J. L. Reynolds A. Kettner M. Burnett M.

Cheang
Can Fundal Height Predict
Birth Weight or Twins?
SUMMARY
To determine how well symphysis fundal
height measurements correlated with birth
weight, the authors retrospectively reviewed
100 records of pregnancy from a family
practice. The sensitivity and specificity of
symphysis fundal height in identifying small
and large for gestational age babies were
determined. While symphysis fundal height
measurements correlated well with birth
weight, the sensitivity was too low and the
number of false positives too high, for
symphysis fundal height measurement alone
to be clinically useful. On reviewing all twin
pregnancies in the same setting, the authors
found that symphysis fundal height
measurements facilitated early diagnosis of
twin gestation. (Can Fam Physician 1986;
32:55-60.)
SOMMAIRE
Pour determiner la qualit6 de la correlation entre les
mesures de la hauteur du fond uterin a partir de la
symphyse pubienne et le poids a la naissance, les
auteurs ont procede a une etude retrospective de 100
dossiers de grossesse provenant d'une pratique
familiale. On a determine la sensibilite et la
specificite de la hauteur du fond ut6rin mesure a
partir de la symphyse pubienne pour identifier les
bebes petits ou gros pour I'age de la grossesse.
Malgre une bonne correlation entre la hauteur
uterine et le poids a la naissance, la sensibilite s'est
averee trop faible et le nombre de faux positifs trop
el'eve pour affirmer que la seule mesure de la
hauteur uterine a partir de la symphyse pubienne
soit cliniquement utile. Lors de la revision de toutes
les gro.ssesses gemellaires dans la meme pratique,
les auteurs ont constate que la mesure de la hauteur
uterine a partir de la symphyse pubienne a facilite le
diagnostic precoce des grossesses gemellaires.
Key words: Fundal height, birth weight,
twins

Drs. Reynolds, Kettner and
Burnett are on the staff of the
Department of Family Medicine at
the University of Manitoba and the
Section of Family Practice
Obstetrics at St. Boniface General
Hospital. Ms. Cheang is a member
of the Department of Social and
Preventive Medicine at the
University of Manitoba. Reprint
requests to: Dr. J. L. Reynolds,
Department of Family Medicine,
University of Manitoba, 5th Floor,
400 Tache Avenue, Winnipeg, MB.
R2H 3E1.
DERINATAL mortality has fallen
r dramatically over the last 30 years,
from 35 per 1,000 births in 1952 to ll
per 1,000 in 1979.1 We may have
reached a plateau, where the major
mortality is due to congenital abnor-
malities and extreme prematurity. One
of the major factors in the improved
perinatal mortality over the past ten
years has been improved neonatal sur-
vival. Similarly, the development of
CAN. FAM. PHYSICIAN Vol. 32: JANUARY 1986
tests of fetal wellbeing including non-
stress tests (NST)2 and intrauterine ul-
trasound biophysical profiles3 appear
to be major advances in assessing the
high risk fetus. One of the continuing
challenges in obstetrics is to identify
the 'fetus at risk'. With limited re-
sources it is neither possible nor rea-
sonable to apply these techniques to all
pregnancies. There is a clear need for
simple, reliable, sensitive and specific
methods that can identify those fetuses
that might benefit from more sophisti-
cated assessment techniques.
One test that has shown promise for
screening low risk pregnancies is fetal
movement counts.4' 5Another method
that has been suggested as a screening
maneuver for identifying the high risk
fetus is symphysis fundal height (SFH)
measurement. It is simple, inexpen-
sive, and appropriate for widespread
use by individuals with minimal train-
ing. If this test could accurately iden-
tify those fetuses that were small for
gestational age or large for gestational
age, it would occupy an important
place in delivering prenatal care.
Size of Infants
For Gestational Age
Infants who are small for gestational
age (usually defined as less than the
tenth percentile) have a six to eight
fold increase in morbidity and mortal-
ity.6' 7 Using ultrasound techniques it
is now possible to diagnose about 94%
of SGA infants.8 Neilson et al.8 in
Glasgow identified 94% of 36 SGA
babies using a two-stage ultrasonic ex-
amination schedule. The first exam-
ination was conducted at the first
antenatal visit (mean gestational age
15 weeks); the second-stage examina-
tion was carried out at 34-36 weeks
and entailed measuring seven fetal
variables. Again, however, the time,
expense and expertise involved pre-
clude the widespread or routine use of
these methods. In spite of our knowl-
edge about predisposing maternal fac-
tors and a range of available biochemi-
cal measures, only about 50% of SGA
infants are detected antenatally.7' 9 If
SFH measurement could improve the
antenatal identification of SGA babies
55
it would be a definite advance. Such
patients could then be considered 'high
risk' and more sophisticated assess-
ment could be done to evaluate fetal
well-being and the need for further in-
tervention.
Similarly, SFH measurement might
detect large for gestational age (LGA)
infants (greater than the 90th percen-
tile). The advantages of antenatal de-
tection would include an increased
vigilance for maternal gestational dia-
betes, forewarning for potential ceph-
alopelvic disproportion, shoulder dys-
tocia, maternal/child birth trauma and
neonatal hypoglycemia. These could
be evaluated (e.g., by a glucose toler-
ance test or more frequent blood glu-
cose determinations) and certainly
kept in mind as possible complications
as the pregnancy progressed and at the
time of labor and delivery. Another
potential benefit of SFH measurement
may be the detection of polyhydram-
nios with its associated risks of infants
of diabetics or with congenital abnor-
malities. Again, the early detection of
twin pregnancies by SFH would allow
earlier intervention in this very high
risk situation.
Critical Review of
SFH Measurement
One criticism of SFH measurement
has been that there are large discrepan-
cies in the reported accuracy. In 1953,
Rumboltz and McGoogan'0 showed
that no increase in fundal height
beyond 31 weeks was usually asso-
ciated with the delivery of a SGA in-
fant. In 1970, Beazley and Underhill"1
defined the increase in fundal height
above the symphysis pubis for each
week of pregnancy (fundal height had
previously been related to the um-
bilicus or xyphisternum). They con-
cluded that the variability of their mea-
surements precluded the use of fundal
height to estimate fetal size.1" Camp-
bell12 reported that only 28.7% of
SGA infants could be predicted. Wes-
tin13 reported much more favorable re-
sults. He detected 75% of all infants of
a birth weight less than one standard
deviation below the mean and 65% of
LGA infants. He also predicted 29 out
of 30 twin pregnancies that had fundal
height measurements more than two
standard deviations above the mean.'3
In the last few years, several investiga-
tors have reviewed the use of SFH
measurements in their setting. Their
results are displayed in Table 1.
CAN. FAM. PHYSICIAN Vol. 32: JANUARY 1986
These studies are very difficult to
compare because of differing criteria
and differing methods of reporting re-
sults. In summary, the sensitivity (the
ability to positively identify patients
with the condition) of SFH in detecting
IUGR varies from 50-86%, while spe-
cificity (the ability to identify patients
who do not have the condition) varies
from 75-96%. However, there are sub-
stantial false positive and false nega-
tive rates. Some additional observa-
tions were made during the course of
these studies. Breech versus cephalic This free booklet talks to mothers the
presentation, engaged versus not en- way you do. It tells them all about
gaged and parity did not seem to affect baby's mouth. It talks about the sucking
measurements.14 Gross obesity contri- urge, breast feeding, nipples and paci-
buted to false negative results in one fiers. And it tells about oral devel-
study.19 It also appears that a single opment and how to help prevent future
measurement for the detection of SGA oral problems. One way is by using the
was most accurate at 32-33 weeks.15 NUK program of nipples and orthodon-
The issue of inter-observer variability tic exercisers -developed by an ortho-
has been studied and does not appear dontist to nearly duplicate mother's
to detract from the measurement's reli- nipple. It is a fascinating, informative
ability. 17 story. For a sample copy, please
None of the reports on SFH mea- send in the
surements in the literature hfave been coupon below.
Canadian studies or have used Cana-
dian standards. Most of them have
used as their study population patients
from high risk centres and under the
care of consultant obstetricians. How-
ever, as Canadian family physicians
continue to provide obstetrical care,
they must be able to detect high risk
pregnancy and to make decisions to
proceed with further investigation or
with consultation.
The University of
Manitoba Study The world's largest selling pacifier.
*TM/M. de Cof
de Mapa GmbH Gummi-und
In our clinic, we routinely use serial Plastikwerke LIC.: Gerber (Canada) Inc.
SFH measurements during antenatal
care and graphically display them in ---- - m
M
each patient's chart. It is our impres- I FREE BOOKLET-Please send
me a free sample copy of the "The
sion that this leads to earlier detection
of deviations from normal growth pat- I Incredible, Insatiable Sucking
Desire." I understand that after U
terns. The objectives of this study
were as follows: - examining the book I can order
* additional free copies for distribu- I
1. To see how well fundal height mea-
surements correlated with birth tion to patients and for use in my
* waitngroom.
weight.
2. To determine the sensitivity and
specificity of fundal height measure-
ments in determining LGA and SGA I Name
babies.
3. To determine whether SFH mea- I Address
surements were useful in the early de-
tection of twin pregnancies. I City Province Postal Code
Send coupon to:
Methods NUK, P.O. Box 1010,
Niagara Falls, Ontario L2E 6W6
The study took place in the Family
Medical Centre, an academic teaching -- - - - - -
57
clinic of the Department of Family pregnancy test done at six weeks and a
Medicine, University of Manitoba pelvic exam at eight weeks. Twenty-
(18,000 charts). One hundred consec- seven percent of the study patients had
utive pregnancies from one of our ultrasound examinations.
practices (JLR) were reviewed retro- Fundal heights have been routinely
spectively. To be included in the study recorded on all prenatal patients at-
the following criteria had to be met: tending our centre for the past eight
1. Caucasian. years, according to a standardized sys-
2. Non-diabetic. (Women with known tem. Fiberglass tape measures were
diabetes before the pregnancy and used from the top of the symphysis
those diagnosed with gestational dia- pubis to the top of the palpable fundus
betes at any point during the preg- over the curve of the abdominal
nancy were excluded from the study uterine wall. Measurements usually
group.) start at 20 weeks. For the purpose of
3. Single fetus. this study, measurements taken at 28,
4. Normal baby (i.e., no genetic or 32, 34 and 36 weeks were recorded.
major congenital abnormalities). The stages of gestation were chosen
5. Certain gestational age. because we felt that this was the time
6. Gestation at delivery, 34 weeks or where SGA and LGA babies could be
greater. detected and because detection here
Further criteria were developed for would have the most clinical value.
certainty of gestational age and in- Measurements were taken by one su-
cluded: pervising staff physician' and approxi-
1. Regular periods. mately 12 family medicine residents
2. Certain of LNMP. who had been carefully instructed in
3. Early positive urine pregnancy test symphysis fundal measurement.
(i.e., six to eight weeks). Where there was discrepancy or an un-
4. Discontinued oral contraceptives for usual measurement, the measurement
at least three months. was checked by another physician and
5. Bimanual examination at or before a consensus achieved.
12 weeks. Maternal weight gain from the first
In order to be included in our sam- visit until delivery and smoking status
ple, the patient had to have met at least were also recorded. The baby's sex,
three of these five criteria or to have gestation at birth and birth weight in
undergone an ultrasound examination grams were also recorded. The baby's
before 30 weeks gestation. The em- weight with respect to its gestational
phasis in our clinic is on early diag- age (percentile weight for gestation)
nosis of pregnancy and the vast major- was derived from data published from
ity of our patients had a urine Montreal.20
TABLE 1
SFH Studies to Date
Results
False
Study Crtena Sens. Spec. Pos.
Belzan 1978
Argentina14 At least 1 SFH value below 10 %ile 86% 90% 10%
Quaranta 1981
England15 <10 %ile on 2 consecutive or 3 isolated readings 75% 77-90% 20%
Wallin 1981 LGA: >3 cm above mean on more than 2 occasions 74% 84% 18%
Sweden'6 SGA: >3 cm below mean on more than 2 occasions 62% 88% 13%
Rosenberg 1982 <10 %ile on 2 consecutive or 3 isolated readings 56% 85% 79%
Scotlandg Multivariate analysis
69% 74% 26%
Little advantage over clinical
detection rate 49%
Calvert 1982 Criteda:
Wales1'7 * 1 value>2 cm below mean or 3 static or 76% 60% 80%
dedining values
* 1 value<10 %ile 64% 79% 71%
* 2 consecutive or 3 isolated values<10 %ile 36% 94% 57%
Wennergren 1982 Risk score, using 8 variables, fundal height 90-100% 95.5% 66%
Sweden'8 having highest weighted value
Cox 1983
Irelandi9 2 or more measurements below 10 %ile 58% 96% 6%
58
Correlation coefficents were calcu-
lated for SFH measurement and per-
centile weight for gestation. The mean
and standard deviations of SFH were
calculated using normal babies-that
is, babies between the 10th and 90th
percentiles. The sensitivity, specific-
ity, false positive and false negative
rates were calculated to determine how
well SFH measurements would have
detected the SGA and LGA babies.
All twin pregnancies from all six
teaching practices were reviewed re-
trospectively. Data were obtained on
fundal height and time of diagnosis.
Results
Fundal height measurements corre-
late very well with fetal weight, with
the strongest correlation being at 34
and 36 weeks. The correlation coeffi-
cients were 0.34 at 28 weeks, 0.32 at
32 weeks, 0.46 at 34 weeks, and 0.45
at 36 weeks. Even though these corre-
lations are highly statistically signifi-
cant, the next and more practical ques-
tion is: "Are they clinically useful?"
There were 11 SGA infants and 13
LGA infants. Table 2 demonstrates the
ability of SFH to predict the SGA
babies. Regardless of whether an indi-
vidual measurement was one or two
standard deviations below the mean,
sensitivity is too low and the false pos-
itive rate too high for this to be a reli-
able predictor of SGA babies. Similar
results were found in our ability to pre-
dict LGA babies, as displayed in Table
3.
Diagnosis of twins occurred on
average at 24.1 weeks of gestation,
with most twin pregnancies being
diagnosed at 20-29 weeks (range
12-39 weeks). The diagnosis was actu-
ally suspected by large SFH in six of
nine patients. On reviewing the prena-
tal records, however, eight out of nine
patients had SFH measurements which
were consistently greater than two
standard deviations beginning from
18.5-33.5 weeks, but usually at 20
weeks.
Three twin pregnancies were ini-
tially not suspected because of large
fundal height. One of these pregnan-
cies was diagnosed by early ultra-
sound. However, on review of the pa-
tient's prenatal sheet, her SFH was
greater than two standard deviations
beginning at 18.5 weeks gestation. A
second twin pregnancy was diagnosed
at 39 weeks by ultrasound. On review-
ing the patient's data, the SFH height
was greater than two standard devia-
CAN. FAM. PHYSICIAN Vol. 32: JANUARY 1986
tions at 33 weeks. The third twin preg-
nancy was diagnosed at 32 weeks,
when the patient had ultrasound as-
sessment following spontaneous rup-
ture of membranes. Her SFH measure-
ments were normal but she had only
two prenatal visits after 20 weeks' ges-
tation and was not Caucasian. Overall,
it appears that SFH may be a reason-
able and simple method for the early
detection of twin pregnancies.
Discussion
This study has been able to demon-
strate in a family practice setting that
fundal height measurements do corre-
late very well with fetal weight. Un-
fortunately, the correlation was not
strong enough for SFH alone to predict
SGA or LGA babies in our study
group. The predictive power might be
better in a larger study or in high risk
groups, as some investigators 14-16, 19
have demonstrated. Our study's sensi-
tivity is one of the lowest reported to
date. The reasons for this are unclear.
Perhaps the small size of the study
population and the small number of
babies with deviation from normal
growth are contributing factors, but
this is the reality in most family prac-
tices, where patients are largely 'low
risk'. For SGA babies, our specificity
and false positive rates are very similar
to those found by Rosenberg,9 Cal-
vert,17 and Wennergren.18 Our study
does, however, reinforce the evidence
that fundal height facilitates the early
detection of twin pregnancy.
Perhaps the most promising method
for detecting SGA and LGA babies in
Canadian primary care settings would
be the adoption of a scoring system
similar to that proposed in Sweden by
Wennergren. 18 This might include
TABLE 2
Ability to Predict SGA Babies
Measurements Sens.
1 or more <1 S.D. 45.5%
2 or more < 1 S.D. 45.5%
1 ormore<2S.D. 27:3%
2 or more <2 S.D. 18.20/o
TABLE 3
Ability to Predict LGA Babies
Measurements Sens.
1 or more >1 S.C. 53.9%
2ormore>1 S.D. 30.8%
1 or more >2 S.D. 23.1%
2ormore >2S.D. 7.7%
60
weighted factors like SFH, maternal References
weight gain, smoking, previous infant 1. Department of Economic and Social Af-
weight and perhaps risk of gestational Statistical Office of the United Na-
fairs
diabetes. When we reviewed our data tions 1981. New York, NY: Demographic
on maternal age, weight gain, smoking Yearbook 1980.
and parity, neither univariate nor mul-2. Phelan JP. The nonstress test: a review
of 3,000 tests. Am J Obstet Gynecol 1981;
tivariate analysis improved our ability 139:7-10.
to predict the SGA and LGA babies. 3. Manning FA, Morrison I, Lange IR, et
This may be explained by the rela- al. Antepartum determination of fetal
tively small number of women in our health: composite biophysical profile scor-
study. We would like to develop and ing. Clin Perinatol 1982; 9:285-96.
4. Neldam S. Fetal movements as an indi-
to test this type of scoring system in a
cator of fetal wellbeing. Lancet 1980;
prospective trial, to see if we could 1:1222-4.
confirm the Swedish results in Cana- 5. Grant A. Do fetal movements reflect
dian patients. fetal wellbeing? Br Med J 1981;
282:1153.
Although we could not demonstrate 6. Norman LA. Intrauterine growth retar-
that SFH measurement alone could dation. Am Fam Physician 1982; 26:171-
predict SGA or LGA babies, we rec- 6.
ommend that the plotting of serial SFH 7. Tropper PJ, Fox HE. Evaluation of
measurements become part of routine antepartum fetal wellbeing by measuring
growth. Clin Perinatol 1982; 9:271-84.
obstetrical practice. Some provinces 8. Neilson JP, Whitfield CR, Aitchison TC.
have actually incorporated graphs for Screening for the small-for-dates fetus: a
plotting SFH measurem,ents against two-stage ultrasonic examination sched-
gestational age as part of the officialule. Br Med J 1980; 280:1203-6.
9. Rosenberg K, Grant JM, Aitchison T.
provincial obstetrical record. It is a Measurement offundal height as a screen-
very simple procedure that correlates ing test for fetal growth retardation. Br J
well with fetal weight, focuses atten- Obstet Gynecol 1982; 89:447-50.
tion on fetal growth, provides a stan- 10. Rumbolz WL, McGoogan LS. Placen-
dardized tool for the assessment of tal insufficiency and the small under-
nourished full-term infant. Obstet Gynecol
fetal growth and facilitates the early 1953; 1:294-301.
detection of twins. This maneuver, 11. Beazley JM, Underhill RA. Fallacy of
along with other clinical information the fundal height. Br Med J 1970; 4:404-
such as maternal weight gain, smoking 6.
and previous baby weight, should im- 12. Campbell S. The assessment of fetal
development by diagnostic ultrasound.
prove our ability to detect very small Clin Perinatol 1974; 1:507-25.
and very large fetuses and twin preg- 13. Westin B. Gravidogram and fetal
nancies. An improved detection rate growth. Acta Obstet Gynecol Scand 1977;
56:2273-82.
with appropriate investigation, referral
14. Belizan JM, Villar J, Nardin JC, et al.
and treatment offers hope for further Diagnosis of intrauterine growth retarda-
improvement in perinatal health. * tion by a simple clinical method: measure-
ment of uterine height. Am J Obstet Gyne-
Acknowledgements col 1978; 131:643-6.
15. Quaranta P, Currell R, Redman CWG,
We wish to thank Gloria Mailhiot et al. Prediction of small-for-dates infants
for her assistance in typing the manu- by measurement of symphysial-fundal-
script. height. Br J Obstet Gynaecol 1981;
88:115-9.
16. Wallin A, Gyllensward A, Westin B.
Symphysis-fundus measurement in predic-
tion offetal growth disturbances. Acta Ob-
Spec. False + False - stet Gynecol Scand 1981; 60:317-23.
17. Cal vert JP, Crean EE, Newcombe RG,
64.5% 81.5% 13.0% et al. Antenatal screening by measurement
82.9% 72.20/o 8.7% of symphysis-fundus height. Br Med J
1982; 285:846-9.
90.1% 70.0%/o 11.1% 18. Wennergren M, Karlsson K, Olsson T.
96.1% 60.0% 11.0% A scoring system for antenatal identifica-
tion offetal growth retardation. Br J Ob-
stet and Gynecol 1982; 89:520-4.
19. Cox G, Walsh P, Stack J, et al. The
value offundal height measurement in pre-
diction offetal growth retardation. Ir Med
Spec. False + False - J 1983; 76:95-6.
75.5% 65% 13.0% 20. Usher R, McLean F. Intrauterine
growth of live-born Caucasian infants at
94.7% 50% 11.1% sea level: standards obtained from mea-
92.8% 62.5% 13.5% surements in 7 dimensions of infants born
14.1% between 25 and 44 weeks of gestation. J
96.1% 75.0% Pediatr 1969; 74.901-10.
CAN. FAM. PHYSICIAN Vol. 32: JANUARY 1986