Fetal growth

how to we measure fetal growth?
In low risk pregnancies
and high risk pregnancies

low risk - fundal symphysis height is used
High risk - USS (ultrasound) may be used

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what are dopplers and how are the used in pregnancies?

- these are in depth ultrasound scans that monitor the oxygen levels between mother and baby

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Liquor volume assessment
what are they used for?
what can they identify?
what can this indicate if these are detected?

- these are used to assess fetal wellbeing as they can identify if there is too much water (polyhydramnios) or too little water (olihydramninos)
- if any of these were detected, it could indicate that the fetus as functioning as we would want it to

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guidance on fundal height and fetal growth monitoring

- NICE - state that fundal height should be monitored in pregnancy from 24 weeks onwards - no earlier
- RCOG - assessment of fetal growth is essential this was further supported by green top guidelines
- these stated that it was essential to use growth

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Why do we monitor fetal growth?

- this is an essential part of midwifery care as it helps to identify deviations from the norm

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FGR
SGA
LGA

- fetal growth restriction - this is defined as any fetus that is unable to meet it genetically determined potential
- small gestational age - this refers to an infant whose birth weight is less than the 10th centile
- large gestational age - this refer

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why is it important to identify babies that are at risk of fetal growth restriction?

- can be associated with adverse outcomes such as
- perinatal morbidity
- stillbirths
- neonatal deaths

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Predisposing MATERNAL factors that can increase the risk of FGR in pregnancies

- age 40+ years
- BMI
- smoking/ substance abuse
- previous stillbirth
- Chronic hypertension
- pre -eclampisa

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Placental factors that can increase the risk of FGR in pregnancies (fetal)

- low PAPP -A - this is a protein in the placenta - low levels of this has been associated with increased risk of FGR (fetal growth restriction)

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Fetal factors that can increase the risk of FGR

- chromosomal conditions
- exposure to infection in pregnancy can impact the fetus eg toxoplasmosis which is found in cat faeces - this is why pregnant women are advised not to empty cat litter trays when pregnant

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What can LGA (large gestational age) increase the risk of?

- instrumental delivery
- postpartum haemorrhage
- birth trauma
- childhood obesity
- shoulder dystocia - this is when the babys shoulder becomes impacted and caught on the mothers pubic bone and can result in injury to the arm throughout the delivery

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The perinatal institute what is it? when was it founded? what does it do?
what are the aims?

- non profit organisation founded in 2013
- focused in supporting NHS maternity services in the provision of safe and high quality maternity care
- goals - are to make fetal growth monitoring customised and individual to each woman.
- reduce clinical b

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GAP learning results
what percentage of the UK use GAP training?

- as birth rates decreased hospitals began to roll out and offer GAP training to more maternity
units
- 78% of units adopt the GAP learning

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When should fundal height be measured?

- measured and recorded at antenatal appointment from 24 weeks

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When should fundal height be assessed?

- should be assessed by abdominal palpation at 36 weeks or later
- USS may be considered when the presentation may be likely to influence plans for birth
- should not be offered before 36 weeks

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What happens if the results of the abdominal palpation were likely to affect the plans for delivery?

- the woman should then be referred to an ultrasound scan which will then confirm the presentation of the fetus and make a plan for the delivery

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auscultation of the fetal heart
what is this?
what does it do?

- this may confirm that the fetus is alive howver, it doesn't give the whole picture of the fetal wellbeing so is therefore not recommended.
- however for some women, they may request this as it can provide reassurance and they like to hear the heartbeat

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why do we preform the abdominal assessment
what 3 parts is it divided into?

- to monitor fetal wellbeing
- look - inspection of the mother
- touch - palpating the abdomen
- listen - auscultation of the fetal heart

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what can affect the size and shape of the uterus and abdomen?

- raised BMI
-lax abdominal muscles
- multiple pregnancy (twins)
- uterine fibroids

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skin changes in pregnancy

- linia nigra - dark line that goes through the abdomen due to hormones
- straie gravidarum (stretch marks)
- previous surgery scars - important to note as women may need to be referred to a consultant to discuss management of labour
- bruising - this

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Palpation
what is this used for and what does it hep us identify?

- used to help assess fetal growth and position
- lie
- attitude
- denominator
- position
- engagement

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What is the lie?
what direction can this be in?
when does it occur?

- longitudinal
- oblique
- transverse
- normally occurs in the latter (later) stages of pregancy - usually longituduanal

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What is the attitude?
what is the ideal attitude?

- the relationship of the fetal head - how tucked in it is or how extended it is
- at term we would want the head of the fetus to be well flexed - this is when the smallest diameters are presenting which enables a more effective labour

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what is the presentation?
what are the 5 different types of presentations?

- this refers to the part of the fetus that lies in the pelvic brim (lower part of the uterus)
- vertex, brow, face, breech and shoulder

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what does the shape of the uterus encourage when it grows?

- encourages the head of the fetus to be the presenting part in delivery

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what is the denominator?
what does each presentation have?

-this is the name given to part of the presentation
- each presentation has a different denominator

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what are the denominators of these presentations?
- cephalic/ vertex
- breech presentation
- face presentation

- occiput
- sacrum
- mentum

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what is the position of the fetus?

- this is the relationship between the denominator and the 8 points within the maternal pelvis
- the denominator can sit at different places within the maternal pelvis

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names of the places the denominator can sit in the pelvis
(8)
(6 on diagram)

- direct occipitoposterior
- direct occipitoanterior
- left occipitoanterior
- right occipitoanterior
- left occipitolateral
- right occipitolateral
- left occipitoposterior
- right occipitoposterior

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when does engagement occur?

- when the widest presenting diameter has passed through the brim of the pelvis

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what is engagement measured in?
what do these measurements indicate?

5/5 - can feel the whole head when palpating
4/5 - head starting to enagage more
3/5 as the measurements get lower the midwfe will be able to palpate less of the fetal head
2/5 the fetal head beins to enter the pelvis
1/5 in abdominal palpation you would

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when does the head start to engage in primigravid women and multipara women?

- primigravid women - 36/40 weeks
- multipara women - may not be up until labour when this happens

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What are the 3 manoeuvres used in palpation?
what is important to be done when carrying out these manoeuvres?

- fundal palpation
- lateral palpation
- pelvic palpation
- carry out them gently to prevent it being painful for the woman

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fundal palpation
what is this? why is it done?
when should it be done and how often?
what can fundal palpation help with?

- used when assessing fetal growth and locate the top of the fundus
- should be preformed from 24/40 weeks
- every 2-3 weeks thoughout pregancy (NICE guidelines)
- help the midwife to gain and understanding of the lie and presentation of the fetus

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fundal height measurement
how is this done?

- using a tape measure the midwife would measure from the top of the fundus to the symphysis pubis
- this would then be documented on the woman's customised growth chart

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Lateral palpation
what is this used for?
what does it help to determine?
how is this done?

-used to locate the fetal back which then helps to determine the position of the baby
- using alternate hands gently palpate down each side of the uterus.
- it can be useful to steady the uterus with the oppostie hand

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Pelvic palpation
what does it help to determine?
what does the fetal head feel like?
what happens at 36/40 weeks if a cephalic presentation is not confirmed?

- helps to determine the presentation and lie
- the level of engagement can be determined by this maneuver
- fetal head feels firm and round
- if presentation is not confirmed the midwife should refer for a ultrasound scan to confirm the presentation

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-Auscultation of the fetal heart (listening)
-what can help with this process?
-what equipment should be used?
-what should be counted during auscultation and -what range should this be?
-what should also be taken at the same time during the auscultation?

-determining the position of the fetus can help when auscultating the fetal heart
- pinnards, stethoscope and sonicaide
- BPM should be counted and the range should be 110-160bpm
- maternal pulse should be taken at the same time to differentiate between

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Pawlinks grip
what is this used to assess?
why should this be avoided ?

- used to assess the fetal presentation
- can be very uncomfortable for women

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Equipment used during palpation

- sonicaide
- fob watch
- pinnard

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Get Revising

Fetal growth

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