The Management of Large and Small for

Gestational Age Fetuses

Philip Steer

The major influence on birth weight is gestational age. At any given week of gestation, however, size
varies enormously. There is no specific cut-off that separates abnormally large or small babies for
gestational age from normal. Instead, function alters as a continuum across the weight distribution.
Small babies are prone to hypoxia, acidosis, and stillbirth. Large babies on the other hand are
associated with prolonged labor and mechanical problems. The optimum size for fetal survival is 1
to 1.5 standard deviations above the mean, whereas cesarean section rates are lowest when the fetal
weight is 0.5 to 1.5 standard deviations below the mean. Antenatal detection of both very small and
very large babies is difficult and imprecise. Expectant management is therefore preferable unless
there are very specific indications for emergency or operative delivery.
© 2004 Elsevier Inc. All rights reserved.

he management of babies that are large or
T small for gestational age presents many
problems, not the least of which is that size at
birth is a continuum without precise cut-offs
delineating normal from abnormal. This can be
illustrated using data from the North West
Thames regional database (containing data on
all pregnancies booked into 15 maternity units
in the North West Thames Region of London
between 1988-1998 inclusive). The database in-
cludes 497,105 pregnancies, of which 439,689
progressed far enough in pregnancy to have a
birth weight recorded. Data were entered by
trained clerks or midwives with on-line valida-
tion and prompting, and standard definitions
for a range of clinical measurements. The qual-
ity of data collected has been shown to be high.1
For the purposes of this paper, I have analyzed
data from 137,114 White European women in
their first registrable pregnancy, and gestational
age at delivery of 37 weeks or more. This avoids
the complication of ethnic differences, and the
effect of preterm delivery. For each week of
gestational age, the mean and the standard de-
viation of birth weight was calculated for boys
and girls, and then the birth weight of each baby
expressed as a positive or negative standard de-
viation from the mean according to gender
(standard deviation score, SDS).
Figure 1 illustrates the distribution of birth
weight by standard deviation scores, in steps of
0.5 of a standard deviation. It can be seen that
outside a standard deviation of 3 (which in-
cludes 99.73% of the population) the number of
cases in each step becomes small, approximately
100 or less.
Figure 2 illustrates that the lowest perinatal
mortality occurs when the birth weight is 1.0 to
1.5 standard deviations (SD) above the mean (1
SD above the mean is approximately the 84th
percentile, 2 SD is approximately the 98th cen-
tile). It can also be seen that perinatal mortality
increases steadily away from this central group,
without any clear cut-off at a particular SDS. As
babies are smaller for gestational age, their peri-
natal mortality increases, reaching 100% at 5.5
standard deviations from the mean. Larger ba-
bies also have a higher perinatal mortality, but
after a standard deviation of 2.5, the numbers of
perinatal deaths are too small to be meaningful.
The overall perinatal mortality rate was 2.63 per
thousand, of which the greater proportion was
made up of stillbirths. Antepartum stillbirths ac-
counted for 1.46 per thousand, intrapartum still-
births 0.39 per thousand, and indeterminate
stillbirths 0.15 per thousand. The pattern of still-
births mirrored that of overall perinatal mortal-
From the Division of Paediatrics, Obstetrics, and Gynecology, De-
partment of Obstetrics and Gynaecology, Imperial College, London,
UK.
Address reprint requests to Philip Steer, BSc, MB, BS, MD, FRCOG,
Academic Department of Obstetrics and Gynaecology, Chelsea and
Westminster Hospital, 369 Fulham Rd, London SW10 9 NH, UK;
e-mail: p.steer@imperial.ac.uk.
© 2004 Elsevier Inc. All rights reserved.
0146-0005/04/2801-0007$30.00/0
doi:10.1053/j.semperi.2003.10.013

Seminars in Perinatology, Vol 28, No 1 (February), 2004: pp 59-66 59

60 Philip Steer

Figure 1. Distribution of birth weight by standard

deviation score (log scale of actual numbers of preg-
nancies analyzed).

Figure 3. The percentage of abnormal fetal heart

ity, whereas that of neonatal deaths showed a less rate patterns in labor according to standard deviation
clear relationship with SDS. score of birth weight.
The main contribution to hypoxic dysfunc-
tion during labor is from babies that are small
small babies relating more to hypoxemia and
for gestational age. Figure 3 illustrates the
acidosis (Figs 6 and 7), while those in the large
higher proportion of abnormal fetal heart rate
babies relate more to trauma, associated with a
patterns during labor associated with being
higher rates of emergency cesarean section
small, compared with average or large babies. A
(Fig 8).
similar pattern is seen with meconium staining
The fact that the dysfunction associated with
of the amniotic fluid during labor (Fig 4), al-
being large or small is a continuum accounts for
though there is a slight increase with large ba-
the failure of consensus on what limits should be
bies. Once again, there is no specific cut-off of
used to define large or small babies for gesta-
SDS that delineates normal from abnormal. On
tional age; the 10th, 5th or 3rd centile, or 2SD,
the other hand, the proportion of babies taken
have all been used to define small for gestational
to the special care baby unit after birth rises
age. Indeed, it can be argued that while size
sharply away from the mean, for both small and
matters, function matters even more.2 Work
large babies (Fig 5). This probably reflects dif-
from our group has shown previously that failure
ferent problems in the 2 groups, those in the

Figure 4. The percentage of meconium staining of

Figure 2. Perinatal mortality (percent, log scale) ac- the amniotic fluid according to standard deviation
cording to standard deviation score of birth weight. score of birth weight.
 Large and Small for GA Fetuses
Figure 5. Percentage of babies transferred to the
special care baby unit following birth according to
standard deviation score of birth weight.
of growth during gestation is a better predictor
of peripartum and neonatal dysfunction than
size per se.3 Many small babies are constitution-
ally small (“healthy small”4), while some babies
that are failing to achieve their growth potential
are above the 10 centile.5 These latter babies can
be termed “normal weight growth restricted.”
Large babies on the other hand may be consti-
tutionally large, or large because their mother is
overweight or diabetic. The implications, such as
neonatal hypoglycemia, are greater in the latter
group, although mechanical problems in labor
such as shoulder dystocia are common in all
Figure 6. Mean lowest pH in labor (⫾ 95% confi-
dence limits) by standard deviation score of birth
weight.
61
Figure 7. Mean Apgar score (⫾ 95% confidence lim-
its) at 5 minutes by standard deviation score of birth
weight.
large babies irrespective of the aetiology of their
macrosomia. Measures of size that take into ac-
count maternal dimensions have advantages
(see Gardosi, this issue), but even then, correc-
tion for severe maternal underweight for exam-
ple may result in false reassurance.
Implications for Management
Small Babies
Antenatal detection of babies that are small for
gestational age is currently neither easy nor ef-
fective. Ideally, and to be most cost-effective,
screening on a population basis should be prac-
tical using history and clinical examination. The
single most effective indicator of a high risk of a
small for dates baby is a small baby in a previous
Figure 8. Percent delivered by emergency caesarean
section by standard deviation score of birth weight.
62 Philip Steer
Figure 9. Number of ultrasound scans per pregnancy
according to standard deviation score of birth weight.
pregnancy (30% recurrence risk), and yet obvi-
ously this history is not available for women in
their first pregnancy. Other factors predisposing
to intrauterine growth restriction include mater-
nal malnutrition (low body mass index), and
smoking. However, most of these historical fea-
tures carry a relative risk of smallness of only 1.3
to 1.8 times and are therefore not specific
enough to allow targeted screening. The only
clinical examination relevant to detecting small
for gestational age babies is symphysis-fundal
height measurement. A recent Cochrane collab-
oration review6 of such measurements found
only one reliable randomised trial, which did
not show a useful pickup rate.7 The predictive
accuracy of third trimester ultrasound for the
detection of intrauterine growth restriction has
been studied extensively, and the abdominal cir-
cumference has been found to be the single
most effective measurement to use.8 However,
the same studies have shown that there is both a
significant false negative, and a large false-posi-
tive rate. The Cochrane review of routine third
trimester ultrasound screening for fetal growth
in low-risk populations came to the conclusion
that it was not effective.9
The North Thames database also suggests
that antenatal detection of significantly “small
for dates” fetuses is poor. The number of ante-
natal scans per pregnancy increases from an
average of 2 per pregnancy for normal weight
babies, to only 3 per pregnancy even for babies
that are 3 standard deviations below mean birth
weight (Fig 9). Even more striking is the lack of
an increased elective cesarean section rate with
such small babies, in contrast to the increased
elective cesarean section rate for large babies
(Fig 10).
How should we manage babies that are diag-
nosed as being very small, either serendipitously
or on the basis of risk factors? Ideally, we should
use a therapy to improve intrauterine fetal
growth. Unfortunately, although many therapies
such as bed rest in hospital,10 maternal nutrient
supplementation,11 maternal oxygen administra-
tion,12 plasma volume expansion,13 and the use
of beta mimetics14 or calcium channel blockers15
to reduce uterine tone and thereby encourage
placental blood flow have been advocated, re-
sults either show no benefit or insufficient evi-
dence of benefit for them to be recommended
at the present time. The only practical approach
is therefore timely delivery of the fetus. The
scheme that we use at the Chelsea and Westmin-
ster hospital is illustrated in Figure 11; such
schemes are widely used.16 The use of Doppler
examination of umbilical artery blood flow as a
screen for uteroplacental dysfunction is well es-
tablished,17 and probably effective at reducing
stillbirth.18 Some regard absent or reversed end
diastolic flow as a sufficient indication for deliv-
ery, even in preterm infants.4 Others, however,
prefer to rely on analysis of the fetal heart rate
pattern. The growth restriction intervention trial
(GRIT)19 was designed to investigate the opti-
mum timing of delivery for babies known to be
small, and with abnormal Doppler blood velocity
waveforms. It was a Bayesian trial, which means
that it was designed to take into account differ-
ences in the threshold of different clinicians to
Figure 10. Percent emergency caesarean section by
standard deviation score of birth weight.
 Large and Small for GA Fetuses
Figure 11. Scheme for antepartum fetal monitoring.
delivery at various gestations, depending on
whether umbilical artery Doppler showed re-
duced, absent, or reversed end diastolic flow.
When the clinicians reached the point at which
they were unsure whether to deliver now, or to
deliver later, the patient was randomised either
to “deliver now” (meaning within 48 hours to
permit completion of the steroids course), or to
“delay delivery” (meaning until delivery was in-
dicated using other tests, commonly analysis of
the fetal heart rate pattern). As might have been
expected, there was a higher stillbirth rate in the
delayed group (9/291 v 2/296), but this was
balanced by a higher neonatal death rate in the
immediate delivery group (23/296 v 12/291).
63
The overall effect was therefore a slightly lower
death rate prior to discharge in the delayed
group (27/291, 9% v 29/296, 10%, including
late neonatal deaths) although this difference
did not reach statistical significance. Although
the average randomization to delivery time was
only 4 days longer in the delayed group, none-
theless, if one includes the effect of the higher
stillbirth rate and the lower neonatal mortality, it
is likely that there was a significant cost benefit
to the delayed delivery policy. This is because
antenatal care is much cheaper than neonatal
intensive care per day. However, the detailed
cost analysis of this study has yet to be reported.
The trial is continuing with the follow-up of the
babies in the 2 groups, and because it is a Bayes-
ian trial, interim results are available. At the time
of writing, Griffiths assessments (a measure of
sensory, motor, and intellectual performance) at
approximately 2 years of age show a slight ad-
vantage in the score for the delayed delivery
group in babies born at 24 to 30 weeks’ gesta-
tional age. The median 2-year score is identical
for babies born at 31 weeks’ gestational age or
more. The full results must be awaited before we
will be able to tell whether this advantage is
significant. Nonetheless, it does appear that
even when the umbilical artery Doppler is ab-
normal, it is reasonable to wait to deliver until
the fetal heart rate pattern becomes abnormal.
Moreover, early evidence of hypoxemia on the
fetal heart rate tracing does not appear to indi-
cate irreversible hypoxic damage. In terms of
accuracy, consistency, and reliability, there may
well be advantages to using online computerized
fetal heart rate analysis, such as that provided by
the Sonicaid 8,000 system (Oxford Instruments
Medical LTD, UK).20,21 More sophisticated mea-
sures of blood flow and distribution are dis-
cussed elsewhere in this issue, but it will be
necessary to conduct further prospective studies
before one can judge whether such sophistica-
tion results in improved outcome. Until such
studies are conducted, it seems reasonable to
continue with the policy as laid out in Figure 11.
Once the decision to deliver has been taken,
it is necessary to consider the mode of delivery.
This will depend on the gestational age of the
fetus, and the ripeness of the cervix. Even if the
indication for delivery is an abnormal cardioto-
cogram, if the cervix is favourable induction of
labor should be considered because experience
64 Philip Steer
shows that in at least 50% of cases the fetal heart
rate pattern returns to normal once labor be-
gins. This is presumably because of increased
sympathetic drive causing redistribution of
blood flow in the fetus toward the vital organs
such as the brain and the heart, resulting in
improved oxygenation. However, if there is evi-
dence of marked hypoxaemia, suggestive of al-
ready established acidosis, delivery by cesarean
section is probably safer because the tolerance of
the growth restricted fetus to further hypoxia
during labor is limited.22,23 Some have suggested
that the addition of intrapartum hypoxemia to
restricted antepartum cardiac output may signif-
icantly increase sequelae such as necrotizing en-
terocolitis,24 although others have found little or
no effect.25,26
It should also always be borne in mind that
the aetiology of intrauterine growth restriction
may not be simply uteroplacental insufficiency.
Any small baby should be screened carefully for
congenital abnormalities, including aneuploidy.
This involves detailed and systematic ultrasound
examination, and chromosomal analysis from
amniocentesis and cordocentesis may also be
necessary. About 1 in 5 very small babies will
prove to have congenital abnormalities, and this
proportion is higher if growth failure is detected
before 26 weeks, or there is associated polyhy-
dramnios.4 This is because growth restriction
associated with uteroplacental insufficiency in-
creases in incidence as pregnancy progresses. It
is uncommon before 26 weeks’ gestation, and is
usually associated with oligohydramnios because
of the reduced renal perfusion in growth re-
stricted babies. Management of growth re-
stricted babies with aneuploidy, particularly tri-
somy 21, can pose ethical problems. Parents may
feel ambivalent about emergency delivery by ce-
sarean section for a Down’s fetus with failure of
growth, or an abnormal fetal heart rate tracing.
However, such babies may not necessarily die
without emergency delivery, and expectant man-
agement can therefore result in a baby with
impaired intellectual potential being further
compromised by hypoxic ischemic damage. An-
other area of ethical difficulty is the manage-
ment of multiple pregnancy, where one or more
of the fetuses is growth restricted, and the re-
mainder are growing normally. To rescue the
growth restricted baby will place the normally
grown fetus at increased risk from preterm de-
livery. There is no simple answer to this di-
lemma, which has to be addressed by close con-
sultation with the parents and neonatologists.
A small but significant proportion of intra-
uterine growth restriction is caused by infection
with cytomegalovirus, which is very difficult to
detect antenatally; it is usually diagnosed by cul-
ture of the virus from the urine of the newborn
baby. Rubella is also a significant cause but is
usually clinically more obvious because of the
maternal rash which occurs. Abnormalities of
growth associated with maternal use of “recre-
ational drugs” (such as cocaine, heroin, and al-
cohol) and medically prescribed drugs such as
anticonvulsants and Warfarin should also be
considered and managed appropriately.
Large Babies
As shown in Figures 1 to 10, the risk to the large
for gestational age baby is not so much antepar-
tum hypoxaemia and acidosis as the problem of
prolonged labor and intrapartum trauma. The
majority of macrosomic babies are not associ-
ated with diabetes, but with large mothers. Thus,
within the North West Thames database cohort
as defined above for this study, macrosomia (de-
fined arbitrarily as a birth weight ⬎ ⫽ 4 kg)
occurred in 9.5% of 123,681 women with normal
carbohydrate tolerance during pregnancy,
15.8% of 766 women with gestational diabetes,
and 23.4% of 312 women with established dia-
betes. However, macrosomia associated with di-
abetes accounted for only 1.6% of all babies
weighing 4 kg or more. In contrast, the risk of
macrosomia rose from 4.8% in underweight
women (body mass index [BMI] ⬍ 20, n ⫽
8,040), to 8.1% in women with a normal BMI (20
to 24.9, n ⫽ 61,260), 12% in overweight women
(BMI 25 to 29.9, n ⫽ 27,687) and 15.6% in obese
women (BMI 30 or more, n ⫽ 9,156). However,
unlike diabetes, overweight was associated with
32.9% of macrosomia, and obesity with 14.1%.
Thus, almost half of all macrosomia occurred in
women who were overweight or obese. More-
over, these macrosomic babies were more than
twice as likely to be delivered by emergency ce-
sarean section as babies weighing less than 4 kg
(21% v10.3%). Unfortunately, it is in obese
mothers that fetal weight assessment is most dif-
ficult, both clinically and by ultrasound, and
 Large and Small for GA Fetuses
both large and small babies are likely to go
undetected.
One of the most feared causes of intrapartum
trauma is shoulder dystocia. Most papers have
reported that fetal macrosomia is the principal
risk factor for shoulder dystocia.27-33 However,
our ability to detect macrosomia antenatally is
limited and none of these studies recommended
routine abdominal delivery for suspected mac-
rosomia. In one study of 4,480 births,30 in which
the overall frequency of shoulder dystocia was
2% (90 cases), the majority of cases (93%, 83
cases) occurred in infants weighing less than
4,500g. In a detailed study of cost effectiveness,
Rouse et al34 concluded that “For the 97% of
pregnant women who are not diabetic, a policy
of elective cesarean delivery for ultrasonographi-
cally diagnosed fetal macrosomia is medically
and economically unsound. In pregnancies com-
plicated by diabetes, such a policy appears to be
more tenable, although the merits of such an
approach are debatable.”
If elective cesarean section is not justified,
what about induction of labor before the due
date? Attempting to deliver the baby vaginally
before it gets too large is a logical approach.
However, even the most recent studies do not
show any advantage to induction before the due
date.35 Moreover, a recent systematic review of 9
observational studies and 2 randomized trials of
labor induction for suspected fetal macrosomia
has shown that such a policy results in an in-
creased cesarean delivery rate without improv-
ing perinatal outcomes.36 It appears that the
benefits of the baby being smaller are vitiated by
the disadvantage of a less efficient labor.
An important aspect of the management is
our ability, or perhaps more correctly our lack of
ability, to identify macrosomic fetuses correctly
by ultrasound. As so often happens, there is a
conflict between sensitivity and specificity. For
example, in the study reported by Gilby et al37 if
an abdominal circumference of 35 cm was used
as the cut-off, 99% of macrosomic babies were
identified, but only one in ten of babies labelled
ultrasonically as macrosomic had a birth
weight ⬎ 4 kg. On the other hand, if a cut-off of
abdominal circumference of 38 cm was used,
more than half the babies so identified weighed
less than 4 kg and only just over 50% of macro-
somic babies were identified. With ultrasonic
fetal weight estimation, as with most techniques,
65
accuracy deteriorates away from the mean value
with a tendency toward the mean. Thus, there is
a tendency to overestimate the weight of small
babies and underestimate the weight of large
ones. For example, in one study, in diabetic
patients, 26.3 % of the birth weights were under-
estimated by more than 15 %, compared to 5.4%
in a nondiabetic control group.38 In another
study, the mean error in diabetic patients was
265g, with the error being over 500g in almost
10%.39 Even in diabetics, maternal weight rather
than glycemic control is one of the most useful
predictors.40 The topic of route of delivery of
macrosomic fetuses in diabetic pregnancies has
recently been fully reviewed in this Journal by
Conway.41
Summary
The management of small for dates and large
for dates fetuses is complicated by the fact that
they exist as part of a continuum, with no clear
distinction between pathology and normality.
Accordingly, management decisions must be
based not only on the estimated fetal weight for
gestational age, but also on functional criteria
such as changes in growth velocity, and mea-
sures of fetal wellbeing including components of
the biophysical profile. The mode of delivery will
depend on a balance being struck between fetal
and maternal risk, the facilities available for
monitoring labor, and the wishes of the parents.
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