Objective: To assess the clinical effectiveness of the TRUFFLE monitoring protocol in a routine clinical setting. Secondary objectives were evaluating timing and indications for delivery, stratified by gestational age at Fetal Growth Restriction (FGR) diagnosis. Design: Retrospective cohort study. Setting: Tertiary Fetal Medicine Unit. Population or Sample: Singleton pregnancies diagnosed with FGR between 2013 and 2024. Methods: FGR was defined as an estimated fetal weight or abdominal circumference <10th centile with an elevated umbilical artery pulsatility index >95th centile, diagnosed before 36 weeks’ gestation. Exclusion criteria were multiple pregnancies, major fetal anomalies, delivery before 26 weeks, and absence of TRUFFLE protocol monitoring. Main outcome measures: Perinatal survival, interval from diagnosis to delivery, and delivery indications. Results: 196 pregnancies met inclusion criteria. Median gestational age at FGR diagnosis was 28 +1 (26 +2-30 +3) weeks and 30 +6 (28 +3-33 +3) at delivery. Overall intact survival was 92.3%, with 2.6% stillbirths and 5.2% neonatal deaths. Diagnosis prior to 26 weeks allowed longer pregnancy prolongation (31 days compared to 10.5 days; p<0.001). Below 32 weeks, the predominant trigger for delivery was abnormal computerised CTG (low STV). Above 32 weeks, abnormal umbilical artery Doppler and maternal indications became more frequent. Conclusions: The TRUFFLE monitoring protocol is clinically effective in managing early-onset FGR outside a trial environment, achieving comparable perinatal outcomes. Routine integration of both Doppler and cCTG STV monitoring, is crucial for optimal timing of delivery. Further research is needed to assess if more frequent or remote fetal monitoring to improve outcomes. Funding: No funding was received.