“Identification and management of the Small for Gestational Age Fetus” GROWTH ASSESSMENT PROTOCOL

Growth Assessment Protocol AIM - Improve the detection of fetal growth abnormalities through the use of customized growth charts and protocols - What is Fetal Growth Restriction? Growth Assessment Protocol

GROWTH ASSESSMENT PROTOCOL Developed by the Perinatal Institute In place since 2008 Funded by Health Education England Growth Assessment Protocol

BACKGROUND on STILLBIRTHS Little change for the last 20 years Largest contributor to perinatal mortality in most develop countries London has the highest rate in UK - 5.3 per 1000. Economic impact  Investigations, cost in future pregnancies, litigation  £16.7 millions per year in UK Growth Assessment Protocol

Growth Assessment Protocol EVIDENCE Confidential enquiries, epidemiological analysis FGR is associated with stillbirth (primary contributor), neonatal death, perinatal morbidity This programme increase FGR detection Potentially 1000 babies could be saved every year in UK Growth Assessment Protocol

Growth Assessment Protocol GRAPHS Growth Assessment Protocol

GRAPHS Population based study in West Midlands (2009-2011) Pregnancies with FGR have a 7 fold higher risk of SB Undetected FGR increases the risk of SB even further Detection results on average in delivery of 10 days earlier. 280  270

Adapted with permission of Perinatal Institute GAP TRAINING Adapted with permission of Perinatal Institute 2015

Growth Assessment Protocol AIMS Understand Risk assessment at booking Increase awareness on Customised Growth Charts and Referral Criteria Standardise FH measurements Growth Assessment Protocol

Growth Assessment Protocol NORMAL GROWTH Average size baby at term? Local definition of SGA Local definition of LGA No more 2.5 Kg rule < 10th centile SGA > 90th centile LGA Growth Assessment Protocol

Growth Assessment Protocol ANTENATAL DETECTION Population based standards group all women together  ONE SIZE DOES NOT FIT ALL. Growth Assessment Protocol

Growth Assessment Protocol “Unexplained” StillBirths in West Midlands Graph, 2001; n=231; <10th Centile: 140= 62% Growth Assessment Protocol

Stillbirths - Wigglesworth classification Growth Assessment Protocol

Recode Classification Growth Assessment Protocol

Fetal Growth surveillance Methods Manual Palpation Landmarks Fundal Height Measurements Tape measure – Gestation=Cms Interpretation Documentation Ultrasound Biometry Estimated Fetal Weight Liquor Volume Doppler Growth Assessment Protocol

Growth Assessment Protocol RCOG guidelines Recommended by RCOG since 2002 Growth Assessment Protocol

Risk Assessment at booking Low risk High risk Growth Assessment Protocol

Risk Assessment at booking Growth Assessment Protocol

Gestation Related Optimal Weight GROW Gestation Related Optimal Weight www.perinatal.org.uk

CUSTOMISED GROWTH CHARTS Adjusted for Height, weight, parity and ethnicity Excludes pathological factors like DM, smoking, anomalies Do no take into account paternal side and fetal gender Growth Assessment Protocol

HOW DO WE CREATE THE CHART Using computer software created by the PI GROW - Gestation Related Optimal Weight https://app.growservice.org/UK/Account/Login Growth Assessment Protocol

Growth Assessment Protocol Examples More than 2.5 Kg is not always NORMAL Para 1 British 169cm 75kg Delivered at 40+12 Birth weight 3.172 kg Birth Centile 5.2! Para 1 Pakistani 163cm 60kg Delivered at 38+2 Birth weight 3.554 kg Birth Centile 94.1! Growth Assessment Protocol

Growth Assessment Protocol Examples Less than 2.5 Kg is not always ABNORMAL Para 0 Indian 152cm 46 kg Delivered at 38+3 Birth weight 2.300 kg Birth Centile 10.2! Growth Assessment Protocol

ADVICE ON BABY MOVEMENTS

Growth Assessment Protocol

MULTIDISCIPLINARY PROGRAMME Midwives Sonographers Obstetricians Neonatologist Growth Assessment Protocol

Role and responsibilities Midwives Inform women about the programme Plot FH from 28 weeks, 2-3 weekly Aware of referral criteria Generate birth centile following delivery Inform neonates when Birth centile <10th or >90th Complete yearly e-learning GAP module

Role and responsibilities Sonographers Booking risk assessment: ? Serial USS Aware of referral criteria Plot EFW on GROW charts Complete yearly e-learning GAP module

Role and responsibilities Obstetricians Aware of GROW charts and their use Aware of referral criteria Ensure appropriate management of care in place Complete yearly e-learning GROW module

Role and responsibilities Neonatologist Aware of the programme Management of babies born below the 10th and above 90th centile

Role and responsibilities Gps Aware of the programme Plotting of FH on GROW chart Aware of referral criteria

Growth Assessment Protocol THANKS Growth Assessment Protocol