RECENT ADVANCES IN

MANAGEMENT OF FETAL
GROWTH DISORDERS
Vairavan Ramesh
Maternal Fetal Medicine
Serdang Hospital

Quick Bites in O & G 23 nov 2019 1

■ Fetal Growth Restriction: Definition in recent literature

■ Institution / Author FGR definition

■ Baschat et al 2007 Combination of small fetal AC with elevated UA Doppler blood flow resistance
■ Cochrane 2013 Failure to reach the growth potential
■ DIGITAT 2012 EFW or AC <10th centile for gestational age
■ ACOG 2013 Fetuses with EFW <10th centile for gestational age
■ RCOG 2013 Small–for–gestational age (SGA) refers to an infant born with a birth weight less
than the 10th centile. Fetal growth restriction (FGR) is not synonymous with SGA.
■ SOGC 2013 Intrauterine growth restriction refers to a fetus with a EFW <10th centile on
ultrasound that, because of a pathologic process, has not attained its biologically
determined growth potential.
■ PORTO 2013 EFW < 5th percentile & umbilical artery PI >95th percentile
■ TRUFFLE 2013 [3] AC < 10th percentile & umbilical artery PI >95th percentile
■ Gordijin 2016 (ISUOG) AC <3rd centile OR EFW <3rd centile OR AREDF
– OR
■ Both of the following: 1) EFW or AC < 10th centile and 2) UtA PI >95th centile OR
UA PI >95th centile.
Intrauterine Growth Restiction (IUGR)/Fetal Growth Restriction
(FGR)

■ A FGR or IUGR fetus is one that has

not achieved its growth potential

■ This condition can be associated with

adverse perinatal and
neurodevelopmental outcomes

■ It has been classified into early-onset

(detected before 32 weeks’ gestation)
and late-onset (detected after 32
weeks’ gestation) types
MATERNAL CLINICAL RISK FACTORS

Vijayaselvi R, Cherian AG. Risk assessment of intrauterine growth restriction. Curr Med
Issues [serial online] 2017 [cited 2019 Nov 22];15:262-6. Available
from: http://www.cmijournal.org/text.asp?2017/15/4/262/218643
DR 60% FP 15%- Only test available for
routine screening is some places
Dating Pregnancies First Trimester

■ Accurate estimation of gestational ■ Dating pregnancies :

age is a prerequisite for determining
whether fetal size is appropriate-for- ■ 8–14 weeks( CRL 84 mm): Fetal
gestational age (AGA). crown–rump length (CRL)
■ Except for pregnancies arising from ■ CRL exceeds 84 mm, HC should be
assisted reproductive technology, the used for pregnancy dating
date of conception cannot be CRL FOR < 8 weeks for dating--??
determined precisely
■ HC, with or without FL, can be used
■ Clinically, most pregnancies are dated for estimation of gestational age from
by the last menstrual period, the mid-trimester( if a first-trimester
though this may sometimes be scan is not available and the
uncertain or unreliable menstrual history is unreliable)
Biparietal Diameter Head circumference
■ Symmetrical plane ■ Symmetrical plane
■ Plane showing ■ Plane showing
■ Thalami ( Bithalamic plane) ■ Thalami ( Bithalamic plane)
■ Cavum Septum Pellucidum (CSP) ■ Cavum Septum Pellucidum (CSP)
■ Whole cerebellum not visible ■ Whole cerebellum not visible
■ Head occupying >50% of the image ■ Head occupying >50% of the image
■ Calliper placed outer to inner table ■ Calliper placed outer to outer table
 Abdominal circumference ( AC)
■ Symmetrical plane-One rib on each side
■ Stomach bubble seen
■ Portal sinus seen ( denoted vein in picture)
■ Kidneys not seen text
■ Abdomen occupying >50% of the image
■ Calipers and dotter ellipse placed correctly
HC and AC Measurements

■ With respect to HC and AC measurements, note that there are two possible
methods, which are equally reproducible:

1. The ellipse tool and

2. The two-diameters method

■ Both cases the calipers should be placed in an outer-to-outer position

■ Using the ellipse measurement tool is recommended

OLDER MACHINES- CHECK IF

AUTOMATED MEASUREMENTS USED
Femur Length
Measurement

■ Both ends of the femur should be

clearly visualised

■ Ideally horizontal; Acceptable :Less

than 45* to the horizontal

■ Femur occupying > 50% of the total

image

45*
■ Callipers placed correctly
Biometry Measurements
(ISUOG)
■ BPD, HC, AC and FL should be
measured on ultrasound scan from
14 weeks onwards (GRADE OF
RECOMMENDATION: D).

■ • HC and AC should be obtained

using the ellipse measurement tool,
by placing the calipers on the outer
edges of the soft-tissue
circumference (GOOD PRACTICE
POINT).
Estimated fetal weight

■ EFW may be used to monitor fetal size and growth

■ However, use of EFW also has disadvantages

1. Errors in single-parameter measurements are multiplied;
2. Accuracy of EFW is compromised by large intra- and interobserver variability, with errors in the
range of 10–15% being common
3. Errors are relatively larger in the fetuses of greatest interest, i.e. those that are SGA or LGA;
4. Very different fetal phenotypes can have the same EFW (e.g. a fetus with large HC and small AC
may have the same EFW as a fetus with small HC and large AC);
5. Most EFW prediction models require AC, a size parameter that can be difficult to measure due to
technical factors.( Fetal breathing, maternal obesity,oligohydramios)
FETAL GROWTH
PRACTICE MODELS

To discuss fetal growth

I Dates must be verified

2 Foetal anatomy must be normal
3 Issues of fetal growth are different for
singleton pregnancies and multiple
pregnancies- This talk on singletons
Perform 100 ultrasound scans under supervision with a logbook consisting of 30 cases comprising of the
following:

Level 1
Requirements- Everyone
Ability to do mid and late pregnancy scans and to obtain appropriate measurements for gestational age.
Ability to come to a conclusion regarding viability and maturity in early pregnancy problems.
Identify common adnexal masses.
Ability to scan for assessment of liquor volume.
Level 2 (Intermediate)

Objectives: MOG/ MRCOG and trainees FMS and trainees

1 Detailed scanning of the mid-trimester foetus (routine) 2 Detection of foetal anomalies at any gestation
including basic foetal echo. 3 Doppler studies and its application in obstetrics. 4 Application of transvaginal
scanning (TVS) in pregnancy.
Requirements:
Attended accredited – intermediate and/or advanced courses. 1 year experience after basic level accreditation
and incorporation into postgraduate training programmes.

Level 3 (Advanced)- MFM

Requirements
1. Ability to do advanced procedures for foetal diagnosis and therapy. 2.Provide second or expert opinion in
doubtful cases.
3. Provide training for Level 1 and Level 2 courses.
 UNDERSTANDING
ULTRASOUND SCREENING
FOR IUGR / FGR
IUGR-Intrauterine Growth Restriction
FGR Fetal Growth Restriction
==========================================
=====
SGA- Small for Gestational Age
GROWTH
SGA and IUGR Basic Understanding in
Obstetric Patients
SGA-Fetal parameters
compared to at Birth Symetrical vs Asymetrical
■ Fetuses with suspected FGR will not ■ Symmetry of fetal body proportions has been seen as
necessarily be SGA at delivery indicative of the underlying etiology for FGR,
1. Symmetrical FGR thought to correspond to fetal
aneuploidy
■ Fetus may fail to achieve its growth potential 2. Asymmetrical FGR thought to indicate placental
(FGR) despite not being SGA at birth insufficiency.
However, fetal aneuploidy can result in asymmetrical FGR
and placental insufficiency can result in symmetrical FGR;
■ Not all SGA fetuses are growth-restricted; Moreover, the symmetry of body proportions alone is not a
most are likely to be ‘constitutionally’ small consistent prognostic predictor
GROWTH CHARTS
Growth Charts
■ Practitioners should be aware of : Retrospective Reference Growth Charts
1. Nationally or locally mandated charts (GOOD PRACTICE POINT).
2. Ultrasound machine programmed Charts
3. Global reference growth charts eg WHO

4. Fetal prescriptive biometry charts which are prescriptive, obtained prospectively, truly
population-based and derived from studies with the lowest possible methodological bias should be used (GOOD
PRACTICE POINT). Intergrowth 21-See later

■ • Routine evaluation of the number (%) of foetuses considered abnormally grown (i.e. below a given cut-off) should be
carried out (GOOD PRACTICE POINT).
Malaysian Growth Charts –Local
Charts- Reference Chart
■ Outdated-Early 1990s ■ Fetal Biometry of Femur Length for Malaysian Pregnant Women
Ramzun Maizan et al Medical Physics Research Group, School of
Physics, Universiti Sains Malaysia, 11800 Penang, Malaysia
■ Small population-33 Indian, 33 Malay, 33 Chinese-
Thus narrow band compared to other charts
■ By ethnicity, no significant difference (p 0.05) was found between
the FL values for fetuses of Malay and Indian ethnic’s mother (t = -
■ ? Real ethnic difference-Sample was small 2.042),

■ Not tested with perinatal outcomes ■ however

■ these two groups shows significantly (p < 0.05) higher values than
those of Chinese ethnic’s mother (t = 4.019, 4.083; accordingly).
■ The FL values of Malaysian resulted as significant difference with
the common reference FL values from USA [1] and UK ….Japan
Ultrasound Charts from the Machine-
Reference Charts

■ The results of these studies have shown that Chinese, Japanese, and (especially) South Asian infants are
smaller for their gestational age than Caucasian
■ whereas
■ North American Indian and North African infants are larger than Caucasian ,
■ In the same geographic setting, even after controlling for socio-demographic differences among the
different ethnic groups

■ Definitely These Charts do not represent Malaysian growth charts

■ Most of us use the biometry on the Ultrasound machine knowing this limitation
References vs Prescriptive Charts

■ All current charts are references rather than prescriptive standards

■ The distinction is critical.
■ Reference charts describe how individuals have grown at a particular time and
place, often decades beforehand.
■ Prescriptive standards, on the other hand, are purposely developed using a
selected, healthy population, to describe how humans fetus should
grow when nutritional, environmental, and health constraints on
growth are minimal

INTERGROWTH 21 is a Prescriptive Standard but use

Is still at research
■ However, only a limited number of descriptive reference ranges or population-based charts (WHO) are of
high methodological quality

■ Prescriptive standards describe growth under optimal conditions; they provide ranges for what should be
expected when women are healthy and are from healthy populations (e.g. INTERGROWTH-21st charts)

■ Comparison with healthy-population standards is the usual method of comparing observations of a

single case in medicine; this may be different from the situation in populations at higher risk of growth
aberrations. Eg Socio Economic groups

■ Prescriptive standards are constructed mainly from prospective data, for which sample size and
population selection are predefined, preferably from
■ international geographical sites,
■ with appropriate pregnancy dating,
■ ultrasound protocols and
■ quality control.
They are based
conceptually on the WHO
1995 recommendation
that “human growth should
be evaluated using
international standards,
describing how individuals
should grow.”

Kiserud et al,

Hospital based, and

generated fetal growth
references not standards

REFERENCES AND
STANDARDS
■ There is agreement about the similarity of human growth across healthy populations in early pregnancy,
and the applicability of international standards to estimate gestational age, evaluate size at birth , and
monitor the growth of term new-borns up to 5 years of age.
■ --------------------------------------------------------------------------------------------------------------------
■ Issues relating to fetal growth monitoring in the second half of pregnancy that are preventing the
introduction of integrated care across the first 1000 days of life.
■ Some members of the obstetric community seem to hold firmly to the view that fetal growth differences
among healthy populations, specifically >14 weeks’ gestation, are strongly influenced by maternal
factors
■ This position is difficult to sustain given the strong evidence, obtained from detailed monitoring of low-
risk cohorts from early pregnancy to 2 years of age, that human growth, evaluated by markers of
skeletal, fat-free mass (ie, fetal crown-rump length [CRL] and head circumference [HC], birth length, HC
at birth, and infant length), is very similar among low-risk populations regardless of where they live, or
their race/ethnicity, as demonstrated more than a decade ago by the World Health Organization (WHO)
Multicenter Growth Reference Study (MGRS).
■ ---------------------------------------------------------------------------------------------------------------
■ Differences observed in perinatal health among general populations across countries are principally due
to the downstream effects of environmental, nutritional, and socioeconomic factors frequently across
generations and this has important consequences. These are well recognized in medicine and public
health, ie, a mother’s ZIP code is a better indicator of her health status than her genetic code.
Intergrowth 21

■ Large prospective study of 59,137 pregnant women Population based: all institutions
providing pregnancy and delivery care in 8 geographically limited urban areas with low
rates of adverse perinatal outcomes and low pollution, domestic smoke, radiation, and
other toxic substances –Cordinated at Oxford UK
■ Sampling of individual women within 8 geographic areas using predefined criteria for
construction of standards
■ Participants followed up to age 2 y Pregnancy, neonatal anthropometry, and perinatal
conditions recorded for total population (59,137 pregnant women) in 8 geographic areas
using standardized procedures, identical equipment, and centrally trained staff
■ Excluded from standards only severe maternal or fetal conditions
Where ever mothers are provided good nutrition
and environment their fetus should grow
normally… followed by post natal growth
Recommendations

■ • The following abbreviations should be used to describe fetal size and growth: AGA,
SGA, LGA and FGR (GOOD PRACTICE POINT).

■ • The terms ‘early-onset’ (detected before 32 weeks’ gestation) and ‘late-onset’

(detected after 32 weeks’ gestation) can be added in case of FGR (GRADE OF
RECOMMENDATION: C).

■ • The terms ‘symmetrical’ and ‘asymmetrical’ FGR should no longer be used, given
that they do not provide additional information with regard to etiology or prognosis
(GRADE OF RECOMMENDATION: D).
Delphi Consensus on Fetal Growth
Restriction
■ An international Delphi consensus • A small fetus (AC or EFW below 10th
recently proposed that a cut-offof centile) should be considered at risk for
AC or EFW below the 3rd centile FGR (GRADE OF RECOMMENDATION:
may be used as the solediagnostic C).
criterion for FGR.

■ In case of AC or EFW below the

Decided 32 weeks cut off for early and
10th centile, the diagnosis of FGR
late onset IUGR
should be considered only in
association with other parameters
Delphi Consensus Definition of Early
and Late Growth Restriction
Early FGR: GA < 32 weeks, in Late FGR:GA ≥ 32 weeks, in absence
absence of congenital anomalies of congenital anomalies
rd rd
AC/EFW < 3 centile or UA‐AEDF AC/EFW < 3 centile
Or Or at least two out of three of the
following
th th
1. AC/EFW < 10 centile combined 1. AC/EFW < 10 centile
with
th
2. UtA‐PI > 95 centile and/or 2. AC/EFW crossing centiles >2
quartiles on growth centiles*
th th
3. UA‐PI > 95 centile 3. CPR < 5 centile or UA‐PI >
th
95 centile
 Difference of EARLY FGR and LATE FGR
Early onset IUGR Late onset IUGR

Challenge Management (Gestational age at Detection and diagnosis

delivery)
Evidence Placental disease High Low
70% abnormal umbilical artery <10% associated with abnormal
Doppler umbilical artery Doppler
60% association with pre 15% association with pre
eclampsia eclampsia
Severe angiogenic disturbances Mild angiogenic distubance
Pathophysiology and oxygen Hypoxia+/++ Hypoxia+
delivered to brain Systemic cadiovascularadaptation Central cardiovascular adaptation
Clinical impact High mortality and morbity Low mortality and morbidity
Prevalence 0.5%-1% 5-10%
Umbilical Artery Doppler

■ Umbilical artery Doppler is the only measure that provides both diagnostic and
prognostic information for the management of FGR

■ A Cochrane systematic review reported that the use of umbilical artery Doppler was
associated with a reduction in perinatal deaths, inductions of labor and cesarean
deliveries .

■ Also according to RCOG the use of umbilical artery Doppler in a high-risk population
has been shown to reduce perinatal morbidity and mortality, and should be the
primary surveillance tool in the SGA fetus
 Umbilical Artery Doppler Early IUGR
■ Absent or reversed end diastolic flow (AEDF or REDF) indicates an important reduction of blood flow and severe fetal
deterioration.

■ Longitudinal studies of high-risk pregnancies, we know that the the transition from AEDF to REDF may be slow and gradual
in early FGR.

■ Absent end-diastolic velocities in the umbilical artery, if not associated with severe maternal disease, can last for days and
weeks before abnormal heart rate pattern or delivery [66].

■ Reverse end-diastolic flow velocity represents an extreme abnormality in waveform and resistance, with a perinatal
mortality of 50% and significant perinatal morbidity .

■ FGR fetuses with absent or reverse end-diastolic flow in the umbilical artery have a higher incidence of long-term
permanent neurologic damage when compared with FGR fetuses with positive diastolic flow in the umbilical circulation [
MCA & Umbilical
Artery shows
reciprocal
changes
Middle Cerebral Artery

■ A condition of chronic hypoxia

determines a fetal flow
redistribution that manifests as
vasodilatation in the brain
circulation.

■ Cerebral vasodilatation, easily

detectable as a reduction in the PI
of the middle cerebral artery (MCA)
represents an adaptative
mechanism in response to hypoxia.
 Early onset (1) intrauterine growth
restriction
POA BPD HC AC FL EFW (g) Doppler

30W 71 275 206 50 922 UA: RI 1.0 Pi 2.46

MCA: Ri 0.9 Pi 2.15

31W 72 272 221 53 1091
 Early Onset (2)Intra Uterine Growth
Restriction
POA BPD HC AC FL EFW (g) Doppler
26W 47 181 136 30 290 Ri 0.74
Pi 1.7
27W 53 203 141 32 327 Ri 0.54
Pi 1.22
29W 49 195 134 31 297 Ri 0.43
Pi 1.1

TORCHES NORMAL
Declined karyotyping
No gross structural anomalies
21
W

29
W
■ Fetus passed away 30 weeks
■ Birth 440 gms

■ Highlight is Umbilical artery AEDF persists for some time before progress to REDV
especially in early pregnancy
Early onset (3) Intrauterine growth
restriction
POA BPD HC AC FL EFW (g) Doppler
25W 53 205 161 31 381 Ri 0.75
Pi 1.27
26W 55 212 152 37 420 Ri 1.0
Pi 2.46
29W 65 238 170 41 565 Ri 0.94
Pi 3.72

STANDARD KARYOTYPING :
NORMAL
TORCHES : CMV IgG and
Rubella IgG reactive
Anomaly scan : Normal
 DOPPLER SUSTAINED
25 29W
W
POA UA DV EFW (g)
25W Ri 0.75 Ri 0.54 381
Pi 1.27 Pi 0.79
26W Ri 1.0 Ri 0.63 420
Pi 2.46 Pi 0.83
29W Ri 0.94 565
Pi 3.72
 DOPPLER SUSTAINED
25 29W
W
Early onset (4) intrauterine growth
restriction
POA BPD HC AC FL EFW (g) Doppler
21W 46 179 141 35 344
28W 68 268 214 53 1029 Ri 0.99
Pi 2.09
29W1D 68 257 235 52 1141 Ri 0.9
Pi 4.27
29W4D 70 270 235 54 1202 Ri 0.86
Pi 2.26

STANDARD KARYOTYPING : Microarray

taken, normal
TORCHES : normal,
Anomaly scan : Normal
AFI adequate Umbilical artery-Absent
end diastolic flow since 25 w
Now 32 w- Umb artry >95 cventile
POA UA MCA EFW (g)

28W Ri 0.99 1029

Pi 2.09

29W1D Ri 0.9 1141

Pi 4.2

29W4D Ri 0.86 Ri 1.0 1202

Pi 2.26 Pi 3.3
GROWTH IS ON 3rd to 10 th Centile
 UA-Umbilical artry flow
MCA Middle cerebral artery flow
POA UA MCA EFW (g)

28W Absent end diastolic flow 1029

29W1D Absent end diastolic flow 1141

29W4D Absent end diastolic flow Normal 1202

28W 29W
 DUCTUS VENOSUS
■ Doppler examination of the ductus venosus (DV) plays an important role in the management of fetuses with early
fetal FGR with the hope of improving the timing of delivery and outcome.

■ Alterations in umbilical artery and middle cerebral artery, which are early signs of adverse outcome, longitudinal
studies have demonstrated that DV flow waveforms become abnormal only in advanced stages of fetal compromise

■ It has been showed that the PI of the DV is related to pH at birth, with higher DV pulsatility associated with lower pH
at birth

■ Ductus venosus PI and short-term variation of fetal heart rate are important indicators for the optimal timing of
delivery before 32 weeks of gestation and correlate with fetal outcome at delivery
■ Early changes occurred in umbilical and middle cerebral arteries (AEDF and brain sparing respectively);
■ Late changes were significantly associated with perinatal death and included umbilical artery REDF and
abnormalities in the DV Doppler (reverse A-wave in particular) [2].
■ Another study demonstrated that absent or reverse velocities in the DV during atrial contraction are associated
with perinatal mortality independently of the gestational age at delivery [
■ In about 50% of cases, abnormal DV precedes the loss of short-term variability in computerized cardiotocography
(CTG) , and in about 90% of cases it is abnormal 48 to 72 h before the biophysical profile (BPP) .
Early Onset IUGR
 ■ The PORTO study demonstrated the
association between redistribution, either
isolated or associated with umbilical artery PI
Late onset IUGR >95th centile, and adverse perinatal
outcome [6, 63].

■ Significantly lower MCA PI and CPR among

fetuses with EFW <10th centile diagnosed
■ MCA may be valuable for the gestation beyond 32 weeks who experienced
identification of adverse outcome adverse perinatal outcomes in terms of
among late-onset FGR intrapartum distress and abnormal cord pH
■ Its role in prediction is weak, ■ Abnormal Doppler patterns have been
independently related to histological signs of placental
insufficiency .
■ Umbilical artery Doppler, which is
often normal in these foetuses ■ Estimated that in late-onset FGR fetuses
abnormal CPR is present before delivery in
■ The cerebroplacental ratio (CPR) 20 to 25% of cases
quantifies the redistribution of
cardiac output by dividing the Doppler
indices of the middle cerebral artery
(MCA) with that of the umbilical
artery.
CPR= PI od MCA/ PI of Umbilical Artery
<1.08 is abnormal (Brain Sparing Effect)
■ Late placental insufficiency and fetal hypoxemia have been proposed to explain the
increased risk of stillbirth in prolonged pregnancies, thus fetal Doppler may help in
their management.
■ The cerebroplacental ratio (CPR), i.e. the ratio of the pulsatility index (PI) of the
middle cerebral artery (MCA) to that of the umbilical artery (UA)
■ Can detect fetal hypoxemia occurring via two different mechanisms: reduced
resistance in the MCA (brainsparing effect) and increasing placental resistance.
■ CPR has been considered superior to Doppler indices of the MCA and UA alone in
predicting adverse outcome in growth-restricted fetuses and prolonged pregnancy
■ The foetuses with an abnormal cerebroplacental ratio (CPR) that are appropriate for gestational age or have late-onset SGA (>34 weeks of gestation) have a higher incidence of
fetal
distress in labor requiring emergency cesarean delivery, a lower cord pH, and an increased admission rate to the newborn intensive
care unit when compared with fetuses with a normal CPR.

■ Fetuses with early-onset SGA (<34 weeks of gestation) with an abnormal CPR have a higher incidence of the following when compared with fetuses with a normal CPR:

■ (1) lower gestational age at birth,

■ (2) lower mean birthweight,
■ (3) lower birthweight centile, (
■ 4) birthweight less than the 10th centile,
■ (5) higher rate of cesarean delivery for fetal distress in labor,
■ (6) higher rate of Apgar scores less than 7 at 5 minutes,
■ (7) an increased rate of neonatal acidosis,
■ (8) an increased rate of newborn intensive care unit admissions,
■ (9) higher rate of adverse neonatal outcome, and
■ (10) a greater incidence of perinatal death. The CPR is also an earlier predictor of adverse outcome than the biophysical
profile, umbilical artery, or middle cerebral artery. In conclusion, the CPR should be considered as an assessment tool in
fetuses undergoing third-trimester ultrasound examination, irrespective of the findings of the individual umbilical artery and
middle cerebral artery measurements
Large for Gestational Age (LGA) and Macrosomia

■ A LGA fetus is one whose size is above a predefined threshold for its gestational age.
■ LGA fetuses typically have EFW or AC above the 90th percentile
■ Although 95th centile, 97th centile, +2SD and Z-score deviation have also been
used as cut-offs in the literature.

■ Macrosomia at term usually refers to a weight above a fixed cut-off (4000 or 4500
g). Malaysian hospitals also may take 3800gms as cut off
 Macrosomia at Term
Definition Cut off Prevalence
Neonate at Term 4.5 kg 1.3-1.5%
Gestation age dependent >97th Centile
Birth weight at term 4.0kg 5-7%
Gestational age dependant 90th Centile

3.8 Kg - ??- No centile available- Maybe 10%- Mainly consultant based-Not evidence based
Does Induction of labour make a difference EFW > 4Kg
Induction at term Waiting

Any fracture 4/1000 babies 20/1000 Induction reduces fractures 16/1000

Shoulder dystocia 41/1000 68/1000 Induction reduces shoulder dystocia 27/1000

Perineal 26/1000 7/1000 Induction increases perineal damage

Damage(Mom)
Brachial plexus injury 1/1000 3/1000 No clear difference

Low APGAR score 7/1000 5/1000 No clear difference

Birthweight Birthweight 178 gm less in induced group

C Sections 267/1000 293/1000 No clear differrence

Instrument 130/1000 152/10000 No clear difference

Four studies Randomised study 1190 non diabetic pregnancies