ASSESSMENT OF FETAL GROWTH AND DEVELOPMENT

Learning outcomes
1. Describe the areas of health assessment commonly included in prenatal visits.
2. Use critical thinking to analyze ways to ensure that prenatal care is family centered.
3. Assess a pregnant woman’s health status and readiness for pregnancy.
4. Integrate knowledge of pregnancy health assessment with nursing process to achieve
quality maternal and child care.

NURSING RESPONSIBILITIES:
signed consent form, scheduling of procedure, explaining the procedure, preparing the woman,
providing support during the procedure, providing necessary follow-up care, managing
equipment & specimens

Purposes of prenatal care:

Establish a baseline of present health.
Determine the gestational age of the fetus
Monitor fetal development and maternal wellbeing.
Identify women at risk for complications.
Minimize the risk of possible complications by anticipating and preventing problems before they
occur.
Provide time for education about pregnancy, lactation and newborn care.

HEALTH HISTORY
Nutritional intake, personal habits (smoking, drug use, exercise), abuse,trauma

Health assessment during prenatal visits

A. Initial interview- Establish rapport
B. 1. History taking- demographic data- name, age, address, telephone number, email ad,
religion and health insurance information.
2. Chief concern- inquire the date of LMP, document if the pregnancy was planned
3. Family profile- get to know the woman earlier, identify important support persons,
identify client’s age, educational level, marital status, occupation and her sexual
partner.
4.history of past illness
5. history of family illness
6. day history/social profile- nutrition, elimination sleep recreation, exercise
7. Gynecological history – 1st menstrual period, menstrual cycle, past surgery, family
planning methods, assess for stress incontinence
8. Obstetric history- history of previous pregnancies, miscarriages, document the child’s
sex and place and date of birth, multigestational pregnancy
9. Review of systems

C. Physical examination:
urine collection
Pelvic examination
Baseline height/weight and vital signs measurement taking
Assessment of systems – Head to toe
D. Measurement of fundal height and fetal heart sounds
E. Pelvic examination and estimating pelvic bones – pap smear to be taken for early
 detection and diagnosis of precancerous conditions

Internal pelvic measurements give the actual diameters of the inlet and outlet through which the
fetus must pass.
 Diagonal conjugate- distance between the anterior surface of the sacral prominence and
the posterior surface of the symphysis pubis
 True conjugate- the measurement between the anterior of the sacral prominence and
posterior surface of the inferior margin of the symphysis pubis
 Ischial tuberosity- is the distance between the ischial tuberosities or the transverse
diameter of the outlet

F. Blood studies
 CBC- Hg, HCT, RBC – to determine the presence of anemia
 Genetic screen- G6PD, sickle cell disease, cystic
fibrosis, thalassemia, blood typing, maternal serum for alpha-fetoprotein, indirect coombs test,
antibody titer for rubella & hepatitis B, HIV screening

G. Urinalysis
H. Tuberculosis screening- PPD (Purified protein derivative) tuberculin test to screen
tuberculosis
I. Ultrasonography- to confirm the pregnancy length and document the healthy fetal growth

ESTIMATING FETAL GROWTH

Definition of Terms:

GRAVIDA - a pregnant woman, any pregnancy regardless of duration

PARA - a woman who has delivered a viable baby
NULLIGRAVIDA – a woman who has never been pregnant
NULLIPARA – a woman who has not delivered a child who reached viability
PRIMIGRAVIDA – a woman pregnant for the first time
PRIMIPARA – a woman who has been pregnant more than once
MULTIGRAVIDA – a woman who has been pregnant more than once
MULTIPARA – a woman who has delivered two or more fetuses past the age of viability
GRANDMULTIPARA – a woman who has had six or more births past the age of viability
VIABILITY – refers to the capability of a fetus to survive outside the uterus after the earliest
gestational age (approximately 20-23 weeks gestation)
IN UTERO – refers within the uterus
TERM INFANT – an infant born between 37-42 weeks
POSTTERM INFANT- an infant born after 42 weeks
PRETERM – an infant born before 37 weeks
PUERPERA – a woman who has just delivered (within 6 weeks after delivery)

NORMAL LENGTH OF PREGNANCY:

267-280 days
40 weeks
10 lunar months
9 calendar months
3 trimesters

First trimester – period of organogenesis; teratogens (alcohol, drugs, virus, radiation) highly
damaging

Second trimester – most comfortable for the mother with continued fetal growth
Third trimester – with rapid deposition of fats, thus period of most rapid growth
- With rapid iron and calcium deposition

Schedule of Clinic Visits:

First visit – as soon as the mother missed a menstrual period, a pregnancy is suspected
First 32 weeks – once a month
From 32 to 36 weeks – twice a month or every 2 weeks
From 36 to 40 weeks – four times a month or every week

EDC:
Nagele’s Rule:
1. count back 3 calendar months from the first day of LMP, add 7 days
2. Date of quickening
Primigravida;
Date of quickening + 4 months and 20 days = EDC
Multigravida:
Date of quickening + 5 months and 4 days = EDC
OR
LMP SAMPLE CASE
January to March +9+7 January 1, 2020
1 / 1 / 20 LMP
+9 +7
10 /8 /20 EDC

April to December -3 +7 +1 June 26, 2020

6 / 26 / 20
-3 +7 +1
3 / 32 / 21
Or
4 / 1/ 21

McDONALD’S RULE
 symphysis-fundal height measurement that determines during mid-pregnancy that the
fetus is growing in-utero
 Distance from the symphysis pubis to the fundus in cm = week of gestation
between the 20th & 31st weeks of pregnancy
 Length of fundus in cm X 8/7 = AOG (weeks)
 Length of fundus in cm X 2/7 = AOG (months)

 HOW: From the notch of the symphysis pubis to the top of the uterine fundus as the
woman lies supine
Inaccurate in 3rd trimester
If fundal height is > standard: multiple pregnancy, hydramnios, miscalculated due date, LGA
baby, H mole
If < standard: IUGR, miscalculation, anencephaly

BARTHOLOMEW’S RULE
12 weeks = fundus is over the symphysis pubis
16 weeks = midway between symphysis pubis and umbilicus
17 weeks = level of umbilicus
36 weeks = at the xiphoid process
40 WEEKS = level of 32 weeks
 

ASSESSING FETAL WELL-BEING

Fetal Movement- Daily Fetal Movement Counting
 Quickening (felt by the mother) at 18 to 20 weeks & peaks at 28 to 38 weeks
Healthy fetus moves with consistency

If < 10 movements per hour, repeat test for next hour; If (<10 for the 2 hours, notify MD)
Mom lies on left recumbent position after a meal & record the # of fetal movements in 1 hour
(SANDOVSKY METHOD); minimum 2x/10 mins or average of 10 to 12 times/hour

COUNT-TO-TEN (CARDIFF METHOD/FETAL KICK COUNT))- mom records time interval it

takes to feel 10 movements (usually within 60 seconds)

Done at the same time daily, preferably after breakfast (most active), lie on left side after
stimulating activity like walking
Warning: > 1 hour for 10 FM or < 10 FM in 12 hours
Alarm: weaker movements, < 3 FM in 12 hours

Fetal Heart Rate

 FHR = 120 to 160 bpm

Rhythm Strip Testing- test for good baseline rate & presence of long- and short-term variability
Semi-Fowler’s position to prevent supine hypotension & for comfort
external fetal heart rate & uterine contraction monitors are attached abdominally
 tocotransducer over fundus-measures contractions & fetal movement
 UTZ transducer over abdominal site where FHR is distinct
 Mother remains in a fairly fixed position for 20 mins

 FHR is recorded for 20 minutes

 baseline reading- ave rate of F heartbeat per minute
short-term variability (beat-to-beat variability)- small changes in rate from second to
second if fetal Parasympathetic NS receives adequate O2 & nutrients. Healthy fetus moves
with consistency
 long-term variability- differences in heart rate over the 20-minute period

NON-Stress Testing
  measures the response of the FHR to fetal movement
 woman is positioned and monitors are attached just like the rhythm strip test
 she pushes a mark button attached to the monitor (similar to the call bell)
whenever she feels the fetus move. A dark line marks the paper tracings at this
point

 with fetal movement, FHR increases 15 bpm & remain elevated for 15 seconds
-it should decrease as soon as the fetus quiets
- no increase in beats, poor O2 perfusion is suggested
-NST done for 10 to 20 minutes

 REACTIVE (NORMAL)- 2 accelerations of FHR (by 15 beats or more) lasting for 15

seconds occur after movement within the chosen time period
 NONREACTIVE- no accelerations with the fetal movement, no movement, low
short-term FHR variability (< 6 bpm) throughout the testing period
 20 minutes without fetal movement- sleeping fetus; give CHO snack or stimulate by a
loud sound
 -if NR after 1 hour, contraction stress testing

VIBROACOUSTIC STIMULATION
 acoustic stimulator to produce a sharp sound 80 decibels at a frequency of 80 Hz,
startling & waking the fetus
 in a NST with no acceleration within 5 mins, a single 1- to 2-second sound
stimulation is applied to the lower abdomen (may be repeated at the end of 10
mins if no movement so that 2 movements within the 20- minute period could be
evaluated

CONTRACTION STRESS TESTING

 FHR is analyzed in conjunction with contractions (achieved by nipple stimulation to release
oxytocin)
baseline FHR is obtained then woman rolls nipple until contraction begins, recorded by a
uterine monitor
3 contractions lasting for 40 sec or more in a 10-minute window

CST Results:
Normal- no FHR decelerations with the contractions
Abnormal (+)- 50% or more of contractions causes late decelerations (dip in FHR towards end
of contraction & continues after the contraction)

3 types of decelerations
 Early deceleration-begins on or after onset of contraction & ends when contraction ends;
due to HEAD COMPRESSION during labor
 Late decelerations- begin after onset & peak of uterine contraction & ends after
contraction; due to uteroplacental insufficiency
 Variable deceleration- u, w or v shape, unrelated to contraction; due to CORD
COMPRESSION

ULTRASONOGRAPHY
Purposes:
 diagnose a pregnancy
 Confirm presence, location, size of placenta & AF
 Establish fetal growth & r/o abnormalities
 Establish sex
 Establish presentation & position of fetus
 Predict maturity via the measurement of biparietal diameter of the head
 Discover complications of pregnancy

 Ask mom to drink a full glass of H20 q 15 minutes beginning 90 mins before the
procedure & should not void before the procedure

BIPARIETAL DIAMETER
Side-to-side measurement of the fetal head via UTZ
8.5 cm or greater, infant will weigh more than 2500 g (5.5 lbs)
BD of 8.5 cm indicates fetal age of 40 weeks
head circumference (34.5 cm indicates 40-week fetus)
Femoral length

HAASE’S RULE
determines length of fetus in cm
1st half(1-5 mos)= month2
2nd half = month X 5

DOPPLER UMBILICAL VELOCIMETRY

Measures velocity at which RBC’s in the BV are flowing; helps determine vascular resistance in
women with DM or HPN of pregnancy and whether placental insufficiency occurred

PLACENTAL GRADING
based on the amount of Ca deposits in the base of the placenta, via UTZ
0 = placenta 12 to 24 weeks
1 = 30 to 32 weeks
2 = 36 weeks
3 = 38 weeks and fetal lungs are mature

AMNIOTIC FLUID ASSESSMENT

 decrease in AF, risk of cord compression
 < 20 WEEKS GESTATION: vertical diameter of the largest pocket of fluid on each side is
measured in cm
 AMNIOTIC VOLUME INDEX = sum of 2 measurements
 <20 weeks, divide into 4 quadrants using linea nigra and umbilicus as the dividing lines
and vertical diameter in each pocket measured then added to obtain AF index

 Normal AFI- 12 to 15 cm between 28 to 40 weeks

AFI> 20 to 24 cm = hydramnios (inability of fetus to swallow)
AFI < 5 TO 6 CM = OLIGOHYDRAMNIOS (decreased AF maybe dt poor perfusion & kidney
failure

ELECTROCARDIOGRAPHY
May be recorded as early as 11th week of pregnancy

MAGNETIC RESONANCE IMAGING

NO harmful effects to the fetus
To diagnose complications like ectopic pregnancy

MATERNAL SERUM ALPHA-FETOPROTEIN

 produced by the fetal liver & present in AF and maternal serum
 high in open spinal or abdominal defect because open defect allows more AFP to appear
 low in Down’s syndrome
 levels begin to rise at 11 weeks and steadily increase til term
 assessed in the 15th week

TRIPLE SCREENING (15-20 weeks)

analysis of 3 indicators (MSAFP, unconjugated estriol, and hCG)
requires only venipuncture of the mother
Quadruple screening- includes INHIBIN determination
Penta screen- + invasive trophoblast antigen (ITA)
Down’s syndrome, NTD

CHORIONIC VILLI SAMPLING

biopsy & chromosomal analysis of CV done at 10 to 12 weeks of pregnancy
coelocentesis (transvaginal aspiration of fluid from the extraembryonic cavity) is an alternative
method to remove cells for fetal analysis

AMNIOCENTESIS
 aspiration of AF from the pregnant uterus for analysis
 ambulatory procedure done at 14th to 16th week
 ask woman to void (to reduce size of bladder preventing puncture)
 Place her on a supine position, drape, place folded towel under her right buttock
 attach FHR & contraction monitors, take BP
 explain that UTZ will determine position of fetus-abdomen is prepped and local
anesthetic given
 sensation of pressure as 3- or 4-inch 20-22gauge spinal needle is inserted
 A SYRINGE IS ATTACHED AND 15 ML OF af IS ASPIRATED
 the needle is removed & the woman rests quietly for 30 mins
 observe FHR during and after 30 minutes of the procedure
 observe for contractions
 if the woman is Rh-(-), RhIg or RhoGAM is administered within 72 hours to prevent fetal
isoimmunization

AMNIOCENTESIS
Amniocentesis can provide information in a number of areas:
a.) COLOR- normally, colorless like water or late in pregnancy, slightly yellow
 strong yellow color- suggests blood incompatibility
 green- meconium staining, suggesting fetal distress
 b.) LECITHIN/SPHINGOMYELIN RATIO
 SHAKE TEST- if bubbly, the ratio is mature
 laboratory analysis- 2:1 is the normal ratio suggesting lung maturity
 infants of diabetic moms- falsely mature readings because stress matures lecithin
pathways early (N= 2.5:1 or 3:1)

c.) PHOSPHATIDYLGLYCEROL & DESATURATED PHOSPHATIDYLCHOLINE

 found also in surfactant and pathways for these compounds mature at 35 to 36
weeks; thus, present only in mature lung function
 more reliable than L/S ratio
d.) BILIRUBIN DETERMINATION
 done is blood incompatibility is suspected
 sample must be free of blood to avoid false-positive results

e.) CHROMOSOME ANALYSIS

 fetal skin cells are present in the AF & may be cultured or stained for karyotyping
 to detect chromosomal diseases
f.) FETAL FIBRONECTIN
 a glycoprotein that plays a part in helping the placenta attach to the uterine deciduas
 early in pregnancy, it can be assessed in cervical mucus but fades after 20 weeks &
can be reassessed during labor in cervical or vaginal fluid
 damage in fetal membranes releases this substance in the AF so it is important in
detecting preterm labor

g.) INBORN ERRORS OF METABOLISM

h.) ALPHA- FETOPROTEIN
 present if fetus has an open body defect such as anencephaly, myelomeningocele,
or omphalocele causing leakage of AFP into the AF
 AFP decreased in Down’s Syndrome
 ACETYLCHOLINESTERASE is also present in AF if a neural tube defect is present

(PUBS)/CORDOCENTESIS/FUNICENTESIS
 aspiration of blood from the umbilical vein for analysis
 UC is located by UTZ then a thin needle is inserted by amniocentesis technique into
the uterus & guided by UTZ, it pierces the UV & a blood sample is taken
 CBC, direct COOMB’S test, blood gases, karyotyping is done

 Kleihauer-Betke test is done first to ensure that the blood is fetal blood before
testing
 If anemic, BT using the same technique
 RhoGAM must be given to Rh-negative women within 72 hours after the procedure
 NST is done before & after the procedure and monitored by UTZ to make sure there
are no uterine contractions and no bleeding

AMNIOSCOPY
 visual inspection of the AF through the cervix & membranes with an amnioscope
(fetoscope)
to detect meconium staining
risk of membrane rupture

FETOSCOPY
 Fetus is visualized by a fetoscope ( an extremely narrow, hollow tube inserted by
amniocentesis technique)
 a photograph may be taken of the fetus
Purposes:
 confirm intactness of the spinal column
 Obtain biopsy samples of the fetal tissue & fetal blood samples
 Perform elemental surgery (shunt for hydrocephalus)

 performed 16th or 17th week of life

 mother is prepared and draped and local anesthesia injected into the abdominal skin
 fetoscope is inserted through a minor abdominal incision
 Meperidine may be given to the mother if the fetus is very active to sedate the fetus
 Risks: premature labor, amnionitis (infection of the AF)
 10 days of antibiotic therapy after the procedure

BIOPHYSICAL PROFILE
5 parameters:
 fetal reactivity,
 fetal breathing movements,
 fetal body movement,
 fetal tone,
 amniotic fluid volume

Fetal apgar
 fetal heart & breathing record measures short-term CNS function
 AF volume measures long-term adequacy of placental function
 more accurate in predicting fetal well-being than any single assessment
 DONE AS OFTEN AS DAILY DURING A HIGH-RISK PREGNANCY
8 to 10 score = fetus is doing well
6 = suspicious
4 = denotes a fetus in jeopardy
modified BP- AF index and nonstress test

BIOPHYSICAL PROFILE SCORING

 
ASSESSMENT INSTRUMENT CRITERIA FOR A SCORE OF 2

Fetal Breathing sonogram At least 1 episode of 30sec sustained fetal

breathing movements within 30 min of
observation
Fetal movement sonogram At least 3 separate episodes of fetal limb or
trunk movement
Within a 30 min observation
Fetal tone sonogram Fetus must extend then flex the extremities
or spine at least once
In 30 minutes
 Amniotic fluid sonogram A pocket of AF measuring > 1cm in vertical
volume diameter
Present
Fetal heart reactivity Non stress test 2 or more FHR accelerations of at least
15bpm above baseline and of 15 sec
duration occur with fetal movement over a
20 minute time period

Birth Plan - is an outline of your preferences during your labor and delivery.
It is a labor manifesto that contains details of preferences when will be the delivery date.
 It is the document that includes birth procedures, preferences, health care practitioners and
immediate family that would help and assist you in your delivery.

Birth plan
1. Basic information
is an outline of preferences during labor and delivery.
It is a labor manifesto that contains details of preferences when will be the delivery date.
It is the document that includes birth procedures, preferences, health care practitioners
and immediate family that would help and assist you in your delivery.
2. Companion/s' details
Person to accompany in the delivery room. Some want their husbands/ partners with
them, while others feel more at ease with their doula around.
3. Labor preferences
Different relaxation techniques
Walking
Sitting
Squatting
Listening to soothing music
4. Pain management
5. Delivery preferences
NSD- normal spontaneous delivery
Caesarean Section
Vacuum Assisted Delivery
VBAC- vaginal birth after caesarian
6. Infant Care
EENC –early essential newborn care
Rooming In Policy
Breastfeeding