Fetal growth restriction (FGR) is associated with an increased risk of perinatal morbidity and mortality and has lifetime implications for the risk of chronic medical conditions. Antenatal diagnosis of FGR remains poor, with the majority of cases remaining undiagnosed. Although several factors contribute to the underdiagnosis of FGR, the error in ultrasound estimation of fetal weight (EFW) generally is not considered in clinical practice. In this commentary, we suggest that the intrinsic, or systematic, error in ultrasound EFW is a significant factor contributing to the underestimation of fetuses predicted to have FGR and should be incorporated into screening and surveillance recommendations. To illustrate this point, we present an analytic model of published data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies characterizing and quantifying the impact of the systematic error in ultrasound EFW on the underdiagnosis of FGR. Independent of the centile at which the risk of adverse outcome related to FGR begins, whether the 10th, 5th or 3rd percentile, our analysis suggests the need to modify to the current paradigm for identifying and responding to fetuses estimated to be at risk.