Chorioamnionitis at Term: Definition, Diagnosis, and Implications for Practice.

Chorioamnionitis is a serious complication during labor at term and is associated with adverse neonatal outcome affecting approximately 10% of pregnancies. It is diagnosed clinically or microbiologically or by histopathologic examination of the placenta and umbilical cord. The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. These subjective findings are neither sensitive nor specific. However, clinical chorioamnionitis requires a high index of suspicion, timely diagnosis, prompt antibiotic treatment, and delivery, which may help reduce the potentially devastating outcome of maternal and neonatal infections. This article focuses on clinical chorioamnionitis and presents the physiologic immune response during pregnancy, the definition of chorioamnionitis, clinical diagnostic criteria, and implications for practice.

Chorioamnionitis: prevention and management.

Chorioamnionitis most often occurs during labor, affecting as many as 10% of laboring women. When intrapartum chorioamnionitis occurs, women are at peripartal risk for endometritis, cesarean birth, and postpartum hemorrhage; and the neonate is at significant risk for sepsis, pneumonia, respiratory distress, and death. The impact is greater for preterm infants where the incidence of chorioamnionitis is nearly 30%. When chorioamnionitis is believed to be present, antibiotics are administered, but not without potential adverse consequence to the mother/fetus, as well as significantly increased healthcare cost. A number of factors increase the risk of chorioamnionitis, including use of intrauterine pressure catheters and fetal scalp electrodes, urogenital tract infections, prolonged rupture of membranes, digital vaginal examinations, and the nature of perineal hygiene. This article presents key intrapartum factors and those nursing actions that can help to reduce rates of chorioamnionitis and improve perinatal outcomes.

Maternal, fetal, and neonatal care in open fetal surgery for myelomeningocele.

Fetal myelomeningocele closure (fMMC) was demonstrated in a randomized, prospective clinical trial to improve outcomes for children diagnosed prenatally. Complex care of the maternal/fetal dyad undergoing fetal surgery requires a well-coordinated multidisciplinary team. Nurses in many roles are essential members of the team that cares for these women across the continuum. In this article we discuss the care of the woman, fetus, and family from initial contact through the discharge of the neonate.

A review of fetal thoracoamniotic & vesicoamniotic shunt procedures.

Fetal anomalies such as lower urinary tract obstructions and fluid-filled space-occupying lesions in the fetal chest can result in severe morbidity or mortality if left untreated. In-utero fetal shunt placement offers the potential to improve outcomes in infants with these conditions. The role of the nurse is paramount in the clinical and psychosocial management of the mother and family.

A primer on antenatal testing for neonatal nurses: part 2: tests of fetal well-being.

A number of new antenatal testing tools are being used in obstetric practice to evaluate the clinical picture of the fetus in utero. Results of these tests may prompt transfer to a tertiary facility for delivery or further antenatal monitoring. Part 2 of this 2-part series will describe antenatal testing methods used to determine fetal well-being, as well as highlight the emerging developments in the field of fetal surveillance. The ability to interpret antenatal testing results may help the neonatal team triage to assure bed availability, and predict and provide appropriate staffing for new admissions, and is an important foundation for subsequent neonatal risks and clinical care.

Family-centered care in the context of fetal abnormality.

Women confronted with prenatal diagnosis of fetal abnormality face emotionally challenging choice options and considerable uncertainty regarding impact of choice on their families. Prenatal diagnosis of fetal abnormality presents childbearing women with difficult choices, such as continuation of pregnancy with no intervention, abortion, and, in selected cases, experimental fetal therapy. Regardless of their decision, it is a time of transition marked by grief and loss. The experience women and families have with the option chosen has an impact on their short- and long-term well-being. Healthcare providers are paramount in facilitating this transitional time in supporting family needs.

Osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a rare congenital disorder of collagen production that results in brittle bones and affects other body systems containing collagen. This article reviews the current body of knowledge about OI and the management of infants with the disorder. Relieving pain, reducing the incidence of new fractures, establishing adequate follow-up, and connecting parents with community resources are the goals of management during the neonatal period. A case study illustrates management and the discharge process.

Alloimmune thrombocytopenia in the fetus: current management theories.

Fetal alloimmune thrombocytopenia (AIT) affects only a small number of fetuses but the consequences may be devastating. Outcomes range from mild thrombocytopenia without signs or symptoms to intracranial hemorrhage (ICH) and fetal or neonatal death. Antenatal screening is available but not used routinely in the United States. The most frequent method of AIT identification is its diagnosis in the neonatal period (index neonate). AIT may be diagnosed antenatally if an ICH is noted on routine obstetric ultrasound. There are accurate predictors of AIT, as well as antenatal therapies, to prevent the occurrence of severe disease and ICH.

Fetal pulse oximetry: an adjunct to electronic fetal heart rate monitoring.

Electronic fetal heart rate monitoring is routinely used as an indirect measure of fetal oxygenation, yet its value continues to be questioned. With a nonreassuring fetal heart rate pattern, the clinician often needs additional information about fetal oxygen status. Fetal pulse oximetry is a new fetal assessment technology. After consideration of the results of a multicenter randomized, controlled, clinical trial on fetal pulse oximetry in the United States, the U.S. Food and Drug Administration approved the technology for clinical use on May 12, 2000. The results of this trial are anticipated to be published in late 2000.

The unborn surgical patient. A nursing frontier.

The fetus can now be considered a patient. Sophisticated imaging techniques and prenatal tests have allowed precise diagnosis of fetal abnormalities. Subsequent recommendations for treatment are evolving depending on diagnosis and progression of disease. For severely affected fetuses with life-threatening problems, fetal surgery is a proposed intervention. Knowledge of the diagnosis and potential treatment modalities are now a prerequisite for providing the necessary support and care of mothers of fetuses with an anomaly. The fetal treatment center provides a regionalized approach to providing specialized care to the mother carrying a fetus with an anomaly. The center provides both prenatal and postnatal diagnosis; treatment; and obstetric, neonatal, and pediatric surgical management for a wide variety of pediatric surgical disorders. The fetal treatment center model is a useful one offering knowledgeable, coordinated, efficient, and compassionate care to parents facing difficult decisions regarding their unborn child. Future interventions include less invasive procedures to the mother, such as videofetoscopic techniques. Use of new research related to scarless wound healing may allow endoscopic techniques to correct cleft lips in utero. Gene and stem cell therapy in utero may ameliorate blood disorders, enzyme deficiencies, hemoglobinopathies, and so on prior to birth. Finally, other lethal fetal anomalies, such as pulmonary atresia and laryngeal atresia may also benefit from in utero intervention.

Diagnosing handicap using the behaviour of the fetus.

The study of fetal behaviour may have important implications for the prenatal diagnosis of handicap. Since behaviour reflects the integrity of the fetal neural system the examination of fetal behaviour enables neurological assessment of the fetus. This paper discusses present methods of assessing fetal well-being and their shortfalls and then considers current research using behaviour to identify the compromised fetus. Studies using both spontaneous and elicited fetal behaviour are discussed. The paper concludes that a greater understanding of fetal behaviour promises great advances in the antenatal detection of handicap or fetal compromise and may enable midwives to become more involved in the assessment of fetal well-being.

Peripartum cardiomyopathy.

Peripartum cardiomyopathy is a rare and devastating disease of unknown etiology that manifests between the last trimester of pregnancy and five postpartum months. This disease often is confused with many other illnesses, and even with hemodynamic changes in normal pregnancy. Pathophysiology, signs, and symptoms of this unique cardiomyopathy are presented and case studies offered. Since outcome of this disease is directly related to duration of the illness, nurses must be aware of the symptoms and investigate them immediately. The nurse must support the patient and involve the family and social services in the patient's recovery.