CONSULTATION DRAFT
5.2 Fetal growth and wellbeing
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.
5.2.1
Fetal growth
During pregnancy, the baby passes through various stages of growth and development. Monitoring
growth aims to identify small- and large-for-gestational age babies, both of whom are at increased risk
of associated morbidity and mortality.
Current practice in Australia for monitoring growth is assessment by abdominal palpation, symphysis–
fundal height measurement, or both.
Perinatal deaths associated with intrauterine growth restriction in Australia
A baby whose estimated weight is below the 10th percentile for its gestational age is considered to be
affected by intrauterine growth restriction (Li et al 2012). In Australia in 2010, intrauterine growth restriction
was the cause of 6.8% of perinatal deaths among singleton babies (Li et al 2012). Perinatal deaths
associated with intrauterine growth restriction among singleton babies were most common at 32–36
weeks gestation (11.3%). Among all perinatal deaths, intrauterine growth restriction was more common
among mothers aged less than 20 years (8%) and more than 40 years (9.4%).
Summary of the evidence
The evidence on methods of growth assessment is limited:
•
an observational study found that abdominal palpation had limited value as a screening tool for
intrauterine growth restriction in low-risk pregnancies (n=6,318) (Bais et al 2004); and
•
two Cochrane reviews (based on the same study) found no difference in detection of intrauterine
growth restriction between repeated symphysis–fundal height measurement and abdominal
palpation (Neilson 2009; Robert Peter et al 2012).
Although current evidence does not conclusively support either method for detecting low or high birth
weight babies, monitoring growth is important (Robert Peter et al 2012).
Consensus-based recommendation i
Offer women assessment of fetal growth (abdominal palpation and/or symphysis-fundal height
measurement) at each antenatal visit to detect small- or large-for-gestational-age infants.
Studies into estimating birth weight before labour have found that:
•
sensitivity and specificity were similar using ultrasound (12.6%; 92.1%), abdominal palpation (11.8%;
99.6%) or maternal estimate (6.3%; 98.0%) (n=246) (Ashrafganjooei et al 2010);
•
abdominal palpation was within 10% of actual birth weight in 65% of babies, with lower accuracy
for low birth weight (n=320) (Belete & Gaym 2008);
•
abdominal palpation and ultrasound had similar sensitivity and specificity for normal and low birth
weights but ultrasound had higher specificity for high birth weight (n=174) (Khani et al 2011); and
•
ultrasound was more accurate in predicting low or high birth weight than abdominal palpation
(n=262) (Peregrine et al 2007).
5.2.2
Fetal movements
Maternal perception of fetal movement (defined as any discrete kick, flutter, swish or roll) (Neldam 1983)
is one of the first indications of fetal life. Most pregnant women become aware of fetal activity
between 18 and 20 weeks of gestation (RCOG 2011). Due to a lack of epidemiological studies on fetal
activity patterns and maternal perception of fetal activity in normal pregnancies, it is not clear what
constitutes a ‘normal’ pattern of fetal movement (RCOG 2011). There is considerable variation in fetal
CONSULTATION DRAFT
movements and estimates cover a wide range (eg from 4–100 movements per hour) (Mangesi & Hofmeyr
2007).
Decreased fetal movement
A significant reduction in fetal movement may be associated with poor perinatal outcomes (RCOG
2011). Women’s perception of decreased fetal movement is reduced with an anterior placenta,
cigarette smoking and maternal obesity (Tuffnell et al 1991).
•
Incidence of decreased fetal movement: 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).
•
Risks of decreased fetal movement: decreased fetal movement indicates that even women with
low-risk pregnancies may be at greater risk of adverse outcomes, including intrauterine growth
restriction, fetal death and preterm birth (ANZSA 2010). However, the absence of perceived fetal
movements does not necessarily indicate fetal compromise or death (Mangesi & Hofmeyr 2007).
Due to the lack of high quality evidence, there is considerable variation in the information provided to
women about decreased fetal movements (Heazell et al 2008; Flenady et al 2009; Unterscheider et al 2010).
Summary of the evidence
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 (ANZSA 2010) and in the
United Kingdom (NICE 2008a; RCOG 2011).
Fetal movement counting
A systematic review (n=71,730) (Mangesi & Hofmeyr 2007) found insufficient evidence to recommend for
or against fetal movement counting to prevent adverse perinatal outcomes, as the included trials did
not compare the effects on perinatal outcome of fetal movement counting with no fetal movement
counting. A subsequent systematic review of single studies (Heazell & Froen 2008) concluded that at
present, there is no evidence that any absolute definition of reduced fetal movements is more valuable
than maternal perception of reduced fetal movements in detecting intrauterine fetal death or fetal
compromise. However, a recent RCT (n=1,076) found that maternal ability to detect clinically important
changes in fetal activity seemed to be improved by fetal movement counting, with increased
detection of intrauterine growth restriction and improved perinatal outcomes (Saastad et al 2011).
Reporting of decreased fetal movement
Guidelines from Australia (ANZSA 2010) and the United Kingdom (RCOG 2011) recommend that women
contact their health professional or maternity unit if they are concerned about a reduction in or
cessation of fetal movements after 28 weeks of gestation.
A recent systematic review (Hofmeyr & Novikova 2012) concluded that there are insufficient data from
randomised trials to guide practice regarding the management of decreased fetal movement. Current
management strategies include early birth, expectant management with close surveillance of the
baby, cardiotocography, ultrasound examination, and fetal arousal tests (either cardiotocography or
clinical observation where electronic fetal assessment methods are not available) to assess the baby’s
wellbeing (Hofmeyr & Novikova 2012).
Consensus-based recommendation ii
Advise women to be aware of the normal pattern of movement for their baby and to contact their
health care professional promptly if they have any concerns about decreased or absent movements.
CONSULTATION DRAFT
Discussing fetal movement
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 generally no reduction in the
frequency of fetal movements in the late third trimester (RCOG 2011);
•
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 mother’s perception of
movements (ANZSA 2010);
•
most women (approximately 70%) who perceive a single episode of decreased fetal movements
will have a normal outcome to their pregnancy (RCOG 2011); and
•
if a woman does report decreased fetal movement, a range of tests can be undertaken to assess
the baby’s wellbeing.
5.2.3
Discussing fetal heart rate assessment
Auscultation of the fetal heart has traditionally formed an integral part of a standard antenatal
examination.
Summary of the evidence
Auscultation
Routine auscultation of the fetal heart rate is recommended against in the United Kingdom (NICE
2008b).
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 2008b).
The sensitivity of Doppler auscultation in detecting the fetal heart is 80% at 12+1 weeks 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 the fetal heart 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.
Consensus-based recommendation iii
If auscultation of the fetal heart rate is performed, a Doppler may be used from 12 weeks and a Pinard
stethoscope from 28 weeks.
Cardiotocography
Electronic fetal heart rate monitoring is not recommended as a routine part of antenatal care in the
United Kingdom (NICE 2008b) or Canada (Liston et al 2007).
A Cochrane review found no evidence on 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 obstetric complications (Mancuso et al 2008).
Consensus-based recommendation iv
Routine use of antenatal electronic fetal heart rate monitoring (cardiotocography) for fetal assessment
in women with an uncomplicated pregnancy is not supported by evidence.
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5.2.4
Practice summary: Fetal growth and wellbeing
Fetal growth
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.
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: If using symphysis-fundal height measurement, start
measuring at the variable point (the fundus) and continue to the fixed point (the symphysis pubis)
using a non-elastic tape measure 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.
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 on 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.
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.
5.2.5
Resources
Measuring fundal height. In: Minymaku Kutju Tjukurpa Women’s Business Manual, 4th edition. Congress Alukura,
Nganampa Health Council Inc and Centre for Remote Health. http://www.remotephcmanuals.com.au
Fetal movements
ANZSA (2010) Clinical practice guideline for the management of women who report decreased fetal movements:
Australian and New Zealand Stillbirth Association.
RCOG (2011) Reduced fetal movements. Green-top guideline no. 57: Royal College of Obstetricians and
Gynaecologists.
5.2.6
References
ANZSA (2010) Clinical Practice Guideline for the Management of Women who Report Decreased Fetal Movements.
Australian and New Zealand Stillbirth Association.
Ashrafganjooei T, Naderi T, Eshrati B et al (2010) Accuracy of ultrasound, clinical and maternal estimates of birth
weight in term women. East Mediterr Health J 16(3): 313–17.
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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
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Belete W & Gaym A (2008) Clinical estimation of fetal weight in low resource settings: comparison of Johnson's
formula and the palpation method. Ethiop Med J 46(1): 37–46.
Flenady V, MacPhail J, Gardener G et al (2009) Detection and management of decreased fetal movements in
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