Case Study: Clinical Risk and the Importance of Recognising Antenatal Care Red Flags

During three separate antenatal checks, a pregnant woman’s general practitioner suspected a discrepancy between the gestational age of the foetus and the fundal height measurement. Also known as McDonald’s rule, fundal height measurements enable doctors to assess the growth of an unborn baby during pregnancy. Among other routine tests, obstetricians and midwives measure fundal height to check the developmental health of the foetus.
Importantly, after around twenty-four weeks of gestation, the number of weeks should be approximately equal to the distance (in centimetres) between the top of the mother-to-be’s pubic bone (the pubic symphysis) and the top of the uterus. At 24 weeks, for instance, the fundal height ought to be between 22 and 26 centimetres. Then again, at 32 weeks, the measurement is typically 30cm to 34cm, allowing tolerance of ±2cm.


In the National Health Service, guidelines published by NICE (The National Institute for Health and Care Excellence) require referrals for ultrasound assessment if there is a discrepancy of three centimetres or more between the actual fundal height and that expected for the gestational age. An ultrasound scan will reveal whether the foetus is small or large for the stage of pregnancy.

Following the appointment in the GP’s surgery, a midwife informed the patient that the fundal height was within the expected limits, allowing for the accepted range of tolerance. Apparently, the midwife made little or no verbal reference to the GP’s previous observations and did not seek a specialist opinion or repeat ultrasound imaging.

Subsequently, after admission to the delivery ward during her labour, the woman gave birth to a baby in poor condition and which subsequently died. Retarded intrauterine growth was evident in the foetus.


Significantly, the female patient had not been referred to an obstetrician by her GP on originally noticing the irregularity. Instead, it seemed that the GP had relied on the patient’s subsequent scheduled appointment with a midwife.

Even though the midwife decided that the fundal height was consistent with gestational age, it would have been expedient to have considered the abnormality noted by the GP. As a result, the patient should have been referred to an obstetrician.

Specifically, neither the GP nor the midwife initiated further checks, tests or investigation to exclude IUGR (intrauterine growth retardation).


In accordance with NICE guidelines, if fundal height measurement varies by 3 cm or more from gestational age in weeks (after 24 weeks), further investigation is necessary to rule out an IUGR foetus.

GPs, midwives and other antenatal care professionals, including oral health care staff, should take a holistic approach to the assessment of pregnancy at all patients’ appointments. Noting recent patient history ought to improve overall consistency and the tracking of abnormal events during gestation. This broader and more inclusive approach is of particular importance when various healthcare professionals share patient care.

Continuing Professional Development (CPD) and other training updates ought to emphasise the importance of fundal height measurements to assess for IUGR babies. At every prenatal assessment, it is essential to consider previous notes as well as the current condition, so that abnormalities are identified within sufficient time to act patients’ best interests.

When routine checks suggest that further investigation is advisable, staff are to schedule specialist appointments without delay. In the case in question, the failure to request an additional gynaecological ultrasound scan represented a missed opportunity to validate either average foetal growth or IUGR. Had the foetus been diagnosed during the pregnancy, the outcome may have been different.


Antenatal clinicians ought to be fully aware of NICE guidelines. Additionally, they should bear in mind that prenatal patients could have seen many healthcare staff and, therefore, might not be aware of suspected complications. To improve detection rates of babies in poor health that would probably not survive, it is essential that staff investigate anomalies and avoid missing such opportunities.