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What is foetal growth restriction and how should it be monitored to reduce the risk of stillbirth?

Not all babies who are small for gestational age have foetal growth restriction (FGR), but the likelihood of it is greater in babies which are small for gestational age (SGA).

When is a baby SGA?

The baby is classed as SGA when it does not reach the 10^th centile on the growth chart. It is severe where it is less than the 3^rd centile.

Major risk factors for a SGA infant are;

• Maternal age 40 or over
• Maternal smoking of more than 11 cigarettes per day
• Cocaine use
• Daily vigorous exercise
• A previous SGA baby
• Previous stillbirth
• Maternal SGA
• Chronic hypertension
• Diabetes with vascular disease
• Renal impairment
• Antiphospholipid syndrome
• Paternal SGA
• Heavy bleeding
• Echogenic bowel
• Pre-eclampsia
• Severe pregnancy induced hypertension
• Unexplained antepartum haemorrhage
• Low maternal weight gain
• PAPP A - this is a hormone that is measured during the 12week combined screening test.  Be alert to a reading less than 0.4.

Screening for small babies is one of the most frequent areas of substandard care.

Often issues that arise with the delivery of care are;

• Failure to act on findings of foetal weight below the 10^th centile on an ultrasound scan.
• Failure to measure symphysis fundal height (the distance between the top of the uterus and the symphysis pubis), contrary to the NICE Guidelines
• Delays between identifying potential growth restriction, referring for and undertaking a growth scan to check size.
• Inaccurate plotting on the growth chart.
• Failure to act on a blood test result at 12 weeks' indicative of risk of developing problem with the placenta.
• Failure to properly review the clinical and ultrasound findings and refer for Doppler studies with regular CTG assessment, and earlier indication for delivery. Monitoring will include repeated ultrasound scans, monitoring of the amniotic fluid index and Doppler for surveillance.
• Reduced foetal movements should be closely reviewed as an infant with FGR will gradually move less as the pregnancy progresses.
• Early admission is recommended in women in spontaneous labour to allow continuous heart monitoring.

If a baby is small it should be monitored. FGR can be evidenced by SGA in between 30-50% of cases and is normally a gradually deteriorating picture, requiring ongoing surveillance.

It is reasonable to offer SGA infants to be delivered at 37 weeks gestation, although this may be required at an earlier stage if clinically indicated.

For further information please contact solicitor Leonie Millard in our Clinical Negligence department via email or phone on 01254 770517. Alternatively send any question through to Forbes Solicitors via our online Contact Form.

Learn more about our Clinical Negligence department here

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