TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT of NURSING

Maternal and Child Health Nursing

107

Presented by: ADORA N. OBREGON

Stages of Fetal
Development
 Stages of
Fetal
Development
 Fertilization
Beginning of
pregnancy
Union of the ovum
and spermatozoon

Usually occurs at
the outer third of
fallopian tube
 Stages of Fetal
Development

 Implantation
Contact
between
growing
structure and
uterine
endometrium
Occurs 8-10
days after
fertilization
 Embryonic and Fetal Structures

 Decidua
1. Decidua basalis:
part of the
endometrium lying
directly under the
embryo (or portion
where the
trophoblast cells
are establishing
communication with
maternal blood
vessels)
Embryonic and Fetal Structures

 Decidua
2. Decidua
capsularis:
portion of the
endometrium
that stretches or
encapsulates the
surface of the
trophoblast
3. Decidua vera:
the remaining
portion of the
uterine lining
 Embryonic and Fetal Structures

 Chorionic villi: the trophoblastic layer

of cells of the blastocyst begins to mature
rapidly, as early as 11th or 12th day,
miniature villi, or probing “fingers” termed
as chorionic villi.
 3 parts
1. Central core: contains fetal capillaries
2. Cytotrophoblast / Langhans’ layer
3. Syncytiotrophoblast or syncytial layer
 Embryonic and Fetal
Structures
Placenta: latin for pancake, arises
out of trophoblast tissue. It serves as
the fetal lungs, kidneys, and GIT and
as a separate endocrine organ
throughout pregnancy.
 Functions of Placenta
1. Respiratory system: achieved by
simple diffusion
2. GIT: nutrients are transported by the
placenta.
Ex: a. Glucose transport: facilitated
diffusion – higher to lower
concentration
b. Amino acid: active transport –
lower to higher concentration
 Functions of Placenta
3. Excretory system: all waste products
are excreted by the placenta; the liver
of the mother detoxify the waste of
the fetus.
4. Circulatory system: by selective
osmosis
5. Protective barrier against some
microorganism: by pinocytosis.
 Embryonic and Fetal Structures

6. Endocrine Function
Human Chorionic Gonadotropin
- 1st hormone to be produced is hCG
- Found in maternal blood and urine
Estrogen
- Contributes to he mammary gland
development
- Stimulates uterine growth to
accommodate the developing fetus
Embryonic and Fetal Structures
Progesterone
- “hormone for mothers”
- maintain the endometrium lining of
uterus
- reduces the contractility of the uterine
musculature during pregnancy which
prevents premature labor.
Human Placental Lactogen
- Growth promoting and lactogenic
(milk-producing); produced at 6th
week.
Placental Circulation
 Embryonic and Fetal Structures

 Umbilical Cord
From fetal membranes
Provides circulatory pathway
Contains one vein and two arteries
NO NERVE SUPPLY
 Embryonic
and Fetal
Structures
 Amniotic
Membranes
 Chorionic
membrane
 Amniotic membrane
 Produces
phospholipid that
initiates the
formation of
PROSTAGLANDIN
which causes
uterine contractions
and maybe the
trigger that initiates
labor.
 Embryonic and
Fetal Structures
 Amniotic Fluid
Never stagnant
Serves to protect
fetus
 Shields against
pressure
 Protects from
temperature
changes
 Protects umbilical
cord from pressure
 Embryonic and
Fetal Structures
 Normal amniotic
fluid: 800-1200ml
 Hydramnios
 Oligohydramnios
 Amniocentesis
 Aspiration of amniotic fluid : done at
around 12-14weeks.
Purpose – obtain a sample of amniotic fluid by
inserting a needle through the abdomen
into the amniotic sac; fluid is tested for:
1. Genetic screening
- Early testing time- 12-14wks with results
available in 10-14days
- Traditional testing time- 14-16th wk, with
results available at 2-4weeks
- Performed to determine presence of such
problem as:
 Amniocentesis
► Maternal serum alpha fetoprotein test
► Inborn errors of metabolism
2. Determination of fetal maturity primarily
by evaluating factors indicative of lung
maturity
- Testing time: during third trimester
around 36 weeks when lung maturation
have occurred
- Factors – both should be present at
approximately 36wks AOG
 Amniocentesis
A. L/S ratio (lecithin/sphyngomyelin)
B. Presence of Phosphatidyl glycerol PG+
3. Indications
a. Family History
b. Women of advanced age, >35 yrs of
age
c. Assurance of lung maturity prior to
inducing labor or performing an elective
CS.
 Amniocentesis
4. Overall complication rate is 1%
5. Protocol
a. Ultrasound – identify placental and
fetal location.
b. Preparation
- Provide emotional support
- Verify informed consent forms are
complete
- Assist woman to empty bladder
 Amniocentesis
- Position – supine, be alert for supine
hypotensive syndrome during and postural
hypotension after the test.
- Assess maternal V/S and FHR before,
during, and after the procedure
- Site preparation]
- After procedure
1. Encourage woman to rest on her side
2. Monitor maternal VS
 Amniocentesis
3. Use external monitor to assess for uterine
contractions and FHR patterns
f. Discharge instructions
1. Report the ff: changes in fetal movement,
vaginal discharge of clear fluid, blood,
thick purulent malodorous discharge,
presence of pain and signs and symptoms
of infection which includes fever, pain and
malaise.
g. Discuss result.
Development of Organs

 Stem cells
 Zygote growth
 Primary germ layers
Development of
Organs

Primary Germ
Layer
1. Amniotic cavity
(large cavity):
lined with
ectoderm.
2. Mesoderm: bet.
Amniotic cavity
and yolk sac
2. Yolk sac (smaller
cavity): lined
with entoderm.
 Fetal System Development
 Cardiovascular system
- 1st system to become functional in
intrauterine life
- 16th day: yolk sac progress to a
network of blood vessels and to a
single heart tube
- 24th day: heartbeat
- 6th or 7th week: septum that divides the
heart into chambers develops
- 10th wk: heartbeat by Doppler
- 11th wk: ECG on fetus maybe recorded
Fetal Circulation
 Fetal System Development
 Fetal hemoglobin: >O2 affinity and
more concentrated
- Normal Hgb: @ birth: 17.1g/100ml
- Hematocrit: 53%
- Normal Hgb: adult: 11g/100ml
- Hematocrit: 45%
Fetal System
Development
 Fetal System Development
 Respiratory
- 3rd wk: respiratory and digestive
tract exist as a single tube
- 24th and 28th wk: alveoli and
capillaries begins to form
- 24th wk: Surfactant develops
- * surfactant: a phospholipid
substance; formed and excreted
by the alveolar cells
 Fetal System Development
 2 components of Surfactant
1. Lecithin: 35wks; surge production
2. Sphingomyelin: chief component
 Normal L/S: 2:1
 Fetal System Development
 Nervous
- 3rd wk: nervous system begins to
develop.
- Neural plate: thickened portion of the
ectoderm
- Top portion differentiates into the
neural tube
1. CNS: brain and spinal cord
2. Neural crest: PNS
 Fetal System Development

 Endocrine
- Fetal adrenal glands supply a
precursor for estrogen synthesis by
the placenta
- Fetal pancreas: produces insulin
- Thyroid and parathyroid gland:
metabolic function and calcium
balance
 Fetal System Development
 Digestive
- 4th wk: digestive tract separates from the
respiratory tract
- 16th wk: meconium forms in the intestine
- Meconium: cellular wastes, bile, fats, mucoproteins,
mucopolysaccharides and portions of vernix
caseosa: black or dark green and sticky
- 32wks or 1,500g: sucking and swallowing reflex is
mature
- Liver is active active throughout gestation as filter;
but immature at birth.
 Fetal System Development
 Musculoskeletal System
- 11th wk: can be seen to move on
Ultrasonography
- 12th wk: ossification of the bone tissue
- 20th wk: quickening
 Fetal System Development

 Reproductive System
- Child’s sex is determined at
the moment of conception
- 6th wks: the gonads formed
- 8th wks: sex can be ascertained
by chromosomal analysis
 Fetal System Development

 Urinary System
- 4th wks: rudimentary kidneys are
present
- 12th wks: urine is formed
- 16th wks: urine is excreted into the
amniotic fluid
- AT TERM: fetal urine is 500ml/day
 Fetal System Development
 Integumentary System
- Thin and almost translucent
- 36 wks: subcutaneous fat begins to be
deposited
- 2 Skin covering of the fetus
1. Lanugo: soft downy hair
2. Vernix caseosa: cream cheese-like substance
Fxns: - for lubrication
- keeping the skin from macerating in
utero
 Fetal System Development
 Immune system
- 3rd tri: IgG maternal antibodies cross the
placenta into the fetus giving the fetus
temporary passive immunity against disease
- Ex: 1. Rubella (German measles)
2. Rubeola (Measles)
3. Diptheria
4. Tetanus
5. Infectious parotitis (mumps)
6. Hepa B
7. Pertussis (Whooping cough)
 Fetal Developments on
“BULLETS”
 16th day: heart valve are developed
 3rd wk: nervous system developed
 8th wk: organogenesis complete
 12th wk: urine is formed, bone
ossification occurs’ heart sound heard
by doppler.
 16th wk: sex’s determined, quickeing for
multipara
 20th wk: heart sound by steth.,
quickening for primipara
 Fetal Developments on
“BULLETS”
 24th wk: head and body proportional
 24th wk: surfactant is developed
 32th wk: testes descends to the
scrotum
 35 -36th wk: L/S ratio: 2:1 – lung is
matured
 40th wk: FULL TERM
Estimated Birth Date
Assessment of Fetal Growth and
Development
1. Health History
- Nutritional intake
- Personal habits
- Accidents
- Partner abuse
 Estimating Fetal Growth
 McDonald’s Rule
- A symphysis-fundal
height
measurement
- Common method of
determining, during
midpregnancy, that
a fetus is growing
in utero.
 Assessing Fetal Well-Being
 Fetal Movement
- FM can be felt by the mother at 18-20th
weeks of pregnancy and peaks at 28-
38th weeks.
- Sandovsky method: lie in a left
recumbent position after meal.
- Healthy fetus: 10 movements/day
- Moves twice every 10 minutes or an
average of 10-12 times an hour.
 Assessing Fetal Well-Being
- Less than 10 movements: repeat the
test after 1 hour.
- 2hours = 10 movements: REPORT
- “Count-to-Ten” (Cardiff method): 10
movements = 60minutes.
 Assessing Fetal Well-Being
 Fetal Heart
- Fetal heart beats at 120 – 160 beats/minute
- Fetal heart sounds at 10th to 11th week by
Doppler
 Rhythm Strip Testing
- Placed in a semi-fowlers position, external
fetal heart rate and uterine contraction
monitors are attached abdominally
- Recorded for 20 minutes
 Assessing Fetal Well-Being
 Nonstress Test
- To determine the response of the fetal
heart rate to the stress to activity
- Indications: pregnancies at risk for
placental insufficiency
- 1. Postmaturity
- 2. PIH, DM
- 3. Maternal history of smoking,
inadequate nutrition
 Assessing Fetal Well-Being
 Procedure: Done within 30 minutes, semi-
fowlers position; external monitor is
applied to document fetal activity.
- Mother activates the “mark button” on the
electronic monitor when she felts fetal
movement.
 Attach external noninvasive fetal monitors
1. Tocotransducer over fundus to detect
uterine contraction and Fm’s
2. Ultrasound transducer over abdominal site
where most distinct fetal heart sounds are
detected
 Assessing Fetal Well-Being
3. Monitor until at least 2 FM’s are
detected in 20 minutes
- If no FM after 40 minutes provide
woman with a light snack or gently
stimulate fetus through abdomen
- If no FM after 1 hour further testing
may be indicated, such as a
Contraction Stress Test
 Assessing Fetal Well-Being
 RESULT:
- Nonreactive, nonstress, not good =
fetal distress
- Reactive, real good = fetal well-being
 Assessing Fetal Well-Being
 Contraction Stress Testing
- Contractions were initiated by the
intravenous infusion of oxytocin.
- Difficult to stop and led to preterm
labor
- Nipple stimulation: releases oxytocin
 Protocol: Begin testing at 32 weeks
gestation
 Assessing Fetal Well-Being
A. Maternal preparation:
1. Empty bladder
2. Restrict solid food during testing since
labor could be stimulated; liquids are
permitted
3. Position- semi-fowlers
4. Encourage mother to use childbirth
breathing techniques with contractions
 Assessing Fetal Well-Being
B. Assess maternal vital signs before and during
test.
C. Obtain a pattern of 3 uterine contractions
lasting at least 40 seconds each in a 10-minute
period; stimulation is usually required
 Administration of Pitocin IV piggyback to a
primary infusion, gradually increasing dosage
to desired contraction pattern. Takes about 60
– 90 minutes.
 Nipple stimulation to facilitate release of
endogenous oxytocin from the posterior
pituitary gland
 Assessing Fetal Well-Being
 Stimulate only one nipple to 2 – 3 minute
stimulation with a 2- minute rest interval
between stimulation.
 Repeat until desired contraction pattern is
obtained : takes about 15 to 45 minutes.

D. Be alert for hyperstimulation of the uterus

 Uterine contractions lasting 90 seconds or
longer and or;
 Contractions that occur at a frequency of
every 2 minutes or less.
 Assessing Fetal Well-Being
E. Measures related to hyperstimulation
 Discontinue uterine stimulus immediately
 Continue IV fluids
 Turn mother on her side
 Administer oxygen via tight mask at 8-10
L/min
 Monitor maternal VS and FHR
 Suppresion of uterine contractions with
tocolytics such as Terbutaline 0.25mg
subcutaneously may be needed.
 Assessing Fetal Well-Being
F. After the test is completed client must wait
until uterine activity subsides
(<contractions in 30 minutes) and a vital
signs and FHR are stable, returning to
baseline levels.
G. Interpretation of Results
1. Negative result = fetal well being
2. Positive result = Fetal distress
3. Equivocal result = late deceleration occur
but with less than 50% of the contractions;
undergo another test
 Assessing Fetal Well-Being
ULTRASOUND
PURPOSE:
a. Diagnose pregnancy by visualizing
gestational sac as early as week 4
b. Date pregnancy by evaluating size or
volume of gestational sac and crown
to rump length (CRL)
c. Detect multiple gestation
 Assessing Fetal Well-Being
d. Monitor fetal growth
e. Evaluate fetal structure and function:
fetal movement, presence of structural
anomalies
f. Estimate amniotic fluid volume
g. Evaluate placental and efficiency of
function
h. Facilitate safe performance of other
antepartal tests by locating essential
structures.
 Assessing Fetal Well-Being
 Approaches: transabdominal and
transvaginal.
 Specific preparation and support
measures:
1. Full bladder (1 ½ liters of water- 1-2hours
before) for transabdominal when woman
is <20 weeks gestation.
2. Test lasts 20-30minutes
3. Be alert for signs of supine hypotension
during the test and postural hypotension
when arising at the end of the test.
 Assessing Fetal Well-Being
Electrocardiography
 Recorded as early as the 11th week of
pregnancy
 Inaccurate before the 20th week
 Used for specific heart anomaly is suspected
Magnetic Resonance Imaging
 Helpful in diagnosing complications such as
ectopic pregnancy or trophoblastic disease.
 Assessing Fetal Well-Being
Daily Fetal Movement Counting (DFMC)
1. Assessment of fetal movement based on
principle that: Vigorous fetal activity =
FETAL WELL BEING, Alteration in pattern of
fetal movement = possible fetal compromise
related to hypoxia.
2. Effective, easy, convenient, noninvasive,
inexpensive screening tool recommended
with increasing frequency for all pregnant
women whether low or high risk. Assessment
is performed at home, results are recorded,
and then reviewed at prenatal visits.
 Assessing Fetal Well-Being
3. PROTOCOL
 Begin at 27th week when 90% of fetal
movements can be perceived.
 Counting times should take into
consideration
a. Fetal sleep-wake cycles
b. Maternal food intake – increase FM
c. Drug-nicotine use – decrease FM.
 Assessing Fetal Well-Being
d. Environmental stimuli, such as music
e. Maternal position – supine position causes
uterus to compress vena cava, which causes
maternal cardiac output to decrease.
 Explain to the patient
1. Timing and position – count in a comfortable,
side-lying position after a meal
2. Counting method to be used – a variety of
methods are currently available
3. Expected findings
4. Warning signs and importance of reporting
them to health care provider
 Assessing Fetal Well-Being
 Cardiff count to 10 method
1. Begin at the same time each day (usually in the
morning, after breakfast) and count each fetal
movement, noting how long it takes to count 10
fetal movements
2. Expected findings – 10 movements/hour
3. Warning signs:
a. More than 1 hour to reach 10 movements
b. Less than 10 movements in 12 hours
c. Longer time to reach 10 FM’s than on previous days
d. Movements are becoming weaker, less vigorous
*** Movements alarm signal= <3FM’s in 12 hours
> Warning signs should be reported to healthcare
provider immediately; often require further testing.
Ex. NST, BPP
 Assessing Fetal Well-Being
BIOPHYSICAL PROFILE
Purpose: assess fetal status (healthy,
compromised, or at risk) by
evaluating several factors
1. NST
2. Fetal breathing movements
3. Fetal body movement
4. Fetal muscle tone
5. Amniotic fluid volume
 Assessing Fetal Well-Being
 Protocol – follow guidelines for UTZ and for
NST; approximately 40 – 60 minutes are
required to perform test in order to
accommodate to the fetal sleep-wake cycle.
 Indications: as for NST and CST; often used
to follow-up on a nonreactive NST or
warning signs found with DFMC
 Interpretation of results
1. Each sign receives a score of 0 (abnormal)
or 2 (normal)- some testing procedures use
a 0,1,2 scoring system with 2 being the
most favorable score for each sign and a
total score of 10 as perfect.
 Assessing Fetal Well-Being
2. Total score of <8 is considered
reflective of a healthy fetus.
3. Low scores may indicate compromise
a. Require follow-up by repeating BPP or
performing another test such as CST
b. Score of <6 requires determination of
need for delivery of fetus-
consideration must be given to
maturity of fetal lungs
 Low incidence of false positives – more
accurate than NST or CST alone in
detecting fetal compromise and risk.
 Assessing Fetal Well-Being
Percutaneous Umbilical Blood Sampling
 Also called cordocentesis or funicentesis :
aspiration of blood from the umbilical vein for
analysis.
Amnioscopy
 Visual inspection of the amniotic fluid through the
cervix and the membranes with an amnioscope (a
small fetoscope)
 Detect meconium staining
Fetoscopy
 Fetus is visualized by inspection through a
fetoscope; photograph can be taken.
 Purposes: corfirm the intactness of the spinal
column and obtain biopsy samples of fetal tissue
and fetal blood samples.
 Psychological
Changes
 Social
 Cultural
 Family
 Individual
 The Psychological Tasks of
Pregnancy
First Trimester: Accepting The Pregnancy
 Accept the reality of the pregnancy
1. THE PARTNER:
 Unwed fathers = not interested in the
pregnancy
 Partners accepting the pregnancy =
acceptance to changed state.
 Partner should be: supportive, proud
and happy
 The Psychological Tasks of
Pregnancy
Second Trimester: Accepting the Baby
THE WOMAN:
 Acceptance of having the baby
 Quickening
 Sonogram
 Imagination of being a mother
 Sex determination
 Shopping for baby clothes, crib etc..
 The Psychological Tasks of
Pregnancy
Second Trimester: Accepting the Baby
THE PARTNER:
 Partner may feel as if he is left
standing in the wings, waiting to be
asked to take part in the event.
 Become overly absorbed in his work
 Some may not be enjoying pregnancy
because of misinformation (breast and
vagina)
The Psychological Tasks of
Pregnancy
Psychological Tasks