Powys Teaching Local Health Board
Directorate: Women’s and Children’s
Author: Lewis, Owen, Revell / Title: Guideline for Assessment of fetal growth
Code: to be completed by Q&S Unit if new policy

Guideline for Assessment of Fetal Growth

Policy Code / Date / Version Number / Planned Review Date
Feb 2012 / 1st Issue / Feb 2015
Document Owner / Approved By / Date
Women’s and Children’s Directorate / Women’s and Children’s Directorate
Clinical Effectiveness / 29/03/12
16/04/12
Document Type / Guidelines

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Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board

Guideline for Assessment of Fetal Growth

Contents / Page
Validation Form / 3
Equality Assessment / 4
Relevant to / 5
Purpose / 5
Definitions / 5
Responsibilities / 5
Process / 5
References / 5
Appendices

For Reviewed / Updated Policies Only:

Relevant Changes – / Date

VALIDATION & RATIFICATION

Title: Guideline for assessment of fetal growth
Authors: Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys, Denise Revell Integrated Midwife
Directorate: Women and Children’s
Approved for submission by: Cate Langley Date: 14/03/12
Evidence Base
Are there national guidelines, policies, legislation or standards relating to this subject area?
If yes, please include below:
Fetal Growth Assessment and Implementation of Customised Growth Charts (accessed 2/2/12)
Morse K, Williams A, Gardosi J (2009): Fetal Growth Screening By Fundal Height Measurement. Best Practice and Research Clinical Obstetrics and Gynaecology 23 (2009) p809-818
National Institute For Clinical Excellence (2008): Antenatal Care – Routine care for the healthy pregnant woman. NICE, London
Royal College of Obstetricians and Gynaecologists (2002): The investigation andmanagement of the small-for-gestational age fetus. RCOG Green Top Guideline No 31. RCOG London.
Wright J, Morse K, Francis A (2006): Audit of fundal height measurement plotted on customised growth charts. MIDIRS, Sept 2006 p341-345
If No, please provide information on the evidence/expert opinion upon which the policy has been based.
CONSULTATION
Please list the groups, specialists or individuals involved in the development & consultation process:
Name / Date
Powys Midwives / 26.3.2012
Supervisor of Midwives / 26.3.2012
Practice Development Midwife / 26.3.2012
Agreed by Women’s and Children’s Directorate / 26.3.2012
Agreed by Head of Midwifery / 26.3.2012
Please insert the name of the Directorate/ Departmental/Discipline Committee or Group that has approved this policy/procedure/guidelines/protocol
Name / Date
Women’s and Children’s Directorate / 29/03/12
Clinical Effectiveness / 16/04/12
Implications
Please state any training implications as a result of implementing the policy / procedure.. None
Please state any resource implications associated with the implementation.
No Additional Resources required
Please state any other implications which may arise from the implementation of this policy/procedure. none
For Completion by Quality & Safety Unit
Checked by: / Date:
Submitted to CEC: / Date:

Equality Assessment Statement

Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all.

Equality statement
No impact / Adverse / Differential / Positive / Comments
Age / X
Disability / X
Gender / X / Woman focused midwifery policy
Race / X
Religion/ Belief / x
Sexual Orientation / X
Welsh Language / X
Human Rights / X

Risk Assessment

Are there any new or additional risks arising from the implementation of this policy?None
Do you believe that they are adequately controlled?N/A.

Relevant to:

Local guideline for all midwives working in Powys.

Purpose:

The overall aim is to assess fetal growth utilising customised fetal growth charts, and implement appropriate action when deviation from normal is identified.

Responsibilities

All midwives working within Powys hold a recognised midwifery qualification. No additional qualifications are required to carry out this policy.

Monitoring

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the Datix reporting system.

Process: Guideline for Assessment of Fetal Growth

Introduction:

NICE (2008) recommend that all women are offered estimation of fetal size to detect small or large for gestational age infants. Symphysis –fundal height (SFH) should be measured and plotted at each antenatal appointment. Evidence does not support the use of routine ultrasound scanning after 24 weeks gestation (NICE 2008).

Customised Growth Charts:

The charts are used to plot both SFH measurements obtained during clinicalexamination and estimated fetal weight (EFW) following an ultrasound examination. They are customisedto each individual taking into account the height, weight, ethnicity, and parity of thewoman. Birthweights of previous children can be inputted to identify previousproblems with growth, but this does not affect the centiles produced.

Each woman will have a customised growth chart printed following her dating scan.The estimated date of delivery (EDD) entered into the software will be the one calculated by the datingultrasound scan. The chart will show the 10th, 50th and 90th centile lines. There is abox in the top left hand corner where her height, weight, ethnicity and parity areshown. A customised centile will be calculated for all previous children; if theywere small for gestational age (SGA) or large for gestational age (LGA) this willalso be highlighted. Mother’s name, reference number and date of birth will appearabove the chart. It is the responsibility of the named midwife to ensure that all details entered on the chart are correct.

Measuring Symphysis-Fundal Height (SFH)

Women who are recognised as low risk and suitable for midwifery led care shouldhave symphysis-fundal height measurements undertaken as a primary screening test for fetalwellbeing. These should commence from 26- 28 weeks gestation. (This would normally be at 28 weeks if following NICE guidelines for antenatal care).

The symphysis-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. It is recommended that the clinician uses both hands to perform anabdominal palpation, identifies the highest point of the uterine fundus then leavesone hand on the fundus. A non-elastic tape-measure, starting at zero, is placed onthe uterine fundus – at the highest point (which may or may not be in the midline).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 thepossibility of bias, the tape measure should be used with the cm side hidden, andthe measurement should be taken once only. The result should be recorded incentimetres on the customised growth chart and the value plotted using a cross.The method for measuring SFH is explained below the customised growth chart tosupport standardised practice.

Referral to Ultrasound:

Indications for a growth scan are:

  • First SFH measurement below 10th centile at 28 weeks
  • Static growth (no increase in sequential measurements)
  • Slow growth (curve not following slope of any curve on the chart)
  • Excessive growth (curve steeper than any curve on the chart)

Note that a first measurement above the 90th centile is NOT an indication for agrowth scan. A scan would however be indicated if there was clinical suspicion ofpolyhydramnios or there was excessive growth on subsequent measurements.If the woman has a raised BMI (35+) then a referral should already have beenmade to a Consultant clinic. Serial scans would be indicated as degrees of errorfrom fundal height measurements are increased with an increased BMI.

Serial Growth Scans for Those at High Risk of Growth Restriction:

Some women will be at increased risk of developing fetal growth restrictionbecause of risk factors in the current pregnancy, past medical history or pastobstetric history. Women who fall into these categories will need referral to aConsultant. The Consultant-led team will arrange for serial scans every two –threeweeks from 28 weeks until delivery. These women will notrequire fundal heightmeasurements while such a serial scanning protocol is being followed.

Growth Scan Requests Related To Current Pregnancy:

  • Concerns related to growth measurements as listed above
  • Clinical suspicion of oligohydramnios or polyhydramnios
  • Known or suspected fetal anomaly
  • Late booker (more than 20 weeks gestation)
  • Substance misuse
  • Multiple pregnancies

Growth Scan Requests Related To Obstetric History:

  • Previous birthweight <10th customised centile
  • Previous unexplained stillbirth

Growth Scan Requests Related To Maternal Medical History:

  • Pre-existing diabetes
  • Body Mass Index (BMI) ≥ 35
  • Uterine fibroids ≥ 6cm
  • Chronic maternal disease

Umbilical Artery Doppler to Be Performed If:

  • Estimated fetal weight (EFW) on or below 10th centile
  • Oligohydramnios

Referral Following Growth Scan:

  • If the EFW plots between 10thand 90th centile and liquor volume is normal, woman to continue planned antenatal care
  • If the EFW is above the 90th centile refer for Glucose Tolerance Test
  • If the EFW is below the 10th centile with normal liquor volume, and normal umbilical Doppler, refer for obstetric review and repeat scan in 2 weeks
  • If the EFW is below the 10th centile with oligohydramnios and/or abnormal artery Doppler, refer for immediate obstetric review

Actions:

  • Customised growth chart to be generated following dating scan and inserted into client held notes
  • Early referral for women with identified risks associated with small/large for gestational age babies
  • Symphysis-fundal height measurements to commence at 28 weeks gestation
  • Where possible same person to undertake measurement using a non-elastic tape measure starting at zero to reduce error
  • Measurements should be plotted in whole centimetres
  • Too frequent measurements e.g. weekly are not recommended
  • Documentation as ‘equal to dates’, (=D) is inaccurate and should not be used
  • Refer for growth scan following above guidelines
  • Management plan to be reviewed and if necessary updated at each antenatal contact

Please Also Refer To The Following Guidelines:

All Wales Birth Centre Guidelines

Antenatal Care Guideline

Guideline for Caring With Women with Medical Conditions

References:

Fetal Growth Assessment and Implementation of Customised Growth Charts (accessed 2/2/12)

Morse K, Williams A, Gardosi J (2009): Fetal Growth Screening By Fundal Height Measurement. Best Practice and Research Clinical Obstetrics and Gynaecology 23 (2009) p809-818

National Institute For Clinical Excellence (2008): Antenatal Care – Routine care for the healthy pregnant woman. NICE, London

Royal College of Obstetricians and Gynaecologists (2002): The investigation andmanagement of the small-for-gestational age fetus. RCOG Green Top GuidelineNo 31. RCOG London.

Wright J, Morse K, Francis A (2006): Audit of fundal height measurement plotted on customised growth charts. MIDIRS, Sept 2006 p341-345

1

Issue Date: 2012
Status: Final / Page 1 of 10 / Review Date: 2015
Approved by: Clinical Effectiveness 16/04/12