Estimation of Fetal Weight

ESTIMATION OF FETAL WEIGHT
NEED FOR ANTENATAL FETAL WEIGHT ESTIMATION
Both low birth weight and excessive fetal weight at delivery are associated with an
increased risk of newborn complications during labor and the puerperium. The perinatal
complications associated with low birth weight are attributable to preterm delivery,
intrauterine growth restriction (IUGR), or both. For excessively large fetuses, the
potential complications associated with delivery include shoulder dystocia, brachial
plexus injuries, bony injuries, and intrapartum asphyxia. The maternal risks associated
with the delivery of an excessively large fetus include birth canal and pelvic floor injuries
and postpartum hemorrhage
The occurrence of cephalopelvic disproportion is more prevalent with increasing fetal

size and contributes to both an increased rate of operative vaginal delivery and cesarean
delivery for macrosomic fetuses compared with fetuses of normal weight. Depending on
many factors, the optimal range for birthweight is thought to be 3000-4000 grams.
Limiting the potential complications associated with the birth of both small and
excessively large fetuses requires that accurate estimation of fetal weight occur in
advance of delivery. A review of the methods that can be used for the accurate estimation
of fetal weight is the focus of this article.
STANDARD FETAL GROWTH CURVES
Mean birth weight has been described as a function of gestational age. Several
studies subdivide such results into those that apply to women of different races,
male versus female fetuses, and primiparous versus multiparous gravidas. Standard
fetal growth curves are useful for estimating the range of expected fetal weight at
any particular gestational age. However, in order for the growth curves to be useful,
all such tables presuppose that the gestational age of the fetus is established
properly. Without adequate gestational dating, the standard fetal growth curves
cannot be interpreted successfully.
The principal limitations of standard fetal growth curves that are derived from
population-based studies are as follows:
• They apply only to fetuses that are of normal size for gestational age and not
to those with significant (and potentially pathologic) growth abnormalities.
• The standard deviation (SD) associated with the mean birth weight estimate
at any particular gestational age is wide, typically exceeding 450-500 grams.
• The gestational age of the fetus must be known with a high degree of
certainty to use the growth curves with any degree of reliability.
In general, these growth curves can be expected to apply to large populations of

pregnant women who have well-dated pregnancies, but the limits of their predictive
accuracy make them less than ideal tools for estimating fetal weight for individual
patients. The range of birth weights at any particular gestational age spans a wide
array of values, with 95% confidence intervals of more than 1600 grams (3 lb 8 oz)
at term. In addition, fetal growth curves are the most inaccurate at the extremes of
fetal weight deviation (ie, women carrying fetuses that are either growth restricted
or macrosomic).
NORMAL RANGE FOR HUMAN BIRTH WEIGHT

Deviations in fetal weight
The diagnosis of deviations in fetal weight presupposes that the reference range for
fetal weight at each gestational age is established. Before a reference range for
human birth weight can be established properly, the gestational age at which human
births occur must first be defined. This issue is of primary importance because fetal
weight increases rapidly once the second trimester of pregnancy is reached.
Variations in fetal weight
The reference range of gestational age for spontaneous delivery in human

pregnancies is well accepted as 280 days (40 wk) from the first day of the last
normal menstrual period (ie, 266 d after fertilization). Because fewer than 3% of
births occur precisely at 40 weeks' gestation and the SD for term pregnancies is 1
week, the normal range of term birth weight is typically referenced to the mean birth
weight for pregnancies delivered at 38-42 weeks' gestation (ie, mean term
gestational age ±2 SD). During this 4-week period, the average fetus gains
approximately 12.7 ±1.4 g/d, with a difference of ±0.3 g/d depending on the sex of
the fetus. The average birth weight during this period varies significantly, depending
on maternal race and ambient elevation.
Birth weights of women from different racial groups
When median term birth weights of newborns from women of different racial groups
are compared, significant differences are apparent. In a study that compared the
median birth weight for 17,347 newborns of white and black women of low
socioeconomic status in the United States from 1959-1966, the median birth weight
at 40 weeks' gestation for live-born white male singletons was 3350 grams
compared to 3210 grams for black male neonates (difference of 140 g). A similar
difference in median birth weight was also evident among female offspring, with
white female newborns at 40 weeks' gestation having a median birth weight of 3210
grams and black females having a median birth weight of 3100 grams (difference of
110 g).
Best method to determine the reference range for term birth weight
Perhaps the best method of defining the reference range for term birth weight is to
examine fetal weights at the two extremes of the reference range birth weight (ie,
5th-10th percentile at the lower end and 90th-95th percentile at the uppermost
extent). In the United States, a recent comprehensive study of 3,134,879 live births
from 1991 showed that from 38-42 weeks' gestation, the fifth percentile of birth
weight was 2543-2764 grams, the 10th percentile was 2714-2935 grams, the 90th
percentile was 3867-4098 grams, and the 95th percentile was 4027-4213 grams.
Perhaps the best method for establishing the reference range of term birth weight is
to define the point at which newborns begin to vary significantly from the mean with
respect to their overall prevalence of perinatal complications and perinatal death.
Even within neonatal groupings that are well matched for gestational age, poor
perinatal outcomes occur most frequently in fetuses who are born with weights at
the extreme ends of the birth weight range (ie, <10th percentile and >90th
percentile ranks for each gestational age). Using this approach to establish a
criterion, the reference range for term birth weight can be defined as approximately
3250 grams at the lower limit to approximately 4250 grams as an upper limit, or
3750 ±500 grams (8 lb 4 oz ±1 lb 2 oz).
Recently, a British cohort study of 3599 neonates of reference range weight during
1946 suggested that increasing term birth weight was correlated positively with
cognitive ability later in life. This result persisted even after neonates of low birth
weight weighing less than 2500 grams were eliminated from analysis, such that all of
the remaining neonates weighed 2500-5000 grams
DEFINITIONS OF DEVIATIONS IN FETAL GROWTH
Fetal weight categories
Fetal weight may be characterized as falling into 1 of 3 categories, as follows:
• Reference range (generally defined as between 10th and 90th percentile for
gestational age)
• Small for gestational age (<10th percentile)
• Large for gestational age (>90th percentile)
Until a fetus is delivered, only those methods that can evaluate fetal size in utero are
of any value in assessing into which of these 3 categories the fetus will fall.
Depending on the precise nature of the patient population used for establishing the
birth weight percentile ranks, these standards may be misleading if applied to other
sets of gravidas. For instance, if standard birth weight curves for white women are
applied inappropriately to black gravidas, a higher proportion of black women would
appear to have birth weights below the 10th percentile compared to a matched
group of white women.
Complications
The term low birth weight has been used to refer to different fetal weight ranges by
different authors during different eras. Whereas substantially excessive neonatal
morbidity and mortality was once associated with newborns weighing 2000-2500
grams, adverse neonatal outcomes attributable to low birth weight have been
impacted successfully by the more modern neonatal care that has become available
during the last quarter century. One classification scheme for the modern era that is
based on fetal weight alone divides underweight newborns into 3 distinct categories.
Using this schema, newborns can be categorized according to their risk for neonatal
complications, as follows:
• Low birth weight (1501-2500 g)

• Very low birth weight (1001-1500 g)
• Extremely low birth weight (500-1000 g)
Subclassifications within these 3 weight groups are possible, according to the overall
incidence of neonatal morbidity and mortality within each group and the gestational
age within these different categories (especially within the very low birth weight and
extremely low birth weight groups). Successfully classifying fetuses within each of
these 3 broad categories with improved accuracy in advance of delivery can
potentially aid in the prediction and possible avoidance of neonatal complications for
underweight newborns.
Fetal macrosomia
The term fetal macrosomia denotes a fetal size that is too large. Ideally, this
designation should be referenced to the mean of fetal and maternal dimensions
within a given population, but, rather arbitrarily, it has been defined previously as a
birth weight greater than 4000 grams, greater than 4100 grams, greater than 4500
grams, or greater than 4536 grams for all gravidas, depending on author and era.
When fetal macrosomia is considered a birth weight greater than 4000 grams (8 lb
13 oz), it affects 2-15% of all gravidas, depending on the racial, ethnic, and
socioeconomic composition of the population under study.
FACTORS CONTRIBUTING TO DIFFERENCES IN FETAL WEIGHT
Many factors, both endogenous and extrinsic, can influence fetal weight. These
include racial, physiologic, genetic, pathologic, and environmental factors, to include
the following:
• Maternal factors (eg, race, stature)

• Environmental factors (eg, altitude, availability of adequate nutrition)
• Physiologic factors (eg, altered glucose metabolism, microvascular integrity)
• Pathologic factors (eg, hypertension, uterine malformations)
• Complications of pregnancy (eg, gestational diabetes mellitus, preeclampsia)
Gestational age at delivery

Gestational age at delivery is the most significant single determinant of newborn
weight. Preterm delivery constitutes the single largest cause for low birth weight in
newborns . Other potential causes for low birth weight can be attributed collectively
to IUGR (previously termed intrauterine growth retardation). Causes include
intrauterine infections, congenital syndromes, genetic abnormalities, and chronic
uteroplacental insufficiency.
Maternal race
Another major determinant of fetal weight is maternal race. Black and Asian women
have smaller fetuses compared to white women when appropriately matched for
gestational age. Not surprisingly, white gravidas show a significantly higher
prevalence of fetal macrosomia compared with black and Asian gravidas, and
nonwhite gravidas have a significantly higher prevalence of small-for-gestational-age
newborns compared to white women.
Other maternal and pregnancy-specific determinants
After gestational age and maternal race, 6 other major maternal and pregnancy-
specific determinants of birth weight are relevant , which include the following:
• Maternal height
• Obesity
• Pregnancy weight gain
• Age
• Parity
• Fetal sex
Taken together, these measurable demographic factors can help explain more than
one third of the variance in term birth weight. By comparison, paternal factors are
only minimally important in determining fetal weight. Paternal height is the only
routinely measured paternal demographic variable that has significant influence on
fetal weight, but it accounts independently for less than 2% of the variance. Fetal
sex is associated significantly with birth weight; female fetuses are known to be
smaller than male fetuses when matched for gestational age. Although fetal sex is a
significant predictor of fetal weight, it accounts independently for less than 2% of the
variance.
Diabetes mellitus
Uncontrolled maternal diabetes mellitus is a condition commonly associated with

excessive fetal weight. Glucose is the primary substrate used by fetuses for growth.
When maternal glucose levels are excessive, abnormally high rates of fetal growth
can be expected. Even in women without frank diabetes mellitus, elevated glucose
screening test values in pregnancy predispose to increasing birth weight. Because of
the stringent glucose criteria now used to monitor and treat women with frank
diabetes during pregnancy, the group of women now most at risk for fetal
macrosomia are those who are unmonitored and untreated who have abnormal 1-
hour glucose screening test results during pregnancy and subsequently have normal
3-hour glucose tolerance tests with a single abnormal value indicative of only mild
glucose intolerance.
Other maternal illnesses and complications of pregnancy
Several maternal illnesses and complications of pregnancy are associated with

decreased birth weight. The most common associated illnesses are chronic maternal
hypertension and preeclampsia. Some intrauterine infections (eg, viral, parasitic,
bacterial) are associated with small-for-gestational-age fetuses. In addition, several
major environmental factors can have an adverse effect on fetal size, with the 2 chief
among these being high altitude and cigarette smoking.
DIAGNOSIS OF DEVIATIONS IN FETAL WEIGHT

Techniques for estimating fetal weight
All the currently available methods for assessing fetal weight in utero are subject to
significant predictive errors. These errors are the most clinically relevant at the 2
extremes of birth weight (eg, those <2500 g who are also more likely the products
of premature deliveries and those >4000 g who are at risk for the complications
associated with fetal macrosomia).
Tactile assessment of fetal size: The oldest technique for assessing fetal weight
involves the manual assessment of fetal size by the obstetrician. Worldwide, this
method is used extensively because it is both convenient and virtually costless;
however, it has long been known as a subjective method that is associated with
significant predictive errors.
Clinical risk factor assessment: Quantitative assessment of clinical risk factors

has previously been shown to be valuable in predicting deviations in fetal weight. In
the case of fetal macrosomia, the odds ratios for the presence of 12 clinical risk
factors are shown in Table 4.
Clinical Risk Factors for Fetal Weight Greater Than 4000 Grams
Risk Factors Percent of Patients with Odds Ratio for Presence

Macrosomic Fetuses with of Risk Factors Compared
Presence of Risk Factors with Controls
†
Maternal diabetes mellitus 2-30% 1.6-3
Abnormal 50-g GST‡ 15-27% 1.8-2.1
(without GDM§)
Abnormal single 3-h GTTll 8-34% 1.9-2.4
value
Prolonged gestation (>41 19-35% 5.5-5.9
wk)
Maternal obesity 16-37% 1.7-4.4
Pregnancy weight gain 21-56% 1.5-2.2
>35 lb
Maternal height >5 ft 3 in 20-24% 1.5-2
Maternal age >35 y 12-21% 1.3-2.3
Multiparity 64-93% 1.2-1.3
Male fetal sex 62-69% 1.2-1.4
White maternal race 45-94% 1.1-2.5
†
All classes, including gestational diabetes mellitus; the wide range of values reflects
differences among studies in the following: (1) criteria used for screening and
diagnosis, (2) prevalence of disease in the populations under study, and (3) success
of glucose control during pregnancy.
‡
GST - One-hour 50-gram oral glucose screening test
§
GDM - Gestational diabetes mellitus
ll
GTT - Three-hour 100-gram oral glucose tolerance test
Maternal self-estimation: A third method for estimating fetal weight is via

maternal self-estimation. Perhaps surprisingly, these maternal self-estimations of
fetal weight in multiparous women show comparable accuracy in some studies to
clinical palpation for predicting abnormally large fetuses .
Obstetric ultrasonography: The most modern method for assessing fetal weight
involves the use of fetal measurements obtained via obstetric ultrasonography. The
advantage of this technique is that it relies on linear and/or planar measurements of
in utero fetal dimensions that are definable objectively and should be reproducible.
Early expectations that this method might provide an objective standard for
identifying fetuses of abnormal size for gestational age were recently undermined by
prospective studies that showed ultrasonographic estimates of fetal weight to be no
better than clinical palpation for predicting fetal weight.
The sonographic prediction algorithms used to make fetal weight estimations in

these various studies were those of Shepard, Hadlock, Sabbagha, and Warsof, in
addition to the best of 8 algorithms based on various combinations of abdominal
circumference (AC), femur length (FL), biparietal diameter (BPD), and head
circumference (HC), both singly and in combination.
Taken together, these findings suggest that the prediction of fetal weight is not an
exact science and requires additional refinement.
ACCURACY OF FETAL WEIGHT PREDICTION USING DIFFERENT MET
Accuracy of clinical palpation for estimating fetal weight
Recently, several investigations showed that the accuracy of clinical palpation for
estimating fetal weight was ±278-599 grams and ±7.5-19.8%, depending on fetal
weight and gestational age. The technique is best for estimating fetal weight in the
reference range birth weight of 2500-4000 grams. Several studies show that the
accuracy of clinical palpation for estimating fetal weight below 2500 grams
deteriorates markedly, with a mean absolute percentage error of ±13.7-19.8%. Only
40-49% of birth weights below the 2500-gram threshold are estimated properly by
clinical palpation to within ±10% of actual birth weight. If less than 1800 grams, the
accuracy of such clinical estimates is reduced even further, with more than half of
these predictions off by more than 450 grams (±25%).
One recent study shows that the sensitivity of clinical palpation for identifying birth
weight of less than 2500 grams is only 17%, with an associated positive predictive
value of 37%. At the upper limit of term fetal weights, 2 recent studies show that the
positive predictive value of clinical palpation for predicting birth weight of greater
than 4000 grams is 60-63%, with an associated sensitivity of 34-54%.
Furthermore, 2 studies previously suggested that the accuracy of this technique does
not depend on the level of training of the operator, whereas another recent study
suggests that resident physicians in obstetrics and gynecology are systematically
better than medical students at estimating term birth weights using this technique.
Using this method, the mean absolute percentage error in birth weight prediction for
term fetuses greater than 37 weeks' gestation is 7.2-10.6% . For a fetus predicted to
weigh more than 4000 grams, the average error in birthweight estimation routinely
exceeds 300-400 grams. In one study, more than 6% of fetal weights were wrongly
assessed by more than 1370 grams (3 lb).
Accuracy of obstetric ultrasonography for estimating fetal weight
Obstetric sonographic assessment for the purpose of obtaining fetal biometric

measurements to predict fetal weight has been integrated into the mainstream of
obstetric practice during the past quarter century. From its inception, this method
has been presumed to be more accurate than clinical methods for estimating fetal
weight. The reasons for this assumption vary, but the fundamental underlying
presumption is that the sonographic measurements of multiple linear and planar
dimensions of the fetus provide sufficient parametric information to allow for
accurate algorithmic reconstruction of the 3-dimensional fetal volume of varying
tissue density. Consistent with these beliefs, much effort has generated best-fit fetal
biometric algorithms that can help make birth weight predictions based on obstetric
ultrasonographic measurements. As such, the ultrasonographic technique represents
the newest and most technologically sophisticated method of obtaining birth weight
estimations.
Modern algorithms that incorporate standardly defined fetal measurements (eg,

some combination of AC, FL, and either BPD or HC) are generally comparable in
terms of overall accuracy in predicting birth weight. The most commonly used fetal
biometric algorithms are shown in Table 6. When other sonographic fetal
measurements are used to estimate fetal weight (eg, humeral soft tissue thickness,
ratio of subcutaneous tissue to FL, cheek-to-cheek diameter), these nonstandard
measurements do not significantly improve the ability of obstetric sonography to
help predict birth weight, except in special patient subgroups (eg, mothers with
diabetes).
Table . Ultrasonographic Fetal Biometric Prediction Algorithms for Calculating

Estimated Fetal Weight*
Source Year Equation

Shepard 1982 Log10 BW* = -1.7492 +
0.0166 (BPD†) + 0.0046
(AC‡) - 0.00002646 (AC X
BPD)
Campbell 1975 Ln§ BW = -4.564 + 0.0282
(AC) - 0.0000331 (AC)2
Hadlock 1 1985 Log10 BW = 1.326 -
0.0000326 (AC X FLll) +
0.00107 (HC¶) + 0.00438
(AC) + 0.0158 (FL)
Hadlock 2 1985 Log10 BW = 1.304 +
0.005281 (AC) + 0.01938
(FL) - 0.00004 (AC X FL)
Hadlock 3 1985 Log10 BW = 1.335 -
0.000034 (AC X FL) +
0.00316 (BPD) + 0.00457
(AC) + 0.01623 (FL)
Warsof 1 1986 Ln BW = 4.6914 +
0.00151 (FL)2 - 0.0000119
(FL)3
Warsof 2 1986 Ln BW = 2.792 + 0.108
(FL) + 0.000036 (AC)2 -
0.00027 (FL X AC)
Combs 1993 BW = [0.00023718 X
(AC)2 X (FL)] +
0.00003312 (HC)3
Ott 1986 Log10 BW = 0.004355 (HC)
+ 0.005394 (AC) -
0.000008582 (HC X AC) +
1.2594 (FL/AC) - 2.0661
*BW - Estimated fetal weight (g)

†
BPD - Fetal biparietal diameter (mm)
‡
AC - Fetal abdominal circumference (mm)
§
Ln – Natural logarithm
ll
FL - Fetal femur length (mm)
¶
HC - Fetal head circumference (mm)
In a recent study of 1034 patients, the mean absolute percentage error associated
with the calculation of estimated fetal weights based on fetal measurements of BPD,
AC, and FL (according to a widely used equation of Hadlock) was 10.0-11.3%,
depending on the gestational age of the fetus (ie, after a crude stratification of fetal
size). When the mean absolute percentage error of the method is assessed for 3
different clinically significant ranges of fetal weight (ie, <2500 g, 2500-4000 g,
>4000 g), the mean absolute percentage error of the technique typically is lowest
(±7.1-10.5%) for the mid range (2500-4000 g) and higher values of fetal weight
(>4000 g) and slightly greater for fetuses weighing less than 2500 grams (±8-11%).
When another commonly used measure of accuracy is used (the percentage of

fetuses with weight accurately estimated to within ±10% of actual birth weight),
56% were predicted accurately to within these limits for fetuses weighing less than
2500 grams, 58% for fetuses weighing 2500-4000 grams, and 62% for fetuses with
actual birth weights greater than 4000 grams.
When the accuracy of the detection of clinically relevant deviations in term birth weight
is assessed using the sonographic technique (ie, ability of the sonographic method to help
accurately identify term fetuses weighing <2500 g, >4000 g, and >4500 g), the positive
predictive value is 44-55%, with associated sensitivities of 58-71%. For preterm fetuses
delivered at less than 37 weeks' gestation, the one-way accuracy of such sonographic fetal
biometric classifications of clinically significant birth weight deviations (ie, low birth
weight) is better; the positive predictive value of a sonographic estimate of fetal weight
less than 2500 grams is 87% for preterm fetuses, with an associated sensitivity of 90%,
and the positive predictive value for a sonographic estimate of fetal weight less than 1500
grams is 86%, with an associated sensitivity of 93%.
The notion that multiple obstetric sonographic fetal biometric evaluations might
prove superior to a single examination for predicting fetal weights has been
examined. One recent study evaluated the advantage of multiple ultrasonographic
examinations compared with a single examination for the purpose of estimating fetal
weight. The accuracy of birth weight percentile predictions was similar whether one
or multiple such examinations were performed during the third trimester. In this
study, which used the ultrasonic algorithm of Shepard, 38% of the fetuses had their
weight accurately estimated to within ±10% after a single ultrasonographic
assessment of fetal dimensions and 42% had such predictions correct to within
±10% after multiple sonographic examinations were performed. No statistically
significant difference occurred in accuracy between these 2 approaches.
The sensitivity, specificity, positive predictive value, and negative predictive value for
the prediction of both small-for-gestational-age and large-for-gestational-age fetuses
using these sonographically derived estimated fetal weights, which are obtained from
one or more sonographic examinations, are shown in Table below
Table. Accuracy of Single Versus Multiple Sonographic Fetal Biometric Examinations

for Detecting Clinically Relevant Deviations in Fetal Weight
Positive
Actual Birth Negative
Sensitivity Specificity Predictive
Weight Predictive Value
Value
Small for gestational age (<10th percentile)†
Single examination 100% 76% 25% 100%
Multiple examinations 100% 75% 25% 100%
Large for gestational age (>90th percentile)†
Single examination 48% 94% 63% 89%
Multiple examinations 62% 100% 100% 92%
*Adapted from Hedriana et al

†
Prevalence of small-for-gestation-age fetuses in the series was 7.2% (19 of 264
patients), and the prevalence of large-for-gestation-age fetuses was 17.4% (46 of
264 patients).
Another question is the potential difference in the predictive accuracy of fetal weight
estimates made using fetal biometric measurements obtained by professional
sonographers in a controlled setting compared with hospital-based resident
physicians performing studies in a labor and delivery unit. Although the interobserver
variation in ultrasonic fetal biometric measurements has been shown to be small,
these differences may still introduce unacceptable variability into the parameters
employed for fetal weight estimation by fetal biometric algorithms.
In a recent study designed to address this clinically important question, the mean
absolute percentage error associated with ultrasonographic estimates of fetal weight
by house staff physicians in a labor and delivery suite (±9.3%) was comparable to
that reported by professional ultrasonographers in a controlled setting. Thus, no
clinically important systematic bias is introduced into such results based on
differences in operator training or diagnostic setting.
Several technical limitations of the sonographic technique for estimating fetal weight
are well known. Among these are maternal obesity, anterior placentation, and
oligohydramnios.
Recently, several studies challenged the overall accuracy of sonographic birth weight
estimations. More than a dozen investigations concluded that ultrasonography may
be no more accurate for predicting birth weight than clinical palpation or even
maternal self-estimations of fetal weight. Two of these studies also suggested that
quantitative assessment of maternal characteristics may be as accurate as obstetric
ultrasonography for the purpose of predicting the occurrence of fetal macrosomia.
Maternal self-estimations of fetal weight
Recently, 3 studies examined the accuracy of patient self-estimations of fetal weight

by parous women. The mean absolute percentage errors for these birth weight
predictions was 8.7-9.5% for term fetuses, with mean absolute birth weight errors of
305-350 grams. In a small study that reported the sensitivity for macrosomia
greater than 4000 grams, it was 56% . These results seem comparable to those
reported for both clinical palpation and obstetric ultrasonography.
Predicting fetal weight using an algorithm derived from maternal and

pregnancy-specific characteristics
Recently, a new, theoretically defensible equation that can predict individual birth
weights prospectively from maternal characteristics was developed. To do this, the
predictive efficacy of 59 scientifically justifiable terms was evaluated simultaneously,
obviating any confounding covariation and determining which of the predictors could
account for variations in birth weight that others could not. Aside from maternal
race, only 6 maternal and pregnancy-specific variables were important in the
prediction of birth weight for otherwise normal gravidas. Only one additional paternal
factor was found to be independently predictive of birth weight (ie, paternal height),
but it accounts separately for less than 2% of the variance.
Using these routinely recorded variables, an equation based on maternal

demographic and pregnancy-related characteristics alone was developed to help
predict birth weight based on the following:
• Maternal height
• Maternal weight at 26 weeks' gestation
• Maternal weight gain rate during the third trimester
• Parity
• Fetal sex
• Gestational age at delivery
These prospectively measurable variables can explain 36% of the variance in term
birth weight and can help predict birth weight accurately to within ±267 grams
(±7.6% of individual birth weights). In addition, 75% of newborn weights can be
estimated properly to within ±10% of actual birth weight using this technique.
Equation 1, the equation generated for this purpose, is as follows:
Birth weight (g) = gestational age (d) X [9.36 + 0.262 X fetal sex +
0.000237 X maternal height (cm) X maternal weight at 26 wk (kg) +
4.81 X maternal weight gain rate (kg/d) X (parity + 1)], where fetal
sex is equal to +1 for males, -1 for females, and 0 for unknown sex
and gestational age is equal to days since onset of last normal
menses, which equals the conception age (d) + 14.
Which of the methods for predicting fetal weight is the most accurate?
The accuracy of the different methods of predicting fetal weight depends on the
gestational age and range of birth weights under study. Again, for this purpose,
dividing fetuses into 3 birth weight categories of less than 2500 grams, 2500-4000
grams, and greater than 4000 grams is useful. . For the clinically significant birth
weight ranges of less than 2500 grams and greater than 4000 grams, the accuracy
of sonographic fetal biometry appears to be superior to clinical palpation for
predicting the occurrence of low birth weight fetuses weighing less than 2500 grams,
whereas the 2 techniques appear to be comparable in predictive accuracy for fetuses
weighing 2500 grams or more.
A recent study directly comparing the 4 different methods of fetal weight prediction
in 44 normal term pregnancies found no difference between the accuracy of the
clinical methods (eg, clinical palpation, birth weight prediction equation, maternal
self-estimation of fetal weight) and ultrasonic fetal biometric techniques for
predicting term birth weight. Eight different ultrasonic fetal biometric algorithms
were assessed for this purpose. The mean birth weight for newborns in this study
was 3445 ±458 grams, with a birth weight range of 2485-4790 grams. No
systematic advantage was found with the ultrasonic technique for predicting term
birth weight over the clinical methods.
Seven other recent studies directly compared the accuracy of clinical palpation to
ultrasonographic fetal biometry using the same gravidas , and 3 compared clinical
palpation to parous patients' self-estimates of fetal weight after 37 completed weeks'
gestation.
One study compared clinical palpation to both ultrasonographic fetal biometry and
parous patients' self-estimations of fetal weight. All of the methods have significant
predictive errors in birth weight estimations for term fetuses that range from 290-
560 grams, and no consistent or clear superiority of ultrasonographic fetal biometry
over the other techniques of fetal weight estimation was found.
DIAGNOSING SIGNIFICANT DEVIATIONS IN FETAL WEIGHT AN

MANAGEMENT OPTIONS
Developing a consensus of indicators
All currently available techniques for estimating fetal weight have significant degrees
of inaccuracy. Wikstrom et al demonstrated that by combining clinical and
ultrasonographic data about fetal size, an improved accuracy in fetal weight
estimations can be obtained. Based on this finding, a reasonable strategy for arriving
at estimated fetal weight is to use multiple estimates based on different sources of
clinical and sonographic information. If such a strategy is accepted, then a practical
and semiquantitative schema for making an accurate antenatal diagnosis of fetal
weight in the clinical setting can be suggested, as follows:
• First, assess maternal risk factors for predispositions to fetal growth

deviations at the initial prenatal visit and again at the start of the third
trimester. Any gravida who has one or more of the following conditions should
be considered at high risk for abnormal fetal growth and should undergo
further assessment via other techniques to estimate their fetal weight:
o Poorly controlled diabetes mellitus (any class, including gestational

diabetes)
o Abnormal 1-hour glucose screening test result (>135 mg/dL)
o Single abnormal value on 3-hour oral glucose tolerance testing
o Obesity
o Abnormally tall or short stature
o Excessive or inadequate pregnancy weight gain
o High parity
o Preterm gestation
o Postdate pregnancy
o Chronic hypertension
o Preeclampsia (including pregnancy-induced hypertension, HELLP
syndrome [hemolysis, elevated liver enzymes, and low platelet count])
o Microvascular disease
o Cigarette smoking
o Residence at high altitude
• Once a gravida is thought to be at risk for either excessive fetal growth or
IUGR, employ all applicable test modalities to determine which of the different
methods (if any) suggest that the fetus has a weight outside of the reference
range for its gestational age.
o The standard fetal weight for comparison can be obtained from the
50th percentile rank of published fetal growth curves that are derived
from patient populations that are well matched to the particular
patient under consideration.
o Clinical palpation and ultrasonographic fetal biometry can always be
used to obtain an estimate of fetal size, regardless of gestational age.
o Additionally, the current version of the birth weight prediction equation
can be used to estimate the upper fetal weight limit for pregnancies in
normal gravidas of all races at or near term.
o If any 2 modalities suggest that the fetal weight is abnormal for
gestational age (ie, >2 SD from the expected mean or 50th percentile
rank value), then presume that the fetus is growing at an abnormal
rate.
o If so, then institute serial assessments of fetal growth to determine the
velocity of ongoing fetal weight gain.
o If both fetal weight for gestational age and the velocity of fetal weight
gain are abnormal, the evidence for a significant abnormality in fetal
growth becomes more compelling. Under such circumstances, manage
the pregnancy accordingly, with the presumption that the fetal size is
outside the reference range of expected values.
Option for suppression of labor in women carrying undersized fetuses
In general, the case can be made to attempt labor suppression in women carrying preterm
fetuses weighing less than 2000-2500 grams. As stressed previously, most low weight
fetuses are associated with preterm gestations. However, any recommendation in this
circumstance regarding tocolysis presupposes the following: (1) no immediate fetal or
maternal indications mitigate toward the timely delivery of the undersized fetus and (2)
the undersized fetus will continue to grow along an acceptable growth curve if the
gestation is allowed to continue. In many cases, both of these assumptions are invalid.
For instance, many women who deliver preterm neonates are allowed to do so because of
compelling fetal or maternal medical conditions that warrant timely delivery (eg,
intrauterine infection, severe uteroplacental insufficiency, severe preeclampsia). If fetal
infection or IUGR is present, the preterm delivery of an underweight fetus may be
indicated.
The increased risk of perinatal complications associated with the delivery of an

underweight fetus in these circumstances may be outweighed entirely by the increased
risk of morbidity and mortality for both the fetus and mother with allowing the pregnancy
to continue. Additionally, in some circumstances, the inadequate velocity of fetal growth
might mandate a decision for delivery. In such cases, the presumption is that extrauterine
growth and development in the neonatal nursery would be superior to that achieved in
utero. Clinical judgment under such circumstances is of paramount importance in
deciding when to effect delivery and when to attempt labor suppression. More detailed
considerations for aiding in this decision are beyond the scope of this article.
Option for labor induction in women carrying oversized fetuses
For fetuses delivered before 37 weeks' gestation, fetal macrosomia is a rarity; more
than 99% of macrosomic fetuses are the product of term gestations. In general,
nearly 95% of fetuses gain 12.7 ±2.8 g/d from 37-42 weeks' gestation, indicating
that an average fetus gains an additional 445 ±98 grams (1 lb ±3 oz) during this
period. If a patient is thought to have a term fetus weighing more than 4000 grams
and is willing to undergo labor induction, effecting vaginal delivery in these gravidas
sooner, rather than awaiting the onset of spontaneous labor and a higher average
birth weight at delivery, is often reasonable.
In studies that have attempted to examine this question, labor induction has not
been demonstrated conclusively to decrease the fetal and maternal risks of
intrapartum complications, and the cesarean delivery rate has been suggested to
increase in several studies, whereas it has been purported to be unchanged in
others. The difficulty in interpreting these results is that significant differences have
been found among the predicted and actual birth weights for patients included for
investigation and the power of the studies conducted to date has been insufficient to
conclusively demonstrate statistically significant differences in adverse fetal
outcomes among different study groups.
As with the case of preterm delivery of underweight fetuses, many considerations,

including the size of the maternal pelvis and the weight of previously delivered
fetuses, should be taken into consideration. Clinical judgment in these circumstances
is of paramount importance in deciding whether or not labor induction is indicated in
an attempt to minimize excessive fetal weight at delivery.
Conclusions
Both low birth weight (<2500 g) and high birth weight (>4000 g) are fetal conditions
that are associated with increased risks of peripartum morbidity and mortality.
Although the absolute risk that fetuses with birth weights of 2000-2500 grams and
4000-4500 grams will have major peripartum complications is not overwhelming, the
risk of such complications increases substantially with both decreasing and increasing
birth weight relative to these lower and upper limits. Thus, birth weight and
gestational age are both important determinants of peripartum outcome. From this
standpoint, the optimal range of newborn weight generally is thought to be 3000-
4000 grams (6 lb 10 oz to 8 lb 13 oz). As always, the problem is knowing the fetal
weight with sufficient accuracy in advance of delivery.
Many factors that impact directly upon birth weight are not modifiable. These include
maternal race, height, parity, paternal height, and fetal sex. However, what can be
influenced with potentially significant effects upon birth weight are the following:
• Prepregnancy weight
• Pregnancy weight gain
• Glucose control in patients with diabetes or glucose intolerance of pregnancy
• Gestational age at delivery
All of these factors can have significant impacts on fetal weight at delivery. Whereas
permitting the delivery of fetuses that weigh 2000-2499 grams typically is not
associated with an overwhelming increase in neonatal complications compared with
normal-weight neonates, those fetuses weighing less than 2000 grams at birth are at
increased risk for perinatal complications in a manner that is commensurate with
their weight.
Similarly, whereas allowing a trial of a vaginal delivery for a fetus estimated to weigh
4000-4499 grams may be reasonable in many circumstances, many sources suggest
that fetuses with estimated weights of 4500 grams or greater should be delivered by
cesarean birth in order to avoid the increased intrapartum risks associated with the
vaginal delivery of a macrosomic fetus. This is especially true when gestational
diabetes is involved and the fetal conformation may be altered to reflect a larger
shoulder girdle or head circumference ratio compared with the offspring of mothers
without diabetes.
In the case of macrosomic fetuses, attempts to predict birth weight from fetal
measurements obtained via ultrasonography have proven unsuccessful from the
standpoint of improving clinical outcomes. Many studies conclude that
ultrasonographic fetal biometric assessments are no more predictive of fetal
macrosomia than clinical assessments of fetal size by simple external abdominal
palpation. Both ultrasonography and manual assessment of fetal size have
sensitivities of less than 60% for the prediction of fetal macrosomia, with false-
positivity rates greater than 40%. Likewise, for small fetuses less than 1800 grams,
ultrasonic fetal weight estimates are often in error by as much as 25%.
By using a birth weight prediction equation that is based on maternal and

pregnancy-specific characteristics alone, fetal weight at and near term can be
predicted with a high degree of accuracy (±7.6%). This approach appears to be at
least as reliable for predicting fetal macrosomia in healthy gravidas as both clinical
palpation and ultrasonographic fetal biometry, neither of which can be used with any
degree of certainty in advance of the date of delivery. Such a quantitative
assessment of maternal characteristics serves to objectively quantify the majority of
previously recognized clinical variables that have long been employed in subjective
clinical assessments and that are thought to be predictive of fetal weight.
By contrast, clinical palpation is a subjective methodology that must be employed at

or near the date of delivery, and it is both patient- and clinician-dependent for its
success (ie, less accurate for obese than nonobese gravidas, significant for
interobserver variation in birth weight predictions even among experienced
clinicians).
The disadvantages of ultrasonographic fetal biometry are that the method is both
complicated and labor-intensive, potentially being limited by suboptimal visualization
of fetal structures. It also requires costly sonographic equipment and specially
trained personnel. Although such expensive imaging equipment is widely available in
the United States and other industrialized countries, this is generally not the case in
developing nations, where medical resources are often scarce.
In the future, combining the different methods of fetal weight prediction to improve
their overall accuracy may be possible. Wikstrom et al suggested that by combining
the independent information about fetal size obtained from the 3 different
approaches (ie, clinical examination, quantitative assessment of maternal
characteristics, ultrasonographic fetal biometry), the predictive value of fetal weight
estimations can be improved dramatically. In the case of excessive fetal size,
combining these methodologies may result in an 80% positive predictive value for
the identification of fetal macrosomia, with a sensitivity of 63% and specificity of
95%.
Recently, a quantitative combination of maternal demographic information (of the

type incorporated in Equation 1) with the independent information obtained by
ultrasonic fetal biometry (AC) has been demonstrated to improve birth weight
prediction substantially, with the area under the receiver operating characteristic
curve increasing to 0.92. The mean absolute percentage error in birth weight
predictions that can be attained using this new combinatorial method is ±5.4%.
With the advent of 3-dimensional fetal imaging, optimism that these new
technologies can provide even better fetal weight estimations may be justified, but
the advantages of estimating fetal weight using these newer techniques have not yet
been demonstrated. Using these new approaches, further improvements in the
accuracy of fetal weight prediction in the future will permit prospective obstetric
intervention to be undertaken more confidently by practicing obstetricians, with the
aim of minimizing intrapartum and peripartum risks for both fetuses and mothers. <!
[endif]>
Fetal development
Conception
See what happens inside you during the conception process.
• Fertilization
• How BabyCenter works out how pregnant you are

One Month
Your baby is an embryo consisting of two layers of cells from which all her
organs and body parts will develop.
• 4 weeks • Twins - 3 weeks

• 5 weeks
• 7 weeks
Two Months
Your baby is now about the size of a kidney bean and is constantly moving. He
has distinct, slightly webbed fingers.

• 9 weeks
• 11 weeks
• 12 weeks
Three Months
By now your baby is around 7 to 8 centimeters (3 inches) long and weighs about
the same as half a banana. Her tiny, unique fingerprints are now in place.

• 14 weeks
• 15 weeks
• 16 weeks
Four Months
Your baby is now about 13 centimeters ( 5.5 inches) long and weighs 140
grams (5 ounces). His skeleton is starting to harden from rubbery cartilage to
bone.

• 18 weeks
• 19 weeks
• 20 weeks
Five Months
Eyebrows and eyelids are now in place. Your baby would now be more than 27
centimeters (10.5 inches) long if you stretched out her legs.

• 22 weeks
• 23 weeks
• 24 weeks
Six Months
Your baby weighs about a 660 grams (1.5 pounds). His wrinkled skin is starting
to smooth out as he puts on baby fat.

• 26 weeks
• 27 weeks
• 28 weeks
• 29 weeks
Seven Months
By now, your baby is more than 40 centimeters (15 inches) long. She can open
and close her eyes and probably see what's around her.

• 31 weeks
• 32 weeks
• 33 weeks
Eight Months
Your baby now weighs around 2.2 kilos (4.7 pounds). His layers of fat are filling
him out, making him rounder, and his lungs are well developed.

• 35 weeks
• 36 weeks
• 37 weeks
• 38 weeks
Nine Months
Your baby is almost due. At birth, the average baby is more than 51 centimeters
(20.5 inches) long from head to toe and weighs approximately 3.4 kilograms (7.5
pounds), but babies vary widely in size at this stage.
• 39 weeks
Summaries For Each Month
See how your baby is developing in more detail. Check out our fetal
development illustrations with interactive glossary.
• 1 Month
• 2 Months
• 3 Months
• 4 Months
• 5 Months
• 6 Months
• 7 Months
• 8 Months
• 9 Months
Prenatal care
From Wikipedia, the free encyclopedia
Jump to: navigation, search
A doctor performs a prenatal exam.
Prenatal care refers to the medical care recommended for women before and during
pregnancy. The aim of good prenatal care is to detect any potential problems early, to
prevent them if possible (through recommendations on adequate nutrition, exercise,
vitamin intake etc), and to direct the woman to appropriate specialists, hospitals, etc. if
necessary. The availability of routine prenatal care has played a part in reducing maternal
death rates and miscarriages as well as birth defects, low birth weight, and other
preventable infant problems in the developed world[citation needed].
While availability of prenatal care has considerable personal health and social benefits,
socioeconomic problems prevent its universal adoption in many developed as well as
developing nations.
One prenatal practice is for the expecting mother to consume vitamins with at least 400
mcg of folic acid to help prevent neural tube defects.
Prenatal care generally consists of:
• monthly visits during the first two trimesters (from week 1-28)
• biweekly from 28 to week 36 of pregnancy
• weekly after week 36 (delivery at week 38-40)
[edit] Physical examination

Physical examinations generally consist of:
• Collection of (mother's) medical history

• Checking (mother's) blood pressure
• (Mother's) height and weight
• Pelvic exam
• Doppler fetal heart rate monitoring
• (Mother's) blood and urine tests
• Discussion with caregiver
[edit] Ultrasound
Obstetric ultrasounds are most commonly performed during the second trimester at
approximately week 20. Ultrasounds are considered relatively safe and have been used
for over 35 years for monitoring pregnancy.
Among other things, ultrasounds are used to:
• Diagnose pregnancy (uncommon)

• Check for multiple fetuses
• Determine the sex of the fetus
• Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic
pregnancy, or a molar pregnancy condition)
• Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched
fists)
• Determine if an intrauterine growth retardation condition exists
• Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull,
other bones)
• Check the amniotic fluid and umbilical cord for possible problems
• Determine due date (based on measurements and relative developmental progress)
Generally an ultrasound is ordered whenever an abnormality is suspected or along a

schedule similar to the following:
• 7 weeks - confirm pregnancy, ensure that it's neither molar or ectopic, determine
due date
• 13-14 weeks (some areas) - evaluate the possibility of Down Syndrome
• 18-20 weeks - see the expanded list above
• 34 weeks (some areas) - evaluate size, verify placental positION
What is Intranatal Care?

Intranatal Care refers to the process of Childbirth. Intranatal care is of extreme
importance for every pregnancy. Such level of care strongly emphasizes on grate deal of
safe procedures on the following:
* Clean surrounding of the Labour Room and the other rooms connected to it.
* Clean hands and hygienic practices
* Following safe and hygienic delivery practices
* Maintaining highest standards of sterility of tools and instruments.
If you happen to go for labour or to assist someone whom you know, make sure the
above mentioned points are followed or else places not keeping above standards would
not be a good place for delivery.
What is the purpose of Intranatal Care?
Intranatal care aims to provide:
* Clean and hygienic delivery conditions

* Safe delivery with minimum injury to the infant and mother
* Preparedness to deal with complications such as prolonged labour, antepartum
hemorrhage, convultions, malpresentations, prolapse of the cord etc.
* Care of the baby
Post Natal Care:
What is postnatal care?
The care of the mother and the newborn child after delivery is known as postnatal care. It
is also called post partal care.
Objectives of Care to Mother:
* To prevent complications of postpartal period

* To provide care for the rapid restoration of the mother to optimum health.
* To check adequacy of breast feeding.
* To provide family planning services
* To provide basic health education to mother and family
Essential Physical Care for Mother:
It should be made sure the mother has three checkups a day for three days after delivery.
The following vitals are supposed to be kept under observation:
* Body temperature
* Pulse & respiration
* Breasts
* Urine and bowel checks
* Involution of uterus
* Keeping check for any sort of infection
* Anaemia
* Nutrition
Frequency of Post natal Checkups:

Three times a day for three days after delivery
Once or twice a week for first few weeks
Once a month for first 6 months
Once in 2-3 months for end of one year
( Make sure you are always in touch with your gynecologist as the frequency of postnatal
check-ups may differ from various cases and incase you notice any sort or abnormality or
discomfort, make sure you visit a doctor soon in order to avoid matters from getting
worse.)
Psychological Health:
As women undergo a lot during and post pregnancy there are possibilities of women
tending to get stressed, frustrated ,insecure or at times even unwillingness towards the
baby itself ie. Postpartum Depression
It is advised that the spouse and family members around should give plenty of emotional
and physical support during and after pregnancy in order to ensure support for the
mother.
Make a point to make those mothers suffering from Postpartum depression undergo
counseling as some take very extreme actions at such a phase.
Care for the baby:
• Make sure the baby is breastfed at proper intervals.
• Change baby diapers regularly and maintain good hygienic practices of cleansing and
using baby wipes.
• Always look out that your baby is comfortable, do make it a point to check the baby if it
cries even after comforting
• The mother’s diet should be free of junk food or items that create gastric effects.
• This makes the baby difficult to digest mother’s milk and can be one factor for colic as
well.
• Keep track of all the vaccinations and other immunization schedules that need to be
followed as per baby’s physician.
• Spend as much time as you can with your baby, this helps child & parental bonding.
• Ensure the baby is put to sleep in proper posture.

Postpartum care: What to expect after a
vaginal birth
Postpartum care involves managing sore breasts, hair loss, mood
changes and more. Here's what to expect as you recover from childbirth.
By Mayo Clinic staff
Pregnancy changes your body in more ways than you may have guessed, and it doesn't stop
when the baby is born. Postpartum care involves managing sore breasts, skin changes, hair
loss and more. Here's what to expect after delivery.
Vaginal soreness
If you had an episiotomy or vaginal tear during delivery, the wound may hurt for a few weeks
— especially when you walk or sit. More extensive tears may take longer to heal. In the
meantime, you can help promote healing:
 Soothe the wound. Use an ice pack, or wrap ice in a washcloth. Chilled witch hazel
pads may help, too. Witch hazel is the main ingredient in many hemorrhoid pads. You
can find witch hazel pads in most pharmacies.
 Keep the wound clean. Use a squirt bottle filled with water to rinse the tissue
between the vaginal opening and anus (perineum) after using the toilet. Soak in a
warm tub.
 Take the sting out of urination. Squat rather than sit to use the toilet. Pour warm
water over your vulva as you're urinating.
 Prevent pain and stretching during bowel movements. Hold a clean pad firmly
against the wound and press upward while you bear down. This will help relieve
pressure on the wound.
 Sit down carefully. To keep your bottom from stretching, squeeze your buttocks
together as you sit down. If sitting is uncomfortable, use a doughnut-shaped pillow to
ease the pressure.
 Do your Kegels. These exercises help tone the pelvic floor muscles. Simply tighten
your pelvic muscles as if you're stopping your stream of urine. Starting about a day
after delivery, try it for five seconds at a time, four or five times in a row. Repeat
throughout the day.
 Look for signs of infection. If the pain intensifies or the wound becomes hot,
swollen and painful or produces a pus-like discharge, contact your health care
provider.
Vaginal discharge
You'll have a vaginal discharge for up to six weeks after delivery. Expect a bright red, heavy
flow of blood for the first few days. If you've been sitting or lying down, you may notice a
small gush when you get up. The discharge will gradually taper off, changing from pink or
brown to yellow or white. To reduce the risk of infection, use sanitary napkins rather than
tampons.
Don't be alarmed if you occasionally pass blood clots. Contact your health care provider if:
 You soak a sanitary pad every hour for more than two hours
 The discharge has a foul odor
 You pass clots larger than a golf ball
 You have a fever of 100.4 F (38 C) or higher
Contractions
You may feel contractions, sometimes called afterpains, during the first few days after
delivery. These contractions help prevent excessive bleeding by compressing the blood vessels
in the uterus. Afterpains tend to occur during breast-feeding sessions and seem to be more
noticeable with second or third babies. Medications to control heavy bleeding after delivery can
increase afterpains as well.
Usually afterpains resemble menstrual cramps. If necessary, your health care provider may
prescribe pain medication. Many medicines are safe even if you're breast-feeding. Contact
your health care provider if you have a fever or if your abdomen is tender to the touch. These
signs and symptoms could indicate a uterine infection.
Difficulty urinating
Swelling or bruising of the tissues surrounding the bladder and urethra may lead to difficulty
urinating. Fearing the sting of urine on the tender perineal area may have the same effect. To
encourage urination, contract and release your pelvic muscles while sitting on the toilet. It
may help to place hot or cold packs on the tissue between the vaginal opening and anus,
straddle the toilet like a saddle or pour water across your vulva while you urinate.
Difficulty urinating usually resolves on its own. Contact your health care provider if:
 It hurts to urinate
 You don't think you're emptying your bladder fully
 You have an unusually frequent urge to urinate
These may be symptoms of a urinary tract infection.
Leaking urine
Pregnancy and birth stretch the connective tissue at the base of the bladder and may cause
nerve and muscle damage to the bladder or urethra. You may leak urine when you cough,
strain or laugh. Fortunately, this problem usually improves within three months. In the
meantime, wear sanitary pads and do your Kegel exercises.
Hemorrhoids
If you notice pain during a bowel movement and feel swelling near your anus, you may have
hemorrhoids — stretched and swollen veins in the anus or lower rectum. To ease any
discomfort while the hemorrhoids heal, soak in a warm tub and apply chilled witch hazel pads
to the affected area. Your health care provider may recommend a topical hemorrhoid
medication as well.
To prevent constipation and straining, which contribute to hemorrhoids, eat foods high in fiber
— including fruits, vegetables and whole grains — and drink plenty of water. Remain as
physically active as possible. If your stools are still hard, your health care provider may
recommend an over-the-counter stool softener or fiber laxative.
Postpartum care: What to expect after a vaginal birth

Bowel movements
You may find yourself avoiding bowel movements out of fear of hurting your perineum or
aggravating the pain of hemorrhoids or your episiotomy wound. To keep your stools soft and
regular, eat foods high in fiber, drink plenty of water and remain as physically active as
possible. Ask your health care provider about a stool softener or fiber laxative, if needed.
Another potential problem for new moms is the inability to control bowel movements (fecal
incontinence) — especially if you had an unusually long labor. Frequent Kegel exercises can
help. If you have persistent trouble controlling bowel movements, consult your health care
provider.
Sore breasts and leaking milk

Several days after delivery, your breasts may become heavy, swollen and tender. This is
known as engorgement. The discomfort usually lasts less than three days. In the meantime, it
helps to express milk — preferably by feeding your baby. If your baby isn't able to nurse, use
a breast pump to ease engorgement. You may also want to apply warm or cold washcloths or
ice packs to your breasts, or take a warm bath or shower. Over-the-counter pain relievers
such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others) may help, too.
If you're not breast-feeding your baby, wear a firm, supportive bra. Compressing your breasts
will help stop milk production. In the meantime, don't pump your breasts or express the milk.
This only tells your breasts to produce more milk.
Leaky breasts are another common problem for new moms. You can't do anything to stop the
leaking, but nursing pads worn inside your bra can help keep your shirt dry. Avoid pads that
are lined or backed with plastic, which can irritate your nipples. Change pads after each
feeding and whenever they get wet. If nighttime leaking is a problem, place a towel under
your breasts at night.
Hair loss
During pregnancy, elevated hormone levels put normal hair loss on hold. The result is often an
extra-lush head of hair. But now it's payback time. After delivery, your body sheds the excess
hair all at once. Within six months, your hair will most likely be back to normal. In the
meantime, shampoo only when necessary, and find a hairstyle that's easy to maintain. Avoid
hair dryers, curling irons and harsh chemicals.
Skin changes
You may notice small red spots on your face. These are caused by small blood vessels
breaking during the pushing stage of labor. Expect the spots to disappear in about a week.
Stretch marks won't disappear after delivery, but eventually they'll fade from reddish purple to
silver or white. Any skin that darkened during pregnancy — such as the line down your
abdomen (linea nigra) — may slowly fade as well.
Mood changes
In addition to physical changes, childbirth triggers a jumble of powerful emotions. Mood
swings, irritability, sadness and anxiety are common. Many new moms experience a mild
depression, sometimes called the baby blues. The baby blues typically subside within seven to
10 days. In the meantime, take good care of yourself. Try to get as much sleep as possible. If
your depression deepens or you feel hopeless and sad most of the time, contact your health
care provider. Prompt treatment is important.
Weight loss
After you give birth, you'll probably feel flabby and out of shape. You may even look like
you're still pregnant. Don't worry. This is perfectly normal. Most women lose about 10 pounds
during birth, including the weight of the baby, placenta and amniotic fluid. During the first
week after delivery, you'll lose additional weight from leftover fluids. After that, healthy eating
and regular exercise can help you gradually return to your pre-pregnancy weight.
The postpartum checkup

About six weeks after the birth, your health care provider will check your vagina, cervix and
uterus to make sure you're healing well. He or she may do a breast exam and check your
weight and blood pressure, too. This is a great time to talk about birth control, breast-feeding
and how you're adjusting to life with a new baby.
Share any concerns you may have about your physical or emotional health. Chances are, what
you're feeling is entirely normal. Look to your health care provider for assurance as you enter
this new phase of life.
Exercise after pregnancy: How to get

started
Exercise after pregnancy can help you feel your best. Consider the
benefits of exercise after pregnancy, plus ways to stay motivated.
Exercise may be the last thing on your mind after giving birth, but it's worthwhile. In fact,
exercise after pregnancy may be one of the best things you can do for yourself. Follow these
tips to keep exercise after pregnancy safe.
Benefits of exercise after pregnancy
Regular exercise after pregnancy can:
 Promote weight loss
 Improve your cardiovascular fitness
 Restore muscle strength
 Condition your abdominal muscles
 Boost your energy level
 Improve your mood
 Relieve stress
 Help prevent postpartum depression
Better yet, including physical activity in your daily routine helps you set a positive example for
your child now and in the years to come.
Exercise and breast-feeding
Exercise isn't thought to have any adverse effects on breast milk volume or composition, nor
is it thought to affect a nursing infant's growth. Some research, however, suggests that high-
intensity physical activity can cause lactic acid to accumulate in breast milk and produce a
sour taste a baby might not like. If you're breast-feeding, you can prevent this potential
problem by sticking to moderate physical activity — or discarding milk produced in the half-
hour following a high-intensity workout.
To stay comfortable while you're exercising, nurse your baby or express milk before your
workout. It also helps to wear a supportive bra. To prevent dehydration, drink plenty of fluids
during and after your workout.
When to start
In the past, health care providers often instructed women to wait at least six weeks after
giving birth to begin exercising. But the waiting game may be over. If you exercised during
pregnancy and had an uncomplicated vaginal delivery, it's generally safe to begin exercising
within days of delivery — or as soon as you feel ready. If you had a C-section, extensive
vaginal repair or a complicated birth, talk to your health care provider about when to start an
exercise program
Exercise after pregnancy: How to get started

Physical activity goals
For most healthy women, the Department of Health and Human Services recommends at least
two and a half hours of moderate-intensity aerobic activity a week — preferably spread
throughout the week — after pregnancy. Consider these guidelines:
 Take time to warm up and cool down.
 Begin slowly and increase your pace gradually.
 Avoid excessive fatigue and dehydration.
 Wear a supportive bra.
 Stop exercising if you feel pain.
 Stop exercising and seek medical help if you have bright red vaginal bleeding that's
heavier than a period.
Activities to try
Leg slide
exercise
Bridge exercise
Pelvic tilt
exercise
When you're ready to exercise, start with something simple — such as a daily walk or laps in a
local pool. If you're looking for camaraderie, check out a postpartum exercise class at a local
fitness club or community center. With your health care provider's OK, also consider these
specific exercises:
 Leg slide. Try leg slides a few times a day to tone your abdominal and leg muscles.
Lie flat on your back and slightly bend your knees. Inhale and slide one leg to a straight
position. Exhale and return to the starting position. Repeat with your other leg.
 Bridge. To strengthen your core muscles, lie on your back with your knees bent. Keep
your back in a neutral position, not arched and not pressed into the floor. Tighten your
abdominal muscles. Raise your hips off the floor until your hips are aligned with your knees
and shoulders. Hold for three deep breaths. Return to the starting position and repeat.
 Pelvic tilt. Try the pelvic tilt a few times a day to strengthen your abdominal muscles.
Lie on your back on the floor with your knees bent. Flatten your back against the floor by
tightening your abdominal muscles and bending your pelvis up slightly. Hold for up to 10
seconds. Repeat five times and work up to 10 to 20 repetitions.
 Kegel exercise. Use this exercise to tone your pelvic floor muscles, which can help
control bladder leaks and heal your perineum and tighten your vagina. Contract the muscle
you use to stop your urine flow. Hold for up to 10 seconds and release. Repeat 10 times at
least three times a day.
Overcoming barriers
When you're caring for a newborn, finding time for physical activity can be challenging.
Hormonal changes may make you emotional, which can lead to sedentary behavior. And some
days you may simply feel too tired for a full workout. But that doesn't mean that you should
put physical activity on the back burner. Instead, do what you can. Seek the support of your
partner, family and friends. Schedule time for physical activity. Exercise with a friend to stay
motivated. Include your baby, either in a stroller while you walk or lying next to you on the
floor while you do abdominal exercises.
Remember, exercise after pregnancy isn't easy. But it can do wonders for your well-being, as
well as give you the energy you need to care for your newborn.
Kegel exercises: How to strengthen pelvic

floor muscles
If you do them the right way, Kegel exercises can help you prevent or
control urinary incontinence and prepare for childbirth. Find out how to
perform Kegel exercises correctly.
Kegel (KAY-gul or KEY-gul) exercises strengthen the pelvic floor muscles, which support the
uterus, bladder and bowel. If you do Kegel exercises regularly and keep your pelvic floor
muscles toned, you may reduce your risk of incontinence and similar problems as you get
older. Kegel exercises can also help you control urinary incontinence.
Learning how to perform Kegel exercises properly can be tricky. How do you know whether
you're working the correct muscles? Here's a guide to perfecting Kegel exercises.
Kegel exercises: Who can benefit
Female pelvic floor

muscles
Many conditions put stress on your pelvic floor muscles:
 Pregnancy
 Childbirth
 Being overweight
 Aging
 A chronic cough
 A genetic predisposition to weak connective tissue
When your pelvic floor muscles weaken, your pelvic organs descend and bulge into your
vagina, a condition known as pelvic organ prolapse. The effects of pelvic organ prolapse range
from uncomfortable pelvic pressure to leakage of urine or feces. Fortunately, Kegel exercises
can strengthen pelvic muscles and delay or maybe even prevent pelvic organ prolapse.
Kegel exercises are recommended especially during pregnancy. Well-toned pelvic floor
muscles may make you more comfortable as your due date approaches. You may be less likely
to develop urine leakage — common near the end of pregnancy and prone to persist after
you've given birth.
Finally, Kegel exercises — along with counseling and sex therapy — may be helpful to women
who have persistent problems reaching orgasm.
How to do Kegel exercises

It takes diligence to identify your pelvic floor muscles and learn how to contract and relax
them. Here are some pointers:
Find the right muscles

To make sure you know how to contract your pelvic floor muscles, try to stop the flow of urine
while you're going to the bathroom. If you succeed, you've got the basic move. Or try another
technique: Insert a finger inside your vagina and try to squeeze the surrounding muscles. You
should be able to feel your vagina tighten and your pelvic floor move upward. Then relax your
muscles and feel your pelvic floor move down to the starting position. As your muscles
become stronger — and you become more experienced with the exercises — this movement
will be more pronounced.
But don't make a habit of starting and stopping your urine stream. Doing Kegel exercises with
a full bladder or while emptying your bladder can actually weaken the muscles. It can also
lead to incomplete emptying of the bladder, which increases your risk of a urinary tract
infection.
If you're having trouble finding the right muscles, don't be embarrassed to ask for help. Your
doctor or other health care provider can give you important feedback so that you learn to
isolate and exercise the correct muscles.
Perfect your technique

Once you've identified your pelvic floor muscles, empty your bladder and sit or lie down. Then:
 Contract your pelvic floor muscles.
 Hold the contraction for three seconds then relax for three seconds.
 Repeat 10 times.
 Once you've perfected three-second muscle contractions, try it for four seconds at a
time, alternating muscle contractions with a four-second rest period.
 Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10
seconds between contractions.
To get the maximum benefit, focus on tightening only your pelvic floor muscles or isolating
your pelvic floor muscles. Be careful not to flex the muscles in your abdomen, thighs or
buttocks. Also, try not to hold your breath. Just relax, breathe freely and focus on tightening
the muscles around your vagina and rectum.
Repeat three times a day

Perform a set of 10 Kegel exercises three times a day. The exercises will get easier the more
often you do them. You might make a practice of fitting in a set every time you do a routine
task, such as checking e-mail or commuting to work.
Vary your technique with one of these methods:
 Try sets of mini-Kegels. Count quickly to 10 or 20, contracting and relaxing your
pelvic floor muscles each time you say a number.
 Visualize an elevator. Slow down the exercises, gradually contracting and releasing
your pelvic floor muscles one at a time. As you contract, visualize an elevator traveling
up four floors. At each floor, contract your muscles a little more until you reach
maximum contraction at the fourth floor. Hold the contraction and then slowly release
the tension as you visualize the elevator returning to the ground floor. Repeat 10
times.
Kegel exercises: How to strengthen pelvic floor muscles

Biofeedback training
If you have trouble doing Kegel exercises, biofeedback training may help. In a biofeedback
session, a nurse, therapist or technician will either insert a small monitoring probe into your
vagina or place adhesive electrodes on the skin outside your vagina or rectal area. When you
contract your pelvic floor muscles, you'll see a measurement on a monitor that lets you know
whether you've successfully contracted the right muscles. You'll also be able to see how long
you hold the contraction.
Another technique uses electrical stimulation to help you feel the muscles contract. The
procedure is painless, although you'll experience a buzzing feeling as a small electrical current
is applied to your pelvic floor muscles, making them contract. Once you feel this sensation a
few times, you'll probably be able to duplicate the exercise on your own. Because simpler
methods work for most women, this technique is rarely used.
When to expect results

If you do your Kegel exercises faithfully, you can expect to see some results, such as less
frequent urine leakage, within about eight to 12 weeks. Your improvement may be dramatic —
or, at the very least, you may keep your problems from worsening. As with other forms of
physical activity, you need to make Kegel exercises a lifelong practice to reap lifelong rewards.
Weight loss after pregnancy: Reclaiming

your body
Weight loss after pregnancy takes time, but it's possible. Concentrate on
eating healthy foods and including physical activity in your daily
routine. Above all, take pride in your healthy lifestyle.
If you're like most new moms, you're eager to hang your maternity clothes in the back of the
closet. Thankfully, there's no secret to weight loss after pregnancy. It takes healthy foods, a
commitment to physical activity — and plenty of patience. Above all, remember that there's
more to weight loss after pregnancy than simply fitting into your favorite jeans again. The
excess pounds you shed now can help promote a lifetime of good health.
Eat good-for-you foods
When you were pregnant, you may have changed your eating habits to support your baby's
growth and development. After pregnancy, proper nutrition is still important — especially if
you're breast-feeding. Making wise choices can promote healthy weight loss after pregnancy.
 Focus on fruits, vegetables and whole grains. Foods high in fiber — such as fruits,
vegetables and whole grains — provide you with many important nutrients while
helping you feel full longer. Other nutrient-rich choices include low-fat dairy products,
such as skim milk, yogurt and low-fat cheeses. Skinless poultry, most fish, beans, and
lean cuts of beef and pork are good sources of protein, as well as zinc, iron and B
vitamins.
 Avoid temptation. Surround yourself with foods that are good for you. If junk food
poses too much temptation, keep it out of the house.
 Eat smaller portions. Don't skip meals or limit your intake of fruits and vegetables.
You'll miss vital nutrients. Instead, scale back your portions of higher calorie foods.
You may want to trade traditional meals for smaller, more frequent meals.
 Eat only when you're hungry. If you're anxious or nervous or if you simply think it's
time to eat, distract yourself. Take your baby for a walk, call a friend or read a favorite
magazine
Weight loss after pregnancy: Reclaiming your body

Ready, set, move!
In the past, women were often instructed to wait at least six weeks after giving birth to begin
exercising. But the waiting game may be over. If you exercised during pregnancy and had an
uncomplicated vaginal delivery, it's generally safe to begin exercising within days of delivery
— or as soon as you feel ready. If you had a C-section or a complicated birth, talk to your
health care provider about when to start an exercise program.
When your health care provider gives you the OK:
 Get comfortable. If you're breast-feeding, feed your baby right before you exercise.
Wear a supportive bra and comfortable clothing.
 Start slowly. Begin with light aerobic activity, such as walking, stationary cycling or
swimming. Avoid jumping and jerky, bouncy or jarring motions.
 Break it up. Exercise in short sessions throughout the day. As your stamina
improves, gradually increase the length and intensity of your workouts.
 Include your baby. Take your baby for a daily walk in a stroller or baby carrier. If
you prefer to jog, use a jogging stroller designed for infants. Lay your baby next to you
while you stretch on the floor. Hold him or her in your arms and dance to your favorite
music.
 Target your abs. Losing abdominal fat takes dietary changes and aerobic exercise,
but abdominal crunches and other ab exercises can help tone your abdominal muscles.
 Remember your Kegels. These exercises won't help you lose weight, but they will
tone your pelvic floor muscles. Simply tighten your pelvic muscles as if you're stopping your
stream of urine. Try it for five seconds at a time, four or five times in a row. Work up to
keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between
contractions. Aim for at least three sets of 10 repetitions a day. You can do Kegels while
standing, sitting or lying down — even while breast-feeding your baby.
Remember to drink plenty of water before, during and after each workout. Stop exercising
immediately if you experience pain, dizziness, blurred vision, shortness of breath or a sudden
increase in vaginal bleeding. These may be signs that you're overdoing it.
Be realistic
Most women lose more than 10 pounds (4.5 kilograms) during childbirth, including the weight
of the baby, placenta and amniotic fluid. During the first week after delivery, you'll lose
additional weight as you shed retained fluids. But the fat stored during pregnancy won't
disappear on its own.
Through diet and exercise, it's reasonable to lose up to 1 pound (0.5 kilogram) a week. It may
take six months or even longer to return to your pre-pregnancy weight — whether you're
breast-feeding or not. And even then, your weight may be distributed differently than it was
before pregnancy. Be gentle with yourself as you accept the changes in your body. Above all,
take pride in your healthy lifestyle.
Sex after pregnancy: Let your body set the
pace
You've just delivered a baby. Is it safe to have sex? Will it hurt? What if
you're not interested? Here are answers to common questions about sex
after pregnancy.
Sex after pregnancy happens. Honestly. But first, vaginal soreness and sheer exhaustion are
likely to take a toll. Whether you're in the mood or sex is the last thing on your mind, here's
what you need to know about sex after pregnancy.
After the baby is born, how soon can I have sex?
Whether you give birth vaginally or by C-section, your body will need time to heal. Many
doctors recommend waiting four to six weeks before resuming intercourse. This allows time for
the cervix to close, postpartum bleeding to stop, and any tears or repaired lacerations to heal.
But the other important timeline is your own. Some women feel ready to resume sex within a
few weeks of giving birth, while others need a few months — or even longer. Factors such as
fatigue, postpartum blues and changes in body image may take a toll on your sex drive.
Will it hurt?
Your vagina may be dry and tender, especially if you're breast-feeding. To ease any
discomfort, take it slow. Start with cuddling, kissing or massage. Gradually build the intensity
of stimulation. If vaginal dryness is a problem, use a lubricating cream or gel. Try different
positions to take pressure off any sore areas and control penetration. Tell your partner what
feels good — and what doesn't.
It's also important to stay centered on the moment. For most women, sexual response
requires the entire brain. Keep your mind on yourself and your partner — not the diapers,
laundry and other household chores.
If sex continues to be painful, consult your doctor. A low-dose estrogen cream applied to the
vagina may help. Rarely, complications of healing may require additional treatment.
Will it feel different?
After several vaginal deliveries, decreased muscle tone in the vagina may reduce pleasurable
friction during sex — which can influence arousal.
To tone your pelvic floor muscles, do Kegel exercises. Simply tighten your pelvic muscles as if
you're stopping your stream of urine. Try it for five seconds at a time, four or five times in a
row. Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10
seconds between contractions. Once you've got the hang of it, do at least three sets of 10
Kegel exercises a day.
Sex after pregnancy: Let your body set the pace

What about birth control?
Unless you're hoping to become pregnant right away, sex after pregnancy requires a reliable
method of birth control — even if you're breast-feeding. Barrier methods such as condoms and
spermicides can be useful. If you're breast-feeding and prefer hormonal birth control, it's
important to select a method that won't decrease your milk supply. Your postpartum checkup
is a great time to ask your doctor about the options.
What if I'm too tired to have sex?

Caring for a newborn is exhausting. If you're too tired to have sex at bedtime, say so. But that
doesn't mean your sex life is over. You may prefer making love early in the morning or during
your baby's nap. Feed your baby first to extend the time you and your partner have together.
What if I'm not interested in sex?

That's OK. There's more to a sexual relationship than intercourse, especially when you're
adjusting to life with a new baby. If you're not feeling sexy or you're afraid sex will hurt, share
your concerns with your partner. Also share your feelings about your new roles as parents.
Although your primary role models are likely to be your own parents, remember that you and
your partner can adopt your own approach to parenthood.
Until you're ready to have sex, maintain intimacy in other ways. Spend time together without
the baby, even if it's just a few minutes in the morning and after the baby goes to sleep at
night. Share short phone calls throughout the day or occasional soaks in the tub. Look for
other ways to express affection. Attend to the spark that brought you together in the first
place.
If communicating with your partner doesn't help, be alert for signs and symptoms of
postpartum depression. If your mood is consistently low, you find little joy in life or you have
trouble summoning the energy to start a new day, contact your doctor promptly.
What can I do to boost my sex drive?
Go easy on yourself. Set reasonable expectations as you adjust to parenthood. Appreciate the
changes in your body. Eat healthy foods, and drink plenty of fluids. Include physical activity in
your daily routine. Rest as much as you can. Spend some time alone. Taking good care of
yourself can go a long way toward keeping passion alive.

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Estimation of Fetal Weight

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ESTIMATION OF FETAL WEIGHT

NEED FOR ANTENATAL FETAL WEIGHT ESTIMATION

The occurrence of cephalopelvic disproportion is more prevalent with increasing fetal

STANDARD FETAL GROWTH CURVES

In general, these growth curves can be expected to apply to large populations of

NORMAL RANGE FOR HUMAN BIRTH WEIGHT

Variations in fetal weight

The reference range of gestational age for spontaneous delivery in human

Birth weights of women from different racial groups

DEFINITIONS OF DEVIATIONS IN FETAL GROWTH

Fetal weight categories

Fetal weight may be characterized as falling into 1 of 3 categories, as follows:

• Low birth weight (1501-2500 g)

FACTORS CONTRIBUTING TO DIFFERENCES IN FETAL WEIGHT

• Maternal factors (eg, race, stature)

Gestational age at delivery

Other maternal and pregnancy-specific determinants

Uncontrolled maternal diabetes mellitus is a condition commonly associated with

Several maternal illnesses and complications of pregnancy are associated with

DIAGNOSIS OF DEVIATIONS IN FETAL WEIGHT

Clinical risk factor assessment: Quantitative assessment of clinical risk factors

Risk Factors Percent of Patients with Odds Ratio for Presence

Maternal self-estimation: A third method for estimating fetal weight is via

The sonographic prediction algorithms used to make fetal weight estimations in

ACCURACY OF FETAL WEIGHT PREDICTION USING DIFFERENT MET

Accuracy of clinical palpation for estimating fetal weight

Accuracy of obstetric ultrasonography for estimating fetal weight

Obstetric sonographic assessment for the purpose of obtaining fetal biometric

Modern algorithms that incorporate standardly defined fetal measurements (eg,

Table . Ultrasonographic Fetal Biometric Prediction Algorithms for Calculating

Source Year Equation

*BW - Estimated fetal weight (g)

When another commonly used measure of accuracy is used (the percentage of

Table. Accuracy of Single Versus Multiple Sonographic Fetal Biometric Examinations

Small for gestational age (<10th percentile)†

Single examination 100% 76% 25% 100%

Multiple examinations 100% 75% 25% 100%

Large for gestational age (>90th percentile)†

Single examination 48% 94% 63% 89%

Multiple examinations 62% 100% 100% 92%

*Adapted from Hedriana et al

Maternal self-estimations of fetal weight

Recently, 3 studies examined the accuracy of patient self-estimations of fetal weight

Predicting fetal weight using an algorithm derived from maternal and

Using these routinely recorded variables, an equation based on maternal

Equation 1, the equation generated for this purpose, is as follows:

DIAGNOSING SIGNIFICANT DEVIATIONS IN FETAL WEIGHT AN

Developing a consensus of indicators

• First, assess maternal risk factors for predispositions to fetal growth

o Poorly controlled diabetes mellitus (any class, including gestational

Option for suppression of labor in women carrying undersized fetuses

The increased risk of perinatal complications associated with the delivery of an

Option for labor induction in women carrying oversized fetuses

As with the case of preterm delivery of underweight fetuses, many considerations,

By using a birth weight prediction equation that is based on maternal and

By contrast, clinical palpation is a subjective methodology that must be employed at

Recently, a quantitative combination of maternal demographic information (of the

See what happens inside you during the conception process.