Routine symphysis-fundal height measurement during pregnancy
The review found no evidence of any benefit or harm associated with the routine measurement of symphysis-fundal height (SFH) in pregnant women. However, available literature indicates that routine SFH measurement is a sound method for detecting small-for-gestational-age babies in developing countries. Hence, it should still be recommended as standard practice for antenatal care and should complement, rather than replace, palpation of the pregnant uterus.
RHL Commentary by Buchmann E
1. EVIDENCE SUMMARY
The Cochrane Review included only one small trial. The review found no evidence of any benefit or harm associated with the routine measurement of symphysis-fundal height (SFH) in pregnant women.
In the discussion section, the author of the review notes that the sensitivity of the methods of detecting small-for-gestational-age (SGA) babies was much lower than that reported in previous observational studies. The reason for this may lie in the very stringent criteria used for suspecting SGA fetuses (three consecutive static measurements, two measurements under the tenth centile SFH or a reduction in SFH). The use of a single measurement under the tenth centile (1), would probably have given greater sensitivity with some loss of specificity. The trial also performed measurements only from the 29th week of pregnancy, further reducing the potential sensitivity of the measurements.
The selection of eligible studies appears to have been performed satisfactorily.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
SGA babies have higher mortality and morbidity rates than infants of normal size do. SGA is a problem in up to 20 % of births in developing countries. Early identification of pregnancies at risk would allow timely measures to be taken, including, for example, transfer to a better equipped centre.
2.2. Feasibility of the intervention
SFH measurement with a tape measure is simple and inexpensive. Health workers and pregnant women are unlikely to resist this type of intervention, especially in areas where there is little recourse to advanced technology, such as ultrasound scanning.
2.3. Applicability of the results of the Cochrane Review
Health workers in under-resourced settings will gain little from the results of this review. There are two reasons for this. Firstly, the review covered only one trial, which was not large enough to clearly define evidence of benefit or harm associated with SFH measurement. Secondly, the trial was performed in Denmark - a country with very advanced health care systems - where all pregnant women have early pregnancy ultrasound, placental lactogen estimation, fetal weight prediction and access to highly specialized care. These results therefore have little relevance for developing countries.
2.4. Implementation of the intervention
Available literature indicates that routine SFH measurement is a sound method for detecting SGA babies in developing countries and that remains a potentially useful intervention (1, 2). SFH measurement may also help in identifying multiple pregnancies and in assessing gestational age at first presentation. It should still be recommended as standard practice for antenatal care in developing countries and should supplement, rather than replace, palpation of the pregnant uterus.
Implementation of routine SFH measurement will require:
a) The provision of tape measures and the provision of antenatal cards that include SFH growth curves on a graph, showing 10th, 50th, and 90th centiles.
b) The training of health workers in the method.
c) The provision of clear protocols for management of the problems detected, including criteria for referral.
d) Continuing audit of practice and quality of SFH measurement.
A large, well-designed multicentre randomized controlled trial is needed to assess the effectiveness of routine SFH measurement in under-resourced settings, in particular where pregnant women have no access to routine ultrasound scanning and where most women present themselves to a health worker only in the second half of pregnancy. The main outcome measures should be perinatal mortality and morbidity. Such a trial would have to deal with an anticipated problem of poor patient follow-up and ensure that this does not invalidate the results.
- Belizan JM, Villar J, Nardin JC, Malamud J, Sainz de Vicuna L. Diagnosis of intrauterine growth retardation by a simple clinical method: measurement of uterine height. American journal of obstetrics and gynecology 1978;131:643-646.
- Pattinson RC, Theron GB. Inter-observer variation in symphysis-fundus measurements. A plea for individualised antenatal care. South African medical journal 1989;76:621-622.
This document should be cited as: Buchmann E. Routine symphysis-fundal height measurement during pregnancy: RHL commentary (last revised: 20 February 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.