Chapter 9: Nursing Care During Normal Pregnancy and Care of the

Developing Fetus

Nursing Process Overview

Assessment
 Measuring fundal height and fetal heart rate
 Knowledge about fetal growth and development
Nursing Diagnosis
 Readiness for enhanced knowledge released to usual fetal growth
 Anxiety related to lack of fetal movement
 Deficient knowledge related for good prenatal care for healthy fetal well-being
Online Resources
- Pp. 174 of maternal and Child Health Nursing Volume 1
Implementation
 Learning how fetus mature at various points of pregnancy
 Viewing sonogram and learning the fetal sex
Outcome Evaluation
 Focus on determining if the woman has made any changes in her lifestyle such as:
a. Smoke-free living by next prenatal visit
b. Records number of movements fetus makes during 1 hour daily
c. Attends all scheduled prenatal visits
d. Looking forward to the birth of her baby

A. The Nursing Role and Nursing care During Normal Pregnancy and Birth
 Assures the health of the mother, and also her baby
 Obtain a complete history and provide a physical examination that influence the
fetal development
 Ensure prenatal visit to avoid risk due to complications.

B. Stages of Fetal Development

 In 38 weeks, a fertilized egg developed into fetus
 Consist of three periods:
a. Pre-embryonic (1st 2 weeks, beginning with fertilization)
b. Embryonic (weeks 3 through 8)
c. Fetal (weeks 8 through birth)

1. Fertilization: The Beginning of Pregnancy

Fertilization. Also known as conception and impregnation. It is known as the
union of an ovum and spermatozoon.
 Occurs in the outer 1/3 of fallopian tube, also known as ampullar
portion
 Only one ovum matures each month, so fertilization must occur
quickly because it has the capable to fertilize for only about 24 hours
and spermatozoon in about 48 hours, possibly as long as 72 hours.
Process:
Ovum exit from the Graafian follicle, surrounded by zona
pellucida (ring of mucopolysaccharide fluid) and corona radiata
(circle of cell).
Zona pellucida and corona radiata serve as protective buffers.
Ovum propelled into fallopian tube by fimbriae through the help of
peristaltic action and movement of tube cilia.
Note: Semen ejaculation averages 2.5 ml of fluid that contains 50
to 200 million sperm, An average of 400 million sperm per
ejaculation.
 Woman cervical mucus reduce, in that way sperm can easily
penetrate it.
The sperm reach the cervix within 90 secs and reach the outer end
of fallopian tube within 5 minutes.
Note: Species-specific reaction is the mechanism of spermatozoa
Note: In order for the sperm to enter the egg, it releases
hyaluronidase (proteolytic enzyme)
After that, a zygote is formed.
Note: Fertilization occur in 3 factors: (a) egg and sperm must be mature, (b)
ability of sperm to reach egg, (c) ability of sperm to penetrate.

2. Implantation
Implantation. Contact between the growing structure and uterine
endometrium, occurs approximately 8 to 10 days after fertilization.
 Occurs high in uterus on the posterior surface
 Zygote migrate toward the body of uterus in 3 to 4 days
 Mitotic cell division occurs

Process:
24 hours- cleavage occurs
Every 22 hours- cleavage division continues
Next 3 to 4 days- large cells collect periphery of the ball.
Trophoblast (outer ring) forms placenta and membranes.
Embryoblast (inner ring) forms the embryo.
8 to 10 days- implantation
Note: if the implantation is low in the uterus, the growing placenta may block
the cervix and make birth child difficult.

C. Embryonic and Fetal Structure

 Placenta and Membranes- serve as the fetal lungs, kidneys, and digestive tracts in
utero as well as help provide protection for the fetus.

1. Decidua 0r uterine Lining

This structure continues to grow in thickness and vascularity instead of falling
off and it will be discarded after birth of child.

2. Chorionic Villi
It is a miniature villus, resembling probing fingers that reach out from
trophoblast cell into uterine endometrium.
It has:
a. Central core- composed of connective tissue and fetal capillaries
-surrounded by double layers that produce placental hormones
(hCG, hPL,estrogen and progesterone) . double layers named
syncytiotrophoblast and cytotrophoblast.

3. Placenta
Latin for “pancake”, 15 to 20 cm in diameter and 2 to 3 cm in depth.
Provides oxygen and nutrients to fetus, and removes waste products from
baby’s blood.

a. Circulation
  12th day of pregnancy, maternal blood begins to collect in the
intervillous spaces of the uterine endometrium surrounding
chorionic villi.
 3rd week, oxygen and other nutrients from the maternal blood
through the cell layers of chorionic villi into villi capillaries
 50 ml/min at 10 weeks to 500 to 600 ml/min at term
Note: Woman should not take nonessential drugs during pregnancy
because it can cause diorders such as unusual facial features, low-set ears
and cognitive challenge.
Note: Mother should lie on her left side because it lifts the uterus away
from the inferior vena cava, prevent blood trap in lower extremities.
b. Endocrine function
 Human Chorionic Gonadotropin
First placental hormone produce that can be found in maternal
blood and urine.
Levels vary throughout pregnancy
Act as a fail-safe measure to ensure the corpus luteum of the ovary
to continues to produce progesterone ans estrogen so the uterine
lining maintain.
Suppress maternal immunologic response

 Progesterone
Hormone that maintains pregnancy
Maintain endometrial lining and present in maternal serum as early
as the 4th week as aresult, continuation of corpus luteum
Reduce contractility of uterus during pregnancy, thus preventing
premature labor.

 Estrogen
Hormone of women
Second product of the syncytial cells of placenta
Contributes to woman’s mammary gland development in lactation
Stimulates uterine growth to accommodate the developing fetus.

 Human Placental Lactogen (Human Chorionic

Somatomammotropin)
Hormone with both growth-promoting and lactogenic properties
Produce by the placenta beginning as early 6 th week, increasing to
a peak level at term
Promotes mammary gland growth in preparation for lactation in
mother.
Serve the important role of regulating maternal glucose, protein
and fat levels so adequate amount of these nutrients available to
the fetus.

c. Placental proteins
Note: Has not been well documented, but may contribute decreasing
immunologic impact of growing placenta and help prevent hypertension

4. Amniotic Membranes
Forms beneath the chorion, it is a dual-walled sac with the chorion as the
outermost part and the amnion as the innermost part.
Have no nerve supply, so when spontaneously rupture at term or are
artificially ruptured via a procedure, neither the mother or fetus experiences
any pain.
 Offers support to amniotic fluid and produces the fluid.
Produces a phospholipid that initiates the formation of prostaglandins. May
triggers that initiates labor.

5. Amniotic Fluid
Shield the fetus against pressure or a blow to the mother’s abdomen
Aids muscular development and allows fetus to move freely
It protects the umbilical cord from pressure, thus protecting the fetal oxygen
supply
Slightly alkaline, with a pH of about 7.2
Never become stagnant because it is constantly being newly formed and
absorbed by direct contact with the fetal surface of placenta.
Ranges from 800 to 1,200 ml

Note: Hydramnios- excessive amniotic fluid (more than 2,000 ml, larger than
8 cm on ultrasound)
Note: Oligohydramnios- a reduction in the amount of amniotic fluid

6. Umbilical Cord
Formed from the fetal membranes, the amnion and chorion, and provides a
circulatory pathway that connects the embryo to the chorionic villi of
placenta.
Transport oxygen and nutrients to the fetus from the placenta and to return
waste products from the fetus to the placenta,
About 53 cm (21 in) in length and 2 cm (0.75) thick
The bulk of chord contains Wharton jelly, gives cord body and prevents
pressure on the vein and arteries that pass through it.
Contains only one vein and two arteries.
Rapid of blood flow is rapid (350 ml/min)

D. Origin and Development of Organ System

1. Stem Cells
 4 days of life- totipotent stem cells
 Another 4 days- pluripotent stem cells
 Another few days- multipotent

2. Zygote Growth
Cephalocaudal- a head to tail direction

3. Primary Germ Layers

Ectoderm, Mesoderm and Endoderm (pp. 181, table 9.2 origin of body tissue)

4. Cardiovascular System
1st system to become functional in intrauterine life
 16th day- network of blood and single heart tube
 24th day- beats
 6th or 7th week- septum develops
 7th week- heart valves develop
 10th or 12th week- heartbeat heard Doppler instrument
 11th week- ECG may be recorded

a. Fetal Circulation
Blood is highly oxygenated and enterd through umbilical vein,
 Infant’s oxygen saturation level- 95% to 100% and pulse rate- 80 to 140
beats/min

b. Fetal Hemoglobin
Different composition that differs from adult hemoglobin)
More concentrated and has greater affinity, 2 features that increase its
efficiency
Newborn’s hemoglobin level- 17.1 g/ml while adult’s hemoglobin- 11g/ml
Newborn’s hematocrit- 53% while adult’s hematocrit- 45%

5. Respiratory System
3rd week of intrauterine life
Exist as a single tube with digestive tract
 End 4th week- septum divide the esophagus from traches; lung buds appear on
trachea
 End of 7th week- diaphragm does not completely divide the thoracic cavity
from the abdomen
 3 months of gestation and continues- spontaneous respiratory practice
movement
 After birth- specific lung fluid is rapidly absorbed
 24th week- surfactant formed and excreted by alveolar cells.

Note: Surfactant has 2 components: lecithin and sphingomyelin.

6. Nervous System
Begins to develop extremely early in pregnancy
 3rd week of gestation- neural plate
 All parts of brain form in utero but none are completely mature
 8th week- brain waves detected on EEG
 24 weeks- ear and eye respond

7. Endocrine System
 Fetal pancreas produce insulin
 Thyroid and parathyroid gland plays vital role in fetal metabolic function and
calcium balance
 Fetal adrenal glands supply precursor for estrogen synthesis by placenta

8. Digestive System
4th week of intrauterine life- separate from respiratory tract
Rapidly grow
 6th week- intestine become too large to be contained in the abdomen
 10th week- portion of intestine pushed into the base of umbilical cord
 16th week- meconium produce
 36th week- secrete enzymes essential for carbs and protein digestion

Note: Omphalocele- intestine remains outside the abdomen in the base of the
cord
Gastroschisis- similar defect, occurs when the original midline fusion that
occurred at the early cell stage is incomplete.
Gastrointestinal tract is sterile before birth
Liver is also active and filter between incoming blood and fetal circulation
and as a deposit site for fetal stores such as iron and glycogen,

9. Musculoskeletal System
 1st 2 weeks- cartilage prototypes provide position and support to the fetus
 12th week- ossification of cartilage bone begins
  11th week- fetus can be seen move on ultrasonography
 16th to 2oth week0 movement of fetus

10. Reproductive System

Sex can be determined at the moment of the conception by a spermatozoon carrying
an X or Y chromosome
 8Th weeks- chromosomal analysis on mother’s bloodstream

11. Urinary System

Presence of kidneys does not appear because the placenta clears the fetus’ waste
products
Fetal urine is being excreted at a rate of up to 500 ml/day

12. Integumentary System

Skin is covered by soft downy hairs (lanugo), it serves as insulation to preserve
warmth in the utero
 36th weeks- skin of fetus appears thin and translucent

13. Immune System

 Early 20th week and by 24th week- Immunoglobin G antibodies cross the
placenta into the fetus
 Fetal has no natural immunity
 Fetus only becomes capable of active antibody produce in late pregnancy
 IgA and IgM cannot cross the placenta

14. Milestones of Fetal Growth and Development (pp. 186 to 187, volume 1)

15. Determination of Estimated Birth Date

Using the Naegele’s rule , a standard method used to predict the length of pregnancy

E. Assessment of Fetal Growth and Development

 Predict outcome of pregnancy
 Manage the remaining weeks of pregnancy
 Plan for possible complications at birth
 Plan for problems that may occur in the newborn infant
 Decide whether to continue the pregnancy
 Find the conditions that may affect future pregnancies
 Nurse must: (a) Verify a signed content, (b)certain that woman and her support
are aware of what procedure, potential risks, (c) prepare woman physically and
psychologically, (d) provide support, € assess both maternal and fetal response
before an dafter procedure, (e)provide follow-up care and manage equipment and
specimen, (f) quiet listening

1. Health History
 Ask mother any prepregnancy illness
 Ask about any drugs a woman intake
 Ask about personal habit
 Ask if woman had any exposure to teratogens
 Ask unintentional injuries and partner violence

2. Physical Examination
 Assess maternal weight and general appearance

3. Estimating Fetal Health

a. Fetal Growth
  12 weeks- over symphysis pubis
 20 weeks- at umbilicus
 36 weeks- at xiphoid process
 McDonald’s Rule- a symphysis-fundal height measurement
-easy method of determining midpregnancy
growth

4. Assessing Fetal Well-Being

 Fetal Heart Rate
 10th to 11th week- heard and counted by use of an ultrasound Doppler
technique
 Daily Fetal movement Count (Kick Counts)
 18th to 20th weeks- quickening
 28th to 38th weeks- peaks intensity of quickening
 Rhythm Strip Testing- assessment of fetal well-being and assess the
fetal heart for a normal baseline rate
 Nonstress Testing- measures the response of the fetal heart rate to fetal
movement
 Vibroacoustic Stimulation- applied to mother’s abdomen to produce a
sharp sound of approx..80 dB at a frequency of 80 Hz thus startling
and waking the fetus
 Ultrasonography- measures the response of sound waves solid objects,
a much used tool for fetal health assessment
o Biparietal Diameter (side to side measurement) : 8.5 cm(head)
and 2,500g (weigh at age of 40th weeks)
o Doppler Umbilical Velocimetry: measures the velocity at
which RBC in the uterine and fetal vessels travel
o Placental Grading for Maturity: placenta can be graded on
particular amount of calcium deposits presen in base
o Amniotic Fluid Volume: another way to estimate fetal health
because of the portion of fluid formed by fetal kidney output
o Nuchal Translucency: pockets fats or fluid in posterior neck
 Biophysical Profile- combines 5 parameters (fetal reactivity, fetal
breathing movements, fetal body movements, fetal tone and amniotic
fluid volume)
 Magnetic Resonance Imaging: -fetal assessment technique because it
identifies structural anomalies/ soft tissue disorder
 Maternal Serum- no, of trophoblast cell pass in maternal bloodstream
beginning at 7th week
o Maternal Serum α-Fetoprotein: produced by fetal liver, found
in both amniotic fluid and maternal serum
o Maternal Serum for Pregnancy-Associated Plasma Protein A:
secreted by placenta, low levels in maternal blood are
associated with fetal chromosomal anomalies
 Quadruple Screening-analyzes 4 indicators of fetal health AFP,
unconjugated estriol, hCG and inhibitin.
 Fetal Gender-determined by ultrasound screen about 4th months,
determined as early as 7 weeks by maternal serum
 Invasive fetal testing-Amniotic fluid can be analyzed for: AFP,
Acetylcholinesterase, Bilirubin determination, Chromosome analysis,
Color, Fibronectin, Inborn errors of metabolism, L/S ratio, and
Phosphatidylyglycerol and desaturated phosphatidylcholine
 Percutaneous Umbilical Blood Sampling- aspiration of blood from the
umbilical vein for analysis
 Fetoscopy- fetus is visualized by inspection through a fetoscope