ASSESS

FETAL G
DEVELO
REPORTERS:
Sharlaine Benavidez
Carla Caoctoy
Nesreen Alapa
BSN 2 – 2
Much information about the size and health of the unborn child can be
gathered through a variety of assessment techniques.

Nursing responsibility:
 seeing that a signed consent form has been obtained as needed,
 scheduling the procedure,
 explaining the procedure to the woman and her support person,
 preparing the woman physically and psychologically,
 providing support during the procedure,
 assessing both fetal and mental responses to the procedure,
 providing follow-up care to the woman,
 managing equipment and specimens.

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 ESTIMATING FETAL GROWTH
McDonald’s Rule – is a method of determining, during mid
pregnancy, that the fetus is growing in utero by measuring fundal
(uterine) height
o Symphysis – Fundal height measurement
o Not documented to be thoroughly reliable
o Between the 20th and 31st weeks of pregnancy the distance
from the uterine fundus to the symphysis pubis in centimeters
is equal to the week of gestation
o Make the measurement from the notch of the symphysis pubis
to over the top of the uterine fundus as a woman lies supine
o Becomes inaccurate during the third trimester of pregnancy
because the fetus is growing more in weight than in height
during this time
12 weeks Over the symphysis
pubis
16 weeks Midway between
symphysis pubis and
umbilicus
20 weeks Umbilicus
36 weeks Xyphoid process
Fundic height (cm) x 8 / 7 = _____ weeks

Fundic height (cm) x 2 / 7 = _____ weeks

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 ASSESSING FETAL WELL – BEING
Quickening 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.

Ask the woman to observe and record the number of

movements the fetus is making to have a gross
assessment of fetal well-being
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.
Cardiff method • For this, a woman records the time
“Count-to-Ten” 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. 6
 FETAL HEART RATE
• Fetal hearts beat at
120 to 160 beats per
minute throughout
pregnancy.
• Fetal heart sounds
can be heard and
counted as early as
the 10th to 11th week
• Can use an ultrasonic
Doppler technique
 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. Semi-Fowler’s position to prevent her uterus from compressing the
vena cava and causing supine hypotension syndrome during the
test.
2. Attach an external fetal heart rate monitor abdominally
3. Ask the woman to remain in a fairly fixed position
4. Record the fetal heart rate for 20 minutes.
 
The 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.
FETAL HEART RATE

Absent none apparent,

nondetectable

Minimal extremely small

fluctuations
Less than undetectable
to
<6 beats/minute

Moderate 6–25 beats per minute

Marked Over 25 beats per

minute
 FETAL HEART RATE
Nonstress Testing - Measures the response of the fetal heart rate to
fetal movement.
Done for 10 to 20 minutes
 
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
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 beats per minute and remain elevated for 15 seconds.
 FETAL HEART RATE

• It should decrease to its

average rate again as the
fetus quiets

• “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.

• “Nonreactive” if no
accelerations occur with the
fetal movements.
 FETAL HEART RATE
Vibroacoustic Stimulation
• Uses a specially designed
acoustic stimulator
• Applied to the mother’s
abdomen to produce a sharp
sound
• Approximately 80 decibels at a
frequency of 80 hz, startling
and waking the fetus
• 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
Contraction Stress Testing
• fetal heart rate is analyzed in
conjunction with contractions through
nipple stimulation
• With external uterine contraction and
fetal heart rate monitors in place, the
baseline fetal heart rate is obtained.
• Three contractions with a duration of
40 seconds or longer must be present
in a 10-minute window before the test
can be interpreted.
• The test is negative (normal) if no fetal
heart rate decelerations are present
with contractions.
• It is positive (abnormal) if 50% or more
of contractions cause a late
 ULTRASONOGRAPHY (Ultrasound)
o Measures the response of sound waves against solid objects, is a much-
used tool in modern obstetrics,
o A permanent record, such as a video or photograph, can be made of the
scan.

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
 
 ULTRASONOGRAPHY (Ultrasound)

• 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.
• Have her drink a full glass of
water every 15 minutes
beginning 90 minutes before
the procedure and not void
until after the procedure.
 ULTRASONOGRAPHY
1. Biparietal Diameter 2. Doppler Umbilical
• Ultrasonography may be used to Velocimetry.
predict fetal maturity by • Doppler ultrasonography
measuring the biparietal diameter measures the velocity at which
(side-to-side measurement) of the red blood cells in the uterine
fetal head, head circumference and fetal vessels travel.
(34.5 cm indicates a 40-week • Assessment of the blood flow
fetus) and femoral length through uterine blood vessels is
  helpful to determine the
vascular resistance present in
women with diabetes or
hypertension of pregnancy and
whether resultant placental
insufficiency is occurring.
 ULTRASONOGRAPHY
4. Amniotic Fluid Volume
3. Placental Grading.
• Based particularly on the amount of Assessment.
• The amount of amniotic fluid present
calcium deposits in the base of the
placenta is yet another way to estimate fetal
• Because fetal lungs are apt to be health because a portion of the fluid
mature at 38 weeks, a grade 3 is formed by fetal kidney output.
• A decrease in amniotic fluid volume
placenta suggests that the fetus is
mature. puts the fetus at risk for compression
  of the umbilical cord and interference
Placentas can be graded by ultrasound with nutrition.
as:  
0 (a placenta 12–24 weeks),
1 (30–32 weeks),
2 (36 weeks),
3 (38 weeks).
ELECTROCARDIOGRAPHY

• 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 tracing.
MAGNETIC RESONANCE IMAGING
• Magnetic resonance imaging (MRI) also may be used to
assess the fetus.

• Because the technique apparently causes no harmful

effects to the fetus or woman

• MRI has the potential to replace or complement

ultrasonography as a fetal assessment technique (Laifer-
Narin et al,, 2007).

• 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
the 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.
• The level is low if 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.
TRIPLE SCREENING
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. As with the
measurement of MSAFP, it requires only a simple venipuncture of the
mother.
CHRONIC VILLI SAMPLING

Chorionic villi sampling (CVS) is a biopsy and chromosomal analysis

of chorionic villi that is done at 10–12 weeks of pregnancy.
 AMNIOCENTESIS
Amniocentesis (from the Greek amnion for “sac” and
kentesis for “puncture”) is the withdrawal of sample
of amniotic fluid (2 to 5 mL) trans abdominally for genetic
analysis.
 It is usally done with an ultrasound visualizations between
14 to 16 weeks (3 to 4 months) or during second
trimester

 Amniocentesis carries only a 0.5% risk of spontaneous

abortion.

 The technique can be used again near term to test for

fetal maturity.
AMNIOCENTESIS
Amniotic fluid is analyzed for:

• Alpha-Fetoprotein (AFP). If the fetus has an open body

defect, such as anencephaly, myelomeningocele, or
omphalocele, increased levels of AFP will be present in the
amniotic fluid because of leakage of AFP into the fluid.

• 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.

• 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.
AMNIOCENTESIS
• 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.

• 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.
AMNIOCENTESIS
• 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.
• 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. 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.
• 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.
 PERCUTANEOUS UMBILICAL BLOOD
SAMPLING
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.
 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.

FETOSCOPY
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.
AMNIOSCOPE

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FETOSCOPE

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 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.
 BIOPHYSICAL PROFILE

A biophysical profile combines five parameters (fetal reactivity, fetal

breathing movements, fetal body movement, fetal tone, and amniotic
fluid volume) into one assessment.
• 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.
• With use of this system, each item has the potential for scoring a 2,
so 10 would be the highest score possible. A biophysical profile is
more accurate in predicting fetal wellbeing than any single
assessment (Lalor, et al, 2009).
• Because the scoring system is similar to that of the Apgar score
determined at birth on infants, it is popularly called a fetal Apgar.
BIOPHYSICAL PROFILE