Fetal and Placental Development and Functioning

1. Pregenesis
2. Conception
3. Placental development
4. Decidua
5. Placenta
6. Embryonic stage

Pregenesis
1. Encompasses the time after formation of the germ cell and before the union of sperm and egg.
2. Begins with differentiation of primitive germ cells to the genital ridge and ends with the
formation of the gametes (karyogamy)
3. Aneuploidies (abnormal numbers of chromosomes) might occur as a consequence of abnormal
meiotic division of chromosomes during gamete formation. This phenomenon increases with
advancing maternal age.

Conception
1. Fertilization occurs in the ampulla of the fallopian tube
2. Estrogen levels increase during ovulation, aiding fertilization and easing a transit of the ovum
down the fallopian tube.
3. The ovum membrane is surrounded by two layers of tissue.
a. An inner layer called the zona pellucida (glycoprotein)
b. An outer layer called the corona radiata.
★ Plasma membrane of ova
4. In a single ejaculation, 400 million spermatozoa are deposited in the vagina, reaching the
fallopian tubes within 5 minutes by frantic movement of their flagellar tails.
A. A sperm may undergo two processes before it is able to penetrate the ovum.
Capacitation: structural changes once in the female genital tract
Acrosomal reaction: the sperm releases enzymes
a. Hyaluronidase causes separation of the corona radiata
b. Acrosin and neuraminidase allow the sperm to enter the zona pellucida
B. Ova is considered fertile for approximately 24 hours ovulation, whereas sperm, although viable
for 72 hours, are believed to be fertile for only 24 hours.
C. At the moment of penetration, the oocyte completes the second meiotic division, whereas
cellular changes prevent other sperm from entering the ovum. (Zona reaction).

5. With fertilization, the diploid number (46) chromosomes are restored, and cell division begins
a. Within the cell, the nuclei of the spermatozoon and oocyte unite, and their nuclear
membranes disappear.
b. The chromosomes pair up, and a new cell, the zygote, which contains a new combination
of genetic material is formed

Pre-Embryonic Stage
 ➔ The first two weeks after fertilization; the blastogenic period is the first four weeks of human
development. This stage is characterized by rapid cell division, cell differentiation, and the
development of embryonic membranes and germ layers.

First Week
1. Division of the zygote occurs within the first 30 hours.
2. The zygote continues to divide into solid ball of cells (morula)
3. The morula floats inside of the uterus for 2 to 3 days obtaining nourishment from the mucous
lining of the uterus and the fluid in the uterine cavity.
★ Blastomere - single cells in morula
★ Epiblast - develops actual organs
★ Pluripotent - can differentiate into any form of cell
★ Blastocoele - fluid cavity in the blastocyst
★ Trophoblast - portion of placenta

4. Two distinct layers of cells develop as the morula hollows out.

a. The inner cell mass (blastocyst), which will form the embryo, the amnion, and the yolk
sac membrane.
b. The outer cell layer (trophoblast), which becomes the fetal side of the placenta and
chorion.

5. Zona pellucida disappears in about 5 days.

a. The blastocyst enlarges
b. The trophoblast attaches to the endometrial epithelium and begins the process of
implantation.
6. The attached portion of the trophoblast develops into two layers
a. The internal cellular layer is called the cytotrophoblast
b. The outer layer is called the syncytiotrophoblast, which invades the endometrium
epithelium by the end of the 7th day.
c. Embedding is completed by the 11th day, with the site of attachment usually being the
upper part of the posterior uterine wall. Attachment can occur anywhere, even
extrauterine.

Second Week
1. The inner cell mass differentiates into two cell layers; the endoderm (the inside of the embryo)
and the ectoderm (the outside of the embryo)
a. The amniotic cavity appears as a space between the inner cell mass and the trophoblast
b. When the embryo becomes a cylinder, the amnion surrounds it and forms the amniotic
sac.
2. By the end of the second week, the embryonic cells and the amniotic and yolk sacs are attached
to the chorionic sac by a slender band, which becomes the umbilical cord.
 3. Malformations that occur during the pre-embryonic stage seldom result in a viable fetus.

Placental Development
1. Description: The placenta is a temporary disk-shaped organ that connects the fetus to the uterine
wall and provides for fetal respiration as well as metabolic and nutrient exchanges between the
maternal and fetal circulations.
2. Approximately 5 to 6 days after fertilization, the blastocyst adheres to the endometrium.
3. Blastocyst penetrates toward the maternal capillaries by eroding the uterine epithelium; this
erosion process continues until the blastocyst is completely embedded in the uterine wall.

Decidua
A portion of endometrium that forms the base of the placenta.
1. Approximately the 14th day, the endometrium changes at the site of the implantation and
becomes the decidua
2. Implantation causes the adjacent decidual cells to engorge with glycogen and lipids (decidual
reaction)
3. The swollen decidual cells release their contents during the erosion process to provide
nourishment
4. The decidua divides into 3 layers:
a. Decidua capsularis: covers the embryoblast
b. Decidua basalis: Maternal portion of the placenta that supplies vessels to nourish the
intervillous spaces
c. Decidua parietalis: lines the remainder of the uterine cavity

Placenta
1. When the embryoblast is partially embedded in the decidua, two distinct layers of cells can be
seen in the trophoblast
a. Inner layer (cytotrophoblast) is made of mononuclear cells
b. Outer layer (syncytiotrophoblast) consists of multi nucleated cells and is responsible for the
erosive ability of the trophoblast.
2. The cytotrophoblast and the syncytiotrophoblast separates the maternal and fetal circulations and
are called the placental barrier.
3. On approximately the 9th days, spaces (vacuoles) appear in the syncytium; these fuse together
to form lacunae (intervillous spaces), which develop into an interconnecting system.
★ Diffusion : process of transferring nutrients.
4. On approximately 11th day:
a. Invading syncytium encounters the congested capillaries of the decidua
b. Syncytium enzymes break down the vessel walls releasing blood into the lacunae.
c. Eventually the syncytium encounters the larger arteries and veins and establishes a directional
flow of blood.
d. Blood enters the lacunae.
i. The embryo experiences a rapid growth because of high concentration of nutrients
ii. This growth results in an increase in the distance that nutrients must travel by diffusion to
reach the embryo
 5. Chorionic villi develop between the 9th to 25th days
a. A chorion (trophoblastic cells) is the first placental membrane to form enclosing the embryo,
aminion, and yolk sac and growing outward, forming fingerlike projections called villi within
which blood vessels develop
b. Initially the chorion covers the whole chorionic surface, but with fetal growth the intraluminal
villi become compressed and degenerate
c. Villi located below the embryo continue to grow, forming a large surface for exchange with villi
that contact the decidua basalis to become anchoring villi
i. Decidual septa form between anchoring villi, which results in 15 to 20 lobes
(cotyledons)
ii. Exchange of gases and nutrients occurs in this vascular system
d. Other villi float free and conduct most of the exchange between mother and developing fetus.
e. No further villi are formed after the 12th week. When fully developed, the villi provide a
surface area of 10 to 14 m^2

Embryonic Stage
Begins with the folding of the disk in week 2 of development

Third Week
A. Gastrulation
1. The embryonic disk converts into a trilaminar embryonic disk comprising three germ
layers: ectoderm (to become the epidermis and the nervous system), mesoderm (to
become the smooth muscle), and endoderm (to become the epithelial lining of the
respiratory and digestive tract).
2. The process is completed in the third with the formation of embryonic mesoderm by the
primitive streak
B. Proliferation and migration of cells from the primitive streak give rise to mesenchyme
1. Cells spread cranially and caudally.
2. Cells begin to form the embryonic endoderm, which gives rise to the lining of the
digestive tract and respiratory tract
3. The cells that remain on the surface of the embryonic disk form the layer of cells called
the embryonic ectoderm, which develop into the nervous system (i.e., the sensory
epithelium of the eye, ear, and nose
C. The mesenchymal cells migrate cephalad under the embryonic ectoderm and form the
notochordal process.
1. These cells grow until they reach the prechordal plate, the future site of the mouth
2. Caudal to the primitive streak is a circular area called the cloacal membrane, which becomes
the anus.
3. The primitive streak continuous to form mesoderm until the end of the fourth week
4. The notochord develops by the transformation of the notochordal process by the end of the third
week of gestation

The Newborn
Neonatal Period - birth through the first 28 days of life.

Unang Yakap
Essential Intrapartum Newborn Care (EINC)
● Simple cost effective care newborn care intervention that improves neonatal and maternal care
● Evidence-Based practices
● Four Time bound, chronologically- ordered, standard procedures
1. Immediate Drying
2. Skin to Skin Contact
3. Cord clamping after 1-3 minutes
4. Breastfeeding Initiation

Immediate Drying
● Using a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes, head, front and back,
arms and legs.
Rationale: Prevents Hypothermia
Complications of Hypothermia
a. Acidosis
b. Hypoglycemia
c. Hypoxemia

Skin to Skin Contact

● Place the newborn prone on the mother's abdomen or chest skin-to-skin.Cover newborn's back
with a blanket and head with a bonnet.
Rationale: Prevents hypothermia
● Increases colonization with protective family bacteria Improves breastfeeding initiation and
exclusivity

Cord Clamping After

1-3 minutes
● Clamp and cut the cord after cord pulsations have stopped (typically at 1-3 minutes).
● Put ties tightly around the cord at 2 centimeters and 5 centimeters from the newborn's abdomen.
● Cut between ties with sterile instrument.
Rationale: Prevents Anemia and Brain Hemorrhage

Breastfeeding Initiation
● Counsel on Positioning and Attachment
a. Make sure the neck is not flexed nor twisted
b. Make sure the newborn is facing the breast with the nose opposite her nipple and chin
touching the breast
c. Hold the newborn's body close to her body
● Support the whole body
● Wait until the newborn's mouth is opened wide
● Move her newborn onto her breast aiming the infant's lower lip well below the nipple
 ● Prepares and Improves Breastfeeding
● Prevents Neonatal Death

EINC Time-Bound Interventions Unang Yakap-DOH EINC

1. Within 30 Seconds
Objective: To stimulate breathing, provide warmth
● Put on double gloves
● Dry thoroughly
● Remove wet cloth
● Quick check of NB's breathing
● Suction only if needed

2. After thorough drying

Objective: To provide warmth, bonding, prevent infection & hypoglycemia
● Put prone on chest/ abdomen skin to skin
● Cover w/ blanket, bonnet
● Place identification on ankle

3. Up to 3 minutes Post-delivery
Objective: To reduce anemia in term & preterm; IVH & transfusions in preterm
● Do not remove vernix
● Remove 1st set of gloves
● Clamp and cut cord after cord pulsations stop (1-3 mins)
● Do not milk cord
● Give oxytocin 10 mg IM to mother

4. Within 90 minutes Of age

Objective: To facilitate initiation of breastfeeding through sustained contact
● Uninterrupted skin to skin contact -Observe NB for feeding cues
● Counsel on positioning & attachment
● Do eye care, injections etc after 1st breastfeed

APGAR SCORING
● Developed by Virginia Apgar
● Performed 1 minute and 5 minutes after Birth
● Rapidly assess the need to resuscitate
● A does not correlate with outcome. low 1-minute score However, a 5-minute score is a valid
predictor of neonatal mortality.
● Several factors may affect the
● APGAR score such as prematurity, sedative drugs, congenital anomalies, and neuropathies.

0 pts 1 pts 2 pts

 Activity (muscle tone) Absent Arms and legs flexed Active movement

Pulse Absent Below 100 bpm Over 100 bpm

Grimace (reflex Flaccid Some flexion of Active motion (sneeze,

irritability) extremities cough, pull away)

Appearance (skin color) Blue, pale Body pink, extremities Completely pink
blue

Respiration Absent Slow, irregular Vigorous cry

Vital Statistics
1. Weight
2. Length
3. Head Circumference
4. Chest Circumference

Note: Safety First! Do not leave the newborn unattended and Protect them against Hypothermia

Weight
● Determines Maturity
● Establish A Baseline
● Depends on Race, Nutrition, Intrauterine Factors and Genetic Factors
● <2 Years Old - Tared Weighing
● >2 Years Old- Weigh the Child Alone
● 2nd born child > 1st Born Child
● Low birth Weight- <2500 grams
● Very low birth weight <1500 grams

Female average weight : 2500 - 3400 grams

Male average weight : 2500 - 3500 grams

● Weight For Age

○ Small for gestational Age- BW is < 10th percentile for gestational age
○ Large for gestational Age- BW is >90th percentile for gestational Age
Plotted on standard neonatal graph in relation to Gestational Age

● Physiologic Weight Loss

○ 5%-10% or 6-10 oz of weight loss during the first few days after birth
○ Diuresis- disappearance of maternal hormones influence
○ Urinating and Passing of Stool
○ Limited Intake
Breastfed Infant- recaptures Birth Weight within 10 days
Formula fed Infant- within 7 Days
 ○ 2lb/month or 6-80z/week- normal weight gain 1st 6 months

● Pathologic Weight Loss

○ >10 percent or >10oz
○ First indicator of inborn error of metabolism or dehydration

Length
Length ( recumbent length) -being measured while the neonate/infant lies flat using the length
board/tape measure.
Height (standing height) - being measured while the child stands on a height board.

● Average Female Birth Length- 46cm- 49cm(19.2 inch)

● Average Male Birth Length-46cm- 50cm(19.6inch)

Head Circumference
Measure across the center of the forehead usually above the eyebrows then around the most prominent
portion of the posterior head (occiput)
● Usual Head Circumference- 34-35cm(13.5 to 14 inches)
● HC >37cm(14.8inch) HC <33cm (13.2 inch). Assess for neurologic involvement
○ Microcephaly
○ Severe Microcephaly
○ Macrocephaly/ Hydrocephalus

Chest Circumference
● Measured at the level of nipples then around the trunk
● Term Newborn- 2 cm less than Head Circumference
● Usual Chest Circumference- 32-33 cm

Temperature
● Usual temperature of the Newborn- 37.2 degree Celsius at birth
● May fall below normal because of:
a. Heat Loss
b. Low temperature of birthing rooms
c. Immature temperature regulating mechanism

Normal newborn temperature :

● 36.5-37.5°C (WHO, 1997; 2003)
● 36.3-37.2 (ACORN, 2012)
● 35-36.3°C - Mild Hypothermia Temperature
● 32-34.9°C - Moderate Hypothermia temperature
● below 32°C - Severe Hypothermia temperature

Characteristics which put Newborns at a greater risk of Heat Loss

● A large surface area-to-body mass ratio
 ● Decreased subcutaneous fat
● Greater body water content
● Immature skin leading to increased evaporative water and heat losses
● Poorly developed metabolic mechanism for responding to thermal stress (e.g. no shivering)
● Altered skin blood-flow (e.g. peripheral cyanosis)

4 Mechanisms of Heat Loss

1. Convection
● flow of heat from the Newborn's body surface to cooler surrounding air especially if
exposed to a draft of open door, window or fan
● Adjust Air conditioners to maintain a room temperature of at least 25-28 degree celsius

2. Conduction
● Transfer of Body heat to a cooler solid object in touch/contact with the baby
● Cover surfaces with warm blankets or towel

3. Radiation
● Transfer of Body heat to a cooler solid object not in touch/contact with the baby
● Move the infant away from the cold object/surface
● Greatest source of heat after birth

4. Evaporation
● Loss of heat through conversion of liquid to vapor
● Dry the infant thoroughly
● Initiate skin to skin contact and cover the back of the baby with warm blanket
● Greatest Source of Heat loss at birth

★ Skin-to-skin contact - optimal method for maintaining temperature in stable neonate

Facts About Newborn's Thermoregulation

● Insulation is ineffective because they have little subcutaneous fat
● Shivering (increases metabolism to produce heat) is rarely seen in newborn
● Newborn conserve or produce heat by:
a. Constricting blood vessels
b. Moving Blood away from the skin
c. Kicking
d. Crying
● Brown Fat- special tissue that helps conserve or produce heat by increasing metabolism
● LOCATION- Intrascapular region, thorax, behind the kidneys

Pulse
● Average Pulse- 120-140 bpm
● When Crying- May rise to 180 bpm
● During Sleep- 90-110 bpm
 ● Apical heartbeat- BEST WAY to measure heart rate
● Transient murmurs (extra heart sound produce by turbulent blood flow) is present due to the
incomplete closure of fetal circulation shunts
● Palpate for FEMORAL PULSE- It's absence suggests possible Coarctation of the Aorta.

Respiration
● Average Respiration- 30-60 bpm
● Periodic Respirations- irregular respirations with short periods of apnea but without cyanosis.
● Coughing and Sneezing reflex are present at birth and help clear the airway
● Newborns are obligate NOSE breathers

Blood Pressure
● At Birth- 80/46 mmHg
● 10th Day- 100/50 mmHg
● Not routinely measured unless with cardiac anomaly
● Blood Pressure increases when crying

Physiologic Functions at Birth

1. Cardiovascular System
Blood Picture of a Newborn
● Blood Volume- 80- 110ml/kg or 300ml
● Hemoglobin Level- 17-18g/100ml
● Hematocrit- 45-50%
● RBC count- 6 million cells/mm3
● Sluggish Peripheral Circulation for the first 24hrs
● WBC-15,000-30,000 cells/mm3; 40,000 cells/mm3 if the birth was stressful
● Absolute Neutrophilic count is being computed by the PEDIATRICIANS to rule out infection:
Formula- Neutrophil(Polys) x WBC
● <20,000 OBSERVE
● Other signs of infection to newborn:
○ Pallor
○ Respiratory difficulty
○ Cyanosis

Fetal Circulation
Placenta - primary organ that works for the infant in intrapartum
3 Shunts
● Foramen ovale
● Ductus venosus
● Ductus arteriosus

AVA- Right atria, Left ventricle, Left atria

Fetal Circulation Process
1. Oxygen and Nutrient Exchange in the Placenta:
● The umbilical cord connects the fetus to the placenta, which is attached to the mother's
uterine wall.
2. Umbilical Vein:
● The umbilical vein transports oxygenated blood from the placenta to the fetus.
3. Ductus Venosus:
● The blood from the umbilical vein flows to the liver, but a shunt called the ductus
venosus allows most of it to bypass the liver and flow directly into the inferior vena cava.
4. Inferior Vena Cava:
● The blood, now mixed with some deoxygenated blood from the lower body, enters the
inferior vena cava.
5. Right Atrium:
● The inferior vena cava delivers the mixed blood to the right atrium of the fetal heart.
6. Foramen Ovale:
● Blood from the right atrium is shunted through the foramen ovale, a hole in the septum
(wall) between the atria, directly into the left atrium.
7. Left Atrium:
● Oxygenated blood in the left atrium is then pumped into the left ventricle.
8. Left Ventricle:
The left ventricle pumps oxygenated blood into the aorta.
9. Aorta:

The aorta carries oxygenated blood to the rest of the fetal body, supplying it with nutrients and
oxygen.
10. Systemic Circulation:
● From the aorta, oxygenated blood is distributed to the fetal tissues and organs, supporting their
growth and development.

★ Pulmonary hypertension due to low O2 level = Hypoxic Vasoconstriction

★ Deoxygenated Blood returns from the fetal body through the superior vena cava, along with
some blood from the coronary sinus (returning blood from the heart muscle).
Right Atrium Again:
The deoxygenated blood returns to the right atrium of the heart.
Right Ventricle:
The right ventricle pumps the deoxygenated blood into the pulmonary artery.
11. Ductus Arteriosus:
● allows most of the blood in the pulmonary artery to bypass the lungs and flow into the aorta.

★ The deoxygenated blood mixes with the oxygenated blood in the aorta, but since most of it is
already oxygenated, the blood remains relatively oxygen-rich.
12. Aorta Again
13. Systemic Circulation
Utilized (deoxygenated) Blood
14. Umbilical Arteries:
● Deoxygenated blood from the fetal body, carrying waste products, is carried back to the placenta
through the two umbilical arteries in the umbilical cord.
15. Placenta (Again):
● At the placenta, the deoxygenated blood is exchanged for oxygen and nutrients, and the waste
products are transferred to the mother's blood for elimination.

Changes once the umbilical cord is cut

● Pulmonary Artery Pressure decreases (no more hypoxic vasoconstriction)
● Ductus Arteriosus(shunt between Pulmonary Artery and Aorta) begins to close
● Increase blood flow to the left side of the heart
● Foramen Ovale (the opening between two atria) also begins to close.
↑O2 ↓ Prostaglandin : vice versa
↑Bradykinin - ↑ O2 and blood flow in the lungs
REMNANTS OF SHUNTS
● Foramen ovale: Fossa Ovalis
● Ductus Venosus- Ligamentum Venosum
● Ductus Arteriosus- Ligamentum Arteriosus
● Umbilical Vein- Ligamentum Teres

Respiratory System
● 10-12 hours- Vital Capacity is established, newborn proportions
● Cesarean Babies has difficulty establishing respirations
● Preterm Newborn alveoli may collapse each time they exhale (Lack of pulmonary surfactant)

First Breath
● Initiated by: Stimulation of Cold Receptors
● Cord Clamping: Lowered partial pressure of oxygen (from 80 to 15mmHg). Increased partial
carbon dioxide pressure (70mmHg)

Blood Coagulation
● Vitamin K is synthesized through the action of the intestinal flora
● Essential for Clotting factors Formation-X, IX, VII, II (1972)
● Level is DECREASED(Sterile intestines) leading to prolonged coagulation or Prothrombin
time.
● Administer Vitamin K, IM, Lateral anterior thigh

Gastrointestinal System
● Sterile after birth
 ● Bacteria may be cultured 5 hrs for most babies or at 24 hrs for all babies
● Sources of Bacteria
a. Enter the tract through newborn's mouth from airborne source
b. Vaginal secretions at birth
c. Hospital Bedding
d. Contact at breast
● Newborn Stomach Capacity- 60-90ml
● Limited digestion of fats and starch(lack of lipase and amylase)
● Regurgitate Easily-Cardiac sphincter between stomach and and esophagus is immature

Immature Liver- low glucose and protein serum levels.

Meconium
● the first stool of a newborn. Sticky, tar-like, blackish-greenish, odorless formed from mucus,
vernix, lanugo, carbohydrates and hormones
● Passed within 24 hrs after birth or up to 48 hrs.
● If not, consider:
a. meconium ileus
b. Imperforate Anus
c. Volvulus
Transitional Stool
● loose and green, may resemble diarrhea
● Passed on the 2nd or 3rd day of life

4th Day of Life

a. Breastfed infants- pass 3-4 light yellow, soft consistency stools per day
b. Formula Fed infants- pass 2 to 3 bright yellow, soft consistency stools per day

Bright green stool (Increased Bilirubin Secretion)- newborn under phototherapy for jaundice

Clay colored/gray stool- newborn with bile duct obstruction

Blood-flecked stools-anal fissure

Black tarry Stool- due to swallowed maternal blood during birth

Stools with mucus or watery and loose- consider milk allergy Lactose intolerance or malabsorption
problems