principles and practice

Measurement of Fundal Height

JANET L. ENGSTROM, CNM, PHD

Fundal height should not be assessed by comparing the uterus

with anatomic landmarks on the maternal abdomen because of the
following reasons: 1) the inability to assess fundal growth
accurately when the uterus is measured in finger breadths or as a
fraction of the distance between two landmarks; 2) biologic
variability in the placement of anatomic landmarks on the maternal
abdomen; 3) disagreement among clinicians and researchers on
the precise relationship between the fundus and anatomic
landmarks at each stage of gestation; and 4) variability among
women in the number of gestational weeks at which the uterine
fundus reaches the umbilicus. A rational basis for continuing the
practice of comparing fundal height with anatomic landmarks on
the maternal abdomen does not exist. Inexpensive and more
accurate techniques of measuring fundal growth are readily
available.

Fundal height measurements t e r ~ a l . ~ Thus,

are used frequently to assess ade-
quacy of uterine growth during
pregnancy. Appropriate uterine
size is associated with normal
pregnancy progress, whereas both
inadequate and excessive uterine
sizes are associated with preg-
nancy complications. Inadequate
uterine size is associated with
complications such as intrauterine
growth retardation, fetal demise,
oligohydramnios, and inaccurate
estimation of the gestational in-
terval.'-8 Excessive uterine size is
associated with complications
such as fetal macrosomia, hy-
dramnios, multiple gestation, hy-
datidiform mole, and inaccurate
estimation of the gestational in-
Accepted: December 1987
-' both inadequate
and excessive uterine sizes are in-
dications for more extensive eval-
uation of pregnancy. These evalu-
ations usually involve the use of
ultrasound to determine the ges-
tational interval, fetal size and
number, and amniotic fluid vol-
ume. Evaluation of the structural
normality of the fetus and placenta
also may be included.
Because clinicians frequently
use fundal height measurements
as a screening technique to assess
pregnancy progress and to deter-
mine if more extensive pregnancy
evaluation is necessary, accurate
measurements a r e essential to
safe clinical practice. Inaccurate
measurements may cause the cli-
nician to overlook serious preg-
nancy complications, which could
result in the inappropriate man-
agement of the complication and
subsequent morbidity or mortal-
ity. Inaccurate measurements also
may cause the clinician to perform
unnecessary diagnostic and thera-
peutic procedures in uncompli-
cated pregnancies. These proce-
dures a r e frequently expensive
and may be invasive.
MEASUREMENT TECHNIQUES
Techniques for measuring fun-
dal height can be classified into
two methods. One method in-
cludes those techniques in which
the measurement is obtained with
an instrument such as a tape mea-
sure or pelvimetry caliper. These
measurements a r e usually re-
corded in centimeters, and nor-
mality is determined by compar-
ing the measurements with pub-

172 May/June 1988 JOG"

lished limits of normal for each
gestational week and with the pa-
tient's previous measurements.
The second group of measurement
techniques includes those proce-
dures in which the height of the
uterine fundus is assessed by
comparing the fundus with ana-
tomic landmarks on the maternal
abdomen such a s the symphy-
sis pubis, umbilicus, and xiphoid
process. These measurements
are usually recorded in finger
breadths above or below the se-
lected landmark, or as a fraction of
the distance between two land-
marks (e.g., half-way or one-
quarter of the way). The normality
of these measurements is deter-
mined by comparing the measure-
ments with published descrip-
tions of where the fundus should
be located on the maternal abdo-
men at each stage of gestation and
with previous assessments of the
relationship between the fundus
and abdominal landmarks.
Accurate fundal height
I
measurements are essential
for safe clinical practice.
Reasons why fundal height
should not be assessed by plotting
uterine growth against anatomic
landmarks on the maternal abdo-
men include
The inability to assess fundal
growth accurately when mea-
sured in finger breadths, or as a
fraction of the distance between
two landmarks, or when fundal
size is compared with the size of
various fruits;
Biologic variability in the place-
ment of anatomic landmarks on
the maternal abdomen;
Disagreement among clinicians
on the precise relationship be-
tween the fundus and anatomic
landmarks at each stage of ges-
tation; and
MayIJune 1988 JOGNN
Variability among women in the
number of gestational weeks at
which the uterine fundus
reaches the umbilicus.
Finger breadths
Fundal height is assessed fre-
quently in measurements of finger
breadths above or below selected
landmarks. Several reasons ex-
plain why this practice is not ap-
propriate for clinical use. First,
finger breadth varies among clini-
cians. This is particularly prob-
lematic in settings where the same
clinician does not examine the pa-
tient at each prenatal visit. Sec-
ondly, finger breadth can vary in
the same clinician, depending on
the amount of pressure applied to
the fingers during examination. Fi-
nally, the clinician's fingers may
not be able to span the distance
between the fundus and the se-
lected abdominal landmark.
Fractions
Fundal height also is assessed
by estimating uterine position be-
tween two landmarks (the fundus
may be one-fourth, one-third, or
one-half the distance between two
landmarks). The distance is as-
sessed visually by the examiner;
no instruments are used to deter-
mine whether the fundus is pre-
cisely half-way between the sym-
physis pubis and umbilicus. Thus,
the assessment is somewhat sub-
jective, and measurement accu-
racy depends on the clinician's
ability to estimate small distances
visually. This practice is problem-
atic because assessing fundal
growth weekly is difficult. A clini-
cian may have the visual ability to
determine that the fundus is
roughly one-quarter way or one-
half way between two landmarks,
but the probability that the clini-
cian will have the skill to deter-
mine that the fundus is precisely
three-eighths or five-sixteenths of
the distance between two land-
marks is unlikely. Thus, the clini-
cian will not be able to detect
small changes in the pattern of
fundal growth and, subsequently,
may fail to detect subtle changes
in the fetal growth pattern or other
serious complications.
Fruits
Another technique for assessing
uterine size is to compare the
uterus with the sizes of selected
fruits such a s pears, oranges,
grapefruits, and melons. The obvi-
ous problem with this practice is
that fruits vary in size. Addition-
ally, uterine growth can only be
assessed by whether growth is
present or absent; growth cannot
be quantified (recording the mea-
surement a s one finger breadth
past grapefruit size would be a bit
unusual).
Measurement of fundal growth
in finger breadths, fractions, and
fruits is a vestige of the time when
tape measures and calipers were
not readily available, and norma-
tive values of fundal height mea-
surements had not been de-
scribed. Today, more accurate
techniques of assessing fundal
growth are readily available, and
the normative values for fundal
height measurements obtained
by these techniques have been
published for selected popula-
tions.'-6*'0 Obviously, clinicians
should use the most accurate as-
sessment techniques, especially
when those techniques are inex-
pensive and readily available.
VARIABILITY IN ANATOMIC
LANDMARKS
One of the primary reasons that
fundal growth should not be plot-
ted against anatomic landmarks
on the maternal abdomen is be-
cause of biologic variability in the
location of these landmarks. Vari-
ability in the distance between the
symphysis pubis and umbilicus
173
was well-described by the end of
the 1800s, and plotting fundal
growth against abdominal land-
marks was strongly discouraged at
that time. In 1887, Spiegelberg re-
ported that the distance between
the symphysis pubis and the um-
bilicus varies from 13 to 28 cm."
Other studies have confirmed
Spiegelberg's findings; the dis-
tance between the symphysis
pubis and umbilicus varies from
11.5 to 31 ~ m . " - 'Given
~ this large
variability, the probability that the
uterine fundus would reach the
umbilicus at the same time in ges-
tation in all women is unlikely.
The possibility that the position
of the umbilicus may change dur-
ing pregnancy due to alterations in
the contour of the maternal abdo-
men also must be considered. This
possibility has not been studied
but seems probable. Support for
this idea is drawn from Beazley
and Underhill's observation that
the distance between the sym-
physis pubis and umbilicus varied
from 11.5 to 19 cm in women less
than 28 weeks of gestation (N
= 233), whereas the distance var-
ied from 12.5 to 23 cm in women
greater than 28 weeks of gestation
(N = 240).13 The larger range of
distances later in gestation may
have been due to chance variation
in subjects or may indicate that
the position of the umbilicus
changes as pregnancy progresses.
However, subjects were not used
as their own controls in this study,
so the results must be interpreted
cautiously. Additionally, means
and standard deviations from each
group were not reported, and sta-
tistical comparisons were not per-
formed. Thus, a conclusion that
the differences between these two
groups were statistically signifi-
cant cannot be made.
Maternal abdominal length,
measured as the distance between
the symphysis pubis and xiphoid
process has not been studied ex-
tensively. However, two studies
174
Fundal height should not
be measured by comparing
the fundus with anatomic
I landmarks on the maternal
abdomen.
indicate that the distance between
the symphysis pubis and xiphoid
process varies widely, with dis-
tances ranging from 25 to 43
cm.10,13
Landmark Inconsistencies
The purported position of the
uterine fundus at each gestational
month in relation to anatomic
landmarks on the maternal abdo-
men varies among authors. For ex-
ample, the fundus is said to reach
the level of the umbilicus at the
fifth month of p r e g n a n ~ y , 'be-
~ predict the delivery date. Al-
tween five and six at
six month^,'^-^^ at the end of six
m ~ n t h s , ~atl - seven
~~ month^,^^-^^
and at the end of seven months.36
The discrepancy between authors
can be explained partly by varia-
tions in maternal position during
measurement. In the early part of
the 1800s, patients were fre-
quently examined while standing.
This accounts for the finding that
early authors tended to report that
the fundus reached the umbilicus
much later in pregnancy than re-
ported by more recent authors. In-
creases in infant birth weight over
the past 150 years may also ac-
count for discrepancies between
authors. Additionally, these differ-
ences may be due to whether fun-
dal growth was recorded in calen-
dar or lunar months. Pregnancy
lasts for nine calendar or ten lunar
months. Thus, the month at which
the fundus reaches the umbilicus
depends on whether calendar or
lunar months are used. As a result,
description of fundal growth in
months should be discouraged.
Recent textbooks continue to
differ in descriptions of the posi-
tion of the fundus at selected
points in pregnancy. The fundus is
said to reach the umbilicus at 20,37
between 20 and 24,' or at 24 weeks'
g e ~ t a t i o n . ~Although
' variations
exist, one of two models is usually
used to describe the pattern of
fundal growth: the rule of thirdsz7
or the rule of fourths" (Figure 1).
Comparing the two techniques,
one can see why some authors
claim that the fundus reaches the
umbilicus at five months' gesta-
tion (20 weeks) and others at six
months' gestation (24 weeks).
Gestational Interval Variations
The date at which the uterine
fundus reaches the maternal um-
bilicus has been used to deter-
mine the gestational interval and
though contemporary authors fre-
quently state that the fundus
reaches the umbilicus between 20
and 24 weeks' gestation, this as-
sumption has not been studied ex-
tensively. Beazley and Underhill,
in their study of the biologic varia-
tion of anatomic landmarks on the
maternal abdomen, reported that
the fundus frequently reached the
umbilicus by 18 weeks of gesta-
tion.I3 Unfortunately, these re-
searchers did not provide the data
to support this report. Aside from
this anecdotal report, only two
other studies on when the fundus
reaches the umbilicus appear in
the literature.
The first study was a retrospec-
tive investigation conducted by
Andersen et al.39 These re-
searchers studied the accuracy of
delivery date predictions as made
by using clinical indicators of ges-
tational age such as the date of the
last menstrual period, quickening,
first auscultated fetal heart tones,
fundal height measurements, and
the date the uterine fundus
reached the umbilicus. The sam-
May/June 1988 JOCNN

I RULE OF FOURTHS
Figure 1. Comparison of the height of the uterine fundus at each gestational month accord-
ing to the Rule of Fourths (left) and the Rule of Thirds (right).
ple was limited to women who ex-
perienced spontaneous onset of
labor and delivered normal, sin-
gleton infants weighing greater
than 3,000 g and who had docu-
mentation in their prenatal rec-
ords of either the date the fundus
reached the umbilicus or the date
the fundus was one centimeter
above or below the umbilicus. In
the latter case, the date the fundus
reached the umbilicus was ad-
justed by one week accordingly.
Table 1. Gestational Interval at Which the Fundus Reaches the Umbilicus in Weeks
Investigator
Andersen et al.39
All patients
Nulliparas
Multiparas
May/June 1988 JOCNN
t h e umbilicus was 19.9 weeks
(Table 1). The fundus reached the
umbilicus slightly earlier in nul-
liparous women than in multipa-
Xiphoid rous women.
Process Although the findings of this
study support the notion that the
uterus reaches the umbilicus at
approximately 20 weeks of gesta-
tion (five lunar months), the study
has serious methodologic limita-
tions. These limitations include
the method used to calculate the
Umbilicus gestational interval; failure to con-
trol factors that may influence
fundal height, such a s maternal
bladder fullness, position during
the measurement, or obesity; in-
Pubic B o n e complete data collection in that
the majority of the patients in-
cluded in the original study did
not have the date the fundus
reached the umbilicus recorded;
variation in examiner skill be-
cause subjects were selected from
I RULE OF THIRDS resident physicians' clinics; exam-
iner bias in that examiners were
not blinded to the gestational in-
terval; and the retrospective na-
ture of the investigation. Thus, the
results of this study should be in-
terpreted cautiously.
Only 95 of the 418 subjects in the
The second study of the gesta-
original sample had this informa-
tional weeks at which the uterine
tion documented in their records.
fundus reaches the umbilicus was
The investigators assumed that
conducted by Jimenez et aL40This
all births occurred at 280 days of
study was a well-controlled, pro-
gestation. The interval between
spective investigation. Subjects
the date the fundus reached the
were limited to women who met
umbilicus and the day of delivery
the following criteria: known date
was subtracted from 280 days to
of the last menstrual period; regu-
estimate the gestational interval at
lar menstrual cycles, every 28 to
which the fundus reached the um-
32 days; no recent use of oral con-
bilicus. The mean gestational in-
traceptives; nonobese; anteflexed
terval at which the fundus reached
uterus at the first prenatal visit;
absence of maternal disease dur-
ing pregnancy; and singleton
fetus. Subjects were asked to re-
turn to the clinic weekly until the
N x SD fundus reached the umbilicus. Be-
fore examination, each subject
95 19.9 2.13 was asked to empty her bladder.
67 19.7 1.91 All subjects were examined by one
28 20.4 2.56 investigator, and the investigator
was blinded to the gestational in-
175
terval when assessing the rela-
tionship between the uterine
fundus and umbilicus.
The mean interval between the
date of the last normal menstrual
period and the date the fundus
reached the umbilicus was 16.6
weeks for those patients who were
examined weekly and 17.2 weeks
for those examined biweekly
(Table 2). These findings indicate
that the uterus reaches the umbi-
licus much earlier in gestation
than previously thought.
NURSING IMPLICATIONS
Assessment of uterine size by
plotting fundal height against the
anatomic landmarks on the mater-
nal abdomen is a vestige of a time
when tape measures and calipers
were not readily available and the
pattern of fundal growth in centi-
meters had not been described ad-
equately. Practice has changed
since that time. Today, tape mea-
sures are readily available and at
reasonable prices. More impor-
tantly, perinatal morbidity and
mortality rates can be reduced if
risk factors and complications are
recognized during the antepartal
period and the appropriate pre-
ventative, diagnostic, and thera-
peutic measures are initiated.41.42
To ensure early detection of risk
factors and potential complica-
tions, the nurse must be able to
identify deviations from normal as
early as possible in the pregnancy.
Because fundal height measure-
ments can assist nurses in identi-
fying serious pregnancy complica-
tions, the measurement obtained
must be as accurate as possible.
During early pregnancy, when
the uterus is still a pelvic organ
and cannot be palpated through
the maternal abdomen, uterine
size should be estimated in centi-
meters rather than by comparison
to fruit size. Average uterine size
in centimeters at each gestational
week in early pregnancy has been
176
Table 2. Gestational Interval Between the Date of the Last Normal Menstrual Period
and the Date the Fundus Reaches the Umbilicus in Weeks
Investigator N x
Jimenez, TYson, and Reisch4'
Weekly visits 23
visits 19
described by Hellman et al.43For
clinicians accustomed to describ-
ing uterine size in fruits, Nichols
provides a comparison of uterine
size in centimeters with fruits in
early pregnancy.44
After the fundus is palpable in
the maternal abdomen, fundal
height should be measured with a
tape measure. Calipers may also
be a useful technique of measuring
fundal height. However, calipers
a r e more expensive and not
readily available in most clinical
settings, and modern caliper stan-
dards have not been published.
Fundal height should be
I
measured by the same
clinician throughout
pregnancy whenever
possible.
Many techniques can be used to
measure fundal height with a tape
measure. However, superiority of
one measurement technique over
another has not been demon-
strated." Fundal height is usually
measured as the distance between
uppermost borders of the sym-
physis pubis and uterine fundus,
in the midline of the maternal ab-
domen, with t h e tape measure
held in contact with the skin of the
maternal abdomen. Regardless of
the measurement technique used,
consistency within and between
clinicians in measurement process
is essential. Recent studies indi-
cate that intraexaminer variability
is much less than interexaminer
SD Minimum Maximum
16.6 0.9 15 19
17.2 1.9 14 21
~ a r i a b i l i t y . ~ Thus,
~ ' ~ ~ ~fundal
~
height measurements should be
obtained by the same clinician
throughout pregnancy whenever
possible.
Bladder fullness also influences
fundal height m e a ~ u r e m e n t s . ~ ~ * ~ ~
Therefore, fundal height measure-
ments should be obtained within
30 minutes of when the woman
last voided.46 Recent studies also
indicate that maternal position
during the measurement (i.e.,
whether the patient's legs are ex-
tended or flexed and whether the
head of the exam table is elevated
o r flat) influences measure-
m e n t ~ . ~Thus,
~ , ~ ' measurements
should always be obtained with
the woman in the same position.
Although normative values of
fundal height measurements at
each gestational week have been
none of these stan-
dards was derived from a sample
of North American women. Pre-
vious investigators have recom-
mended that standards specific to
the target population be devel-
oped.4v50 If this is not possible and
nurses plan to adopt one of the
existing curves, the validity of the
curve in specific populations
should be tested, and the fundal
height should be measured using
the technique described by the
originator of the curve.
SUMMARY
Fundal height measurements
can assist the nurse in identifying
serious pregnancy complications.
Thus, accurate fundal height mea-
May/June 1988 JOCNN
surements are essential t o safe
clinical practice. Fundal h e i g h t
measurements should not be ob-
tained by simply comparing t h e
height of t h e uterine fundus with
landmarks on t h e maternal abdo-
men because uterine size and fun-
dal growth cannot be assessed ac-
curately. I n s t e a d , f u n d a l h e i g h t
measurements should be obtained
with a tape measure of a pelvime-
try caliper. In addition, t h e mea-
s u r e m e n t s s h o u l d be obtained
when t h e m a t e r n a l bladder is
empty, and t h e patient should be
in t h e same position e a c h time t h e
measurements are o b t a i n e d . Fi-
nally, m e a s u r e m e n t s s h o u l d be
o b t a i n e d by t h e same clinician
throughout pregnancy w h e n e v e r
possible.
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43.
41. Iffy, L., 1. Bilenki, and J.J. Appuz-
zio, et al. 1986. The role of obstet-
ric factors in perinatal mortality
trends. Int. J. Cynaecol. Obstet.
42. Dobson, P.C., D.A. Abell, and N.A.
Beischer. 1982. Antenatal preg-
177
 nancy complications and fetal
growth retardation. Aust. N. Z. J.
Obstet. Gynaecol. 22:203-05.
43. Hellman, L.M., M. Kobayashi, and
L. Fillisti, et al. 1969. Growth and
development of the human fetus
prior to the twentieth week of ges-
tation. Am. J. Obstet. Gynecol.
103:789-800.
44. Nichols, C. 1987. Dating preg-
nancy: Gathering and using a reli-
able data base. J. Nurse-Midwif.
32~195-204.
45. Bagger, P.V., P.S. Eriksen, and N.J.
Secher, et al. 1985. The precision
and accuracy of symphysis-fundus
distance measurements during
pregnancy. Acta Obstet. Gynecol.
Scand. 64:371-74.
46. Engstrom, J.L., K.G. Ostrenga, and
R.V. Plass. 1987. The effect of ma-
ternal bladder volume on fundal
height measurements. Unpub-
lished paper.
47. Worthen, N., and M. Bustillo. 1980.
Effect of urinary bladder fullness
on fundal height measurements.
Am. J. Obstet. Gynecol. 138:759-62.
48. Quill, J.E. 1982. The relationship
of maternal position to fundal
height measurements. Master’s
thesis: University of Colorado,
Denver.
49. Engstrom, J.L., L.J. Alsen, and
L.M. Kane, et al. 1987. The effect of
maternal position of fundal height
measurements. Unpublished paper.
50. Wise, D., and J.L. Engstrom. 1985.
The Dredictive validitv of fundal
heigit curves in the idkntification
of small- and large-for-gesta-
tional-age infants. JOCN Nurs.
14~87-92.
Address for correspondence: Janet L.
Engstrom, CNM, PhD, University of II-
linois at Chicago, College of Nursing,
845 S. Damen Avenue, Chicago, IL
60612.
Janet L. Engstrom is an assistant professor
in the Nurse-Midwifery Sequence, Depart-
ment of Maternal-Child Nursing, University
of Illinois at Chicago in Chicago, Illinois. Dr.
Engstrorn is a member of NAACOG, ACNM,
and ANA.

ADDENDUM
Standards for fundal height measurements obtained from women in the United States were
recently published in the following paper: Azziz, R., S. Smith, and S.Fabro. 1988. The development
and use of a standard symphysial-fundal height growth curve in the prediction of small for gesta-
tional age neonates. Int. J. Gynaecol. Obstet. 26:81-7. The following study also describes the
relationship between fundal height and anatomic landmarks on the maternal abdomen: Smibert, J.
1962. Aust. N.Z.J. Obstet. Gynaecol. 3:125-31.

Between May 1 and May 15, NAACOG will be moving to permanent office space in Washington,
D.C. When the move is complete, NAACOG’s new address will be 409 12th Street, S.W., Washing-
ton, DC 20024-2191, The organization’s telephone number (202)638-0026, and toll-free telephone
number, 1-800-533-8822, are expected to remain the same.
In addition to its street address, NAACOG can be contacted at P.O. Box 71437, Washington, DC
20024-1437. This post office box is being used currently and will remain in use during and after the
move.

178 May/June 1988 JOGNN