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Customised Antenatal Growth Chart 2015 11 16.docx
Customised Antenatal Growth Chart
Document Type Guideline Function(s) Clinical Practice Directorate(s) Women’s Health Departments affected Maternity Applicable for which patients, clients or residents?
All maternity women
Applicable for which staff members?
All clinicians in maternity including access holder lead maternity carers (LMCs) Key words fundus, gestation, birth weight, Author – role only Maternal Fetal Medicine Consultant, Women’s Health Owner (see ownership structure) Clinical Director Secondary Maternity Edited by Clinical Policy Advisor Date first published August 2005 Date this version published November 2015 Review frequency 3 yearly Unique Identifier NMP200/SSM/
Contents
- Purpose of guideline
- Guideline management principles & goals
- Accessing customised antenatal growth charts
- Fundal height measurement procedure
- Supporting evidence
- Associated Auckland DHB documents
- Disclaimer
- Corrections and amendments
Customised Antenatal Growth Chart 2015 11 16.docx
1. Purpose of guideline
This guideline establishes the correct procedure for measurement of fundal height within Auckland District Health Board (Auckland DHB) and for use of a customised growth chart to aid interpretation of fundal height and ultrasound estimated fetal weight.
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2. Guideline management principles & goals
Each pregnant woman should be provided with a customised growth chart that estimates the expected growth in fundal height and or estimated fetal weight (if a growth scan is done) for her individual pregnancy. Fundal height measurements should be recorded from 26 - 28 weeks onwards and should not be plotted more frequently than fortnightly.
A woman with BMI >
The BMI at which fundal height measurement is unreliable is difficult to determine as it depends on distribution of maternal adipose tissue and also maternal height. As a guide, a plan for growth scan(s) is usually recommended with a BMI of >35 (RCOG Guideline 2013, NZMFM SGA Guideline 2014). Estimated fetal weight measurements from growth scans should be plotted on the GROW chart as well as on the population ultrasound charts. Growth scans in a woman with BMI >35 should be performed if clinical assessment is not possible because of body habitus (which is often the case). Suggested timings for ultrasound growth assessment(s) are 30-32 and 36-38 weeks. A scan in late pregnancy is more likely to detect aberrations in growth but serial scans enable growth velocity to be assessed. For further information, see the NZMFM SGA guideline.
Fundal height > 90th^ centile
The primary purpose of a customised antenatal growth chart is to increase antenatal detection of a SGA baby. When SFH is tracking along or above the 90th^ centile, gestational diabetes needs exclusion. A growth scan is not indicated unless there is clinical concern re polyhydramnios or there is a sudden increase in fundal height. In women who do not have gestational diabetes, intervention is not usually recommended at National Women’s Health when a baby is suspected to be large for gestational age. Therefore, growth scans and referral are not usually required. See flowchart: Diabetes Screening
A woman at high risk of SGA
A woman at high risk of SGA e.g. previous SGA baby <10th percentile, chronic hypertension, antiphospholipid syndrome, renal disease etc. should continue to have growth scans at regular intervals as before. The frequency of scanning will be individualised according to the previous gestation at delivery and severity of SGA or the nature of the underlying medical condition. Even though customised growth charts
Customised Antenatal Growth Chart 2015 11 16.docx
4. Fundal height measurement procedure
- Mother semi-recumbent, with bladder empty
Explain the procedure to the Mother and gain verbal consent Wash hands Have a non-elastic tape measure to hand Ensure the mother is comfortable in a semi-recumbent position, with an empty bladder Expose enough of the abdomen to allow a thorough examination
- Palpate to determine fundus
Ensure the abdomen is soft (not contracting and baby not actively moving) Perform abdominal palpation to enable accurate identification of the uterine fundus
- Secure tape with hand at top of fundus
Use the tape measure with the centimetres on the underside to reduce bias Secure the tape measure at the fundus with one hand
Customised Antenatal Growth Chart 2015 11 16.docx
- Measure along longitudinal axis of uterus
Measure along the longitudinal axis to the highest point of the uterus, which is not always in the midline
Measure only once
- Measure to top of symphysis pubis
Measure from the top of the fundus to the top of the symphysis pubis The tape measure should stay in contact with the skin
Customised Antenatal Growth Chart 2015 11 16.docx
5. Supporting evidence
A UK controlled trial showed an increased detection of small for gestational age (SGA) babies from 29% in the control group to 48% in the group with a customised growth chart (Gardosi 1999). An Australian study reported an increase in detection of SGA, from 25% to 43%, after customised antenatal growth charts were introduced as unit policy (Roex). A recent publication reported reduced stillbirth rates in three regions of the UK, which had a high uptake of training and implementation of GROW (Gardosi BMJ 2013). A reduction in stillbirths associated with fetal growth restriction has been reported in the West-Midlands region of the UK, which has very high utilisation of GROW (Gardosi 2013). Audits performed at National Women’s Health show antenatal detection of SGA of 40-60 % with use of GROW.
Anderson NH, Sadler L, Stewart A, McCowan LE. Maternal and pathological pregnancy characteristics in customised birthweight centiles and identification of at- risk small-for-gestational-age infants: a retrospective cohort study. BJOG 2012;119(5):589-595. DOI: 10.1111/j.1471-0528.2012.03313.x.
Gardosi J, Francis A. Controlled trial of fundal height measurement plotted on customised antenatal growth charts. B J Obstet Gynaecol 1999; 106:309-
Gardosi, J., et al., Association between reduced stillbirth rates in England and regional uptake of accreditation training in customised fetal growth assessment. BMJ Open,
- 3 (12): p. e003942.
Gardosi, J., et al. Reducing stillbirths in the West Midlands. 2013; Available from: http://medweb4.bham.ac.uk/websites/key_health_data/2011/pdf/KHD%202011- 12%20Chapter%204%20Reducing%20Stillbirths.pdf.
NZMFM 2014, Guideline for the management of suspected small for gestational age singleton pregnancies after 34 weeks’ gestation (www.nzmfm.health.nz see guidelines)
RCOG, The investigation and management of small-for-gestational-age fetus: Green top guideline No 31, 2013.
Roex A, Nikpoor P, Eerd EV, Dekker G Serial Plotting on customised fundal height charts results in doubling of antenatal detection of small for gestational age fetuses in nulliparous women. Aust NZ J Obstet Gynaecol.2012;52:78- Back to Contents
6. Associated Auckland DHB documents
Protocol for IUGR Management in Day Assessment Unit Referral - Maternal Fetal Medicine (MFM) Small for Gestational Age (SGA) over 34 weeks - Clinical Pathway Flowchart: Diabetes Screening
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Customised Antenatal Growth Chart 2015 11 16.docx
7. Disclaimer
No guideline can cover all variations required for specific circumstances. It is the responsibility of the health care practitioners using this Auckland DHB guideline to adapt it for safe use within their own institution, recognise the need for specialist help, and call for it without delay, when an individual patient falls outside of the boundaries of this guideline. Back to Contents
8. Corrections and amendments
The next scheduled review of this document is as per the document classification table (page 1). However, if the reader notices any errors or believes that the document should be reviewed before the scheduled date, they should contact the owner or the Clinical Policy Advisor without delay. Back to Contents
