Maternal and Child Health Nursing (NCM 65):

Nursing care during normal

Pregnancy & care of
developing fetus
Ms. Grace Bautista | Sept. 14, 2021

OUTLINE • End of 20th gestational week

I. Fetal Growth and Development
• End of 24th gestational week (second trimester
II. Embryonic and Fetal Structures
A. Circulation • End of 28th gestational week
B. Origin and Development of Organ Systems
C. Critical Periods of Fetal Growth • End of 32nd gestational week
III. 2020 Natl Health Goals r/t Fetal Growth
• End of 36th gestational week
IV. Assessing Fetal Growth and Development
V. Nursing Diagnoses: Fetal Growth and Development • End of 40th gestational week (third trimester)
VI. Nursing Outcomes: Fetal Growth and Development
VII. Implementing Nursing Care
VIII. Evaluating Nursing Care

I. FETAL GROWTH AND DEVELOPMENT

• Stages of development
1. Fertilization
o (also referred to as conception and
impregnation): union of ovum and
spermatozoon
o This usually occurs in the outer third of a
fallopian tube, termed the ampullar
portion.
o only one of a woman’s ova reaches
maturity each month.
o ovum is capable of fertilization for only
about 24 hours (48 hours at the most)
o functional life of a spermatozoon is also
about 48 hours, possibly as long as 72
hours
o the total critical time span during which
sexual relations must occur for fertilization
to be successful is about 72 hours (48
hours before ovulation plus 24 hours
afterward
2. Implantation II. EMBRYONIC AND FETAL STRUCTURES
o contact between growing structure and 1. THE DECIDUA OR UTERINE LINING
uterine endometrium, approximately 8 to
10 days after fertilization 2. CHORIONIC VILLI

3. THE PLACENTA

A. CIRCULATION
4. ENDOCRINE FUNCTION

5. PLACENTAL PROTEINS

• End of fourth gestational week

• End of eighth gestational week

• End of 12th gestational week (first trimester)

• End of 16th gestational week

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6. THE AMNIOTIC MEMBRANES
7. THE AMNIOTIC FLUID
8. THE UMBILICAL CORD
B. ORIGIN AND DEVELOPMENT OF ORGAN SYSTEMS
9. STEM CELLS
10. ZYGOTE GROWTH
11. PRIMARY GERM LAYERS
12. CARDIOVASCULAR SYSTEM
o One of the first systems to become functional in
intrauterine life. Simple blood cells joined to the walls of
the yolk sac progress to become a network of blood
vessels and a single heart tube, which forms as early as
the 16th day of life and beats as early as the 24th day
o The septum that divides the heart into chambers
develops during the sixth or seventh week; heart valves
develop in the seventh week. The heartbeat may be
heard with a Doppler instrument as early as the 10th to
12th week of pregnancy.
o An electrocardiogram (ECG) may be recorded on a
fetus as early as the 11th week, although early ECGs
are not accurate until conduction is more regulated at
about the 20th week of pregnancy.
o The heart rate of a fetus is affected by oxygen level,
activity, and circulating blood volume, just as in
adulthood. After the 28th week of pregnancy, when the
sympathetic nervous system matures, the heart rate
stabilizes, and a consistent heart rate of 110 to 160
beats/min is assessed.
o Fetal Hemoglobin Fetal hemoglobin differs from adult
hemoglobin in several ways
o It has a different composition (two α and two γ
chains compared with two α and two β chains
of adult hemoglobin).
o It is also more concentrated and has greater
oxygen affinity, two features that increase its
efficiency. Because hemoglobin is more
concentrated, a newborn’s hemoglobin level is
about 17.1 g/100 ml compared with a normal
adult level of 11 g/100 ml; a newborn’s
hematocrit is about 53% compared with a
normal adult level of 45%.
o The change from fetal to adult hemoglobin
levels begins before birth (γ cells are
exchanged for β cells), but the process is still
not complete at birth.
o Major blood dyscrasias, such as sickle cell
anemia, tend to be defects of the β-hemoglobin
chain, which is why clinical symptoms of these
disorders do not become apparent until the
bulk of fetal hemoglobin has matured to adult
hemoglobin, at about 6 months of age
o Blood arriving at the fetus from the placenta is highly
oxygenated. This blood enters the fetus through the
umbilical vein (which is still called a vein even though it
carries oxygenated blood because the direction of the
blood is toward the fetal heart).
o Specialized structures present in the fetus then shunt
blood flow to first supply the most important organs of
the body: the liver, heart, kidneys, and brain.
o Blood flows from the umbilical vein to the ductus
venosus, an accessory vessel that discharges
oxygenated blood into the fetal liver, and then connects
to the fetal inferior vena cava so oxygenated blood is
directed to the right side of the heart.
o Because there is no need for the bulk of blood to pass
through the lungs, the bulk of this blood is shunted as it
enters the right atrium into the left atrium through an
opening in the atrial septum called the foramen ovale.
o From the left atrium, it follows the course of adult
circulation into the left ventricle, then into the aorta, and
out to body parts. A small amount of blood that returns
to the heart via the vena cava does leave the right
atrium by the adult circulatory route; that is, through the
tricuspid valve into the right ventricle and then into the
pulmonary artery and lungs to service the lung tissue.
However, the larger portion of even this blood is
shunted away from the lungs through an additional
structure, the ductus arteriosus, directly into the
descending aorta.
o As the majority of blood cells in the aorta become
deoxygenated, blood is transported from the descending
aorta through the umbilical arteries (which are called
arteries because they carry blood away from the fetal
heart) back through the umbilical cord to the placental
villi, where new oxygen exchange takes place.
o At birth, an infant’s oxygen saturation level is 95% to
100% and pulse rate is 80 to 140 beats/min. Because
there is a great deal of mixing of blood in the fetus, the
oxygen saturation level of fetal blood reaches only about
80%.
o A normal fetal heart rate is 110 to 160 beats/min,
supplying needed oxygen to cells. Even with this low
blood oxygen saturation level, however, carbon dioxide
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 does not accumulate in the fetal system because it
rapidly diffuses into maternal blood across a favorable
placental pressure gradient.
13. RESPIRATORY SYSTEM
o By the end of the fourth week, a septum begins to divide
the esophagus from the trachea. At the same time, lung
buds appear on the trachea. Until the seventh week of
life, the diaphragm does not completely divide the
thoracic cavity from the abdomen.
o At the third week of intrauterine life, the respiratory and
digestive tracts exist as a single tube. Like all body
tubes, initially, this forms as a solid structure, which then
canalizes (i.e., hollows out). By the end of the fourth
week, a septum begins to divide the esophagus from
the trachea.
o At the same time, lung buds appear on the trachea.
Until the seventh week of life, the diaphragm does not
completely divide the thoracic cavity from the abdomen.
This causes lung buds to extend down into the
abdomen, reentering the chest only as the chest’s
longitudinal dimension increases and the diaphragm
becomes complete (at the end of the seventh week).
o Other important respiratory developmental milestones
include:
1. Spontaneous respiratory practice movements
begin as early as 3 months gestation and
continue throughout pregnancy.
2. Specific lung fluid with a low surface tension
and low viscosity forms in alveoli to aid in
expansion of the alveoli at birth; it is rapidly
absorbed shortly after birth.
3. Surfactant, a phospholipid substance, is
formed and excreted by the alveolar cells of
the lungs beginning at approximately the 24th
week of pregnancy. This decreases alveolar
surface tension on expiration, preventing
alveolar collapse and improving the infant’s
ability to maintain respirations in the outside
environment at birth (Rojas-Reyes, Morley, &
Soll, 2012).
o Surfactant has two components: lecithin and
sphingomyelin. Early in the formation of surfactant,
sphingomyelin is the chief component. At approximately
35 weeks, there is a surge in the production of lecithin,
which then becomes the chief component by a ratio of
2:1. As a fetus practices breathing movements,
surfactant mixes with amniotic fluid. Using an
amniocentesis technique, an analysis of the
lecithin/sphingomyelin (L/S) ratio in surfactant (whether
lecithin or sphingomyelin is the dominant component) is
a primary test of fetal maturity.
o Respiratory distress syndrome, a severe breathing
disorder, can develop if there is a lack of surfactant or it
has not changed to its mature form at birth
o Any interference with the blood supply to the fetus, such
as placental insufficiency or maternal hypertension, may
raise steroid levels in the fetus and enhance surfactant
development.
o Synthetically increasing steroid levels in the fetus (e.g.,
the administration of betamethasone to the mother late
in pregnancy) can also hurry alveolar maturation and
surfactant production without interfering with permanent
lung function prior to a preterm birth (Smith, 2016).
14. NERVOUS SYSTEM
o A neural plate (a thickened portion of the ectoderm) is
apparent by the third week of gestation.
o All parts of the brain (cerebrum, cerebellum, pons, and
medulla oblongata) form in utero, although none are
completely mature at birth.
o Like the circulatory system, the nervous system begins
to develop extremely early in pregnancy.
o A neural plate (a thickened portion of the ectoderm) is
apparent by the third week of gestation. The top portion
differentiates into the neural tube, which will form the
central nervous system (brain and spinal cord), and the
neural crest, which will develop into the peripheral
nervous system.
o All parts of the brain (cerebrum, cerebellum, pons, and
medulla oblongata) form in utero, although none are
completely mature at birth. Brain growth continues at
high levels until 5 or 6 years of age.
o Brain waves can be detected on an
electroencephalogram (EEG) by the eighth week.
o The eye and inner ear develop as projections of the
original neural tube. By 24 weeks, the ear is capable of
responding to sound, and the eyes exhibit a pupillary
reaction, indicating sight is present.
o The neurologic system seems particularly prone to insult
during the early weeks of the embryonic period and can
result in neural tube disorders, such as a meningocele
(i.e., herniation of the meninges), especially if there is
lack of folic acid (which is contained in green leafy
vegetables and pregnancy vitamins) (Cohen & Uddin,
2011).
o All during pregnancy and at birth, the system is
vulnerable to damage if anoxia should occur.
o By 24 weeks, the ear is capable of responding to sound,
and the eyes exhibit a pupillary reaction, indicating sight
is present.
15. ENDOCRINE SYSTEM
o The fetal pancreas produces insulin needed by the
fetus.
o The thyroid and parathyroid glands play vital roles in
fetal metabolic function and calcium balance.
o The fetal adrenal glands supply a precursor necessary
for estrogen synthesis by the placenta
o The function of endocrine organs begins along with
neurosystem development:
1. The fetal pancreas produces insulin needed by
the fetus (insulin is one of the few substances
that does not cross the placenta from the
mother to the fetus).
2. The thyroid and parathyroid glands play vital
roles in fetal metabolic function and calcium
balance.
3. The fetal adrenal glands supply a precursor
necessary for estrogen synthesis by the
placenta
16. DIGESTIVE SYSTEM
o The digestive tract separates from the respiratory tract
at about the fourth week of intrauterine life and, after
that, begins to grow extremely rapidly.
17. MUSCULOSKELETAL SYSTEM
o During the first 2 weeks of fetal life, cartilage prototypes
provide position and support to the fetus.
o Ossification of this cartilage into bone begins at about
the 12th week and continues all through fetal life and
into adulthood.
o Carpals, tarsals, and sternal bones generally do not
ossify until birth is imminent.
o A fetus can be seen to move on ultrasonography as
early as the 11th week, although the mother usually
does not feel this movement (quickening) until 16 to 20
weeks of gestation. It is usually felt earlier in
multigravida women.
18. REPRODUCTIVE SYSTEM
o A child’s sex is determined at the moment of conception
by a spermatozoon carrying an X or a Y chromosome
and can be ascertained as early as 8 weeks by
chromosomal analysis or analysis of fetal cells in the
mother’s bloodstream. At about the sixth week after
implantation, the gonads (i.e., ovaries or testes) form
o If testes form, testosterone is secreted, apparently
influencing the sexually neutral genital duct to form
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 other male organs (i.e., maturity of the wolffian, or C. CRITICAL PERIODS OF FETAL GROWTH
mesonephric, duct).
o In the absence of testosterone secretion, female organs
will form (i.e., maturation of the müllerian, or
paramesonephric, duct).
o The testes first form in the abdominal cavity and do not
descend into the scrotal sac until the 34th to 38th week
of intrauterine life. Because of this, many male preterm
infants are born with undescended testes. These boys
need a follow-up to be certain their testes do descend
when they reach what would have been the 34th to 38th
week of gestational age because testicular descent
does not always occur as readily in extrauterine life as it
would have in utero.
o Testes that do not descend (cryptorchidism) require
surgery as they are associated with poor sperm
production and possibly testicular cancer later in life
19. URINARY SYSTEM
o Although rudimentary kidneys are present as early as
the end of the fourth week of intrauterine life, the
presence of kidneys does not appear to be essential for
life before birth because the placenta clears the fetus of
waste products.
o Urine, however, is formed by the 12th week and is
excreted into the amniotic fluid by the 16th week of
gestation.
o At term, fetal urine is being excreted at a rate of up to
500 ml/day. An amount of amniotic fluid less than usual
(oligohydramnios) suggests fetal kidneys are not
secreting adequate urine and that there is a kidney,
ureter, or bladder disorder (Kumar, 2012).
o The complex structure of the kidneys gradually develops
during intrauterine life and continues to mature for
months afterward.
o Early in the embryonic stage of urinary system
development, the bladder extends as high as the
umbilical region, and there is an open lumen between III. 2020 NATL HEALTH GOALS R/T FETAL GROWTH
the urinary bladder and the umbilicus.
o Reduce the fetal death rate (death between 20 and 40
o If this fails to close, (termed a patent urachus), this is
weeks of gestation) to no more than 5.6 per 1,000 live
revealed at birth by the persistent drainage of a clear,
births from a baseline of 6.2 per 1,000.
acid–pH fluid (urine) from the umbilicus (Samra, o Reduce low birth weight to an incidence of 7.8% of live
McGrath, & Wehbe, 2011).
births and very low birth weight to 1.4% of live births
20. INTEGUMENTARY SYSTEM
from baselines of 8.2% and 1.5%.
o Skin is covered by soft downy hairs (lanugo) that serve
o Increase the proportion of women of childbearing
as insulation to preserve warmth in utero as well as a potential with an intake of at least 400 mg of folic acid
cream cheese– like substance, vernix caseosa, which is
from fortified foods or dietary supplements from a
important for lubrication and for keeping the skin from
baseline of 23.8% to 26.2%.
macerating in utero
21. IMMUNE SYSTEM
o Immunoglobulin (Ig) G maternal antibodies cross the IV. ASSESSING FETAL GROWTH AND DEVELOPMENT
placenta into the fetus as early as the 20th week and 1. Reasons for testing
certainly by the 24th week of intrauterine life to give a o Predict outcome of pregnancy
fetus temporary passive immunity against diseases for o Manage remaining weeks of pregnancy
which the mother has antibodies. o Plan for possible complications at birth
o These often include poliomyelitis, rubella (German o Plan for problems that may occur in newborn
measles), rubeola (regular measles), diphtheria, o Decide whether to continue pregnancy
tetanus, infectious parotitis (mumps), hepatitis B, and o Find conditions that may affect future pregnancies
pertussis (whooping cough). Infants born before this 2. Health history
antibody transfer has taken place have no natural 3. Physical examination
immunity and so need more than the usual protection 4. Estimating fetal health
against infectious disease in the newborn period. o Fetal growth
o A fetus only becomes capable of active antibody  McDonald’s rule
production late in pregnancy. Generally, it is not 5.
necessary for a fetus to produce antibodies because
they need to be manufactured only to counteract an
invading antigen, and antigens rarely invade the
intrauterine space.
o Because IgA and IgM antibodies (the types which
develop to actively counteract infection) cannot cross
the placenta, their presence in a newborn is proof that
the fetus has been exposed to an infection.

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6. Measuring V. NURSING DIAGNOSES: FETAL GROWTH AND
Fundal Height DEVELOPMENT
1. Focus on mother, family, and fetus:
o Readiness for enhanced knowledge related to
usual fetal development
o Anxiety related to lack of fetal movement
o Deficient knowledge related to need for good
prenatal care for healthy fetal well-being
7. Fetal well-being
o Fetal movement (kick counts) VI. NURSING OUTCOMES: FETAL GROWTH AND
o Fetal heart rate: DEVELOPMENT
1. Outcome identification and planning
o Parental education
 Be realistic
 Based on parents’ previous knowledge
and desire for information
 Explain additional assessment measures
needed
Quality & Safety Education for Nurses (QSEN)
• Patient-Centered Care
• Teamwork & Collaboration
o Ultrasonography • Evidence-Based Practice
o Biophysical profile • Quality Improvement
o MRI • Safety
8. • Informatics

VII. IMPLEMENTING NURSING CARE

• Teaching about fetus at various points in pregnancy to help
parents visual coming newborn
• Teaching about healthy behaviors
• Showing sonogram to help initiate bonding
• Individualize care

VIII. EVALUATING NURSING CARE

9. Maternal serum analysis
o Maternal serum α-fetoprotein
o Maternal serum for pregnancy-associated plasma
protein A
o Quadruple screening
o Fetal gender
10. Invasive fetal testing
o Chorionic villi sampling
o Amniocentesis:
o Percutaneous umbilical blood sampling
o Fetoscopy
• Outcomes evaluation
• Were healthy lifestyle changes made?
• Do the parents have confidence that baby is healthy and
growing?
Q&A
A fetus is able to maintain blood circulation in utero by the presence
of circulatory shunts. The nurse understands this is because the
ductus arteriosus in utero shunts blood in which direction?
A. Left to right heart atria
B. Aorta to the pulmonary veins
C. Right ventricle to the aorta
D. Pulmonary artery to the aorta
Mrs. Smith asks the nurse to compute her expected due date. Based
on the fact that her last menstrual flow began on July 20, which due
date would the nurse estimate?
A. April 27
B. March 13
C. April 13
D. May 20
Which of the following nursing interventions is appropriate when
preparing a woman for an amniocentesis?
A. Inform her that a narcotic premedication will be given to
prevent pain during needle insertion.
B. Be certain she knows that there is a slight risk of
complication, such as premature labor, from
amniocentesis.
C. Instruct her not to empty her bladder prior to the procedure.
D. Suggest that she take a deep breath and hold it during
needle insertion.

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