Assessment of Fetal Gowth and

Development
Health History
1. Nutritional intake
– because, if a woman is not eating a well-balanced
diet, she may not be taking in sufficient nutrients
for fetal growth.
2. Personal habits such as;
– cigarette smoking,
– recreational drug use, and
– exercise,
3. Asking if the woman has had any, hx
– accidents
– experienced intimate partner abuse

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Estimating Fetal Growth

McDonald’s Rule
– a symphysis-fundal height measurement,
– is an easy method of determining during
midpregnancy that a fetus is growing in utero.
• the distance from the uterine fundus to the
symphysis pubis in centimeters is equal to the
week of gestation between the 20th and 31st
weeks of pregnancy.
• although not documented to be thoroughly
reliable

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 McDonald’s Rule

• As a woman lies supine

• Measure fundal height from the superior aspect of the pubis to the
fundal crest.
• The tape is pressed flat against the abdomen for the measurement.

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McDonald’s Rule
Typical measurements
12 weeks -the symphysis pubis

20 wks - At the umbilicus

36 wks - At the xiphoid process

• Rises about 1cm per week;

after which it varies

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 McDonald’s rule
• During the third trimester of pregnancy it becomes inaccurate.
– because the fetus is growing more in weight than in height during this
time.
• A fundal height much greater than the standard suggests
– multiple pregnancy,
– a miscalculated due date,
– a large-for-gestational-age infant,
– hydramnios (increased amniotic fluid volume),
– or possibly even hydatidiform mole
• A fundal measurement much less than this suggests;
– intrauterine growth restriction
– the pregnancy length was miscalculated,
– or an anomaly, such as anencephaly, has developed.
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 Assessing Fetal Well-being
1. Fetal Movement
2. Fetal Heart Rate
3. Ultrasonography
4. Electrocardiography
5. Magnetic Resonance Imaging
6. Maternal Serum Alpha-Fetoprotein
7. Triple Screening
8. Chorionic Villi Sampling
9. Amniocentesis
10. Percutaneous Umbilical Blood Sampling
11. Amnioscopy
12. Fetoscopy
13. Biophysical Profile
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 Assessing Fetal Well-being
1. Fetal Movement
• Quickening - fetal movement that can be felt
by the mother
– 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.
• Based on this, asking a woman to observe and
record the number of movements the fetus is
making offers a gross assessment of fetal well-
being
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 Assessing Fetal Well-being
1. Fetal Movement
The Sandovsky Method
• ask the woman to lie in a left recumbent
position after a meal and
• record how many fetal movements she feels
over the next hour
• 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.
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 Assessing Fetal Well-being
1. Fetal Movement
The Cardiff method (“Count-to-Ten”)
• a woman records the time interval it takes for
her to feel 10 fetal movements 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
– the time since she last ate.

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 Assessing Fetal Well-being
2. Fetal Heart Rate
• 120 to 160 beats per minute throughout
pregnancy.
• 10th to 11th week of pregnancy
– Fetal heart sounds can be heard and counted
– With the use of an ultrasonic Doppler technique

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2. Fetal Heart Rate

Methods of acquiring FHR:

✓Rhythm Strip Testing
✓Nonstress Testing
✓Vibroacoustic Stimulation
✓Contraction Stress Testing

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 2. Fetal Heart Rate

Rhythm Strip Testing

• assessment of the fetal heart rate for whether a good baseline
rate and a degree of variability are present.
1. woman into a semi-Fowler’s
position
✓ to prevent her uterus from
compressing the vena cava and
causing supine hypotension
syndrome during the test.
2. Requires a woman to remain in
a fairly fixed position.
3. Attach an external fetal heart
rate monitor abdominally .
4. Record the fetal heart rate for
20 minutes.
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2. Fetal Heart Rate

• Baseline reading refers to the average rate of the

fetal heartbeat per minute.
• Variability refers to small changes in rate that occur if
the fetal parasympathetic and sympathetic nervous
systems are receiving adequate oxygen and
nutrients.
It is categorized as
1) absent (none apparent);
2) minimal (extremely small fluctuations);
3) moderate (amplitude range of 6–25
beats per minute);
4) marked (amplitude range over 25 beats
per minute)
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 2. Fetal Heart Rate

In the rhythm strip, the baseline (average) of the fetal

heartbeat is 130 beats per minute, although over the
recorded period, it varies from 120 to 150 beats per
minute.
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2. Fetal Heart Rate
Nonstress Testing
A nonstress test measures the response of the fetal heart
rate to fetal movement.
– usually is done for 10 to 20 minutes.
• The test results:
1. Reactive
– if two accelerations of fetal heart rate (by 15 beats or
more) lasting for 15 seconds occur after movement within
the chosen time period.
2. Nonreactive
– if no accelerations occur with the fetal movements.
– The results also can be interpreted as nonreactive if no
fetal movement occurs
– or if there is low short-term fetal heart rate variability (less
than 6 beats per minute) throughout the testing period
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2. Fetal Heart Rate
Nonstress Testing
Procedure:
1. Position a woman and attach both a fetal
heart rate and a uterine contraction monitor.
2. 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.
• The fetus also maybe stimulated by a loud
sound to cause movement.

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2. Fetal Heart Rate

• Vibroacoustic 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 80 Hz,
• startling and waking the fetus
• During a standard nonstress test, if a
spontaneous acceleration has not occurred
within 5 minutes,
• apply a single 1- to 2-second sound stimulation to the lower
abdomen.
• This can be repeated again at the end of 10 minutes if no
further spontaneous movement occurs, so that two
movements within the 20-minute window can be evaluated.
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• Fetal Heart Rate

• Contraction Stress Testing

– the fetal heart rate is analyzed in conjunction with
contractions.
– Contactions are initiated by oxytocin
• Gentle stimulation of the nipples releases oxytocin in the
same way as happens with breastfeeding.
Procedue:
• external uterine contraction and fetal heart rate
monitors in place, the baseline fetal heart rate is
obtained.
• Next, the woman rolls a nipple between her
finger and thumb until uterine contractions
begin, which are recorded by a uterine monitor.
• Three contractions with a duration of 40 seconds
or longer must be present in a 10-minute window
before the test can be interpreted.
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• Fetal Heart Rate

Contraction Stress Testing

The test result is
• Negative (normal)
– if no fetal heart rate decelerations are present
with contractions.
• Positive (abnormal)
– if 50% or more of contractions cause a late
deceleration (a dip in fetal heart rate that occurs
toward the end of a contraction and continues
after the contraction)

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Comparison of Nonstress and Contraction Tests

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3. Ultrasonography
• Ultrasonography, which measures the response of sound
waves against solid objects,

It can be used to:

• Diagnose pregnancy as early as 6 weeks’ gestation
• Confirm the presence, size, and location of the placenta and
amniotic fluid
• Establish that a fetus is growing and has no gross anomalies,
such as hydrocephalus, anencephaly, or spinal cord, heart,
kidney, and bladder defects
• Establish sex if a penis is revealed
• Establish the presentation and position of the fetus
• Predict maturity by measurement of the biparietal diameter of
the head
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3. Ultrasonography
Can also be used to discover complications of pregnancy, such as
• the presence of an intrauterine device,
• hydramnios or oligohydramnios,
• 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.

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3. Ultrasonography
• Woman should have 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.
Pocedure:
• 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.

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3. Ultrasonography
• 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.

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3. Ultrasonography

Uses of Ultrasound for assessing fetal growth and

development:
1. Biparietal Diameter
2. Doppler Umbilical Velocimetry
3. Placental Grading
4. Amniotic Fluid Volume Assessment

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3. Ultrasonography

Biparietal Diameter.
• used to predict fetal maturity by measuring the biparietal
diameter (side-to-side measurement) of the fetal head.
• biparietal diameter of the fetal head is
– 8.5 cm or greater, infant will weigh more than 2500 g (5.5
lb) or is at a fetal age of 40 weeks
Two other measurements commonly made by ultrasound to
predict maturity are
• head circumference (34.5 cm indicates a 40-week fetus)
• femoral length.

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3. Ultrasonography
Biparietal Diameter

An ultrasound at 24 weeks’
gestation showing
measurement of the biparietal
diameter.
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3. Ultrasonography

Doppler Umbilical Velocimetry.

• measures the velocity at which red blood cells in the uterine
and fetal vessels travel.
• to determine the vascular resistance present in women with
diabetes or hypertension of pregnancy and whether resultant
placental insufficiency is occurring.
– it will limit the number of nutrients that can reach the
fetus,
• decreased velocity is an important predictor of poor neonatal
outcome

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3. Ultrasonography

Placental Grading
• Based particularly on the amount of calcium deposits in the
base of the placenta, placentas can be graded by ultrasound
as
• 0 (a placenta 12–24 weeks),
• 1 (30–32 weeks),
• 2 (36 weeks),
• 3 (38 weeks)
• Because fetal lungs are apt to be mature at 38 weeks, a grade
3 placenta suggests that the fetus is mature.

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3. Ultrasonography

Amniotic Fluid Volume Assessment

• A decrease in amniotic fluid volume puts the fetus at risk for
compression of the umbilical cord and interference with
nutrition.
• Amniotic Volume Index (AFI) or total is the sum of the two
measurements.
– For gestations of less than 20 weeks, the uterus is
hypothetically divided along the midpoint (the linea nigra
on the woman’s abdomen) into two vertical halves.
– The vertical diameter of the largest pocket of amniotic
fluid present on each side is measured in centimeters.

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3. Ultrasonography

Amniotic Fluid Volume Assessment

• For gestations of 20 weeks or more, the uterus is dividedinto
four quadrants, using the linea nigra again as the vertical
dividing line and the level of the umbilicus as the horizontal
dividing line.
• The vertical diameter of the largest pocket of fluid in each
quadrant is obtained, and the four values are then added to
produce the amniotic fluid index.

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3. Ultrasonography

Amniotic Fluid Volume Assessment

• The average index is approximately

– 12–15 cm between 28 and 40 weeks.

– An index greater than 20–24 cm indicates hydramnios

– An index less than 5–6 cm indicates oligohydramnios

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 Assessing Fetal Well-being

4. Electrocardiography
• Fetal ECGs may be recorded as early as the 11th
week of pregnancy.
• 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 tracing.
• It is rarely used unless a specific heart anomaly is
suspected.

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4. Electrocardiography

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 Assessing Fetal Well-being

Magnetic resonance imaging (MRI)

• used to assess the fetus.
• 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.

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 Assessing Fetal Well-being
5. Maternal Serum Alpha-Fetoprotein
• AFP is a
– substance produced by the fetal liver
– present in both amniotic fluid and maternal serum.
• Maternal Serum (MSAFP)
– If the level is abnormally high, it indicates fetal defects
• open spinal or abdominal defect such as spina bifida or
omphalocele,
• If the level is low
– the fetus has a chromosomal defect such as Down syndrome.
• MSAFP levels begin to rise at 11 weeks’ gestation and then
steadily increase until term.
• Traditionally assessed at the 15th week of pregnancy,
• Between 85% and 90% of neural tube defects and
• 80% of Down syndrome babies can be detected by this
method
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 Assessing Fetal Well-being

Triple screening, or analysis of three

indicators (MSAFP, unconjugated estriol, and
hCG),
• may be performed in place of simple AFP
testing to yield even more reliable results.
• it requires only a simple venipuncture of the
mother.

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 Assessing Fetal Well-being

Chorionic villi sampling (CVS)

• is a biopsy and
chromosomal analysis of
chorionic villi that is done
at 10–12 weeks of
pregnancy.
• Coelocentesis
(transvaginal aspiration of
fluid from the
extraembryonic cavity) is
an alternative method to
remove cells for fetal
analysis.

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 Assessing Fetal Well-being

Amniocentesis
• from the Greek amnion for
“sac” and kentesis for
“puncture”
• is the aspiration of amniotic
fluid from the pregnant
uterus for examination.
• scheduled between the 14th
and 16th weeks of pregnancy
– to allow for a generous amount
of amniotic fluid to be present.

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Amniocentesis
Preparation for amniocentesis
1. ask the woman to void
2. Place her in a supine position on an examining table and
drape her appropriately, exposing only her abdomen.
3. Place a folded towel under her right buttock to tip her
body slightly to the left and move the uterus off the vena
cava.
4. Attach fetal heart rate and uterine contraction monitors.
5. Take her blood pressure and measure the fetal heart rate
for baseline levels.

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Amniocentesis
Procedure for amniocentesis
1. An ultrasound is then done to determine the position
of the fetus and the location of a pocket of amniotic
fluid and the placenta.
2. The abdomen is then washed with an antiseptic
solution, and a local anesthetic is injected.
3. Caution the woman that she may feel a sensation of
pressure as the needle used for aspiration, a 3- or 4-
in, 20- to 22-gauge spinal needle, is introduced.
4. Do not suggest that she take a deep breath and hold it
as a distraction against discomfort:

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 Assessing Fetal Well-being

Amniocentesis
Fetal complications
• hemorrhage from
penetration of the placenta,
• infection of the amniotic
fluid
• puncture of the fetus.

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 Assessing Fetal Well-being

Amniocentesis
Fetal complications
• hemorrhage from
penetration of the placenta,
• infection of the amniotic
fluid
• puncture of the fetus.

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 Assessing Fetal Well-being
Amniocentesis

5. The needle is inserted until it reaches the amniotic cavity

and a pool of amniotic fluid, carefully avoiding the fetus and
placenta
6. about 15 mL of amniotic fluid is withdrawn.
7. The needle is then removed, and the woman rests quietly
for about 30 minutes.
8. During the procedure and for the 30 minutes afterward,
observe the fetal heart rate monitor to be certain the rate
remains within normal values and observe the uterine
contraction monitor to be sure that no contractions are
occurring.
✓ If the woman has Rh-negative blood, Rho(D) immune globulin
(RhIG; RhoGAM) is administered after the procedure to
prevent fetal isoimmunization.

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 Assessing Fetal Well-being

Amniotic fluid is analyzed for:

1. Alpha-Fetoprotein (AFP)
2. Bilirubin Determination
3. Chromosome Analysis
4. Color
5. Fetal Fibronectin
6. Inborn Errors of Metabolism
7. Lecithin/Sphingomyelin Ratio
8. Phosphatidyl Glycerol and Desaturated
Phosphatidylcholine
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 Assessing Fetal Well-being

Amniotic fluid is analyzed for:

1. Alpha-Fetoprotein (AFP)
• increased levels of AFP
– If the fetus has an open body defect,
• decreased level in the amniotic fluid of
– fetus with chromosomal defects such as Down
syndrome.
• Acetylcholinesterase
– A compound obtained fom amniotic fluid
– high levels in amniotic fluid indicates neural tube defect

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 Assessing Fetal Well-being
Amniotic fluid is analyzed for:
2. Bilirubin Determination
• The presence of bilirubin may be analyzed if a blood
incompatibility is suspected. If bilirubin is going to be
analyzed, the specimen must be free of blood or a
false-positive reading will occur.

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 Assessing Fetal Well-being
Amniotic fluid is analyzed for:
3. Chromosome Analysis
• A few fetal skin cells are always present in amniotic
fluid.
• These cells may be cultured and stained for
karyotyping for genetic analysis.

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 Assessing Fetal Well-being
Amniotic fluid is analyzed for:
4. Color
• Normal amniotic fluid is the color of water;
• Late in pregnancy, it may have a slightly yellow tinge.
• 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.

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 Assessing Fetal Well-being

Amniotic fluid is analyzed for:

5. Fetal Fibronectin
• Fibronectin is a glycoprotein that
• plays a part in helping the placenta attach to the
uterine decidua.
• 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.

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 Assessing Fetal Well-being

Amniotic fluid is analyzed for:

6. Inborn Errors of Metabolism
• Detects some inherited diseases cause by IEM
• There are presence of the errant enzyme in the
amniotic fluid as early as the time of the procedure
• Examples of illnesses
– Cystinosis
– maple syrup urine disease (amino acid disorders).

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 Assessing Fetal Well-being
Amniotic fluid is analyzed for:
7. Lecithin/Sphingomyelin Ratio
• Lecithin and sphingomyelin are the protein components of the lung
enzyme surfactant that the alveoli begin to form at the 22nd to 24th
weeks of pregnancy.
Shake Test
– Can be done immediately after amniocentesis
– (if bubbles appear in the amniotic fluid after shaking, the ratio is
mature)

• for laboratory analysis.

– An L/S ratio of 2:1 is traditionally accepted as lung maturity.
– Some laboratories interpret a ratio of 2.5:1 or 3:1 as a mature
indicator in infants of women with diabetes.

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 Assessing Fetal Well-being
Amniotic fluid is analyzed for:
8. Phosphatidyl Glycerol and Desaturated Phosphatidylcholine
• These are additional compounds found in surfactant.
• Pathways for these compounds mature at 35–36 weeks.
• present only with mature lung function,
• presence in the sample of amniotic fluid obtained can be
predicted with even greater confidence that respiratory
distress syndrome is not likely to occur.

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 Assessing Fetal Well-being

Percutaneous Umbilical Blood Sampling (PUBS )

• also called cordocentesis or funicentesis
• is the aspiration of blood from the umbilical vein for analysis.
Umbilical cord is located by ultrasound,
Pocedue:
1. a thin needle is insertedby into the uterus and is
guided by ultrasound until it pierces the umbilical vein.
2. Blood sample is then removed for blood studies
3. Kleihauer-Betke test is done.
– To measures the difference between adult and
fetal blood.

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 Assessing Fetal Well-being

Percutaneous Umbilical Blood Sampling (PUBS )

4. RhIG is given to Rh-negative women to prevent
sensitization.
– fetal blood could enter the maternal circulation
after the procedure
5. The fetus is monitored by :
• Nonstress test before and after the
procedure
• Ultrasound

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 Assessing Fetal Well-being

• 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.

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 Assessing Fetal Well-being

Fetoscopy
• in which the fetus is visualized by inspection through a
fetoscope (an extremely narrow, hollow tube inserted
by amniocentesis technique)
• helpful to assess fetal well-being
• it can document a problem or reassure parents that
their infant is perfectly formed.
• can be performed in about the
16th or 17th week

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 Assessing Fetal Well-being

Fetoscopy
The procedure is used to:
• Confirm the intactness of the spinal column
• Obtain biopsy samples of fetal tissue and fetal blood
samples
• Perform elemental surgery, such as inserting a
polyethylene shunt
– into the fetal ventricles to relieve
hydrocephalus or
– anteriorly into the fetal bladder to
relieve a stenosed urethra

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 Assessing Fetal Well-being

Fetoscopy
Procedure:
1. The mother is prepared and draped as for
amniocentesis.
2. A local anesthetic is injected into the abdominal skin.
3. The fetoscope is then inserted through a minor
abdominal incision.
4. Fetus is sedated if very active
– meperidine (Demerol) may be administered to the
woman to

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 Assessing Fetal Well-being

Fetoscopy
Complication/Risk:
1. small risk of premature labor.
2. Amnionitis
– infection of the amniotic fluid) may occur.
– To avoid infection, the woman may be prescribed 10
days of antibiotic therapy after the procedure.

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 Assessing Fetal Well-being
Biophysical Profile
Combines five parameters into one assessment
1. fetal reactivity,
2. fetal breathing movements,
3. fetal body movement,
4. fetal tone, and
5. amniotic fluid volume
• The fetal heart and breathing record measure short-term central
nervous system function;
• the amniotic fluid volume helps measure long-term adequacy of
placental function.
• more accurate in predicting fetal wellbeing than any single
assessment
• popularly called a fetal Apgar.
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 Assessing Fetal Well-being
Biophysical Profile
If the fetus score on a complete profile
❑ 8–10, the fetus is considered to be doing well
❑ 6 is considered suspicious
❑ 4 denotes a fetus probably in jeopardy
• For simplicity, some centers use only
• for assessment.
Modified biophysical profile
two assessments
1. amniotic fluid index
• long-term viability by the AFI.
2. nonstress test
• predicts short-term viability by the nonstress test
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 Assessing Fetal Well-being
Biophysical Profile

Modified biophysical profile

two assessments
1. amniotic fluid index
• long-term viability by the AFI.
2. nonstress test
• predicts short-term viability by the nonstress test
A healthy fetus should
• show a reactive nonstress test
• AFI range between 5 and 25 cm

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 Assessing Fetal Well-being

Biophysical Profile Scoring

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