Aripin, Alshammae N.
II BSN - H
Assessment of Fetal Growth &
Development
Introduction
Fetal growth and development can be
compromised if a fetus has a metabolic or
chromosomal disorder that interferes with normal
growth, if the supporting structures such as the
placenta or cord do not form normally, or if
environmental influences such as cigarette smoking
(the nicotine in cigarettes causes fetal growth
restriction) or alcohol consumption (alcohol causes
severe cognitive challenge) interfere with fetal
growth. Much information regarding whether a fetus
is growing and is healthy can be gathered through
a variety of assessment techniques. Nursing
responsibilities for these assessment procedures
include seeing that a signed consent form has been
obtained as needed, scheduling the procedure,
explaining the procedure to the woman and her
support person including what the procedure will
entail and any potential risks, preparing a woman
physically and psychologically, providing support
during the procedure, assessing both fetal and
maternal responses to the procedure, providing any
necessary follow-up care, and managing
equipment and specimens.
Health History
Like all assessments, fetal assessment begins with
a health history. Ask about:
1. Nutritional Intake
2. Personal habits such as cigarette smoking,
recreational drug use, and exercise
3. Has had any accidents or experienced
intimate partner abuse helps reveal whether
the fetus could have suffered any trauma
(intimate partner abuse tends to increase
during pregnancy because of the stress a
pregnancy can create)
Assessing Fetal Well-being
Fetal Movement
● Fetal movement that can be felt by the
mother (quíckening) occurs at
approximately 18 to 20 weeks of pregnancy
and peaks in intensity at 28 to 38 weeks.
● A healthy fetus moves with a degree of
consistency, or at least 10 times a day.
● In contrast, a fetus not receiving enough
nutrients because of placental insufficiency
has greatly decreased movements.
Sandovsky Method
- One popular way to approach this
assessment is to ask the woman to lie in the
left recumbent position after a meal and
record how many fetal movements she feels
over the next hour. In this position, a fetus
normally moves a minimum of twice every
10 minutes or an average of 10-12 times an
hour. If less than 10 movements occur
within an hour, the woman repeats the test
for the next hour. She should call her health
care provider if she feels fewer than 10
movements (half the normal number) during
the chosen 2 hours.
"Count-to-Ten" (the Cardiff method)
- A woman records the time interval it takes
for her to feel 10 fetal movements. Usually,
this occurs within 60 minutes. Make sure to
assure a woman that fetal movements do
vary, especially in relation to sleep cycles of
the fetus, her activity, and the time since
she last ate. Otherwise, she can become
unduly worried that her fetus may be in
jeopardy when the fetus is just having an
inactive time.
Fetal Heart Rate
- Fetal heartbeat at 120 to 160 bpm
throughout pregnancy. Fetal heart sounds
can be heard and counted as early as the
10th to 11th week of pregnancy by the use
of an ultrasonic Doppler technique.
● Rhythm Strip Testing
The term "rhythm strip testing" means assessment
of the fetal heart rate for whether a good baseline

rate and a degree of variability are present. For
this, help a woman into a semi-Fowler's position
(either in a comfortable lounge chair or on an
examining table or bed with an elevated backrest)
to prevent her uterus from compressing the vena
cava and causing supine hypotension syndrome
during the test. Attach an external fetal heart rate
monitor abdominally. Record the fetal heart rate for
20 minutes.
Rhythm strip testing requires a woman to remain in
a fairly fixed position for 20 minutes. Keep her well
informed of the purpose of the test, how it is
interpreted, and the meaning of results after the
test. The more she understands about the process,
the better she can cooperate to make it successful.
● Nonstress Testing
A nonstress test measures the response of the fetal
heart rate to fetal movement. Position a woman and
attach both fetal heart rate and a uterine
contraction monitor. Instruct a woman to push a
button attached to the monitor (similar to a call bell)
whenever she feels the fetus move. This will create
a dark mark on the paper tracing at these times.
When the fetus moves, the fetal heart rate should
increase about 15 bpm and remain elevated for 15
seconds. It should decrease to its average rate
again as the fetus quiets. If no increase in bpm is
noticeable on fetal movement, poor oxygen
perfusion of the fetus is suggested.
● Vibroacoustic Stimulation
For acoustic (sound) stimulation, a specially
designed acoustic stimulator is applied to the
mother’s abdomen to produce a sharp sound of
approximately 80 decibels at a frequency of Hz,
startling and waking the fetus. (Chang &
Blakemore, 2007).
During a nonstress test, if a spontaneous
acceleration has not occurred within 5 mins, apply
a single 1-2 second sound stimulation to the lower
abdomen. This can be repeated again at the end of
10 mins if no further spontaneous movement
Aripin, Alshammae N. II BSN - H
occurs, so that movements within the 20 minute
window can be evaluated.
Ultrasonography (UTZ)
Measuring the response of sound waves against
solid objects is a much-used tool in modern
obstetrics, although the recommendations for its
use are being questioned because of unproven
benefits in the face of added expense.
It can be used to:
1. Diagnose pregnancy as early as 6 weeks’
gestation
2. Confirm the presence, size, and location of
the placenta and amniotic fluid
3. Establish that a fetus is growing and has no
gross anomalies such as hydrocephalus,
anencephaly, or spinal cord, heart, kidney,
and bladder defects
4. Establish sex if a penis is revealed
5. Establish the presentation and position of
the fetus
6. Predict maturity by measurement of the
biparietal diameter of the head
Ultrasonography can also be used to discover
complications of pregnancy, such as the presence
of an intrauterine device, hydramnios or
oligohydramnios, ectopic pregnancy, missed
miscarriage, abdominal pregnancy, placenta previa,
premature separation of the placenta, coexisting
uterine tumors, multiple pregnancy, or genetic
disorders such as Down syndrome. Fetal
anomalies such as neural tube disorders,
diaphragmatic hernia, or urethral stenosis also can
be diagnosed. Fetal death can be revealed by a
lack of heartbeat and respiratory movement. After
birth, an ultrasound may be used to detect a
retained placenta or poor uterine involution in the
new mother.
Before an ultrasound examination, be sure that a
woman has received a good explanation of what
will happen and reassurance that the process does
not involve x-rays. This means it is safe for the

father of the child to remain in the room during the
test.
For the sound waves to reflect best and the uterus
to be held stable, it is helpful if the woman has a full
bladder at the time of the procedure. To ensure this,
have her drink a full glass of water every 15
minutes beginning 90 minutes before the procedure
and not void until after the procedure.
Help the woman up to an examining table and
drape her for modesty, but with her abdomen
exposed. To prevent supine hypotension syndrome,
place a towel under her right buttock to tip her body
slightly so that the uterus will roll away from the
vena cava. A gel is then applied to her abdomen to
improve the contact of the transducer. Be certain
that the gel is at room temperature or even slightly
warmer, or it can cause uncomfortable uterine
cramping. The transducer is then applied to her
abdomen and moved both horizontally and
vertically until the uterus and its contents are fully
scanned. Ultrasonography also may be performed
using an intravaginal technique although this is not
necessary for routine testing.
● Biparietal Diameter
Ultrasonography may be used to predict fetal
maturity by measuring the biparietal diameter
(side-to-side measurement) of the fetal head. In
80% of pregnancies in which the biparietal diameter
of the fetal head is 8.5 cm or greater, it can be
predicted that the infant will weigh more than 2500
g (5.5 |b) or is at a fetal age of 40 weeks. The
picture is an ultrasound showing the biparietal
diameter of a fetus at 24 weeks. Two other
measurements commonly made by ultrasound to
predict maturity are head circumference (34.5 cm
indicates a 40- week fetus) and femoral length.
● Doppler Umbilical Velocimetry
Doppler ultrasonography measures the velocity at
which red blood cells in the uterine and fetal
vessels travel. Assessment of the blood flow
through uterine blood vessels is helpful to
determine the vascular resistance present in
women with diabetes or hypertension of pregnancy
Aripin, Alshammae N. II BSN - H
and whether resultant placental insufficiency is
occuring. Because it will limit the number of
nutrients that can reach the fetus, decreased
velocity is an important predictor of poor neonatal
outcome.
● Amniotic Fluid Volume Assessment
The amount of amniotic fluid present is yet another
way to estimate fetal health because a portion of
the fluid is formed by fetal kidney output. If a fetus
is becoming stressed in utero so that circulatory
and kidney functions are failing, urine output and
consequently, the volume of amniotic fluid also will
decrease. A decrease in amniotic fluid volume puts
the fetus at risk for compression of the umbilical
cord and interference of nutrition.
Electrocardiography (ECG)
Fetal ECGs may be recorded as early as the 11th
week of pregnancy. The ECG is inaccurate before
the 20th week, however, because until this time
fetal electrical conduction is so weak that it is easily
masked by the mother’s ECG training. It is rarely
used unless a specific heart anomaly is suspected.
Magnetic Resonance Imaging (MRI)
May be used to assess the fetus. The technique
apparently causes no harmful effects to the fetus or
woman (although extensive long-term testing is not
yet available), MRI has the potential to replace or
complement ultrasonography as a fetal assessment
technique. It may be most helpful in diagnosing
complications such as ectopic pregnancy or
trophoblastic disease, because later in a pregnancy
fetal movement (unless the fetus is sedated) can
obscure the findings.
Maternal Serum Alpha-Fetoprotein
AFP is a substance produced by the fetal liver that
is present in both amniotic fluid and maternal
serum. The level is abnormally high in maternal
serum (MSAFP) if a fetus has an open spinal or
abdominal defect such as spina bifida or

omphalocele, because the open defect allows more
AFP to enter the mother’s circulation. Although the
reason is unclear, the level is low if the fetus has
chromosomal defects such as Down Syndrome.
MSAFP levels begin to rise at 11 weeks gestation
and then steadily increase until term. Traditionally
assessed at 15th week of pregnancy, between 85%
and 90% of neural tube defects and 80% of Down
Syndrome babies can be detected by this method.
Amniocentesis
(from the Greek amnion for “sac” and kentesis for
“puncture”.) the aspiration of amniotic fluid from the
pregnant uterus for examination. The procedure
can be done at a physician's office or ambulatory
clinic. It is typically scheduled between the 14th and
15th week of pregnancy to allow for a generous
amount of amniotic fluid to be present. The
technique can be used again near term to test for
the fetal maturity.
Amniocentesis is technically an easy procedure,
but it can be frightening to women. Because it
involves penetration of the integrity of the amniotic
sac, there are also risks for the fetus, although the
incidence of this is low (less than 0.5%). Fetal
complications range from hemorrhage from
penetration of the placenta, infection of the amniotic
fluid, and puncture of the fetus. If it leads to
irritation of the uterus, it can initiate premature
labor.
Amniotic fluid is analyzed for:
1. Alpha-Fetoprotein (AFP)
2. Bilirubin Determination - The presence of
bilirubin may be analyzed if a blood
incompatibility is suspected. If the bilirubin is
going to be analyzed, the specimen must be
free of blood or a false-positive reading will
occur.
3. Chromosome Analysis - A few fetal skin
cells are always present in amniotic fluid.
These cells may be cultured and stained for
karyotyping for her netic analysis.
Aripin, Alshammae N. II BSN - H
4. Color - Normal amniotic fluid is the color of
water; late in pregnancy, it may have slight
yellow tinged. A strong yellow color
suggests a blood incompatibility (the yellow
results from the presence of bilirubin
released with the hemolysis of red blood
cells). A green color suggests meconium
staining, a phenomenon associated with
fetal distress.
5. Fetal Fibronectin - Fibronectin is a
glycoprotein that plays a part in helping the
placenta attach to the uterine decidua. Early
in pregnancy, it can be assessed in the
woman's cervical mucus, but the amount
then fades until, after 20 weeks of
pregnancy, it is no longer present in cervical
mucus. As labor approaches and cervical
dilatation begins, it can be found again in
cervical or vaginal fluid. Damage to fetal
membranes from cervical dilatation releases
a great deal of the substance, so detection
of fibronectin in either the amniotic fluid or in
the mother's vagina can serve as an
announcement that preterm labor may be
beginning.
6. Inborn Errors of Metabolism - Some
inherited diseases that are caused by inborn
errors of metabolism can be detected by
amniocentesis. For a condition to be
identified, an errant enzyme must be
present in the amniotic fluid as early as the
time of the procedure. Examples of illnesses
that can be detected in this way are
cystinosis and maple syrup urine disease
(amino acid disorders).
7. Lecithin/ Sphingomyelin Ratio - are the
protein components of the lung enzyme
surfactant that the alveoli begin from at the
22nd to 24th weeks of pregnancy. After
amniocentesis the L/S ratio may be
determined quickly by a shake test (if
bubbles appear in the amniotic fluid after
shaking, the ratio is mature) or sent for
laboratory analysis. An L/S ratio of 2:1 is

traditionally accepted as lung maturity.
Infants of mothers with severe diabetes may
have false-mature readings of lecithin
because the stress to the infant in utero
tends to mature lecithin pathways early.
This means that fetal values must be
considered in light of the presence of
maternal diabetes, or the infant may be born
with mature lung function but be immature
overall (fragile giants) causing them to not
do well in postnatal life. Some laboratories
interpret a ratio of 2.5:1 or 3:1 as a mature
indicator in infants of women with diabetes.
8. Phosphatidyl Glycerol and Desaturated
Phosphatidylcholine - These are
additional compounds, in addition to lecithin
and sphingomyelin, found in surfactant.
Pathways for these compounds mature at
35-36 weeks. Because they are present
only with mature lung function, if they are
present in the sample of amniotic fluid
obtained by amniocentesis, it can be
predicted with even greater confidence that
respiratory distress syndrome is not likely to
occur.
Percutaneous Umbilical Blood
Sampling
Aripin, Alshammae N. II BSN - H
could enter the maternal circulation after the
procedure, so RhIG is given to Rh-negative women
to prevent sensitization. The fetus is monitored by a
nonstress test before and after the procedure to be
certain that uterine contractions are not present and
by ultrasound to see that no bleeding is evident.
This procedure carries little additional risk to the
fetus or woman over amniocentesis and can yield
information not available by any other means,
especially about blood dycrasias.
Amnioscopy
Amnioscopy is the visual inspection of the amniotic
fluid through the cervix and membranes with an
amnioscope (a small fetoscope). The main use of
the technique is to detect meconium staining. It
carries some risk of membrane rupture.
Fetosopy
Fetoscopy, in which the fetus is visualized by
inspection through a fetoscope (an extremely
narrow, hollow tube inserted by amniocentesis
technique), can be helpful to assess fetal well-being
(Lopriore et al., 2007). If a photograph is taken
through the fetoscope, it can document a problem
or reassure parents that their infant is perfectly
formed.

PUBS (also called cordocentesis or funicentesis) is

the aspiration of blood from the umbilical vein for
analysis. After the umbilical cord is located by
ultrasound, a thin needle is inserted by
amniocentesis technique into the uterus and is
guided by ultrasound until it pierces the umbilical
vein. A sample of blood is then removed for blood
studies, such as a complete blood count, direct
Coombs' test, blood gases, and karyotyping. To
ensure that the blood obtained is fetal blood, it is
submitted to a Kleihauer-Betke test which
measures the difference between adult and fetal
blood. If the test reveals that a fetus is anemic,
blood may be transfused using this same
technique. Because the umbilical vein continues to
ooze for a moment after the procedure, fetal blood