Routine weighing during antenatal visits
Joseph Onwude1992, BMJ
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A weight off my mind: The abandonment of routine antenatal weighing a change of practice research
Australian College of Midwives Incorporated Journal, 1999
The 50 year old tradition of routinely weighing pregnant women, which has been identified as an obsolete practice, is still practiced by many. The antenatal clinic and community midwives, and medical staff from the Divison of Obstetrics (Central Coast Area Health Service) as well as pregnant women attending the clinics have been surveyed to identify the impact on implementing evidence based practice (ceasing routine antenatal weighing). Using both quantitative and qualitative methods to provide a rich and detailed picture, the outcomes showed that the importance of weighing decreased for most of pregnant women. Midwives were surprised at the womens' acceptance to the change; and both health professional groups did not feel a loss of overall care. This research suggests that organised and planned change can achieve acceptance of evidence based practice.
The validity and reliability of weight and height measurements and body mass index calculations in early pregnancy
Journal of Human Nutrition and Dietetics, 2011
Background: Obesity is increasing in the UK and this is having an impact on the health of pregnant women and their infants. It is recommended that all pregnant women have their height and weight measured and their body mass index (BMI, kg m)2) calculated and recorded in the midwifery notes. The aim of the present audit was to determine the extent of compliance with this recommendation. Methods: An audit was undertaken in a large district general hospital in the South West of England. A convenience sample of the midwifery notes was accessed retrospectively on the post-natal wards. Data collected from the notes included weight, height, BMI and gestational age when first recorded. Results: A total of 486 maternal notes were audited; of these, 9% did not have the BMI recorded. In total, 53.8% of the sample had either height or weight not recorded; however, 90.9% of the sample had a BMI recorded. In addition, 39.7% (n = 126) of heights and 16.0% (n = 63) of weights were recorded in imperial format. There was a high prevalence overweight (26.2%) and obesity (21.3%) amongst the sample. Conclusions: Recommendations for measurement of height, weight and calculation of BMI were not always followed. Where BMI was recorded, many notes had either height or weight missing or had measurements recorded in imperial units. This raises the question of how BMI was calculated and its accuracy. Inaccuracies in BMI could lead to individuals being overlooked as high risk and may not be referred for appropriate care including dietetic care. Accurate anthropometric measurements are important for dietary management and monitoring of weight gain.
Assessment of weight changes during and after pregnancy: practical approaches
Maternal & Child Nutrition, 2007
The usefulness of routine prenatal weight measurements in predicting pregnancy outcomes is still a controversial issue. Comparisons among studies and the interpretation of research findings are complicated due to the variety of indicators applied to express maternal weight changes during and after pregnancy. A review of literature was conducted to clarify the definitions and examine the strengths and limitations of methods for measuring gestational weight gain (WG) and postpartum weight changes. The reasons for weak correlations or non-significant associations between gestational WG and maternal and neonatal outcomes were probably owing to poor quality of obstetrics records and selection of wrong indicators to compute gestational WG. The choice of an indicator depends on clinical and research purpose, availability and reliability of data and cost. Considering the health implication of gestational WG, it is necessary to take into account the measurements used as initial and final weight, accuracy of gestational age estimation and the inclusion of fetal weight as part of maternal WG. Regardless of the indicators used to compute the weight changes after delivery, attention is drawn to the approach for designating prepregnancy weight, the time frame of postpartum weight measurements and the use of overlapping variables, which results in bias (part-whole correlation). It is necessary to address criticisms on the accuracy of prenatal weight measurements and the way of expressing the maternal weight changes during and after pregnancy in order to have reliable results from research.
Maternal estimation of fetal weight as a complementary method of fetal weight assessment: A prospective clinical trial
American Journal of Obstetrics and Gynecology, 2004
OBJECTIVE: To assess the accuracy of fetal weight estimations performed by parturients vs. clinical and sonographic estimates. STUDY DESIGN: Term parous women were included in this prospective trial. Each woman estimated the weight of her fetus. Fetal weight was also estimated sonographically and clinically. The clinical evaluations were performed by an attending gynecologist and a resident. Estimate accuracy for extreme fetal weights was evaluated separately. RESULTS: We enrolled 128 women. Maternal and resident estimations' accuracy was identical. The attending physician estimates were superior to the residents' and parturients', with a mean absolute error of 318 g and 67% of the evaluations within the 10% boundaries of the actual birth weight. Sonographic evaluation was the most accurate method, with a mean absolute error of 244 g and 76% of evaluations within 10% of the actual birth weight. When partitioned to extreme fetal weight groups (upper and lower 10th percentiles), the maternal evaluation was at least as accurate as the clinical evaluations of both the attending and resident. CONCLUSION: Maternal evaluation of the fetus's weight is as accurate as physicians' clinical estimations, and is advised as a complementary method of assessment. This estimation may have greater relevance when intrauterine growth restriction or macrosomia is suspected. (J Reprod Med 2006;51:0000-0000)
Value of a single early third trimester fetal biometry for the prediction of birth weight deviations in a low risk population
Journal of Perinatal Medicine, 2008
Objective: To analyze the value of a single ultrasound biometry examination at the onset of the third trimester of pregnancy for the detection of small-for-gestationalage (SGA) and large-for-gestational-age (LGA) at birth in a low risk population. The aim of this study was to develop a simple and useful method for the detection of growth deviations during pregnancy in primary care (midwife or general practitioner) practices. Setting: A Dutch primary care midwifery practice. Study design: In an earlier study, we developed parity and sex specific fetal growth charts of abdominal circumference (AC) and head circumference (HC) on the basis of ultrasound data of a low-risk midwifery population in the Netherlands. In the present study, we calculated sensitivity, specificity and predictive values at different cutoff points of AC and HC for the prediction of growth deviations at birth. Patients booked for perinatal care between 1 January 1993 and 31 December 2003 (ns3449) were used for the identification of cutoff points (derivation cohort) and those admitted between 1 January 2004 and 31 December 2005 (ns725) were used to evaluate the performance of these cutoffs in an independent population (validation cohort). For the determination of SGA and macrosomia at birth, we used the recently published Dutch birth weight percentiles.
Antenatal biochemical screening to predict low birthweight infants
Bjog: An International Journal Of Obstetrics And Gynaecology, 1983
Urine and plasma oestriol, plasma progesterone, human placental lactogen, p ,-glycoprotein and serum cystyl aminopeptidase were measured at intervals during 608 pregnancies. The predictive accuracy of low values for identification of pregnancies with low birthweight outcomes was assessed for each test at various gestations. Data were analysed to obtain 10th-90th centile values for each test from 28 weeks to delivery. Groups with values under different centile levels were compared: those under the lower centiles had higher proportions but smaller absolute numbers of low birthweight infants than those under higher centiles. No test was superior to the others at all centiles and gestations. Biochemical screening of pregnant populations to identify high-risk groups for intensive fetal monitoring has limited potential. If screening is used, the definition of high-risk groups is best achieved by practical rather than statistical criteria. If monitoring facilities are available and well accepted by patients then higher centile 'cut-offs' to define fetal risk may be used than when they are not. Combining any pair of tests with values below the 10th centile did not reduce false positive and negative predictions any more than could be achieved by movement of centiles up or down for a single test.
A randomized controlled trial of daily weighing in pregnancy to control gestational weight gain
BMC Pregnancy and Childbirth, 2020
Background Excessive gestational weight gain is a modifiable risk factor for the development of obstetric and neonatal complications, and can have a lifelong impact on the health of both mother and offspring. The purpose of this study was to assess whether in addition to standardized medical advice regarding weight gain in pregnancy (including adherence to the Institute of Medicine (IOM) guidelines) (IOM (Institute of Medicine) and NRC (National Research Council, Weight Gain During Pregnancy: Re-examining the guidelines, 2009)), the addition of daily weighing would provide a low cost and simple intervention to reduce excessive weight gain in pregnancy by maintaining weight gain within the target range. Methods Women presenting for antenatal care to a secondary level hospital were randomised to routine care or daily weight monitoring. Both groups received nutrition and exercise advice. Results Three hundred and ninety-six women were randomised to either the daily weight monitoring gr...
Antenatal Weight Management: Women's Experiences, Behaviours, and Expectations of Weighing in Early Pregnancy
Journal of pregnancy, 2016
The current emphasis on obstetric risk management helps to frame gestational weight gain as problematic and encourages intervention by healthcare professionals. However pregnant women have reported confusion, distrust, and negative effects associated with antenatal weight management interactions. The MAGIC study (MAnaging weiGht In pregnanCy) sought to examine women's self-reported experiences of usual-care antenatal weight management in early pregnancy and consider these alongside weight monitoring behaviours and future expectations. 193 women (18 yrs+) were recruited from routine antenatal clinics at the Nottingham University Hospital NHS Trust. Self-reported gestation was 10-27 weeks, with 41.5% (n = 80) between 12 and 14 and 43.0% (n = 83) between 20 and 22 weeks. At recruitment 50.3% of participants (n = 97) could be classified as overweight or obese. 69.4% of highest weight women (≥30 kg/m(2)) did not report receiving advice about weight, although they were significantly m...
Comparison of Clinical Foetal Weight and Ultrasonography Detected Foetal Weight
Journal of Current and Advance Medical Research, 2019
Background: Comparison of foetal weight detection between clinical examination and ultrasonography is very important. Objective: The purpose of the present study was to compare the detection of foetal weight between clinical examination and ultrasonography. Methodology: This cross-sectional comparative study was carried out in the Department of Obstetrics & Gynaecology at Rajshahi Medical Hospital Hospital (RMCH), Rajshahi, Bangladesh from July 2012 to June 2014 for a period of 2(two) years. Pregnant women with known gestational age at term (38 to 40 weeks of pregnancy), singleton pregnancy with longitudinal lie were included in this study. The clinical estimation of foetal weight was done. Foetal weight was estimated by using Johnson’s formula. The patient was then taken to Dept. of Radiology & Imaging, RMCH. Ultrasonographic estimation of foetal weight was done from estimation of foetal abdominal circumference (AC), biparietal diameter (BPD) and foetal femur length (FL). All the w...
The performance of various anthropometric assessment methods for predicting low birth weight in pregnant women
Revista Brasileira de Saúde Materno Infantil, 2009
OBJECTIVES: to assess the performance of various anthropometric methods for the evaulation of the nutritional status of pregnant women as a means of predicting low birth weight (LBW). METHODS: a descriptive cross-cutting study carried out among 433 pregnant women…
satisfy the normal requirements for screening
tests: each test should be cheap, easy to apply,
reliably reproduced, sensitive, and specific.
Although routine weighing satisfies the first two
criteria, none of the quoted references suggests
that it comes anywhere near to satisfying the
remainder. If we are to make progress in detecting
poor fetal growth we must begin to apply scientific
principles to antenatal care. No longer is it sufficient to answer the question "Why should it not be
done?" The important question is "Why should
this be done?"
Dawyes and Grudzinskas have shown that routine
repeated measurement of maternal weight in all
patients adds nothing to the reliable prediction of
babies who are small for gestational age.2 Further
studies have confirmed this finding and indicated
why the observation lacks sensitivity and specificity.34 If serial measurement of weight had never
been a part of antenatal care there would not be any
reason to introduce it now. This is not to imply,
however, that measurement of maternal weight
during pregnancy is never appropriate, merely that
routine measurements are a waste of resources and
may be misleading.
In the same issue as the editorial M G Dawes and
colleagues highlight the confusion surrounding the
perceived reasons for routine weighing in antenatal
clinics.' Those who currently apply this test gave
40 different reasons for doing so. Clearly there is no
consensus, even among practising health care
workers, over its application let alone its interpretation.
Routine serial measurement of maternal weight
during pregnancy is not a valuable procedure and
should be abandoned.
K R YOUNG
Cambridge Military Hospital,
Aldershot,
Hampshire GU ll 2AN
1 Dimperio DL, Fentzen BH. Curz A. Routine weighing during
antenatal visits. BMJ 1992;304:460. (22 February.)
2 Dawes MG, Grudzinskas JG. Repeated measurement of matemal
weight during pregnancy. Is this a useful practice? BrJ Obstet
Gyneacol 1991;98:189-94.
3 Dawes MG, Grudzinskas JG. Patterns of maternal weight gain in
pregnancy. BrJ Obstet Gynaecol 1991;98:195-201.
4 Lawrence M, McKillop FM, Durnin JVGA. Women who gain
more fat during pregnancy may not have bigger babies:
implications for recommended weight gain during pregnancy.
BrJ Obstet Gynaecol 1991;98:254-9.
5 Dawes MG, Green J, Ashurst H. Routine weighing in pregnancy.
BMJ 1992;304:487-9. (22 February.)
SIR,-Diane L Dimperio and colleagues conclude
that serial antenatal weighing should continue as a
screening test for preterm delivery, low birth
weight, and pre-eclampsia' but provide no evidence
that it fulfils the criteria for a successful screening
test.2 Certainly the conditions they wish to identify
are common and important enough for screening
to be worth while, but there is no evidence of a
silent period in the development of any of these
conditions during which treatment is beneficial,
with the possible exception of treatment with low
dose aspirin for pre-eclampsia. Pre-eclampsia
is better screened by measuring urine protein
excretion or blood pressure, or both, than by serial
weighing.
Even if there were effective interventions none
of the papers quoted by the authors give data in a
form such that the sensitivity and specificity of the
test can be derived. They all simply describe weak
correlations between low weight gain and various
poor outcomes. Only Dawes and Grudzinskas have
described the test characteristics of low weight gain
(below the 10th centile) for predicting small for
gestational age babies (sensitivity 19%, specificity
87%) and of high weight gain (above the 90th
centile) for predicting high blood pressure (sensitivity 26%, specificity 80%).' This performance is
much worse than that of other variables measured
in screening tests, such as fundal height, ultrasonographic measurements, blood pressure,
BMJ VOLUME 304
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16 MAY 1992
and urinary variables. Dimperio and colleagues
provide nothing in their editorial to contradict
Dawes and Grudzinskas's conclusions that routine
weighing fulfils only two screening criteria (it is
cheap and acceptable) and that it should stop.3
It is profoundly depressing that at a time when
obstetricians are attempting to rationalise their
management of pregnant women4 the editorial
should respond to this excellent scientific evaluation of a common screening procedure in such an
unscientific way.
J L ONWUDE
Department of Obstetrics and Gynaecology,
St James's University Hospital,
Leeds LS9 7TF
J G THORNTON
Institute of Epidemiology,
University of Leeds,
Leeds LS2 9LN
1 Dimperio DL, Frentzen BH, Cruz A. Routine weighing during
antenatal visits. BMJ 1992;304:460. (22 February.)
2 Grant A, Mohide P. Screening and diagnostic tests in antenatal
care. In: Enkin M, Chalmers I, eds. Effectiveness and satisfaction
in antenatal care. London: Intemational Medical Publications,
1982:22-7.
3 Dawes MG, Grudzinskas JG. Repeated measurement of
maternal weight during pregnancy. Br J7 Obstet Gynaecol
1991;98: 189-94.
4 Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy
and childbirth: a synopsis for guiding practice and research.
In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in
pregnancy and childbirth. Vol 2. Oxford: Oxford University
Press, 1989:1465-77.
AUTHOR'S REPLY,-Though one objective of
antenatal care is to screen for problems, another is
to provide teaching and anticipatory guidance
that, if followed, result in optimum outcomes for
both the mother and the newborn infant. Active
promotion of healthy behaviours, such as consumption of a diet that provides adequate but
not excessive energy, should be part of routine
prenatal care. Methods of estimating the energy
requirement of a pregnant woman exist but are
time consuming, do not take into account individual variation, and have not been correlated with
the outcome of pregnancy. A simple and more
effective method of assessing energy sufficiency
during pregnancy is weight gain. A comprehensive
analysis of scientific data has resulted in guidelines
for weight gain that are consistent with desirable
outcomes for mothers and newborn infants. '
As both inadequate and excessive gains in
weight are associated with undesirable outcomes of
pregnancy they should be avoided. Weight gain
in the second half of pregnancy is especially
correlated with fetal growth,2 and thus assessments
of weight after the initial booking continue to be
essential for good care. Those providing care
should routinely monitor weight gain to reinforce a
positive pattern or intervene if the pattern is
becoming abnormal. Women with poor weight
gain should be assessed to determine why their
energy intake is insufficient for their requirements.
Unusually high weight gain may, but does not
necessarily, reflect excess energy intake. When it
occurs, assessment should determine whether it is
a result of excess energy intake, abnormal fluid
retention, or multiple pregnancy.
The routine of weighing the patient and subsequent counselling has two additional benefits: it
relieves patients' anxiety about weight gain and
introduces the topic of the overall nutritional
adequacy of the diet. Promotion of good nutrition
should be an important component of antenatal
care. Women who receive intervention with
emphasis on achieving an optimum weight gain
and nutritional adequacy have improved outcomes
compared with those who do not.3 Routine weighing of all women as part of antenatal care is valuable
and should not be discarded.
DIANE DIMPERIO
University of Florida College of Medicine,
Gainesville,
Florida 32610,
USA
1 Institute of Medicine. Nutrinon during pregnancy. Washington:
National Academy, 1990.
2 Lawton FG, Mason G, Krystyna K, Ramsay I, Morewood G.
Poor maternal weight gain between 28 and 32 weeks gestation
may predict small-for-gestational-age infants. Br J Obstet
Cynaecol 1988;95:884-7.
3 Bruce L, Tchabo J-G. Nutrition intervention program in a
prenatal clinic. Obstet Gynecol 1989;74:310-2.
Manipulative therapy and
physiotherapy for persistent
back and neck complaints
SIR,-Bart W Koes and colleagues have shown the
benefits of manipulative therapy compared with
physiotherapy,' supporting the findings of an
earlier trial conducted by the Medical Research
Council.2
Firstly, however, contrary to the statement in
their paper, it is not possible to differentiate
patients with disc herniation from those with other
causes of back pain on the basis of a non-specific
complaint and physical examination. Radiological
investigations such as computed tomography,
myelography, and magnetic resonance imaging are
usually required to achieve this distinction.
Secondly, intervertebral discs start to degenerate
in early adulthood, becoming symptomatic after
fragmentation, with herniation through an intact
annulus or impingement on the spinal canal.3 As
manipulative therapy entails small movements
of high velocity, applying sudden stresses to
chronically degenerating discs may precipitate
protrusion of a disc. Manipulating the spines of
patients with back pain of undiagnosed aetiology is
not without risk, and known complications,
although rare, range from injury to the cervical
cord4 to brain stem infarction.5 Our experience
includes two cases of compression of the cauda
equina after chiropractic manipulation6 in which
the diagnosis was delayed, resulting in long term
disability. As a result we endorse calls for further
trials to elucidate the role of spinal manipulation in
the management of low back pain and for a review
of chiropractic training in the United Kingdom. 8
O J LEHMANN
Royal Eye Hospital,
Manchester M13 9WH
N D MENDOZA
National Hospital for Nervous Diseases,
London WC1N 3BG
R BRADFORD
Department of Neurosurgery,
Royal Free Hospital,
London NW3 2QG
I Koes BW, Bouter LM, van Mameren H, Essers AHM, Verstegen
GMJR, Hofhuizen DM, et al. Randomised clinical trial of
manipulative therapy and physiotherapy for persistent back
and neck complaints: results of one year follow up. BM7
1992;304:601-5. (7 March.)
2 Meade TW, Dyer S, Browne W, Townsend J, Frank AO.
Low back pain of mechanical origin: randomised comparison
of chiropractic and hospital outpatient treatment. BMJ
1990;300: 1431-7.
3 Maurice-Williams RS. Disorders of the spinal nerve roots. In:
Weatherail DJ, Ledingham JGG, Warrell DA, eds. Oxford
textbook of medicine. Oxford: Oxford University Press,
1987:21.112-5.
4 Rinsky LA, Reynolds GG, Jameson RM, Hamilton RD.
A cervical cord injury following chiropractic manipulation.
Paraplegia 1976;13:223-7.
5 Mueller S, Sahs AL. Brain-stem dysfunction related to cervical
manipulation. Neurology 1976;26:547-50.
6 Lehmann OJ, Mendoza ND, Bradford R. Beware the prolapsed
disc. Br7HospMed 1991;46:52.
7 Chiropractors and low back pain [Editorial]. Lancet 1990;336:
220.
8 Meade TW, Frank AO. Chiropractors and low back pain. Lancet
1990;336:572.
SIR,-I am concerned about the inappropriate
selection of patients and treatment in the study by
Bart W Koes and colleagues.'
The introduction mentions that, in the patients
selected, no underlying disease could be established
and the causes of the complaints remained unknown. Why? Were the assessors lacking the
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