MS, BSN, RN
I deliver babies every working day. I coach women through the challenges of ever-changing labor and celebrate their birth experiences with them. I am a labor/delivery nurse. When a woman with concerns of decreased fetal movement arrives, I need to change my care delivery to meet a different set of clinical and emotional support needs.
Fortunately, this is rare. In my 30 years of labor/delivery care, I have only experienced this once.
This blog explains Intrauterine Fetal Demise (IUFD) and how to care for these patients with competence and compassion.
IUFD is fetal death in pregnancy more than 20 weeks along, with a baby weighing more than 350 grams. Mother’s groups prefer the term stillborn, and providers are transitioning to that kinder language.
The cause may not be known in many cases. But some causes include:
Your patient may present to triage with concerns of decreased fetal movement. She may be sent from the healthcare provider’s office where she was just diagnosed with IUFD. She may be your labor patient with complications.
Assess your patient as quickly as possible to confirm fetal status and begin to identify associated health factors. My first question in this situation is, “When was the last time you felt your baby move?”
Confirm the presence or absence of fetal heart tones by placing electronic fetal monitors externally. If you’re unable to detect fetal heart tones, immediately progress to doppler evaluation. If you still don’t have confirmation, proceed to an ultrasound evaluation.
Be aware that if you’re monitoring with a fetal scalp electrode, it’s possible to pick up the mother’s heart rate when the baby’s heart tones are absent. Always use a pulse oximeter to concurrently monitor maternal heart rate and establish fetal heart tone separately.
If you confirm the absence of fetal heart tones, best practice is to have the healthcare provider at the bedside to confirm and discuss the plan of care with your patient. The nursing role is to be present and supportive, but not diagnose IUFD.
You’ll conduct a full physical assessment to clarify factors that might have contributed to, or may complicate, care. Does she have signs of infection, preterm labor, diabetic symptoms, or Pregnancy Induced Hypertension (PIH) symptoms?
Your patient needs a careful exam of her abdomen for signs of trauma, contour, pain, guarding, rebound tenderness, contractions, and fundal height. Other concerning findings include Cerebrovascular Vascular Accident (CVA) tenderness, hyperactive reflexes, excessive edema, rashes, itching, petechiae, signs of drug abuse, shortness of breath, tachypnea, rales or crackles, vaginal bleeding, and discharge.
The patient’s social history might reveal past drug and alcohol use, prior surgeries, and prior diseases that could affect care. The history of asthma or hypertension changes the recommended medical response to hemorrhage. A history of uterine surgery increases the risk of placental anomaly. During your social assessment, evaluate who’s available to help your patient and understand any abuse threats she may be experiencing.
Emotional support and privacy needs are observed and clarified during your history and physical assessment. Patient questions, concerns, and requests are honored.
You’ll need to be present when the healthcare provider discusses the medical plan of care. Often the patient and support visitors will selectively hear in this stressful time. They’ll think of questions during care. The decision for expectant care or induction will be based on gestation, Bishop score, complications, and the patient’s consent. A cesarean delivery is rarely needed.
Inform your patient of what to expect during delivery and after delivery. Ensure that she has adequate pain management and assess her readiness to receive new information. Explain to her, according to the baby’s gestational age, how developed and what size her baby may be. Explain that her baby’s color may be dark, and her baby may feel cool to the touch. Explain that she can see and hold her baby for as long as she wants.
Offer to do footprints and pictures for her baby’s memory box. Inform her that a pastor is available to visit at her request and her baby may be baptized if she desires. She needs to know the methods of disposal or burial available for the gestation of her baby. Social services may be available to assist with funeral arrangements and post-discharge support groups. She and her partner need to know that everyone grieves differently.
When an early gestation baby delivers, it may be spontaneous when no nurse or healthcare provider is in the room. Explain that it is not an emergency when this happens. Instruct her to use her call light to let her nurse know. If that does happen with your patient, inform the healthcare provider and stay with your patient. Always be patient and allow the placenta to deliver spontaneously.
Wrap the baby in a small blanket and offer to show the baby to your patient and her support person. Offer to have her hold her baby, but if she is reluctant that is perfectly fine. Handle the baby with respect. You will need to weigh, measure, take footprints, and take photographs of the baby. Sometimes it works better to do these tasks outside of the patient’s room. Return their baby wrapped and looking snug.
You will also monitor your patient’s recovery. If the placenta doesn’t deliver intact, or the immature cord breaks and the placenta is retained, she’ll need to go to the operating room for a D&C.
The family can keep the baby with them for as long as they would like. Nurses prepare a small sleeping nest with ice packs under the baby’s blanket to slow deterioration. When the family is ready, you will prepare the baby for the morgue.
When your patient is stable you will give her discharge instructions. Her journey of loss has just begun. You have given her competent care that has kept her safe, informed, and comforted. You have broadened her base of social support through pastoral care, social services, community referrals, and family that have heard that grief is different for each of us. You have given her compassionate care, undoubtedly sprinkled with tears and hugs.
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