Diseases and Disorders Intrauterine Fetal Demise INTRODUCTION

DRG Category: 774

Mean LOS: 3.3 days

Description MEDICAL: Vaginal Delivery with Complicating Diagnoses

DRG Category: 775

Mean LOS: 2.3 days

Description MEDICAL: Vaginal Delivery without Complicating Diagnoses

classification section:

An intrauterine fetal demise (IUFD), or stillbirth, is defined as a death that occurs in utero or during delivery after the completion of the 20th week of pregnancy, or the death of a fetus that weighs 500 g or more in utero or during delivery. IUFD is more common with decreasing gestational age; 80% of all stillbirths occur before term, and more than half occur before 28 weeks. The specific gestational age and weight that classify the fetus as an IUFD vary among states in the United States. Labor and delivery of the dead fetus usually occur spontaneously within 2 weeks. Patients are under tremendous psychological stress and are at a higher risk for postpartum depression. Disseminated intravascular coagulation (DIC) is the main complication that can result. Thromboplastin released from the dead fetus is thought to mediate DIC.

CAUSES

Approximately 1%, or 30,000, pregnancies per year end in an IUFD. While 25% to 35% of fetal deaths are unexplainable, many potential causes have been identified via autopsy: genetic anomalies that are incompatible with life, uteroplacental insufficiency, umbilical cord prolapse or other cord problems, twin-to-twin transfusion, maternal disease (hypertension, diabetes mellitus, and gestational diabetes insipidus [GDI], sepsis, acidosis, hypoxia, infection, anaphylaxis), trauma, placenta previa, abruptio placentae, uterine rupture, pseudoamniotic band syndrome, and postterm pregnancy. New research is suggesting that IUFD may also be caused by various perinatal infections, and some case reports have included positive fetal cultures for Erythrovirus B19, Haemophilus influenzae, hepatitis E, group B streptococci, and even Rothia dentocariosa, a normal bacteria found in the oral cavity of humans. Also, domestic violence should be ruled out. Patients have the option of requesting an autopsy to determine the cause of death. If an autopsy is not performed, it may not be possible to determine the exact cause of fetal death.

GENETIC CONSIDERATIONS

Genetic abnormalities are a significant cause of pregnancy loss including chromosomal abnormalities such as the trisomies (see Spontaneous Abortion, p. 12).

GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS

The likelihood of the occurrence of an IUFD decreases with good prenatal care. IUFD occurs more often in older women and is thought to be the reason for the increase in perinatal mortality in this age group. IUFD accounts for 50% of all perinatal deaths. Ethnicity and race have no known effects on the risk for IUFD.

GLOBAL HEALTH CONSIDERATIONS

IUFD rates globally vary significantly depending on the quality of healthcare in each country and the definition used for classifying fetal deaths.

ASSESSMENT

HISTORY. Obtain a thorough obstetric and medical history. Determine the gestational age of the fetus by asking the patient the date of her last menstrual period and using Nagele's rule. Inquire about any contractions, bleeding, or leakage of fluid. Ask about exposure to environmental teratogens or the use of recreational or prescription drugs. Ask the patient when she last felt the baby move. Also inquire about any cultural and religious preferences related to labor, delivery, postpartum care, autopsy, and receiving a blood transfusion.

PHYSICAL EXAM. Attempt to auscultate a fetal heart rate with a Doppler or electronic fetal monitor. If no heartbeat is heard, perform an ultrasound to be sure no heart rate is present. Determine McDonald's measurement and compare this with previous data; the measurement is usually less than that expected for the gestational age if an IUFD has occurred. Palpate the abdomen for rigidity, which is often present with abruptio placentae, or for change in shape, which is often present with uterine rupture. Inspect the perineum for bleeding, and note any foul odors. Perform a vaginal examination to check for a prolapsed cord, and note any cervical dilation and effacement. If possible, determine the fetal presenting part and the station. Check the patient's vital signs. A temperature higher than 100.4F may indicate the presence of infection. Weigh the patient; some may experience a weight loss. Because DIC is a potential complication of IUFD, monitor the patient for the following signs and symptoms of DIC: bleeding from puncture sites, episiotomy, abdominal incision, or gums; hematuria; epistaxis; increased vaginal bleeding, bruising, and petechiae.

A thorough physical examination is done of the fetus, umbilical cord, amniotic fluid, placenta, and membranes to determine the cause of death. Knowing the cause may be therapeutic for the parents and helps relieve guilt feelings.

PSYCHOSOCIAL. Assess the patient's reaction and ability to cope with the fetal death and her anxiety about going through the labor process. Determine the meaning of the pregnancy for the patient. Observe the interaction between the patient and her significant other to assess potential support.

Diagnostic Highlights

General Comments: Abdominal ultrasound easily and accurately confirms the diagnosis of IUFD. Placental abnormalities at 19 to 23 weeks gestation may be indicative of poor outcomes assessed by uterine artery Doppler.

Test

Normal Result Abnormality with Condition

Explanation

Ultrasound (abdominal) Heartbeat seen; fetal growth appropriate for gestational age No heartbeat seen; "fetal collapse" noted; gestational age smaller than expected Absence of heartbeat and shriveled fetal appearance indicative of IUFD

Other Tests: If sepsis or DIC is a potential threat, coagulation studies (fibrinogen, fibrin split products, prothrombin time, partial thromboplastin time, D-dimer) are done serially.

PRIMARY NURSING DIAGNOSIS

DIAGNOSIS. Anticipatory grieving related to fetal loss

OUTCOMES. Grief resolution

INTERVENTIONS. Grief work facilitation: Perinatal death; Active listening; Presence; Truth telling; Support group

PLANNING IMPLEMENTATION

COLLABORATIVE

The treatment involves inducing labor to deliver the fetus. The timing of the delivery varies. A 48-hour wait is recommended to give the patient time to gather support from her family and to fathom the reality of the situation. Other patients may prefer to let the labor start on its own, but this could take weeks. The danger with this conservative treatment is that the necrotic fetus can lead to either DIC or infection, or both, in the mother. A cesarean section is rarely done unless the maternal condition necessitates an immediate delivery.

Induction of labor is often a 2-day process. Insertion of a Laminaria tent into the endocervical canal dilates the cervix. If necessary, the Laminaria can be held in place by a tampon. The risk of infection in the presence of a dead fetus needs to be considered. Prostaglandin E2 gel or 20-mg suppositories are alternatives to Laminaria. By the second day, the cervix is usually ripe, and an oxytocic induction of labor can begin. When infusing oxytocin, assess often for resting tone, as uterine rupture caused by hyperstimulation can occur. Labor contractions are very uncomfortable for the patient. Liberal dosages of analgesia or anesthesia may be given if the patient desires because their effects on the fetus do not need to be considered. Intravenous narcotics, an epidural, and sedatives may be ordered for relief of pain and anxiety.

If the patient has an epidural, turn her from side to side hourly to ensure an adequate distribution of anesthesia. Patients have limited mobility and require assistance in turning and positioning comfortably. Use pillows to support the back and abdomen and between the knees to maintain alignment. Check the blood pressure and pulse every 30 minutes. Most patients are unable to void and require a straight catheterization every 2 to 3 hours to keep the bladder empty. Maintain the infusion of intravenous fluids to prevent hypotension, which can result from regional anesthesia. Monitor the patient's pain relief and notify the nurse anesthetist or physician if the patient is uncomfortable.

Pharmacologic Highlights

Medication or Drug Class

Dosage Description

Rationale

Dinoprostone (Prostaglandin, Cervidil, Prepidil gel) 20-mg suppository; 0.5-mg gel; 10-mg inserts Prostaglandins Ripens, softens, begins to dilate the cervix and prepare it for labor Oxytocin (Pitocin) Oxytocic 10 U in 500 mL of IV fluid; start at 1 mU/min and increase 12 mU/min q 30 min Induces labor contractions

Analgesia/anesthesia Varies by drug; medication given either intravenous push (IVP) or via epidural catheter Narcotic analgesics; anesthetics Labor contractions are very uncomfortable and especially difficult to tolerate with a demise of the fetus RhoD immunoglobulin (RhoGAM) 120 g prepared by blood bank Immune serum Prevents Rh isoimmunizations in future pregnancies; given if mother is Rh-negative and infant is Rh-positive

INDEPENDENT

If possible, admit the patient to a room that is isolated from the nursery, patients in labor, and crying of newborns. Often, units have some small symbol (a small bear, a heart, a leaf with a raindrop representing a tear) to hang on the door that denotes the patient has an IUFD to alert any healthcare workers who come into contact with the patient to be sensitive.

The nurse is present through the entire labor and delivery and plays a key role in assisting the patient and family through the initial grieving process. During this shocking event, encourage the patient and significant others to verbalize their feelings. Discuss the grieving process and expected feelings; use therapeutic communication skills. Be aware of the content of your messages to the patient.

Involve the patient and significant other in all decisions and discussions related to the labor, delivery, and aftercare. Before the delivery, educate them about the labor process. Prepare them for the appearance of a dead fetus (maceration of the skin, discolorations, specific anomalies, and trauma that can occur during delivery). During delivery, have only the minimum number of staff needed to provide safe care. Keep the room quiet and dim to promote a calm and peaceful atmosphere. Honor the parents' desires for seeing, holding, and touching the newborn. Prepare a "memory box" that contains tangible items, such as footprints, handprints, pictures, a lock of hair, identification bands, and any other items used for the baby. After the patient delivers, monitor her vital signs, location and firmness of fundus, amount of vaginal bleeding, ability to void, presence of edema and hemorrhoids, comfort level, and ability to cope. Provide time for the patient and significant other to be alone with the infant.

Provide reading material for the parents on coping with a neonatal loss. Offer to notify clergy if the patient desires, and respect any religious requests. Although it may be difficult to discuss, offer information regarding funeral arrangements. Discuss an autopsy and explain the advantages of determining the exact cause of death. Refer the patient to a bereavement support group, such as

SHARE. Often, follow-up counseling is done by a hospital grief counselor or by the nurse who was present at the delivery