Original Article Serial plotting on customised fundal height charts results in doubling of the antenatal detection of small for gestational age fetuses in nulliparous women Alphonse ROEX, 1 * Payam NIKPOOR, 1 Eva van EERD, 1 Nicolette HODYL 2 and Gus DEKKER 1 1 Department of Obstetrics and Gynaecology, Lyell McEwin Hospital, The University of Adelaide, Adelaide, and 2 Robson Institute LMH, The University of Adelaide, Adelaide, South Australia, Australia Background: The antenatal detection of fetal growth restriction is a focus point of antenatal care. If detected fetal demise may be prevented and perinatal complications could be managed more appropriately. Aims: To investigate whether introducing serial plotting on customised fundal height charts can increase the detection rate of small for gestational age (SGA) fetuses in low risk nulliparous women attending antenatal clinics in a public teaching hospital in Adelaide, South Australia. Methods: An observational study was employed to compare SGA detection rates, utilising data from an historical Control group compared to data collected after the study intervention. In the Control group the fundal height (FH) was measured for every antenatal visit and documented in the notes, but not plotted on a chart. The study intervention used serial FH plotting on customised charts, with a dedicated clinical practice guideline and regular audits to increase clinician awareness of the intervention. Results: The antenatal detection rate of SGA was 31/125 (24.8%) in the Control group and 44/87 (50.6%) in the Intervention group (P < 0.001; OR 3.10; 95% CI 1.73–5.57). Conclusions: Serial plotting of the FH on customised charts supported by a clinical practice guideline resulted in a doubling of the antenatal detection of SGA in nulliparous pregnant women at low risk for SGA. Key words: antenatal detection of SGA fetus, customised fundal height chart, serial plotting of fundal height. Introduction The detection of a small-for-gestational-age fetus (SGA) is an important objective of antenatal care. SGA is associated with an increased risk of stillbirth, neonatal death and other adverse outcomes. 1 SGA is linked to over 50% of stillbirths and 42% of early neonatal deaths. 2,3 Moreover, SGA is associated with perinatal morbidity, including fetal compromise during labour and increased risk of cerebral palsy in childhood. 4,5 . A confidential enquiry into stillbirths because of missed SGA in the UK showed that six of seven deaths were because of substandard care and therefore potentially avoidable. 6 This study was triggered by a number of undetected SGA babies born in our unit. The adage fundal height (FH) in cm = gestational in weeks is currently the guideline used in most obstetric units in Australia (www. thewomens.org.au/StandardAntenatalCheck). Gardosi and Francis reported that the likelihood of detecting SGA increased twofold from 29.2% to 47.9% with serial plotting of the FH on customised charts. 7 The introduction of customised FH charts did not increase utilisation of ultrasound scans. 8 On the basis of this evidence, a RCOG guideline recommended this method. 9 However, other studies have questioned the usefulness of the FH measurements. 10–12 In 2007, the RCOG released a statement indicating that customised growth charts need to be piloted more widely to determine whether growth restriction can be identified and managed appropriately’ (www.rcog.org.uk/what-we-do/campaigning- and-opinions/statement/rcog-statement-channel-4-dispatches- programme-undercov.) The non-randomised, quasi-controlled Nottingham study was undertaken in a primary health care setting by midwives and general practitioners. 7 To date, these findings have not been confirmed elsewhere. Our aim was to investigate whether antenatal SGA detection in our practice would improve after the introduction of serial *Correspondence: Dr. Alphonse Roex, Haydown Road, Adelaide, SA 5112, Australia. Email: alphonseroex@gmail.com Received 12 January 2011; accepted 8 December 2011. 78 © 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Australian and New Zealand Journal of Obstetrics and Gynaecology 2012; 52: 78–82 DOI: 10.1111/j.1479-828X.2011.01408.x he Australian and New Zealand Journal of Obstetrics and Gynaecology