CLINICAL GUIDELINE

ASSESSMENT OF FETAL GROWTH DURING THE Register No: 15004

ANTENATAL PERIOD Status: Public

Developed in response to: NICE Guidelines

Review of Clinical Guideline
CQC Fundamental Standards: 11, 12

Consulted With: Post/Committee/Group: Date:

Anita Rao/ Clinical Director for Women’s and Children’s Division April 2018
Alison Cuthbertson
Vidya Thakur Consultant for Obstetrics and Gynaecology
Alison Cuthbertson Associate Director of Midwifery/Nursing
Dr Hassan Consultant Paediatrician
Paula Hollis Lead Midwife Acute Inpatient Services
Chris Berner Lead Midwife Clinical Governance
Emma Neate Antenatal and Newborn Screening Midwife
Sarah Moon Specialist Midwife Guidelines and Audit
Deborah Lepley Senior Librarian, Warner Library

Professionally Approved By:

Miss Rao Lead Consultant for Obstetrics and Gynaecology April 2018

Version Number 2.0

Issuing Directorate Women’s and Children’s
Ratified by DRAG Chairmans Action
Ratified on 2nd August 2018
Implementation Date 28 August 2018
Executive Management Group Date September 2018
Next Review Date July 2021
Author/Contact for Information Dr Sameena Kausar, Consultant Obstetrician
Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians and appropriately
trained health care professionals
Distribution Method Trust intranet and website
Related Trust Policies (to be read in 04071 Standard Infection Prevention
conjunction with) 04072 Hand Hygiene
06036 Guideline for Maternity Record Keeping including
Documentation in Handheld Records
04272 Maternity Care
07043 Abdominal Palpation and Examination in Pregnancy
08013 Care of preterm and small for gestational age infants on
the postnatal ward
04265 Fetal heart rate monitoring in pregnancy and monitoring
register number
14026 Ultrasound assessment of fetal growth in the 2nd & 3rd
trimester
Document Review History:
Review No: Authored/Reviewed by: Issue Date:
1.0 Roslyn Bullen-Bell, Midwife; GAP Programme Project Lead 4th March 2015
1.1 Roslyn Bullen-Bell – clarification to 6.2.1 20 September 2016
1.2 Roslyn Bullen-Bell – clarification to 8.3 27 February 2017
2.0 Sameena Kausar – Full Review 28 August 2018

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INDEX

1. Purpose

2. Equality and Diversity

3. Background

4. Scope

5. Objectives

6. Customised Growth Charts

7. Measuring Fundal Height

8. Referral to Ultrasound

9. Management in Labour

10. Following the Birth

11. Staff Training

12. Professional Midwifery Advocates

13. Audit and Monitoring

14. Guideline Management

15. Communication

16. References

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1.0 Purpose

1.1 To provide guidance for clinical staff responsible for the Management of fetal growth
when using the customised growth charts.

1.2 Each woman will have a customised growth chart printed following her dating scan
and secured in her hand held pregnancy notes. The antenatal lead midwife will
generate a customised growth chart in the antenatal clinic following the ultrasound at
11 weeks and 2 days gestation to 14 weeks and 1 day gestation.

1.3 Not all pregnancies are suitable for primary surveillance by fundal height
measurement and require ultrasound biometry instead

2.0 Equality and Diversity

2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service
that is fair, accessible and meets the needs of all individuals.

3.0 Scope

3.1 This guideline is relevant to all healthcare professionals involved in the care of
pregnant women including Midwives, General Practitioners, Obstetricians and
Sonographers.

3.2 This guideline addresses the following areas:

• Use and production of a customised growth chart

• Booking risk assessment
• When and how to measure fundal height using a standardised technique
• When to refer to Ultrasound for a growth scan
• Serial growth scans for women at high risk of fetal growth restriction

3.3 This guideline does not seek to cover management of pregnancy once intra-uterine
growth restricted baby has been diagnosed.
(Refer to the guideline entitled ‘Care of preterm and small for gestational age infants
on the postnatal ward’; register number 08013)

4.0 Background

4.1 Fetal growth restriction is associated with stillbirth, neonatal death and perinatal
morbidity. Confidential Enquiries have demonstrated that most stillbirths due to fetal
growth restriction are associated with sub-optimal care and are potentially avoidable.

4.2 A recent epidemiological analysis based on the comprehensive West Midlands

database has underlined the impact that fetal growth restriction has on stillbirth rates,
and the significant reduction which can be achieved through antenatal detection of
pregnancies at risk.

4.3 Customised assessment of birth weight and fetal growth has also been
recommended by the RCOG since 2002 and is re-emphasised in the 2013 revision
of the Green Top Guidelines. Most studies use a one off measurement to predict
IUGR; however it is the growth trend that is of more value in predicting poor fetal
outcome.

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5.0 Objectives

5.1 To ensure that there is accurate fetal surveillance, through standardised fundal
height measurements of low risk women and serial growth scans for high risk
women.

5.2 To ensure that serial fundal height measurements are plotted correctly on
customised growth charts.

5.3 Where growth problems are suspected from fundal height measurements, referral for
a growth scan and appropriate further investigations to assess fetal wellbeing should
be undertaken as soon as possible and within at most 96 hours (4 working days).

5.3 Where a problem has been identified, referral is indicated to the Obstetric team for
discussion and agreement of an appropriate management plan; to be seen following
the ultrasound in the Day Assessment Unit.

5.4 To ensure that there is identification of all infants born below the 10th customised
centile at birth an appropriate management initiated postnatally.

6.0 Customised Growth Charts

6.1 The charts are used to plot both fundal height measurements obtained during clinical
examination and estimated fetal weight following an ultrasound examination. They
are customised to each individual taking into account the height, weight, ethnicity,
parity of the women. Birth weights of previous children need to be inputted to identify
previous problems with growth, but this does not affect the centiles produced.

6.2 Chart production

6.2.1 Each woman will have a customised growth chart printed following her dating scan
and secured in her hand held pregnancy notes.

6.2.2 The estimated date of birth entered into the software will be the one calculated by the
dating ultrasound scan. The chart will show the 10th, 50th and 90th centile lines (the
5th and 95th centiles can be printed as an option if required). There is a box in the top
left hand corner where her height, weight, ethnicity and parity are shown. A
customised centile will be calculated for all previous children; if they were small for
gestational age (SGA) or large for gestational age (LGA) this will also be highlighted.
Mother’s name, reference number and date of birth will appear above the chart.

6.2.3 The charts are very easy to produce and can be generated at any time during
pregnancy. The software can be accessed on all computers in maternity or via
contacting the Perinatal Institute’s specialist maternity team at
grow@perinatal.org.uk

6.2.4 All late bookers or women who transfer care should be referred to see the antenatal
clinic lead midwife for a customised growth chart. In cases where the woman has
not had an ultrasound scan at 11 weeks and 2 days gestation to 14 weeks and 1 day
gestation an estimated due date will not be available. Therefore an estimate date of
delivery will have to be used from the most current scan. Women who present in
labour and unbooked will not be eligible for GROW charts.

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7.0 Measuring Fundal Height
(Refer to the guideline entitled ‘Abdominal Palpation and Examination in Pregnancy’; register
number 07043)

7.1 Who to measure - not all pregnancies are suitable for primary surveillance by fundal
height measurement, and require ultrasound biometry instead. In most instances,
these pregnancies fall into the following categories:

• Fundal height measurement unsuitable/inaccurate e.g. large fibroids, high

maternal BMI, multiple pregnancy
• Pregnancy considered high risk requiring serial ultrasound e.g. pre-existing
diabetes

7.1.1 Women who are recognised as low risk and suitable for midwifery led care should
have serial fundal height measurements undertaken as a primary screening test for
fetal wellbeing. These should commence from 26-28 weeks gestation.

7.2 How to measure - the fundal height measurement should be performed with the
mother in a semi-recumbent position, with an empty bladder and the uterus relaxed
and non-contracting.

7.2.1 It is recommended that the clinician uses both hands to perform an abdominal
palpation, identifying the highest point of the uterine fundus; then leaves one hand on
the fundus. A non-elastic tape-measure, starting at zero, is placed on the uterine
fundus – at the highest point (which may or may not be in the midline).

7.2.2 The tape measure should then be drawn down to the top of the symphysis pubis (in
the midline) and the number read in whole centimetres. To reduce the possibility of
bias, the tape measure should be used with the cm side hidden, and the
measurement should be taken once only.

7.2.3 The result should be recorded in centimetres on the customised growth chart and the
value plotted using a cross.

7.2.4 The method for measuring FH is explained below the customised growth chart to
support standardised practice.

7.3 Serial fundal height measurements should be carried out 2-3 weekly from 26-28
weeks gestation until delivery.

8.0 Referral to Ultrasound

(Refer to the guideline entitled ‘Ultrasound assessment of fetal growth in the 2nd and
3rd trimester; register number 14026)

8.1 Indications for a growth scan are:

• First Fundal Height measurement below 10th centile at 26-28 weeks

• Static growth: no increase in sequential measurements
• Slow growth: curve linking up plots crossing centiles in a downward direction
• Excessive growth (and is above 90th Centile): curve linking up lots of crossing
centiles in a steep upward direction

Note that a first measurement above the 90th centile is not an indication for a
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 growth scan. A scan would however be indicated if there was clinical suspicion of
polyhydramnios or there was excessive growth on subsequent measurements.

8.2 For patients where SFH is below the 10th centile or above the 90th centile requests
for a growth scan should be made directly to the Ultrasound department who will give
an appointment as soon as possible but within 4 days. Arrangements for follow-up by
the referrer should be made assuming the scan is normal. If there are concerns
regarding the scan, the Sonographer will either refer the woman to be seen in the
Consultant clinic or on the Day Assessment Unit depending on the time of day i.e. to
ensure they are reviewed on the same day.
(Refer to Appendix 1 and section 7.2)

8.3 Serial growth scans for those at high risk of growth restriction - some women
will be at increased risk of developing fetal growth restriction because of risk factors
in the current pregnancy, past medical history or past obstetric history. All women
should be assessed at booking for risk factors to identify those who need increased
surveillance. Women who fall into these categories will need referral to a Consultant.
The Consultant-led team will arrange for serial scans from 28 weeks until delivery
(earlier gestation or higher frequency if required in individual cases). These women
will not require fundal height measurements while such a serial scanning protocol is
being followed.

8.4 Growth scan requests related to obstetric history include:

• Previous birth weight(s) <10th customised centile

• Previous unexplained stillbirth

8.5 Growth scan requests related to maternal medical history include:

• Pre-existing diabetes and essential hypertension with/without vascular disease

• Chronic maternal disease e.g. Moderate or severe renal impairment;
antiphospholipid syndrome, autoimmune disease on immunosuppression
treatment, cyanotic heart disease and thrombophilia;
• Uterine fibroids greater than 6cm diameter;
• BMI < 20 or >/= 40 .

8.6 Growth scan requests related to current pregnancy include:

• Concerns related to growth measurements, as listed above

• PAPPA-A (<0.4 MoM) and/or a low hCG (<0.5 MoM)
• Clinical suspicion of oligohydramnios or polyhydramnios
• Known or suspected fetal anomaly
• Fetal Echogenic bowel
• Preeclampsia
• Unexplained APH
• Late booker (20+ weeks gestation)
• Substance misuse
• Multiple pregnancies (refer to multiple pregnancy and birth guidelines)

8.7 Referral following a growth scan - these referrals will be made by the sonographer
once the growth scan has been completed and the EFW plotted on the customised
growth chart (with a circle).

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8.8 If the EFW plots between the 10th and 90th centile and is following the centile
Curve; and the liquor volume is normal the woman will be asked to attend her next
antenatal appointment as planned (this should already have been confirmed with
the woman by the referring carer).

8.9 If the EFW does not plot within the 10th and 90th centile or is not following a centile
curve, or there are concerns regarding the liquor volume, then the following referrals
should be made:

8.9.1 EFW above 90th centile on GROW

• For Obstetric team to review in Day Assessment Unit or Antenatal Clinic. With
polyhydramnios repeat scan in 2 weeks; without polyhydramnios repeat scan in 4
weeks;

• Organise glucose tolerance test if </=34 weeks or monitor CBGs (after discussing
with diabetic team) if >34 weeks;

8.9.2 EFW below 10th centile or reduced growth velocity, normal liquor volume, normal
umbilical artery Doppler

• For Obstetric team to review in Day Assessment Unit or Antenatal Clinic following
a discussion with the Obstetric Registrar and repeat scan in 2 weeks

8.9.3 EFW below 10th centile or reduced growth velocity with oligohydramnios and/or
abnormal umbilical artery Doppler and/or abnormal middle cerebral

• For immediate obstetric review in the Day Assessment Unit and referral to FMU.

9.0 Management in Labour

9.1 Early admission should be recommended in women in spontaneous labour with a

fetus where growth problems have been identified, in order to investigate continuous
fetal heart rate monitoring
(Refer to the guideline entitled ‘Fetal heart rate monitoring in pregnancy and
monitoring’; register number 04265)

10.0 Following the Birth

10.1 Once the baby has been weighed, plot the weight on the customised growth chart,
the purpose being to see how precise the measurements were antenatally. If the
birth weight falls below the 10th Centile in an undiagnosed intrauterine growth
restricted baby then the details should be completed electronically via DatixWeb. In
cases where there are suspected/ confirmed intrauterine growth restriction, the
DatixWeb process is not required.

11.0 Staff Training

11.1 All staff should ensure that their knowledge and skills are up-to-date in order to
complete their portfolio for appraisal.

11.2 The Practice Development Midwife, in association with all midwifery managers, will
determine if training, regarding the guideline, is required and action accordingly. The
Practice Development Midwife will ensure that training records are maintained
regarding this agenda.
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12.0 Professional Midwifery Advocates

12.1 Professional Midwifery Advocates provide a mechanism of support and guidance to

women and midwives. Professional Midwifery Advocates are experienced practising
midwives who have undertaken further education in order to supervise midwifery
services and to advise and support midwives and women in their care choices.

13.0 Audit and Monitoring

13.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity
annual audit work plan; to encompass national and local audit and clinical
governance identifying key harm themes. The Women’s and Children’s Clinical Audit
Group will identify a lead for the audit.

13.2 The findings of the audit will be reported to and approved by the Multi-disciplinary
Risk Management Group (MRMG) and an action plan with named leads and
timescales will be developed to address any identified deficiencies. Performance
against the action plan will be monitored by this group at subsequent meetings.

13.3 The audit report will be reported to the monthly Directorate Governance
Meeting (DGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.

13.4 Key findings and learning points from the audit will be submitted to the Clinical
Governance Group within the integrated learning report.

13.5 Key findings and learning points will be disseminated to relevant staff.

14.0 Guideline Management

14.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.

14.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.

14.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.

14.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During
this meeting the practice development midwife can highlight any areas for further
training; possibly involving ‘workshops’ or to be included in future ‘skills and drills’
mandatory training sessions.

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15.0 Communication

15.1 A quarterly ‘maternity newsletter’ is issued and available to all staff including an
update on the latest ‘guidelines’ information such as a list of newly approved
guidelines for staff to acknowledge and familiarise themselves with and practice
accordingly.

15.2 Approved guidelines are published monthly in the Trust’s Staff Focus that is sent via
email to all staff.

15.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

15.4 Regular memos are posted on the ‘Risk Management’ notice boards in each clinical
area to notify staff of the latest revised guidelines and how to access guidelines via
the intranet or clinical guideline folders.

16.0 References

Birthweight: de Jong CLD et al. (1998). Application of a customised birthweight

standard in the assessment of perinatal outcome in a high risk population. BJOG
105:531-35

Clausson B et al. Perinatal outcome in SGA births defined by customised versus

population based birthweight standards. BJOG 2001;108:830-4

McCowan L, Harding JE, Stewart AW. Customised birthweight centiles predict

SGA pregnancies with perinatal morbidity. BJOG 2005;112:1026-1033.

Gardosi J, Clausson B, Francis A. The value of customised centiles in assessing

perinatal mortality risk associated with parity and maternal size. BJOG
2009;116:1356-63.

Fetal Growth: Mongelli M, Gardosi J. Longitudinal study of fetal growth in subgroups

of a low risk population. Ultrasound Obstet Gynecol 1995; 6: 340-344,

de Jong CLD et al. Fetal weight gain in a serially scanned high-risk population.
Ultrasound Obstet Gynecol 1998;11:39-43.

Mongelli M, Gardosi J. Reduction of false-positive diagnosis of fetal growth

restriction by application of customized fetal growth standards. Obstet Gynecol
1996;88:844-848.

Fundal height: Gardosi J, Francis A. Controlled trial of fundal height measurement

plotted on customised antenatal growth charts. BJOG 1998 106(4):309-17.

Wright J, Morse K et al. MIDIRS Midwifery Digest, 2006; vol 16, no 3, pp 341-345.
Reviews / Best Practice

Gardosi J Intrauterine growth restriction: new standards for assessing adverse

outcome. Best Practice & Research Clinical Obstet Gynaecol 2009;23;741–749

Morse K., Williams M. and Gardosi J. Fetal growth screening by fundal height
measurement. Best Practice & Research Clin Obstet Gynaecol 2009;23;6:809-819
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Figueras F. Gardosi J. Intrauterine growth restriction: new concepts in antenatal
surveillance, diagnosis, and management. AJOG 2010; 204:4;288-300.

Royal College of Obstetricians and Gynaecologists. The investigation and

management of the small-for-gestational age fetus. RCOG Green Top Guideline
No 31, 2002. RCOG, London.

National Institute for Clinical Excellence. Antenatal care: routine care for the
healthy pregnant woman. NICE Clinical Guideline 62. NICE, London.

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Appendix 1 Ref: Morse - Best Practice

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Appendix 2

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