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

2. 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

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

4. 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 per 1000.
Economic impact  Investigations, cost in future pregnancies, litigation  £16.7 millions per year in UK
Growth Assessment Protocol

5. 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

6. Growth Assessment Protocol
GRAPHS
Growth Assessment Protocol

7. 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

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

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

10. 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

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

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

13. Stillbirths - Wigglesworth classification
Growth Assessment Protocol

14. Recode Classification
Growth Assessment Protocol

15. 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

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

17. Risk Assessment at booking
Low risk High risk
Growth Assessment Protocol

18. Risk Assessment at booking
Growth Assessment Protocol

19. Gestation Related Optimal Weight
GROW
Gestation Related Optimal Weight

20. 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

21. HOW DO WE CREATE THE CHART
Using computer software created by the PI
GROW - Gestation Related Optimal Weight
Growth Assessment Protocol

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

30. 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 kg
Birth Centile 10.2!
Growth Assessment Protocol

48. ADVICE ON BABY MOVEMENTS

49. Growth Assessment Protocol

50. MULTIDISCIPLINARY PROGRAMME
Midwives Sonographers Obstetricians Neonatologist
Growth Assessment Protocol

51. 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

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

53. 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

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

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

56. Growth Assessment Protocol
THANKS
Growth Assessment Protocol