Beta We are building this new website to better deliver information. Learn more about this site.
Pregnancy Care Guidelines

22 Fetal growth restriction and well-being

Antenatal visits provide an opportunity to assess fetal growth, auscultate the fetal heart (although this cannot predict pregnancy outcomes) and encourage women to be aware of the normal pattern of fetal movements for their baby.

22.1 Fetal growth restriction

The information and recommendations in this chapter have been adapted from RCOG (2014) The Investigation and Management of the Small-For Gestational Age Fetus: Green-Top Guideline 31. London: Royal College of Obstetricians and Gyneacologists. This involved mapping of clinical questions and rewording of recommendations for consistency within these Guidelines.[17]

Monitoring growth aims to identify small-for-gestational age babies, who are at increased risk of associated morbidity and mortality.

22.1.1 Background

Perinatal deaths associated with small-for-gestational age in Australia

In Australia in 2014, intrauterine growth restriction was the cause of 5.4% of perinatal deaths among singleton babies (AIHW 2016). Perinatal deaths associated with intrauterine growth restriction among singleton babies were most common at 28–31 weeks gestation (13.2%).

Risk factors for small-for-gestational age

Major risk factors (OR>2.0) for having a small-for-gestational age fetus or newborn include (RCOG 2014):

  • maternal diabetes with vascular disease (OR 6.0, 95%CI 1.5 to 2.3), renal impairment (aOR 5.3, 95%CI 2.8 to 10) chronic hypertension (ARR 2.5, 95%CI 2.1 to 2.9) or antiphospholipid syndrome (RR 6.22, 95%CI 2.43 to 16.0).
  • having a previous small-for-gestational age baby (OR 3.9, 95%CI 2.14 to 7.12) or stillbirth (OR 6.4, 95%CI 0.78 to 52.56)
  • vigorous daily exercise (leading to being very out of breath) (aOR 3.3, 95%CI 1.5 to 7.2)
  • maternal age >40 years (OR 3.2, 95%CI 1.9 to 5.4)
  • PAPP-A <0.4 MoM (OR 2.6)
  • using cocaine in pregnancy (OR 3.23, 95%CI 2.43 to 4.3)
  • smoking 11 or more cigarettes a day in pregnancy (OR 2.21, 95%CI 2.03 to 2.4).
  • maternal (OR 2.64, 95%CI 2.28 to 3.05) or paternal (OR 3.47, 95%CI 1.17 to 10.27) history of being a small-for-gestation-age baby is also a significant risk factor but may not be ascertainable.

Other risk factors (OR <2.0) include (RCOG 2014):

  • maternal diet (low fruit intake pre-pregnancy) (AOR 1.9; 95%CI 1.3 to 2.8)
  • nulliparity (OR 1.89; 95%CI 1.82 to 1.96)
  • in vitro fertilisation (IVF) singleton pregnancy (OR 1.6; 95%CI 1.3 to 2.0)
  • BMI ≥30 (RR 1.55; 95%CI 1.3 to 1.7)
  • smoking up to 10 cigarettes a day (OR 1.54; 95%CI 1.39 to 1.7)
  • history of pre-eclampsia (AOR 1.31; 95%CI 1.19 to 1.44)
  • pregnancy interval of <6 months (AOR 1.26; 95%CI 1.18 to 1.33) or ≥60 months (AOR 1.29; 95%CI 1.2 to 1.39).

Recommendation

  • Practice point
  • FF

Early in pregnancy, assess women for risk factors for having a small-for-gestational-age fetus/newborn.

Approved by NHMRC in October 2017; expires October 2022

Recommendation

  • Consensus-based
  • XII

When women are identified as being at risk of having a small-for-gestational-age fetus/newborn, provide advice about modifiable risk factors. 

Approved by NHMRC in October 2017; expires October 2022

Recommendation

  • Consensus-based
  • XIII

Refer women with a major risk factor or multiple other factors associated with having a small-for-gestational-age fetus/newborn for ultrasound assessment of fetal size and wellbeing at 28–30 and 34–36 weeks gestation.

Approved by NHMRC in October 2017; expires October 2022

22.1.2 Protective and preventive factors

A high green leafy vegetable intake pre–pregnancy has been reported to be protective (AOR 0.44, 95% CI 0.24– 0.81) (RCOG 2014).

Low-dose aspirin for women at risk of pre-eclampsia is likely to reduce intrauterine growth restriction by about 10% (whether taken earlier or later than 16 weeks) (Meher et al 2017).

22.1.3 Assessing fetal growth

Abdominal palpation

Low-level evidence from cohort and case–control studies performed in low-risk populations has consistently shown abdominal palpation to be of limited accuracy in the detection of a small-for-gestational age newborn (sensitivity 19–21%, specificity 98%) and severely small-for-gestational age newborn (<2.3rd centile, sensitivity 28%) (Kean & Liu 1996; Bais et al 2004). In mixed-risk populations, the sensitivity increases to 32–44% (Hall et al 1980; Rosenberg et al 1982). In high-risk populations sensitivity is reported as 37% for a small-for-gestational age newborn and 53% for severely small-for-gestational age newborn (c) (low quality evidence).

Recommendation

  • Consensus-based
  • XIV

Do not assess fetal growth based solely on abdominal palpation.

Approved by NHMRC in October 2017; expires October 2022

Measurement of fundal height

A systematic review highlighted the wide variation of predictive accuracy of fundal height measurement for a small-for-gestational age newborn (Morse et al 2009). Although early studies reported sensitivities of 56–86% and specificities of 80–93% for fundal height detection of small-for-gestational age (Belizan et al 1978; Cnattingius et al 1984; Mathai et al 1987), a large study (n=2,941) reported fundal height to be less predictive with a sensitivity of 27% and specificity of 88% (LR+ 2.22, 95% CI 1.77 to 2.78; LR– 0.83, 95% CI 0.77 to 0.90) (Persson et al 1986). Maternal obesity, abnormal fetal lie, large fibroids, polyhydramnios and fetal head engagement contribute to the limited predictive accuracy of fundal height measurement. Fundal height is associated with significant intra– and inter– observer variation (Bailey et al 1989;  Morse et al 2009) and serial measurement may improve predictive accuracy (Pearce & Campbell 1987).

The impact on perinatal outcome of measuring fundal height is uncertain. A systematic review found only one trial (n=1,639), which showed that fundal height measurement did not improve any of the perinatal outcomes measured (Neilson 2000).

Recommendation

  • Consensus-based
  • XV

At each antenatal visit from 24 weeks, measure fundal height in centimetres.

Approved by NHMRC in October 2017; expires October 2022

Recommendation

  • Practice point
  • GG

Refer women after 24 weeks gestation with a fundal height ≥3cm less than expected, a single fundal height which plots below the 10th centile or serial measurements that demonstrate slow or static growth by crossing centiles for ultrasound measurement of fetal size.

Approved by NHMRC in October 2017; expires October 2022

Recommendation

  • Practice point
  • HH

Refer women in whom measurement of fundal height is inaccurate (for example: BMI >35, large fibroids, polyhydramnios) for serial assessment of fetal size using ultrasound.

Approved by NHMRC in October 2017; expires October 2022

Customised charts

Customised fundal height charts are adjusted for maternal characteristics (eg maternal height, weight). As no RCTs have compared customised with non–customised fundal height charts, the evidence for their effectiveness in improving outcomes such as perinatal morbidity/mortality is lacking (RCOG 2014).

22.2 Fetal movements

The information and recommendations in this chapter have been adapted from Gardener G, Daly L, Bowring V et al (2017) Clinical Practice Guideline for the Care of Women with Decreased Fetal Movements. Brisbane: The Centre of Research Excellence in Stillbirth. This involved mapping of clinical questions and rewording of recommendations for consistency within these Guidelines.[18]

Fetal movement assessment is widely used to monitor fetal wellbeing (Froen et al 2008; O’Sullivan et al 2009) and is most commonly undertaken through subjective maternal perception. Fetal movement counting is a more formal method to quantify fetal movements (Mangesi & Hofmeyr 2007). Maternal perception rather than formal fetal movement counting is recommended in Australia (Gardener et al 2017) and in the United Kingdom (NICE 2008; RCOG 2011). Maternal reporting of decreased fetal movement occurs in 5–15% of pregnancies in the third trimester (Froen 2004; Heazell et al 2008; Flenady et al 2009).

22.2.1 Background

Risks associated with decreased fetal movement

Stillbirth, which affects over 2,700 families in Australia and New Zealand each year (Hilder et al 2014), is often preceded by maternal perception of decreased fetal movement (Froen 2004; Erlandsson et al 2012). Decreased fetal movement is also strongly linked to other adverse perinatal outcomes such as neurodevelopmental disability, infection, feto-maternal haemorrhage, umbilical cord complications, low birth weight and fetal growth restriction (Froen et al 2008; Heazell & Froen 2008). Decreased fetal movements for some women may be associated with placental dysfunction or insufficiency, which could lead to fetal growth restriction and/or stillbirth (Warrander et al 2012).

22.2.2 Information on fetal movements

Antenatal education about fetal movement has been shown to reduce the time from maternal perception of decreased fetal movements to health-seeking behaviour (Tveit et al 2009). A reduction in stillbirth rates has been associated with increased awareness of decreased fetal movements among women and health professionals in both the overall study population (OR 0.67, 95% CI: 0.49-0.94) and in women with decreased fetal movements (aOR 0.51, 95% CI: 0.32 to 0.81) (Tveit et al 2009; Saastad et al 2010).

However, many women do not receive adequate information about fetal movements (Saastad et al 2008; Peat et al 2012). A recent study found that more than one-third of women at 34 weeks gestation or later did not recall receiving information from their healthcare professional about fetal movement (McArdle et al 2015). Another study found that information provided by midwives was not always consistent with evidence-based guidelines (Warland & Glover 2017). Pregnant women preferred to be given as much information as possible about fetal movements and cited health professionals as a trustworthy source (McArdle et al 2015).

Recommendation

  • Consensus-based
  • XVI

Early in pregnancy provide women with verbal and written information about normal fetal movements. This information should include a description of the changing patterns of movement as the fetus develops, normal wake/sleep cycles and factors that may modify the mother’s perception of fetal movements.

Approved by NHMRC in October 2017; expires October 2022

Recommendation

  • Consensus-based
  • XVII

Advise women with a concern about decreased fetal movements to contact their health professional immediately.

Approved by NHMRC in October 2017; expires October 2022

Recommendation

  • Practice point
  • II

Emphasise the importance of maternal awareness of fetal movements at every antenatal visit.

Approved by NHMRC in October 2017; expires October 2022

22.2.3 Monitoring fetal movements

A Cochrane review assessed the effect of formal fetal movement counting and recording (eg using kick charts) on perinatal death, major morbidity, maternal anxiety and satisfaction, pregnancy intervention and other adverse pregnancy outcomes (5 RCTS; n=71,458) (Mangesi et al 2015). The review did not find sufficient evidence to inform practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Only two studies compared routine fetal movements with standard antenatal care. Indirect evidence from a large cluster-RCT (Grant et al 1989) suggested that more babies at risk of death were identified in the routine fetal monitoring group but this did not translate to reduced perinatal mortality.

Recommendation

  • Consensus-based
  • XVIII

Do not advise the use of kick charts as part of routine antenatal care.

Approved by NHMRC in October 2017; expires October 2022

Recommendation

  • Practice point
  • JJ

Maternal concern about decreased fetal movements overrides any definition of decreased fetal movements based on numbers of fetal movements.

Approved by NHMRC in October 2017; expires October 2022

22.2.4 Discussing fetal movements

Information given to women should include that:

  • most women are aware of fetal movements by 20 weeks of gestation, and although fetal movements tend to plateau at 32 weeks of gestation, there is no reduction in the frequency of fetal movements in the late third trimester
  • patterns of movement change as the baby develops, and wake/sleep cycles and other factors (eg maternal weight and position of the placenta) may modify the woman’s perception of movements
  • taking a short amount of time each day to be aware of the baby’s movements is a good way for women to ‘check on’ the baby
  • most women (approximately 70%) who perceive a single episode of decreased fetal movements will have a normal outcome to their pregnancy (RCOG 2011)
  • if a woman reports decreased fetal movement, tests can be undertaken to assess the baby’s wellbeing.

22.3 Fetal heart rate assessment

Auscultation of the fetal heart has traditionally formed an integral part of a standard antenatal assessment.

22.3.1 Auscultation

Routine auscultation of the fetal heart rate is not recommended in the United Kingdom (NICE 2008).

Although successful detection of a fetal heart confirms that the baby is alive, it does not guarantee that the pregnancy will continue without complications (Rowland et al 2011) and is unlikely to provide detailed information on the fetal heart rate such as decelerations or variability (NICE 2008).

The sensitivity of Doppler auscultation in detecting the fetal heart is 80% at 12 weeks + 1 day gestation and 90% after 13 weeks (Rowland et al 2011). Attempts to auscultate the fetal heart before this time may be unsuccessful, and lead to maternal anxiety and additional investigations (eg ultrasound) in pregnancies that are actually uncomplicated (Rowland et al 2011). It is unlikely that a fetal heart rate will be audible before 28 weeks if a Pinard stethoscope is used (Wickham 2002).

Although there is no evidence on the psychological benefits of auscultation for the mother, it may be enjoyable, reduce anxiety and increase mother–baby attachment.

Recommendation

  • Consensus-based
  • XIX

If auscultation of the fetal heart rate is performed, a Doppler may be used from 12 weeks and either Doppler or a Pinard stethoscope from 28 weeks.

Approved by NHMRC in October 2017; expires October 2022

22.3.2 Cardiotocography

Electronic fetal heart rate monitoring is not recommended as a routine part of antenatal care in the United Kingdom (NICE 2008) or Canada (Liston et al 2007).

A Cochrane review found no clear evidence to support the use of cardiotocography in women at low risk of complications (Grivell et al 2010).

Anxiety levels in women who undergo routine cardiotocography are increased. This reaction seems to be influenced by the perception of fetal movement during the examination and is more evident in women whose pregnancies are affected by complications (Mancuso et al 2008).

Recommendation

  • Consensus-based
  • XX

Do not routinely use electronic fetal heart rate monitoring (cardiotocography) for fetal assessment in women with an uncomplicated pregnancy.

Approved by NHMRC in October 2017; expires October 2022

22.4 Practice summary: Fetal growth restriction and wellbeing

Fetal growth restriction

When

At all antenatal visits.

Who

  • Midwife
  • GP
  • obstetrician
  • Aboriginal and Torres Strait Islander Health Practitioner
  • Aboriginal and Torres Strait Islander Health Worker
  • multicultural health worker.

What

  • Discuss fetal growth
    Early in pregnancy, give all women appropriate written information about the measurement of fetal growth and an opportunity to discuss the procedure with a health professional.
  • Take a consistent approach to assessment
    When measuring fundal height, use a non-elastic tape with numbers facing downwards so that an objective measurement is taken. Measure from the variable point (the fundus) and continue to the fixed point (the symphysis pubis) or vice versa. Take and document measurements in a consistent manner.
  • Take a holistic approach
    Abdominal palpation provides a point of engagement between the health professional and mother and baby.

Fetal movements

When

At antenatal visits from 20 weeks.

Who

  • Midwife
  • GP
  • obstetrician
  • Aboriginal and Torres Strait Islander Health Practitioner
  • Aboriginal and Torres Strait Islander Health Worker
  • multicultural health worker.

What

  • Discuss fetal movement patterns
    Emphasise the importance of the woman’s awareness of the pattern of movement for her baby and factors that might affect her perception of the movements.
  • Advise early reporting
    Women should report perceived decreased fetal movement on the same day rather than wait until the next day.
  • Take a holistic approach
    Support information given with appropriate resources (eg written materials suitable to the woman’s level of literacy, audio or video) and details of whom the woman should contact if decreased fetal movements are perceived.

Fetal heart rate

When

At antenatal visits between 12 and 26 weeks gestation.

Who

  • Midwife
  • GP
  • obstetrician
  • Aboriginal and Torres Strait Islander Health Practitioner
  • Aboriginal and Torres Strait Islander Health Worker
  • multicultural health worker.

What

  • Discuss fetal heart rate
    Explain that listening to the fetal heart does not generally provide any information about the health of the baby and that other tests (such as ultrasound) are relied upon for identification of any problems with the pregnancy.
  • Take a holistic approach
    Some women may be reassured by hearing the fetal heart beat.

22.5 Resources

22.5.1 Fetal growth

22.5.2 Fetal movements

References

  • AIHW (2016) Australia’s Mothers and Babies 2014—in brief. Canberra: Australian Institute of Health and Welfare.
  • Bailey SM, Sarmandal P, Grant JM (1989) A comparison of three methods of assessing inter-observer variation applied to measurement of the symphysis-fundal height. Br J Obstet Gynaecol 96(11): 1266-71.
  • Bais JM, Eskes M, Pel M et al (2004) Effectiveness of detection of intrauterine growth retardation by abdominal palpation as screening test in a low risk population: an observational study. Eur J Obstet Gynecol Reprod Biol 116(2): 164-9.
  • Belizan JM, Villar J, Nardin JC et al (1978) Diagnosis of intrauterine growth retardation by a simple clinical method: measurement of uterine height. Am J Obstet Gynecol 131(6): 643-6.
  • Cnattingius S, Axelsson O, Lindmark G (1984) Symphysis-fundus measurements and intrauterine growth retardation. Acta Obstet Gynecol Scand 63(4): 335-40.
  • Erlandsson K, Lindgren H, Davidsson-Bremborg A et al (2012) Women’s premonitions prior to the death of their baby in utero and how they deal with the feeling that their baby may be unwell. Acta Obstet Gynecol Scand 91(1): 28-33.
  • Flenady V, MacPhail J, Gardener G et al (2009) Detection and management of decreased fetal movements in Australia and New Zealand: a survey of obstetric practice. Aust N Z J Obstet Gynaecol 49(4): 358–63.
  • Froen JF (2004) A kick from within--fetal movement counting and the cancelled progress in antenatal care. J Perinat Med 32(1): 13-24.
  • Froen JF, Tveit JV, Saastad E et al (2008) Management of decreased fetal movements. Semin Perinatol 32(4): 307–11.
  • Gardener G, Daly L, Bowring V et al (2017) Clinical practice guideline for the care of women with decreased fetal movements. Brisbane: The Centre of Research Excellence in Stillbirth.
  • Grant A, Elbourne D, Valentin L et al (1989) Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet2(8659): 345-9.
  • Grivell RM, Alfirevic Z, Gyte GM et al (2010) Antenatal cardiotocography for fetal assessment. Cochrane Database Syst Rev(1): CD007863.
  • Hall MH, Chng PK, MacGillivray I (1980) Is routine antenatal care worth while? Lancet 2(8185): 78-80.
  • Heazell AE & Froen JF (2008) Methods of fetal movement counting and the detection of fetal compromise. J Obstet Gynaecol 28(2): 147-54.
  • Heazell AE, Green M, Wright C et al (2008) Midwives’ and obstetricians’ knowledge and management of women presenting with decreased fetal movements. Acta Obstet Gynecol Scand 87(3): 331–39.
  • Hilder L, Zhichao Z, Parker M et al (2014) Australia’s mothers and babies 2012. Canberra: AIHW.
  • Kean LH & Liu DTY (1996) Antenatal care as a screening tool for the detection of small for gestational age babies in the low risk population. J Obstet Gynaecol16(2): 77–82.
  • Liston R, Sawchuck D, Young D (2007) Fetal health surveillance: antepartum and intrapartum consensus guideline. J Obstet Gynaecol Can 29(9 Suppl 4): S3–56.
  • Mancuso A, De Vivo A, Fanara G et al (2008) Effects of antepartum electronic fetal monitoring on maternal emotional state. Acta Obstet Gynecol Scand 87(2): 184–89.
  • Mangesi L & Hofmeyr GJ (2007) Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev(1): CD004909.
  • Mangesi L, Hofmeyr GJ, Smith V et al (2015) Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev 10: Cd004909.
  • Mathai M, Jairaj P, Muthurathnam S (1987) Screening for light-for-gestational age infants: a comparison of three simple measurements. Br J Obstet Gynaecol94(3): 217-21.
  • McArdle A, Flenady V, Toohill J et al (2015) How pregnant women learn about foetal movements: sources and preferences for information. Women Birth 28(1): 54-9.
  • Meher S, Duley L, Hunter K et al (2017) Antiplatelet therapy before or after 16 weeks’ gestation for preventing preeclampsia: an individual participant data meta-analysis. Am J Obstet Gynecol 216(2): 121-28 e2.
  • Morse K, Williams A, Gardosi J (2009) Fetal growth screening by fundal height measurement. Best Pract Res Clin Obstet Gynaecol 23(6): 809-18.
  • Neilson JP (2000) Symphysis-fundal height in pregnancy. Cochrane Database Syst Rev: CD000944.
  • NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman. National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence. London: RCOG Press.
  • O’Sullivan O, Stephen G, Martindale E et al (2009) Predicting poor perinatal outcome in women who present with decreased fetal movements. J Obstet Gynaecol 29(8): 705–10.
  • Pearce JM & Campbell S (1987) A comparison of symphysis-fundal height and ultrasound as screening tests for light-for-gestational age infants. Br J Obstet Gynaecol 94(2): 100-4.
  • Peat AM, Stacey T, Cronin R et al (2012) Maternal knowledge of fetal movements in late pregnancy. Aust N Z J Obstet Gynaecol 52(5): 445-9.
  • Persson B, Stangenberg M, Lunell NO et al (1986) Prediction of size of infants at birth by measurement of symphysis fundus height. Br J Obstet Gynaecol 93(3): 206-11.
  • RCOG (2011) Reduced Fetal Movements. Green-top Guideline No. 57. London: Royal College of Obstetricians and Gynaecologists.
  • RCOG (2014) The Investigation and Management of the Small-For Gestational Age Fetus: Green-Top Guideline 31. London: Royal College of Obstetricians and Gyneacologists.
  • Rosenberg K, Grant JM, Hepburn M (1982) Antenatal detection of growth retardation: actual practice in a large maternity hospital. Br J Obstet Gynaecol 89(1): 12-5.
  • Rowland J, Heazell A, Melvin C et al (2011) Auscultation of the fetal heart in early pregnancy. Arch Gynecol Obstet 283 Suppl 1: 9–11.
  • Saastad E, Ahlborg T, Froen JF (2008) Low maternal awareness of fetal movement is associated with small for gestational age infants. J Midwifery Womens Health 53(4): 345-52.
  • Saastad E, Tveit JV, Flenady V et al (2010) Implementation of uniform information on fetal movement in a Norwegian population reduces delayed reporting of decreased fetal movement and stillbirths in primiparous women - a clinical quality improvement. BMC Res Notes 3(1): 2.
  • Tveit JV, Saastad E, Stray-Pedersen B et al (2009) Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth 9(1): 32.
  • Warland J & Glover P (2017) Fetal movements: What are we telling women? Women Birth 30(1): 23-28.
  • Warrander LK, Batra G, Bernatavicius G et al (2012) Maternal perception of reduced fetal movements is associated with altered placental structure and function. PLoS One 7(4): e34851.
  • Wickham S (2002) Pinard wisdom. Tips and tricks from midwives (Part 1). Pract Midwife 5(9): 21.
  • 17 The information and recommendations in this chapter have been adapted from RCOG (2014) The Investigation and Management of the Small-For Gestational Age Fetus: Green-Top Guideline 31. London: Royal College of Obstetricians and Gyneacologists. This involved mapping of clinical questions and rewording of recommendations for consistency within these Guidelines.
  • 18 The information and recommendations in this chapter have been adapted from Gardener G, Daly L, Bowring V et al (2017) Clinical practice guideline for the care of women with decreased fetal movements. Brisbane: The Centre of Research Excellence in Stillbirth. This involved mapping of clinical questions and rewording of recommendations for consistency within these Guidelines.
Last updated: 
20 November 2018