Small for gestational age - induction

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so this is my third baby and up until our 26 week midwife appointment all was well, I hadn’t had my bump measured before the 26 week appt and bump was measuring small (which it did with my last pregnancy - dd born at 6lbs 9oz) and my midwife (same midwife for previous pregnancy) obviously had to plot the bump and it meant I was asked in for a growth scan at 28 weeks, I had a trainee sonographer that measured babies stomach and it came up smaller than her head and femur so I was monitored for half an hour and that went well with HR, BP, kicks etc so sent home and she was plotted just below 10th percentile. Then a consultant called to book me for a follow up scan with him and at this scan all measurements where in proportion so stomach not measuring smaller however she was still under 10th but growing, it was here that he told me I will be having an induction at 37 weeks I panicked and just said ‘right okay’ but I don’t want one I have two children at home with me this being my final baby I wanted to have a home birth. Went back for a 32 week growth scan today and again she’s small but in proportion and she is growing on her own consistent line sonographer said she’s really happy with babies health she’s active she is growing my cord bloods are strong all things looking fine she is just however a small baby then an hour later I got a call from the consultants assistant saying he wants to see me Monday to do his own scan I didn’t ask why and now I’m worrying that they’ve seen something concerning but why wouldn’t they tell me and I’m still against having the induction I was induced with my 1st due to pre eclampsia and it has traumatised me. Any advice on what i do next bc I just feel so in the dark about what the problem is why they keep wanting me in but then saying all is fine and pushing me for an induction I don’t want. Where do I go from here?

Does you hospital have a consultant midwife? Or advocate so you can have a discussion with them over what you want. Obviously listen to medical advice but you need it to be objective- consultant should have offered and induction not just said you were having one. What is their concern other than small? Surely letting baby grow as much as they can before going through birth would be better? (I'd be asking the consultant that) why not regular monitoring? I would go with a list of questions and as I said take an advocate with me.

I have only ever spoken to the consultant that took my case and it was that one time where he just said ‘you’ll be having an induction at 37 weeks… have you had one before?’ No body has explained exactly what the issue is other than currently she’s predicted to be 3lbs 8ozs at 32 weeks so she’s smaller than most her gestational age but she’s growing and all other obs are fine. I definitely need to write a list of questions to take with me and have someone else also present otherwise I do clam up and turn into the Churchill dog just nodding away with internal panic.

My first kid was small but in proportion and I was led to believe that if they are in proportion then it's not a sign of bad health, just a small baby.

are you a genetically small family? is your DH a different race to you (one that makes smaller babies)? they don't take these things into account.

Maybe ask them what the margin of error is in their scan estimates. I was told 10%.

Regardless thats very unprofessional for the doc to tell you that you are having an induction rather than explaining the situation and then providing their recommendation. No wonder you don't trust him/ her.

Oh bless you.
My 6 month old was SGA/IUGR
In the end she was induced at 40 weeks when we had static growth (and I did feel it was right) but before that we had many scans and consultations. The consultants were vile and the pressure to induce was insane. Like you I felt the recommendation was not backed up sufficiently. I discussed with the consultant midwife and head of the homebirth team and our plan was that no intervention was needed whilst growth, CTG, and dopplers were fine. Please don't take this as medical advice, your situation might be different.
But do not accept being told, there should always be a discussion. The BRAIN acronym is helpful when considering these decisions.

Obviously you can't know exactly what's going on but just wanted to share my experience. I had extra scans throughout pregnancy due to high BP. At 37 weeks I was told baby was measuring too small, would only be 5lb when he came. They said I'd need an induction which I point blank refused. Little one was born at 38 weeks weighing 6lb7oz. He was on the 9th centile and was perfect in every way. Obviously you consider all medical advice but it's not illegal to go against them. Do what feels right for you

We are both white British however we are both small I’m 5”3 and my partner is 5”5 (he would lie and say 5”7) he’s not we’re almost the same height when I wear converse but who am I to ruin a lifetime of delusion 😂

this is exactly what’s caused more confusion that todays sonographer told me that my chart looks odd because the consultant only ever scans on a certain machine a Toshiba and they don’t use the same one as him and they know that his machines readings always come out bigger than their machine? So I left thinking how on earth can anyone be certain of her estimated weight when the two machines used to do my growth scans apparently measure differently all the time.

I just feel so deflated like I’ve not been told what the overriding reason is for an early term induction and no conversation ab the pros/ cons for it. I’ve been googling since I got home the reported risks associated with inductions of SGA babies and what the percentage rates of complications are that would lead to emergency sections etc bc no one’s told me anything.

This is how I’ve been left feeling like I’ve been given no options other than an induction and that I’ve not even been told clearly why and what benefit it has. I still haven’t currently been diagnosed with SGA or IUGR so I’m just in limbo and my consultants assistant was really mean to me on the phone when I said I wasn’t sure I’d make the scan on Monday as my partner is away so I’d have to let her know tomorrow if I can arrange transport and childcare as it’s short notice she told me not to waste too much time and ended our call by saying ‘oh also If your babies movements decrease you’ll have to come see us earlier anyway’… I know all health professionals in the field of pre natal do remind everyone kicks count but that was her parting message on the phone which made me feel great.

this is what I want to do I want to stand up for myself and say whilst all things are progressing and looking good I don’t feel I need to be induced I would rather just continue being checked if I must but in the room it’s like the power is stripped away from me and I hear any type of intervention I just auto pilot. I think I need to probably have this entire thread open on Monday 😂

If you’ve had pre eclampsia before do you think this could be the beginnings of pre eclampsia, which is why they’re being cautious? My baby started measuring small a few weeks before my BP went up and I was diagnosed with pre eclampsia. In any event, an extra scan can’t be a bad thing, although it would make me anxious too. Best of luck

Have you got someone who can go with you for support? I understand how you feel, I'm just lucky in that I'm not scared to speak my mind, don't really care what people think of me 🤭 it's just I remember seeing all the women who were being induced at the hospital and every single one I spoke to didn't really want to do it but felt like they couldn't say no. Hope you find your courage Monday 😊

If your baby is happy and active you don't need to be induced, so that is something you can push back on. Before you push for a home birth I'd have a scan and make sure that baby isn't too small. I say this only because there is a correlation between small birthweight and non-productive labour, which is as painful and exhausting as normal labour, but doesn't move things forward or affect the cervix. I mention this only as my first babies were small due to husband's genetics: I was in full (painful) labour for a couple of days before they started the clock as there was no cervical effacement.

My midwife came along to one of the appointments with me for support, are you able to do that?
Most women don't question, it's really sad. Be proud!
The narrative needs to be totally turned on it's head, it's completely your decision and there's so much unnecessary intervention these days.
Even during birth OP, I literally said no to the drip that I 'had to have after 4 hours' and refused to lie down on the bed. It was a great birth as a result. It's only when you question things that it becomes apparent when recommendations are properly justified.

Like pp, i would strongly recommend asking to discuss with the consultant midwife. Its sometimes called a birth options meeting. They are generally very good at going through the risks and benefits of all the options - much more than the obstetricians. I found ours really helpful when my baby was breech. My appointment was 90mins, plus the consultant midwife offered a follow up teams meeting to make sure i had chance to sleep on our discussion so lots of opportunities to ask loads of questions.

I think with your history, they are probably thinking about preeclampsia as well? My DD1 (now 3 yo) was dropping down the centiles at each scan and it was suspected SGA / IUGR. I was offered induction at 39w but she came without any interventions at 38w. When she arrived, she was below 10th centile (5lbs 12oz at 38w) and my BP was extremely high. My DD2 (6 months) was not SGA but still little (6lbs 3oz at 39+3) and i developed preeclampsia in that pregnancy. So clearly my babies growth are both affected by whatever goes on with my BP when I am pregnant. Maybe they are also thinking if that's the case for you? Have you had any other issues in pregnancy? I had high uterine pressure which is also known to affect baby's growth.

It's known that little babies can sometimes start to struggle in labour, so regardless of where it takes place, induction or no induction, you need to have a really clear plan of potential different scenarios so you are prepared for whatever happens (including transferring to hospital if you did end up having a home birth). With DD1, she was doing quite well until all of a sudden she was starting to struggle between contractions and we needed to get her out ASAP. Maybe have a chat with the midwife about what happens if you need to be transferred in an ambulance so it isnt a shock to you. If you don't want an induction, you could also consider an election c section? The recovery won't be the easiest with two older ones, but everyone i know who has had an elective section has said it is lovely and calm - very different to inductions / emergency sections. The important thing is getting baby here safely and in a way that you are comfortable that you've considered all the risks and benefits and you aren't feeling rushed into a decision.

I was induced with my 1st at 41 weeks and he ended up being 6lb12 which is classed as small. When I was pregnant with my 2nd i was consultant lead as I have small babies, from around 30 weeks they scanned me once a week, one week to check my placenta, the next week to check measurements. At 30 weeks I had to have steroid injections as he was measuring behind and they thought they may have had to intervene, at 32 weeks he had grown so they carried on, this ended up being the case until 38 weeks when his measurements had dipped down, so they told me I would need to be induced the next day. That took 3 days and he ended up being 6lb4, so not too far away from his brother if they just let him grow.
I'm currently pregnant with my 3rd and they have said I'll be heavily monitored again with regular scans but I've told my midwife I don't want to be induced again and shes said there are consultant midwives now who will advocate for me if I really dont want to.

They will probably start to scan you more regularly to check on your placenta and measurements, as long as the measurements are rising they shouldn't pressure you into an induction, it's just taking it week by week, but you can refuse the induction if you don't feel like it's for the best.

It sounds like there's a lot going on and that you aren't in the loop with some of the conversation. It's bound to make you feel quite anxious.

I would prepare a specific lists of questions for the consultant on Monday

Something like
What are the concerns about the size?
What growth would trigger early induction?
How clinically necessary is that early induction, with monitoring could you wait?

Look at Sara Wickhams website and book on induction. It’s is always your choice. If baby is growing along their own scale, and is healthy; you should feel that induction doesn’t have to be necessary

To update this situation not much has changed in regards to the consultant really pushing for induction but now at 39 weeks he’s still adamant that it’s the best option although at my previous scan her growth is continuing she’s just under the 10th percentile but still growing at her own rate and again the fetal Doppler comes back healthy and all other readings are normal and healthy… but he still wants to induce me as she’s predicted to be just a generally small baby. My midwife has said we can potentially start stretch and sweeps from 38 weeks to see if we can avoid the induction entirely but if I’m honest I don’t really fancy doing any of that 😂 but they have scared the heck out of me by constantly reminding me that ‘small babies loose a lot of energy in labour and can have some serious health effects’.
So for now I am 37 weeks with a birth plan that doesn’t really meet the wishes I had for this but also too scared to risk babies health if she is very small and needs assistance.

also so greatful to all the advice and help on this post it did give me a confidence boost to actually corner my consultant at the last scan and ask for some more explanations to which his response was pretty much a blanket statement about her being small the things that can go wrong he definitely said stillbirth to me at one point. I have another scan on Monday with him and will endeavour to push back with more questions and see what progress she has made in these last two and a half weeks to determine what the next step is.

I had this with my second at about 32 and was basically told they would recommend induction at 37 weeks. By 38 weeks it was clear she wasn't as small as they had predicted. She was born at 41 +6 and was 8lbs 10oz.

One thing to bear in mind that in many areas the growth charts are personalised. This means that your centile lines are individual to you and if your BMI is raised that it will predict that you "should" have a large baby, which means that 10th centile could be quite a healthy weight for a smaller woman having a baby if that makes any sense. The centiles can also be a bit skewed if you're not white or older.I found it easier to follow the line and see what the predicted actual weight would be at 40 weeks rather than think about the centiles. It's also worth bearing in mind that there's an accepted 10-15% margin of error with the predicted weights of growth scans.

Hi OP,

I know this thread is old - can I ask how it all went for you?

I'm in a similar boat but a bit earlier on, currently 26w+5. I had my fundal length measured by a midwife last week (27cm, so all fine there) but I had some concerns over baby's movements which had gone from really strong to quite faint. They put me on the machine and HR and movements all fine.

Then I got asked to have a scan. All the measurements seemed fine but they were concerned about baby's weight. He's apparently measuring on the 3.6 centile.

I've been referred for fortnightly scans and the consultant already mentioned getting him out at 37 weeks.

I really don't want this. My first baby was also SGA, and they induced me at 37w4d - after two pessaries, 2 lots of gel and 4 days in the nightmare induction ward, nothing happened (we weren't ready) and I was not allowed to go home, so forced into a csection I didn't want. DD was perfectly healthy, as was placenta - just small.

Despite being 5ft10 myself and heavy, I seemingly make small babies. My husband is 5ft11 now and also a big muscular man, but was born at 36w and only 3lbs. So he was a small baby, as was his sibling.

I would really love to avoid induction (unless I'm pretty much ready) and csection if I can help it.

Is the way to refuse induction at 37w and get them to agree to monitoring, plus sweeps, and hope for the best?

Congratulations!!

I’m really sorry to hear about your previous birth experience it sounds gruelling and like an emotional rollercoaster. so I eventually sat down with my consultant at our final meeting and said I am not going forward with an induction when all the signs where showing she was healthy but small. I really suggest reading ‘inducing labour: making informed decisions’ by Sara wickham, here is the passage I read to him;

“Induction for suspected small babies:
On the whole, induction is not recommended when there is fetal growth restriction; that is, when the baby is thought to be too small for gestational age or not growing appropriately. But in practice it is often offered, especially in less severe cases.Some smaller studies have looked specifically at whether induction is beneficial where babies are suspected to be small. A review of outcomes in one medical centre found that, “Early term induction for SGA fetuses results in an increased risk of cesarean deliveries as well as neonatal metabolic and respiratory complications, with no apparent neonatal benefit.” (Ofir et al 2013).”

He then agreed that there wasn’t actually an urgent need to have an induction and so we could play it by ear and go with the flow. Monday 4th November I saw my midwife for my 38 week check up I was 38+3 I also informed her I didn’t want any sweeps and although I couldn’t have a home birth because of SGA I wanted to keep it as natural and hands off as possible so the plan was just turn up to hospital when things started.
Following day contractions started, 10 days early - labour was super quick literally from the first contraction to birth was like two hours but I only actively pushed for about 6 minutes and had no medical interventions not even a paracetamol 😂 she was born at 5lbs3oz so quite small (my placenta was also smaller than average) due to her weight we had to stay in transition bay for two nights she had regular jaundice and glucose tests which she didn’t need any medical assistance for she was under the jaundice level for treatment and her glucose was also fine.
I honestly think you need to be firm with what you want from your birth and also be open to anything happening on the day. As long as baby’s movements are still strong, the dopplers come back fine from your regular scans and baby is comfortable I would hold off on letting them make that decision for you.

Do expect a longer stay if baby is small, more tests, paediatrics outpatient for weight checks by a consultant. Also remember this is your second baby and typically they happen a lot faster and in the most part they come a bit earlier.

good luck x

Thanks so much - you've given me so much confidence.

My 1st baby was 5lb 13oz at 38 weeks exactly so not even that small! I think I'm going to refuse induction completely and I will have a look at Sara Wickham. I think I was just so afraid last time that I didn't consider how silly the argument is for induction of SGA babies when they also claim those babies can't cope with the labour process. Then why make it 10x more stressful for them?! I think for me it is going to be natural or repeat cs.