Lesson 4: FERTILIZATION, IMPLANTATION AND FETAL

DEVELOPMENT
Topic Outline
Learning Objectives
Introduction
Activating prior Knowledge
Discussion of Key Concepts
Cell Division and gametogenesis
Stages of Fetal Development
Terms used to described Fetal Growth
Fertilization
Sex Determination

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Tubal Transport of the Zygote
Implantation of the Zygote
Development
Cell Differentiation
Accessory Structures of Pregnancy
The Placenta
The Umbilical Cord
Fetal Circulation
Circulation before Birth
Circulation after Birth
Closure of Fetal Circulating Shunts
Fetal Lung Preparation for Birth
Methods of Evaluating Fetal Growth, Maturity and Well-being
Review Questions
Summary
Critical Thought Questions
References

Learning Objectives
After studying this module, you will be able to:
1. Describe the process of gametogenesis in human reproduction
2. Explain human fertilization and implantation
3. Describe embryonic development
4. Describe fetal development and the maturation of body systems.
5. Describe the development and functions of the amniotic fluid, placenta, and umbilical cord.
6. Compare fetal circulation with circulation after birth.

Introduction
The human body contains many millions of cells at birth, but life begins with a single cell created
by the fusion of a sperm with an ovum. Deoxyribonucleic acid (DNA) programs a genetic code into the
nucleus of the cell; the nucleus controls the development and function of the cell. Defects in the DNA
code can result in inherited disorders. The genes and chromosomes contained within the DNA determine
the uniqueness of the traits and features of the developing person.
Normal human chromosomes begin in pairs, one supplied by the mother and the other by the
father. Each boy cell contains 46 chromosomes, made up of 22 pairs of autosomes (body chromosome
contains genes that involve hereditary, and 1 pair contains the sex chromosomes (XX or XY). The sex
cells (gametes) of the male and female are unlike the rest of the cells found in the body. Cell division
then occurs, which is the basis of human growth and regeneration.

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 Biological development is not isolated. It influenced by the external environment, such as
maternal drug use (teratogens that cause damage to growing cells include some prescribed medications),
maternal undernutrition, or maternal smoking . In addition, it is now known that sounds such as music
are heard by the fetus and are recognized by the newborn. All these factors influence prenatal growth
and development. The experience of the fetus during prenatal life influences the healthy outcome of the
newborn and influence susceptibility to diseases that may occur when the fetus reaches adulthood. Early
prenatal care is essential to an optimal outcome of the pregnancy. The experience of the fetus during
prenatal life influence both the healthy outcome of the newborn and the susceptibility of the newborn
and susceptibility to diseases that may occur when the newborn reaches adulthood.

Discussion of Key Concepts

Cell Division and Gametogenesis

The division of a cell begins in its nucleus, which contains the gene-bearing chromosomes. The
two types of cell division are mitosis and meiosis. Mitosis is a continuous process by which the body

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grows and develops and deal body cells are replaced. In this type of cell division, each daughter cell
contains the same number of chromosomes as the parent cell. The 46 chromosomes in a body cell are
called the diploid number of chromosomes. The process of mitosis in the sperm is called
spermatogenesis, and in the ovum it is called oogenesis.
Miosis is a differential type of cell division in which the reproductive cells i=undergo two
sequential divisions. During meiosis, the number of chromosomes in each cell is reduced by half, to 23
chromosomes per cell, each including only one sex chromosome. This is called the haploid number of
chromosomes. This process is completed in the sperm before it travels toward the fallopian tube and in
the ovum if it is fertilized after ovulation. At the moment of fertilization (when the sperm and the ovum
unite), the new cell contains 23 chromosomes from the sperm and 23 chromosomes from the ovum,
thus returning to the diploid number of chromosomes (46); traits are therefore inherited from both the
mother and the father. The formation of gametes by this type of cell division is called gametogenesis.

Figure 1. Normal gametogenesis. Four sperm develop from one spermatocyte, each with 23
chromosome- including one sex chromosome, either an x or a Y. In oogenesis, one ovum develops with
23 chromosomes- including one sex chromosome, always an X. An XY combination produces a boy, and
and XX combination produces a girl.

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 Stages of Fetal Development
• Pre-embronic (first 2 weeks, beginning with fertilization)
o Zygote forms: ovum fertilized in fallopian tube undergoes cell divisions (cleavage) on
way to uterus
o Morula forms: solid mass of about 16 microscopic cells resembling mulberry; enters
uterus on third day
o Blastocyst: morula develops fluid filled cavity: Trophoblast: outer wall of blastocyst:
embryoblast: inner cell mass from which embryo eventually forms.
o Beginning of implantation of blastocyst in endometrium by invading trophoblastic tissue
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• Embryonic (weeks 3 through 8)
o Implantation deepens and is completed: primitive uteroplacental circulation originates
from enlarging trophoblast and maternal endometrial tissues.
o Amniotic cavity appears as an opening between inner cell mass and invading trophoblast;
a thin lining becomes amnion.
o Two-layered (bilaminar)) embryo called embryonic disc develops to formed by ectoderm
and endoderm

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o Yolk sac present
o Thickening in midline of ectoderm gives rise to mesoderm, a third layer between
ectoderm and endoderm forming trilaminar embryo; basic embryological beginning of
body systems and organs (Box 1)
• Fetal (from week 8 through birth)
o Development mainly involves growth and maturation of structures begun in embryo;
fetus less vulnerable to effects of drugs; most infectious, and radiation.

Terms Used to Described Fetal Growth

Term Fetal Growth (Time Period)
Ovum from ovulation to fertilization
Zygote from fertilization to implantation
Embryo from implantation to 5-8 weeks
Fetus from 5-8 weeks until term
Conceptus developing embryo and placental structure throughout pregnancy
Age of Viability The earliest age at which fetuses survive if they are born is generally accepted
as 24 weeks or at the point a fetus weighs more than 500-600g
Fertilization
Fertilization occurs when a sperm penetrates an ovum and unites with it, restoring the total
number of chromosomes to 46. It normally occurs in the outer of the fallopian tube, near the ovary. The
sperm pass through the cervix and the uterus and into the fallopian tubes by means of the flagellar
(whiplike) activity of their tails and can reach the fallopian tubes within 5 minutes after coitus. As soon
as fertlization occurs, a chemical change in the membrane around the fertilized ovum prevents
penetration by another sperm
The time during which fertilization can occur is brief because of the short life span of mature
gametes. The ovum is estimated to survive for up to 24 hours after ovulation. The sperm remains capable
of fertilizing the ovum for up to 5 days after being ejaculated into the area of the cervix.

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Figure 2. Ovulation, fertlization and implantation. Ovulation occurs; the egg is caught by the
fimbrae (fingerlike projections of the fallopian tube) and is guided into the fallopian tube
where fertilization occurs. The zygote continues to multiply (but not grow in size) as it passes
through fallopian tube and implants into the posterior wall of the uterus.

Sex Determination
The sex of human offspring is determined at fertilization. The ovum always contributes an X
chromosome (gamete), whereas the sperm can carry an X or a Y chromosome (gamete). When a sperm
carrying the X chromosome fertilizes the X-bearing ovum, a female offspring (XX) results. When a Y-
bearing sperm fertilizes the ovum, a male offspring (XY is produced.
Because sperm can carry either an X or a Y chromosome, the male partner determines the sex
of the child. However, the pH of the female reproductive tract and the estrogen levels of the woman’s
body affects the survival rate of the X- and Y- bearing sperm (adrosperm) as well as the speed of their
movement through the cervix and the fallopian tubes. Thus, the female physiology has some influence
on which sperm fertilizes the mature ovum.
By 6 to 7 weeks gestation, the embryo differentiates under the influence of the Y chromosome,
and testosterone secretion begins by 8 weeks gestation. Female gonadal development occurs in the
presence of estrogen and the absence of testosterone. By the 6 to 8 weeks gestation, two female gonaads
develop into ovaries, which will produce ova only during fetal life.

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Figure 3. Sex determination. If an X chromosome from the man unites with an X chromosome from
the woman, the offspring will be female (XX). If a Y chromosome from the man unites with an X
chromosomes from the woman, the offspring will be male (XY).

Tubal Transport of the Zygote

The zygote is the cell formed by the union of the sperm and the ovum, and it is transported
through the fallopian tube and into the uterus. Fertlization normally occurs in the outer third of the
fallopian tube. During transport through the fallopian tube, the zygote undergoes rapid mitotic division,
or cleavage. Cleavage begins with two cells, which subdivide into four and then eight cells to form the
blastomere. The size of the zygote does not increase; rather the individual cells become smaller as they
divided and eventually form a solid ball called morula.
The morula enters the uterus on the third day and floats there for another 2 to 4 days. The cells
form a cavity, and two distinct layer layers evolve. The inner layer is a solid mass of cells called the
blastocyst, which develops into an embryonic membrane, the chorion. Occasionally, the zygote does not
move through the fallopian tube and instead becomes implanted in the lining of the tube, resulting in
tubal ectopic pregnancy.

Implantation of the Zygote

The zygote usually implants in the upper section of the posterior uterine wall. The cells burrow
into the prepared lining of the uterus, called the endometrium. The endometrium is now called the
decidua; the area under the blastocyst is called decidua basalis and gives rise to the maternal part of
the placenta (Figure 4).

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Figure 4. The pregnant uterus at 4 weeks showing the relationship of the fetal membranes to the decidua
of the uterus and the embryo.

Development
Cell Differentiation

During the week between fertilization and implantation, the cells within a zygote are identical to
one another. After implantation the cell begin to differentiate and develop special functions. The chorion,
amnion, yolk sac and primary germ layers appear.

Chorion
The chorion develops from the trophoblast (outer layer of embryonic cells) and envelops the amnion,
embryo, and yolk sac. It is thick membrane with fingerlike projections called villi on its outermost surface.
The villi immediately below the embryo extend into the decidua basalis on the uterine wall and form the
embryonic or fetal portion of the placenta (Figure 5 )

Figure 5. Maternal-fetal circulation showing the relationship of the fetus and the placenta in the uterus.

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 CHORION- together with the decidua basalis, gives rise to the placenta, which starts to forma 8 weeks
gestation. It develops into 15-20 subdivisions called cotyledons. The placenta serves the following
purposes:
o Respiratory system- exchange of gases takes place in placenta, not in the fetal lungs.
o Renal system- waste products are excreted through the placenta. (note: it is the
mother;s liver which detoxifies fetal waste products.)
o Gastrointestinal system- nutrients are passed on to the fetus via the placenta by
diffusion through the placental tissues.
o Circulatory system- feto-placental circulation is established by selective osmosis.
o Endocrine system- it produces the following important hormones (before 8 weeks
gestation, the corpus luteum is the one producing these hormones):
▪ Human chorionic gonadotropin (HCG). “order” the corpus luteum to keep on
producing estrogen and progesterone, that is why menstruation does not take
place during pregnancy.
▪ Human placental lactogen (HPL) or human chorionic
somatomammotropin. Promotes growth of mammary glands necessary for

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lactation. It also has growth-stimulating properties.
▪ Estrogen and Progesterone
Protective barrier- inhibits the passage of some bacteria and large molecules

Amnion
The amnion is the second membrane; it is thin structure that envelops and protects the embryo.
It forms the boundaries of the amniotic cavity, and its outer aspect meets the inner aspect of the chorion.
The chorion and the amnion together form an amniotic sac filled with fluid (bag of water) that
permits the embryo to float freely. Amniotic fluid is clear, has a mild odor, and often contains bits of
vernix (fetal skin covering) or lanugo (fetal hair on the skin) the volume of amniotic fluid steadily
increases from 30 ml at 10 weeks gestation to 350 ml at 20 weeks. The volume of fluids is about 1000ml
at 37 weeks. In the later part of pregnancy, the fetus may swallow up to 400 ml of amniotic fluid per
day and normally excretes urine into the fluid.

The Amniotic Membrane

The chorionic villi on the medial surface of the trophoblast i.e., those that are not involved in
implantation because they do not touch the endometrium) gradually thin until they becomes
chorionic membrane, the outermost fetal membrane. The amniotic membrane or amnion forms
beneath the chorion. Beginning early in pregnancy, these membranes become so adherent they
seem as one at term. They have no nerve supply, so when they spontaneously rupture at term or
artificially ruptured, neither mother nor baby experiences no pain.

In contrast to the chorionic membrane, the second membrane (amniotic membrane) not only offers
support to amniotic fluid but also actually produces the fluid. In addition, it produces a phospholipid
that initiates the formation of prostaglandins, which may be trigger that initiation of labor

The Amniotic Fluid

Amniotic fluid is vital to the well-being of the fetus. It cushions the fetus from injury, helps prevent
compression of the umbilical cord, and allows room for it to move and grow. In addition, its
bacteriostatic action helps prevent infection of the intra-amniotic environment. The quantity of
amniotic fluid at any time in gestation is the product of water exchange between the mother, fetus,
and placenta, and is maintained within a relatively narrow range. Amniotic fluid is slightly alkaline
with a pH of about 7.2

In the first half of pregnancy, amniotic fluid is derived from fetal and possibly maternal
compartments. Water and solutes freely traverse fetal skin and may diffuse through the amnion
and chorion as well. Thus, amniotic fluid in early gestation is a dialysate that is identical to the fetal
and maternal plasma, but with a lower protein concentration. Active secretion of fluid from the
amniotic epithelium had been previously suggested to play a role in early amniotic fluid formation,
but this has not been demonstrated.

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 By the second trimester, the fetal skin becomes keratinized, making it impermeable to further
diffusion. At this time, a fetus contributes to amniotic fluid volume and composition almost
exclusively through urination. Urine has been observed in the fetal bladder as early as 11 weeks
transabdominally and 9 weeks transvaginally.

At term, the amount of amniotic fluid has grown so much it ranges from 800 to 1,200 ml. if for any
reason, the fetus is unable to swallow (esophageal atresia or anencephaly are the two most common
reason), excessive amniotic fluid or hydramnious (polyhydramnious- more than 2,000ml in total
or pocket of fluids larger than 8 cm on ultrasound. Hydramnious occurs in women with diabetes
because hyperglycemia causes excessive shifting of fluid into the amniotic space.

Early in fetal life, as soon as the fetal kidneys become active, fetal urine adds to the quantity of the
amniotic fluid. A disturbance of kidney function, therefore may cause Oligohydramnious, or a
reduction in the amount of amniotic fluid (less than 300 ml in total, or no pocket on ultrasound larger
than 1 cm).
The following are functions of amniotic fluids.
o Maintains an even temperature

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o Prevents the amniotic sac from adhering to the fetal skin
o Allows symmetrical growth
o Allows buoyancy and fetal movement
o Acts as cushion to protect the fetus and the umbilical cord from injury.

Yolk Sac
On the ninth day after fertilization, a cavity called the yolk sac forms in the blastocyst. It functions
only during embryonic life and initiates the production of red blood cells. This function continues for
about 6 weeks until the embryonic liver takes over. The umbilical cord then encompasses the yolk sac,
and the yolk sac degenerates.

Germ Layers
After implantation, the zygote in the blastocyst stage transforms its embryonic disc into three
primary germ layers known as ectoderm, mesoderm and endoderm. Each germ layer develops into
different part of the growing embryo. The specific body parts that develop from each layer are listed in
Box 1.

Box 1. Body Part that Develops from the Primary Germ Layers
Germ Layer Body Parts Formed
Ectoderm Central Nervous System (brain and spinal cord); peripheral
(outer layer) nervous system; skin, hair, nails, and tooth enamel; sense
organs; mucous membrane of the anus, mouth, and nose;
Mammary glands
Mesoderm Supporting structure of the body ( connective tissue , bones,
(middle layer) cartilage, muscle, ligaments, and tendons); Upper portion of the
urinary system (kidneys and ureters); Reproductive system;
Heart, lymph, and circulatory systems and blood cells.
Endoderm Lining of pericardium, pleura, and peritoneal cavities; lining of the
(inner layer) gastrointestinal tract, tonsils parathyroid, thyroid, and thymus
glands; Lower urinary system (bladder and urethra)

Prenatal development Milestones

Figure 6. presents the developmental milestones during intrauterine development. Developmental milestones
exist in fetal growth and development, as they do in growth and development after birth. Three basic stages
characterize prenatal development: Zygote, embryo, and fetus. The zygote continues to grow and develop as
it passes through the fallopian and implants into the wall of the uterus. The period of development from 2 to 8
weeks is known as the embryonic stage; the developing infant is called an embryo. From the ninth week of

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 development until birth, the developing infant is called a fetus. By the second week after fertilization, the
ectoderm, endoderm, and amnion begin to develop.

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Figure 6. Embryonic and Fetal Development

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 Accessory Structure of Pregnancy
` The placenta, umbilical cord, and fetal circulation support the fetus as it completes
prenatal and prepares for birth.

The Placenta
The placenta is a temporary organ for fetal respiration, nutrition and excretion. It also functions as an
endocrine gland. The placenta forms when the chorionic villi of the embryo extend into the blood-filled spaces
of the mother’s decidua basalis. The maternal part of the placenta arises from the decidua basalis and has
beefy, red appearance. The fetal side of the placenta arises from the chorionic villi and chorionic blood
vessels. The amnion covers the fetal side and the umbilical cord and gives them a grayish, shiny
appearance at term. An enlarged placenta may signal maternal diabetes mellitus and may indicate increased
morbidity of the fetus in the neonatal period or a later stage of life (Burton et.al., 2017). Stress,
undernutrition, exposure to steroids during pregnancy, and chorionic hypoxia can cause a small placenta.
The placenta plays an important role in fetal development and has a clinical impact that extends beyond 9
months of gestation. This structure provides oxygen and nutrients to your growing baby and removes waste
products from your baby's blood.

The placenta is much larger than the developing infant during early pregnancy, but the fetus grows

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faster. At term, the placenta weighs about one-sixth the weight of the infant. Placenta weight can be an
important indicator of nutritional or environmental problems in the newborn that may require follow-up
care.

Placental Transfer
A thin membrane separates the maternal and fetal blood, and the two blood supplies do not
normally mix (see Figure 4). However, separation of the placenta at birth may allow some fetal blood
to enter the maternal circulation., which can cause problems with fetuses in subsequent pregnancies if
the blood types are not compatible.
Fetal deoxygenated blood and waste products leave the fetus through the two umbilical arteries
and enter the placenta through the branch of a main stem villus, which extends into the intervillous
space (lacuna). Oxygenated nutrient-rich blood from the mother spurts into the intervillous space from
the spiral arteries in the decidua (see Figure 4 and 5). The fetal blood releases carbon dioxide and waste
products and takes in oxygen and nutrients before returning to the fetus through the umbilical vein.
The thin placental membrane provides some protection but is not a barrier to most substances
ingested by the mother. Many harmful substances such as drugs (therapeutic and recreational), nicotine
and viral infectious agents are transferred to the fetus and may cause fetal drug addiction, congenital
anomalies, or fetal infections.

Placental Hormones
Four hormones are produced by the placenta: progesterone, estrogen, human chorionic
gonadotropin (hCG), and human placental lactogen (hPL).

Progesterone
Progesterone is first produced by the corpus luteum and later by the placenta. It has the following
functions during pregnancy:
• Maintains uterine lining for implantation of the zygote.
• Reduces uterine contractions to prevent spontaneous abortion.
• Prepares the glands of the breast for lactation
• Stimulates testes to produce testosterone, which aids the male fetus in developing the
reproductive tract.
Estrogen
Estrogen has three important functions during pregnancy:
1. Stimulates uterine growth
2. Increases the blood flow to uterine vessels
3. Stimulates development of the breast ducts to prepare for lactation.

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 The effects of estrogen not directly related to pregnancy include the following:
• Increased skin pigmentation (such as the “mask of pregnancy”)
• Vascular changes in the skin and the mucous membranes of the nose and mouth
• Increased salivation

Human Chorionic Gonadotroopin (hCG)

hCG is the hormone “signal” sent to the corpus luteum that conception has occurred. hCG causes the
corpus luteum to persist an dto continue the production of estrogen and progesterone to sustain
pregnancy. hCG is detectable in maternal blood as soon as implantation occurs-usually 7 to 9 days after
fertilization-and is the basis for pregnancy test.

Human Placental Lactogen

hPL is also known as human chorionic somatomammotropin. hPL causes decreased insulin sensitivity
and utilization of glucose by the mother, making more glucose available to the fetus to meet growth
needs.

The Umbilical Cord

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The umbilical cord develops with the placenta and fetal blood vessels and is the lifetime between the
mother and fetus. Two arteries carry blood from the fetus, and one vein returns blood to the fetus.
Wharton’s jelly covers and cushions the cord vessels and keeps the three vessels separated. The
vessels are coiled within the cord to allow movement and stretching without restricting circulation. The
normal length of the cord is about 55 cm (22 inches). The umbilical cord usually protrudes from the
center of the placenta.

Interactive Link
Circulatory Adaptation
https://www.youtube.com/watch?v=EIfCa0OUbPA

Fetal Circulation
After the fourth week of gestation, circulation of blood through the placenta to the fetus is well
established. Because the fetus does not have to process most waste products, several physiological
diversions in the prebirth circulatory route are needed. There are three fetal circulatory shunts.
1. Ductus Venosus: divert some blood away from the liver as it returns from the placenta
2. Foramen Ovale: diverts most blood from the right atrium directly to the left atrium, rather than
circulating it to the lungs
3. Ductus arteriosus: diverts most blood from the pulmonary artery into the aorta.
4. Umbilical Vein: within the umbilical cord carries blood from the placenta to the fetus, entering
the fetal body at the umbilicus
5. Umbilical Arteries: transported blood from the descending aorta, carries deoxygenated away
from fetal heart back to through the umbilical cord to the placental villi for new oxygen exchange
takes place

Circulation Before Birth

Oxygenated blood enters the fetal body through the umbilical vein. About half of the blood goes to the
liver through the portal sinus, with the remainder entering the inferior vena cava through the ductus
venosus. Blood in the inferior vena cava enters the right atrium, where most passes directly into the left
atrium through the foramen ovale. A small amount of blood is pumped to the lungs by the right ventricle.
The rest of the blood from the right ventricle joins the blood from the left ventricle through the ductus
arteriosus. After circulating through the fetal body, blood containing waste products is returned to the
placenta through the umbilical arteries.

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 Circulation after Birth
Fetal shunts are not needed following birth after the infant breathes and blood is circulated to the
lungs. The foramen ovale closes because pressure in the right side of the heart falls as the lungs becomes
fully inflated, and there is now little resistance to blood flow. The infant’s blood oxygen level rises, causing
the ductus arteriosus to constrict. The ductus venosus closes when the flow from the umbilical cord stops
(see Figure 7)

Closure of Fetal Circulatory Shunts

The foramen ovale closes functionally (temporarily) within 2 hours after birth and permanently
by age 3 months. The ductus arteriosus closes functionally within 15 hours and permanently in about
3 weeks. The ductus venosus closes functionally when the cord is cut and permanently in about 1 week.
After permanent closure, the ductus arteriosus and the ductus venosus become ligaments.

Because the foramen ovale and ductus arteriosus are initially closed functionally, some
conditions may cause one or the other to reopen after birth. Condition that impedes full lung
expansion (e.g., respiratory distress syndrome) can increase resistance to blood levels and can cause
the ductus arteriosus to remain open.

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Fetal Lung Preparation for Birth
Fluid in the lung maintains lungs expansion and allows for lung growth. Lung fluid decreases during
labor to provide for transition to extrauterine breathing of air. Several hormones increase in the fetus
during the labor process that decreases lung fluid production and increase lung fluid resorption to prepare
the lung to accept air. In cesarean sections or rapid delivery, this process is limited and thought to be
the cause of “wet lung” in the newborn (Ross and Ervin, 2017).

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Figure 7. Changes in feta-newborn circulation at birth. The changes in the circulation of the fetus and
the neonate are shown. The ductus arteriosus, ductus venosus, and foramen ovale are shunts that close
because of the expansion of the lungs and pressure changes within the heart.

Methods of Evaluating Fetal Growth, Maturity and Well-being

The maturity of a fetus at birth is important to its survival outside the uterus. Clinical assessment,
combined with technological tools, can be used to evaluate intrauterine growth and fetal well-being. The
nurse must recognize that the woman is likely to be apprehensive about many of these tests. It is
important to assess whether she understands the reason for the tests, and to educate her about
necessary preparations and what to expect during the tests. The nurse may also need to assist. With
clarifying tests results. Tests that assess age, size, maturity and well-being are heightened in Box 2.

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 Box 2. Showing the evaluation of the unborn infant

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Ultrasound
Ultrasonography detects differences in tissue density by directing high-frequency sound waves into tissue
and electrically measuring the reflected echoes from internal structures. It can be inserted to the
woman’s abdomen or a transducer can be inserted into the vagina/ Ultrasound scanning uses static or a
combination of static and real-time scanner. Real time imaging offers the benefits of being able to
visualize fetal breathing, tone, movement, urination, and cardiac activity.
Ultrasound is a valuable tool for assessing fetal age and intrauterine growth. It can also be used to
visualize the placenta, confirm fetal presentation, determine amniotic fluid levels, evaluate umbilical
artery blood flow, and detect congenital anomalies such as hydrocephaly. Ultrasound is a useful adjunct
to other test, such as amniocentesis and percutaneous umbilical blood sampling, providing guidance for
needle placement and helping to avoid damage to the placenta or fetus.

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 Maternal Serum Screening
Because number of a discarded trophoblast (placenta) cells or fetal red cells always enters the maternal
bloodstream ( few in number during the first and second trimesters, but plentiful during the third trimester. A
sample of maternal blood can be examined for a karyotype, fetal DNA, and sex of the fetus as early as 7
weeks of pregnancy.

a. Alpha-Fetoprotein test (AFP)- AFP is a glycoprotein produced by the fetal liver and
embryonic sac. AFP is performed between the 15th and 20th weeks of pregnancy, a
woman’s blood is obtained for the test
o Elevated AFP in maternal blood more than twice the value of the eman for
gestational age indicates a neural tube defect such as myelomeningocele, Spina
bifida
o Decreased in amount indicates chromosomal disorder such as trisomy 21 (Down
syndrome)
b. Pregnancy-associated plasma protein-A (PAPP-A) combined with a test for human
chorionic gonadotropin (hCG)- test during first trimester.

Course Code and Title

o If PAPP-P test is low it suggest a trisomy disorder (such as Down syndrome)
o If elevated suggest presence of a midline closure anomaly ( neural tube defect)
Nursing Considerations
• Explain that the AFP tests helps in monitoring fetal development, screens for a need for further
testing, helps detect possible congenital defects in the fetus, and monitors the patient’s response to
therapy by measuring a specific blood protein, as appropriate.
• Inform the patient that she need not restrict food, fluids, or medications.
• Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and
when.
• Explain to the patient that she may experience slight discomfort from the tourniquet and needle
puncture.
• Place the patient in comfortable position.
• Encourage deep breathing exercise to alleviate fear.
• Apply direct pressure to the venipuncture site until bleeding stops.

Possible Complication
Less/Non-invasive for both mother and fetus hence, no risk for fetal infection or a disruption of the pregnancy

Amniocentesis
Amniocentesis is a technique in which amniotic fluid is aspirated transabdominally or suprapubically from
the amniotic sac the amniotic fluid contains fetal cells that are then analyzed. When done in early
pregnancy (14-20 weeks), this procedure is usually for the purpose of determining developmental
anomalies and genetic makeup, including gender.
It can also be done in the third trimester to evaluate fetal lung maturity (the lecithin-spingomyelin (L/S
ration and the presence of phosphatidyglycerol (PGJ). This phospholipids are components of surfactant,
which lower lung surface tension, stabilizing the alveoli and preventing the lungs from collapsing.
Amniotic fluid can also be tested for infection, monitored to determine the severity of RH disease, and
tested for Alpha-fetoprotein (AFP) level in rule out a neural tube defect.

Nursing Considerations
• Have the client signed consent, and record vital signs (pulse rate, respiratory rate, blood
pressure, as well as fetal heart rate placental position, fetus and umbilical cord and location of
amniotic fluid pocket through ultrasound.
• If performed before 20 weeks of pregnancy instruct the client to have full bladder during the
procedure to easily visualize and support uterus.
• If performed after 20 weeks of pregnancy the bladder should be empty to minimize the chance
of puncture
• Women with RH-negative blood type need to RH immune globulins administration after the
procedure to protect against isoimmunization in the fetus.
• Woman need to be stay on bed and observed for about 30 minutes after the procedure to be
certain labor contraction.

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 Possible Maternal Risk
• Amniotic embolism
• Hemorrhage secondary to perforation of uterine or other abdominal vessels.
• Infection
• Induced labor
• Abruptio placenta
• Puncture of the Intestine
• Rh isoimmunization
Possible Fetal Risk
• Fetal death
• Amnionitis
• Injuries directly induced by the needle
• Leakage of amniotic fluid
• Bleeding

Chorionic Villus Sampling (CVS)

Course Code and Title

CVS is an alternative to amniocentesis for prenatal diagnosis of genetic disorders. Because CVs can be
done earlier in pregnancy (8 to 11 weeks’ gestation) and test is usually done using real time imaging
while the physician passes a catheter through the cervical os and aspirate chorionic villi from the
placenta.
Nursing Considerations
• Educate client about the procedure and a signed consent form are required.
• A full bladder may help position the uterus for easier catheter insertion.

Electronic Fetal Heart Rate Monitoring

During the third trimester evaluation of fetal well-being is indicated for women with diabetes, pregnancy-
induced hypertension, and other high-risk conditions. It is desirable for those women who are overdue
(41 or more weeks’ gestation), since placental aging may compromise fetal oxygenation. The woman is
placed is a semi-fowlers position and an electronic fetal monitor is applied to her abdomen. Fetal
movement and fetal heart rate are recorded. A “reactive” NST demonstrates at least two fetal heart rate
accelerations (15 second duration, 15 beats per minute increase) with fetal movements in a 20-minute
period. Acceleration of the fetal heart rate indicate an intact nervous system that is not compromised.

Increasingly, sound (acoustic) or vibration with sound (vibroacoustic) is used to stimulate the fetus
during NST. A device, such as an artificial larynx, is held to the mother’s abdomen and the sound or
combined sound and vibration stimulates fetal movement and fetal heart rate accelerations. This
technique typically shortens the time necessary for an NST.

In the event of a nonreactive NST or other high risk condition the health care provider may order a
contraction stress test to evaluate placental functioning. Contractions are induced by nipple stimulation
or an intravenous oxytocin infusion. The goal of this test is to achieve three contractions lasting 40 to
60 seconds within a 10-minute period. The fetal heart rate is observed for late decelerations, which
indicate diminished fetal reserves.

Fetal Heart Rate

Fetal heart sound can be heard and counted as early as the 10 th to 11th weeks’ of pregnancy by the use
of an ultrasound doppler technique, which is done routinely at every prenatal visits past 10 weeks.

Daily Fetal Movement Count (Kick Count)

Quickening is a fetal movement felt by the mother occurs at approximately 18 to 20 weeks of pregnancy
and peaks in intensity at 28 weeks. After that time, a healthy fetus moves with a degree of consistency,
at about 10 times per hour. If fetus is not receiving enough nutrients because of poor maternal nutrition
or placental insufficiency has greatly decreased movement.
For High-risk pregnancy, ask woman to:
o Lie in a left recumbent position after meal.

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 o Observed and record the number of fetal movements (kicks) their fetus makes until they have
counted 10 movements
o Record the time (typically this is under an hour)
o If an hour passes without 10 kicks, they should walk around a little and try a count again.
o If 10 movements (kicks) cannot be felt in a second 1-hour period, they should inform their
primary health care provider. The fetus could be healthy but sleeping during this time, so lack
of typical movements may not be serious, but it is an indication of further assessment

Summary
• Gametogenesis in the male is called spermatogenesis. Each mature sperm has 22 autosomes
plus either an X or a Y sex chromosome for a total of 23. Gametogenesis in the female is called
oogenesis. It begins at ovulation and is not completed until fertilization occurs. The mature ovum
has 22 autosomes plus the X sex chromosomes at a total of 23. At conception the total number
of chromosomes is restored to 46.
• When the ovum is fertilized by an X-bearing sperm, a female offspring results; when it is fertilized
by a Y-bearing sperm, a male offspring results.

Course Code and Title

• After fertilization in the fallopian tube, the zygote enters the uterus, where implantation is
complete by 7 days after fertilization. If the zygote fails to move through the tube, implantation
occurs there, and a tubal ectopic pregnancy results.
• When implantation occurs in the uterine lining, the cells of the zygote differentiate and develop
into the following structures: chorion, amnion, yolk sac, and primary germ layers. The chorion
develops into the embryonic or fetal portion of the placenta; the amnion encloses the embryo
and the amniotic fluid; the primary germ layers develop into different parts of the growing fetus;
and the yolk sac, which functions only during embryonic life, begins to form red blood cells.
• The three germ layers of the embryo are the ectoderm, the mesoderm, and the endoderm. All
structures of the individual develop from these layers.
• All body systems are formed and functioning in a simple way by the end of the eight week.
• All body system are formed and functioning in a simple way by the end of the eight week.
• The accessory structures of pregnancy are the placenta, umbilical cord, and fetal circulation.
These structures continuously support the fetus throughout prenatal life in preparation for birth.
• The amniotic fluid maintains an even temperature around the fetus, allows free floating and
symmetrical growth, and acts as cushion to protect the fetus and the umbilical cord.
• The placenta is an organ for fetal respiration, nutrition, and excretion. It is a temporary endocrine
glands that produces progesterone, estrogen, human chorionic gonadotropin and human
placental lactogen.
• The umbilical cord contains two arteries that carry blood away from the fetus and one vein that
carries blood to the fetus.
• The fetal circulation transports oxygen and nutrients to the fetus and disposes of carbon dioxide
and other waste products from the fetus. The temporary fetal circulatory structures are the
foramen ovale, the ductus arteriosus, and ductus venosus. They divert most blood from the fetal
liver and lungs, because these organs do not fully function during prenatal life.
• Methods of evaluating fetal well-being before labor includes ultrasonography, maternal serum
screening ( PAPP-A with hCG and AFP), Amniocentesis, chorionic villus sampling, electronic fetal
heart rate monitoring, daily fetal movement screening (kicks test)

Readings and References

• Maternal and Child Health Nursing: Care for Childbearing and Childrearing Family 7 th Edition
by Adele Pilliterri; Chapter 9: Nursing Care of the Growing Fetus; pp. 189-201
• Carpenito, L. J. (2004). Handbook of nursing diagnosis (10th ed.). Philadelphia:
Lippincott Williams & Wilkins.
• Introduction to Maternity and Pediatric Nursing 8th Edition by Gloria Leifer
• Study Guide for Maternal and Child Nursing Care 5 th Edition by Karen A.Piotrowski & David Wilson
Ingalls & Salermo’s Maternal and Child Health Nursing 8th Edition Novak & Broom

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is s trictly prohibited.
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