When you have completed this unit you should be able to: • Assess normal fetal growth. • List the causes of intra-uterine growth restriction. • Understand the importance of measuring the symphysis-fundus height. • Understand the clinical significance of fetal movements. • Use a fetal-movement chart. • Manage a patient with decreased fetal movements. • Understand the value of antenatal fetal heart rate monitoring.

1. “
”
Assessment of fetal growth and
condition during pregnancy
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2. Objectives
 When you have completed this unit you should be able to:
 • Assess normal fetal growth.
 • List the causes of intra-uterine growth restriction.
 • Understand the importance of measuring the symphysis-fundus
height.
 • Understand the clinical significance of fetal movements.
 • Use a fetal-movement chart.
 • Manage a patient with decreased fetal movements.
 • Understand the value of antenatal fetal heart rate monitoring.
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3. The condition of the fetus before
delivery is assessed by:
 1. Documenting fetal growth.
 2. Recording fetal movements.
 What is normal fetal growth?
 If the assessed fetal size is within the expected range for the duration of pregnancy, then the fetal
growth is regarded as normal.
 When may fetal growth appear to be abnormal?
 Fetal growth will appear to be abnormal when the assessed fetal size is greater or less than that
expected for the duration of pregnancy. Remember that incorrect menstrual dates are the
commonest cause of an incorrect assessment of fetal growth.
 When is intra-uterine growth restriction suspected?
 Intra-uterine growth restriction is suspected when the size of the fetus is assessed as being less than
the normal range for the duration of pregnancy.
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4. What maternal and fetal factors are
associated with intra-uterine growth restriction?
 Maternal factors
 Low maternal weight, especially a low body-mass index (BMI) resulting from undernutrition.
 Tobacco smoking.
 Alcohol intake.
 Strenuous physical work.
 Poor socio-economic conditions.
 Pre-eclampsia and chronic hypertension.
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5. What maternal and fetal factors ( + placental) are
associated with intra-uterine growth restriction?
 Fetal factors
 Multiple pregnancy.
 Chromosomal abnormalities
 Severe congenital malformations.
 Chronic intra-uterine infection, e.g. congenital syphilis.
 Placental factors
 Poor placental function (placental insufficiency) is usually due to a maternal problem such as pre-eclampsia.
 Smoking. Poor placental function is uncommon in a healthy woman who does not smoke.
 If severe intra-uterine growth restriction is present, it is essential to look for a maternal or fetal cause. Usually a cause
can be found.
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6. How can you estimate fetal weight?
 The following methods can be used:
 1. Measure the size of the uterus on abdominal examination.
 2. Palpate the fetal head and body on abdominal examination.
 3. Measure the size of the fetus using antenatal ultrasonography
(ultrasound).
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11. When are fetal movements first felt?
 1. At about 20 weeks in a primigravida.
 2. At about 16 weeks in a multigravida.
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12. FETAL MOVEMENTS
Can fetal movements be used
to determine the duration of
pregnancy accurately?
 No, because the gestational age
when fetal movements are first felt
differs a lot from patient to patient.
Therefore, it is only useful as an
approximate guide to the duration of
pregnancy.
What is the value of assessing
fetal movements?
 Fetal movements indicate that the
fetus is well. By counting the
movements, a patient can monitor the
condition of her fetus.
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13. FETAL MOVEMENTS
From what stage of pregnancy will
you advise a patient to become
aware of fetal movements in order
to monitor the fetal condition?
 From 28 weeks, because the fetus can
now be regarded as potentially viable
(i.e. there is a good chance that the
infant will survive if delivered). All
patients should be encouraged to
become aware of the importance of
an adequate number of fetal
movements.
What is a fetal-movement
chart?
 A fetal-movement chart records the
frequency of fetal movements and
thereby assesses the condition of the
fetus. The name ‘kick chart’ is not
correct, as all movements must be
counted, i.e. rolling and turning
movements, as well as kicking.
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14. FETAL MOVEMENTS
What is the least number of
movements per hour which
indicates a good fetal condition?
 1. The number of movements during
an observation period is less important
than a decrease in movements when
compared to previous observation
periods. If the number of movements is
reduced by half, it suggests that the
fetus may be at an increased risk of fetal
distress.
 2. If a fetus normally does not move
much, and the count falls to 3 or fewer
per hour, the fetus may be in danger.
What would you advise if the fetal
movements suggest that the fetal
condition is not good?
 1. The mother should lie down on
her side for another hour and repeat
the count.
 2. If the number of fetal movements
improves, there is no cause for
concern.
 3. If the number of fetal movements
does not improve, she should report
this to her clinic or hospital as soon as
possible.
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15. What should the doctor/midwife do, in a hospital
without fetal heart rate monitoring equipment, if
there are decreased fetal movements?
 First make sure that the fetus is potentially viable (at least 28 weeks or 1000 g).
Further management will then depend on whether or not there are signs of
intra-uterine growth restriction:
 1. If there are clinical signs of intra-uterine growth restriction:
 • If the cervix is favourable, the membranes must be ruptured. The fetal
heart rate must be very carefully monitored with a stethoscope during labour.
 • If the cervix is unfavourable, a Caesarean section must be done.
 • If the estimated weight of the fetus is 1500 g or more, the delivery may be
managed in a level 1 or 2 hospital. However, if the estimated weight of the
fetus is less than 1500 g, then the delivery must take place in a level 2 hospital
with a neonatal intensive care unit, or a level 3 hospital.
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16. What should the doctor do, in a hospital without fetal
heart rate monitoring equipment, if there are
decreased fetal movements?
 2. If there are no clinical signs of intra-uterine growth restriction:
 • If the cervix is favourable and the pregnancy is of more than 36
weeks duration, the membranes should be ruptured. The fetal heart rate
must be carefully monitored with a stethoscope during labour.
 • If the cervix is unfavourable, and the patient is more than 42 weeks
pregnant, a Caesarean section must be done.
 • If the patient does not fall into either of the above-mentioned
categories, she must be observed for a further 6 hours in hospital. If there is
no improvement in the number of fetal movements, the patient must be
referred to a hospital which has facilities for electronic fetal heart rate
monitoring.
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17. Antenatal fetal heart rate
monitoring
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18. What is antenatal fetal heart rate
monitoring?
 Antenatal (electronic) fetal heart rate monitoring assesses the condition of
the fetus by documenting the pattern of heart rate changes.
 It is done with a cardiotocograph (the machine) which produces a
cardiotocogram (the paper strip showing the uterine contractions and the
fetal heart rate pattern).
 Antenatal fetal heart rate monitoring is currently regarded as one of the
best ways to assess the fetal condition.
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19. When is antenatal fetal heart rate
monitoring indicated?
 1. If a patient with a viable fetus reports a decrease in fetal movements
or a poor fetal movement count which does not improve when the count is
repeated.
 2. If a high-risk patient has a condition for which the value of fetal
movement counts has not yet been proven, e.g. insulin-dependent
diabetes, preterm rupture of the membranes or severe pre-eclampsia, the
patient needs to be managed conservatively.
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20. How do you interpret an antenatal
fetal heart rate pattern?
 1. The fetal condition is good when:
 •There is a reactive (normal) fetal heart rate pattern.
 •There is a normal stress test.
 2. No comment can be made about the fetal condition when there is a non-reactive fetal
heart rate pattern.
 3. Fetal distress is present when:
 •There is an abnormal stress test.
 •There are repeated U-shaped decelerations at regular intervals, even though no contractions
are observed.
 •There is fetal bradycardia, with a fetal heart rate constantly below 100 beats per minute.
 •There is a non-reactive fetal heart rate pattern with poor variability (i.e. less than 5 beats).
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21. What are reactive and non-reactive
heart rate patterns?
 1. The fetal heart rate pattern is said to be reactive when it has at least 2
accelerations per 10 minutes, each with an amplitude (increase in the
number of beats) of 15 or more beats per minute and a duration of at least
15 seconds
 2. In a non-reactive fetal heart rate pattern there are no accelerations.
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23. What is good and poor variability in
the fetal heart rate?
 1. With good variability:
 • The variability in the heart rate will be 5 beats or more, in other words,
will involve 1 or more blocks in the cardiogram. Each block indicates 5
beats
 • Good variability indicates fetal wellbeing.
 2. With poor variability:
 • The variability in the heart rate will be less than 5 beats, in other
words, will remain within 1 block
 • The fetal heart monitoring must be repeated after 45 minutes.
 • If the poor variability persists, there is fetal distress.
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25. Why must you repeat the cardiotocogram after
45 minutes in a patient with a non-reactive fetal
heart rate pattern and poor variability?
 1. Because a sleeping fetus may have a non-reactive fetal heart rate
pattern with poor variability.
 2. A fetus does not sleep for longer than 45 minutes. In a sleeping fetus
the fetal heart rate pattern should, therefore, after 45 minutes have returned
to a reactive pattern or a non-reactive pattern with good variability.
 3. A persistent non-reactive fetal heart rate pattern with poor variability
is abnormal and indicates fetal distress.
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26. STRESS TESTS
What is a stress test?
 If contractions are present during fetal
heart rate monitoring in the antenatal
period, then the monitoring is called a
stress test. The fetal heart rate pattern
can now be assessed during the stress
of a uterine contraction.
How is a stress test interpreted?
 1. A normal stress test has no fetal
heart rate decelerations during or
following at least 2 contractions which
last at least 30 seconds
 2. An abnormal stress test has late
decelerations associated with uterine
contractions
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28. What should you do in the case of an abnormal stress test, fetal
bradycardia, repeated decelerations, or a non-reactive fetal
heart rate pattern with persistent poor variability?
 1. The patient is managed as an acute emergency as these fetal heart rate patterns
indicate fetal distress.
 2. However, false-positive abnormal stress tests can be caused by postural hypotension
or spontaneous overstimulation of the uterus. Therefore, a stress test must always be
performed with the patient on her side in the 15 degrees lateral position.
 3. Whenever a fetal heart rate pattern indicates fetal distress, the cardiogram must be
repeated immediately. If it is again abnormal, action should be taken
 4. A persistent fetal bradycardia is usually a preterminal event and, therefore, an
indication for an immediate Caesarean section if the fetus is viable.
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29. Why should you not immediately do a Caesarean
section if the fetal heart rate pattern indicates fetal
distress and the fetus is viable?
 Studies have shown that a false-
positive abnormal stress test can occur
in up to 80% of cases (i.e. an abnormal
stress test in a healthy fetus).
 Therefore, whenever a fetal heart
pattern indicates fetal distress, the
cardiogram must always be repeated
immediately.
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30. What is the emergency management of
proven fetal distress with a viable fetus?
 1. Turn the patient onto her side.
 2. Give 40% oxygen through a face mask.
 3. Start an intravenous infusion of Ringer’s lactate and give 250 µg (0.5 ml) salbutamol
slowly intravenously if there are no contraindications. The 0.5 ml salbutamol must first be
diluted in 9.5 ml sterile water. Monitor the maternal heart rate for tachycardia.
 4. Deliver the infant by the quickest possible route. If the patient’s cervix is 9 cm or
more dilated and the head is on the pelvic floor, proceed with an assisted delivery.
Otherwise, perform a Caesarean section.
 5. If the patient cannot be delivered immediately (e.g. she must be transferred to
hospital) then a side-infusion of 200 ml saline with 1000 μg salbutamol given at a rate of 30
ml per hour (150 μg per hour) until no further contractions occur, or when the maternal
pulse rate reaches 120 beats per minute
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31. What are the aims of fetal
resuscitation?
 1. Suppressing uterine contractions and reducing uterine tone, which
increases maternal blood flow to the placenta and, thereby, the oxygen
supply to the fetus.
 2. Giving the mother extra oxygen which will also help the fetus.
 It is, therefore, possible to improve the fetal condition temporarily while
preparations are being made for the patient to be delivered, or to be
transferred to the hospital.
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32. Figure 2-12: The interpretation of variability when the fetal heart rate pattern is nonreactive with no
spontaneous uterine contractions
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33. Reference list
 https://www.babycenter.com/pregnancy/your-baby/fetal-development-
week-by-week_10406730
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