Critical illness during pregnancy: considerations for evaluation and treatment of the fetus as the second patient

When a critically ill woman is pregnant, clinical interventions for the mother can have a profound effect on fetal status. It is essential that the fetus be considered as the second patient when developing the plan of care. The most practical solution for providing comprehensive care to pregnant women in the intensive care unit (ICU) is a collaborative approach involving members of the ICU and the perinatal team, each contributing their unique knowledge and skills to the care of the mother and her unborn baby. The purpose of this article is to describe a collaborative approach to caring for a pregnant woman in the ICU along with a brief overview of fetal assessment for ICU care providers so they can become familiar with terms and methods used in assessing fetal status and common interventions that promote fetal well-being.     

Critical care obstetrics: management of the fetus.

Whenever a critically ill gravida presents for care, consideration should be given to consulting an obstetrician or a maternal-fetal medicine specialist. The technological advances of the past two decades permit these critical care obstetrical specialists to immediately assess fetal health with ultrasonography or a fetal monitor. By so doing, maternal and fetal care can be optimized through a team approach.     

Fetal surveillance in the intensive care unit: understanding electronic fetal monitoring.

Electronic fetal monitoring has become an integral component of current obstetric nursing care. The goals of surveillance are to establish fetal well-being and identify the fetus at risk for asphyxia and death. Fetal heart rate (FHR) responses provide a cardiovascular indication of fetal acid-base status. To evaluate FHR tracings and plan care accordingly, the nurse must understand the physiologic regularity mechanisms of the fetus, baseline patterns, and periodic changes of the fetal heart rate.     

Customized fetal weight limits for antenatal detection of fetal growth restriction.

OBJECTIVE: To define cut-off limits for individually adjustable fetal weight standards for the detection of intrauterine growth restriction. DESIGN: Retrospective study, with the outcome measures small-for-gestational age (SGA) birth weight, operative delivery for fetal distress, umbilical artery pH < 7.15, and admission to the neonatal intensive care unit. SUBJECTS AND METHODS: Two hundred and fifteen women considered to be at increased risk of uteroplacental insufficiency were recruited to a study of serial ultrasound scans. Fetal weights were derived using standard formulae and, retrospectively, weight percentiles were calculated after individual adjustment for maternal height, weight in early pregnancy, ethnic group, parity and fetal sex. INTRODUCTION: One or more antenatal scans indicative of fetal weight below the 10th customized percentile were predictive for a SGA neonate at birth (P < 0.001), operative delivery for fetal distress (P < 0.01) and admission to neonatal intensive care (P < 0.01) but not for a low umbilical artery pH (P = 0.6). Receiver-operator curves showed the optimal customized fetal weight percentile limit for predicting an SGA neonate to be the 18th percentile (sensitivity 83%, specificity 79%, positive predictive value 63% and negative predictive value 92%). For the prediction of operative delivery for fetal distress and admission to neonatal intensive care, the optional customized cut-off value was the 8th percentile. CONCLUSIONS: The assessment of fetal weight using ultrasound and an individually-adjusted standard is predictive of growth restriction and perinatal events associated with hypoxia or diminished reserve. The optimal cut-off value for predicting operative delivery for fetal distress or admission to the neonatal intensive care unit suggests that the 10th customized percentile is a good limit for clinical use.     

影响远程胎儿监护质量的因素与对策

目的探讨影响远程胎儿监护质量的因素及应对措施。方法对132例次不满意远程胎儿监护信息进行跟踪追访,分析影响监护质量的原因。结果人为因素是影响远程胎儿监护质量的最主要因素,占87.1%,设备因素占5.3%,其他不确定因素占7.6%。结论加强对孕妇及家属的培训,做好仪器的养护,可有效提高远程胎儿监护质量。     

心理干预对妊娠合并糖尿病患者的影响

目的:探讨心理干预对妊娠合并糖尿病患者的影响。方法:将140例妊娠合并糖尿病患者随机分为观察组76例和对照组64例,观察组给予针对性心理护理干预,对照组给予常规护理,比较两组患者SCL-90各因子评分及胎儿异常率。结果:两组患者SCL-90的比较,除了人际关系、精神病性、敌对性,其他方面观察组评分均低于对照组(P<0.01);观察组出现胎儿异常率为2.63%,对照组出现胎儿异常率为7.81%,比较无显著性差异(P>0.05)。结论:对妊娠合并糖尿病患者行心理护理干预能够很好的控制患者的情绪,有助于降低胎儿异常率,在临床上值得推广应用。     

Mother and child. Trauma in pregnancy

The role of the emergency physician in optimizing outcome for the maternal and fetal victims of trauma is pivotal. Knowledge of the anatomic and physiologic changes of pregnancy aid in understanding the nuances of care of the pregnant trauma patient. Both catastrophic and noncatastrophic trauma can be managed with confidence and expertise by recalling the maternal and fetal pathophysiologic responses to trauma. Burns and electrical injuries carry significant fetal risks, which may be minimized by rapid and knowledgeable emergency care.     

胎儿镜下治疗复杂性单绒毛膜双胎手术护理

近年来随着胎儿镜在宫内治疗上的不断发展，我院也陆续收治复杂性单绒毛膜双胎妊娠孕妇，本文总结4例胎儿镜下治疗复杂性双胎妊娠孕妇围手术期护理，为临床胎儿镜手术护理提供参考。     

Lived experience of multifetal pregnant women with fetal reduction

The purpose of this study was to explore the lived experience of multifetal pregnant women who underwent fetal reduction. Using a qualitative research design, we recruited ten multifetal pregnant women with fetal reduction from an obstetrics and gynecology clinic in Taipei. The researcher, as a nurse counselor, collected data while providing care. Data were collected during the first counseling scheduled prior to the fetal reduction to five weeks post the procedure. Approximately five face-to-face interviews and eight phone follow-ups were completed for each subject. Data were recorded in a narrative form and analyzed based on interpretive research strategies of phenomenology. According to the data, the lived experience was categorized into seven themes: (a) pre-fetal reduction: feeling threatened by the confirmed diagnosis of multifetal pregnancy, facing guilt and conflict of undergoing fetal reduction; (b) undergoing fetal reduction: getting confused due to family's concern about fetal reduction, losing a sense of body boundary intactness, and worrying about the safety of the remaining fetuses; (c) post-fetal reduction: grieving for losing fetus, returning to the course of normal pregnancy. The findings indicate that undergoing fetal reduction impacted the physical and psychological well-being of multifetal pregnant women. Health care providers should provide individual yet holistic care in a timely fashion.     

Psychotropic medication in pregnancy: ethical aspects and clinical management

This article explores the dilemma of whether women with mental illness should take potentially teratogenic psychotropic medications during pregnancy, from both the maternal and fetal perspectives. Ethical and social aspects of the dilemma are presented to assist perinatal and psychiatric practitioners to provide holistic and competent care to the mother/fetus dyad. Specific fetal risks involved with maternal psychotropic drug use are described and contrasted with fetal risks of an untreated, psychiatrically ill mother. Nursing and healthcare considerations for the care of this population are presented in general, and specific psychotropics are reviewed for their risk profile in pregnancy. The article concludes with a discussion of actions to reduce maternal and fetal risk for women who are mentally ill and are currently taking, or considering taking, a psychotropic medication.     

The knowledge of women with diabetes mellitus regarding preconception care and maternal-fetal risks

The objective of this study was to describe the reproductive profile of women with diabetes mellitus (DM) and to identify their knowledge regarding maternal and fetal risks and preconception care. This exploratory study was performed at the Integrated Center for Hypertension and Diabetes, from March to July 2009, on a sample consisting of 106 women. The variables were: number of pregnancies, births and abortions, and planning the pregnancy. The data were collected through interviews that followed a preconceived form. The reproductive profile of women with DM proved to be permeated with risks and showed negative repercussions to maternal and fetal health. Of the 106 (100%) women studied, 44 (41.5%) demonstrated adequate knowledge regarding preconception care, while 58 (54.7%) had limited knowledge regarding maternal and fetal risks. It is necessary to provide information to women with diabetes to promote knowledge of maternal and fetal risks and preconceptional care.     

Technology in the birthing room

The use of technology is not benign. As with any health care intervention, there are associated risks and benefits. The practitioner needs to constantly consider the benefits of the technology versus the naturalistic birth experience. The use of technology should optimize birth outcomes while maintaining a balance that provides for the best possible human birth experience. Technology, however, does have merit in the birth setting, regardless of location, but its use should be evaluated on an individual, as needed, basis. The most common technological advances currently available for assessment and maternal/fetal care during birth include electronic fetal monitoring, ultrasonography, blood pressure screening, maternal/fetal pulse oximetry, and infusion pumps. All obstetrical care providers must be familiar with the forms of technology currently available and be aware of emerging technologies for use during the birthing process.     

Nursing care of the patient with preterm premature rupture of membranes

Preterm premature rupture of the membranes (PPROM) is diagnosed when rupture of the amniotic membranes occurs prior to the completion of the 36th week of gestation. PPROM accounts for 25% of all cases of premature rupture of the membranes and is responsible for 30%-40% of all preterm deliveries. In mothers diagnosed with PPROM without evidence of infection, active labor, or fetal compromise, the current standard of care is expectant management. The goal of expectant management is the prolongation of the pregnancy to increase fetal gestational age thus potentially decreasing the effects of prematurity. Expectant management consists of ongoing observation for signs and symptoms of infection, active labor, and/or nonreassuring fetal status. This article provides clinical nursing guidelines for the mother diagnosed with PPROM who is managed expectantly. Eight targeted areas for nursing assessment and intervention are described: preterm labor, side effects of tocolytic therapy, maternal/fetal infection, fetal compromise, side effects of extended bed rest, maternal stress, educational needs, and routine prenatal care.     

Ethical decisions in fetal medicine and neonatal intensive care

The Nuffield Council on Bioethics (2006) report Critical Care Decisions in Fetal and Neonatal Medicine: Ethical issues addressed three areas of concern to professionals and the public: fetal medicine, the borderline of viability, and critical care decision making for babies receiving intensive care. Common principles and initial recommendations for professional practice are presented in the report which is based on wide consultation. While many professionals may feel that the report re-iterates current good practice, it also demonstrates inequity and inconsistency in practice across the country. Royal Colleges and other interested parties need to act to address these inconsistencies and further develop consensus guidelines. The need for transparency in decision making and for a true partnership approach to all aspects of fetal and neonatal care is reaffirmed, with recommendations for action by government and professional bodies as well as by professionals delivering obstetric and neonatal care and their educators.     

Quality of obstetric care and occurrence of fetal asphyxia and cerebral palsy. Is there a relationship?

Whether a relationship exists between the quality of obstetric care and poor fetal outcome, notably cerebral palsy, remains uncertain. We herein report a study which suggests that substandard obstetric care bears little relationship to the etiology of cerebral palsy. In none of our 34 cases of cerebral palsy was there any recognized delay on the physician's part in reacting to evidence of fetal asphyxia.     

Interdisciplinary Team Huddles for Fetal Heart Rate Tracing Review

To address an increase in unexpected poor outcomes in term neonates, our team developed a goal of high reliability and improved fetal safety in the culture of the Labor and Delivery nursing department. We implemented interdisciplinary reviews of fetal heart rate, along with a Category II fetal heart rate management algorithm and a fetal heart rate assessment rapid response alert to call for unscheduled reviews when needed. Enhanced communication between nurses and other clinicians supported an interdisciplinary approach to fetal safety, and we observed an improvement in health outcomes for term neonates. We share our experience with the intention of making our methods available to any labor and delivery unit team committed to safe, high-quality care and service excellence.     

State of the art prenatal care from the Swiss viewpoint

Prenatal care has significantly reduced perinatal and maternal mortality. Screening for maternal disease allows us to reduce or to prevent an unfavourable fetal or obstetrical outcome. Prenatal care should start with a first preconceptional visit. Folic acid intake is recommended for all reproductive-age women who are capable of becoming pregnant. The fetal nuchal translucency measurement has revolutionized prenatal care as a non-invasive, effective screening for chromosomal abnormalities and other diseases of the fetus. Vertical transmission of infections has to be prevented if possible. As an example caesarean section in combination with antiretroviral therapy reduces the transmission of HIV significantly. Screening for sexually transmitted diseases (STD) remains important as at present the incidence of STD is increasing again. In this short review on prenatal care as it is done in Switzerland, we try to enlighten its most important aspects. For the patients and your own benefit as a physician it is important to follow guidelines, although of course each patient has to be treated individually.     

What can be learned from cordocentesis?

Cordocentesis is a well-accepted procedure that is widely practiced by experienced perinatologists. Its facile and safe access to the fetal circulation has broadened the spectrum of congenital disorders diagnosed prenatally. Some fetal disease states can now be identified and treated earlier, directly, more quickly, and more effectively than before, resulting in improved patient care. Although cordocentesis has been embraced by the perinatal community, it is, by definition, a technique of obtaining a fetal blood sample. A prerequisite for the procedure to exert its full impact on perinatal care is a highly capable clinical laboratory. The facility must be aware of the commonly requested fetal serologic, hematologic, and serum chemistry studies, as well as their normal values. Efforts must be made to perform fetal blood studies rapidly and reliably on small specimens. Laboratory personnel should be familiar with the indications and pitfalls of these tests and those that are best referred to a specialty laboratory. A general understanding of the perinatologist's needs and concerns will lead to a cooperative working relationship between clinician and laboratory. In this manner, we will truly discover what can be learned from cordocentesis.     

Screening fetal echocardiography by telemedicine: efficacy and community acceptance.

OBJECTIVE: Our aim was to assess whether tertiary level screening fetal echocardiography can be extended to primary care facilities with telemedicine assistance. METHODS: Assessment of image quality and the adequacy of fetal echocardiograms recorded after random transmission at 128, 384, or 768 kbits/s was performed. Live fetal echocardiograms were transmitted at 384 kbits/s (3 integrated services digital network lines) from the remote primary care center. Patient satisfaction was assessed by surveys obtained after office-based and telemedicine consultations. RESULTS: A total of 58 recorded normal studies had similar image quality and adequacy on transmission at 384 and 768 kbits/s (P =.08 and.49, respectively) and were significantly better than 128 kbits/s (P <.01). During live screening transmitted at 384 kbits/s from the primary care center, 3 of 34 fetuses were diagnosed with heart disease. Surveys from patients with direct physician contact and by telemedicine showed a high satisfaction with telemedicine-assisted screening and counseling. CONCLUSION: Adequate screening for fetal heart disease is technically feasible at or above data transmission rates of 384 kbits/s. Community acceptance for telemedicine-assisted screening and counseling is not adversely affected by a lack of direct personal contact with the specialist.