Antenatal care guidelines review Public consultation draft 22 May 2017 Contents

19.2Fetal 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.

19.2.1Fetal growth restriction

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

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

Significant risk factors 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)

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)

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 include nulliparity, low fruit intake pre-pregnancy, in vitro fertilisation (IVF) singleton pregnancy, smoking up to 10 cigarettes a day, history of pre-eclampsia, pregnancy interval of <6 months or ≥60 months and BMI ≥30 (RCOG 2014).

Practice point

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

Consensus-based recommendations

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

22.Consider referring women who have a significant risk factor for having a small-for-gestational-age fetus/newborn for serial ultrasound measurement of fetal size and assessment of wellbeing with umbilical artery Doppler from 26–28 weeks of pregnancy.

Practice point

23.Consider referring women who have three or more minor risk factors for having a small-for-gestational age fetus/newborn for uterine artery Doppler at 20–24 weeks of pregnancy.

Summary of the evidence

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 (Bais et al 2004) (low quality evidence).

Consensus-based recommendation

24.Do not assess fetal growth based solely on abdominal palpation.

Measurement of symphysis-fundal height

A systematic review highlighted the wide variation of predictive accuracy of symphysis-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 symphysis-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 symphysis-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 symphysis-fundal height measurement. Symphysis-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 symphysis-fundal height is uncertain. A systematic review found only one trial (n=1,639), which showed that symphysis-fundal height measurement did not improve any of the perinatal outcomes measured (Neilson 2000).

Consens-based recommendation

25.At each antenatal visit from 24 weeks, measure symphysis-fundal height.

Customised charts

A customised symphysis-fundal height chart is adjusted for maternal characteristics (maternal height, weight, parity and ethnic group). No trials were identified that compared customised with non–customised symphysis-fundal height charts and thus evidence for their effectiveness on outcomes such as perinatal morbidity/mortality is lacking (RCOG 2014).

However observational studies suggest that customised symphysis-fundal height charts may improve the detection of a small-for-gestational age newborn. In one study, use of customised charts, with referral when a single symphysis-fundal height measurement fell below the 10th centile or the last two measurements were above 10th centile but the slope was flatter than the 10th centile line, resulted in improved sensitivity for a small-for-gestational age newborn (48% vs 29%, OR 2.2, 95% CI 1.1 to 4.5) compared to abdominal palpation (Gardosi & Francis 1999). Use of customised charts was also associated with fewer referrals for investigation and fewer admissions. An audit study also showed that use of customised symphysis-fundal height charts detected 36% of small-for-gestational age newborns compared with only 16% when customised charts were not used (Wright et al 2006).

Practice points

26.If plotting symphysis-fundal height, use a customised chart rather than a population–based chart.

27.Women with a single symphysis fundal height which plots below the 10th centile or serial measurements that demonstrate slow or static growth by crossing centiles should be referred for ultrasound measurement of fetal size.

28.Women in whom measurement of symphysis fundal height is inaccurate (for example: BMI >35, large fibroids, polyhydramnios) should be referred for serial assessment of fetal size using ultrasound.

28.1.1Fetal movements

Fetal movement assessment is widely used to monitor fetal wellbeing (Froen et al 2008a; 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 2016) and in the United Kingdom (NICE 2008b; RCOG 2011). Maternal reporting of decreased fetal movement occurs in 5–15% of pregnancies in the third trimester (Froen 2004a; Heazell et al 2008; Flenady et al 2009).

Risks associated with decreased fetal movement

Stillbirth, which affects over 2,700 families in Australia and New Zealand (Hilder et al 2014), is often preceded by maternal perception of decreased fetal movement (Froen 2004b; 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 2008b; 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).

Summary of the evidence

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).

Consensus-based recommendations

29.Routinely provide women with verbal and written information about normal fetal movements.

30.Advise women to contact their health professional if they have any concern about decreased or absent fetal movements and not to wait until the next day to report decreased fetal movements.

Practice point

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

Monitoring fetal movements

A Cochrane review assessed the effect of formal fetal movement counting and recording 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. 

Consensus-based recommendations

32.Advise women to monitor fetal movements but do not advise formal fetal movement counting as part of routine antenatal care.

33.Advise a woman who is unsure whether fetal movements are decreased to count while lying down on her side and to contact her health care professional if there are less than 10 movements in 2 hours.

Practice point

34.Maternal concern about decreased fetal movements overrides any definition of decreased fetal movements based on counting and women with a concern about decreased fetal movements should be encouraged to contact their health professional.

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

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

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 does report decreased fetal movement, a range of tests can be undertaken to assess the baby’s wellbeing.

34.1.1Fetal heart rate assessment

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

Summary of the evidence

Auscultation

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

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 2008a).

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 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.

Consensus-based recommendation

35.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 2008a) or Canada (Liston et al 2007).

A Cochrane review found no 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 obstetric complications (Mancuso et al 2008).

Consensus-based recommendation

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

36.1.1Practice 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.

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 symphysis-fundal height, start measuring at the variable point (the fundus) and continue to the fixed point (the symphysis pubis) using a non-elastic tape measure with the numbers facing downwards so that an objective measurement is taken. Document measurements in a consistent manner, using a customised fetal growth chart.

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 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.

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.

36.1.2Resources

Fetal growth

Measuring fundal height. In: Minymaku Kutju Tjukurpa Women’s Business Manual, 4th edition. Congress Alukura, Nganampa Health Council Inc and Centre for Remote Health.

Fetal movements

Gardener G, Daly L, Bowring V et al (2016) Clinical practice guideline for the care of women with decreased fetal movements. Brisbane: The Stillbirth and Neonatal Death Alliance of the Perinatal Society of Australia and New Zealand.

RCOG (2011) Reduced fetal movements. Green-top guideline no. 57: Royal College of Obstetricians and Gynaecologists.

36.1.3References

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