WHO recommendation on symphysis-fundal height measurement.

WHO recommendation on symphysis-fundal height measurement.



Replacing abdominal palpation with symphysis-fundal height (SFH) measurement for the assessment of fetal growth is not recommended to improve perinatal outcomes. A change from what is usually practiced (abdominal palpation or SFH measurement) in a particular setting is not recommended.

(Context-specific recommendation)


Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016



  • SFH measurement is routinely practiced in many ANC settings. Due to a lack of clear evidence of accuracy or superiority of either SFH measurement or clinical palpation to assess fetal growth, the GDG does not recommend a change of practice.
  • The GDG agreed that there is a lack of evidence on SFH, rather than a lack of effectiveness, particularly in LMIC settings.
  • Apart from false reassurance, which might occur with both SFH measurement and clinical palpation, there is no evidence of harm with SFH measurement.
  • Research is needed to determine the role of SFH measurement in detecting abnormal fetal growth and other risk factors for perinatal morbidity (e.g. multiple pregnancy, polyhydramnios) in settings where antenatal ultrasound is not available.



SFH measurement is a commonly-practiced method of fetal growth assessment that uses a tape measure to measure the SFH, in order to detect intrauterine growth restriction (IUGR). It also has the potential to detect multiple pregnancy, macrosomia, polyhydramnios and oligohydramnios. For fetuses growing normally, from 24 weeks of gestation, the SFH measurement in centimetres should correspond to the number of weeks of gestation, with an allowance of a 2-cm difference either way (109). Other methods of fetal growth assessment include abdominal palpation of fundal height in relation to anatomical landmarks such as the umbilicus and xiphisternum, abdominal girth measurement, and serial ultrasound measurement of the fetal parameters (109). Accurate low-cost methods for detecting abnormal growth are desirable because ultrasound, the most accurate screening tool, is resource-intensive and not widely available in LMICs. (1)



The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

For pregnant women (P), does SFH measurement (I) compared with clinical palpation for antenatal assessment of fetal growth (C) improve maternal and perinatal outcomes (O)?



Evidence summary

The evidence on the effects of SFH measurement was derived from a Cochrane review that included only one trial conducted in Denmark involving 1639 pregnant women enrolled at about 14 weeks of gestation (1). SFH measurement or abdominal palpation were performed from 28 weeks of gestation. Most women had at least three assessments, with measurements plotted on a chart.

Maternal outcomes

Low-certainty evidence suggests that there may be little or no difference in the effect of SFH measurement versus clinical palpation on caesarean section (1639 women; RR: 0.72, 95% CI: 0.31–1.67) and induction of labour (1639 women; RR: 0.84, 95% CI: 0.45–1.58).

Fetal and neonatal outcomes

Moderate-certainty evidence shows that SFH measurement versus clinical palpation probably makes little or no difference to the antenatal detection of SGA neonates (1639 women; RR: 1.32, 95% CI: 0.92–1.90) and low-certainty evidence suggests that it may make little or no difference to perinatal mortality (1639 women; RR: 1.25, 95% CI: 0.38–4.07). No other ANC guideline outcomes were reported in the review.


Additional considerations

The GDG also considered evidence from a test accuracy review regarding the accuracy of SFH in predicting SGA at birth (birthweight < 10th centile), where SGA was a proxy outcome for IUGR (6). The DTA review included seven studies conducted in HICs, which used different measurement thresholds to detect SGA. SFH measurement had a sensitivity ranging from 0.27 to 0.76, suggesting that it fails to identify up to 73% of pregnancies affected by SGA at birth. However, there was generally a high degree of specificity (0.79–0.92), suggesting that a normal SFH measurement may be a reasonable indicator of a healthy baby. In practice, this could mean that few healthy pregnancies are referred for ultrasound examination; however, most true SGA cases may be missed. Comparable test accuracy evidence on abdominal palpation is not available.



Both abdominal palpation and SFH measurement are low-cost interventions with the main cost being staff training. SFH requires tape measures to be available.



LMICs bear the global burden of perinatal morbidity and mortality, and women who are poor, least educated and residing in rural areas of LMICs have lower ANC coverage and worse pregnancy outcomes than more advantaged women (7). Therefore, simple, effective, low-cost, routine antenatal interventions to assess fetal well-being could help to address health inequalities by improving detection of complications in low-resource settings.



SFH and clinical palpation are non-invasive approaches for fetal assessment, which are widely used and not known to be associated with acceptability issues.

However, in some settings women experience a sense of shame during physical examinations, and this needs to be addressed with sensitivity by health-care providers (low confidence in the evidence) (8).



Both methods are considered equally feasible, provided tape measures are available.


Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:




Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.


Research implications

The GDG identified this priority question related to this recommendation:

  • What are the effects and accuracy of SFH measurement to detect abnormal fetal growth and other risk factors for perinatal morbidity (e.g. multiple pregnancy, polyhydramnios) in settings without routine ultrasound?


Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health



  1. Robert Peter J, Ho JJ, Valliapan J, Sivasangari S. Symphysial fundal height (SFH) measurement in pregnancy for detecting abnormal fetal growth. Cochrane Database Syst Rev. 2015;(9):CD008136.
  2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  6. Pay ASD, Wiik J, Backe B, Jacobsson B, Strandell A, Klovning A. Symphysis-fundus height measurement to predict small-for-gestationalage status at birth: a systematic review. BMC Pregnancy Childbirth. 2015;15:22. doi:10.1186/ s12884-015-0461-z.
  7. State of inequality: reproductive, maternal, newborn and child health. Geneva: World Health Organization; 2015 (http://www.who.int/gho/ health_equity/report_2015/en/, accessed 29 September 2016).
  8. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392


Citation: WHO Reproductive Health Library. WHO recommendation on symphysis-fundal height measurement. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.