluation, the multicentric prospective design of this study, with its different populations and clinical settings, gives generalizability to the study results and supports the integration of maternal FM perception across clinical settings. Thirdly, the population included is adequate to support our conclusion and the exclusion of pregnancy complicated by other comorbidities could ensure homogeneity in the samples. Lastly, the cCTG parameters offer an objective evaluation and analysis of the fetal status, reducing the intra and inter-observer variability, and a physician administered the questionnaire. Different limitations are present. Maternal perception of the FM remains a subjective evaluation that could be influenced by BMI or maternal emotional status [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Concluding, this research supports a multidimensional approach to fetal monitoring using technology and FM during pregnancy. The promotion of such integration can help clinicians identify earlier fetal compromise and intervene appropriately to achieve better fetal care in individualized antenatal settings. This is a multicenter pilot study. The data here is preliminary and only concerned the maternal perception of fetal movements with the cCTG parameters. Further stages in this project, will use numerous and quantitative methods, like ultrasound evaluation for amniotic fluid and fetal doppler. This comprehensive approach will allow the maternal perception of FM to be compared with more objective endpoints and outcome-based thresholds.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIncreased FM frequency in the last two weeks and maternal perception of fetal hiccups are associated with objective sign of fetal well-being supported by the cCTG evaluation. These findings should support clinicians during prenatal care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFM \u0026nbsp; \u0026nbsp; \u0026nbsp;Fetal Movements\u003c/p\u003e\n\u003cp\u003eCTG \u0026nbsp; \u0026nbsp;Cardiotocography\u003c/p\u003e\n\u003cp\u003ecCTG Computerized cardiotocography\u003c/p\u003e\n\u003cp\u003eAI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Artificial Intelligence\u003c/p\u003e\n\u003cp\u003eLTV \u0026nbsp; \u0026nbsp;Long-term variability\u003c/p\u003e\n\u003cp\u003eSTV \u0026nbsp; \u0026nbsp;Short-term variability\u003c/p\u003e\n\u003cp\u003eFHR \u0026nbsp; \u0026nbsp;Fetal heart rate\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was not supported by any sponsor or funder.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of University of Campania \u0026ldquo;L. Vanvitelli\u0026rdquo; of Naples (protocol code 0020184/i and date of approval: 23/07/2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e Data are not publicly available due to privacy or ethical restrictions. Data will be made available on reasonable request. Further enquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization, M.L.V.; methodology, P.H. and B.G.; validation, M.D., and P.D.F.; formal analysis, M.F.; investigation and data curation, D.P. and L.M.; writing\u0026mdash;original draft preparation, D.P. and L.M.; writing\u0026mdash;review and editing, M.L.V.; visualization, L.P.; supervision, D.L. and B.G.; All authors have read and agreed to the published version of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors thank the AI-RITM interdepartmental project for its support in this research and the Department of Woman, Child and General and Specialized Surgery, University of Campania \u0026quot;Luigi Vanvitelli\u0026quot;.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSandall, J. et al. Short-term and long-term effects of caesarean section on the health of women and children. \u003cem\u003eLancet\u003c/em\u003e \u003cb\u003e392\u003c/b\u003e (10155), 1349\u0026ndash;1357 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDAS, A. \u0026amp; MAJUMDAR, M. K. DEY AK. Relationship of Cardiotocography and Umbilicalartery Doppler Findings with Perinatal Outcome in Low Risk Pregnancies with Decreased Fetal Movements. \u003cem\u003eEur. J. Cardiovasc. 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Syst.\u003c/em\u003e \u003cb\u003e47\u003c/b\u003e (1), 82 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalma, U., Jabeen, M., Shimul, S. \u0026amp; Akhter, D. Analysis of cardiotocography findings in pregnancy with less fetal movement and its association with perinatal outcome. \u003cem\u003eMed. Today\u003c/em\u003e. \u003cb\u003e30\u003c/b\u003e (1), 19\u0026ndash;22 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBailey, D. Assessment of reduced fetal movements with cardiotocography. \u003cem\u003eJ. Obstet. Gynaecol.\u003c/em\u003e \u003cb\u003e23\u003c/b\u003e (sup1), S32\u0026ndash;S (2003).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTveit, J. V. H. Decreased fetal movements in late pregnancy-importance today? (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLa Verde, M. et al. Impact of Braxton-Hicks contractions on fetal wellbeing; a prospective analysis through computerised cardiotocography. \u003cem\u003eJ. Obstet. Gynaecol.\u003c/em\u003e \u003cb\u003e42\u003c/b\u003e (4), 569\u0026ndash;573 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKodkin, V. Cardiotocography in obstetrics: New solutions for routine technology. \u003cem\u003eSensors\u003c/em\u003e \u003cb\u003e22\u003c/b\u003e (14), 5126 (2022).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, Fetal movement, Computerized Cardiotocography, Cardiotocography, Maternal perception, Active fetal movements, Fetal Health Monitoring, Prenatal Care","lastPublishedDoi":"10.21203/rs.3.rs-9012661/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9012661/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eMaternal perception of the fetal movement (FM) is an indirect indicator of fetal well-being. The aim was to investigate the relationship between computerized cardiotocography (cCTG) and maternal perception of FM.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a multicentric prospective observational study, including two tertiary referral hospitals. After cCTG, all women completed a questionnaire regarding the maternal FM and fetal hiccups perception. The primary outcome was the relation between integrate multiple cCTG parameters and maternal perceptions of FM.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe included 419 patients. Women reporting two times less FM from 26 weeks of pregnancy, had a high long-term variability (p\u0026thinsp;=\u0026thinsp;0.032). Increased FM frequency perception in the last two weeks had and increased number of accelerations (p\u0026thinsp;=\u0026thinsp;0.0099). The Dawson\u0026ndash;Redman criteria need more time to be satisfied in pregnant with no hiccup perception (p\u0026thinsp;=\u0026thinsp;0.0063). No other statistical correlation were found.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis pilot multicenter study found that cCTG-assessed fetal well-being was associated with more frequent FM and the presence of fetal hiccups. In future phases, this research will integrate the maternal FM perception, cCTG, prenatal ultrasound, and the neonatal outcomes to provide a comprehensive evaluation of the subjective evaluation of the maternal perception of FM.\u003c/p\u003e","manuscriptTitle":"Alterations in maternally perceived fetal movement and computerized cardiotocography parameters: what's the link? A multicentre pilot study on Fetal Health.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-10 09:36:51","doi":"10.21203/rs.3.rs-9012661/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fbf5bd7f-9f38-465c-b163-a60641488004","owner":[],"postedDate":"April 10th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-07T12:20:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T11:08:48+00:00","index":98,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65888087,"name":"Health sciences/Health care"},{"id":65888088,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-05-07T12:26:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-10 09:36:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9012661","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9012661","identity":"rs-9012661","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}