Methods in Assessing the

Fetal Well-Being
A. FETAL MOVEMENT (Kick counts)
▪ Quickening – begins at 18 – 20 wks. AOG; peaks at
28 – 38 wks. AOG
▪ Average fetal movement = 10 – 12x/ day
▪ Decreased fetal movement = placental insufficiency
▪ SANDOVSKY METHOD
➢ Counting & recording the number of fetal movements in
an hour after meal (mother in left recumbent position)
➢ Normal: 2x/ 10 min. or 10 – 12x/ hr.
➢ Needs Referral: 10 fetal movements in 2 hours

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 ▪ CARDIFF METHOD (Count-to-Ten)
➢ Recording the time interval it takes for the pregnant woman to
feel the fetal movement.
➢ Normal: 10 fetal movements/ hr.

B. FETAL HEART RATE

▪ As early as the 10th – 11th wk. AOG by Doppler
▪ Normal: 120 – 160 beats/ min.
1) RHYTHM STRIP TESTING
❖ Determine the presence of good baseline rate, long & short
term variability by the use of external fetal heart rate & uterine
contraction monitors for 20 min.
❖ Position: SEMI – FOWLERS
❖ SHORT-TERM VARIABILITY – small changes in FHB from
second to second
❖ LONG-TERM VARIABILITY – differences in FHR that occur
over 20 min. period.
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2) NONSTRESS TESTING
➢ Response of FHR to fetal movement in which the FHR
and Uterine Contraction Monitors are attached.
➢ Position: SEMI-FOWLERS/ LEFT LATERAL
➢ Normal : REACTIVE NONSTRESS TEST
2 – 4 FHR accelerations in 10 min.
➢ Abnormal: NON-REACTIVE NONSTRESS TEST
No accelerations with the fetal movements

3) VIBROACOUSTIC STIMULATION
➢ Test used to stimulate fetal movement by the use of
acoustic stimulator especially if a spontaneous
acceleration has not occurred within 20 min. during
NONSTRESS TEST.

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4) CONTRACTION STRESS TESTING
▪ Assessing FHR response to uterine contractions
▪ Purpose: to assess the fetal ability to tolerate the stress of
labor.
▪ Position: LEFT LATERAL/ SEMI-FOWLERS
▪ Normal result: NEGATIVE
> No late FHR decelerations present by 3
contractions in 10 min. period
▪ Abnormal: POSITIVE
> presence of late FHR decelerations by
50% or more of uterine contractions.
▪ Contraindication:
➢ Placenta previa
➢ Multifetal pregnancy
➢ Incompetent cervix
➢ Rupture of membranes
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C. ULTRASONOGRAPHY
▪ Purposes:
1. To diagnose pregnancy as early a s 6 wks.

2. To confirm the size, presence, & location of placenta &

amniotic fluid

3. To establish that a fetus is growing and has no gross

anomalies.

4. To establish sex of the fetus.

5. To establish the presentation and position of the fetus.

6. To predict the maturity of the fetus.

7. To discover complications of pregnancy

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Preparation for Ultrasound
1. Explain the procedure
2. Encourage to have a full bladder at the time of
procedure (drink a full glass of water every 15 min.
beginning 90 min. before the procedure)
3. Position patient in supine
4. Place a rolled towel or blanket under the right
buttock (prevent supine hypotension syndrome).
5. The gel must be at room temp. or slightly warm
before applying on the abdomen

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C.1. BIPARIETAL DIAMETER
▪ 8.5 cm. = 40 wks. Of fetal age
C.2. DOPPLER UMBILICAL VELOCIMETRY
▪ Measures the velocity at which RBCs in the uterine
and fetal vessels and traveling.
▪ velocity = poor neonatal outcome
C.3. PLACENTAL GRADING
▪ Grade 0 = 12 – 24 wks. AOG
▪ Grade 1 = 30 – 32 wks.
▪ Grade 2 = 36 wks.
▪ Grade 3 = 38 wks.

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C.4. AMNIOTIC FLUID VOLUME ASSESSMENT
▪ The sum of the largest pocket measurements of
amniotic fluid.
▪ Average fluid index = 12 – 15 cm bet. 28 – 40 wks.
▪ Abnormal Finding:
▪ Hydramnios = > 20-24 cm fluid index
▪ Oligohydramnios = < 5 – 6 cm fluid index

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D. MATERNAL SERUM ALPHA-FETOPROTEIN
 Alpha-fetoprotein (AFP)
➢ A substance produced by the fetal liver that is present in
amniotic fluid and maternal serum.
➢ MSAFP = spina bifida
➢ An AFP multiple of the median (MoM) <2.5 is reported as
screen negative. AFP MoMs > or =2.5 (singleton and twin
pregnancies) are reported as screen positive.
➢ MSAFP = down syndrome
E. TRIPLE SCREENING
▪ An analysis of 3 indicators:
1) MSAFP
2) Unconjugated estriol
3) hCG

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F. CHORIONIC VILLI SAMPLING

 A biopsy & chromosomal or DNA analysis of chorionic

villi done at 10 – 12 wks. AOG

 An invasive procedure, Ultasonography is used to

direct the procedure.

 COMPLICATIONS:
1) Infection
2) Bleeding
3) Threatened miscarriage

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Chorionic Villi Sampling

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G. AMNIOCENTESIS
▪ An invasive procedure that involves withdrawal of
amniotic fluid through the abdominal wall at 14th –
16th wk. of pregnancy.
▪ Women with Rh – blood type need Rh immune
globulin adm. after the procedure to protect fetus
from isoimmunization
 Ultrasonography is used to direct the procedure
 PURPOSE:
➢ To evaluate fetal status (maturity, congenital
anomalies)

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Amniocentesis

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▪ INDICATIONS:

1. Maternal age of 35 yrs. or older

2. Previous child with chromosomal abnormalities
3. Parent with chromosomal abnormalities
4. Familial history of neural tube defects
5. Fetal abnormalities per ultrasound
6. Assessment of fetal pulmonary maturity
7. Evaluate alpha-fetal protein (AFP)
8. Diagnosis of fetal hemolytic disease

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COLOR OF AMNIOTIC FLUID:

➢ NORMAL:
clear, slightly yellow tinge during late pregnancy

➢ ABNORMAL:
strong yellow (blood incompatibility)
green color (meconium staining)

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 Amniocentesis can provide the
following informations:
1. L/S (Lecithin/sphingomyelin ratio)
▪ These are the protein components of the lung enzyme
surfactant that the alveoli begin to form at about 22nd –
24th wks. Pregnancy
▪ Surfactant
▪ A substance composed of lipoprotein that is secreted by the
alveolar cells of the lung and
serves to maintain the stability of pulmonary tissue by reducing
the surface tension of fluids that coat the lung.
▪ NORMAL: 2:1 (fetal lung maturity)

2. Phosphatidyl Glycerol (PG)

▪ Precursor of surfactant; presence in amniotic fluid of the
NB indicates lung maturity.
▪ Helps confirm fetal maturity
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3. Bilirubin level
▪ Indicates blood incompatibility or the degree of
destruction of fetal RBCs in an RH sensitized woman.
▪ 1 – 4 mg/100 ml
▪ If elevated:
▪ Reflects release of bilirubin as excessive RBC begin their
breakdown
▪ Bilirubin:
▪ A byproduct of RBC breakdown
4. Creatinine
▪ Level of < 1.8 mg/dl demonstrates maturing kidney
function of fetus
5. Alpha-Fetoprotein
indicates NEURAL TUBE DEFECT

indicates DOWN’S SYNDROME

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6. Chromosome analysis
▪ Skin cells in the amniotic fluid may be cultured and
stained for karyotyping.

7. Fetal Fibronectin
▪ A glycoprotein that helps placenta attach to the
uterine decidua.
▪ Found abundantly in the amniotic fluid
▪ Can be found in the woman’s cervical mucus early in
pregnancy (fades after 20 wks. AOG)
▪ Detection of this in the amniotic fluid or in the
mother’s vagina indicates that preterm labor may
begin

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8. Inborn Errors of Metabolism
▪ Examples:
✓ Cystinosis = characterized by cystinuria (characterized by
stone formation in the urinary tract)
✓ Maple syrup urine disease (amino acid disorders) =
characterized by :
❖ Vomiting
❖ Hypertonicity
❖ Severe mental retardation
❖ Seizures
✓ Phenylketonuria
❖ Enzyme deficiency resulting in accumulation of
phenylalanine (an essential amino acid) & its metabolites
in the blood causing severe mental retardation.

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THERAPEUTIC NURSING
MANAGEMENT
1. Assist with procedure, monitor for sterility
2. Determine whether the client is to empty her bladder prior
to procedure (empty the bladder to prevent inadvertent
puncture)
3. Position client in left lateral
4. Provide emotional support
5. Refer client for genetic counseling when indicated
6. Women who are Rh negative receive Rho (D) immune
globulin (RhIG; RhoGAM) after the procedure to prevent
fetal isoimmunization (development of antibodies in
response to antigen from another individual of the same
specie)
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7. Secure an informed consent form, including a clear
explanation of risks of the procedure before the
procedure is done
8. Use universal precautions during the procedure.

COMPLICATIONS:
1. Needle puncture of the fetus
2. Bleeding
3. Loss of amniotic fluid
4. Infection
5. Premature labor
6. Spontaneous abortion
7. Fetal distress

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H. Percutaneous Umbilical Blood Sampling (PUBS/
Cordocentesis or Funicentesis)
▪ Removal of blood from the fetal umbilical cord (vein)
at about 17 wks.

▪ Blood studies:
1) CBC
2) Direct Coomb’s test (agglutination test used to detect
proteins esp. antibodies on the surface of RBC.
3) Blood gases
4) Karyotyping (chromosomal characteristics)

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I. Amnioscopy

▪ Visual inspection of the amniotic fluid through the

cervix and membranes with an amnioscope.

▪ PURPOSE:
✓ To detect meconium staining

▪ COMPLICATION:
✓ Rupture of membrane

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J. FETOSCOPY
▪ Visual inspection of the fetus through a fetoscope
that is inserted by amniocentesis technique in
assessing fetal well-being.
▪ PURPOSES:
1) To confirm intactness of the spinal column
2) Obtain biopsy sample of fetal tissue and fetal blood
samples
3) Perform elemental surgery, such as:
1) inserting polyethylene shunt into the fetal ventricles to
relieve hydrocephalus, or
2) into the bladder to relieve stenosed urethra
▪ COMPLICATION:
1) Premature labor
2) Amnionitis
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K. BIOPHYSICAL PROFILE
▪ 5 parameters:
1) Fetal heart reactivity
 2 or more accelerations of at least 15 bpm for 15 sec.
over a period of 20 min.
2) Fetal breathing movements
 1 episode of 30 sec. of sustained fetal breathing
movement within 30 min. of observation.
3) Fetal body movements
 3 separate episodes of fetal limb or trunk movements
within 30 min.
4) Fetal tone
 Fetus extends then flexes extremities or spine of at least
once in 30 min.
5) Amniotic volume
 Pocket of amniotic fluid measuring 1 cm in vertical
diameter.
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K. BIOPHYSICAL PROFILE

Score:
8 – 10 fetus is doing well; healthy fetus
6 - suspicious; requires determination of the need
for immediate delivery of the fetus, considering
maturity of the fetal lungs.
4 - fetus in jeopardy

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