Fetal neurobehavior and consciousness: a systematic review of 4D ultrasound evidence and ethical challenges.

Authors

Pramono MBA,Andonotopo W,Bachnas MA,Dewantiningrum J,Sanjaya INH,Sulistyowati S,Stanojevic M,Kurjak A

Affiliations (6)

  • Department of Obstetrics and Gynecology, Fetomaternal Division, Medical Faculty of Diponegoro University, Dr. Kariadi Hospital, Semarang, Indonesia.
  • Department of Obstetrics and Gynecology, Fetomaternal Division, Women Health Center, Ekahospital BSD City, Tangerang, Banten, Indonesia.
  • Department of Obstetrics and Gynecology, Fetomaternal Division, Medical Faculty of Sebelas Maret University, Dr. Moewardi Hospital, Solo, Surakarta, Indonesia.
  • Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Faculty of Medicine Universitas Udayana, Prof. dr. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia.
  • Department of Neonatology and Rare Diseases, Medical University of Warsaw, Warsaw, Poland.
  • Department of Obstetrics and Gynecology, Medical School University of Zagreb, Zagreb, Croatia.

Abstract

Recent advancements in four-dimensional (4D) ultrasonography have enabled detailed observation of fetal behavior <i>in utero</i>, including facial movements, limb gestures, and stimulus responses. These developments have prompted renewed inquiry into whether such behaviors are merely reflexive or represent early signs of integrated neural function. However, the relationship between fetal movement patterns and conscious awareness remains scientifically uncertain and ethically contested. A systematic review was conducted in accordance with PRISMA 2020 guidelines. Four databases (PubMed, Scopus, Embase, Web of Science) were searched for English-language articles published from 2000 to 2025, using keywords including "fetal behavior," "4D ultrasound," "neurodevelopment," and "consciousness." Studies were included if they involved human fetuses, used 4D ultrasound or functional imaging modalities, and offered interpretation relevant to neurobehavioral or ethical analysis. A structured appraisal using AMSTAR-2 was applied to assess study quality. Data were synthesized narratively to map fetal behaviors onto developmental milestones and evaluate their interpretive limits. Seventy-four studies met inclusion criteria, with 23 rated as high-quality. Fetal behaviors such as yawning, hand-to-face movement, and startle responses increased in complexity between 24-34 weeks gestation. These patterns aligned with known neurodevelopmental events, including thalamocortical connectivity and cortical folding. However, no study provided definitive evidence linking observed behaviors to conscious experience. Emerging applications of artificial intelligence in ultrasound analysis were found to enhance pattern recognition but lack external validation. Fetal behavior observed via 4D ultrasound may reflect increasing neural integration but should not be equated with awareness. Interpretations must remain cautious, avoiding anthropomorphic assumptions. Ethical engagement requires attention to scientific limits, sociocultural diversity, and respect for maternal autonomy as imaging technologies continue to evolve.

Topics

Journal ArticleReview

Ready to Sharpen Your Edge?

Join hundreds of your peers who rely on RadAI Slice. Get the essential weekly briefing that empowers you to navigate the future of radiology.

We respect your privacy. Unsubscribe at any time.