Chapter 9: Nursing Care During Normal Pregnancy

and Care of the Developing Fetus.

Fertilization
 Also referred to as conception and
impregnation
 Is the union of an ovum and a spermatozoon

Stages of Fetal Development

Example of abnormality in Fertilization:

 Hydatiform Mole Implantation
 Occurs the 3 to 4 days toward the body of
uterus

 Examples of abnormality in implantation

 Placentia Previa
How fertilization occur

 Ectopic Pregnancy

The zygote
•Immediately after penetration of the ovum
cortical reaction occur
- Plasma membrane will become
impermeable to other sperm cells Embryo
• The chromosomal material of the ovum and  Embyonic and Fetal Structures
spermatozoon fuse to form a zygote.  The placenta, which will serve as the
- Because the spermatozoon and ovum each fetal lungs, kidneys, and digestive
carried 23 chromosomes (22 autosomes tract in utero, begins growth in early
and 1 sex chromosome), the fertilized ovum pregnancy in coordination with
has 46 chromosomes. embryo growth.
- If an X-carrying spermatozoon entered the 1. Decidua or uterine lining
ovum, the resulting child will have two X  After fertilization, the corpus luteum
chromosomes and will be female (XX). in the ovary continues to function
- If a Y-carrying spermatozoon fertilized the rather than atrophying under the
ovum, the resulting child will have an X and influence of human chorionic
a Y chromosome and will be male (XY) gonadotrophin (HCG)
 It will be discarded after the birth of
the child
2. Chorionic Villi

 11th to 12th day after fertilization

 Resembling probing fingers
 Reach out from the trophoblast cells
into the uterine endometrium to
begin formation of the placenta
 Cytotrophoblast or Langerhan’s
layer: protect the growing embryo 5. Amniotic Fluid
and fetus from certain infectious  Constantly being newly formed and
organisms such as the spirochete of absorbed by direct contact with the fetal
syphilis early in pregnancy surface of the placenta
3. Placenta  800 to 1200 ml
 To shield the fetus against pressure or a
blow from the mother’s abdomen
 7.2 pH (alkaline)
 Hydramnios
- Excessive amniotic fluid
- More than 2,000 in total or
pockets of fluid larger than 8cm
on ultrasound
 Pancake - Diabetes women because of
 Grows from the few identifiable excessive fluid
trophoblast cells at the beginning of  Oligohydramnios
pregnancy to an organ 15 to 20cm in - Reduction in the amount of amniotic
diameter and 2 to 3 cm in depth fluid
 Placental Circulation - Less than 300 ml in total, or no
pocket on ultrasound larger than
1cm

6. Umbilical Cord
 Formed from the fetal membranes (amnion
and chorion) and provides a circulatory
pathway that connects the embryo to the
chorionic villi of the placenta
 Its function is to transport oxygen and
 Endocrine Function
nutrients to the fetus from the placenta and
- hCG
to return waste products to the placenta
- Progesterone
 53(21inch) in length, 2cm(0.75in) in width
- Estrogen
 Wharton Jelly
- hPL
- Gives the cord body and prevents
4. Amniotic Membranes
pressure on the vein and arteries that
 The chorionic villi on the medial surface
pass through.
of the trophoblast (those that are not
 1 vein, 2 arteries
involved in implantation because they
 Hypocoiling
do not touch the endometrium)
- Associated with maternal hypertension
 Chorionic membrane
 Hypercoiling
- The outermost fetal membrane
- Associated with respiratory distress in
 Amniotic membrane
the newborn
- Or amnion, forms beneath the
chorion
  Nuchal Cord

 Chord Prolapse

Development of Organ Systems

1. Cardiovascular System

Origin Organ System

 Stem Cells
- During the first 4 days of life, zygote cells
are termed totipotent stem cells, or cells
 Fetal Circulation (REVIEW!!!)
that are so undifferentiated they have the
 Adult Remnants of fetal heart
potential to form a complete human being.
- In another 4 days, as the structure implants
and becomes an embryo, cells begin to
show differentiation and lose their ability to
become any body cell.
- Instead, they are now slated to become
specific body cells, such as nerve, brain, or
skin cells, and are termed pluripotent stem
cells.
- In yet another few days, the cells grow so  Fetal Hemoglobin
specific that they are termed multipotent or - Fetal hemoglobin differs from adult
are so specific they cannot be deterred rom hemoglobin in several ways:
growing into a particular body organ such as - 1. It has a different composition (two a
spleen or liver or brain. and two y chains compared
 Zygote Growth - with two a and two B chains of adult
- From the beginning of fetal growth, hemoglobin).
development proceeds in a - 2. It is also more concentrated and has
cephalocaudal (head-to-tail) direction; greater oxygen affinity
that is, head development occurs first - 3. NB hemoglobin level is about 17.1
and is followed by development of the g/100 ml compared with a
middle and, finally, the lower body - normal adult level of 11 g/100 ml
parts. - 4. NB hematocrit is about 53%
- This pattern of development continues compared with a normal adult level of
after birth as shown by the way infants - 45%.
are able to lift up their heads 2. Respiratory System
approximately 1 year before they are
able to walk.
- As a fetus grows, body organ systems
develop from specific tissue layers called
germ layers.
 PRIMARY GERM LAYERS
- As a fetus grows, body organ systems
develop from specific tissue layers called
germ layers.
- At the time of implantation the 3. Nervous System
blastocyst already has differentiated to a
point at which three separate layers of
these cells are present: the ectoderm,
the endoderm, and the mesoderm
  GASTROSCHISIS

4. Endocrine System
 The function of endocrine organs begins
along with neuro-system development. 6. Musculoskeletal System
a. fetal pancreas: produces insulin needed
by the fetus (insulin is one of the few
substances that does not cross the
placenta from the mother to the fetus)
b. thyroid and parathyroid glands: play
vital roles in fetal metabolic function
and calcium balance.
c. fetal adrenal glands: supply a precursor
necessary for estrogen synthesis by the 7. Reproductive System
placenta.
5. Digestive System

8. Urinary System

 STENOSIS and ATRESIA OF THE INTESTINE

9. Integumentary System

 VOLVULUS OF THE INTESTINE

10. Immune System

Milestones of Fetal Growth and

Development
 lunar months = 4-week periods
 trimesters = 3-month periods
 In lunar months, a pregnancy is 10 months
(40 weeks, or 280 days)
 long; a fetus grows in utero 9.5 lunar
 OMPHALOCELE months or three full trimesters (38 weeks,
or 266 days).

End of 4th Gestational Week

 At the end of the fourth week of gestation,
the human embryo is a group of rapidly
growing cells but does not yet resemble a
human being.
 Length: 0.75–1 cm
 Weight: 400 mg
 The spinal cord is formed and fused at the
midpoint.
  The head folds forward and becomes  Meconium is present as far as the rectum.
prominent, representing about one-third of  Active production of lung surfactant begins.
the entire structure.  Eyelids, previously fused since the week,
 The rudimentary heart appears as a now open; Pupils are capable of reacting to
prominent bulge on the anterior surface. light.
 Arms and legs are budlike structures:  Hearing can be demonstrated by response
Rudimentary eyes, ears, and nose are to sudden sound.
discernible  When fetuses reach 24 weeks, or 601 g,
End of 8th Gestational Week they have achieved a practical low-end age
 Length: 2.5 cm (1 in) of viability (earliest age at which fetuses
 Weight: 20 g could survive if bornat that time), if they are
 Organogenesis is complete. cared for after birth in a modern intensive
 The heart, with a septum and valves, is care facility
beating rhythmically. End of 28th Gestational Week
 Facial features are definitely discernible;  Length: 35–38 cm
Arms and legs have developed.  Weight: 1200 g
 External genitalia are forming, but sex is not  Lung alveoli begin to mature, and surfactant
yet distinguishable by simple observation. can be demonstrated in amniotic fluid.
 The abdomen bulges forward because the  Testes begin to descend into the scrotal sac
fetal intestine is growing so rapidly. from the lower abdominal cavity.
 A sonogram shows a gestational sac,  The blood vessels of the retina are formed
diagnostic of pregnancy but thin and extremely susceptible to
End of 12th Gestational Week (First damage from high oxygen concentrations
Trimester) (an important consideration when caring for
 Length: 7–8 cm preterm infants who need oxygen).
 Weight: 45 g End of 36th Gestational Week
 Nail beds are forming on fingers and toes.  Length: 42–48 cm
 Spontaneous movements are possible,  Weight: 1800–2700 g (5–6 lb)
although they are usually too faint to be felt  Body stores of glycogen, iron, carbohydrate,
by the mother. and calcium are deposited.
 Some reflexes, such as the Babinski reflex,  Additional amounts of subcutaneous fat are
are present. deposited.
 Bone ossification centers begin to form.  Sole of the foot has only one or two
 Tooth buds are present. crisscross creases, compared with the full
 Sex is distinguishable by outward crisscross pattern that will be evident at
appearance. term.
 Urine secretion begins but may not yet be  Amount of lanugo begins to diminish.
evident in amniotic fluid.  Most babies turn into a vertex (head down)
 The heartbeat is audible through Doppler presentation during this month.
technology End of 40th Gestational Week (Third
End of 20th Gestational Week Trimester)
 Length: 25 cm  Length: 48–52 cm (crown to rump, 35–37
 Weight: 223 g cm)
 Spontaneous fetal movements can be  Weight: 3000 g (7–7.5 lb)
sensed by the mother.  Fetus kicks actively, hard enough to cause
 Antibody production is possible. the mother considerable discomfort.
 The hair forms on the head, extending to  Fetal hemoglobin begins its conversion to
include eyebrows. adult hemoglobin.
 Meconium is present in the upper intestine.  Vernix caseosa starts to decrease after the
 Brown fat, a special fat that will aid in infant reaches 37 weeks gestation and may
temperature regulation at birth, begins to be more apparent in the creases than the
be formed behind the kidneys, sternum, covering of the body as the infant
and posterior neck: Vernix caseosa begins to approaches 40 weeks or more gestational
form and cover the skin. age.
 Passive antibody transfer from mother to  Fingernails extend over the fingertips.
fetus begins.  Creases on the soles of the feet cover at
 Definite sleeping and activity patterns are least two thirds of the surface
distinguishable (the fetus has developed  In primiparas (women having their first
biorhythms that will guide sleep/wake baby), the fetus often sinks into the birth
patterns throughout life) canal during the last 2 weeks, giving the
End of 24th Gestational Week (Second Trimester) mother afeeling that the load she is carrying
 Length: 28–36 cm is less.
 Weight: 550 g
  This event, termed lightening, is a fetal the fundus of the uterus above the
announcement that the third trimester of symphysis pubis.
pregnancy has ended and birth is at hand • Bartholomew's rule does not use a
numerical height value to compute
Assessment of Fetal Growth and gestational age, but landmarks.
Development (Computation) • Fundic height is determined by
 Fetal growth and development can be palpation and by relating to the
compromised if a fetus has a metabolic or different landmarks in the abdomen
chromosomal disorder that interferes with umbilicus, symphysis pubis,
normal growth, if the supporting structures xiphoid process
such as the placenta or cord do not form
normally, or if environmental influences
such as cigarette smoking (the nicotine in
cigarettes causes fetal growth restriction) or
alcohol consumption (alcohol causes severe
cognitive challenge) interfere with fetal
growth.
1. Computations
d) Johnson’s rule
- Much information regarding
•Johnson’s rule is used to estimate the
whether a fetus is growing and is
weight of the fetus in grams. To
healthycan be gathered through a
determine this, a standard formula is
variety of assessment techniques.
used.
a) Fundic Height
• Formula: fundic height in cm – n x k
•measured to estimate
• Where:
AOG
• K= 155 ( constant)
EDD
• N= 12 if engaged ( do Leopolds to find
fetal growth rate
out)
• Measure fundic height from top of
• N= 11 if not yet engaged
symphysis pubis to the top of
fundus with the bladder empty
b) McDonald’s rule
• A symphysis-fundal height
measurement (FUNDIC HEIGHT)
• Although not documented to be
thoroughly reliable, is an easy method
of determining during midpregnancy e) Haase’s Rule
that a fetus is growing in utero •Is used to determine length of fetus
• Typically, the distance from the uterine A. During the first half of pregnancy,
fundus to the symphysis pubis in square the number of months.
centimeters is equal to the week of B. During the second half of pregnancy ,
gestation between the 20th and 31st multiply the number of
weeks of pregnancy. months by five.
• Is used to calculate AOG •Greater Fundic height indicate
• Fundic height (cm) x 2 ÷ 7 = AOG in • Multiple pregnancy
lunar months • Miscalculated due date

f) 6. Naegele’d Formula
• Fundic height (cm) x 8 ÷ 7 = AOG in •Used for Calculating EDD (Estimated
weeks date of Delivery).
• Based on the LMP (Last menstrual
Period)
• FORMULA: - 3 months + 7 days
Consideration:
•If LMP is April to December add 1 year
•If Day if more than the total days of the
particular month add 1 to the
month. Make sure to check number of
c) Bartolomew’s rule days in the particular month.
• This method estimates the age of
gestation relative to the height of
2. Fetal Heart Rate
 Fetal heart sounds can be heard and
countered as early as the 10th to 11th week
of pregnancy by the use of an ultrasound
Doppler technique. This is done routinely at
every prenatal visit past 10 weeks.

3. Daily Fetal Movement Count (Kick Count)

 Fetal movement that can be felt by the
mother (quickening) occurs at
approximately 18 to 20 weeks of pregnancy
and peaks in intensity at 28 to 38 weeks.
 After that time, a healthy fetus moves a
degree of consistency at about 10 times per
hour.
4. Other tests
 Rhythm Strip Testing
 Nonstress Testing – comparing FHR and
Fetal movement
 Vibroscoustic Stimulation
 Ultrasonography
 Biparietal Diameter
 Doppler Umbilical Velocimetry
 Placental Grading for Maturity
 Amniotic Fluid Volume
 Nuchal Translucency
 Biophysical Profile