(White, Duncan, & Baumle, 2011)

ASSESSMENT OF FETAL
WELL-BEING
When complications arise in a pregnancy, more intense and
specific assessments of the fetus are required.
Ultrasound

Two-dimensional (2D) ultrasound allows visualization of

the uterine contents. The fetal assessments described in

the Prenatal Care chapter are also used. High-frequency,

inaudible sound waves are directed toward the uterus. The
sound waves reflected back are converted into a visual image
(Figure 2-1).
Ultrasound provides the following information.

First Trimester
• Early positive diagnosis of pregnancy about 5 or 6 weeks
after LMP.
• Identification of more than one fetus.
• Observation of cardiac activity at 21 days and respiratory movements about 11th week of gestation.
• Diagnosis of an ectopic pregnancy.
• Diagnosis of a molar pregnancy.
• Visualization of ultrasonic “soft” markers indicating chromosomal abnormalities (Woo, 2009).

Second and Third Trimester

• Location of pockets of amniotic fluid for retrieval of fluid
for testing.
• Measurement of biparietal diameter, femur length, overall
length (crown-heel and crown-rump), gestational age,
and intrauterine growth restriction (IUGR), formerly
intrauterine growth retardation.
• Detection of some fetal anomalies, especially anencephaly
and hydrocephalus.
• Detection of amniotic fluid volume, including
hydramnios, also known as polyhydramnios, (excessive
amniotic fluid) or oligohydramnios (deficiency of
amniotic fluid), either of which is frequently associated
with fetal anomalies.
• Identification of amniotic fluid pockets; a vertical pocket
of 2 cm is associated with normal fetal status.
• Location of the placenta, which is necessary
before an amniocentesis and to determine placenta
abnormalities.
• Determination of fetal position and presentation.
• Detection of fetal death; fetal heart beating is not
visualized, and the bones in the fetal head separate.
• Evaluation of cervical length.

Three- and four-dimensional (3-D and 4-D) ultrasound

is currently used to improve visualization of fetal anatomic
structures and to promote parental bonding. Pictures are
obtained with sound waves similar to 2-D, but 3-D images
are more life-like in appearance. 4-D ultrasounds are 3-D
images shown in rapid succession to view the image as if it is
moving. 2-D ultrasound is the standard, and benefits of 3- and
4-D images will be determined with more research (Lee &
Simpson, 2007; NIH, 2009).

Transabdominal Ultrasound
The mother is asked to have a full bladder when the ultrasound
is performed. This allows the other structures to
be assessed in relation to the bladder. The transducer is
moved slowly over the abdomen while the client lies on
her back. This position may cause shortness of breath or
supine hypotension syndrome. The procedure takes about
20 to 30 minutes.
Transvaginal Ultrasound
During a transvaginal ultrasound or endovaginal ultrasound,
a probe is inserted into the vagina and placed close
to the structures being imaged. This produces a clearer
image. The client is in the lithotomy position and has an
empty bladder. These scans assist with early detection of
ectopic pregnancies, fetal abnormalities in the first trimester,
and diagnosing congenital anomalies in the second
trimester (Woo, 2009).
Nonstress Test
A nonstress test (NST) assesses the well being of
the fetus by recording the fetal heart rate (FHR) and
determining increased heart rate with fetal movement.
Fetal movement indicates a well oxygenated fetus with
a healthy central and autonomic nervous system. An
NST requires an electronic fetal monitor to record fetal
movement and FHR accelerations (short-term increases
in FHR caused by fetal movement). Specific equipment
may vary. The mother reclines in a chair or in bed in
semi-Fowler’s or side-lying position. This noninvasive
test is used every day or once weekly as needed after
30 weeks gestation in high-risk clients (Figure 2-2).

The test is reactive if there are two accelerations of

15 beats/min, lasting 15 seconds in a 20-minute period. This
indicates that the fetus has adequate oxygenation and an intact
central nervous system.
The test is nonreactive if the criteria for reactive are not
met. This may indicate that the fetus is asleep or there are
problems with fetal oxygenation, and the health care provider
is notified. A repeat NST or additional testing is ordered to
determine fetal status.
An unsatisfactory test is identified if there is inadequate
fetal activity or the data cannot be interpreted. If decelerations
of the FHR are noted, the health care provider is notified
promptly.
Vibroacoustic Stimulation
Test
The vibroacoustic stimulation (VAS) test, also called the
fetal acoustic stimulation test (FAST) is used in conjunction
with the NST. A small, battery-operated device is placed on
the mother’s abdomen over the fetal head. A low-frequency
vibration and a buzzing sound are emitted from the device to
stimulate the fetus who had a nonreactive NST. The sounds
emitted last no more than 3 seconds and are repeated every
minute if no accelerations occur.
Biophysical Profile

The fetal biophysical profile (BPP) assesses five biophysical

variables: fetal breathing movement, fetal movements of
body or limbs, fetal tone (extension/flexion of extremities),
amniotic fluid volume, and reactive NST (Table 2-2). The first
four are assessed by ultrasound. A score of 8 or more shows
probable fetal well-being.

Modified Biophysical Profile

The modified biophysical profile (MBPP) assesses only
two of the variables of the BPP; the NST and the amniotic
fluid volume. The MBPP indicates positive fetal well-being if
the NST is reactive and the amniotic fluid volume is greater
than 5 cm. If either of these two assessments is abnormal,
the complete BPP is completed. The MBPP saves time and
decreases the cost of fetal surveillance.
Fetal Movements
From the time of quickening (16 to 20 weeks), fetal movement
is reassuring to the mother. Counting fetal movement
daily provides evidence that the fetus is not having difficulty.
One method is to count fetal movements for 10 minutes
three times a day. Another, which is the Cardiff method,
requires the mother to count fetal movements at the same
time each day until 10 movements are felt. The start and stop
times are recorded.
The health care provider should be contacted if there are:
• fewer than 10 movements in 12 hours
• no movements for 8 hours
• sudden violent movements followed by reduced movements
Biochemical Assessments
Three tests include maternal serum alpha-fetoprotein, estriol,
and human placental lactogen.
Maternal Serum Alpha-Fetoprotein
Maternal serum alpha-fetoprotein (MSAFP) identifies some
birth defects and chromosomal anomalies during the antepartum
period. AFP is found in maternal serum about 7 weeks’
gestation and rises steadily until the last trimester. Women
should have the test between 16 and 18 weeks’ gestation.
Because there is a normal range for each week of pregnancy,
a correct gestational age is important to the interpretation of
the test.
If the MSAFP level is high, it indicates a fetal open neural
tube defect, multiple gestation, Rh isoimmunization, maternal
diabetes mellitus, or fetal distress and death. If the MSAFP
level is low, the fetus may have Down syndrome or there may
be a maternal hypertensive state.
Estriol
Maternal estriol level indicates fetoplacental function. Essential
precursors from the fetal adrenal glands are converted by
the placenta to estriol. The level in maternal serum and urine
usually increases throughout pregnancy, so there must be a
series of tests throughout pregnancy. Gradual increase in the
maternal estriol level indicates that the fetal adrenal glands and
the placenta are functioning normally.
Human Placental Lactogen
Human placental lactogen (hPL) increases throughout pregnancy
correlating with increased fetal weight.
Amniocentesis

Amniocentesis is a procedure in which a needle is inserted

through the abdomen into the amniotic sac. Amniotic fluid

is withdrawn and sent to the laboratory for testing. At 14 to

16 weeks’ gestation, an amniocentesis may be performed for
diagnosis of genetic diseases or birth defects if the mother is
older than 35 or either parent has a family history of genetic
disease (Figure 2-3).
Later in pregnancy, amniocentesis is most often used to
determine fetal lung maturity. In a high-risk pregnancy when
preterm delivery of the fetus is a possibility, the physician
will often try to maintain the pregnancy until the lungs are
mature.
An ultrasound is used to determine the location of pockets
of fluid so the fetus, placenta, and cord are not damaged.
The nurse assists the physician performing the amniocentesis
and provides emotional support to the client.
Tests on Amniotic Fluid
Both the fluid and the cells in the amniotic fluid are used for
testing. The fluid should be clear, colorless, and may have
flecks of vernix caseosa floating in it.
Lecithin/Sphingomyelin Ratio Surfactant is phospholipids
in the lungs that lower surface tension and stabilize the
alveoli so they do not collapse on exhalation. The ratio of two
phospholipids, which are components of surfactant, lecithin
and sphingomyelin (L/S ratio), determines the maturity of
the lungs.

Early in pregnancy, the lecithin level is low and the sphingomyelin

level is high. At about 32 weeks’ gestation, this relationship
begins to change. By 35 weeks’ gestation, the lecithin
level is twice as high as the level of sphingomyelin. An L/S
ratio of 2:1 is considered indicative of lung maturity.
Some conditions may accelerate lung maturation, such as
severe pregnancy-induced hypertension (PIH), chronic maternal
hypertension, or prolonged rupture of membranes. Diabetes
and Rh isoimmunization seem to delay fetal lung maturity.
Phosphatidylglycerol Another phospholipid in surfactant,
phosphatidylglycerol (PG), appears in the amniotic fluid
when the lungs are mature, about 35 weeks’ gestation.
Bilirubin In clients with Rh incompatibility, there is bilirubin
in the amniotic fluid. The level of bilirubin corresponds to
the degree of fetal anemia.
Sex Determination The sex of the fetus can be accurately
determined by cell studies. This is important in sex-linked
genetic abnormalities.
Chorionic Villi Sampling
In chorionic villi sampling (CVS), samples of chorionic villi
from the developing placenta are obtained to assess for the
same genetic disorders as in amniocentesis. CVS is performed
between 8 and 10 weeks’ gestation. Either a vaginal or abdominal
approach is used (Figure 2-4).
Contraction Stress Test
A contraction stress test (CST) evaluates the respiratory function
of the placenta. During a uterine contraction, blood flow
to the intervillous spaces is momentarily reduced, thus decreasing
oxygen available to the fetus. A healthy fetus tolerates this
well. Fetal hypoxia, myocardial depression, and a decrease in
FHR occur if the placenta’s reserve is not sufficient. This test is used with clients who have heart disease,
hypertension, gestational hypertension, sickle-cell anemia, previous
stillbirths, Rh sensitization, or a nonreactive NST. It
is most often performed on the client with diabetes (chronic or
gestational).
The vascular changes that take place in diabetes also
affect the placenta. Vascular changes in the placenta cause
placental insufficiency, so the fetus will not tolerate a CST
well. Contraindications for use of this test are placenta previa,
abruptio placenta, premature rupture of membranes, a history
of preterm labor, or previous cesarean birth.
The uterine contractions are induced by either intravenous
oxytocin or breast self-stimulation. An electronic fetal
monitor provides continuous information of the FHR and
uterine contractions. The FHR is observed for decelerations
with the contractions. A 15-minute baseline recording on the
fetal monitor is obtained before contractions are stimulated.
Intravenous oxytocin is given piggyback to another IV so it
can be stopped when necessary. When three uterine contractions
lasting 40 to 60 seconds occur in 10 minutes, the oxytocin
is stopped. If three late decelerations occur, the oxytocin
is stopped.
For nipple stimulation, warm washcloths are applied to
the breasts and/or one nipple is manually rolled by the client.
When three uterine contractions lasting 40 to 60 seconds occur
in 10 minutes, the stimulation is discontinued. If a decrease
in FHR occurs with a contraction, the nipple stimulation is
stopped.
A negative CST with no late decelerations indicates
the fetus is well-oxygenated. The fetus is able to tolerate the
hypoxia of uterine contractions. A CST with late decelerations
that occur with at least 50% of contractions is considered a
positive CST, which indicates fetoplacental exchange may be
compromised. The CST is more invasive and time consuming,
so the BPP or MBPP is the preferred method of determining
fetal well-being.
Electronic Fetal Monitoring

Electronic fetal monitoring (EFM) provides a visual record of

the FHR in relation to the uterine contractions. It allows early
detection of fetal distress and abnormal uterine activity. Highrisk
clients and clients with a problem in their pregnancy are
candidates for EFM. Most birthing places routinely have all
clients on EFM.
External (Indirect) Monitoring
A tocodynamometer (tocotransducer) that records uterine
activity is placed on the mother’s abdomen, on the fundus of
the uterus. The least amount of tissue is between the dynamometer
and fundus at this location so activity is recorded
more accurately. With this device, contraction frequency, the
amount of time between the beginning of one contraction
to the beginning of the next contraction, is determined. The
nurse palpates the client’s abdomen during a contraction to
determine the contraction strength.
An ultrasound transducer that records the FHR is
placed over the maternal abdomen in a location where the
fetal heart is heard. When the head is the presenting part,
the fetal heart is usually best heard just below the umbilicus
on one side or the other. With this device, sound waves are
bounced off the fetal heart and picked up and displayed as a

rate by the monitor. FHR baseline and periodic/nonperiodic

changes of the FHR are determined. Elastic bands are placed
around the maternal abdomen to hold the transducers in
place (Figure 2-5A).
Internal (Direct) Monitoring
This is a more reliable method then external monitoring.
An EKG electrode to directly monitor FHR is attached to
the fetal presenting part (head) (Figure 2-5B). For this to be
initiated, the membranes must be ruptured, the cervix must
be dilated at least 2 cm, the presenting part must be down
against the cervix, and the presenting part must be known.
Only a person specially trained for this procedure should
perform it.
Either the external tocodynamometer or an intrauterine
catheter may be used to assess uterine contractions. A thin,
flexible polyethylene catheter filled with sterile, distilled water
is inserted into the amniotic fluid in the uterus. Other catheters
used are solid and flexible. In either case, the catheter is
inserted between the fetus and the uterine wall into a pocket
of amniotic fluid.
The increased pressure on the fluid during a contraction
is translated into an electrical signal. This provides reliable
information about the contractions. Sterile technique is

used when inserting both the scalp electrode and the

catheter.
Interpretations
The National Institute of Child Health and Human Development
(NICHD) recommended EFM interpretations
as follows (Macones, Hankins, Spong, Hauth, & Moore,
2008). These are recommended for use in labor and delivery
units across the nation to achieve a more consistent use
of terms.
Baseline Rate Baseline rate is the average FHR during a
10-minute period. The normal rate is 110 to 160 beats/minute.
A rate greater than 160 beats/minute is tachycardia, and a rate
below 110 beats/minute is bradycardia.
Baseline Variability Variability is determined by the irregular
fluctuations of the FHR, quantified as the peak to trough
amplitude noted in beats per minute (bpm) that occurs during
a 10-minute period. These are classified into one of four categories:
absent (no difference), minimal (> 0 to </=5 bpm),
moderate (6 to </=25 bpm) or marked (>25 bpm).
Accelerations Accelerations are short-term increases in
FHR and are usually caused by fetal movement. There is a
change in FHR that is a visible abrupt increase: (onset of
acceleration to peak less than 30 seconds) by at least 15 bpm,
lasting at least 15 seconds. The presence of accelerations indicates
the fetus has a pH of at least 7.2, which is normal. The
fetus is not in an acidotic state.
Early Deceleration Early decelerations are gradual reductions
in FHR that begin early with the contraction and
typically mirror the contraction. Head compression during
contractions causes a decrease in cerebral blood flow, which
stimulates a vagal response and causes the heart rate to
decrease. The decreased heart rate displays on the monitor as
an early deceleration. As pressure is relieved, the FHR returns
to normal by the end of the contraction. No intervention is
required (Figure 2-6).
Late Deceleration Late decelerations are reductions in
FHR that begin at or after the peak of the contraction and
increase to the baseline level after the contraction has ceased,
caused by uteroplacental insufficiency. When a timing discrepancy
exists and early versus late decelerations are in
question, the nadir (the lowest point) of the deceleration
and the peak of the contraction will differentiate early from
late. Oxygen administered to the mother may be started. Late
decelerations should be reported to the health care provider
(Figure 2-6).
Variable Deceleration Variable decelerations are abrupt
reductions in FHR that have no relationship to contractions
of the uterus. They occur when compression of the umbilical
cord reduces blood flow between fetus and placenta. A
change in the mother’s position may take pressure off the
cord. When pressure is relieved, the FHR abruptly returns
to the baseline. These should also be reported immediately
(Figure 2-6).