How many times has someone commented on the size of your tummy? Hearing “you look too small” can really send you into a spin. 

So let’s talk about what “too small” means.

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At your antenatal appointments, from about 20 weeks of your pregnancy you will (…should) be having some monitoring of your baby’s growth. Firstly, by the simple tape measure test, up over your tummy to the top of your uterus and then by ultrasound if needed.

What we are trying to determine is if your baby is small for dates. This is known as Intrauterine Growth Restriction or IUGR.

In this podcast we talk about:

• What is EFW or estimated fetal weight
• How EFW is measured and the measurement accuracy.
• What other ways we measure your baby’s health
• Problems that can arise if your baby is diagnose with IUGR
• What plans need to be made if your baby is measuring small for dates.
• When sometimes… you just have a small baby.

Brigid: [00:00:36] Welcome everyone. Today’s topic, we’re going to be talking about growth restriction or our IUGR.

Dr Pat: [00:00:42] Welcome everybody

Brigid: [00:00:44] Now. How are you going, Pat?

Dr Pat: [00:00:46] Very well, yes, we just went out and got a coffee.

Brigid: [00:00:49] We needed a perk up, so that’s good. We have a coffee addiction. Don’t we?

Dr Pat: [00:00:55] Yes. One proper coffee a day if you’re pregnant, everybody else, knock yourself out.

Brigid: [00:01:01] No, I don’t think that it’s the advice that is not official medical advice people. Right. I did want to start with a review on our iTunes podcast. So. This is about that fragile X pre mutation carrier.

You know, we did that podcast early on “What I wish everybody knew about their pregnancy”. Yeah. One of our very, very early podcasts. So it comes from Anna

“A friend of mine, excitedly recommended this podcast. When I first told her that I was starting to think about our own pregnancy journey. I’d been given a trial packet of elevit from my gynecologist and a leaflet for reproductive carrier screening, which were both chucked into my bag after my last routine visit.

Never to be seen in the light of day again. I listened to your podcast, however, and those words carry a test popped up again. I asked my friend if she had had her test done because Pat and Brigid say, you really should.”

That’s the bit I love the most.

Uh, “and she said she had and was in the clear. She also only knew you such a test existed because of your podcast. Friends and family thought I was going a little bit overboard and were more concerned about my anxiety around ticking all the boxes, but I really want it to cover all bases well before getting pregnant cut to two weeks later.

And on a Monday, my GP phoned me with news that has completely turned my exciting journey upside down. I apparently do have the pre mutation for fragile X. I am cleared for CF. Cystic fibrosis and SMA. I was devastated by the news, of course, and I’m still grappling with it, but I honestly believe I would be even more devastated had I not had the test only to find out my child, once my child was born with physical characteristics or when they weren’t making their developmental milestones, as they grew.

Which is the only way I could possibly have known. None of my family knew this genetic condition even existed and not one has been tested for it. The news has sent ripples through my family too. We are slowly piecing together things that have happened in our family as out of the blue, a great aunt who went through menopause at 34 as actually genetically inherited conditions.

My sister and my cousin, and now getting tested too. And I’m set to speak with a genetic counselor to discuss my next steps. And we will start looking into the very real possibility of needing IVF or other treatments to manage this gene. Thank you for your informative, warm and calming podcast. I don’t feel like a specimen, but I feel like a hopeful new mum, fingers crossed, trying to find her way through mountains of information tests and other sources jammed with scary terms and complicated medical jargon.

Thank you for making our journey a little more enjoyable and warmer to wade through, Anna. Wow. And a kiss.

Dr Pat: [00:03:33] So that’s just amazing. Isn’t it? That’s fantastic. So that’s somebody who’s heard about that through our podcast, gone and had it, and then there are important implications for her and for the other women in her family.

That’s so fascinating and such warm feedback.

Brigid: [00:03:50] We love it. Yeah. That’s right. Thank you, Anna, for taking the time to tell us about your journey and good luck on the next steps.

Dr Pat: [00:03:57] Yeah. There’s plenty that can be done of course, to manage that. And it’s just a matter of how far it leads to be taken depending on more testing.

Brigid: [00:04:03] Yeah, that’s right. And depending on her partner.

Dr Pat: [00:04:05] yeah, so of course, the ideal time to try and nut this all out is before you get pregnant.

Brigid: [00:04:09] Yeah. Yeah. Yep. Okay. So now we’re going to be covering our lUGR and we sort of, we have in the last few episodes, like we realized how much that term kept cropping up. So it’s about time that we look at it and it’s also, it also came from a DM that we had from our Instagram.

[Now, again, if you’re not following us, it’s at @grow_my_baby. I know some people are finding the Kick pregnancy podcast on Instagram and following that, but we never post in there. So I’m sorry if you’ve sent us a DM in there, I do check, but come over to grow my baby.]

And she went for a non-routine ultrasound, a 4d ultrasound, and her sonographer said the baby’s weight looked small and it started that whole cascade of, Oh my gosh. I think my, baby’s got IUGR. And she was asking about the accuracy of the ultrasound.

Dr Pat: [00:04:59] So? Well, let’s discuss that today. Yeah. So IUGR of course is intrauterine growth restriction when baby is too small for the known dates.

Brigid: [00:05:11] Yup. And what do you mean by too small?

Dr Pat: [00:05:14] Well, whenever you have a, you know, an assessment of fetal weight. So for example, an ultrasound, then they come up with an EFW estimated fetal weight. And that can be put on a graph where the estimate of weight of the baby is graphed against the number of weeks of the pregnancy.

And that’s ideally a graph that’s been made where the normal values are, are based on other women in your ethnic background. Right? And then, uh, an assessment can be made as to where your baby sits on that. So the babies that are in the bottom 10% are of concern to us. That’s IUGR and that’s babies that are at higher risk of significant problems in pregnancy.

And then the baby’s in the top 10% are of concern to us because they might be getting too big to fit out or they might have, they might be that big for a pathological reason. And everyone in between from the 10th centile to the 90th percentile is essentially normal.

Brigid: [00:06:10] So you’re talking about ultrasound, but how else is fetal weight measured?

Dr Pat: [00:06:14]

Well that’s where every time you come to see us, we, we get the tape measure out and measure your tummy. So there’s an official way of doing that, where we, uh, start on the pubic bone and measure, up over the top of the tummy.  You should be, as the examiner, you shouldn’t be looking at the numbers on the tape measure because that kind of gives the game away and you might be more likely to stretch the tape to give you the figure that you’re expecting. Where as you should be just measuring and then turning the tape over and looking at what the number is.

Brigid: [00:06:43] Oh, wow. Okay. There’s a little trick. I know that we’ve got other professionals listening to this podcast, so there you go.

Dr Pat: [00:06:49] I think that’s a more honest way of doing it because otherwise you might think, well, this lady’s 25 weeks. It’ll probably be 25 and you just sort of stretch the tape till it gets to 25.

Brigid: [00:06:56] Is that commonly taught or is that something you came up with?

Dr Pat: [00:06:58] No, no, I was taught that once I’m sure. Okay. So, uh, when you make the measurement, just by it, be coincidence, it should measure one centimeter per week of pregnancy after 20 weeks.

Dr Pat: [00:07:10] yes. And by the time you get to 20 weeks, the pregnancy should be up to the belly button. Um,

Brigid: [00:07:14] and I know that’s called the fundal height?

Dr Pat: [00:07:16] Yep. Yep. So, and then after that, we should get about a centimeter a week per week of fundal height. So at 30 week pregnancy should measure 30 centimeters from the pubic bone to the top of the fundus, which is the top of the part of the uterus you can. Yeah.

Brigid: [00:07:28] And are there any times where that measurement just doesn’t work?

Dr Pat: [00:07:31]

Lots where it doesn’t work and that’s where ultrasound really comes in. So there’s a few scenarios where we wouldn’t trust it at all. For example, twins, twins, and triplets. No good at all. If the baby’s transverse. So neither the head nor the breech is in the pelvis, but the baby’s literally sideways. Yeah.

Then often the fundal height will be really small, but it might still be normal. Yes. Yep. And things that just make measurement difficult, like a very overweight woman. Yeah. Where we’re measuring her tummy yeah. More than the baby.

Brigid: [00:08:04] And I think in our placenta episode, we talked about the position. An anterior placenta, does that matter?

Dr Pat: [00:08:10]

No. The placental position, then it’s going to take up some of the insides no matter where it is. Yeah. So it’s not so relevant the placental position, but multiple pregnancy, definitely obesity, definitely. And even women who are very, very tall or very short, I think you have to be, have a little higher index of suspicion about, about your measurements.

And then basically if that measurement is. Uh, is off compared to where you expect to be measuring, then you’ve got to get out an ultrasound.

Brigid: [00:08:39] Okay. And so is a person sent to a specific ultrasound place, or can you, does your obstetrician do that or what happens?

Dr Pat: [00:08:46] It depends. Um, sometimes like, for example, in my consulting room, I’ve got my ultrasound machine and over the years I’ve become much better at it to the point where I’ll often be very confident to do growth scans myself, particularly in the third trimester.

But other people may be less so they might refer all of their scans to an outside ultrasound provider, but whoever does it, there’s a protocol for how to accurately measure the baby. And there are some pregnancies, even if the woman’s only middle-sized and there’s no other reason why you would just distrust the tape measure system.

There are some situations where you might get growth scans anyway, and they’re related to conditions where a small baby can hide in plain sight. So that, for example, a woman who had normal fundal height measurements right throughout her first pregnancy and the baby came out and it was 2.1 kilos and we missed it.

Brigid: Right? How could you miss that?

Dr Pat: Well, you can, so they can hide in plain sight. They can look bigger. So if you’ve got a woman who’s very slim, then even a small baby will look big on her tummy. And you can be fooled. And so if a woman has shown in the past that her pregnancies don’t tend to measure up with the tape measure, then we want to do it off ultrasound.

Brigid: [00:10:04] Yeah. And on ultrasound, you’re doing things like measuring the head size and the belly circumference.

Dr Pat: [00:10:09] Yeah. So the baseline measurements are the head diameter. The head circumference, the belly circumference and the femur length. Right. And those four figures go into a formula and predict an estimated fetal weight.

Brigid: [00:10:26] Yeah. And are you looking at anything else on ultrasound?

Dr Pat: [00:10:30] Well, there are lots of other things we look for. There are signs of what we call fetal wellbeing. So for example, if we’re looking in the third trimester, we don’t only want to know how big the baby is, but what sort of condition the baby’s in as well.

So we might look at how much water is around the baby, which gives us a good idea of fetal urine output.

Brigid: [00:10:47] Cause you say a healthy baby does lots of wee.

Dr Pat: [00:10:49] Yeah, of course. Yeah. Yeah. So, uh, you know, imagine, imagine if we were hit by a train, you and I were hit by a train, and we were in the intensive care.

One of the things that they would be doing would be there’d be a catheter in our bladder measuring our urine output and that. Would indicate lots of stuff about how we were going.

Brigid: [00:11:06] I like how you said we were both hit by the train, you couldn’t decide whether it was going to be me or you then could you,

Dr Pat: [00:11:10] No, if we have to go we are going together.

Yeah. Uh, so the intensive care doctors would be measuring a urine output and that would tell them tonnes about how well our kidneys were working. And that will tell them how well our heart was pumping and all sorts of clever things. And so the amount of water around the baby is like that.

If we, if there’s lots, you know, in the normal range, then we know that baby is going well. Yeah, you can also measure flow down the cord. It’s called Doppler and flow within various arteries within the baby. Yeah. Yeah. So in particular, one artery up in the baby’s brain that tells us a lot about what the baby is doing. So for example, if the baby is getting very growth restricted, it might start sending more blood up to the brain.

Yeah. Preferentially give blood to the brain and we can measure that. So you can tell not only what the baby’s doing right now, but how things are trending.

Brigid: [00:12:00] And I’m cheating a little bit because I’ve just reviewed that video that you did for our program on growth scanning and third trimester scanning where you we’ve got this video that is narrated to show you exactly what’s happening within that ultrasound

Dr Pat: [00:12:14] Yes we talk people through it because it’s not just about getting a pretty picture and it’s not just about making sure the baby’s the right size. There’s, there’s tonnes that they can tell about fetal condition now, not just the growth.

Brigid: [00:12:25] One thing that I wanted to ask and it’s often on the interwebs, is, are scans accurate?

Dr Pat: [00:12:31] Let’s look at third trimester scanning, for example, there might be, for example, the report will say, we think the baby is 3.2 kilos plus or minus 10%. You’re thinking, well, which is it, you know, is it minus 10%? That’s minus 320 grams off that figure. Plus 320 grams on the other side of that. This might be the error at term. Well, you know, that sounds an awful lot. And it’s one of the reasons why we’re going to look at other things like the overall condition of the baby.

But one thing that is better , more than a one-off, which might have an error is serial measurement. So if we get serial measurements one after the other about two weeks apart, and in particular, if the same person, the same technician, doctor ultrasound guy, whoever  does the measurements, then you’ve got the same person using the same technique, putting the little measurement errors at the exact same position on the baby’s head.

And that’s a much more accurate way to do it, to look at trends.

Brigid: [00:13:27] So that woman who DM’d us, um, she was concerned that the baby wasn’t where she expected to be. At that time, you would advise her to go back and have another ultrasound.

Dr Pat: [00:13:37] You can’t get terribly troubled about a single measurement in particular, if that was a one-off measurement.

If everything else was normal. Yeah. So yes, baby looked like they were small ish, but the water level was fine. Cord Doppler was fine. The baby’s middle cerebral artery in the brain Doppler was fine. We came away and I say, this looks like a healthy baby. Then next thing you do is turn around, have a look at mum and dad.

Brigid: [00:14:04] Potentially in the 10th centile because you’re little people yourselves?

Dr Pat: [00:14:07] Yes. So there are some well babies in the 10th centile. Yeah, absolutely. Even the less than 10th centile. Yeah. And one of the ways to work out, whether that’s physiological or pathological is to look at the other things on the scan and have a look at mum and dad. So it’s a picture that you have to put together. And by far, the best thing is to do serial scanning. For example, if a baby’s on the ninth centile on one scan, you do it again. Two weeks later, nine centile, again, two weeks later, ninth centile again. Fetal movements are normal, liquor volume, the water around the baby is normal,  normal cord doctors know that that’s a happy baby on the ninth centile.

Most likely two weeks later, you do another scan and it’s now the third centile and there’s not enough water and the Dopplers are abnormal. Well, that’s something’s wrong. Yeah. Yep.

Brigid: [00:14:54] Yep. You know, we all talk about our dates and trying to compare that to where that baby is, but are the dates ever wrong, do you ever get to a point in a pregnancy?

Okay, well, let’s go back to the first date?

Dr Pat: [00:15:05] Dates can be wrong and it’s a potential explanation if the growth seems wildly out in particular at the start. So, you know, at the start of a pregnancy, all of the little fetuses are the same size. So everyone’s 10 week fetus should be pretty much be exactly the same size.

Yeah. Whether you’re an African or an Eskimo or anybody and genetic and racial background features coming later. Right. In terms of size. So if you had a really tall couple and a really short couple, their 10 week babies are the same size. But at term babies, won’t be, yeah. So if there’s, if it’s really out in the first trimester, your dates may well be wrong.

And it’s one of the very handy reasons. If people who’ve got a growth scan, we can go off the growth date.

Brigid: [00:15:51] Yeah. When can you get your most accurate dating scan?

Dr Pat: [00:15:54] That’s in the first trimester before any of those genetic differences,

Brigid: [00:15:57] anything before 10 weeks will be a better predictor of dates?

Dr Pat: [00:16:01] Yes. So if someone thinks that they’re 12 weeks pregnant and they have their first scan and it says that they’re eight weeks pregnant, they’re eight weeks pregnant.

Brigid: [00:16:10] Yeah,

Dr Pat: [00:16:10] yeah, yeah. They’ve missed a cycle. The date is wrong. Yeah. Yeah.

Brigid: [00:16:15] What about, I know, like we just expect everything to be lineal growth in a baby, but do babies in utero ever go through growth spurts?

Dr Pat: [00:16:24] Yeah, it’s possible. That’s not a silly question. They do go through growth spurts, I guess even in the, in the natural ebb and flow of growth.

But the, the babies that were really interested in are small already, and we’re not going to go around looking for benign explanations for them being that small. Yeah. So it would be a mistake to say growth will probably get better next week, especially if there are other things that seem abnormal on the ultrasound.

Yeah. So on the countrary, we have to identify those babies, uh, accurately and confidently and make a plan for their surveillance and their, which may well involve early delivery. So I always talk to my junior doctors about this. You have to look at that baby and say, today is this baby better out than in?

And if you think you’re heading towards the day, when it’s better off out, then you have to prepare for that and do things like give antenatal steroids. So an injection of cortisone to the mum so that the baby comes out with better lungs. Take mum and dad on a tour of the nursery. Introduced mum and dad to the paediatricians.

Talk about what it’s like to have a 32 week baby. How big are they? What color are they? What will they be able to do on their own? And what will they not be able to do on their own.

Brigid: [00:17:36] And listen to our prematurity podcast “when your baby comes too early” So that’s what the management might be, but can we go back a step and say like, what is the problem with having a baby that has IUGR? We haven’t really talked about that yet.

Dr Pat: [00:17:50] Like what’s causing it and what’s behind it.

Brigid: [00:17:53] Sure. Let’s do that first.

Dr Pat: [00:17:53] Yeah. So there’s lots of conditions that contribute to IUGR and sometimes they’re things that we know that the woman’s got or experiencing, and sometimes it’s things we only find out about because we see the IUGR and then go and look for conditions that might’ve caused it.

But they’re common things. Uh, gestational diabetes, preeclampsia. Smoking drug and alcohol. And we’ve got a bit of a checklist that we go through to see whether these are things that we can manage. And sometimes there are things that we can manage now, and other times there’s stuff that we’re stuck with.

And then we need to just put a management plan in place. Occasionally the explanation is a major fetal problem. For example, if you go along for your 20 week ultrasound, your middle trimester ultrasound and the baby is already way too small. That’s bad. That’s probably a syndromic baby. Yeah.

Brigid: [00:18:54] Something like down syndrome?

Dr Pat: [00:18:55] Exactly. Yeah. The more benign causes of growth restriction like familial small babies or even smoking, it tends to kick into the third trimester. Something’s much more wrong if your baby is way too small at 20 weeks. Yeah. And that would be a typical finding of down syndrome.

Brigid: [00:19:14] Yeah. And those women that are perhaps got those lifestyle issues, uh, you know, smoking, or, um, I even read something about low fruit and veg intake diet has something to do with it too?

Dr Pat: [00:19:25]. So there are lots of things that I would consider perhaps a second tier. There’s all sorts of data on this. Obviously, people are being probably interested in this for ever. How can I best nourish my baby? And yeah, there’s some less impressive data on all sorts of different things that might, um, contribute.

Yeah. But not nearly as powerfully as, as something like smoking.

Brigid: [00:19:49] Yep. Now I’m going to rephrase my question. What is the problem with having a baby with low birth weight?

Dr Pat: [00:19:56] Right. Uh, well, if you’ve got one of the babies that has a lowish birth weight because that’s, and that’s just them. Yeah. Then nothing much really, that baby might be born small, but vigorous.

Yep. The problem with being in the bottom centile is that a good number of those babies are small because there’s something wrong. They’re not small for no reason. And that’s why we’re so interested in those babies because whatever the something is that might be wrong, it might get worse. And if we don’t get the baby out in time, the baby might be born in very bad condition or stillborn.

Right. So it’s a continuum that we have to intervene before it gets that bad. Yeah. So babies that are born very, very small will typically have problems with feeding. It might need a nasal gastric tube down and feeding via a formula or breast milk via the tube because they’re not strong enough or vigorous enough to suck on the breast.

They might have respiratory problems. They might have problems maintaining their body temperature and all sorts of other things that might mean they need a care in the neonatal nursery for, uh, a week, a month, a year.

Brigid: [00:21:08] Yeah.

Dr Pat: [00:21:12] How many times have you Googled something about your pregnancy? When I was

Brigid: [00:21:15] pregnant all the time. Dr. Pat,

Dr Pat: [00:21:18] we get it. You may be confused or overwhelmed. It’s normal to want information, but where’s the reliable stuff from experts.

Brigid: [00:21:25] Yeah. Now, if you like our podcast, dr. Pat and I have developed an online program to help guide you through whatever stage of pregnancy you’re at,

Dr Pat: [00:21:33] it’s taken us literally two years to put it together

Brigid: [00:21:36] long, hard years. Wasn’t it? But,

Dr Pat: [00:21:39] you know, it is a game changer in how pregnancy information is given,

Brigid: [00:21:43] how it works is, uh, you get to sign up at whatever stage of pregnancy you’re at. Like, so you could be pre pregnant in your very early stages of pregnancy, late pregnancy preparing for birth, or maybe you’ve just brought your baby home and you get lots of information around that.

And then you also get to join our closed Facebook group. So we’ll have some Q and A’s and some lives happening in there. So we really get to interact with you.

Dr Pat: [00:22:04] We’ve called in all our contacts too. So we’ve got a dietician and neath test physiotherapists. Who else? A pediatric nurse obstetrician, mother of four,

Brigid: [00:22:15] just all the people you need to hear from.

Dr Pat: [00:22:17] So if that’s you come and join us at www.growmybaby.com.au

Brigid: [00:22:23] So apart from, like we mentioned about the lifestyle factors in the second tier stuff, so there is a lot of guilt. For women, you know, if they feel like somehow they’ve done something to make their baby have a IUGR. Yeah. Do you see that?

Dr Pat: [00:22:40] I see the guilt all the time. I must say that there aren’t many cases where this is down to a maternal decision.

Brigid: [00:22:50] Yeah.

Dr Pat: [00:22:51] Smoking, drug and alcohol. Yes. But the vast majority of cases in our community are not those things. And, you know, we’re fortunate enough to live in a part of the world where maternal nutrition is not the problem.

It’s things entirely beyond the woman’s control, preeclampsia, gestational diabetes, and syndromic babies. Okay. And whilst there is no legitimate place for guilt in that situation. It’s a natural human response to two things for what did I do? Why I haven’t tried hard enough. I haven’t done the right thing.

Yeah.

Brigid: [00:23:25] And I know that we do live in a, in a very privileged health society, but I did want to mention that. For our indigenous people. IUGR is a common problem. Isn’t it?

Dr Pat: [00:23:37] And that’s multifactorial. Yes. There might be for example, poorer levels of nutrition and high levels of smoking, but there’s definitely less antenatal care.

Yeah. So if you’re a traditional living Aboriginal person living in a Aboriginal community in the middle of Australia, you are getting less ante-natal care than a patient who lives down the street from my private consulting rooms in Ballarat, and we can do our best. But there is no doubt that someone, for example, in that group who has an IUGR baby, it’s less likely to be detected.

It’s less likely to be managed and it’s less likely to be managed successfully, which is reflected in the nearly doubling of the stillbirth rates.

Brigid: [00:24:18] Yeah. Wow. So can we talk about, because we do get this question quite a lot. What would be your gold standard of care in managing somebody? To detect and treat IUGR

Dr Pat: [00:24:30] in terms of?

Brigid: [00:24:31] uh, in terms of your private care, what do you like doing

Dr Pat: [00:24:33] well?

Um, I’m not sure if it’s gold standard.

Brigid: [00:24:35] Of course it is Dr Pat.

Dr Pat: [00:24:37] I can tell you what I like doing. Um, I think that we should be doing a fundal height measurement, at every visit

Brigid: [00:24:42] So, um, just we’ll go back and just say that from 20 weeks, how many times is somebody coming to see you?

Dr Pat: [00:24:48] Well from 20 weeks, 24 and 28, then fortnightly from 28.

30 32, 34 36 weeks. Yep. And weekly from 36. Yep. So what are the big ticket things that cause growth restriction, hypertension, preeclampsia. So you take blood pressure every time and diabetes. We test for diabetes and we manage appropriately. We want to detect that growth restriction. Well, how are we going to do it?

Well, we can’t do it from across the room. So we’re going to, there’s a laying on of hands. We’re going to put hands on tummy feeling every time. Yeah. First thing I tell to my students is. Stand back at the end of the bed and have a look at the woman’s stomach. Does she look like someone who’s 34 weeks? It’s amazing how sometimes people will get missed and the growth restricted babies hiding in plain sight.

And if you already knew, like, for example, if you had, if the woman was in a room and you didn’t tell the examiner what her gestation was, and they just had to go in and work it out from the end of the bed, they might do a better job than somebody who already knew that that woman was 32 weeks and therefore interpret all of their findings.

To expect them to equal 32 weeks. Does that make sense?

Brigid: [00:25:50] Yeah. So you’re saying don’t let your bias come in.

Dr Pat: [00:25:52] Yes. So measure the fundal heart as dispassionately as you can turn the tape over and just do your best to say, do you look about right? Yeah. And then improving people’s access to ultrasound.

Brigid: [00:26:06] Yeah. Yeah. So you mean that they should be going to ultrasound if they’re under any sort of suspicion of IUGR.

Dr Pat: [00:26:12] So if you are a private obstetrician, lucky enough to have an ultrasound machine and get out and make some baseline measurements and watch that baby closely. If you’re a referrer for scans, then go ahead and refer, do it with confidence.

You’ll find that you’re right. You know, if you think the baby’s growth restricted, it probably is.

Brigid: [00:26:28] And a non-sort of medical practitioner listening to this, which is most people. This is something that, that perhaps you could advocate for, to make sure that this these are the milestones in their pregnancies that they’re experiencing.

And if they feel that they’re not, then just ask!

Dr Pat: [00:26:42] Yes you must be your own best advocate. And the, one of the problems with that is that, is it the whole, world’s an obstetrician. And when you’re pregnant about half, the people tell you you’re too big. And half the people tell you you’re too small and they’re probably both wrong.

You’re probably fine. But if you’ve had a baby before. And you think you are miles smaller this time than you were the first time? You probably, right? Yes. So absolutely bring it up. “It doesn’t, I don’t seem to be growing”.

“I’m fitting into the same pants now as I did a month ago”. You should have grown out of them. Yeah. So those sorts of things, people do notice, and we’re good at managing growth restriction when we know about it, but we miss some yeah. Altogether.

Brigid: [00:27:22] Yeah. And this is where the woman’s there counting her fetal movements and managing, you know, measuring her fetal movements.

That’s one thing that she could be doing,

Dr Pat: [00:27:31] but when the movements go off, that’s a late finding. Okay. We want to pick up growth restriction. Well, before the baby gets too sick to move and that’s by monitoring growth. And then once we know about it, we’re really good at that. Yeah. Yeah. Make a plan, give the steroids, maybe transfer care from mid-level hospital to the high level hospital, depending on the availability of pediatric care, uh, neonatal nursery, a neonatal intensive care unit and picking the right day when the babies, the perfect balance between fetal maturity versus not too late.

Brigid: [00:28:03] I think I’ve missed this question. A baby that is growth restricted. Do you then go on to induce, obviously you go on to induce. If you feel that that baby’s better out than in yeah. Can that baby go through a vaginal birth?

Dr Pat: [00:28:17] Well, it depends on number of things. The gestation, when the growth restriction came on.

Yeah, what’s wrong. And how severe. Yep. So if we’ve got a baby near term that we’ve determined is maybe the fifth centile, you know, the bottom 5% and the water levels a bit down and the cord Dopplers are perhaps reassuring for the moment, but we’ve decided overall that it’s time to get on with it, then sure.

We would try and do, uh, an induction of vaginal birth for that baby. Break the waters may put up some syntocinon infusion and get that labour up and going. Yep. And watch very closely, probably continuous, fetal monitoring. And make sure that the baby’s coping with the extra forces of labour. And so it’s a big day for the baby being born.

Brigid: [00:28:58] Yeah. We sort of forget about that. It is, you know, they’re getting squished and pulled and pushed.

Dr Pat: [00:29:02] exhausted. Yeah. And that might be fine. And it might go well and have a vaginal birth or that the baby might start showing signs in particular on the fetal heart rate trace that they’re not coping with the contractions. Okay. That’s the common outcomes.

Yeah. And then we might have another situation where we just think this baby’s sick, baby is too small and it’s too early. Yeah. And there’s just about no chance that this baby is going to go well in a vaginal birth, especially if it’s mum’s first time and the labour is expected to take ages and you might just do an elective caesarean section.

Yep. And in cases of very severe growth restriction or very early babies, that’s also a less traumatic way for that baby to be born. You can have a small, delicate baby directly from the uterus straight to the hands of the peadiatricians without the rigors of the natural birth.

Brigid: [00:29:57] I could imagine it’d be quite distressing to have a diagnosis of IUGR , but I hope that, you know, just as a recap, that there’s some babies that are healthy in the low centiles and we just need to plan for those that we think we need to keep a close eye on.

Dr Pat: [00:30:13] Yeah. So trust your team that once the diagnosis has been made, the management is good. Yeah. The improvement that we’ve got to do is, is in making the diagnosis in the first place. And if you, as the pregnant mother feel, there’s a problem with the growth of your baby, you may well be correct and speak up a reassuring ultrasound will be incredibly reassuring for you and your team.

And an abnormal ultrasound is the way forward. You’ll say, okay, fine. We’ve got a problem.

Brigid: [00:30:36] Yeah, we need a plan to fix it. Now these are the, these are the plans and the protocols, because I could imagine this is something you guys are doing, you know, a lot.

Dr Pat: [00:30:43] Yeah, exactly. Yep.

Brigid: [00:30:44] Excellent. Well, I hope that that’s helpful for all those people that have asked for a podcast on IUGR, I forgot to ask how common is it Pat?

Dr Pat: [00:30:52] It depends on severity and so forth, but at least 3% of babies and maybe as many as 7% of babies, depending on your definition. Yeah. Yeah. I think because of the contribution being made in a country like Australia from obesity and diabetes. I think those numbers won’t be going down.

Brigid: [00:31:11] No, that’s right.

Dr Pat: [00:31:12] Yeah.

There’s an important contribution from both those conditions and the rate of those things are going up.

Brigid: [00:31:18] All right, there we go. People. I hope that that was good. And if you are so inclined pop over and give us a five stars on our iTunes, or just send us a DM, we love hearing from you and we hope you have a great week.

Dr Pat: [00:31:30] Thanks for listening everybody.