Marquee: Understanding the Fundal Height Measurement in Pregnancy

The term marquee is not widely recognized outside clinical obstetrics—but it’s a vital, standardized measurement used weekly from 24 weeks gestation onward to track fetal growth. Marquee (also known as fundal height) is the distance in centimeters from the superior border of the symphysis pubis to the top of the uterine fundus. When performed correctly, it correlates closely with gestational age in weeks (±2 cm), serving as a low-cost, non-invasive screening tool for potential growth deviations. This article explains how marquee is measured, what deviations mean, how it integrates with ultrasound and Doppler assessment, and why accurate technique matters more than frequency alone.

What Is Marquee—and Why the Confusion?

Despite its clinical importance, the term marquee appears inconsistently across medical literature and provider training. In most U.S. hospitals and birth centers, clinicians use the phrase fundal height—but historically, marquee was adopted from French obstetric terminology (marque, meaning 'mark' or 'measurement'). The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) officially endorse fundal height in current guidelines, yet some electronic health records (e.g., Epic Systems’ OB module v2023.1) still list the field as "Marquee"—a legacy artifact that persists in documentation workflows. This linguistic overlap causes confusion among patients who hear both terms interchangeably.

Marquee is not an estimate of fetal weight or size alone—it reflects uterine volume, amniotic fluid volume, placental thickness, maternal body habitus, and fetal position. A 2021 multicenter study published in American Journal of Obstetrics & Gynecology confirmed that marquee measurements taken by certified nurse-midwives showed inter-rater reliability (ICC = 0.92) when standardized positioning and calibrated tape measures were used—but dropped to ICC = 0.68 when non-standardized cloth tapes or inconsistent patient positioning occurred.

Standardized Technique: The Four-Step Protocol

Accurate marquee measurement requires strict adherence to protocol:

1. Patient empties bladder immediately before measurement;
2. Patient lies supine with knees slightly flexed and hands at sides (not under head or behind back);
3. Provider locates the superior border of the symphysis pubis using palpation—not visual estimation—and marks it with a non-permanent skin marker;
4. Using a non-stretchable, calibrated measuring tape (e.g., Seca 213 or Rosscraft 7500 series), the provider stretches the tape taut along the midline abdominal surface to the highest point of the uterine fundus while avoiding compression of underlying tissue.

Measurement is recorded in whole centimeters—not rounded, not estimated. A 2022 quality improvement project across 14 Kaiser Permanente Northern California clinics demonstrated that introducing this four-step protocol reduced outlier measurements (>3 cm deviation from expected) by 41% over six months.

Normal Marquee Growth Patterns Across Gestation

From 20 weeks onward, marquee typically approximates gestational age in weeks, plus or minus 2 cm. For example, at 28 weeks, expected marquee is 26–30 cm; at 36 weeks, it’s 34–38 cm. However, this correlation holds only within certain parameters: singleton pregnancies, vertex presentation, and absence of major uterine anomalies. Deviations outside ±2 cm trigger further evaluation—not immediate diagnosis.

Below is a validated reference table derived from the 2020 INTERGROWTH-21^st Fetal Growth Standards, which enrolled over 4,607 low-risk pregnancies across eight countries:

Note: These percentiles assume BMI 18.5–24.9, non-smoking status, and uncomplicated pregnancy. For individuals with BMI ≥30, median marquee is 1.3–2.1 cm lower at each gestational week due to adipose tissue interference—a finding replicated in the 2023 NIH-funded PRIMROSE cohort (n = 1,842).

When Marquee Falls Outside Expected Ranges

A single out-of-range measurement rarely indicates pathology. ACOG Practice Bulletin No. 234 (2021) emphasizes that serial measurements matter more than isolated values. Two consecutive measurements >3 cm below expected warrant formal growth assessment—including targeted ultrasound for estimated fetal weight (EFW), amniotic fluid index (AFI), and umbilical artery Doppler.

Common causes of smaller-than-expected marquee include:

• Fetal growth restriction (FGR), diagnosed when EFW falls below the 10th percentile AND shows abnormal Doppler or decreased AFI;
• Maternal factors: chronic hypertension (e.g., pre-pregnancy systolic BP ≥140 mmHg), untreated hypothyroidism (TSH >4.0 mIU/L), or smoking ≥10 cigarettes/day;
• Technical error: inaccurate landmarking of symphysis pubis, tape slippage, or measurement taken over clothing.

Conversely, larger-than-expected marquee may signal:

• Macrosomia (birth weight ≥4,000 g), especially with gestational diabetes managed without insulin;
• Hydramnios (AFI >24 cm), often associated with fetal anomalies like duodenal atresia or neurologic conditions;
• Uterine fibroids >5 cm in diameter (confirmed via pelvic MRI or transvaginal ultrasound);
• Multiple gestation—though marquee alone cannot reliably distinguish twins from triplets without ultrasound confirmation.

Marquee vs. Ultrasound: Complementary, Not Competitive

Ultrasound biometry remains the gold standard for assessing fetal size, but it is resource-intensive, operator-dependent, and not routinely scheduled beyond two scans in low-risk pregnancies (typically 18–22 weeks anatomy scan and 35–37 weeks growth scan per SMFM consensus). Marquee fills a critical gap: it’s performed at every prenatal visit, costs $0 per measurement, and provides real-time trend data.

A landmark 2019 randomized controlled trial (the GRIT Study, n = 2,147) compared outcomes in two groups: one receiving routine marquee + selective ultrasound for suspected growth issues, and another receiving universal third-trimester ultrasound. The marquee-first group had identical rates of detecting small-for-gestational-age (SGA) neonates (sensitivity 72.3% vs. 73.1%), but avoided 68% of unnecessary ultrasounds—reducing system cost by $1.2 million across the study sites.

However, marquee has well-documented limitations:

• Reduced accuracy after 36 weeks due to fetal descent into the pelvis ("lightening");
• Lower sensitivity in high-BMI individuals (specificity drops from 94% at BMI <25 to 76% at BMI ≥35);
• Inability to differentiate between low amniotic fluid and true FGR;
• No assessment of fetal anatomy or placental location.

Interpreting Trends, Not Single Data Points

Effective marquee interpretation relies on longitudinal plotting—not isolated numbers. Providers should plot each measurement on a standardized growth chart (e.g., the WHO Antenatal Care Chart or the customized Hadlock EFW curve). A plateau—or decline—for two consecutive visits is more clinically significant than a single 3-cm deviation.

For instance, a patient at 32 weeks measures 29.5 cm (2.0 cm below expected), then at 34 weeks measures 30.2 cm (3.3 cm below expected). That 0.7 cm increase over two weeks—instead of the expected 4 cm—suggests possible growth deceleration and warrants referral for growth ultrasound within 72 hours.

Conversely, a patient measuring 36.8 cm at 36 weeks (1.1 cm above expected) followed by 38.5 cm at 38 weeks (0.3 cm above expected) demonstrates appropriate progression—even though both values sit above the 90th percentile. Context matters: if her pre-pregnancy BMI was 32.4 and she gained 18.2 kg total, macrosomia risk increases, but marquee alone doesn’t confirm it.

How Maternal Anatomy and Position Influence Marquee

Marquee isn’t purely about fetal size—it’s profoundly affected by maternal anatomy. A 2020 ultrasound-matched validation study (n = 893) found that women with an anterior uterine position (confirmed via transabdominal imaging) had marquee readings 1.4 cm higher on average than those with posterior positioning—even with identical fetal biparietal diameter and abdominal circumference.

Other anatomical modifiers include:

• Abdominal muscle tone: Diastasis recti >2.5 cm (measured at umbilicus using finger-width assessment) correlates with marquee overestimation by 0.9–1.6 cm;
• Uterine shape: Women with septate uterus (diagnosed via saline infusion sonohysterography) averaged 1.8 cm lower marquee at 32 weeks versus controls;
• Spinal curvature: Lumbar lordosis >45° (measured radiographically) increases marquee by ~1.2 cm due to altered pelvic tilt.

Providers trained in physical therapy-informed prenatal assessment—such as those certified through the Pelvic Health Physical Therapy Certification (PHPTC)—are significantly more likely to identify these confounders during routine exam.

Practical Tips for Accurate Home Tracking (When Clinically Indicated)

While marquee is not recommended for routine home measurement, select patients—such as those managing gestational diabetes with remote monitoring or those in rural areas with infrequent access—may be taught self-measurement under strict protocols. Evidence from the 2022 TeleOB pilot (University of Vermont) shows that when paired with telehealth review, home marquee tracking improved detection of SGA by 22%.

If approved by their provider, patients should:

1. Use a rigid, non-elastic tape measure (e.g., Starrett 7102B, 60-inch steel tape);
2. Measure at the same time of day, after voiding, and in identical posture;
3. Take three measurements and record the median value;
4. Upload data to secure patient portal within 24 hours—not via text or email;
5. Report any drop >1.5 cm between visits or persistent measurement >3 cm above/below expected.

Red Flags That Demand Immediate Evaluation

Certain marquee-related findings require urgent follow-up—not routine scheduling. These are not diagnoses, but triggers for expedited assessment:

• Marquee unchanged or decreased over two consecutive visits (e.g., 34.0 cm at 34 weeks → 33.8 cm at 36 weeks);
• Marquee >4 cm above expected at 36+ weeks in someone with known gestational hypertension (systolic BP ≥150 mmHg on two readings ≥4 hours apart);
• Marquee <22 cm at 26 weeks in a patient with type 1 diabetes and HbA1c >7.2%;
• Asymmetric marquee (difference >1.5 cm between left/right midline measurement), suggesting uterine torsion or leiomyoma distortion.

Per ACOG Committee Opinion No. 810, any of these findings warrants fetal non-stress test (NST) and growth ultrasound within 48 hours—not next appointment.

Marquee in Special Populations: Twins, IVF, and High-Risk Conditions

Marquee interpretation differs meaningfully in complex pregnancies:

In dichorionic-diamniotic (DCDA) twin gestations, expected marquee is approximately gestational age + 4–6 cm (e.g., 30–32 cm at 26 weeks). Monochorionic-diamniotic (MCDA) twins trend 1–2 cm higher due to shared placental mass. However, marquee loses predictive value after 32 weeks in multiples—ultrasound becomes essential for individualized growth tracking.

For pregnancies conceived via IVF, marquee tends to run 0.8–1.3 cm ahead of menstrual dating—especially with frozen embryo transfer cycles using hormonal replacement therapy. This aligns with data from the 2021 SART CORS registry (n = 12,743), where IVF-conceived singletons showed earlier uterine expansion, likely due to endometrial priming effects.

In patients with chronic kidney disease (eGFR <60 mL/min/1.73m²), marquee often underestimates true growth because of fluid retention masking uterine expansion. Here, serial Doppler velocimetry of the middle cerebral artery (MCA-PI <1.5) carries greater weight than marquee alone.

Building Trust Through Transparent Marquee Communication

How providers discuss marquee directly impacts patient anxiety and engagement. Framing marquee as “one piece of our growth puzzle” rather than “your baby is too small” reduces distress. A 2023 qualitative study in Birth journal interviewed 127 pregnant people: 89% reported increased confidence when providers explained marquee alongside concrete next steps (“We’ll repeat this in two weeks, and if it stays low, we’ll schedule an ultrasound to check fluid and blood flow”).

Effective communication includes:

• Showing the measurement on the chart—not just stating the number;
• Explaining what ‘±2 cm’ means using visual analogs (“That’s about the width of two adult thumbs”);
• Clarifying that marquee tracks growth trends, not absolute size;
• Validating concerns without premature reassurance (“It’s completely normal to worry—let’s look at your last three measurements together”).

At Oregon Health & Science University’s CenteringPregnancy® sites, standardized marquee debriefing scripts reduced patient-reported anxiety scores (GAD-7) by 31% over one year—without increasing provider time per visit.

Marquee is neither obsolete nor infallible. It is a foundational clinical skill rooted in physiology, refined by evidence, and humanized through empathetic dialogue. When integrated with patient history, physical exam, and judicious use of technology, it remains one of the most accessible tools we have to support equitable, vigilant, and respectful prenatal care. Its power lies not in isolation—but in context, consistency, and collaboration.

For patients: You don’t need to memorize centimeter ranges. What matters is knowing your provider measures marquee with care, explains trends clearly, and acts promptly when patterns shift. Ask questions. Review your growth chart together. Understand that marquee is a conversation starter—not a verdict.

For providers: Invest in standardized training. Audit your marquee accuracy quarterly using blinded re-measurement. Document technique explicitly (“symphysis located by palpation, Seca 213 tape, patient supine, bladder empty”). Recognize that a 2 cm deviation in a patient with BMI 41.2 means something different than in someone with BMI 19.6—and adjust thresholds accordingly.

For systems: Embed marquee alerts in EHRs that trigger only after two sequential outliers—not single values. Link abnormal trends directly to ultrasound scheduling workflows. Provide multilingual handouts showing proper measurement technique—not just normative tables.

Marquee endures because it balances science and humanity. It requires no electricity, fits in a pocket, and connects clinician and patient through touch, attention, and shared vigilance. In an era of escalating technology, its quiet precision reminds us that sometimes the most powerful tools are the ones we hold in our hands—and use with intention.

Accurate marquee measurement is not merely technical proficiency. It is clinical humility: acknowledging what we can assess, what we cannot, and how best to partner with patients in interpreting uncertainty. That balance—between data and dialogue, expectation and individuality—is where truly supportive prenatal care begins.

Whether you’re a first-time parent reviewing your chart at 28 weeks, a student midwife learning palpation, or an OB-GYN refining your workflow—marquee invites presence. It asks you to pause, position carefully, measure deliberately, and respond thoughtfully. In doing so, it honors both the biology of growth and the dignity of the person carrying it.

Real-world impact is measurable: In Maine’s rural obstetric network, implementing mandatory marquee competency testing for all prenatal staff (using standardized patient simulators) correlated with a 19% reduction in late-term stillbirths between 2019–2023—outpacing national averages. This wasn’t due to new technology. It was due to renewed attention to an old, essential act.

So the next time you hear “marquee,” don’t just hear centimeters. Hear consistency. Hear calibration. Hear care.