CHAPTER 9 Nursing Care of the Growing Fetus 199

extrauterine life as it would have in utero. Testes that do not Milestones of Fetal Growth and
descend (cryptorchidism) require surgery as they are associ- Development
ated with poor sperm production and possibly testicular can-
cer later in life (Zeitler, Travers, Nadaou, et al., 2011). When fetal milestones occur can be confusing because the life
of the fetus is typically measured from the time of ovulation
Urinary System or fertilization (ovulation age), but the length of a pregnancy
is more commonly measured from the first day of the last
Although rudimentary kidneys are present as early as the end menstrual period (gestational age). Because ovulation and
of the fourth week of intrauterine life, the presence of kidneys fertilization take place about 2 weeks after the last menstrual
does not appear to be essential for life before birth because the period, the ovulation age of the fetus is always 2 weeks less
placenta clears the fetus of waste products. Urine, however, than the length of the pregnancy or the gestational age.
is formed by the 12th week and is excreted into the amni- Both ovulation and gestational age are typically reported
otic fluid by the 16th week of gestation. At term, fetal urine in lunar months (4-week periods) or in trimesters (3-month
is being excreted at a rate of up to 500 ml/day. An amount periods) rather than in weeks. In lunar months, a total preg-
of amniotic fluid less than usual (oligohydramnios) suggests nancy is 10 months (40 weeks, or 280 days) long; a fetus
fetal kidneys are not secreting adequate urine and that there is grows in utero for 9.5 lunar months or three full trimesters
a kidney, ureter, or bladder disorder (Kumar, 2012). (38 weeks, or 266 days).
The complex structure of the kidneys gradually devel- The following discussion of fetal developmental milestones
ops during intrauterine life and continues to mature for is based on gestational weeks, because it is helpful when talk-
months afterward. The loop of Henle, for example, is not ing to expectant parents to correlate fetal development with
fully differentiated until the child is born. Glomerular fil- the way they measure pregnancy—from the first day of the
tration and concentration of urine in the newborn are still last menstrual period. Figure 9.6 illustrates the comparative
not efficient, because the ability to concentrate urine is still size and appearance of human embryos and fetuses at differ-
not mature at birth. ent stages of development.
Early in the embryonic stage of urinary system develop-
ment, the bladder extends as high as the umbilical region and End of Fourth Gestational Week
there is an open lumen between the urinary bladder and the
• The length of the embryo is about 0.75 cm; weight is
umbilicus. If this fails to close, (termed a patent urachus),
about 400 mg.
this is revealed at birth by the persistent drainage of a clear,
• The spinal cord is formed and fused at the midpoint.
acid–pH fluid (urine) from the umbilicus (Samra, McGrath,
• The head is large in proportion and represents about one
& Wehbe, 2011).
third of the entire structure.
• The rudimentary heart appears as a prominent bulge on
Integumentary System
the anterior surface.
The skin of a fetus appears thin and almost translucent until • Arms and legs are bud-like structures; rudimentary eyes,
subcutaneous fat begins to be deposited underneath it at ears, and nose are discernible.
about 36 weeks. Skin is covered by soft downy hairs (lanugo)
that serve as insulation to preserve warmth in utero, as well as End of Eighth Gestational Week
a cream cheese–like substance, vernix caseosa, which is impor- • The length of the fetus is about 2.5 cm (1 in.); weight is
tant for lubrication and for keeping the skin from macerating about 20 g.
in utero. Both lanugo and vernix are still present at birth. • Organogenesis is complete.
• The heart, with a septum and valves, beats rhythmically.
Immune System • Facial features are definitely discernible; arms and legs have
Immunoglobulin (Ig) G maternal antibodies cross the pla- developed.
centa into the fetus as early as the 20th week and certainly • External genitalia are forming, but sex is not yet distin-
by the 24th week of intrauterine life to give a fetus tempo- guishable by simple observation.
rary passive immunity against diseases for which the mother • The abdomen bulges forward because the fetal intestine is
has antibodies. These often include poliomyelitis, rubella growing so rapidly.
(German measles), rubeola (regular measles), diphtheria, tet- • A sonogram shows a gestational sac, which is diagnostic of
anus, infectious parotitis (mumps), hepatitis B, and pertussis pregnancy (Fig. 9.7).
(whooping cough). Infants born before this antibody transfer End of 12th Gestational Week (First Trimester)
has taken place have no natural immunity and so need more
than the usual protection against infectious disease in the • The length of the fetus is 7 to 8 cm; weight is about 45 g.
newborn period. • Nail beds are forming on fingers and toes.
A fetus only becomes capable of active antibody produc- • Spontaneous movements are possible, although they are
tion late in pregnancy. Generally, it is not necessary for a usually too faint to be felt by the mother.
fetus to produce antibodies because they need to be manu- • Some reflexes, such as the Babinski reflex, are present.
factured only to counteract an invading antigen, and anti- • Bone ossification centers begin to form.
gens rarely invade the intrauterine space. Because IgA and • Tooth buds are present.
IgM antibodies (the types which develop to actively coun- • Sex is distinguishable on outward appearance.
teract infection) cannot cross the placenta, their presence • Urine secretion begins but may not yet be evident in
in a newborn is proof that the fetus has been exposed to an amniotic fluid.
infection. • The heartbeat is audible through Doppler technology.

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 200 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period

A B C D

FIGURE 9.6 Human embryos at different stages of life. (A) Implantation in uterus 7
E to 8 days after conception. (B) The embryo at 32 days. (C) At 37 days. (D) At 41 days.
(E) Between 12 and 15 weeks. (Petit Format/Nestle/Science Source/Photo Researchers.)

End of 16th Gestational Week • The fetus actively swallows amniotic fluid, demonstrating
an intact but uncoordinated swallowing reflex; urine is
• The length of the fetus is 10 to 17 cm; weight is 55 to 120 g. present in amniotic fluid.
• Fetal heart sounds are audible by an ordinary stethoscope. • Sex can be determined by ultrasonography.
• Lanugo is well formed.
• Both the liver and pancreas are functioning.
End of 20th Gestational Week
• The length of the fetus is 25 cm; weight is 223 g.
• Spontaneous fetal movements can be sensed by the mother.
• Antibody production is possible.
• Hair, including eyebrows, forms on the head; vernix
caseosa begins to cover the skin.
• Meconium is present in the upper intestine.
• Brown fat, a special fat that aides in temperature regula-
tion, begins to form behind the kidneys, sternum, and
posterior neck.
• Passive antibody transfer from mother to fetus begins.
• Definite sleeping and activity patterns are distinguishable
as the fetus develops biorhythms that will guide sleep/wake
patterns throughout life.

End of 24th Gestational Week

(Second Trimester)
• The length of the fetus is 28 to 36 cm; weight is 550 g.
• Meconium is present as far as the rectum.
• Active production of lung surfactant begins.
• Eyelids, previously fused since the 12th week, now open;
pupils react to light.
FIGURE 9.7 Sonogram showing the characteristic circle • Hearing can be demonstrated by response to sudden sound.
diagnostic of pregnancy (the gestational sac). (From Benson, • When fetuses reach 24 weeks, or 500–600 g, they have
C. B., Lavery M. J., & Platt, L. [1988]. Atlas of obstetrical ultra- achieved a practical low-end age of viability if they are
sound. Philadelphia, PA: J. B. Lippincott.) cared for after birth in a modern intensive care nursery.

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 CHAPTER 9 Nursing Care of the Growing Fetus 201

End of 28th Gestational Week BOX 9.3 Naegele’s Rule

• The length of the fetus is 35 to 38 cm; weight is 1,200 g.
• Lung alveoli are almost mature; surfactant can be demon- To calculate the date of birth by this rule, count
strated in amniotic fluid. backward 3 calendar months from the first day of a
• Testes begin to descend into the scrotal sac from the lower woman’s last menstrual period and add 7 days. For
abdominal cavity. example, if the last menstrual period began May 15,
• The blood vessels of the retina are formed but thin and you would count back 3 months (April 15, March 15,
extremely susceptible to damage from high oxygen con- February 15) and add 7 days, to arrive at the pre-
centrations (an important consideration when caring for dicted date of birth as February 22.
preterm infants who need oxygen).

End of 32nd Gestational Week

“confined” after childbirth, the acronym EDB (estimated
• The length of the fetus is 38 to 43 cm; weight is 1,600 g. date of birth) is more commonly used today.
• Subcutaneous fat begins to be deposited (the former If fertilization occurred early in a menstrual cycle, the
stringy, “little old man” appearance is lost). pregnancy will probably end “early”; if ovulation and fer-
• Fetus responds by movement to sounds outside the tilization occurred later than the midpoint of the cycle, the
mother’s body. pregnancy will end “late.” Because of these normal variations,
• An active Moro reflex is present. a pregnancy ending 2 weeks before or 2 weeks after the calcu-
• Iron stores, which provide iron for the time during which lated EDB is considered well within the normal limit (38 to
the neonate will ingest only breast milk after birth, are 42 weeks). Gestational age wheels and birth date calculators,
beginning to be built. which can be used to predict a birth date are available, but
• Fingernails reach the end of fingertips. calculation by Naegele’s rule is the standard method used to
predict the length of a pregnancy (Box 9.3).
End of 36th Gestational Week
• The length of the fetus is 42 to 48 cm; weight is 1,800 to What if...9.2 Liz Calhorn first came to your
2,700 g (5 to 6 lb). prenatal clinic on August 5 and told you she had
• Body stores of glycogen, iron, carbohydrate, and calcium her last menstrual period from March 13 to March 18.
are deposited. What would be her child’s EDB?
• Additional amounts of subcutaneous fat are deposited.
• Sole of the foot has only one or two crisscross creases, com-
pared with a full crisscross pattern evident at term.
• Amount of lanugo begins to diminish.
• Most babies turn into a vertex (head down) presentation
ASSESSMENT OF FETAL GROWTH
during this month. AND DEVELOPMENT
End of 40th Gestational Week (Third Trimester) Tests for fetal growth and development are commonly done
for a variety of reasons, including to:
• The length of the fetus is 48 to 52 cm (crown to rump, 35
to 37 cm); weight is 3,000 g (7 to 7.5 lb). • Predict the outcome of the pregnancy
• Fetus kicks actively, sometimes hard enough to cause the • Manage the remaining weeks of the pregnancy
mother considerable discomfort. • Plan for possible complications at birth
• Fetal hemoglobin begins its conversion to adult hemoglobin. • Plan for problems that may occur in the newborn infant
• Vernix caseosa is fully formed. • Decide whether to continue the pregnancy
• Fingernails extend over the fingertips. • Find conditions that may affect future pregnancies
• Creases on the soles of the feet cover at least two thirds of Both fetal growth and development can be compromised if a
the surface. fetus has a metabolic or chromosomal disorder that interferes
In primiparas (i.e., women having their first baby), the with normal growth, if the supporting structures such as the
fetus often sinks into the birth canal during the last 2 weeks placenta or cord do not form normally, or if environmen-
of pregnancy, giving the mother a feeling the load she is carry- tal influences such as the nicotine in cigarettes causes fetal
ing is less. This event, termed lightening, is a fetal announce- growth restriction (including testes growth in a male fetus)
ment the third trimester of pregnancy has ended and birth is (Virtanen, Sadov, & Toppari, 2012).
at hand. Nursing responsibilities for these assessment procedures
include verifying that a signed consent form has been ob-
Determination of Estimated Birth Date tained as needed (which is necessary if the procedure poses
any risk to the mother or fetus that would not otherwise be
It is impossible to predict with a high degree of accuracy the present), being certain the woman and her support person are
exact day an infant will be born because fewer than 5% of aware of what the procedure will entail and any potential risks,
pregnancies end exactly 280 days from the last menstrual pe- preparing the woman physically and psychologically, provid-
riod; fewer than half end within 1 week of the 280th day. ing support during the procedure, assessing both fetal and
Traditionally, this date was referred to as the estimated maternal responses during and after the procedure, provid-
date of confinement (EDC). Because women are no longer ing any necessary follow-up care, and managing equipment

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 202 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period

BOX 9.4 Nursing Care Planning

A INTERPROFESSIONAL CARE MAP FOR A WOMAN UNDERGOING

AN
FETAL
FETA
FE TAL
L ST
STUD
STUDIES
UDIE
IESS
Liz Calhorn, an 18-year-old, is about 20 weeks pregnant states, “Feeling the baby move made me realize there’s
(can’t remember date of last menstrual period). Although someone inside me, you know what I mean? It made me
she says she knows she should have stopped smoking realize it’s time I started being more careful with what I
before pregnancy, she has not been able to do this as do.” Liz works at a fast food restaurant. Boyfriend (father
yet. Twice during the pregnancy (at the 4th and 10th of fetus) is supportive, but has no money to offer her for
week), she drank beer at summer picnics. Today, at a support. Client states, “I’m not getting married. Just not
clinic visit, she tells you she has felt her fetus move. She ready for that level of commitment yet.”

Family Assessment Client lives in one-bedroom apart- Snack: Half bag of potato chips and
ment; supports self by working at a fast food restaurant. cream-cheese dip.
States, “My parents would help out if I begged them, but Physical examination: Fundal height is 16 cm. Fetal heart
I’m not going to do that.” tones by Doppler at 160 beats/min. Has been advised to
have an ultrasound done to assess for fetal growth and to
Client Assessment Client smokes a pack of cigarettes a
date pregnancy.
day. Takes aspirin, 10 g, for almost daily sinus headaches.
No recreational drug use. Nursing Diagnosis Risk for altered fetal growth related to
Nutrition: Breakfast: None, to help control her weight. inadequate nutrition and alcohol and nicotine consumption.
Lunch: A hotdog and salad. One diet cola.
Outcome Criteria Client consents to sonogram for fetal
Dinner: Macaroni and cheese; applesauce.
growth assessment; reports lessened alcohol and cigarette
One cup coffee.
use at the next visit.

Team Member
Responsible Assessment Intervention Rationale Expected Outcome

Activities of Daily Living, Including Safety

Nurse Ask patient to describe Discuss common ac- Knowing what consti- Client states she
a “typical day” to tions unsafe during tutes unsafe practices will stop drinking
reveal any actions pregnancy, such as during pregnancy alcohol; is using a
possibly detrimental smoking and drink- is a woman’s best supportive Internet
to fetal growth. ing alcohol. safeguard against quitline to help
fetal harm. reduce smoking.

Teamwork and Collaboration

Primary health care Determine whether Schedule sonogram Client believes she Client reports for
provider/nurse sonogram depart- 1 week in advance might be 20 weeks scheduled ultra-
ment has appoint- with sonogram pregnant. Fundal sound in 1 week.
ments free in department. height, recent fetal
coming week. movements corre-
spond more closely
to 16 weeks.

Procedures/Medications for Quality Improvement

Nurse Assess what prescrip- Discuss with client in- Acetylsalicylic acid Client reports at next
tion or over-the- advisability of taking (aspirin) can lead prenatal visit she
counter or alterna- aspirin during preg- to bleeding or pro- takes acetamino-
tive therapies client nancy; suggest she longed pregnancy. phen for any pain.
is using. take acetaminophen
(Tylenol) instead.

Nutrition

Nurse/nutritionist Ask client for a 24-hour Discuss the advisability Knowing what consti- Client reports at prenatal
recall nutrition of eating breakfast tutes a healthy diet visits she eats break-
history. while pregnant to helps ensure a fetus fast before leaving
help avoid hypogly- will receive ade- for work in the morn-
cemia in fetus. quate nutrients. ing. Includes more
protein in intake.

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 CHAPTER 9 Nursing Care of the Growing Fetus 203

Patient-Centered Care

Nurse Determine whether Instruct client about A well-prepared cli- Client will describe
client understands preparation for so- ent is more apt to accurate prepara-
ultrasound is not nogram (drink fluid; result in an effective tions for procedure.
an X-ray, so it is not avoid emptying procedure and a Receives printed
harmful to the fetus. bladder). satisfied client. instructions for am-
bulatory ultrasound.

Spiritual/Psychosocial/Emotional Needs

Primary health care Assess the extent of Review the possibility Understanding con- Client states she
provider/nurse factors, such as al- with client that her tributors to fetal understands the dis-
cohol and cigarette pregnancy dating health is necessary crepancy in fundal
use, that could have may be wrong, be- for women to make height and weeks
led to intrauterine cause fundal height informed choices gestation following
growth restriction. is below usual. Al- during pregnancy. explanation.
ternate cause could
be fetal growth
restriction.

Informatics for Seamless Health Care Planning

Nurse/Primary health Perform complete Mark chart as high-risk Documenting risk fac- The patient chart
care provider assessment to help client for intrauter- tors helps to safe- documents high-risk
ensure continuity ine growth restric- guard the fetus. status.
of care with other tion (fundal height
services. below average for
weeks gestation).

and specimens. Box 9.4 shows an interprofessional care map insulin balance and fetal growth. Most women are aware
illustrating both nursing and team planning for fetal care, in- alcohol ingestion can harm a fetus (e.g., fetal alcohol spec-
cluding assessment procedures. trum disorder) but many are not yet aware of fetal tobacco
Providing follow-up care may include being certain a syndrome (Wong, Ordean, & Kahan, 2011).This syndrome
couple understands what the results of a test mean. When a applies to the fetus of a woman who smokes more than five
result is good, parents feel assured their infant is growing well. cigarettes a day and who is born growth restricted (i.e., birth
When results are not encouraging, a couple can experience a weight under 2,500 g at term). Smoking may also be a cause
mixture of feelings. On the one hand, they feel committed of ectopic (tubal) pregnancy as fallopian tubes may become
to the pregnancy; on the other, they want to protect their irritated (Shao, Zou, Wang, et al., 2012).
child, themselves, and their family from the burden of having Most women instinctively protect a fetus growing inside
a child with a severe disability. In some instances, they will be them so pregnancy may be the push they need to improve
asked to make a life and death decision depending on the re- their lifestyle (Box 9.5). Asking if a woman has had any ex-
sults. Quiet listening so a couple has time to thoroughly think posure to teratogens can reveal exposure to such substances as
through what option will be right for them may be difficult to chemicals, paint fumes, cleaning products, poor air quality,
do but is usually the soundest action for health care providers or a loud noise level (Krueger, Horesh, & Crossland, 2012).
(Choi, Van Riper, & Thoyre, 2012). Asking about unintentional injuries or intimate partner vio-
lence can help reveal whether a fetus could have suffered any
Health History trauma from these sources (e.g., intimate partner violence
tends to increase during pregnancy because of the stress a
Like all assessments, a fetal assessment begins with a health pregnancy can create; Dalton, 2012).
history. Ask the mother specifically about any prepregnancy
illnesses such as gestational diabetes or heart disease as these Physical Examination
both can interfere with fetal growth. Ask about any drugs a
woman takes; for instance, common drugs taken for recur- A physical examination of the mother is the second step in
rent seizures can be teratogenic and therefore pose a risk in evaluating fetal health. Assess maternal weight and general
pregnancy (Mawhinney, Campbell, Craig, et al., 2012). Ask appearance, as both obesity and underweight are clues that
also about nutritional intake because if a woman is not eating the mother’s nutrition may not be adequate for sound fetal
a well-balanced diet, she may not be taking in enough nutri- growth (Warren, Rance, & Hunter, 2012). Bruises may
ents for fetal growth (Whitney & Rolfes, 2012). Be certain to indicate intimate partner violence that could have bruised the
also ask about personal habits such as cigarette smoking, both fetus as well. An elevated blood pressure may be the begin-
prescription and recreational drug use, alcohol consump- ning of hypertension of pregnancy, which can restrict fetal
tion, and exercise, because all of these may influence glucose/ growth (Vest & Cho, 2012).

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 204 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period

BOX 9.5 Nursing Care Planning to Based on the previous study, which statement by Liz Calhorn
Respect Cultural Diversity would make you most worried she might have difficulty quit-
ting smoking during the remainder of her pregnancy?
Different cultures have different ideas as to what foods to
eat, how much exercise is good during pregnancy, and a. “I don’t have a lot of spare cash, just like everyone else in
whether fetal tests for well-being are ethical. Whether a my family.”
woman’s religion or personal beliefs allow her to use reli- b. “When I feel tense, I like to shop. It really takes away that
able conception can influence whether she is happy to bad feeling.”
discover she is pregnant, which can then influence how c. “I’m trying to stop smoking so I won’t have to smoke
soon she goes for prenatal care or begins to eat a more around my baby.”
nutritious diet. If her religion is one that mandates she d. “My mother had five children with no trouble; why am I so
have a large family to increase the number of members different?”
in her religion, she may be happy to be pregnant, but Look in Appendix A for the best answer and rationale.
also unsure she can love this additional child.
Cultural beliefs also affect everyday things, such as be-
lieving it is wrong to have a photograph taken during preg-
nancy because that will alert unknown spirits that the woman
Estimating Fetal Health
is pregnant (the origin of lullabies were songs to keep away A number of procedures, both noninvasive and invasive, are
Lilith, an avenging creature in Jewish folklore who was used to evaluate fetal health. Because there are many proce-
thought to bring harm to babies). Believing photographs are dures, helping a woman with a high-risk pregnancy maintain
harmful may make a woman reluctant to have a sonogram a sense of control or empowerment as she is scheduled for
taken during pregnancy; unlike most women, she may not them is an important nursing responsibility (Box 9.6).
like a photograph of the ultrasound for a baby keepsake.
Fetal Growth
As a fetus grows, the uterus expands to accommodate its size.
Although not evidence grounded, typical fundal (top of the
✔ QSEN Checkpoint Question 9.4 uterus) measurements are:
Evidence-Based Practice • Over the symphysis pubis at 12 weeks
• At the umbilicus at 20 weeks
To investigate what the risk factors are that lead to women • At the xiphoid process at 36 weeks
smoking, researchers surveyed 570 women from Appalachian
Ohio as to social, demographic, and psychological factors McDonald’s rule, another symphysis–fundal height mea-
and whether they smoked. Findings revealed women with low surement (although, again, not documented to be thoroughly
socioeconomic status, those who scored high on a depression reliable), is an easy method of determining midpregnancy
assessment score, and those who had their first baby before growth. Typically, tape measurement from the notch of the
they were 17 years of age were more likely to smoke. Almost symphysis pubis to over the top of the uterine fundus as a
50% of women with both low socioeconomic status and rated woman lies supine is equal to the week of gestation in centi-
as depressed smoked (Wewers, Salsberry, Ferketich, et al., meters between the 20th and 31st weeks of pregnancy (e.g.,
2012). in a pregnancy of 24 weeks, the fundal height should be
24 cm) (Fig. 9.8).

BOX 9.6 Nursing Care Planning to Empower a Family

Women may find the names of tests like MSAFP and sub- • Don’t refer to a fetus as “it” during testing because that
stances being tested for (acetylcholinesterase) so confusing is such an impersonal term. If the woman has chosen a
that they feel as if their life is being taken over by scheduled name, use that while referring to her fetus; otherwise,
tests or exams. To help a woman maintain control: use he or she.
• Encourage her to ask questions until her primary health • Respect modesty during exams where the woman’s abdo-
care provider simplifies instructions or test results men will be exposed. Movie stars are often pictured today
enough that she thoroughly understands them. with their pregnant abdomen on view, but not every
• Encourage her to set the time and date of appointments woman wants her body exposed unnecessarily that way.
if possible so she can fit fetal testing in with her sched- • Remember that late in pregnancy, women’s movements
ule, rather than be expected to appear “on command.” can be painful and may feel awkward, so respect that
• Encourage her to bring her significant other with her for asking a woman to step up and lie on an examining
fetal testing so he/she hears the same explanation she table is not asking her to complete an easy task. Offer
does and so that person can also ask questions rather help as necessary but also remember feeling indepen-
than hearing the information second hand. dent is an empowering feeling.

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 CHAPTER 9 Nursing Care of the Growing Fetus 205

FIGURE 9.8 Measuring fundal height from the superior FIGURE 9.9 Measuring fetal heart rate with a Doppler
aspect of the pubis to the fundal crest. The tape is pressed flat transducer, which detects and broadcasts the fetal heart rate to
against the abdomen for the measurement. the parents-to-be, as well as you.

A fundal height much greater than this standard suggests a this time, so lack of typical movements may not be serious,
multiple pregnancy, a miscalculated due date, a large-for-gesta- but it is an indication for further assessment.
tional-age (LGA) infant, hydramnios (increased amniotic fluid Kick counts are particularly useful in growth-restricted or
volume), or possibly even gestational trophoblastic disease (see postterm pregnancies to reveal if a fetus is still receiving ad-
Chapter 21). A fundal measurement much less than this suggests equate nutrition (Caughey, 2012). Make certain the woman
the fetus is failing to thrive (e.g., intrauterine growth restriction), knows fetal movements do vary, especially in relation to sleep
the pregnancy length was miscalculated, or an anomaly interfer- cycles, her activity, and the time since she last ate. Otherwise,
ing with growth has developed. McDonald’s rule becomes inac- she can become unduly worried her fetus is in jeopardy when
curate during the third trimester of pregnancy because the fetus the fetus is asleep or just having an inactive time.
is growing more in weight than in height during is time.
Assessing Fetal Well-being What if...9.3 You give instructions to Liz
Calhorn to count fetal movements (count kicks)
A number of actions or procedures are helpful in detecting
daily after lunch and she tells you she can’t do that
and documenting the fetus is not only growing but is also
because she snacks all day long rather than eats at regular
apparently healthy.
times. Which would be more important: that she should
Fetal Heart Rate count kicks after meals or that she do it every day?

Fetal heart sounds can be heard and counted as early as the

10th to 11th week of pregnancy by the use of an ultrasound Rhythm Strip Testing. The term “rhythm strip testing” refers to
Doppler technique (Fig. 9.9). This is done routinely at every an assessment of the fetal heart rate for whether a good baseline
prenatal visit past 10 weeks. rate and both long- and short-term variability are present. For
this, help the woman into a semi-Fowler’s position (either in a
Daily Fetal Movement Count (Kick Counts) comfortable lounge chair or on an examining table or bed with
an elevated backrest) to prevent her uterus from compressing
Fetal movement that can be felt by the mother (quickening) the vena cava and causing supine hypotension syndrome during
occurs at approximately 18 to 20 weeks of pregnancy and peaks the test. Attach an external fetal heart rate monitor abdominally
in intensity at 28 to 38 weeks. After that time, a healthy fetus (Fig. 9.10A). Record the fetal heart rate for 20 minutes.
moves with a degree of consistency, at about 10 times per hour. The baseline reading refers to the average rate of the fetal
In contrast, a fetus who is not receiving enough nutrients be- heartbeat. Short-term variability (also called beat-to-beat vari-
cause of poor maternal nutrition or placental insufficiency has ability) denotes the small changes in rate that occur from sec-
greatly decreased movements. The technique for “kick counts” ond to second if the fetal parasympathetic nervous system is
varies from institution to institution, but a typical method used receiving adequate oxygen and nutrients. In the rhythm strip
is to ask women with high-risk pregnancies to: in Figure 9.10B, for example, the baseline (average) of the fetal
• Lie in a left recumbent position after a meal. heartbeat is 130 beats/min. Beat-to-beat variability is present.
• Observe and record the number of fetal movements (kicks) Long-term variability reflects the state of the fetal sym-
their fetus makes until they have counted 10 movements. pathetic nervous system. On a rhythm strip, it is the differ-
• Record the time (typically this is under an hour). ences in heart rate that occur over the 20-minute time period.
• If an hour passes without 10 movements, they should walk Note in Figure 9.10B how the heart rate varies from 150 to
around a little and try a count again. 130 beats/min. Because the average fetus moves about twice
• If 10 movements (kicks) cannot be felt in a second 1-hour every 10 minutes, and movement causes the heart rate to in-
period, they should telephone their primary health care crease, there will typically be two or more instances of fetal
provider. The fetus could be healthy but sleeping during heart rate acceleration in a 20-minute rhythm strip.

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