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When you have completed this unit you should be able to:
The condition of the fetus before delivery is assessed by:
When managing a pregnant woman, remember that you are caring for two individuals.
If the assessed fetal weight is within the expected range for the duration of pregnancy, then the fetal growth is regarded as normal.
To determine fetal growth you must have an assessment of both the duration of pregnancy and the weight of the fetus.
Fetal growth will appear to be abnormal when the assessed fetal weight 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 the weight of the fetus is assessed as being less than the normal range for the duration of pregnancy, then intra-uterine growth restriction (fetal growth restriction) is suspected.
Intra-uterine growth restriction may be associated with either maternal, fetal and placental factors:
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.
The following methods can be used:
The symphysis-fundus growth curve compares the S-F height to the duration of pregnancy. The growth curve should preferably form part of the antenatal card. The solid line of the growth curve represents the 50th centile, and the upper and lower dotted lines, the 90th and 10th centiles, respectively. If intra-uterine growth is normal, the S-F height will fall between the 10th and 90th centiles. The ability to detect abnormalities from the growth curve is much increased if the same person sees the patient at every antenatal visit.
Between 18 and 36 weeks of pregnancy, the S-F height normally increases by about 1 cm a week.
If any of the following are found:
Note that a measurement that was originally normal, but on subsequent examinations has fallen to below the 10th centile, indicates intra-uterine growth restriction and not incorrect dates.
With severe intra-uterine growth restriction, the difference between the actual duration of pregnancy and that suggested by plotting S-F height is 4 weeks or more.
Yes. Descent of the presenting part may occur in the last 4 weeks of pregnancy. Therefore, after 36 weeks the above criteria are no longer valid, if at subsequent antenatal visits progressively less of the fetal head is palpable above the pelvic inlet.
The patient must be referred to a fetal evaluation clinic or level 2 hospital for a Doppler measurement of blood flow in the umbilical arteries:
If Doppler measurement is not available, the patient must be managed as given in 2-14.
Figure 2-1: The symphysis-fundus growth chart
Figure 2-2: One measurement below the 10th centile
Figure 2-3: Three successive measurements that remain the same
Figure 2-4: A measurement less than that recorded 2 visits before
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.
Fetal movements indicate that the fetus is well. By counting the movements, a patient can, therefore, monitor the condition of her fetus.
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.
Asking the patient if the fetus is moving normally on the day of the visit is an important way of monitoring the fetal wellbeing.
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, e.g. rolling and turning movements, as well as kicking.
A fetal movement chart need not be used routinely by all antenatal patients, but only when:
Fetal movements should be counted and recorded on the chart over a period of an hour per day after breakfast. The patient should preferably rest on her side for this period.
A good fetal movement count always indicates a fetus in good condition. A distressed fetus will never have a good fetal movement count. However, a low count or a decrease in fetal movements may also be the result of periods of rest or sleep in a healthy fetus. The rest and sleep periods can last several hours.
Tests with electronic equipment have shown that mothers can detect fetal movements accurately. With sufficient motivation, the fetal movement chart can be an accurate record of fetal movements. It is, therefore, not necessary to listen to the fetal heart at antenatal clinics if the patient reports an adequate number of fetal movements, or an adequate number of fetal movements has been recorded for the day.
A uterus which increases in size normally, and an actively moving fetus, indicate that the fetus is well.
A patient who lives far away from her nearest hospital or clinic should continue with bed rest, but if the movements are 3 or fewer over a 6 hour period, then arrangements must be made for her to be moved to the nearest hospital.
The patient should be given a drink containing sugar (e.g. tea) to drink to exclude hypoglycaemia as the cause of the decreased fetal movements.
A patient is seen at the antenatal clinic at 37 weeks gestation. She is clinically well and reports normal fetal movements. The S-F height was 35 cm the previous week and is now 34 cm. The previous week the fetal head was ballotable above the brim of the pelvis and it is now 3/5 above the brim. The fetal heart rate is 144 beats per minute. The patient is reassured that she and her fetus are healthy, and she is asked to attend the antenatal clinic again in a week’s time.
No, as the fetal head is descending into the pelvis. The head was 5/5 above the brim of the pelvis and is now 3/5 above the brim.
The fetus is healthy as the S-F height is normal for 37 weeks and the fetus is moving normally.
The fetal heart rate is not a useful measure of the fetal condition before the onset of labour. If the fetus moves well during the antenatal period, there is no need to listen to the fetal heart.
Active fetal movements, noted that day, indicate that the fetus is healthy. The patient can, therefore, monitor the condition of her fetus by taking note of fetal movements.
You examine a 28 year old gravida 4 para 3 patient who is 34 weeks pregnant. She has no particular problems and mentions that her fetus has moved a lot, as usual, that day. The S-F height has not increased over the past three antenatal visits but only the last S-F height measurement has fallen to the 10th centile. The patient is a farm labourer and she smokes.
They indicate that the fetus may have intra-uterine growth restriction, as the last three measurements have remained the same even though the S-F height measurement has not fallen below the 10th centile.
Hard physical labour and smoking. Both these factors can cause intra-uterine growth restriction.
Both these possibilities are most unlikely as the patient has reported normal fetal movements.
Arrangements should be made, if possible, for the patient to stop working. She must also stop smoking, get enough rest and have a good diet.
She must be given a fetal movement chart and you must explain clearly to her how to use the chart. She must be placed in the high-risk category and, therefore, seen at the clinic every week. If the fundal growth does not improve, the patient must be hospitalised and labour should be induced at 38 weeks.
If a Doppler blood flow measurement of the umbilical arteries indicates normal placental function, routine management of a low-risk patient can be given. Induction at 38 weeks is not needed.
A patient, who is 36 weeks pregnant with suspected intra-uterine growth restriction, is asked to record her fetal movements on a fetal movement chart. She reports to the clinic that her fetus, which usually moves 20 times per hour, only moved 5 times during an hour that morning.
Rather than come to the clinic, she should have counted the number of fetal movements for a further hour.
She must not go home unless you are sure that her fetus is healthy. She should lie on her side and count the number of fetal movements during one hour. If she has not had breakfast, give her a cold drink or a cup of sweetened tea to make sure that she is not hypoglycaemic.
If the number of fetal movements returns to more than half the previous count (i.e. more than 10 times per hour), she can go home and return to the clinic in a week. In addition, she must count the fetal movements daily.
If the fetal movement count remains less than half the previous count, the patient should be transferred to a hospital where antenatal electronic fetal heart monitoring can be done. Further management will depend on the result of the monitoring.
Fetal movements should be counted for a full 6 hours. If the fetus moves fewer than 4 times, there is a high chance that the fetus is distressed. A doctor must now examine the patient and decide whether the fetus should be delivered and what would be the safest method of delivery.
Figure 2-5: The management of a patient with decreased fetal movements