Fetal growth restriction — structured oral station (12 minutes)

Opening prompt — "Is this baby just small?"

Model response — lead with the classification, then the meaning: ^[1]

• "This is late fetal growth restriction, not just a small baby. Under the Gordijn Delphi consensus, late FGR (32 weeks and over) is defined by an AC or EFW under the 3rd centile, or a contributory combination — and her EFW on the 6th centile with a cerebroplacental ratio under the 5th centile meets that contributory definition."^[1]
• "The low cerebroplacental ratio tells me the baby is redistributing blood flow to the brain — brain-sparing — which is the fetus's response to placental insufficiency. It is a sign of compensation, and a flag that the placenta is not delivering enough."^[1]

Probe 1 — "How would you distinguish this from a constitutionally small fetus?"

• "A constitutionally small fetus has normal growth velocity, a normal umbilical artery Doppler, a normal cerebroplacental ratio, and normal amniotic fluid. This fetus has an abnormal CPR, so it crosses the line from 'small' to 'growth-restricted'."^[1]
• "Her previous small baby raises the recurrence risk — a previous affected pregnancy roughly doubles the risk — which is why we have been scanning her, and why this finding matters."^[1]

Probe 2 — "What is your surveillance plan?"

• "Umbilical artery Doppler is the cornerstone — the Alfirevic Cochrane review shows it reduces perinatal death in high-risk pregnancy (RR 0.71). I would not use a CTG alone for the growth-restricted fetus."^[3]
• "At 36 weeks with late FGR and a low CPR but normal UA Doppler, I would surveillance with twice-weekly Doppler and CTG, and a repeat growth scan in two to three weeks, planning delivery around 37 to 38 weeks."^[4]

Probe 3 — "She asks to be delivered now. What does the evidence say?"

• "At term, the DIGITAT trial compared induction with expectant monitoring for suspected FGR and found they were equivalent for neonatal outcomes — 5.3 percent composite adverse outcome with induction versus 6.1 percent with expectant, and similar caesarean rates. So a woman who prefers to avoid induction can safely choose expectant management with intensive surveillance."^[2]
• "At 36 weeks, with a low CPR, I would lean toward delivery around 37 weeks rather than waiting longer, because the low CPR indicates a fetus that is compensating and may decompensate. But I would present it as a shared decision and respect her preference."^[2][4]

Probe 4 — "What about next pregnancy?"

• "She has now had two small babies, so her recurrence risk is high. I would start low-dose aspirin 100 to 150 mg before 16 weeks next time — the Roberge meta-analysis shows aspirin at least 100 mg started at or before 16 weeks reduces preterm pre-eclampsia (RR 0.62), and the placental pathology is shared with FGR."^[5]
• "Early dating scan, risk reassessment, and serial growth ultrasoids from 28 weeks."^[5]

Probe 5 — communication: "She says 'I just want what's safest.' Talk to her."

Three of the eight domains are scored here. Say the words out loud. ^[4]

• "Your baby is growing more slowly than we would like, and the blood-flow test shows the placenta is working harder than it should. The good news is the main blood vessel to the baby is still flowing normally — that is reassuring for now." ^[2]
• "The safest thing is to have the baby a little earlier than your due date — around 37 weeks — because we know babies in this situation do better out than in once we get to that stage. The trial evidence shows that inducing at this point and waiting a little longer give similar results, but given what we are seeing I would recommend planning the birth at 37 weeks."
• "Between now and then, we will watch the baby closely — twice-weekly checks — and if anything changes, we move sooner. You will not be left to wonder."
• Check understanding by asking her to say the plan back, and document the shared decision.