Chapter 10

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C h a p ter 9
Nursing Care of the Growing Fetus
KEY TERMS
• age of viability • foramen ovale
• amniocentesis • hydramnios
• amniotic membrane • implantation
• cephalocaudal • McDonald’s rule
• chorionic membrane • meconium
• chorionic villi
• decidua
• nonstress test
• oligohydramnios iz Calhorn, an 18-year-old, is 20 weeks
• embryo • organogenesis pregnant. Although she says she knows
• estimated date of birth • surfactant she should have stopped smoking before
• fertilization • trophoblast
• fetoscopy • umbilical cord pregnancy, she has not been able to do this
• fetus • zygote as yet. Twice during the pregnancy (at the 4th
and 10th week), she drank beer at summer
picnics. Today, at a clinic visit, she tells you she
has felt her fetus move. She states, “Feeling the
baby move made me realize there’s someone
OBJECTIVES inside me, you know what I mean? It made
After mastering the contents of this chapter, you should be able to: me realize it’s time I started being more
1. Describe the growth and development of a fetus by gestation week. careful with what I do.” Liz works at a fast food
2. Identify 2020 National Health Goals related to fetal growth that nurses
restaurant. Her boyfriend (the father of fetus)
can help the nation achieve.
3. Assess fetal growth and development through maternal and is supportive, but has no money to give her.
pregnancy landmarks. Client states, “I’m not getting married. Just not
4. Formulate nursing diagnoses related to the needs of a fetus.
5. Establish expected outcomes to meet the perceived needs of a ready for that big a commitment yet.”
growing fetus as well as manage a seamless transition from fetus to Feeling a fetus move is often the trigger
newborn.
that makes having a baby “real” for many
6. Using the nursing process, plan nursing care that includes the six
competencies of Quality & Safety Education for Nurses (QSEN): women. The more women know about fetal
Patient-Centered Care, Teamwork & Collaboration, Evidence-Based development before and after this event,
Practice (EBP), Quality Improvement (QI), Safety, and Informatics.
the easier it is for them to begin to think of
7. Implement nursing care to help ensure both a safe fetal environment
and a safe pregnancy outcome. the pregnancy not as something interesting
8. Evaluate expected outcomes for achievement and effectiveness of care. happening to them, but as an act producing
9. Integrate knowledge of fetal growth and development with the
interplay of nursing process, the six competencies of QSEN, and a separate life. A previous chapter described
Family Nursing to promote quality maternal and child health reproductive anatomy. This chapter adds
nursing care. information about fetal growth and
development and assessment of fetal health.
In light of Liz’s revelation, what additional

health teaching does she need?
187
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188 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period
Throughout history, different societies have held a variety BOX 9.1 Nursing Care Planning
of beliefs and superstitions about the way the fetus (i.e., the
infant during intrauterine life) originates and grows. Medi-
Based on 2020 National Health Goals
eval artists depicted a fetus as already formed as a miniature
man. Leonardo da Vinci, in his notebooks of 1510 to 1512, A number of 2020 National Health Goals address fetal
made several sketches of unborn infants, which suggest he growth.
believed the fetus was immobile and essentially more a part
of the mother, sharing her blood and internal organs, than • Reduce the fetal death rate (death between 20
a separate individual. During the 17th and 18th centu- and 40 weeks of gestation) to no more than 5.6 per
ries, a fetus was thought to grow to a miniature size in the 1,000 live births from a baseline of 6.2 per 1,000.
mother’s ovaries; only when male cells were introduced did • Reduce low birth weight to an incidence of 7.8% of
the baby expand to birth size. Yet another theory was that live births and very low birth weight to 1.4% of live
the child existed in the head of the sperm cell as a fully births from baselines of 8.2% and 1.5%.
formed being, the uterus serving only as an incubator in • Increase the proportion of women of childbearing
which it grew. potential with an intake of at least 400 mg of folic
In 1758, Kaspar Wolff proposed that both parents con- acid from fortified foods or dietary supplements from
tribute equally to the structure of the baby. Thanks to the a baseline of 23.8% to 26.2% (U.S. Department of
work of modern research and photographers who have been Health and Human Services [DHHS], 2010; see www
able to capture the process of fertilization and fetal develop- .healthypeople.gov).
ment by ultrasound and high-tech photography, there is now Folic acid deficiency in pregnancy can lead to mid-
a clear picture of what a fetus looks like from the moment line closure defects such as neural tube disorders.
of conception until birth. It allows both families and health Nurses can help the nation achieve these goals by
care providers to view the fetus as a patient separate from the urging women to plan their pregnancies so they
mother (McCoyd, 2013; Miesnik, 2012). can enter the pregnancy in good health and with an
Because you cannot have healthy children without optimum folic acid level. Educating women about
healthy intrauterine growth, several 2020 National Health the importance of attending prenatal care is another
Goals speak to the importance of protecting fetal growth important role.
(Box 9.1).
Nu r s in g Pro c e s s Overview Be certain that outcome criteria established for teaching

about fetal growth are realistic and based on the parents’
To Help Ensure Fetal Health previous knowledge and desire for information. When
Assessment additional assessment measures are necessary, such as an
Assessing fetal growth throughout pregnancy, by such amniocentesis or an ultrasound examination, add this in-
means as measuring fundal height and fetal heart rate, formation to the teaching plan, explaining why further
is important because these signs of fetal development assessment is necessary and what the parents can expect
provide guidelines for determining the well-being of a from the procedure. Interesting Web sites for parents
fetus. For the expectant family, knowledge about fetal that show fetal development in photographs are www.
growth and development can help a woman understand Babycenter.com and www.MedicineNet.com. Suspected
some of the changes going on in her body as well as allow workplace teratogens can be reported to the Occupa-
all family members to begin thinking about and accept- tional Safety & Health Administration at www.osha.gov.
ing a new member to their family. For this reason, not Implementation
only assess fetal development at prenatal visits but also Most expectant parents are interested in learning about
convey the findings to the family in as much detail as how mature their fetus is at various points in pregnancy
parents request. as this helps them visualize their coming newborn. This,
Nursing Diagnosis in turn, helps them to understand the importance of
Common nursing diagnoses related to growth and de- implementing healthy behaviors, such as eating well and
velopment of the fetus focus on the mother and family avoiding substances that may be dangerous to a fetus
as well as the fetus. Examples might include: such as recreational drugs. Viewing a sonogram and
learning the fetal sex is a big step toward helping initiate
• Readiness for enhanced knowledge related to usual bonding between the parents and the infant. Remem-
fetal development ber each woman’s pregnancy is unique to her; be certain
• Anxiety related to lack of fetal movement implementations are individualized for each woman for
• Deficient knowledge related to the need for good pre- the best chance of outcome success.
natal care for healthy fetal well-being
Outcome Evaluation
Outcome Identification and Planning An outcome evaluation related to fetal growth and de-
Be certain plans for care include ways to educate potential velopment usually focuses on determining whether
parents about teratogens (i.e., any substance harmful to a a woman or family has made any changes in lifestyle
fetus) that have the potential to interfere with fetal health. necessary to ensure fetal growth and whether a woman

CHAPTER 9 Nursing Care of the Growing Fetus 189
voices confidence that her baby is healthy and growing. As the ovum is extruded from the graafian follicle of an
Examples of expected outcomes include: ovary with ovulation, it is surrounded by a ring of muco-
• Parents describe smoke-free living by next prenatal visit. polysaccharide fluid (the zona pellucida) and a circle of cells
• Client records number of movements fetus makes dur- (the corona radiata). The ovum and these surrounding cells
ing 1 hour daily. (which increase the bulk of the ovum and serve as protective
• Couple attends all scheduled prenatal visits. buffers against injury) are propelled into a nearby fallopian
• Client states she is looking forward to the birth of her tube by currents initiated by the fimbriae—the fine, hairlike
baby. structures that line the openings of the tubes. A combination
of peristaltic action of the tube and movements of the tube
cilia help propel the ovum along the length of the tube.
Normally, an ejaculation of semen averages 2.5 ml of fluid
containing 50 to 200 million spermatozoa per milliliter, or an
STAGES OF FETAL DEVELOPMENT average of 400 million sperm per ejaculation (Christianson &
Wallach, 2011). At the time of ovulation, there is a reduction in
In just 38 weeks, a fertilized egg (ovum) matures from a single the viscosity (thickness) of the woman’s cervical mucus, which
cell to a fully developed fetus ready to be born. Although makes it easy for spermatozoa to penetrate it. Sperm transport
different cultures or religions debate the point at which life is so efficient close to ovulation that spermatozoa deposited in
begins, for ease of discussion, all agree fetal growth and devel- the vagina generally reach the cervix within 90 seconds and the
opment can be divided into three time periods: outer end of a fallopian tube within 5 minutes after deposition.
The mechanism whereby spermatozoa are drawn toward
• Pre-embryonic (first 2 weeks, beginning with fertilization)
an ovum is probably a species-specific reaction, similar to an
• Embryonic (weeks 3 through 8)
antibody–antigen reaction. Spermatozoa move through the
• Fetal (from week 8 through birth)
cervix and the body of the uterus and into the fallopian tube,
Table 9.1 lists common terms used to describe the fetus at toward a waiting ovum by the combination of movement by
various stages in this growth. their flagella (tails) and uterine contractions.
All of the spermatozoa that reach the ovum cluster around
Fertilization: The Beginning of Pregnancy its protective layer of corona cells. Hyaluronidase (a proteo-
lytic enzyme) is released by the spermatozoa and dissolves
Fertilization (also referred to as conception and impregna-
the layer of cells protecting the ovum. Under ordinary cir-
tion) is the union of an ovum and a spermatozoon. This usu-
cumstances, only one spermatozoon is able to penetrate the
ally occurs in the outer third of a fallopian tube, termed the
cell membrane of the ovum. Once it penetrates the cell, the
ampullar portion (Taylor & Badell, 2011).
cell membrane changes composition to become impervious
Usually, only one of a woman’s ova reaches maturity each
to other spermatozoa. An exception to this is the formation
month. Once the mature ovum is released (i.e., ovulation),
of gestational trophoblastic disease in which multiple sperm
fertilization must occur fairly quickly because an ovum is ca-
enter an ovum; this leads to abnormal zygote formation
pable of fertilization for only about 24 hours (48 hours at the
(Digiulio, Wiedaseck, & Monchek, 2012) (see Chapter 21).
most). After that time, it atrophies and becomes nonfunc-
Immediately after penetration of the ovum, the chromo-
tional. Because the functional life of a spermatozoon is also
somal material of the ovum and spermatozoon fuse to form
about 48 hours, possibly as long as 72 hours, the total critical
a zygote. Because the spermatozoon and ovum each carried
time span during which sexual relations must occur for fer-
23 chromosomes (22 autosomes and 1 sex chromosome), the
tilization to be successful is about 72 hours (48 hours before
fertilized ovum has 46 chromosomes. If an X-carrying sper-
ovulation plus 24 hours afterward).
matozoon entered the ovum, the resulting child will have two
X chromosomes and will be female (XX). If a Y-carrying sper-
matozoon fertilized the ovum, the resulting child will have an
TABLE 9.1 Terms Used to Describe X and a Y chromosome and will be male (XY).
Fetal Growth Fertilization is never a certain occurrence because it de-
Name Time Period pends on at least three separate factors:
• Equal maturation of both sperm and ovum
Ovum From ovulation to fertilization.
• Ability of the sperm to reach the ovum
Zygote From fertilization to implantation. • Ability of the sperm to penetrate the zona pellucida and
cell membrane and achieve fertilization
Embryo From implantation to 5–8 weeks. Out of this single-cell fertilized ovum (zygote), the future
Fetus From 5–8 weeks until term.
child and also the accessory structures needed for support
during intrauterine life (placenta, fetal membranes, amniotic
Conceptus Developing embryo and placental struc- fluid, and umbilical cord) will form.
tures throughout pregnancy.
Implantation
Age of viability The earliest age at which fetuses survive
if they are born is generally accepted Once fertilization is complete, a zygote migrates over the next 3
as 24 weeks, or at the point a fetus to 4 days toward the body of the uterus, aided by the currents
weighs more than 500–600 g. initiated by the muscular contractions of the fallopian tubes.
During this time, mitotic cell division, or cleavage, begins.

The first cleavage occurs at about 24 hours; cleavage divisions the implanting trophoblast cells. A woman who normally has
continue to occur at a rate of about one every 22 hours so by a particularly scant menstrual flow could mistake implantation
the time the zygote reaches the body of the uterus, it consists of bleeding for her menstrual period. If this happens, the pre-
16 to 50 cells. Over the next 3 or 4 days, large cells tend to col- dicted date of birth of her baby (based on the time of her last
lect at the periphery of the ball, leaving a fluid space surround- menstrual period) will be calculated 4 weeks late.
ing an inner cell mass. At this stage, the structure is termed
a blastocyst. The cells in the outer ring are trophoblast cells.
They are the part of the structure that will later form the pla-
✔ QSEN Checkpoint Question 9.1
centa and membranes. The inner cell mass (embryoblast cells) Teamwork & Collaboration
is the portion of the structure that will form the embryo. Liz Calhorn, 18 years of age, asks how much longer her
Implantation, or contact between the growing structure and women’s nurse practitioner will refer to the baby inside her as
the uterine endometrium, occurs approximately 8 to 10 days an embryo. So your team members will use terms consistently
after fertilization. About 8 days after ovulation, the blastocyst you would want them to know the conceptus is classified as
sheds the last residues of the corona and zona pellucida, brushes an embryo at what time?
against the rich uterine endometrium (in the second [secretory]
a. At the time of fertilization
phase of the menstrual cycle), and settles down into its soft
b. When the placenta forms
folds. The stages to this point are depicted in Figure 9.1.
c. From implantation until 20 weeks
Implantation usually occurs high in the uterus, on the pos-
d. From implantation until 5 to 8 weeks
terior surface. If the point of implantation is low in the uterus,
the growing placenta may occlude the cervix and make birth Look in Appendix A for the best answer and rationale.
of the child difficult (placenta previa), because the placenta can
block the birth canal. Almost immediately, the blastocyst bur-
rows deeply into the endometrium and establishes an effective
communication network with the blood system of the endo-
metrium. Once implanted, the zygote is called an embryo. EMBRYONIC AND FETAL
Implantation is an important step in pregnancy, because as STRUCTURES
many as 50% of zygotes never achieve it (Gardosi, 2012). In
these instances, the pregnancy ends as early as 8 to 10 days after The placenta and membranes, which will serve as the fetal
conception, often before a woman is even aware she was preg- lungs, kidneys, and digestive tract in utero as well as help pro-
nant. Occasionally, a small amount of vaginal spotting appears vide protection for the fetus, begin growth in early pregnancy
on the day of implantation because capillaries are ruptured by in coordination with embryo growth.
Corona radiata
Zona
Ovum pellucida
Ovulation
Day 1
Fertilization
Day 2
First cell
Blastocyst Amniotic
division
Morula Day 4 cavity
(zygote)
Day 3
Yolk sac
Embryonic
Trophoblast cells cells:
Ectoderm
Implantation
Mesoderm
Endoderm
Day 8-10
FIGURE 9.1 Ovulation, fertilization, and implantation. The blastocyst is differentiated into
three germ layers—the ectoderm, mesoderm, and endoderm. Cells at the periphery are tropho-
blast cells that mature into the placenta.

The Decidua or Uterine Lining organisms such as the spirochete of syphilis early in preg-
nancy. Because this layer of cells disappears between the 20th
After fertilization, the corpus luteum in the ovary continues to and 24th week of pregnancy, this is why syphilis is not con-
function rather than atrophying under the influence of human sidered to have a high potential for fetal damage early in preg-
chorionic gonadotropin (hCG) secreted by the trophoblast nancy, only after the point at which cytotrophoblast cells are
cells. This hormone also causes the uterine endometrium no longer present. The layer appears to offer little protection
to continue to grow in thickness and vascularity instead of against viral invasion at any point (Stohl & Satin, 2011).
sloughing off as in a usual menstrual cycle. The endometrium
is now typically termed the decidua (the Latin word for “fall- The Placenta
ing off ”), because it will be discarded after birth of the child.
The placenta (Latin for “pancake,” which is descriptive of
Chorionic Villi its size and appearance at term) grows from a few identifi-
able trophoblast cells at the beginning of pregnancy to an
As early as the 11th or 12th day after fertilization, minia- organ 15 to 20 cm in diameter and 2 to 3 cm in depth, cover-
ture villi, resembling probing fingers and termed chorionic ing about half the surface area of the internal uterus at term
villi, reach out from the trophoblast cells into the uterine (Huppertz & Kingdom, 2012).
endometrium to begin formation of the placenta. Chorionic
villi have a central core consisting of connective tissue and Circulation
fetal capillaries surrounded by a double layer of cells, which
produce various placental hormones, such as hCG, somato- Placental circulation is shown in Figure 9.2. As early as the
mammotropin (human placental lactogen [hPL]), estrogen, 12th day of pregnancy, maternal blood begins to collect in
and progesterone. The middle layer, the cytotrophoblast or the intervillous spaces of the uterine endometrium surround-
Langhans’ layer, appears to have a second function to pro- ing the chorionic villi. By the third week, oxygen and other
tect the growing embryo and fetus from certain infectious nutrients such as glucose, amino acids, fatty acids, minerals,
Cotyledon
Septa
Myometrium
Villi
capillaries
Maternal
vein
Maternal
artery
Maternal blood
Trophoblastic layer
Fetal blood
capillaries
Umbilical cord
Intervillous space
Umbilical
arteries Umbilical vein
Amnion Chorionic villus

Chorionic plate
FIGURE 9.2 Placental circulation.

vitamins, and water osmose from the maternal blood through Endocrine Function
the cell layers of the chorionic villi into the villi capillaries.
From there, nutrients are transported to the developing Besides serving as the source of oxygen and nutrients for the
embryo. fetus, the syncytial (outer) layer of the chorionic villi develops
Because placental transfer is so effective, all but a few into a separate and important hormone-producing system.
substances are able to cross from the mother into the fetus. Human Chorionic Gonadotropin. The first placental hor-
Because almost all drugs are able to cross into the fetal circula- mone produced, hCG, can be found in maternal blood and
tion, it is important that a woman take no nonessential drugs urine as early as the first missed menstrual period (shortly after
(including alcohol and nicotine) during pregnancy (Cleary, implantation has occurred) through about the 100th day of
Eogan, O’Connell, et al., 2012). Alcohol, as an example, be- pregnancy. Because this is the hormone analyzed by pregnancy
cause it perfuses across the placenta so well, can cause fetal tests, a false-negative result from a pregnancy test may be ob-
alcohol spectrum disorder (e.g., unusual facial features, low- tained before or after this period. The mother’s blood serum
set ears, and cognitive challenge). As it’s difficult to tell what will be completely negative for hCG within 1 to 2 weeks after
quantity is “safe,” pregnant women are advised to drink no birth. Finding no serum hCG after birth can be used as proof
alcohol during pregnancy to avoid these disorders (Rogers & that placental tissue is no longer present.
Worley, 2012). hCG’s purpose is to act as a fail-safe measure to ensure the
Theoretically, because the exchange process depends on corpus luteum of the ovary continues to produce progesterone
osmosis, there is no direct exchange of blood cells between and estrogen so the endometrium of the uterus is maintained.
the embryo and the mother during pregnancy. Occasionally, hCG also may play a role in suppressing the maternal im-
however, fetal cells do cross into the maternal bloodstream, munologic response so placental tissue is not detected and re-
as well as fetal enzymes such as ␣-fetoprotein (AFP) projected as a foreign substance. Because the structure of hCG is
duced by the fetal liver (this allows testing of fetal cells for similar to that of luteinizing hormone of the pituitary gland,
genetic analysis as well as the level of AFP in the maternal if the fetus is male, it exerts an effect on the fetal testes to
blood). begin testosterone production and maturation of the male re-
As the number of chorionic villi increases with preg- productive tract (Huppertz & Kingdom, 2012).
nancy, the villi form an increasingly complex communica- At about the eighth week of pregnancy, the outer layer
tion network with the maternal bloodstream. Intervillous of cells of the developing placenta begins to produce pro-
spaces grow larger and larger, becoming separated by 30 or gesterone, making the corpus luteum, which was producing
more partitions or septa. These compartments (cotyledons) progesterone, no longer necessary. In coordination with this,
are what make the maternal side of the placenta look rough the production of hCG, which sustained the corpus luteum,
and uneven. begins to decrease at this point.
To provide enough blood for exchange, the rate of utero-
placental blood flow in pregnancy increases from about Progesterone. Estrogen is often referred to as the “hormone
50 ml/min at 10 weeks to 500 to 600 ml/min at term. No of women,” and progesterone as the “hormone of mothers.”
additional maternal arteries appear after the first 3 months This is because, although estrogen influences a female appear-
of pregnancy; instead, to accommodate the increased blood ance, progesterone is necessary to maintain the endometrial
flow, the arteries increase in size. The woman’s heart rate, total lining of the uterus during pregnancy. It is present in maternal
cardiac output, and blood volume all increase to supply blood serum as early as the fourth week of pregnancy as a result of
to the placenta (Pipkin, 2012). Braxton Hicks contractions, the continuation of the corpus luteum. After placental produc-
the barely noticeable uterine contractions present from about tion begins (at about the 12th week), the level of progesterone
the 12th week of pregnancy on, aid in maintaining pres- rises progressively during the remainder of the pregnancy. This
sure in the intervillous spaces by closing off the uterine veins hormone also appears to reduce the contractility of the uterus
momentarily with each contraction. during pregnancy, thus preventing premature labor.
Uterine perfusion and placental circulation are most Estrogen. Estrogen (primarily estriol) is produced as a sec-
efficient when the mother lies on her left side, as this position ond product of the syncytial cells of the placenta. Estrogen
lifts the uterus away from the inferior vena cava, preventing contributes to the woman’s mammary gland development
blood from becoming trapped in the woman’s lower extremi- in preparation for lactation and stimulates uterine growth to
ties. If the woman lies on her back and the weight of the accommodate the developing fetus.
uterus compresses on the vena cava, placental circulation can
be so sharply reduced that supine hypotension (i.e., very low Human Placental Lactogen (Human Chorionic Somato-
maternal blood pressure and poor uterine circulation) can mammotropin). hPL is a hormone with both growth-
occur (Coad & Dunstall, 2011a). promoting and lactogenic (i.e., milk-producing) properties.
At term, the placental circulatory network has grown so It is produced by the placenta beginning as early as the sixth
extensively that a placenta weighs 400 to 600 g (1 lb), one- week of pregnancy, increasing to a peak level at term. It pro-
sixth the weight of the newborn. If a placenta is smaller than motes mammary gland (breast) growth in preparation for lac-
this, it suggests circulation to the fetus may have been in- tation in the mother. It also serves the important role of regu-
adequate. A placenta bigger than this also may indicate cir- lating maternal glucose, protein, and fat levels so adequate
culation to the fetus was threatened, because it suggests the amounts of these nutrients are always available to the fetus.
placenta was forced to spread out in an unusual manner to Placental Proteins
maintain a sufficient blood supply. The fetus of a woman
with diabetes may also develop a larger than usual placenta In addition to hormones, the placenta also produces a num-
from excess fluid collected between cells. ber of plasma proteins. The function of these has not been

well documented, but they may contribute to decreasing the to swallow (esophageal atresia or anencephaly are the two most
immunologic impact of the growing placenta and help pre- common reasons), excessive amniotic fluid or hydramnios
vent hypertension of pregnancy (discussed in Chapter 21) (more than 2,000 ml in total, or pockets of fluid larger than
(Feng, Zhou, Li, et al., 2012). 8 cm on ultrasound) will result (Ghionzoli, James, David, et al.,
2012). Hydramnios may also occur in women with diabetes,
The Amniotic Membranes because hyperglycemia causes excessive fluid shifts into the am-
The chorionic villi on the medial surface of the trophoblast niotic space (Peroviá, Garalejiá, Gojniá, et al., 2011).
(i.e., those that are not involved in implantation because they Early in fetal life, as soon as the fetal kidneys become ac-
do not touch the endometrium) gradually thin until they be- tive, fetal urine adds to the quantity of the amniotic fluid. A
come the chorionic membrane, the outermost fetal mem- disturbance of kidney function, therefore, may cause oligo-
brane. The amniotic membrane or amnion, forms beneath hydramnios, or a reduction in the amount of amniotic fluid
the chorion (Fig. 9.3). Beginning early in pregnancy, these (less than 300 ml in total, or no pocket on ultrasound larger
membranes become so adherent they seem as one at term. than 1 cm) (Petrozella, Dashe, McIntire, et al., 2011).
They have no nerve supply, so when they spontaneously rup- The most important purpose of amniotic fluid is to shield
ture at term or are artificially ruptured, neither mother nor the fetus against pressure or a blow to the mother’s abdomen.
child experiences any pain (Coad & Dunstall, 2011b). Because liquid changes temperature more slowly than air, it also
In contrast to the chorionic membrane, the second mem- protects the fetus from changes in temperature. Another func-
brane (the amniotic membrane) not only offers support to tion is that it aids in muscular development, as amniotic fluid
amniotic fluid but also actually produces the fluid. In addi- allows the fetus freedom to move. Finally, it protects the umbili-
tion, it produces a phospholipid that initiates the formation of cal cord from pressure, thus protecting the fetal oxygen supply.
prostaglandins, which may be the trigger that initiates labor. Even if the amniotic membranes rupture before birth
and the bulk of amniotic fluid is lost, some will always sur-
The Amniotic Fluid round the fetus in utero, because new fluid is constantly
being formed. Amniotic fluid is slightly alkaline, with a pH
Amniotic fluid never becomes stagnant because it is con- of about 7.2. Checking the pH of the fluid at the time mem-
stantly being newly formed and absorbed by direct contact branes rupture and amniotic fluid is released helps to dif-
with the fetal surface of the placenta. The major method of ferentiate amniotic fluid from urine, because urine is acidic
absorption, however, happens within the fetus. Because the (pH 5.0 to 5.5).
fetus continually swallows the fluid, it is absorbed from the
fetal intestine into the fetal bloodstream. From there, it goes The Umbilical Cord
to the umbilical arteries and to the placenta and is exchanged
across the placenta to the mother’s bloodstream. The umbilical cord is formed from the fetal membranes
At term, the amount of amniotic fluid has grown so much it (amnion and chorion) and provides a circulatory pathway
ranges from 800 to 1,200 ml. If for any reason the fetus is unable that connects the embryo to the chorionic villi of the pla-
centa. Its function is to transport oxygen and nutrients to the
fetus from the placenta and to return waste products from the
fetus to the placenta. It is about 53 cm (21 in.) in length at
term and about 2 cm (0.75 in.) thick. The bulk of the cord is
a gelatinous mucopolysaccharide called Wharton jelly, which
gives the cord body and prevents pressure on the vein and
arteries that pass through it.
An umbilical cord contains only one vein (carrying blood
from the placental villi to the fetus) but two arteries (carrying
blood from the fetus back to the placental villi). The number
of veins and arteries in the cord is always assessed and re-
corded at birth because about 1% to 5% of infants are born
with a cord that contains only a single vein and artery. Of
Amnion these infants, 15% to 20% are found to have accompanying
chromosomal disorders or congenital anomalies, particularly
of the kidney and heart (Schneider, 2011).
Placenta
The rate of blood flow through an umbilical cord is rapid
Chorion (350 ml/min at term). The adequacy of blood flow (blood
velocity) through the cord, as well as both systolic and dia-
stolic cord pressure, can be determined by ultrasound exami-
nation. Counting the number of coils in the cord may be
used as a prediction of healthy fetal growth, as hypocoiling
is associated with maternal hypertension and hypercoiling is
associated with respiratory distress in the newborn (Chitra,
Sushanth, & Raghavan, 2012).
Because the rate of blood flow through the cord is so rapid,
it is unlikely a cord will twist or knot enough to interfere with
FIGURE 9.3 Membranes, with embryo lying within amniotic sac. the fetal oxygen supply. In about 20% of all births, a loose

loop of cord is found around the fetal neck (nuchal cord) Primary Germ Layers
at birth (Hoh, Sung, & Park, 2012). If this loop of cord is
removed before the newborn’s shoulders are born (not usually As a fetus grows, body organ systems develop from specific tis-
hard to do) so there is no traction on it, the oxygen supply to sue layers called germ layers. At the time of implantation, the
the fetus remains unimpaired. blastocyst already has differentiated to a point at which three
The walls of the umbilical cord arteries are lined with separate layers of these cells are present: the ectoderm, the en-
smooth muscle. When these muscles contract after birth, the doderm, and the mesoderm (see Fig. 9.1). Each of these germ
cord arteries and vein are compressed to prevent hemorrhage layers develops into specific body systems (Table 9.2). Know-
of the newborn through the cord. Because the umbilical cord ing which structures arise from each germ layer is helpful to
contains no nerve supply, it can be clamped and cut at birth know because coexisting congenital disorders found in new-
without discomfort to either the child or mother. borns usually arise from the same germ layer. For example, a
fistula between the trachea and the esophagus (both of which
arise from the endoderm layer) is a common birth anomaly. In
✔ QSEN Checkpoint Question 9.2 contrast, it is rare to see a newborn with a malformation of the
Safety heart (which arises from the mesoderm) and also a malforma-
tion of the lower urinary tract (which arises from the endo-
Suppose Liz Calhorn tells you she is worried her baby will be derm). One reason rubella infection is so serious in pregnancy
born with a congenital heart disease. What assessment of is because this virus is capable of infecting all three germ layers
the umbilical cord at birth would be most important to help so can cause congenital anomalies in a myriad of body systems
detect congenital heart defects? (White, Boldt, Holditch, et al., 2012).
a. Assessing whether the pH of the Wharton jelly is higher All organ systems are complete, at least in a rudimentary
than 7.2 form, at 8 weeks gestation (the end of the embryonic pe-
b. Assessing whether the umbilical cord has two arteries and riod). During this early time of organogenesis (organ for-
one vein mation), the growing structure is most vulnerable to invasion
c. Measuring the length of the cord to be certain it is longer by eratogens (i.e., any factor that affects the fertilized ovum,
than 3 ft embryo, or fetus adversely, such as a teratogenic medicine; an
d. Determining that the umbilical cord is neither green nor infection such as toxoplasmosis; cigarette smoking; or alcohol
yellow stained ingestion) (Box 9.2). Figure 9.4 illustrates critical periods of
fetal growth when it is most important for women to min-
Look in Appendix A for the best answer and rationale.
imize their exposure to teratogens. The effect of individual
teratogens and how to avoid them is discussed in Chapter 12.
Cardiovascular System
ORIGIN AND DEVELOPMENT OF The cardiovascular system is one of the first systems to be-
ORGAN SYSTEMS come functional in intrauterine life. Simple blood cells joined
Following the moment of fertilization, the zygote, which later

becomes an embryo and then a fetus, begins to grow at an TABLE 9.2 Origin of Body Tissue
active pace. Germ Layer Body Portions Formed
Stem Cells Ectoderm Central nervous system (brain and spinal cord)
Peripheral nervous system
During the first 4 days of life, zygote cells are termed toti- Skin, hair, nails, and tooth enamel
potent stem cells, or cells so undifferentiated they have the Sense organs
potential to grow into any cell in the human body. In an- Mucous membranes of the anus, mouth, and
other 4 days, as the structure implants and becomes an em- nose
bryo, cells begin to show differentiation, or lose their ability Mammary glands
to become any body cell. Instead, they are slated to become
specific body cells, such as nerve, brain, or skin cells and are Mesoderm Supporting structures of the body (con-
termed pluripotent stem cells. In yet another few days, the nective tissue, bones, cartilage, muscle,
ligaments, and tendons)
cells grow so specific they are termed multipotent, or are so
Upper portion of the urinary system (kidneys
specific they cannot be deterred from growing into a particu- and ureters)
lar body organ such as spleen or liver or brain (Bernstein & Reproductive system
Srivastava, 2012). Heart, lymph, and circulatory systems and
blood cells
Zygote Growth
Endoderm Lining of pericardial, pleura, and peritoneal
As soon as conception has taken place, development proceeds in cavities
a cephalocaudal (head-to-tail) direction; that is, head develop- Lining of the gastrointestinal tract, respira-
ment occurs first and is followed by development of the middle, tory tract, tonsils, parathyroid, thyroid,
and finally, the lower body parts. This pattern of development and thymus glands
continues after birth as shown by the way infants are able to lift Lower urinary system (bladder and urethra)
up their heads approximately 1 year before they are able to walk.

BOX 9.2 Nursing Care Planning Based on Family Teaching
Q. Liz Calhorn tells you, “I have to work. How can I guard against fetal teratogens at work?”
A. Here are a number of helpful tips:
• Ask your employer for a statement on hazardous substances at your work site; discuss your need to avoid these
substances during pregnancy.
• Ask your employer to maintain a smoke-free site if that is not already a rule.
• Avoid any room, such as a coffee room, where smokers gather.
• Refrain from drinking alcohol, a frequent accompaniment to work lunches or social functions; ask for nonalcoholic
drinks to be available at such events.
• Locate a fellow coworker who will “buddy” with you to help you avoid alcohol or tobacco at work activities.
• If quitting smoking is difficult, try a supportive telephone or Internet quitline. Ask your primary health care provider
before using a nicotine patch, nicotine gum, or bupropion (Zyban), a drug to assist smokers to quit. Both nicotine
and Zyban are category C drugs; Zyban is particularly contraindicated in women with symptoms of gestational
hypertension as it can cause seizures in high doses.
to the walls of the yolk sac progress to become a network of The heart rate of a fetus is affected by oxygen level, activ-
blood vessels and a single heart tube, which forms as early as ity, and circulating blood volume, just as in adulthood. After
the 16th day of life and beats as early as the 24th day. The the 28th week of pregnancy, when the sympathetic nervous
septum that divides the heart into chambers develops during system has matured, the heart rate stabilizes or begins to show
the sixth or seventh week; heart valves develop in the seventh a consistent beat of 110 to 160 beats/min.
week. The heartbeat may be heard with a Doppler instrument
as early as the 10th to 12th week of pregnancy. An electro- Fetal Circulation
cardiogram (ECG) may be recorded on a fetus as early as the
11th week, although the accuracy of such ECGs is in doubt Fetal circulation (Fig. 9.5) differs from extrauterine circulation
until about the 20th week of pregnancy, when conduction is because the fetus derives oxygen and excretes carbon dioxide not
more regulated. from gas exchange in the lungs but from exchange in the placenta.
Age of Embryo and Fetus in Weeks

1 2 3 4 5 6 7 8 9 10 16 20-36 38
Central nervous system
Heart
Upper limbs
Eyes
Lower limbs
Teeth
Palate
External genitalia
Ears
FIGURE 9.4 Critical periods of fetal growth.

To head
To arm
Aorta
Superior vena cava Ductus

arteriosus
Right lung Left lung
Right atrium Left atrium
Foramen ovale
Aorta
Inferior vena cava
Liver
Ductus venosus
Portal vein
Umbilicus
Umbilical vein
From placenta
To leg
To placenta
Umbilical arteries
FIGURE 9.5 Fetal circulation.
Blood arriving at the fetus from the placenta is highly oxy- A small amount of blood that returns to the heart via the
genated. This blood enters the fetus through the umbilical vein vena cava does leave the right atrium by the adult circula-
(which is still called a vein even though it carries oxygenated tory route; that is, through the tricuspid valve into the right
blood because the direction of the blood is toward the fetal ventricle, and then into the pulmonary artery and lungs to
heart). Specialized structures present in the fetus then shunt service the lung tissue. However, the larger portion of even
blood flow to first supply the most important organs of the this blood is shunted away from the lungs through an ad-
body: the liver, heart, kidneys, and brain. Blood flows from the ditional structure, the ductus arteriosus, directly into the de-
umbilical vein to the ductus venosus, an accessory vessel that scending aorta.
discharges oxygenated blood into the fetal liver, then connects As the majority of blood cells in the aorta become de-
to the fetal inferior vena cava so oxygenated blood is directed to oxygenated, blood is transported from the descending aorta
the right side of the heart. Because there is no need for the bulk through the umbilical arteries (which are called arteries
of blood to pass through the lungs, the bulk of this blood is because they carry blood away from the fetal heart) back
shunted as it enters the right atrium into the left atrium through through the umbilical cord to the placental villi, where new
an opening in the atrial septum, called the foramen ovale. oxygen exchange takes place.
From the left atrium, it follows the course of adult circulation At birth, an infant’s oxygen saturation level is 95% to
into the left ventricle, then into the aorta, and out to body parts. 100% and pulse rate is 80 to 140 beats/min. Because there

is a great deal of mixing of blood in the fetus, the oxygen Surfactant has two components: lecithin (L) and sphin-
saturation level of fetal blood reaches only about 80%. In gomyelin (S). Early in the formation of surfactant, sphingo-
light of this, the fetal heart has to beat rapidly (110 to 160 myelin is the chief component. At about 35 weeks, there is
beats/min) to supply needed oxygen to cells. Even with this a surge in the production of lecithin, which then becomes
low blood oxygen saturation level, however, carbon dioxide the chief component by a ratio of 2:1. As a fetus practices
does not accumulate in the fetal system because it rapidly breathing movements, surfactant mixes with amniotic fluid.
diffuses into maternal blood across a favorable placental pres- Using an amniocentesis technique, an analysis of the lecithin/
sure gradient. sphingomyelin (L/S) ratio in surfactant (whether lecithin or
sphingomyelin is the dominant component) is a primary
Fetal Hemoglobin test of fetal maturity. Respiratory distress syndrome, a severe
breathing disorder, can develop if there is a lack of surfactant or
Fetal hemoglobin differs from adult hemoglobin in several it has not changed to its mature form at birth (see Chapter 26).
ways. It has a different composition (two alpha and two Any interference with the blood supply to the fetus, such as
gamma chains, compared with two alpha and two beta occurs with placental insufficiency or maternal hypertension,
chains of adult hemoglobin). It is also more concentrated appears to raise steroid levels in the fetus and enhance surfactant
and has greater oxygen affinity, two features that increase its development. Synthetically increasing steroid levels in the fetus
efficiency. Because hemoglobin is more concentrated, a new- (e.g., the administration of betamethasone to the mother late
born’s hemoglobin level is about 17.1 g/100 ml, compared in pregnancy) can also hurry alveolar maturation and surfactant
with a normal adult level of 11 g/100 ml; a newborn’s he- production without interfering with permanent lung function
matocrit is about 53%, compared with a normal adult level prior to a preterm birth (Hjalmarson & Sandberg, 2011).
of 45%.
The change from fetal to adult hemoglobin levels begins
before birth (gamma cells are exchanged for beta cells) but the ✔ QSEN Checkpoint Question 9.3
process is still not complete at birth. Major blood dyscrasias, Informatics
such as sickle cell anemia, tend to be defects of the beta he-
moglobin chain, which is why clinical symptoms of these dis- Liz Calhorn asks you why her nurse midwife is concerned
orders do not become apparent until the bulk of fetal hemo- whether her fetus’s lungs are producing surfactant. Your best
globin has matured to adult hemoglobin, at about 6 months answer would be:
of age (Panepinto & Scott, 2011). a. “Surfactant keeps lungs from collapsing at birth, so it aids
newborn breathing.”
Respiratory System b. “Surfactant is produced by the fetal liver, so its presence
reveals liver maturity.”
At the third week of intrauterine life, the respiratory and di-
c. “Surfactant is necessary for antibody production, so it helps
gestive tracts exist as a single tube. Like all body tubes, ini-
prevents infection.”
tially this forms as a solid structure, which then canalizes (i.e.,
d. “Surfactant reveals mature kidney function, as it is impor-
hollows out). By the end of the fourth week, a septum begins
tant for fetal growth.”
to divide the esophagus from the trachea. At the same time,
lung buds appear on the trachea. Look in Appendix A for the best answer and rationale.
Until the seventh week of life, the diaphragm does not
completely divide the thoracic cavity from the abdomen.
This causes lung buds to extend down into the abdomen, Nervous System
re-entering the chest only as the chest’s longitudinal dimen-
sion increases and the diaphragm becomes complete (at the Like the circulatory system, the nervous system begins to de-
end of the seventh week). If the diaphragm fails to close velop extremely early in pregnancy.
completely, the stomach, spleen, liver, or intestines may be • A neural plate (a thickened portion of the ectoderm) is
pulled up into the thoracic cavity. This causes the child to be apparent by the third week of gestation. The top portion
born with intestine present in the chest (i.e., diaphragmatic differentiates into the neural tube, which will form the cen-
hernia), compromising the lungs and perhaps displacing the tral nervous system (brain and spinal cord), and the neural
heart (Gowen, 2011). crest, which will develop into the peripheral nervous system.
Other important respiratory developmental milestones • All parts of the brain (cerebrum, cerebellum, pons, and
include: medulla oblongata) form in utero, although none are
• Spontaneous respiratory practice movements begin as early completely mature at birth. Brain growth continues at high
as 3 months gestation and continue throughout pregnancy. levels until 5 or 6 years of age.
• Specific lung fluid with a low surface tension and low • Brain waves can be detected on an electroencephalogram
viscosity forms in alveoli to aid in expansion of the alveoli (EEG) by the eighth week.
at birth; it is rapidly absorbed shortly after birth. • The eye and inner ear develop as projections of the original
• Surfactant, a phospholipid substance, is formed and neural tube.
excreted by the alveolar cells of the lungs beginning at • By 24 weeks, the ear is capable of responding to sound and
about the 24th week of pregnancy. This decreases alveolar the eyes exhibit a pupillary reaction, indicating sight is present.
surface tension on expiration, preventing alveolar collapse The neurologic system seems particularly prone to insult
and improving the infant’s ability to maintain respira- during the early weeks of the embryonic period and can result
tions in the outside environment at birth (Rojas-Reyes, in neural tube disorders, such as a meningocele (i.e., herniation
Morley & Soll, 2012). of the meninges), especially if there is lack of folic acid (which

is contained in green leafy vegetables and pregnancy vitamins) necessary for digestion of complex starches, does not mature
(Cohen & Uddin, 2011). All during pregnancy and at birth, until 3 months after birth. Many newborns have also not
the system is vulnerable to damage if anoxia should occur. yet developed lipase, an enzyme needed for fat digestion (a
reason breast milk is the best food for newborns because its
Endocrine System digestion does not depend on these enzymes).
The liver is active throughout intrauterine life, function-
The function of endocrine organs begins along with neuro- ing as a filter between the incoming blood and the fetal cir-
system development. culation and as a deposit site for fetal stores such as iron and
• The fetal pancreas produces insulin needed by the fetus glycogen. Unfortunately, during intrauterine life, the fetal
(insulin is one of the few substances that does not cross the liver is unable to prevent recreational drugs or alcohol in-
placenta from the mother to the fetus). gested by the mother from entering the fetal circulation and
• The thyroid and parathyroid glands play vital roles in fetal possibly causing birth anomalies (Singer, Moore, Fulton, et
metabolic function and calcium balance. al., 2012). Newborns need careful assessment at birth for hy-
• The fetal adrenal glands supply a precursor necessary for poglycemia (low blood sugar) and hyperbilirubinemia (exces-
estrogen synthesis by the placenta. sive breakdown products from destroyed red blood cells), two
serious problems that can occur in the first 24 hours after
Digestive System birth because, although active, liver function is still immature.
The digestive tract separates from the respiratory tract at about Musculoskeletal System
the fourth week of intrauterine life and, after that, begins to
grow extremely rapidly. Initially solid, the tract canalizes (hol- During the first 2 weeks of fetal life, cartilage prototypes pro-
lows out) to become patent. Later in the pregnancy, the endo- vide position and support to the fetus. Ossification of this
thelial cells of the gastrointestinal tract proliferate extensively, cartilage into bone begins at about the 12th week, continues
occluding the lumen once more, and the tract must canalize all through fetal life and into adulthood. Carpals, tarsals, and
again. Atresia (blockage) or stenosis (narrowing) of the track sternal bones generally do not ossify until birth is imminent.
are common fetal anomalies and develop if either the first A fetus can be seen to move on ultrasonography as early as
or second canalization does not occur (Lin, Munsie, Herdt- the 11th week, although the mother usually does not feel this
Losavio, et al., 2012). The proliferation of cells shed in the sec- movement (quickening) until almost 20 weeks of gestation.
ond recanalization forms the basis for meconium (see below).
Because of this rapid intestinal growth, by the sixth week
of intrauterine life, the intestine becomes too large to be con- What if...9.1 Liz Calhorn repeats that not
only have her feelings toward her baby changed
tained by the abdomen. A portion of the intestine, therefore,
since she felt the baby move but she’s also more interested
is pushed into the base of the umbilical cord, where it remains
in how to keep him safe now. How would you modify your
until about the 10th week of intrauterine life or until the ab-
health teaching with her because of this?
dominal cavity has grown large enough to accommodate the
bulky intestines. As intestine returns to the abdominal cavity
at this point, it must rotate 180 degrees. Failure to do so can Reproductive System
result in inadequate mesentery attachments, possibly leading
to volvulus of the intestine in the newborn. A child’s sex is determined at the moment of conception by a
If any intestine remains outside the abdomen in the base spermatozoon carrying an X or a Y chromosome and can be
of the cord, a congenital anomaly, termed omphalocele, will ascertained as early as 8 weeks by chromosomal analysis or
be present at birth. A similar defect, gastroschisis, occurs when analysis of fetal cells in the mother’s bloodstream. At about
the original midline fusion that occurred at the early cell stage the sixth week after implantation, the gonads (i.e., ovaries or
is incomplete (Thilo & Rosenberg, 2011). testes) form. If testes form, testosterone is secreted, appar-
Meconium, a collection of cellular wastes, bile, fats, mu- ently influencing the sexually neutral genital duct to form
coproteins, mucopolysaccharides, and portions of the vernix other male organs (i.e., maturity of the wolffian, or meso-
caseosa (i.e., the lubricating substance that forms on the fetal nephric, duct). In the absence of testosterone secretion, fe-
skin), accumulates in the intestines as early as the 16th week. male organs will form (i.e., maturation of the müllerian, or
Meconium is sticky in consistency and appears black or dark paramesonephric, duct). This is an important phenomenon,
green (obtaining its color from bile pigment). An important because if a woman should unintentionally take an androgen
neonatal nursing responsibility is recording that a newborn or an androgen-like substance during this stage of pregnancy,
has passed meconium as this rules out a stricture (noncanali- a child who is chromosomally female could appear more male
zation) of the anus (Marcelis, de Blaauw, & Brunner, 2011). than female at birth. If deficient testosterone is secreted by
The gastrointestinal tract is sterile before birth. Because the testes, both the müllerian (female) duct and the wolffian
vitamin K, necessary for blood clotting, is synthesized by the (male) duct could develop (i.e., pseudohermaphroditism, or
action of bacteria in the intestines, vitamin K levels are almost intersex) (Douglas, Axelrad, Brandt, et al., 2012).
nonexistent in a fetus and are still low in a newborn (vitamin The testes first form in the abdominal cavity and do not
K is routinely administered intramuscularly at birth). Suck- descend into the scrotal sac until the 34th to 38th week of
ing and swallowing reflexes are not mature until the fetus is at intrauterine life. Because of this, many male preterm infants
about 32 weeks gestation, or weighs 1,500 g. are born with undescended testes. These boys need a follow-
The ability of the gastrointestinal tract to secrete enzymes up to be certain their testes do descend when they reach what
essential for carbohydrate and protein digestion is mature at would have been the 34th to 38th week of gestational age,
36 weeks. However, amylase, an enzyme found in saliva and because testicular descent does not always occur as readily in

extrauterine life as it would have in utero. Testes that do not Milestones of Fetal Growth and
descend (cryptorchidism) require surgery as they are associ- Development
ated with poor sperm production and possibly testicular can-
cer later in life (Zeitler, Travers, Nadaou, et al., 2011). When fetal milestones occur can be confusing because the life
of the fetus is typically measured from the time of ovulation
Urinary System or fertilization (ovulation age), but the length of a pregnancy
is more commonly measured from the first day of the last
Although rudimentary kidneys are present as early as the end menstrual period (gestational age). Because ovulation and
of the fourth week of intrauterine life, the presence of kidneys fertilization take place about 2 weeks after the last menstrual
does not appear to be essential for life before birth because the period, the ovulation age of the fetus is always 2 weeks less
placenta clears the fetus of waste products. Urine, however, than the length of the pregnancy or the gestational age.
is formed by the 12th week and is excreted into the amni- Both ovulation and gestational age are typically reported
otic fluid by the 16th week of gestation. At term, fetal urine in lunar months (4-week periods) or in trimesters (3-month
is being excreted at a rate of up to 500 ml/day. An amount periods) rather than in weeks. In lunar months, a total preg-
of amniotic fluid less than usual (oligohydramnios) suggests nancy is 10 months (40 weeks, or 280 days) long; a fetus
fetal kidneys are not secreting adequate urine and that there is grows in utero for 9.5 lunar months or three full trimesters
a kidney, ureter, or bladder disorder (Kumar, 2012). (38 weeks, or 266 days).
The complex structure of the kidneys gradually devel- The following discussion of fetal developmental milestones
ops during intrauterine life and continues to mature for is based on gestational weeks, because it is helpful when talk-
months afterward. The loop of Henle, for example, is not ing to expectant parents to correlate fetal development with
fully differentiated until the child is born. Glomerular fil- the way they measure pregnancy—from the first day of the
tration and concentration of urine in the newborn are still last menstrual period. Figure 9.6 illustrates the comparative
not efficient, because the ability to concentrate urine is still size and appearance of human embryos and fetuses at differ-
not mature at birth. ent stages of development.
Early in the embryonic stage of urinary system develop-
ment, the bladder extends as high as the umbilical region and End of Fourth Gestational Week
there is an open lumen between the urinary bladder and the
• The length of the embryo is about 0.75 cm; weight is
umbilicus. If this fails to close, (termed a patent urachus),
about 400 mg.
this is revealed at birth by the persistent drainage of a clear,
• The spinal cord is formed and fused at the midpoint.
acid–pH fluid (urine) from the umbilicus (Samra, McGrath,
• The head is large in proportion and represents about one
& Wehbe, 2011).
third of the entire structure.
• The rudimentary heart appears as a prominent bulge on
Integumentary System
the anterior surface.
The skin of a fetus appears thin and almost translucent until • Arms and legs are bud-like structures; rudimentary eyes,
subcutaneous fat begins to be deposited underneath it at ears, and nose are discernible.
about 36 weeks. Skin is covered by soft downy hairs (lanugo)
that serve as insulation to preserve warmth in utero, as well as End of Eighth Gestational Week
a cream cheese–like substance, vernix caseosa, which is impor- • The length of the fetus is about 2.5 cm (1 in.); weight is
tant for lubrication and for keeping the skin from macerating about 20 g.
in utero. Both lanugo and vernix are still present at birth. • Organogenesis is complete.
• The heart, with a septum and valves, beats rhythmically.
Immune System • Facial features are definitely discernible; arms and legs have
Immunoglobulin (Ig) G maternal antibodies cross the pla- developed.
centa into the fetus as early as the 20th week and certainly • External genitalia are forming, but sex is not yet distin-
by the 24th week of intrauterine life to give a fetus tempo- guishable by simple observation.
rary passive immunity against diseases for which the mother • The abdomen bulges forward because the fetal intestine is
has antibodies. These often include poliomyelitis, rubella growing so rapidly.
(German measles), rubeola (regular measles), diphtheria, tet- • A sonogram shows a gestational sac, which is diagnostic of
anus, infectious parotitis (mumps), hepatitis B, and pertussis pregnancy (Fig. 9.7).
(whooping cough). Infants born before this antibody transfer End of 12th Gestational Week (First Trimester)
has taken place have no natural immunity and so need more
than the usual protection against infectious disease in the • The length of the fetus is 7 to 8 cm; weight is about 45 g.
newborn period. • Nail beds are forming on fingers and toes.
A fetus only becomes capable of active antibody produc- • Spontaneous movements are possible, although they are
tion late in pregnancy. Generally, it is not necessary for a usually too faint to be felt by the mother.
fetus to produce antibodies because they need to be manu- • Some reflexes, such as the Babinski reflex, are present.
factured only to counteract an invading antigen, and anti- • Bone ossification centers begin to form.
gens rarely invade the intrauterine space. Because IgA and • Tooth buds are present.
IgM antibodies (the types which develop to actively coun- • Sex is distinguishable on outward appearance.
teract infection) cannot cross the placenta, their presence • Urine secretion begins but may not yet be evident in
in a newborn is proof that the fetus has been exposed to an amniotic fluid.
infection. • The heartbeat is audible through Doppler technology.

A B C D
FIGURE 9.6 Human embryos at different stages of life. (A) Implantation in uterus 7
E to 8 days after conception. (B) The embryo at 32 days. (C) At 37 days. (D) At 41 days.
(E) Between 12 and 15 weeks. (Petit Format/Nestle/Science Source/Photo Researchers.)
End of 16th Gestational Week • The fetus actively swallows amniotic fluid, demonstrating
an intact but uncoordinated swallowing reflex; urine is
• The length of the fetus is 10 to 17 cm; weight is 55 to 120 g. present in amniotic fluid.
• Fetal heart sounds are audible by an ordinary stethoscope. • Sex can be determined by ultrasonography.
• Lanugo is well formed.
• Both the liver and pancreas are functioning.
End of 20th Gestational Week
• The length of the fetus is 25 cm; weight is 223 g.
• Spontaneous fetal movements can be sensed by the mother.
• Antibody production is possible.
• Hair, including eyebrows, forms on the head; vernix
caseosa begins to cover the skin.
• Meconium is present in the upper intestine.
• Brown fat, a special fat that aides in temperature regula-
tion, begins to form behind the kidneys, sternum, and
posterior neck.
• Passive antibody transfer from mother to fetus begins.
• Definite sleeping and activity patterns are distinguishable
as the fetus develops biorhythms that will guide sleep/wake
patterns throughout life.

(Second Trimester)
• The length of the fetus is 28 to 36 cm; weight is 550 g.
• Meconium is present as far as the rectum.
• Active production of lung surfactant begins.
• Eyelids, previously fused since the 12th week, now open;
pupils react to light.
FIGURE 9.7 Sonogram showing the characteristic circle • Hearing can be demonstrated by response to sudden sound.
diagnostic of pregnancy (the gestational sac). (From Benson, • When fetuses reach 24 weeks, or 500–600 g, they have
C. B., Lavery M. J., & Platt, L. [1988]. Atlas of obstetrical ultra- achieved a practical low-end age of viability if they are
sound. Philadelphia, PA: J. B. Lippincott.) cared for after birth in a modern intensive care nursery.

End of 28th Gestational Week BOX 9.3 Naegele’s Rule

• The length of the fetus is 35 to 38 cm; weight is 1,200 g.
• Lung alveoli are almost mature; surfactant can be demon- To calculate the date of birth by this rule, count
strated in amniotic fluid. backward 3 calendar months from the first day of a
• Testes begin to descend into the scrotal sac from the lower woman’s last menstrual period and add 7 days. For
abdominal cavity. example, if the last menstrual period began May 15,
• The blood vessels of the retina are formed but thin and you would count back 3 months (April 15, March 15,
extremely susceptible to damage from high oxygen con- February 15) and add 7 days, to arrive at the pre-
centrations (an important consideration when caring for dicted date of birth as February 22.
preterm infants who need oxygen).
End of 32nd Gestational Week

“confined” after childbirth, the acronym EDB (estimated
• The length of the fetus is 38 to 43 cm; weight is 1,600 g. date of birth) is more commonly used today.
• Subcutaneous fat begins to be deposited (the former If fertilization occurred early in a menstrual cycle, the
stringy, “little old man” appearance is lost). pregnancy will probably end “early”; if ovulation and fer-
• Fetus responds by movement to sounds outside the tilization occurred later than the midpoint of the cycle, the
mother’s body. pregnancy will end “late.” Because of these normal variations,
• An active Moro reflex is present. a pregnancy ending 2 weeks before or 2 weeks after the calcu-
• Iron stores, which provide iron for the time during which lated EDB is considered well within the normal limit (38 to
the neonate will ingest only breast milk after birth, are 42 weeks). Gestational age wheels and birth date calculators,
beginning to be built. which can be used to predict a birth date are available, but
• Fingernails reach the end of fingertips. calculation by Naegele’s rule is the standard method used to
predict the length of a pregnancy (Box 9.3).
• The length of the fetus is 42 to 48 cm; weight is 1,800 to What if...9.2 Liz Calhorn first came to your
2,700 g (5 to 6 lb). prenatal clinic on August 5 and told you she had
• Body stores of glycogen, iron, carbohydrate, and calcium her last menstrual period from March 13 to March 18.
are deposited. What would be her child’s EDB?
• Additional amounts of subcutaneous fat are deposited.
• Sole of the foot has only one or two crisscross creases, com-
pared with a full crisscross pattern evident at term.
• Amount of lanugo begins to diminish.
• Most babies turn into a vertex (head down) presentation
ASSESSMENT OF FETAL GROWTH
during this month. AND DEVELOPMENT
End of 40th Gestational Week (Third Trimester) Tests for fetal growth and development are commonly done
for a variety of reasons, including to:
• The length of the fetus is 48 to 52 cm (crown to rump, 35
to 37 cm); weight is 3,000 g (7 to 7.5 lb). • Predict the outcome of the pregnancy
• Fetus kicks actively, sometimes hard enough to cause the • Manage the remaining weeks of the pregnancy
mother considerable discomfort. • Plan for possible complications at birth
• Fetal hemoglobin begins its conversion to adult hemoglobin. • Plan for problems that may occur in the newborn infant
• Vernix caseosa is fully formed. • Decide whether to continue the pregnancy
• Fingernails extend over the fingertips. • Find conditions that may affect future pregnancies
• Creases on the soles of the feet cover at least two thirds of Both fetal growth and development can be compromised if a
the surface. fetus has a metabolic or chromosomal disorder that interferes
In primiparas (i.e., women having their first baby), the with normal growth, if the supporting structures such as the
fetus often sinks into the birth canal during the last 2 weeks placenta or cord do not form normally, or if environmen-
of pregnancy, giving the mother a feeling the load she is carry- tal influences such as the nicotine in cigarettes causes fetal
ing is less. This event, termed lightening, is a fetal announce- growth restriction (including testes growth in a male fetus)
ment the third trimester of pregnancy has ended and birth is (Virtanen, Sadov, & Toppari, 2012).
at hand. Nursing responsibilities for these assessment procedures
include verifying that a signed consent form has been ob-
Determination of Estimated Birth Date tained as needed (which is necessary if the procedure poses
any risk to the mother or fetus that would not otherwise be
It is impossible to predict with a high degree of accuracy the present), being certain the woman and her support person are
exact day an infant will be born because fewer than 5% of aware of what the procedure will entail and any potential risks,
pregnancies end exactly 280 days from the last menstrual pe- preparing the woman physically and psychologically, provid-
riod; fewer than half end within 1 week of the 280th day. ing support during the procedure, assessing both fetal and
Traditionally, this date was referred to as the estimated maternal responses during and after the procedure, provid-
date of confinement (EDC). Because women are no longer ing any necessary follow-up care, and managing equipment

BOX 9.4 Nursing Care Planning
A INTERPROFESSIONAL CARE MAP FOR A WOMAN UNDERGOING

AN
FETAL
FETA
FE TAL
L ST
STUD
STUDIES
UDIE
IESS
Liz Calhorn, an 18-year-old, is about 20 weeks pregnant states, “Feeling the baby move made me realize there’s
(can’t remember date of last menstrual period). Although someone inside me, you know what I mean? It made me
she says she knows she should have stopped smoking realize it’s time I started being more careful with what I
before pregnancy, she has not been able to do this as do.” Liz works at a fast food restaurant. Boyfriend (father
yet. Twice during the pregnancy (at the 4th and 10th of fetus) is supportive, but has no money to offer her for
week), she drank beer at summer picnics. Today, at a support. Client states, “I’m not getting married. Just not
clinic visit, she tells you she has felt her fetus move. She ready for that level of commitment yet.”
Family Assessment Client lives in one-bedroom apart- Snack: Half bag of potato chips and
ment; supports self by working at a fast food restaurant. cream-cheese dip.
States, “My parents would help out if I begged them, but Physical examination: Fundal height is 16 cm. Fetal heart
I’m not going to do that.” tones by Doppler at 160 beats/min. Has been advised to
have an ultrasound done to assess for fetal growth and to
Client Assessment Client smokes a pack of cigarettes a
date pregnancy.
day. Takes aspirin, 10 g, for almost daily sinus headaches.
No recreational drug use. Nursing Diagnosis Risk for altered fetal growth related to
Nutrition: Breakfast: None, to help control her weight. inadequate nutrition and alcohol and nicotine consumption.
Lunch: A hotdog and salad. One diet cola.
Outcome Criteria Client consents to sonogram for fetal
Dinner: Macaroni and cheese; applesauce.
growth assessment; reports lessened alcohol and cigarette
One cup coffee.
use at the next visit.
Team Member
Responsible Assessment Intervention Rationale Expected Outcome
Activities of Daily Living, Including Safety
Nurse Ask patient to describe Discuss common ac- Knowing what consti- Client states she
a “typical day” to tions unsafe during tutes unsafe practices will stop drinking
reveal any actions pregnancy, such as during pregnancy alcohol; is using a
possibly detrimental smoking and drink- is a woman’s best supportive Internet
to fetal growth. ing alcohol. safeguard against quitline to help
fetal harm. reduce smoking.
Teamwork and Collaboration
Primary health care Determine whether Schedule sonogram Client believes she Client reports for
provider/nurse sonogram depart- 1 week in advance might be 20 weeks scheduled ultra-
ment has appoint- with sonogram pregnant. Fundal sound in 1 week.
ments free in department. height, recent fetal
coming week. movements corre-
spond more closely
to 16 weeks.
Procedures/Medications for Quality Improvement
Nurse Assess what prescrip- Discuss with client in- Acetylsalicylic acid Client reports at next
tion or over-the- advisability of taking (aspirin) can lead prenatal visit she
counter or alterna- aspirin during preg- to bleeding or pro- takes acetamino-
tive therapies client nancy; suggest she longed pregnancy. phen for any pain.
is using. take acetaminophen
(Tylenol) instead.
Nutrition
Nurse/nutritionist Ask client for a 24-hour Discuss the advisability Knowing what consti- Client reports at prenatal
recall nutrition of eating breakfast tutes a healthy diet visits she eats break-
history. while pregnant to helps ensure a fetus fast before leaving
help avoid hypogly- will receive ade- for work in the morn-
cemia in fetus. quate nutrients. ing. Includes more
protein in intake.

Patient-Centered Care
Nurse Determine whether Instruct client about A well-prepared cli- Client will describe
client understands preparation for so- ent is more apt to accurate prepara-
ultrasound is not nogram (drink fluid; result in an effective tions for procedure.
an X-ray, so it is not avoid emptying procedure and a Receives printed
harmful to the fetus. bladder). satisfied client. instructions for am-
bulatory ultrasound.
Spiritual/Psychosocial/Emotional Needs
Primary health care Assess the extent of Review the possibility Understanding con- Client states she
provider/nurse factors, such as al- with client that her tributors to fetal understands the dis-
cohol and cigarette pregnancy dating health is necessary crepancy in fundal
use, that could have may be wrong, be- for women to make height and weeks
led to intrauterine cause fundal height informed choices gestation following
growth restriction. is below usual. Al- during pregnancy. explanation.
ternate cause could
be fetal growth
restriction.
Informatics for Seamless Health Care Planning
Nurse/Primary health Perform complete Mark chart as high-risk Documenting risk fac- The patient chart
care provider assessment to help client for intrauter- tors helps to safe- documents high-risk
ensure continuity ine growth restric- guard the fetus. status.
of care with other tion (fundal height
services. below average for
weeks gestation).
and specimens. Box 9.4 shows an interprofessional care map insulin balance and fetal growth. Most women are aware
illustrating both nursing and team planning for fetal care, in- alcohol ingestion can harm a fetus (e.g., fetal alcohol spec-
cluding assessment procedures. trum disorder) but many are not yet aware of fetal tobacco
Providing follow-up care may include being certain a syndrome (Wong, Ordean, & Kahan, 2011).This syndrome
couple understands what the results of a test mean. When a applies to the fetus of a woman who smokes more than five
result is good, parents feel assured their infant is growing well. cigarettes a day and who is born growth restricted (i.e., birth
When results are not encouraging, a couple can experience a weight under 2,500 g at term). Smoking may also be a cause
mixture of feelings. On the one hand, they feel committed of ectopic (tubal) pregnancy as fallopian tubes may become
to the pregnancy; on the other, they want to protect their irritated (Shao, Zou, Wang, et al., 2012).
child, themselves, and their family from the burden of having Most women instinctively protect a fetus growing inside
a child with a severe disability. In some instances, they will be them so pregnancy may be the push they need to improve
asked to make a life and death decision depending on the re- their lifestyle (Box 9.5). Asking if a woman has had any ex-
sults. Quiet listening so a couple has time to thoroughly think posure to teratogens can reveal exposure to such substances as
through what option will be right for them may be difficult to chemicals, paint fumes, cleaning products, poor air quality,
do but is usually the soundest action for health care providers or a loud noise level (Krueger, Horesh, & Crossland, 2012).
(Choi, Van Riper, & Thoyre, 2012). Asking about unintentional injuries or intimate partner vio-
lence can help reveal whether a fetus could have suffered any
Health History trauma from these sources (e.g., intimate partner violence
tends to increase during pregnancy because of the stress a
Like all assessments, a fetal assessment begins with a health pregnancy can create; Dalton, 2012).
history. Ask the mother specifically about any prepregnancy
illnesses such as gestational diabetes or heart disease as these Physical Examination
both can interfere with fetal growth. Ask about any drugs a
woman takes; for instance, common drugs taken for recur- A physical examination of the mother is the second step in
rent seizures can be teratogenic and therefore pose a risk in evaluating fetal health. Assess maternal weight and general
pregnancy (Mawhinney, Campbell, Craig, et al., 2012). Ask appearance, as both obesity and underweight are clues that
also about nutritional intake because if a woman is not eating the mother’s nutrition may not be adequate for sound fetal
a well-balanced diet, she may not be taking in enough nutri- growth (Warren, Rance, & Hunter, 2012). Bruises may
ents for fetal growth (Whitney & Rolfes, 2012). Be certain to indicate intimate partner violence that could have bruised the
also ask about personal habits such as cigarette smoking, both fetus as well. An elevated blood pressure may be the begin-
prescription and recreational drug use, alcohol consump- ning of hypertension of pregnancy, which can restrict fetal
tion, and exercise, because all of these may influence glucose/ growth (Vest & Cho, 2012).

BOX 9.5 Nursing Care Planning to Based on the previous study, which statement by Liz Calhorn
Respect Cultural Diversity would make you most worried she might have difficulty quit-
ting smoking during the remainder of her pregnancy?
Different cultures have different ideas as to what foods to
eat, how much exercise is good during pregnancy, and a. “I don’t have a lot of spare cash, just like everyone else in
whether fetal tests for well-being are ethical. Whether a my family.”
woman’s religion or personal beliefs allow her to use reli- b. “When I feel tense, I like to shop. It really takes away that
able conception can influence whether she is happy to bad feeling.”
discover she is pregnant, which can then influence how c. “I’m trying to stop smoking so I won’t have to smoke
soon she goes for prenatal care or begins to eat a more around my baby.”
nutritious diet. If her religion is one that mandates she d. “My mother had five children with no trouble; why am I so
have a large family to increase the number of members different?”
in her religion, she may be happy to be pregnant, but Look in Appendix A for the best answer and rationale.
also unsure she can love this additional child.
Cultural beliefs also affect everyday things, such as be-
lieving it is wrong to have a photograph taken during preg-
nancy because that will alert unknown spirits that the woman
Estimating Fetal Health
is pregnant (the origin of lullabies were songs to keep away A number of procedures, both noninvasive and invasive, are
Lilith, an avenging creature in Jewish folklore who was used to evaluate fetal health. Because there are many proce-
thought to bring harm to babies). Believing photographs are dures, helping a woman with a high-risk pregnancy maintain
harmful may make a woman reluctant to have a sonogram a sense of control or empowerment as she is scheduled for
taken during pregnancy; unlike most women, she may not them is an important nursing responsibility (Box 9.6).
like a photograph of the ultrasound for a baby keepsake.
Fetal Growth
As a fetus grows, the uterus expands to accommodate its size.
Although not evidence grounded, typical fundal (top of the
✔ QSEN Checkpoint Question 9.4 uterus) measurements are:
Evidence-Based Practice • Over the symphysis pubis at 12 weeks
• At the umbilicus at 20 weeks
To investigate what the risk factors are that lead to women • At the xiphoid process at 36 weeks
smoking, researchers surveyed 570 women from Appalachian
Ohio as to social, demographic, and psychological factors McDonald’s rule, another symphysis–fundal height mea-
and whether they smoked. Findings revealed women with low surement (although, again, not documented to be thoroughly
socioeconomic status, those who scored high on a depression reliable), is an easy method of determining midpregnancy
assessment score, and those who had their first baby before growth. Typically, tape measurement from the notch of the
they were 17 years of age were more likely to smoke. Almost symphysis pubis to over the top of the uterine fundus as a
50% of women with both low socioeconomic status and rated woman lies supine is equal to the week of gestation in centi-
as depressed smoked (Wewers, Salsberry, Ferketich, et al., meters between the 20th and 31st weeks of pregnancy (e.g.,
2012). in a pregnancy of 24 weeks, the fundal height should be
24 cm) (Fig. 9.8).
BOX 9.6 Nursing Care Planning to Empower a Family
Women may find the names of tests like MSAFP and sub- • Don’t refer to a fetus as “it” during testing because that
stances being tested for (acetylcholinesterase) so confusing is such an impersonal term. If the woman has chosen a
that they feel as if their life is being taken over by scheduled name, use that while referring to her fetus; otherwise,
tests or exams. To help a woman maintain control: use he or she.
• Encourage her to ask questions until her primary health • Respect modesty during exams where the woman’s abdo-
care provider simplifies instructions or test results men will be exposed. Movie stars are often pictured today
enough that she thoroughly understands them. with their pregnant abdomen on view, but not every
• Encourage her to set the time and date of appointments woman wants her body exposed unnecessarily that way.
if possible so she can fit fetal testing in with her sched- • Remember that late in pregnancy, women’s movements
ule, rather than be expected to appear “on command.” can be painful and may feel awkward, so respect that
• Encourage her to bring her significant other with her for asking a woman to step up and lie on an examining
fetal testing so he/she hears the same explanation she table is not asking her to complete an easy task. Offer
does and so that person can also ask questions rather help as necessary but also remember feeling indepen-
than hearing the information second hand. dent is an empowering feeling.

FIGURE 9.8 Measuring fundal height from the superior FIGURE 9.9 Measuring fetal heart rate with a Doppler
aspect of the pubis to the fundal crest. The tape is pressed flat transducer, which detects and broadcasts the fetal heart rate to
against the abdomen for the measurement. the parents-to-be, as well as you.
A fundal height much greater than this standard suggests a this time, so lack of typical movements may not be serious,
multiple pregnancy, a miscalculated due date, a large-for-gesta- but it is an indication for further assessment.
tional-age (LGA) infant, hydramnios (increased amniotic fluid Kick counts are particularly useful in growth-restricted or
volume), or possibly even gestational trophoblastic disease (see postterm pregnancies to reveal if a fetus is still receiving ad-
Chapter 21). A fundal measurement much less than this suggests equate nutrition (Caughey, 2012). Make certain the woman
the fetus is failing to thrive (e.g., intrauterine growth restriction), knows fetal movements do vary, especially in relation to sleep
the pregnancy length was miscalculated, or an anomaly interfer- cycles, her activity, and the time since she last ate. Otherwise,
ing with growth has developed. McDonald’s rule becomes inac- she can become unduly worried her fetus is in jeopardy when
curate during the third trimester of pregnancy because the fetus the fetus is asleep or just having an inactive time.
is growing more in weight than in height during is time.
Assessing Fetal Well-being What if...9.3 You give instructions to Liz
Calhorn to count fetal movements (count kicks)
A number of actions or procedures are helpful in detecting
daily after lunch and she tells you she can’t do that
and documenting the fetus is not only growing but is also
because she snacks all day long rather than eats at regular
apparently healthy.
times. Which would be more important: that she should
Fetal Heart Rate count kicks after meals or that she do it every day?
Fetal heart sounds can be heard and counted as early as the

10th to 11th week of pregnancy by the use of an ultrasound Rhythm Strip Testing. The term “rhythm strip testing” refers to
Doppler technique (Fig. 9.9). This is done routinely at every an assessment of the fetal heart rate for whether a good baseline
prenatal visit past 10 weeks. rate and both long- and short-term variability are present. For
this, help the woman into a semi-Fowler’s position (either in a
Daily Fetal Movement Count (Kick Counts) comfortable lounge chair or on an examining table or bed with
an elevated backrest) to prevent her uterus from compressing
Fetal movement that can be felt by the mother (quickening) the vena cava and causing supine hypotension syndrome during
occurs at approximately 18 to 20 weeks of pregnancy and peaks the test. Attach an external fetal heart rate monitor abdominally
in intensity at 28 to 38 weeks. After that time, a healthy fetus (Fig. 9.10A). Record the fetal heart rate for 20 minutes.
moves with a degree of consistency, at about 10 times per hour. The baseline reading refers to the average rate of the fetal
In contrast, a fetus who is not receiving enough nutrients be- heartbeat. Short-term variability (also called beat-to-beat vari-
cause of poor maternal nutrition or placental insufficiency has ability) denotes the small changes in rate that occur from sec-
greatly decreased movements. The technique for “kick counts” ond to second if the fetal parasympathetic nervous system is
varies from institution to institution, but a typical method used receiving adequate oxygen and nutrients. In the rhythm strip
is to ask women with high-risk pregnancies to: in Figure 9.10B, for example, the baseline (average) of the fetal
• Lie in a left recumbent position after a meal. heartbeat is 130 beats/min. Beat-to-beat variability is present.
• Observe and record the number of fetal movements (kicks) Long-term variability reflects the state of the fetal sym-
their fetus makes until they have counted 10 movements. pathetic nervous system. On a rhythm strip, it is the differ-
• Record the time (typically this is under an hour). ences in heart rate that occur over the 20-minute time period.
• If an hour passes without 10 movements, they should walk Note in Figure 9.10B how the heart rate varies from 150 to
around a little and try a count again. 130 beats/min. Because the average fetus moves about twice
• If 10 movements (kicks) cannot be felt in a second 1-hour every 10 minutes, and movement causes the heart rate to in-
period, they should telephone their primary health care crease, there will typically be two or more instances of fetal
provider. The fetus could be healthy but sleeping during heart rate acceleration in a 20-minute rhythm strip.

FIGURE 9.10 Rhythm strip and nonstress testing of fetal

heart rate. (A) The woman sits in a comfortable chair to avoid FHR 240 bpm
supine hypotension. Both a uterine contraction monitor and
fetal heart rate monitor are in place on her abdomen. (Photo- 210
graph by Melissa Olson, with permission of Chestnut Hill Hospi-
tal, Philadelphia, PA.) (B) A rhythm strip. The upper strip signifies
heart rate; the lower strip indicates uterine activity. Arrows signal 180
fetal movement. (C) Baseline fetal heart rate on this strip is 130
to 132 beats/min. This strip shows fetal heart rate acceleration 150
in response to fetal movement, shown by arrows. (Photograph
by Melissa Olson, with permission of Chestnut Hill Hospital,
Philadelphia, PA.) 120
90
60
30
100
12
10 75
8
50
6
4
25
2
0 kPa UA 0 mm Hg
A C
FHR 240bpm FHR 240bpm FHR 240bpm
210 210 210
180 180 180
150 150 150
120 120 120
90 90 90
60 60 60
30 30 30
100 100 100

12 12 12
10 75 10 75 10 75
8 8 8
50 50 50
6 6 6
4 4 4
25 25 25
2 2 2
0 kPa UA0 mm Hg 0 kPa UA0 mm Hg 0 kPa UA0 mm Hg
B
Variability is rated as: • Marked: An amplitude range is detectable; rate is greater

• Absent: No peak-to-trough range is detectable than 25 beats/min (American Congress of Obstetricians
• Minimal: An amplitude range is detectable but the rate is and Gynecologists [ACOG], 2009)
5 beats/min or fewer Rhythm strip testing requires a woman to remain in a fairly
• Moderate or normal: An amplitude range is detectable; fixed position for 20 minutes. Keep her well informed of the
rate is 6 to 25 beats/min importance and purpose of the test and be certain she understand

the meaning of the results after the test. Electronic fetal heart • Establish a fetus is growing and has no gross anomalies
rate recording is further discussed in Chapter 15 as it can also be such as hydrocephalus; anencephaly; or spinal cord, heart,
used to assess fetal well-being at the beginning of labor. kidney, and bladder concerns.
• Establish the sex if a penis is revealed.
Nonstress Testing. A nonstress test measures the response • Establish the presentation and position of the fetus.
of the fetal heart rate to fetal movement. Position the woman • Predict maturity by measurement of the biparietal diam-
and attach both a fetal heart rate and a uterine contraction eter of the head or crown-to-rump measurement.
monitor. Instruct the woman to push the button attached • Discover complications of pregnancy, such as the pres-
to the monitor (similar to a call bell) whenever she feels the ence of an intrauterine device, hydramnios (excessive
fetus move. This will create a dark mark on the paper tracing amniotic fluid) or oligohydramnios (lessened amniotic
at these times. fluid), ectopic pregnancy, missed miscarriage, abdominal
When the fetus moves, the fetal heart rate should increase pregnancy, placenta previa (a low-implanted placenta),
about 15 beats/min and remain elevated for 15 seconds. premature separation of the placenta, coexisting uterine
It should decrease to its average rate again as the fetus quiets tumors, or multiple pregnancy. Genetic disorders such as
(Fig. 9.10C). If no increase in beats per minute is noticeable on Down syndrome and fetal anomalies such as neural tube
fetal movement, poor oxygen perfusion of the fetus is suggested. disorders, diaphragmatic hernia, or urethral stenosis also
A nonstress test usually is done for 20 minutes. The can be diagnosed. Fetal death can be revealed by a lack of
test is said to be reactive (healthy) if two accelerations of heartbeat and respiratory movement.
fetal heart rate (by 15 beats or more) lasting for 15 seconds • After birth, a sonogram may be used to detect a retained
occur after movement within the time period. The test is placenta or poor uterine involution in the new mother.
nonreactive (fetal health may be affected) if no accelera-
tions occur with the fetal movements. The results also can For an ultrasound, intermittent sound waves of high fre-
be interpreted as nonreactive if no fetal movement occurs quency (above the audible range) are projected toward the
or if there is low short-term fetal heart rate variability (less uterus by a transducer placed on the abdomen or in the vagina.
than 6 beats/min) throughout the testing period (Russo, The sound frequencies that bounce back from the fetus can be
Henderson, & Costigan, 2011). displayed on an oscilloscope screen as a visual image. The fre-
If a 20-minute period passes without any fetal movement, quencies returning from tissues of various thicknesses and prop-
it may only mean that the fetus is sleeping, although other erties present distinct appearances. A permanent record can be
reasons for lessened variability are maternal smoking, drug made of the scan for the woman’s electronic health record; a
use, or hypoglycemia. Although not evidence based, if you copy of the scan can be offered to her as a baby book souvenir.
give the woman an oral carbohydrate snack, such as orange Images are so clear that the fetal heart as well as movement
juice, it can cause her blood glucose level to increase enough of the extremities, such as bringing a hand to the mouth to
to cause fetal movement. The fetus also may be stimulated by suck a thumb, can be seen. A parent who is in doubt her fetus
a loud sound (discussed later) to cause movement. is well or whole can be greatly reassured by viewing such a
Because both rhythm strip and nonstress testing are non- sonogram image.
invasive procedures and cause no risk to either mother or Before an ultrasound examination, be certain a woman has
fetus, they can be used as screening procedures in all preg- received a good explanation of what the procedure will be like
nancies. They can be done at home daily as part of a home and reassurance that the process does not involve X-rays and
monitoring program for the woman who is having a com- so will be safe for the fetus (Box 9.7). This means it is also safe
plication of pregnancy. If a nonstress test is nonreactive, an for the father of the child to remain in the room during the
additional fetal assessment, such as a biophysical profile test, test and see the images as well.
will be scheduled. The sound waves reflect best if the uterus can be held sta-
ble so it is helpful if the woman has a full bladder at the time
Vibroacoustic Stimulation. For acoustic (sound) stimula- of the procedure. To ensure this, ask her to drink a full glass
tion, a specially designed acoustic stimulator is applied to the of water every 15 minutes beginning 90 minutes before the
mother’s abdomen to produce a sharp sound of approximately procedure and to not void until after the procedure.
80 dB at a frequency of 80 Hz, thus startling and waking the Help the woman up to an examining table and drape her
fetus (Russo et al., 2011). for modesty, but with her abdomen exposed. To prevent su-
During a standard nonstress test, if a spontaneous accel- pine hypotension syndrome, place a towel under her right
eration has not occurred within 5 minutes, apply a single 1- buttock to tip her body slightly so the uterus will roll away
to 2-second sound stimulation to the lower abdomen. This from the vena cava. A gel is then applied to her abdomen to
can be repeated again at the end of 10 minutes if no further improve the contact of the transducer. Be certain the gel is at
spontaneous movement occurs, so two movements within the room temperature or even slightly warmer, or it may cause un-
20-minute window can be evaluated. comfortable uterine cramping. The transducer is then applied
to her abdomen and moved both horizontally and vertically
Ultrasonography until the uterus and its contents are fully scanned (Fig. 9.11).
Ultrasonography also may be performed using an intravaginal
Ultrasonography, which measures the response of sound technique, although this is not necessary for routine testing.
waves against solid objects, is a much-used tool for fetal Although the long-term effects of ultrasound are not yet
health assessments. It can be used to: known, the technique appears to be safe for both mother
• Diagnose pregnancy as early as 6 weeks gestation. and fetus and causes no discomfort to the fetus. Usually, the
• Confirm the presence, size, and location of the placenta only discomfort for the woman is the messiness of the con-
and amniotic fluid. tact lubrication and a strong desire to void before the scan is

BOX 9.7 Nursing Care Planning Based on Effective Communication
Liz Calhorn is scheduled for an ultrasound.
Less Effective Communication More Effective Communication

Nurse: Do you have any questions about what will hap- Nurse: Do you have any questions about what will
pen, Liz? happen, Liz?
Liz: I guess. I can’t decide if I want to know my baby’s sex Liz: I guess. I can’t decide if I want to know my baby’s sex
or not. or not.
Nurse: Most people do these days. It helps them plan Nurse: That’s an individual decision. What things are you
better. thinking about?
Liz: I think I’d rather be surprised. I know I don’t want a Liz: I think I’d rather be surprised. I know I don’t want a boy.
boy. Nurse: You don’t want a boy?
Nurse: If it were me, I’d want to know. How else do you Liz: A guy got me into this trouble. The last thing I need is
know what color clothes to buy? another one around the house.
Liz: Okay, tell me what the ultrasound shows. Nurse: Let’s talk about what it will mean if you should
have a boy.
Becoming so engrossed in sharing her personal feelings, the nurse in the first example forgot to listen to
exactly what the client was saying. Taking the time to discover what the client wanted, as was done in the
second example, revealed the sex of the child was only a small part of what the mother was afraid to learn.
completed. Taking home a photograph of the sonographic Figures 9.12 and 9.13 are sonograms showing the biparietal
image can enhance bonding because it is proof the pregnancy diameter of a fetus at 24 weeks and a fetus close to term.
exists and the fetus appears well. As desirable as it is, however, Figure 9.12 is a sonogram showing the biparietal diam-
caution women against having ultrasound images done just eter of a fetus at 24 weeks. Figure 9.13 shows a fetus close
for the purpose of having “keepsake” photographs. Commer- to term.
cial firms offering these services are not well regulated and
their equipment may be outdated and unsafe. Doppler Umbilical Velocimetry. Doppler ultrasonography
In medical practice, a number of specific features are measures the velocity at which red blood cells in the uterine
studied by sonogram. and fetal vessels travel. Assessment of the blood flow through
uterine blood vessels is helpful to determine the vascular re-
Biparietal Diameter. Ultrasonography may be used to predict sistance present in women with gestational diabetes or hy-
fetal maturity by measuring the biparietal diameter (side-to- pertension and whether resultant placental insufficiency is
side measurement) of the fetal head. In 80% of pregnancies occurring. Decreased velocity is an important predictor that
in which the biparietal diameter of the fetal head is 8.5 cm uterine growth restriction will occur because it reveals that
or greater, it can be predicted the infant will weigh more only a limited number of nutrients are able to reach the fetus
than 2,500 g (5.5 lb) at birth or is at a fetal age of 40 weeks. (Kaponis, Harada, Makrydimas, et al., 2011).
Biparietal
diameter
Occipitofrontal
diameter
FIGURE 9.11 A sonogram being recorded. Notice FIGURE 9.12 A sonogram at 24 weeks gestation showing
the mother’s interest in being able to see her baby’s first measurement of the biparietal diameter. (Courtesy of the Depart-
photograph. ment of Medical Photography, Children’s Hospital, Buffalo, NY.)

FIGURE 9.13 A sonogram showing a fetus close to term.
Placental Grading for Maturity. Placentas can be graded by Nuchal Translucency. Children with a number of chromo-
ultrasound based on the particular amount of calcium depos- some anomalies have unusual pockets of fat or fluid present
its present in the base. Placentas are graded as: in their posterior neck, which show on sonograms as nuchal
• 0: Between 12 and 24 weeks translucency. Chromosomal anomalies associated with this
• 1: 30 to 32 weeks are discussed in Chapter 7.
• 2: 36 weeks
• 3: 38 weeks (Because fetal lungs are apt to be mature by
38 weeks, a grade 3 placenta suggests the fetus is mature.)
✔ QSEN Checkpoint Question 9.5
Patient-Centered Care
Amniotic Fluid Volume. The amount of amniotic fluid pres-
ent is yet another way to estimate fetal health because a por- Liz Calhorn is scheduled to have an ultrasound examination
tion of the fluid is formed by fetal kidney output. If a fetus and you want to ensure that she understands and is prepared
is becoming so stressed in utero that circulatory and kidney for this procedure to mitigate her anxiety. What instruction
function is failing, urine output and, consequently, the volume would you give her before her examination?
of amniotic fluid will decrease. A decrease in amniotic fluid a. “Use the restroom immediately before the procedure to
volume puts the fetus at risk for compression of the umbilical reduce your bladder size.”
cord with interference of nutrition as well as lack of room to b. “The intravenous fluid used to dilate your uterus does not
exercise and maintain muscle tone. Between 28 and 40 weeks, hurt the fetus.”
the total pockets of amniotic fluid revealed by sonogram c. “You will need to drink at least three glasses of water be-
average 12 to 15 cm. An amount greater than 20 to 24 cm fore the procedure.”
indicates hydramnios (i.e., excessive fluid, perhaps caused by d. “You can have medicine for the pain of any contractions
inability of the fetus to swallow). An amount less than 5 to caused by the test.”
6 cm indicates oligohydramnios (i.e., decreased amniotic fluid, Look in Appendix A for the best answer and rationale.
perhaps caused by poor perfusion and kidney failure).

Biophysical Profile Maternal Serum

A biophysical profile combines five parameters (i.e., fetal re- Because a number of trophoblast cells pass into the maternal
activity, fetal breathing movements, fetal body movement, bloodstream beginning at about the seventh week of preg-
fetal tone, and amniotic fluid volume) into one assessment. nancy, maternal serum analysis can reveal information about
The fetal heart and breathing record measures short-term the mother as well as the fetus.
central nervous system function; the amniotic fluid volume
helps measure long-term adequacy of placental function. The Maternal Serum ␣-Fetoprotein. AFP is a substance produced
scoring for a complete profile is shown in Table 9.3. By this by the fetal liver that can be found in both amniotic fluid and
system, each item has the potential for scoring a 2, so 10 maternal serum (maternal serum ␣-fetoprotein [MSAFP]).
would be the highest score possible. A biophysical profile is The level is abnormally high if the fetus has an open spinal or
more accurate in predicting fetal well-being than any single abdominal wall defect, because the open defect allows more
assessment (Oyelese & Vintzileos, 2011). Because the scoring AFP to enter the mother’s circulation than usual. Although
system is similar to an Apgar score determined at birth on the reason is unclear, the level is low if the fetus has a chromo-
infants, it is popularly called a fetal Apgar score. somal defect such as Down syndrome. MSAFP levels begin
Biophysical profiles may be done as often as daily during a to rise at 11 weeks gestation and then steadily increase until
high-risk pregnancy. The fetal scores are as follows: term. Traditionally assessed at the 15th week of pregnancy,
between 85% and 90% of neural tube anomalies and 80% of
• A score of 8 to 10 means the fetus is considered to be babies with Down syndrome can be detected by this method
doing well. (Rogers & Worley, 2012).
• A score of 6 is considered suspicious.
• A score of 4 denotes a fetus potentially in jeopardy. Maternal Serum for Pregnancy-Associated Plasma Protein A.
Pregnancy-associated plasma protein A (PAPP-A) is a pro-
For simplicity, some centers use only two assessments (am- tein secreted by the placenta; low levels in maternal blood
niotic fluid index [AFI] and a nonstress test) for the analysis. are associated with fetal chromosomal anomalies, including
Referred to as a modified biophysical profile, this predicts trisomies 13, 18, and 21 or small-for-gestational-age (SGA)
short-term viability by the nonstress test and long-term via- babies. A high PAPP-A level may predict an LGA baby.
bility by the AFI. A healthy fetus should show a reactive non-
stress test and an AFI range between 5 and 25 cm (Russo Quadruple Screening. Quadruple screening analyzes four
et al., 2011). Nurses play a large role in obtaining the infor- indicators of fetal health: AFP, unconjugated estriol (UE; an
mation for both a modified and a full biophysical profile by enzyme produced by the placenta that estimates general well-
obtaining either the nonstress test or the sonogram reading. being), hCG (also produced by the placenta), and inhibin A (a
protein produced by the placenta and corpus luteum associated
Magnetic Resonance Imaging with Down syndrome).
As with the measurement of MSAFP, quadruple testing re-
Magnetic resonance imaging (MRI) is yet another way to as- quires only a simple venipuncture of the mother. Because it mea-
sess a growing fetus. Because the technique apparently causes sures four separate values, it the most common of the maternal
no harmful effects to the fetus or woman, MRI has the po- serum tests used today (Manipalviratn, Trivax, & Huang, 2013).
tential to replace or complement ultrasonography as a fetal
assessment technique because it can identify structural anom- Fetal Gender. Although fetal gender is usually determined by
alies or soft tissue disorders (O’Connor, Rooks, & Smith, an ultrasound screen at about 4 months, it can be determined
2012). An MRI may be most helpful in diagnosing complica- as early as 7 weeks by analysis of maternal serum. This early
tions such as ectopic pregnancy or trophoblastic disease (see diagnosis could be helpful to a woman who has an X-carrying
Chapter 21), because later in a pregnancy, fetal movement genetic disorder so she could discover if she has a male fetus
(unless the fetus is sedated) can obscure the findings. who could inherit the disease or a female fetus who will be dis-
TABLE 9.3 Biophysical Profile Scoring

Assessment Instrument Criteria for a Score of 2
Fetal breathing Sonogram At least one episode of 30 s of sustained fetal breathing movements
within 30 min of observation.
Fetal movement Sonogram At least three separate episodes of fetal limb or trunk movement within a
30-min observation.
Fetal tone Sonogram The fetus must extend and then flex the extremities or spine at least once
in 30 min.
Amniotic fluid volume Sonogram A pocket of amniotic fluid measuring more than 2 cm in vertical diameter
must be present.
Fetal heart reactivity Nonstress test Two or more accelerations of fetal heart rate of 15 beats/min lasting 15 s or
more following fetal movements in a 20-min period.

ease free (Mortarino, Garagiola, Lotta, et al., 2011). Screening

of this type has some ethical connotations, because if the fetus
is determined to be the “wrong” gender, there could be serious
consequences for the now unwanted child.
Invasive Fetal Testing
If a genetic or growth concern is identified by noninvasive
measures, a number of invasive measures allow for more re-
fined investigation.
Chorionic Villi Sampling. Chorionic villi sampling (CVS) is
a biopsy and chromosomal analysis of chorionic villi done at
10 to 12 weeks of pregnancy. As fetal cells can be more eas-
ily obtained from the maternal blood stream for study, the
method may be used for chromosomal analysis but is rarely
necessary (see Chapter 7 for chromosome analysis).
Amniocentesis. Amniocentesis (from the Greek amnion for
“sac” and kentesis for “puncture”) is the aspiration of amniotic
fluid from the pregnant uterus for examination. The proce-
dure can be done in a health care office or in an ambulatory
clinic. It is typically scheduled between the 14th and 16th
weeks of pregnancy so a generous amount of amniotic fluid
will be present. The technique can be used again near term to
test for fetal maturity.
Amniocentesis is a technically easy procedure, but it can
be very frightening to the woman on whom it is done. Be-
cause it involves penetration of the integrity of the amniotic
sac, there also are risks to the fetus such as hemorrhage from
penetration of the placenta, infection of the amniotic fluid,
and puncture of the fetus, although the incidence of these is
very low (less than 0.5%). If the procedure leads to irritation
of the uterus, it could initiate premature labor and preterm
birth (Attilakos & Overton, 2012). FIGURE 9.14 Amniocentesis. A pocket of amniotic fluid is
In preparation for amniocentesis, ask the woman to void located by sonogram. A small amount of fluid is removed by
(to reduce the size of the bladder and prevent an inadvertent needle aspiration.
puncture). Place her in a supine position on an examining
table and drape her appropriately, exposing only her abdo-
men. Slip a folded towel under her right buttock to tip her
body slightly to the left to move her uterus off her vena cava procedure to prevent fetal isoimmunization or help ensure
and help prevent supine hypotension syndrome. Attach fetal maternal antibodies will not form against any placental red
heart rate and uterine contraction monitors. Take her blood blood cells that might have accidentally been released into the
pressure and measure the fetal heart rate for baseline levels. maternal bloodstream during the procedure.
Next, a sonogram is done to determine the position of Amniotic fluid can be analyzed for:
the fetus, the location of a pocket of amniotic fluid, and the • AFP.
placenta. The abdomen is then swabbed with an antiseptic • Acetylcholinesterase, another compound that rises to high
solution, and a local anesthetic is injected. Caution a woman levels if a neural tube anomaly is present.
she may feel a slight prick as the anesthetic is introduced and • Bilirubin determination. The presence of bilirubin may be
a sensation of pressure as the needle used for aspiration, a analyzed if a blood incompatibility is suspected. If biliru-
3- or 4-in., 20- to 22-gauge spinal needle, is introduced. Do bin is going to be analyzed, the specimen must be free of
not suggest she take a deep breath and hold it as a distraction blood or a false-positive reading will occur.
against discomfort because this lowers the diaphragm against • Chromosome analysis. A few fetal skin cells are always
the uterus and shifts intrauterine contents. present in amniotic fluid so these cells may be cultured and
The needle is inserted, carefully avoiding the fetus and stained for karyotyping for genetic analysis. Examples of
placenta, until it reaches a pool of amniotic fluid (Fig. 9.14). genetic diseases that can be detected by prenatal amnio-
A syringe is attached, and about 15 ml of amniotic fluid is centesis and their significance to health are discussed in
withdrawn. The needle is then removed, and the woman rests Chapter 7.
quietly for 30 minutes. During the procedure and for the • Color. Normal amniotic fluid is the color of water; late in
30 minutes afterward, observe the fetal heart rate monitor to be pregnancy, it may have a slightly yellow tinge. A strong
certain the rate remains normal, and observe the uterine con- yellow color suggests a blood incompatibility (the yellow
traction monitor to be certain no contractions begin to occur. results from the presence of bilirubin released from the
If the woman has Rh-negative blood, Rho(D) im- breakdown of red blood cells). A green color suggests meco-
mune globulin (RhIG; RhoGAM) is administered after the nium staining, a phenomenon associated with fetal distress.

• Fibronectin. Fibronectin is a glycoprotein that plays a part Percutaneous Umbilical Blood Sampling. Percutaneous um-
in helping the placenta attach to the uterine decidua. Early bilical blood sampling (PUBS; also called cordocentesis or fu-
in pregnancy, it can be assessed in the woman’s cervical nicentesis) is the aspiration of blood from the umbilical vein
mucus, but the amount then fades until, after 20 weeks of for analysis. After the umbilical cord is located by sonography,
pregnancy, it is no longer present in cervical mucus. As labor a thin needle is inserted by amniocentesis technique into the
approaches and cervical dilation begins, it can be found uterus and is then guided by ultrasound until it pierces the
again in cervical or vaginal fluid. Damage to fetal mem- umbilical vein. A sample of blood is then removed for blood
branes from cervical dilatation releases a great deal of the studies, such as a complete blood count, direct Coombs test,
substance, so detection of fibronectin in either the amniotic blood gases, and karyotyping. To ensure the blood obtained
fluid or in the mother’s vagina late in pregnancy can serve as is fetal blood, it is submitted to a Kleihauer–Betke test, which
an announcement that preterm labor may be beginning. measures the difference between adult and fetal hemoglobin.
• Inborn errors of metabolism. A number of inherited dis- If a PUBS test reveals that the fetus is anemic, blood may be
eases that are caused by inborn errors of metabolism can be transfused into the cord using this same technique. Because
detected by amniocentesis. For a condition to be identi- the umbilical vein continues to ooze for a moment after the
fied, an errant enzyme must be present in the amniotic procedure, there is a high chance fetal blood could enter the
fluid as early as the time of the procedure. Examples of maternal circulation after the procedure, so RhIG is given to
illnesses that can be detected in this way are sickle cell dis- Rh-negative women to prevent sensitization. Fetal heart rate
ease, cystic fibrosis, muscular dystrophy, Tay-Sachs disease, and uterine contractions need to be monitored before and
and maple syrup urine disease (an amino acid disorder). after the procedure to be certain uterine contractions are not
• L/S ratio. Lecithin and sphingomyelin are the protein com- beginning and also by ultrasound to be certain no bleeding
ponents of the lung enzyme surfactant that the alveoli begin is evident. This procedure carries little additional risk to the
to form at the 22nd to 24th weeks of pregnancy. Follow- fetus or woman over amniocentesis and can yield informa-
ing an amniocentesis, the L/S (lecithin to sphingomyelin) tion not available by any other means, especially about blood
ratio may be determined quickly by a shake test (if bubbles dyscrasias.
appear in the amniotic fluid after shaking, the ratio is
mature), but the specimen is then sent for laboratory analy- Fetoscopy. The use of a fetoscopy, in which the fetus is
sis for a definite analysis. An L/S ratio of 2:1 is traditionally visualized by inspection through a fetoscope (an extremely
accepted as lung maturity. Infants of mothers with severe narrow, hollow tube inserted by amniocentesis technique),
diabetes may have false-mature readings of lecithin because can be yet another way to assess fetal well-being. This
stress to the infant in utero tends to mature lecithin path- method allows direct visualization of both the amniotic
ways early. This means fetal values must be considered in fluid and the fetus (Richter, Wergeland, Dekoninck, et al.,
light of the presence of maternal diabetes, or the infants may 2012). If a photograph is taken through the fetoscope,
be born with mature lung function but be immature overall it can document a problem or reassure parents that their
(a fragile giant), causing them to not do well in postnatal life infant is perfectly formed. The main reasons the procedure
(Hay, 2012). Some laboratories interpret a ratio of 2.5:1 or is used are to:
3:1 as a mature indicator in infants of women with diabetes. • Confirm the intactness of the spinal column.
• Phosphatidylglycerol and desaturated phosphatidylcholine. • Obtain biopsy samples of fetal tissue and fetal blood samples.
These are additional compounds, in addition to lecithin • Determine meconium staining is not present.
and sphingomyelin, found in surfactant. Pathways for • Perform elemental surgery, such as inserting a polyeth-
these compounds mature at 35 to 36 weeks. Because they ylene shunt into the fetal ventricles to relieve hydro-
are present only with mature lung function, if they are cephalus or anteriorly into the fetal bladder to relieve a
present in the sample of amniotic fluid, it can be predicted stenosed urethra. It may be possible to repair a neural
with even greater confidence that respiratory distress syn- tube defect such as meningocele or improve the outcome
drome is not likely to occur. of myelomeningocele by fetoscopy (Danzer, Johnson, &
Adzick, 2012).
✔ QSEN Checkpoint Question 9.6 The earliest time in pregnancy a fetoscopy can be per-
formed is about the 16th or 17th week. For the procedure,
Quality Improvement the mother is draped as for amniocentesis. A local anesthetic
is injected into the abdominal skin. The fetoscope is then in-
Liz Calhorn is scheduled to have an amniocentesis to test for fetal
serted through a minor abdominal incision. If the fetus is
maturity. To help make sure the procedure is successful, what
very active, meperidine (Demerol) may be administered to
instruction would be best to give her before this procedure?
the woman to help sedate the fetus to avoid fetal injury by the
a. “Void (pee) immediately before the procedure to reduce scope and allow for better observation.
the size of your bladder.” A fetoscopy carries a small risk of premature labor or am-
b. “The X-ray used to reveal your fetus’s position will have no nionitis (infection of the amniotic fluid). To avoid infection,
long-term fetal effects.” the woman may be prescribed antibiotic therapy after the
c. “The IV fluid used to dilate your uterus is isotonic saline so procedure. The number of procedures performed by a fetos-
will not hurt the fetus.” copy is limited because of the manipulation involved and the
d. “Your fetus will have less amniotic fluid for the rest of preg- ethical quandary of the mother’s autonomy being compro-
nancy, but that’s all right.” mised by fetal needs if further procedures are necessary such
Look in Appendix A for the best answer and rationale. as asking the mother to undergo general anesthesia so the
fetus can have surgery.

WOMEN WITH UNIQUE NEEDS OR ultrasonography, MRI, MSAFP, amniocentesis, PUBS,

quadruple screening, and fetoscopy.
CONCERNS ● A biophysical profile is a combination of fetal assessments
that predicts fetal well-being better than measuring single
Fetal assessment can be more difficult in some women than
parameters.
others. It is more difficult to hear fetal heart sounds in a mor-
bidly obese woman, for example. If the straps for fetal heart
rate monitors are not long enough to circle a woman’s abdo- CRITICAL THINKING CARE STUDY
men, they may need to be held in place manually. If a woman
is not easily mobile, she can have difficulty obtaining a clean
catch urine for protein and glucose testing. Be ready to assist
aeve is a 35-year-old woman who is
about 3 months pregnant. She recently broke her
in these circumstances as needed. fibula in a touch football game and so has her leg
Women who are wheelchair challenged can remain in encased in a mid-calf level cast. It’s not a walking
their wheelchair for fetal heart rate monitoring. All indi- cast, so she will be using a wheelchair for the next 6
viduals who use wheelchairs need to periodically press on weeks. She’s worried she’ll gain too much weight be-
the armrests with their hands and raise their buttocks off cause she’s no longer active. As she’s not sure of the
the seat of the wheelchair to help prevent pressure ulcers as date of her last menstrual period, she’d like a sono-
the danger of ulcers increases with pregnancy because of the gram done to date her pregnancy. She asks if that can
added weight. During a lengthy test, a woman may need to be done with her in a wheelchair.
take a break to stretch; mark the break on a rhythm strip so
a sudden corresponding fetal movement on the strip is not 1. How would you answer Maeve’s question about using her
misinterpreted. wheelchair for a sonogram?
Remember that women who are hearing challenged will 2. What other special considerations does Maeve need with
not be able to hear their baby’s heartbeat by Doppler assess- regard to fetal health because she uses a wheelchair?
ment. Observing a rhythm strip is a better method to prove 3. Maeve asks you if her baby has hair yet. That’s important to her
to them their baby appears healthy. In contrast, a woman who because if her baby is a boy she doesn’t want him to be as bald
is visually impaired would be most assured by listening to the as her husband, who at 36, has already lost most of his hair.
beeping of a Doppler rather than the blurry outlines (for her)
of a rhythm strip. Women with special needs are further dis-
cussed in Chapter 22. Assess each woman individually to be Patient Scenario:
certain each has obtained and understands the results of fetal The Menendez Family
assessments accurately and doesn’t have continuing questions
about her baby’s health. Read about the Menendez family, a family who has
concerns about fetal health, then answer the questions to
further sharpen your skills and grow more familiar with
What if...9.4 You are particularly interested NCLEX-type questions related to fetal health. Confirm
in exploring one of the 2020 National Health Goals your answers are correct by reading the rationales.
in respect to fetal health (see Box 9.1). What would be a Visit http://thePoint.lww.com
possible research topic to explore pertinent to this goal
that would be applicable to Liz and her family and also
advance evidence-based practice?
Answers and Rationales
Looking for answers to the What If. . . and Critical Think-
ing Care Study questions?
KEY POINTS FOR REVIEW ●Visit http://thePoint.lww.com
● Being aware of healthy fetal growth helps in planning References

nursing care that not only meets QSEN competencies, American Congress of Obstetricians and Gynecologists. (2009). ACOG
but also best meets a family’s need for health teaching. practice bulletin: Intrapartum fetal heart rate monitoring. Obstetrics &
● The union of a single sperm and egg (fertilization) signals Gynecology, 114(1), 193–200.
the beginning of pregnancy. Attilakos, G., & Overton, T. G. (2012). Antenatal care. In D. K. Edmonds
● The fertilized ovum (zygote) travels by way of a fallopian (Ed.), Dewhurst’s textbook of obstetrics & gynaecology (6th ed., pp. 42–52).
tube to the uterus, where implantation takes place in Oxford, UK: John Wiley & Son.
about 8 days. Bernstein, H. S., & Srivastava, D. (2012). Stem cell therapy for cardiac
● From implantation to 5 to 8 weeks, the growing structure disease. Pediatric Research, 71(4, Pt. 2), 491–499.
is called an embryo. The period after 8 weeks until birth Caughey, A. G. (2012). Post term pregnancy. In D. K. Edmonds (Ed.),
is the fetal period. Dewhurst’s textbook of obstetrics & gynaecology (6th ed., pp. 269–286).
Oxford, UK: John Wiley & Son.
● Growth of the umbilical cord, amniotic fluid, and Chitra, T., Sushanth, Y. S., & Raghavan, S. (2012). Umbilical coiling
amniotic membranes proceeds in concert with fetal index as a marker of perinatal outcome: An analytical study.
growth. The placenta produces a number of impor- Obstetrics and Gynecology International. Advance online publication. doi:
tant hormones: estrogen, progesterone, hPL, and 10.1155/2012/213689
hCG. Choi, H., Van Riper, M., & Thoyre, S. (2012). Decision making following
● Various methods to assess fetal growth and development a prenatal diagnosis of Down syndrome: An integrative review. Journal
include fundal height, fetal movement, fetal heart tones, of Midwifery & Women’s Health, 57(2), 156–164.

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In light of Liz’s revelation, what additional

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Nu r s in g Pro c e s s Overview Be certain that outcome criteria established for teaching

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Amnion Chorionic villus

FIGURE 9.2 Placental circulation.

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Following the moment of fertilization, the zygote, which later

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BOX 9.2 Nursing Care Planning Based on Family Teaching

Age of Embryo and Fetus in Weeks

Central nervous system

FIGURE 9.4 Critical periods of fetal growth.

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Superior vena cava Ductus

Right lung Left lung

Right atrium Left atrium

FIGURE 9.5 Fetal circulation.

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End of 24th Gestational Week

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End of 28th Gestational Week BOX 9.3 Naegele’s Rule

End of 32nd Gestational Week

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BOX 9.4 Nursing Care Planning

A INTERPROFESSIONAL CARE MAP FOR A WOMAN UNDERGOING

Activities of Daily Living, Including Safety

Teamwork and Collaboration

Procedures/Medications for Quality Improvement

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Informatics for Seamless Health Care Planning

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BOX 9.6 Nursing Care Planning to Empower a Family

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Fetal heart sounds can be heard and counted as early as the

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FIGURE 9.10 Rhythm strip and nonstress testing of fetal

FHR 240bpm FHR 240bpm FHR 240bpm

210 210 210

180 180 180

150 150 150

120 120 120

100 100 100

Variability is rated as: • Marked: An amplitude range is detectable; rate is greater

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BOX 9.7 Nursing Care Planning Based on Effective Communication

Liz Calhorn is scheduled for an ultrasound.

Less Effective Communication More Effective Communication

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FIGURE 9.13 A sonogram showing a fetus close to term.