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CHAPTER 9 The Growing Fetus 207

Nutrition

Nutritionist Assess and analyze Discuss advantages of Client needs to improve Client meets with clinic
the 24-hour recall good pregnancy total nutrition, nutritionist to
history. nutrition with client especially intake of discuss better nutri-
and define healthy protein sources, to tion pattern. Reports
pregnancy nutrition. better support improved protein
pregnancy. sources in diet.

Patient/Family Education

Nurse Determine whether Instruct client about A well-prepared client Client will describe ac-
client understands preparation for is more apt to result curate preparations
that ultrasound is ultrasound (drink in an effective for procedure.
not x-ray, so is not fluid; avoid emptying procedure and a Receives printed
harmful to fetus. bladder). satisfied client. instructions for
ambulatory
ultrasound.

Spiritual/Psychosocial/Emotional Needs

Nurse/ Assess the extent of Review the possibility Understanding contrib- Client states that she
physician factors, such as al- with client that her utors to fetal health understands the dis-
cohol and cigarette pregnancy dating is necessary for crepancy in fundal
use, that could have may be wrong, be- women to make in- height and weeks’
led to intrauterine cause fundal height formed choices dur- gestation following
growth restriction. is below normal. ing pregnancy. explanation.
Alternate cause
could be fetal
growth restriction.

Discharge Planning

Nurse/ Perform complete Mark chart as high-risk Documenting risk The patient chart
physician assessment to help client for intrauterine factors helps to documents high-risk
ensure continuity of growth restriction. safeguard the fetus. status.
care with other Stress importance of Client continues prena-
services. continuing prenatal tal care.
care.

Fetal Movement with a degree of consistency, or at least 10 times a day. In

contrast, a fetus not receiving enough nutrients because of
Fetal movement that can be felt by the mother (quickening) placental insufficiency has greatly decreased movements.
occurs at approximately 18 to 20 weeks of pregnancy and Based on this, asking a woman to observe and record the
peaks in intensity at 28 to 38 weeks. A healthy fetus moves number of movements the fetus is making offers a gross as-
sessment of fetal well-being (Chang & Blakemore, 2007).
Because of variations in movements among normal,
healthy fetuses, as well as variations in different health care
providers’ level of confidence in the technique, a variety of
protocols have been developed by different institutions. One
popular way to approach this assessment is to ask the woman
to lie in a left recumbent position after a meal and record
how many fetal movements she feels over the next hour (the
Sandovsky method). In this position, a fetus normally moves
a minimum of twice every 10 minutes or an average of 10–12
times an hour. If less than 10 movements occur within an
hour, the woman repeats the test for the next hour. She
should call her health care provider if she feels fewer than
10 movements (half the normal number) during the
chosen 2 hours. Another protocol is “Count-to-Ten” (the
Cardiff method). For this, a woman records the time interval
FIGURE 9.9 Measuring fundal height from the superior aspect it takes for her to feel 10 fetal movements. Usually, this oc-
of the pubis to the fundal crest. The tape is pressed flat curs within 60 minutes. Make sure to assure a woman that
against the abdomen for the measurement. fetal movements do vary, especially in relation to sleep cycles
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208 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period

of the fetus, her activity, and the time since she last ate. will typically be two or more instances of fetal heart rate
Otherwise, she can become unduly worried that her fetus may acceleration in a 20-minute rhythm strip.
be in jeopardy when the fetus is just having an inactive time. Rhythm strip testing requires a woman to remain in a
fairly fixed position for 20 minutes. Keep her well informed
What if... You give instructions to Liz Calhorn, the of the purpose of the test, how it is interpreted, and the mean-
woman described at the beginning of the chapter, to ing of results after the test. The more she understands about
count fetal movements for 1 hour two times a day after the process, the better she can cooperate to make it successful.
meals and she tells you that she snacks all day long
rather than eats at regular times? Would you modify your in-
Nonstress Testing. A nonstress test measures the response
of the fetal heart rate to fetal movement. Position a woman
structions? Which is more important—that she count move-
and attach both a fetal heart rate and a uterine contraction
ments after meals or that she does it two times a day?
monitor. Instruct a woman to push a button attached to the
monitor (similar to a call bell) whenever she feels the fetus
move. This will create a dark mark on the paper tracing at
Fetal Heart Rate these times.
Fetal hearts beat at 120 to 160 beats per minute throughout When the fetus moves, the fetal heart rate should increase
pregnancy. Fetal heart sounds can be heard and counted as about 15 beats per minute and remain elevated for 15 sec-
early as the 10th to 11th week of pregnancy by the use of an onds. It should decrease to its average rate again as the fetus
ultrasonic Doppler technique (Fig. 9.10). quiets (see Fig. 9.11C). If no increase in beats per minute is
noticeable on fetal movement, poor oxygen perfusion of the
Rhythm Strip Testing. The term “rhythm strip testing” fetus is suggested.
means assessment of the fetal heart rate for whether a good A nonstress test usually is done for 10 to 20 minutes. The
baseline rate and a degree of variability are present. For this, test is said to be reactive if two accelerations of fetal heart rate
help a woman into a semi-Fowler’s position (either in a (by 15 beats or more) lasting for 15 seconds occur after
comfortable lounge chair or on an examining table or bed movement within the chosen time period. The test is nonre-
with an elevated backrest) to prevent her uterus from com- active if no accelerations occur with the fetal movements.
pressing the vena cava and causing supine hypotension syn- The results also can be interpreted as nonreactive if no fetal
drome during the test. Attach an external fetal heart rate movement occurs or if there is low short-term fetal heart rate
monitor abdominally (Fig. 9.11A). Record the fetal heart variability (less than 6 beats per minute) throughout the test-
rate for 20 minutes. ing period (Chang & Blakemore, 2007).
The baseline reading refers to the average rate of the fetal If a 20-minute period passes without any fetal movement,
heartbeat per minute. Variability refers to small changes in it may mean only that the fetus is sleeping. Other reasons for
rate that occur if the fetal parasympathetic and sympathetic lessened variability are maternal smoking, drug use, or hypo-
nervous systems are receiving adequate oxygen and nutrients. glycemia. If you give the woman an oral carbohydrate snack,
It is categorized as absent (none apparent); minimal (ex- such as orange juice, it can cause her blood glucose level to
tremely small fluctuations); moderate (amplitude range of increase enough to cause fetal movement. The fetus also may
6–25 beats per minute); and marked (amplitude range over be stimulated by a loud sound (discussed later) to cause
25 beats per minute) (Macones et al., 2008). In the rhythm movement.
strip in Figure 9.11B, for example, the baseline (average) of Because both rhythm strip and nonstress testing are non-
the fetal heartbeat is 130 beats per minute, although over the invasive procedures and cause no risk to either mother or
recorded period, it varies from 120 to 150 beats per minute. fetus, they can be used as screening procedures in all preg-
Because the average fetus moves about twice every 10 min- nancies. They can be done at home daily as part of a home
utes, and movement causes the heart rate to increase, there monitoring program for the woman who is having a compli-
cation of pregnancy.
If a nonstress test is nonreactive, additional fetal assess-
ment, such as a contraction stress test or a biophysical profile
test, will be scheduled.
Vibroacoustic Stimulation. For acoustic (sound) stimula-
tion, a specially designed acoustic stimulator is applied to the
mother’s abdomen to produce a sharp sound of approxi-
mately 80 decibels at a frequency of 80 Hz, startling and
waking the fetus (Chang & Blakemore, 2007).
During a standard nonstress test, if a spontaneous acceler-
ation has not occurred within 5 minutes, apply a single 1- to
2-second sound stimulation to the lower abdomen. This can
be repeated again at the end of 10 minutes if no further spon-
taneous movement occurs, so that two movements within
the 20-minute window can be evaluated.

FIGURE 9.10 Measuring fetal heart rate with a Doppler trans- Contraction Stress Testing. With contraction stress testing,
ducer, which detects and broadcasts the fetal heart rate to the the fetal heart rate is analyzed in conjunction with contractions.
parent-to-be as well as to the nurse. (© Barbara Proud.) When this test was first developed, contractions were initiated
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CHAPTER 9 The Growing Fetus 209

FIGURE 9.11 Rhythm strip and nonstress testing of fetal heart FHR 240 bpm
rate. (A) The woman sits in a comfortable chair to avoid supine
hypotension. Both a uterine contraction monitor and fetal heart 210
rate monitor are in place on her abdomen. (Photoraph by
Melissa Olson, with permission of Chestnut Hill Hospital,
Philadelphia, PA.) (B) A rhythm strip. The upper strip signifies 180
heart rate; the lower strip indicates uterine activity. Arrows
signal fetal movement. (C) Baseline fetal heart rate is 130–132.
This strip shows fetal heart rate acceleration in response to fetal 150
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

by the intravenous infusion of oxytocin. However, once With external uterine contraction and fetal heart rate
started, contractions begun this way were sometimes difficult monitors in place, the baseline fetal heart rate is obtained.
to stop and led to preterm labor. For this reason, a source of Next, the woman rolls a nipple between her finger and
oxytocin for contraction stress testing currently is achieved by thumb until uterine contractions begin, which are recorded
nipple stimulation. Gentle stimulation of the nipples releases by a uterine monitor. Three contractions with a duration of
oxytocin in the same way as happens with breastfeeding. 40 seconds or longer must be present in a 10-minute window
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210 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period

before the test can be interpreted. The test is negative For an ultrasound, intermittent sound waves of high fre-
(normal) if no fetal heart rate decelerations are present with quency (above the audible range) are projected toward the
contractions. It is positive (abnormal) if 50% or more of con- uterus by a transducer placed on the abdomen or in the
tractions cause a late deceleration (a dip in fetal heart rate vagina. The sound frequencies that bounce back can be dis-
that occurs toward the end of a contraction and continues played on an oscilloscope screen as a visual image. The fre-
after the contraction) (Chang & Blakemore, 2007). See quencies returning from tissues of various thicknesses and
Chapter 15 for further discussion of fetal heart rate monitor- properties present distinct appearances. A permanent record,
ing as this is also measured with labor contractions. such as a video or photograph, can be made of the scan.
Nonstress tests and contraction stress tests are compared The intricacy of the image obtained depends on the type
in Table 9.4. After a contraction stress test, encourage a or mode of process used. B-mode scanning allows patterns to
woman to remain in the health care facility for about 30 min- merge and form a still picture, similar to a black-and-white
utes, to be certain that contractions have quieted and preterm snapshot (called gray-scale imaging). Real-time mode in-
labor is not a risk. volves the use of multiple waves that allow the screen picture
to move. On this type of ultrasound, the fetal heart can be
Ultrasonography seen to move, and even movement of the extremities, such as
bringing a hand to the mouth to suck a thumb, can be seen.
Ultrasonography, which measures the response of sound A parent who is in doubt that her fetus is well or whole can
waves against solid objects, is a much-used tool in modern be greatly reassured by viewing a real-time ultrasound image.
obstetrics, although the recommendations for its use are Before an ultrasound examination, be sure that a woman
being questioned because of unproven benefits in the face of has received a good explanation of what will happen and re-
added expense (Neilson, 2009). It can be used to: assurance that the process does not involve x-rays (Box 9.6).
• Diagnose pregnancy as early as 6 weeks’ gestation This means it is also safe for the father of the child to remain
• Confirm the presence, size, and location of the placenta in the room during the test.
and amniotic fluid For the sound waves to reflect best and the uterus to be
• Establish that a fetus is growing and has no gross anom- held stable, it is helpful if the woman has a full bladder at the
alies, such as hydrocephalus, anencephaly, or spinal cord, time of the procedure. To ensure this, have her drink a full
heart, kidney, and bladder defects glass of water every 15 minutes beginning 90 minutes before
• Establish sex if a penis is revealed the procedure and not void until after the procedure.
• Establish the presentation and position of the fetus Help the woman up to an examining table and drape her
• Predict maturity by measurement of the biparietal diame- for modesty, but with her abdomen exposed. To prevent
ter of the head supine hypotension syndrome, place a towel under her right
buttock to tip her body slightly so that the uterus will roll
Ultrasonography can also be used to discover complica- away from the vena cava. A gel is then applied to her ab-
tions of pregnancy, such as the presence of an intrauterine domen to improve the contact of the transducer. Be certain
device, hydramnios or oligohydramnios, ectopic pregnancy, that the gel is at room temperature or even slightly warmer,
missed miscarriage, abdominal pregnancy, placenta previa, or it can cause uncomfortable uterine cramping. The trans-
premature separation of the placenta, coexisting uterine tu- ducer is then applied to her abdomen and moved both hori-
mors, multiple pregnancy, or genetic disorders such as Down zontally and vertically until the uterus and its contents are
syndrome. Fetal anomalies such as neural tube disorders, di- fully scanned (Fig. 9.12). Ultrasonography also may be per-
aphragmatic hernia, or urethral stenosis also can be diag- formed using an intravaginal technique although this is not
nosed. Fetal death can be revealed by a lack of heartbeat and necessary for routine testing.
respiratory movement. After birth, an ultrasound may be Although the long-term effects of ultrasound are not yet
used to detect a retained placenta or poor uterine involution known, the technique appears to be safe for both mother and
in the new mother. fetus and involves no discomfort for the fetus. Usually, the only

TABLE 9.4 ✽ Comparison of Nonstress and Contraction Tests

Assessment Nonstress Contraction

What is measured Response of fetal heart rate in relation Response of fetal heart rate in relation to
to fetal movements uterine contractions produced by nipple
stimulation
Normal findings Two or more accelerations of fetal No late decelerations with contractions
heart rate of 15 beats/min lasting
15 sec or longer following fetal
movements in a 20-min period
Safety considerations Woman should not lie supine to prevent In addition to preventing supine hypotension
supine hypotension syndrome syndrome, observe woman for 30 min
afterward to see that contractions are
quiet and preterm labor does not begin
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CHAPTER 9 The Growing Fetus 211

BOX 9.6 ✽ Focus on Communication

Liz Calhorn is scheduled for an ultrasound.

Less Effective Communication
Nurse: Do you have any questions about what will hap-
pen, Liz?
Liz: I guess. I can’t decide if I want to know my baby’s
sex or not.
Nurse: Most people do these days. It helps them plan
better.
Liz: I think I’d rather be surprised. I know I don’t want a
boy.
Nurse: If it were me, I’d want to know. How else do you
know what color clothes to buy? FIGURE 9.12 An ultrasound being recorded. Notice the
Liz: Okay, tell me what the ultrasound shows. mother’s interest in being able to see her baby’s first
photograph.
More Effective Communication
Nurse: Do you have any questions about what will
happen, Liz?
Liz: I guess. I can’t decide if I want to know my baby’s Biparietal Diameter. Ultrasonography may be used to pre-
sex or not. dict fetal maturity by measuring the biparietal diameter
Nurse: That’s an individual decision. What things are (side-to-side measurement) of the fetal head. In 80% of
you thinking about? pregnancies in which the biparietal diameter of the fetal
Liz: I think I’d rather be surprised. I know I don’t want a head is 8.5 cm or greater, it can be predicted that the infant
boy. will weigh more than 2500 g (5.5 lb) or is at a fetal age of
Nurse: Tell me about that. Why is that? 40 weeks. Figure 9.13 is an ultrasound showing the bipari-
Liz: A guy got me into this trouble. I don’t need another etal diameter of a fetus at 24 weeks.
one around the house. Two other measurements commonly made by ultrasound
Nurse: Let’s talk about what it will mean if you should to predict maturity are head circumference (34.5 cm indi-
have a boy. cates a 40-week fetus) and femoral length.
Becoming so engrossed in sharing her personal feelings, Doppler Umbilical Velocimetry. Doppler ultrasonography
the nurse in the first example forgot to determine the measures the velocity at which red blood cells in the uterine
exact information that the client wanted. Taking the time and fetal vessels travel. Assessment of the blood flow through
to discover what the client wanted, as was done in the uterine blood vessels is helpful to determine the vascular re-
second example, revealed that the sex of the child was sistance present in women with diabetes or hypertension of
only a small part of what the mother was afraid to learn. pregnancy and whether resultant placental insufficiency is
occurring. Because it will limit the number of nutrients that
can reach the fetus, decreased velocity is an important pre-
discomfort for the woman is that the contact lubricant may be dictor of poor neonatal outcome (Valcamonico et al., 2007).
messy and she may experience a strong desire to void before the
scan is completed. Taking home a photograph of the ultra-
sound image can enhance bonding because it is proof that the
pregnancy exists and the fetus appears well. As desirable as it is,
however, caution women against having ultrasound images
done just for the purpose of having “keepsake” photographs,
because commercial firms offering these services are not well
regulated so their equipment could be outdated and unsafe.
Biparietal
✔Checkpoint Question 9.4 diameter

Liz Calhorn is scheduled to have an ultrasound examination.

What instruction would you give her before her examination?
a. “Void immediately before the procedure to reduce your
Occipitofrontal
bladder size.” diameter
b. “The intravenous fluid infused to dilate your uterus does not
hurt the fetus.”
c. “You will need to drink at least 3 glasses of fluid before the
procedure.” FIGURE 9.13 An ultrasound at 24 weeks’ gestation showing
measurement of the biparietal diameter. (Courtesy of the
d. “You can have medicine for pain for any contractions
Department of Medical Photography, Children’s Hospital,
caused by the test.” Buffalo, NY.)
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Placental Grading. Based particularly on the amount of cal- clear, the level is low if the fetus has a chromosomal defect
cium deposits in the base of the placenta, placentas can be such as Down syndrome. MSAFP levels begin to rise at 11
graded by ultrasound as 0 (a placenta 12–24 weeks), 1 weeks’ gestation and then steadily increase until term.
(30–32 weeks), 2 (36 weeks), and 3 (38 weeks). Because fetal Traditionally assessed at the 15th week of pregnancy, be-
lungs are apt to be mature at 38 weeks, a grade 3 placenta tween 85% and 90% of neural tube defects and 80% of
suggests that the fetus is mature. Down syndrome babies can be detected by this method
(Crombleholme, 2009).
Amniotic Fluid Volume Assessment. The amount of am-
niotic fluid present is yet another way to estimate fetal
health because a portion of the fluid is formed by fetal kid- Triple Screening
ney output. If a fetus is becoming stressed in utero so that Triple screening, or analysis of three indicators (MSAFP, un-
circulatory and kidney functions are failing, urine output conjugated estriol, and hCG), may be performed in place of
and, consequently, the volume of amniotic fluid also will simple AFP testing to yield even more reliable results. As
decrease. A decrease in amniotic fluid volume puts the fetus with the measurement of MSAFP, it requires only a simple
at risk for compression of the umbilical cord and interfer- venipuncture of the mother.
ence with nutrition.
For gestations of less than 20 weeks, the uterus is hypo- Chorionic Villi Sampling
thetically divided along the midpoint (the linea nigra on the
woman’s abdomen) into two vertical halves. The vertical di- Chorionic villi sampling (CVS) is a biopsy and chromoso-
ameter of the largest pocket of amniotic fluid present on mal analysis of chorionic villi that is done at 10–12 weeks of
each side is measured in centimeters. The amniotic volume pregnancy. This procedure is discussed in Chapter 7.
index (AFI) or total is the sum of the two measurements. Coelocentesis (transvaginal aspiration of fluid from the ex-
For gestations of 20 weeks or more, the uterus is divided traembryonic cavity) is an alternative method to remove
into four quadrants, using the linea nigra again as the verti- cells for fetal analysis.
cal dividing line and the level of the umbilicus as the hori-
zontal dividing line. The vertical diameter of the largest Amniocentesis
pocket of fluid in each quadrant is obtained, and the four Amniocentesis (from the Greek amnion for “sac” and kente-
values are then added to produce the amniotic fluid index. sis for “puncture”) is the aspiration of amniotic fluid from the
The average index is approximately 12–15 cm between 28 pregnant uterus for examination. The procedure can be done
and 40 weeks. An index greater than 20–24 cm indicates hy- in a physician’s office or in an ambulatory clinic. It is typi-
dramnios (excessive fluid, perhaps caused by inability of the cally scheduled between the 14th and 16th weeks of preg-
fetus to swallow); an index less than 5–6 cm indicates oligo- nancy to allow for a generous amount of amniotic fluid to be
hydramnios (decreased amniotic fluid, perhaps caused by present. The technique can be used again near term to test
poor perfusion and kidney failure). for fetal maturity.
Amniocentesis is a technically easy procedure, but it can
Electrocardiography
be frightening to a woman. Because it involves penetration of
Fetal ECGs may be recorded as early as the 11th week of the integrity of the amniotic sac, there also are risks to the
pregnancy. The ECG is inaccurate before the 20th week, fetus, although the incidence of these is low (less than 0.5%).
however, because until this time fetal electrical conduction is Fetal complications range from hemorrhage from penetra-
so weak that it is easily masked by the mother’s ECG tracing. tion of the placenta, infection of the amniotic fluid, and
It is rarely used unless a specific heart anomaly is suspected. puncture of the fetus. If it leads to irritation of the uterus, it
can initiate premature labor (Alfirevic, 2009).
Magnetic Resonance Imaging In preparation for amniocentesis, ask the woman to void
(to reduce the size of the bladder and prevent an inadver-
Magnetic resonance imaging (MRI) also may be used to as-
tent puncture). Place her in a supine position on an exam-
sess the fetus. Because the technique apparently causes no
ining table and drape her appropriately, exposing only her
harmful effects to the fetus or woman (although extensive
abdomen. Place a folded towel under her right buttock to
long-term testing is not yet available), MRI has the potential
tip her body slightly to the left and move the uterus off the
to replace or complement ultrasonography as a fetal assess-
vena cava, to prevent supine hypotension syndrome. Attach
ment technique (Laifer-Narin et al,, 2007). It may be most
fetal heart rate and uterine contraction monitors. Take her
helpful in diagnosing complications such as ectopic preg-
blood pressure and measure the fetal heart rate for baseline
nancy or trophoblastic disease (see Chapter 21), because later
levels.
in a pregnancy fetal movement (unless the fetus is sedated)
An ultrasound is then done to determine the position of
can obscure the findings.
the fetus and the location of a pocket of amniotic fluid and
Maternal Serum Alpha-Fetoprotein the placenta. The abdomen is then washed with an antisep-
tic solution, and a local anesthetic is injected. Caution the
AFP is a substance produced by the fetal liver that is present woman that she may feel a sensation of pressure as the nee-
in both amniotic fluid and maternal serum. The level is ab- dle used for aspiration, a 3- or 4-in, 20- to 22-gauge spinal
normally high in maternal serum (MSAFP) if the fetus has needle, is introduced. Do not suggest that she take a deep
an open spinal or abdominal defect such as spina bifida or breath and hold it as a distraction against discomfort: this
omphalocele, because the open defect allows more AFP to lowers the diaphragm against the uterus and shifts intrauter-
enter the mother’s circulation. Although the reason is un- ine contents.
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CHAPTER 9 The Growing Fetus 213

The needle is inserted until it reaches the amniotic cavity • Bilirubin Determination. The presence of bilirubin may
and a pool of amniotic fluid, carefully avoiding the fetus and be analyzed if a blood incompatibility is suspected. If
placenta (Fig. 9.14). A syringe is attached, and about 15 mL bilirubin is going to be analyzed, the specimen must be
of amniotic fluid is withdrawn. The needle is then removed, free of blood or a false-positive reading will occur.
and the woman rests quietly for about 30 minutes. During • Chromosome Analysis. A few fetal skin cells are always
the procedure and for the 30 minutes afterward, observe the present in amniotic fluid. These cells may be cultured and
fetal heart rate monitor to be certain the rate remains within stained for karyotyping for genetic analysis. Examples of
normal values and observe the uterine contraction monitor genetic diseases that can be detected by prenatal amnio-
to be sure that no contractions are occurring. centesis and their significance to health are discussed in
If the woman has Rh-negative blood, Rho(D) immune Chapter 7.
globulin (RhIG; RhoGAM) is administered after the proce- • Color. Normal amniotic fluid is the color of water; late
dure to prevent fetal isoimmunization. This is to ensure that in pregnancy, it may have a slightly yellow tinge. A
maternal antibodies will not form against any placental red strong yellow color suggests a blood incompatibility (the
blood cells that might have accidentally been released during yellow results from the presence of bilirubin released
the procedure. with the hemolysis of red blood cells). A green color sug-
Amniotic fluid is analyzed for: gests meconium staining, a phenomenon associated with
fetal distress.
• Alpha-Fetoprotein (AFP). If the fetus has an open body
• Fetal Fibronectin. Fibronectin is a glycoprotein that
defect, such as anencephaly, myelomeningocele, or om-
plays a part in helping the placenta attach to the uterine
phalocele, increased levels of AFP will be present in the
decidua. Early in pregnancy, it can be assessed in the
amniotic fluid because of leakage of AFP into the fluid.
woman’s cervical mucus, but the amount then fades until,
The level will be decreased in the amniotic fluid of
after 20 weeks of pregnancy, it is no longer present in cer-
fetuses with chromosomal defects such as Down syn-
vical mucus. As labor approaches and cervical dilatation
drome. Acetylcholinesterase is another compound that
begins, it can be found again in cervical or vaginal fluid.
can be obtained from amniotic fluid in high levels if a
Damage to fetal membranes from cervical dilatation re-
neural tube defect is present.
leases a great deal of the substance, so detection of fi-
bronectin in either the amniotic fluid or in the mother’s
vagina can serve as an announcement that preterm labor
may be beginning.
• Inborn Errors of Metabolism. Some inherited diseases
that are caused by inborn errors of metabolism can be de-
tected by amniocentesis. For a condition to be identified,
an errant enzyme must be present in the amniotic fluid as
early as the time of the procedure. Examples of illnesses
that can be detected in this way are cystinosis and maple
syrup urine disease (amino acid disorders).
• Lecithin/Sphingomyelin Ratio. Lecithin and sphin-
gomyelin are the protein components of the lung enzyme
surfactant that the alveoli begin to form at the 22nd to
24th weeks of pregnancy. After amniocentesis, the L/S
ratio may be determined quickly by a shake test (if bub-
bles appear in the amniotic fluid after shaking, the ratio
is mature) or sent for laboratory analysis. An L/S ratio of
2:1 is traditionally accepted as lung maturity. Infants of
mothers with severe diabetes may have false-mature read-
ings of lecithin because the stress to the infant in utero
tends to mature lecithin pathways early. This means that
fetal values must be considered in light of the presence of
maternal diabetes, or the infant may be born with mature
lung function but be immature overall (fragile giants)
causing them to not do well in postnatal life. Some labo-
ratories interpret a ratio of 2.5:1 or 3:1 as a mature indi-
cator in infants of women with diabetes.
• Phosphatidyl Glycerol and Desaturated Phosphatidyl-
choline. These are additional compounds, in addition to
lecithin and sphingomyelin, found in surfactant.
Pathways for these compounds mature at 35–36 weeks.
Because they are present only with mature lung function,
if they are present in the sample of amniotic fluid ob-
FIGURE 9.14 Amniocentesis. A pocket of amniotic fluid is lo- tained by amniocentesis, it can be predicted with even
cated by ultrasound. A small amount of fluid is removed by greater confidence that respiratory distress syndrome is
needle aspiration. not likely to occur.
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Percutaneous Umbilical Blood Sampling The earliest time in pregnancy that fetoscopy can be per-
formed is about the 16th or 17th week. For the procedure,
PUBS (also called cordocentesis or funicentesis) is the aspira- the mother is prepared and draped as for amniocentesis. A
tion of blood from the umbilical vein for analysis. After the local anesthetic is injected into the abdominal skin. The fe-
umbilical cord is located by ultrasound, a thin needle is in- toscope is then inserted through a minor abdominal incision.
serted by amniocentesis technique into the uterus and is If the fetus is very active, meperidine (Demerol) may be ad-
guided by ultrasound until it pierces the umbilical vein. A ministered to the woman to help sedate the fetus to avoid
sample of blood is then removed for blood studies, such as a fetal injury by the scope and to allow better observation.
complete blood count, direct Coombs’ test, blood gases, and Fetoscopy carries a small risk of premature labor.
karyotyping. To ensure that the blood obtained is fetal blood, Amnionitis (infection of the amniotic fluid) may occur. To
it is submitted to a Kleihauer-Betke test which measures the avoid this, the woman may be prescribed 10 days of antibiotic
difference between adult and fetal blood. If the test reveals therapy after the procedure. The number of procedures per-
that a fetus is anemic, blood may be transfused using this formed by fetoscopy is limited because of the manipulation
same technique. Because the umbilical vein continues to ooze involved and the ethical quandary of the mother’s autonomy
for a moment after the procedure, fetal blood could enter the being compromised by fetal needs if further procedures are
maternal circulation after the procedure, so RhIG is given necessary (e.g., asking the mother to undergo general anes-
to Rh-negative women to prevent sensitization. The fetus is thesia so that the fetus can have surgery).
monitored by a nonstress test before and after the procedure
to be certain that uterine contractions are not present and by
ultrasound to see that no bleeding is evident. This procedure Biophysical Profile
carries little additional risk to the fetus or woman over am- A biophysical profile combines five parameters (fetal reac-
niocentesis and can yield information not available by any tivity, fetal breathing movements, fetal body movement,
other means, especially about blood dyscrasias. fetal tone, and amniotic fluid volume) into one assessment.
Amnioscopy The fetal heart and breathing record measure short-term
central nervous system function; the amniotic fluid volume
Amnioscopy is the visual inspection of the amniotic fluid helps measure long-term adequacy of placental function.
through the cervix and membranes with an amnioscope (a The scoring for a complete profile is shown in Table 9.5.
small fetoscope). The main use of the technique is to detect With use of this system, each item has the potential for
meconium staining. It carries some risk of membrane rupture. scoring a 2, so 10 would be the highest score possible. A
biophysical profile is more accurate in predicting fetal well-
Fetoscopy being than any single assessment (Lalor, et al, 2009).
Fetoscopy, in which the fetus is visualized by inspection Because the scoring system is similar to that of the Apgar
through a fetoscope (an extremely narrow, hollow tube in- score determined at birth on infants, it is popularly called a
serted by amniocentesis technique), can be helpful to assess fetal Apgar.
fetal well-being (Lopriore et al., 2007). If a photograph is Biophysical profiles may be done as often as daily during
taken through the fetoscope, it can document a problem or a high-risk pregnancy. If the fetus score on a complete pro-
reassure parents that their infant is perfectly formed. The file is 8–10, the fetus is considered to be doing well. A score
procedure is used to: of 6 is considered suspicious; a score of 4 denotes a fetus
probably in jeopardy. For simplicity, some centers use only
• Confirm the intactness of the spinal column two assessments (amniotic fluid index and a nonstress test)
• Obtain biopsy samples of fetal tissue and fetal blood for assessment. Referred to as a modified biophysical pro-
samples file, this predicts short-term viability by the nonstress test
• Perform elemental surgery, such as inserting a polyethylene and long-term viability by the AFI. A healthy fetus should
shunt into the fetal ventricles to relieve hydrocephalus or show a reactive nonstress test and an AFI range between 5
anteriorly into the fetal bladder to relieve a stenosed urethra and 25 cm (Chang & Blakemore, 2007). Nurses play a

TABLE 9.5 ✽ Biophysical Profile Scoring

Assessment Instrument Criteria for a Score of 2

Fetal breathing Ultrasound At least one episode of 30 sec of sustained fetal breathing movements
within 30 min of observation
Fetal movement Ultrasound At least three separate episodes of fetal limb or trunk movement within a
30-min observation
Fetal tone Ultrasound The fetus must extend and then flex the extremities or spine at least once
in 30 min
Amniotic fluid volume Ultrasound A range of amniotic fluid between 5 and 25 cm must be present
Fetal heart reactivity Nonstress test Two or more fetal heart rate accelerations of at least 15 beats/min above
baseline and of 15 sec duration occur with fetal movement over a
20-min time period
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CHAPTER 9 The Growing Fetus 215

large role in obtaining the information for both a modified

and a full biophysical profile by obtaining either the non- they are “time-consuming and boring.” How could you
stress test or the ultrasound reading. make such tests more appealing to help increase her
cooperation?
✔Checkpoint Question 9.5 4. Examine the National Health Goals related to fetal
growth and assessment. Most government-sponsored
Liz Calhorn is scheduled to have an amniocentesis to test for
fetal maturity. What instruction would you give her before this
money for nursing research is allotted based on these
procedure? goals. What would be a possible research topic to explore
pertinent to these goals that would advance evidence-
a. “Void immediately before the procedure to reduce your
based practice in relation to Liz Calhorn or her family?
bladder size.”
b. “The x-ray used to reveal your fetus’s position has no long-
term effects.”
c. “The intravenous fluid infused to dilate your uterus does not
hurt the fetus.”
d. “Your fetus will have less amniotic fluid for the remainder of CRITICAL THINKING SCENARIO
your pregnancy.”
Open the accompanying CD-ROM or visit http://
thePoint.lww.com and read the Patient Scenario in-
cluded for this chapter, then answer the questions to
Key Points for Review further sharpen your skills and grow more familiar
with NCLEX types of questions related to fetal
● The union of a single sperm and egg (fertilization) signals growth. Confirm your answers are correct by reading
the beginning of pregnancy. the rationales.
● The fertilized ovum (zygote) travels by way of a fallopian
tube to the uterus, where implantation takes place in
about 8 days.
● From implantation to 5 to 8 weeks, the growing structure
is called an embryo. The period after 8 weeks until birth
REFERENCES
is the fetal period. Ainbinder, S. W., Ramin, S. M., & DeCherney, A. H. (2007). Sexually
transmitted diseases and pelvic infections. In A. H. DeCherney & L.
● Growth of the umbilical cord, amniotic fluid, and amni-
Nathan (Eds.). Current diagnosis and treatment in obstetrics and gynecol-
otic membranes proceeds in concert with fetal growth. ogy (10th ed.). Columbus, OH: McGraw-Hill.
The placenta produces several important hormones: estro- Alfirevic, Z. (2009). Early amniocentesis versus transabdominal chorion vil-
gen, progesterone, human placental lactogen, and human lus sampling for prenatal diagnosis. Cochrane Database of Systematic
chorionic gonadotropin. Reviews, 2009(1), (CD000077).
Burkman, R. T. (2007). Contraception and family planning. In A. H.
● Various methods to assess fetal growth and development
DeCherney & L. Nathan (Eds.). Current diagnosis and treatment in ob-
include fundal height, fetal movement, fetal heart tones, stetrics and gynecology (10th ed.). Columbus, OH: McGraw-Hill.
ultrasonography, magnetic resonance imaging, maternal Bush, M. C., & Pernoll, M. L. (2007). Multiple pregnancy. In A. H.
serum alpha-fetoprotein, amniocentesis, percutaneous um- DeCherney & L. Nathan (Eds.). Current diagnosis and treatment in ob-
bilical blood sampling, amnioscopy, and fetoscopy. stetrics and gynecology (10th ed.). Columbus, OH: McGraw-Hill.
Chang, D., & Blakemore, K. (2007). Fetal assessment. In Fortner, K. B., et
● A biophysical profile is a combination of fetal assessments
al. (Eds). The Johns Hopkins manual of gynecology and obstetrics.
that predicts fetal well-being better than measuring single Philadelphia: Lippincott Williams & Wilkins.
parameters. Crombleholme, W. R. (2009). Obstetrics. In McPhee, S. J., & Papadakis,
M. A. (Eds.). Current medical diagnosis and treatment. Columbus, OH:
McGraw-Hill.
Firpo, M., & Kikyo, N. K. (2007). A primer on stem cell research.
CRITICAL THINKING EXERCISES Minnesota Medicine, 90(5), 36–38.
Goldman, A. (2007). Stem cells discovered in menstrual blood. Stem Cell
1. Liz Calhorn, whom you met at the beginning of the Research News, 9(21), 1.
Hol, L., & Kuipers, E. J. (2007). Clinical challenges and images in GI.
chapter, has stated that her feelings have changed since Meckel’s diverticulum. Gastroenterology, 133(2), 392–393.
she felt her baby move. Would you modify your health Jackson, H., Melvin, C., & Downe, S. (2007). Midwives and the fetal
teaching with her because of this statement? nuchal cord: a survey of practices and perceptions. Journal of Midwifery
2. When Liz is scheduled for an ultrasound examination at & Women’s Health, 52(1), 49–55.
20 weeks’ gestation, she tells you she does not want to Knuppel, R. A. (2007). Maternal-placental-fetal unit: fetal and early neona-
tal physiology. In A. H. DeCherney & L. Nathan (Eds.). Current diag-
know the sex of her fetus. Why do some women want nosis and treatment in obstetrics and gynecology (10th ed.). Columbus,
to know this, whereas some do not? Is there an advan- OH: McGraw-Hill.
tage to knowing or not knowing? Kumar, M., Das, S., & Kumar, B. (2007). Amniotic band syndrome.
3. Late in pregnancy, Liz is scheduled for weekly nonstress Ultrasound, 15(2), 96–98.
tests. She invariably comes late for these tests because Laifer-Narin, S., et al. (2007). Fetal magnetic resonance imaging: a review.
Current Opinion in Obstetrics & Gynecology, 19(2), 151–156.