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  6. Monitoring and Management of Suspected Fetal Growth Restriction (414)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Monitoring and Management of Suspected Fetal Growth Restriction (414)

Please report any inaccuracies or issues with this guideline using our online form

 

 

Definitions

For the purposes of this guideline the following definitions apply:

Small for gestational age (SGA): Estimated fetal weight (EFW) or abdominal circumference (AC) <10th centile

Fetal growth restriction (FGR):  Where a fetus fails to reach its growth potential as adapted from the Delphi consensus:

Early Onset FGR <32wks

Late onset FGR ≥32wks

EFW or AC <3rd centile

Or Absent umbilical artery end diastolic flow (EDF)

Or EFW/AC <10th centile with at least one of:

  • Umbilical artery pulsatility index >95th centile or absent or reversed EDF
  • Uterine artery pulsatility index >95th centile

EFW <3rd centile

Or At least two of the following:

  • EFW <10th centile
  • EFW crossing ≥50 centiles
  • Umbilical artery pulsatility index >95th centile or absent or reversed EDF

This guideline does not apply to multiple pregnancies or babies with congenital abnormalities.

Estimated fetal weight should be used after 22+0wks as plotted on the Intergrowth chart on Badgernet. Prior to 22+0wks abdominal circumference should be used.

Identifying non-placental causes of FGR

Babies found to have an AC <3rd centile at the time of routine anomaly scan should be referred to a fetal medicine specialist within the unit. Serological screening for cytomegalovirus and toxoplasmosis should be offered along with invasive testing for full karyotype and microarray.

Monitoring of babies found to be SGA

The purpose of monitoring is to identify those babies suspected to have FGR and therefore at greater risk of adverse perinatal outcome. Birth timing balances risk of stillbirth against risk of prematurity including adverse outcomes associated with early term birth (37+0 - 38+6wks).

For babies identified as SGA with no features of FGR suitable surveillance is ultrasound every 2wks for biometry, umbilical artery doppler and liqor volume. In the absence of fetal or maternal compromise birth should be offered at 39+0wks. Examples of fetal or maternal compromise include hypertension, reduced fetal movements, reduced liqor volume or abnormal CTG.

Monitoring of babies identified as early onset FGR

For babies identified as early onset FGR, fetal biometry should be performed every 2wks with weekly liqor volume and umbilical artery doppler. If there is absent or reversed EDF prior to 32+0wks then twice weekly doppler should be performed and birth is indicated if the ductus venosus a wave is absent or reversed.

Cardiotocograph (CTG) can be performed from 26+0wks. If computerised CTG is available then short term variability (STV) should be used to guide birth timing. STV <2.6ms between 26+0 and 28+6wks or <3.0ms between 29+0 and 31+6wks indicates birth should be offered as does the presence of persistent unprovoked decelerations at any gestation. Frequency of CTG monitoring will be determined by the individual circumstances.

Monitoring of babies identified as late onset FGR

For babies identified as late onset FGR, fetal biometry should be performed every 2wks with weekly liqor volume and umbilical artery doppler. Middle cerebral artery doppler performed after 34wks gestation may guide timing of birth but further evidence is awaited on this.  

Frequency of CTG monitoring will depend on individual circumstances. If computerised CTG is available then birth is indicated if STV is <3.5ms between 32+0 and 33+6 or < 4.5ms at gestations >34wks, or in the presence of persistent unprovoked decelerations at any time.

Birth is indicated between 32+0 and 33+6wks if the umbilical artery EDF is reversed. Birth >34wks is indicated if umbilical artery EDF is absent or reversed. Early birth may also be indicated by other evidence of fetal compromise such as decreased liqor volume, maternal hypertension or reduced fetal movements.

If monitoring is reassuring then birth can be offered at 37wks for babies with suspected FGR.

Identifying babies with suboptimal growth

A proportion of babies who are growth restricted will not be SGA, particularly those presenting late in the third trimester.

Evidence of reduced growth velocity or “tailing growth”  is defined as a drop of 50 centiles  on sequential scanning for example a drop from the 70th to the 20th percentile. This should prompt further ultrasound in two weeks with birth offered at 37wks, earlier if there is evidence of fetal or maternal compromise as outlined above. If EFW falls below 10th centile or there are abnormal dopplers then ongoing monitoring and birth timing is as for late onset FGR babies.

Pathway

Algorithm for the monitoring and management of fetal growth restriction

Editorial Information

Last reviewed: 27/02/2024

Next review date: 08/02/2027

Author(s): Roseanna Metcalfe.

Version: 2

Approved By: Maternity Clinical Governance Group

Document Id: 414

Evidence method

Adapted from Saving Baby’s Lives Care Bundle V 3 (2023) and the ISUOG Practice Guideline on diagnosis and management of SGA fetus and FGR (2020)