GROW chart and measuring small - induction

[TremoloGreen]

I'm 39+6 today, but based on my previous pregnancy, may still have a way to go (41+4 for DD1!)

At 38 weeks, my bump (findal height) was small for dates so I was referred for a growth scan. In my trust, they use the customised GROW chart to predict the baby's expected weight at various stages. Here's where it gets complicated... I transferred here at 20 weeks. In my previous trust, they don't use this chart. The chart is based on parameters such as previous babies' birth weights, mother's weight, mother's ethnic group etc. The mothner's weight has quite a large weighting in determining the curve. The problem is. I was never weighed at booking in. I know this sounds crazy, but the first midwife I ever saw was a bit dippy and one of the things she overlooked was weighing me - she just gave me the notes to fill in and as I never weigh myself, I just guessed my weight at around 52 kg. When I was weighed at 24 weeks, I weighed 54... so possible I overestimated.

The problem is that now the baby looks SGA, as they are just below the 10th centile line on this chart... which was generated on the basis of (likely) incorrect information. At 38+4 according to the growth scan, she was 6 lbs 8 oz and just a hair's breadth below the 10th centile line, which interestingly, comes out at DD1s birth weight, so only a smidgen smaller than her sister at the same age - she was 7lbs 3oz at birth.

So now, I'm classified as high risk, recommended induction and continuous CTG in labour and my planned homebirth is recommended against. I declined all the interventions because there are no other signs that the baby is at risk (great CTGs, placenta fine, Doppler of umbilical artery fine) but agreed to daily CTG and another growth scan next week. I've had the obstetrician come and shout at me (yes, really) that I was taking unnecessary risks of my baby dying or being disabled. I happen to think that induction carries it own risks and they outweigh the benefits in my case. The consultant got really annoyed at that and snapped "what exactly are you worried about??!"

My confidence is really shaken now and I keep crying all the way to the hospital, where I have to go every day now, have more CTG, be told that I should be induced and that I am going against medical advice and have the latter phrase written all over my notes. They are making me feel like a terrible irresponsible person all because of this chart. I don't know what to do now. I still want to have my home birth, but I feel like I'm doing something wrong, but I know when I go into labour, I'll be too terrified to go into hospital because things escalated into panic mode so quickly on the day I went in for the scan. I can stand my ground normally, but I'm worried I'll be too vulnerable in labour to resist all the interventions or consider all the risks/benefits objectively.

I'm sorry this is so long. If anyone has read and has any experience or advice for me, I would love to hear from you. I just woke up and I'm feeling crap already about going ot hospital again today

Hi OP,

You poor thing, I got diagnosed with gestational diabetes at the end of my first pregnancy and I had people shouting at me and stressing me out too. It was truly awful. I also wanted a homebirth, in the end agreed to the birth centre up to 42 weeks (even though I had to fight induction from 40 weeks). My baby didn't come by 42 weeks and I was induced and it was terrible. I totally agree with you I think induction carries it own risks.

Anyway, I did have an actual condition (although mild and with no brilliant evidence to support their suggested interventions) - this all sounds a bit bonkers in your case. So they think your baby is about the same size as your previous baby and this is sparking off some massive panic?!

I wonder if there is any evidence for the use of this GROW chart? I would be very interested to hear about it from your clinicians, particularly the shouty ones.

I know was it feels like to be vulnerable and lonely at the end of pregnancy, how you of all people most desperately want your baby to be born safely. And how bewildering it is that you are trying to make the "safest" and most sensible decision and yet you are being bombarded by information that is presented as fact, and yet seems to have very little fact behind it.

But for what it's worth - I, a huge amount of midwives and doulas, and tons of women don't think you are crazy to push back a little against the "system", if that's what seems best to you at the time. Now if you broke your leg and said you wanted to wait and let it heal on it's own then I might think you were a bit bonkers! But it is not bonkers to see "risk" as a much more grey area than obstetric care does in this country. I could never understand with my first pregnancy why noone was acknowledging that. But plenty of people do and I'm included.

I never went to any diabetes appointments with my second baby. I just managed it myself. I had a homebirth which was actually unassisted in the end as I called the midwife too late! It was a brilliant birth for me and my daughter.

Thinking of you OP in whatever you decide :)

Thank you so much lovemakespeace.

I'm feeling a bit more confident today after another very reassuring CTG and also the midwives at the day assessment unit made a few comments, which while I know they are not going to contradict the consultant's advice, suggested they didn't think I needed to be there. I also spoke to the supervisor of midwives and she explained that my home birth plans would be supported as long as I understood the risk of the various scenarios as it was up to me where I give birth.

The evidence for customised/personalised growth charts is mainly focused on comparing their predictive validity with just using population averages. So does GROW predict [x bad outcome] better than just using a UK/WHO average growth curve for a baby. The answer is, it does generally, although some of the effects are quite modest, it's probably quite a good tool overall. Not all trusts have adopted it though.

The RCOG guidelines suggest in cases like mine, that serial growth scans and Doppler of the umbilical artery should be used to determine the baby's health and induction should be OFFERED from 37 weeks. Basically the evidence suggests induction does no harm. Of course, they don't look at all the outcomes down the line for these women and what effects induction had for them and the baby, just that induction doesn't affect the very serious adverse outcomes they were looking at (death/disability for example).

This recommendation is based on a post-hoc analysis of one randomised study (TRUFFLE) that compared induction of labour with 'expectant management' in babies who were SGA and had abnormal Doppler results. There was a very small decrease in the proportion of babies who died or were disabled, but not statistically significant. This was in a population of low birth weight babies with abnormal Doppler results and a high percentage of mothers with hypertension in pregnancy, so not especially applicable to my case anyway. Another European study found no differences between immediate and deferrred delivery.

Sorry, that's the VERY long answer to your question about evidence (oh, my job involves evaluating clinical evidence... can you tell? So not a completely uninformed patient ) Sorry to bore you, I just thought it might be interesting if any other mums were googling. I just wish I had done this reading prior to my showdown with the consultant.

Despite all this, it's still so, so hard going against the advice. I just feel so vulnerable at the moment. It was really helpful to hear about your successful home birth, thanks

Ah no you are certainly not an uninformed patient! ;) I am also a scientist, and also wished I had evaluated the evidence for myself before an awful consultant appointment where she wrote RISK OF STILL BIRTH in my notes! She was very obtuse, it probably wouldn't have made any difference. And my perineum and PND is testament that difficult births can have adverse outcomes that aren't just related to death/disability.

So, the GROW thing sounds logical if you are talking about using it compared to generalised data. But surely it only counts if you do it properly?! I wonder how much difference would it make if your weight was a few kg less at the beginning. And anyway the fact your baby is looking perfect sounds very reassuring based on that other study.

My home birth midwife didn't ever measure my bump for my second pregnancy, she used to look at it and say things like "looks like there is a baby in there". I love her. I'm 18 weeks pregnant and if this baby is a girl I am genuinely naming her after her.

I'm not reckless and I'm not encouraging you to be - I would never tell anyone what I thought they should do. But I think you sound like a logical informed lady who will make the best decisions for her baby.

That CTG monitoring really did my head in. My first baby was very lazy and they used to make me stay in it for ages even thought the trace technically met their criteria. It was all so stressful and horrible. I remember it so well. I really feel for you.

I'm glad you are feeling a bit more settled. I hope you have support - my husband was fabulous and I couldn't have got through those weeks without him.

Keep us posted :)

Good to hear you're feeling better about things. I had loads of extra scans with dd. ds (22 months)was born weighing 6lb 5 and whilst a few people commented that he was a tiddler no fuss was made....until I got pregnant with dd.

I was sent for a growth scan at 24 weeks where it emerged that she was just (and I mean just below the 10th centile). I was then immediately transferred from mw-led to consultant led care and had to go onto the hospital every week for scans. After 6 weeks dd was growing exactly in line with the curve but as it was under the 10th centile I had to keep going. I know they were being thorough but it was a total pita.To complicate things a little dd was breech at every scan. By 33 weeks they were saying things like "If she doesn't turn you will have an ecv", "If that doesn't work you will have an elcs", "If she turns but doesn't grow you will be induced at 38 weeks". As if I had no opinion or choice whatsoever.

As it happened at 36 weeks dd turned and at 37 weeks she gained a tiny bit of weight which put her a whisker above the 10th centile line and I was back in the care of mw, mlu was back as an option, induction off. Whilst this was obviously good news it just seemed so bloody arbitrary. When push came to shove so to speak(!) dd was born on a trolley in the closed induction suite, delivered by a passing random mw. After weeks of hauling me on there, when I went into labour they didn't believe me and wouldn't admit me!! Dd was a small but perfectly formed 6lb11oz.

The GROW charts imho should be used as a guide to inform choice. They should not dictate your birth. At some of my later scans the sonographers were bemused and frustrated in equal measure that they were having to measure a perfectly healthy looking baby again only a week after the last time they measured her.It caused me a great deal of stress and worry.

Personally I don't get the personalised growth charts. My 1st baby was born at 40+4 & weighed 6lb 10 & who stayed pretty much on 9th-25th centile & no one was worried about her size (this was less then 4 years ago). With my son I was measuring on the 75th centile & when the next measurement was taken he'd dropped to just under the 75th line & as he'd crossed into a different line I had to have a growth scan to check all was well. To be honest I was never really that bothered as I didn't think he'd be that big & as my kind mw pointed out it was probably just me that measuring big (lovely lady). At the scan he was Measuring on 50th line & I was told nothing to worry about so totally pointless chart & scan (although I did Like an extra look as I'd already started maternity leave at that point). Oh & he arrived 13 days late (1 year ago today) weighing a massive 7lb 14 so I don't think there's any scientific point to the charts.
I had a friend who had to keep going into hospital to be monitored over the Easter holidays due to measuring small, cancelling plans to visit family, was pushed into being induced & her son was born more than 7lbs so not small.
Sorry for waffling on-long day.
The point is the growth chart is only 1 small measurement (like the estimated due date) & cannot be totally relied on. Glad to hear you're feeling more positive & hope you get your home birth as I was incredibly relived to get mine x

My trust had the personalised charts when I was pregnant. I measured the median line all the way through up to 38 weeks. Different midwife. Measured me 3 cm smaller than 36wk measurement. Referred for growth scan and transferred from MLU to consultant led pending scan results. Scan appointment took 10 days to get to me. Sonographer said since introduction of the personalised charts growth scan referrals had gone through the roof. Scan was fine. Baby estimated at 7lb 10 at 39 + 5 wk at that point. A perfectly healthy weight for full term. DS was born 40+3 weighing 8 lb which was spot on the " 50th percentile" for baby boys.
It's a load of nonsense. He's since settled down to 9th percentile for height and weight (now 16 months)

My mw never measured me at all I second pregnancy. I got a different mw at my 37 week apt and bump was measuring 34 weeks but mw said it was fine and as I'm petite she would expect a neat bump.

How far 'behind' were you measuring? The predicted weight seems pretty healthy to me but I'm obviously not an expert. If the predicted weight was 4lbs or something then I would probably have the induction but given its so borderline I think it would be unnecessary.
My dd was born at 39+6 and weighed 6lbs 14oz. I got my home birth. At 38+4 she was probably around a similar weight to your baby.

Obviously Drs and hcp know more than me but given the skewed information and that the estimated weight isn't really low,personally I would refuse induction at present. Xx

Thanks all. I've had another reassuring CTG today so I am going to give the hospital a miss tomorrow and just go back in for my second growth scan/Doppler on Tuesday if I haven't had the baby by then.

I had a show yesterday evening but midwife could not do a sweep today (only 1cm) and no contractions. Still, I'm way ahead of where I was at this stage last time (DD1 was born 11 days after the so-called due date).

I spoke to the midwife today about maybe delivering at the MLU if I have any worries about the home birth and she seemed to think that would be OK... I think I need to double-check this and get it written somewhere in big letters on my notes. I'm just worried that I will turn up and get sent straight to the main labour ward with the scary consultants, I know at the hospital I previously gave birth in, they were really strict about who could use MLU and wouldn't even admit women who were e.g. overweight.

Scattymum I was measured as 35cm at 39 weeks however, I have consistently been 3cm 'behind dates' - I am just under 5'3'' and BMI ~19.5 so quite petite but not absolutely tiny. The midwives for the last few days have just been writing "fundus = dates" on my notes, but they haven't actually got a tape measure out, so no idea what that means. The growth scan put me about 50 grams below the 10th centile line.

Sounds very similar to me only no one ever expressed any concern. Bizarre isn't it. I'm just over 5ft 4 with bmi of 20.4 and had a very neat bump. Dd2 was and still is very petite but perfectly healthy.

The Mlu sounds like a good compromise although I understand your concerns about being transferred very quickly. It happened to me with dd1 for no real reason and was one reason I opted for home birth second time around. X

So I'm 41 weeks today and still bloody pregnant! Feel knackered and so fed up. I've stopped going for the daily CTG as it was causing too much anxiety and I was spending three hours plus at the hospital every day and not getting to see my daughter at all.

I'm still going every two to three days for sweeps/ further scans and CTG. They haven't been able to do a proper sweep as my cervix is unfavourable, even today. I've had every test going and they're all fine which is reassuring.

I won't be able to use the MLU and I'm really torn now between home birth or going in to hospital. To be fair to the hospital, they've been so nice and bent over backwards to try and persuade me that I can have as natural a birth as possible on CLU and what they will do to facilitate it. The SoM has even helped me write a birth plan, but I've had a birth plan completely ignored before, so I'm uncertain. ALso, hospitals make me so anxious and are such an alien environment, I don't think I'll be able to manage my pain and stay calm there. I've booked induction for next week but I'm so upset by the idea I can't even think about it.

I was sent for growth scans all through my pregnancy and even when I was in labour and they measured my bump at 40+2 they said I was measuring at 37wks! I gave birth to a 8lb 3oz baby yesterday! So I don't know how that works! Good luck

Good luck, I got my home birth at 41+6. Hope you get yours or you get a fab hospital birth. My SOM recommended to me to staple a copy of my birth plan to the inside cover of my maternity notes with the most Important bits highlighted, they certainly won't be able to miss it there!

Poor you! I hope things go the way you want... Or at least close to that. Good luck.

Thanks everyone. Had about an hour of mild contractions in the early hours this morning, but they stopped.

2nd growth scan/ 3rd Doppler tomorrow. If anything doesn't look tip top this time, I will have the induction. I'm trying to pack my hospital bag and I have everything I need for the baby, but no idea what to take for myself as I haven't planned a hospital birth before or had a hospital stay on postnatal.

I've got a nightie, toothbrush and hairbrush, facecloth, pads and big knickers. I guess I should take my TENS machine - no idea if that'll be allowed with all the monitoring?