Crit Care Nurs Q Vol. 29, No. 1, pp. 20–31 c 2006

LWW/CCNQ LWWJ199-09 December 30, 2005 18:1 Char Count=

Crit Care Nurs QVol. 29, No. 1, pp. 20–31c© 2006 Lippincott Williams & Wilkins, Inc.

Critical Illness DuringPregnancyConsiderations for Evaluationand Treatment of the Fetus asthe Second Patient

Kathleen Rice Simpson, PhD, RNC, FAAN

When a critically ill woman is pregnant, clinical interventions for the mother can have a profoundeffect on fetal status. It is essential that the fetus be considered as the second patient when devel-oping the plan of care. The most practical solution for providing comprehensive care to pregnantwomen in the intensive care unit (ICU) is a collaborative approach involving members of the ICUand the perinatal team, each contributing their unique knowledge and skills to the care of themother and her unborn baby. The purpose of this article is to describe a collaborative approachto caring for a pregnant woman in the ICU along with a brief overview of fetal assessment forICU care providers so they can become familiar with terms and methods used in assessing fetalstatus and common interventions that promote fetal well-being. Key words: critical care obstet-rics, critically ill pregnant women, electronic fetal monitoring, fetal assessment, fetal heart ratepatterns

ADMISSION of a pregnant woman to theintensive care unit (ICU) presents a

unique challenge. Care is required for 2 pa-tients, one of which is unseen, but for whomthere are significant implications based on themother’s condition and clinical interventions.The primary method of assessing fetal sta-tus is electronic fetal monitoring (EFM). Be-cause pregnant women are generally youngand healthy, they are seldom patients in theICU. Therefore, knowledge and skills relatedto fetal heart rate (FHR) pattern interpreta-tion are not expected of ICU care providers.Similarly, perinatal care providers have limitedexposure to patients requiring ventilator sup-port or hemodynamic monitoring. The mostpractical solution for providing comprehen-sive care to pregnant women in the ICU is

From St. John’s Mercy Medical Center, St. Louis, Mo.

Corresponding author: Kathleen Rice Simpson, PhD,RNC, FAAN, St. John’s Mercy Medical Center, 7140 Per-shing Ave, St. Louis, MO 63130 (e-mail: [email protected]).

a collaborative approach involving membersof the ICU and the perinatal team, each con-tributing its unique knowledge and skills tothe care process. The purpose of this article isto describe a collaborative approach to caringfor a pregnant woman in the ICU and to pro-vide a brief overview of fetal assessment forICU care providers so that they can becomefamiliar with terms and methods used in as-sessing fetal status and common interventionsthat promote fetal well-being.

COLLABORATION AND PLANNING

Pregnant women rarely develop conditionsrequiring ICU care. In a recent study ana-lyzing 14 years of data from ICU admissionsin the state of Maryland, it was found thatICU admissions of pregnant women were0.14% of all inpatient births in major teachinghospitals, 0.13% in minor teaching hospitals,and 0.11% in community hospitals.1 Themedian length of stay was 2 days, with45% of women requiring 1 day or less ofICU care. The most common diagnoses for

20


Critical Illness During Pregnancy 21

obstetric admissions to the ICU include (inorder of frequency) preeclampsia/eclampsia,postpartum hemorrhage, abruption ofplacenta/placenta previa, pulmonary com-plications, infection, anesthesia-relatedcomplications, cardiac complications, shock,gestational diabetes, acute renal failure, cere-bral vascular accident, and amniotic and/orblood clot embolism.1–4 The unusual natureof this type of admission creates distinctchallenges because it is unlikely that teammembers from either the ICU or the perinatalunit have the dual set of knowledge and skillsrequired to care for both the critically illmother and her unborn baby. Collaborationbetween ICU and perinatal care providersis the best approach to promote the mostoptimal outcome for both patients.

Ideally, a formal plan should be devel-oped by the leadership team of both spe-cialty units. In community hospitals, this planshould involve written criteria for transfer to ahigher level of care as appropriate, with agree-ments with physician specialists in the re-ceiving institution to accept pregnant womenwho require ICU care. Preferably, a mater-nal transport team in the receiving institu-tion should be available to assume responsi-bility for care during transport. In institutionsthat provide ICU care for pregnant women,a well-coordinated system should be estab-lished that involves availability of a team ofcare providers including members who arecompetent in fetal assessment, hemodynamicmonitoring, and ventilatory support. An on-call system to ensure timely availability ofqualified personnel works well. Place of careshould be determined on the basis of mother’sclinical condition. If the critically ill woman isnonlaboring, the ICU setting is likely most ap-propriate, with a labor nurse at the bedsideif fetal monitoring is necessary. However, ifthe woman is in labor, the labor and birth unitmay be a more proper setting, with membersof the critical care team in attendance to takeresponsibility for ventilatory support and/orhemodynamic monitoring.

A mutually agreed upon plan should beavailable on the labor unit and in the ICU.

Considerations for developing a formal planor policy include the following5,6:

• Criteria for admission of a pregnantwoman to the ICU

• Under what clinical circumstances shouldlabor and/or birth occur in the ICU?

• Is the best place for this patient the ICUwith a labor nurse at the bedside or thelabor unit with a critical care nurse at thebedside?

• Who will be ultimately responsible for di-recting care and treatment?

• Plans for an emergent cesarean birth if in-dicated

• Plans for attendance of the neonatal resus-citation team at birth

• An on-call or contingency plan to assureavailability of appropriate care providersin a timely manner

When a critically ill woman is pregnant,clinical interventions, including medications,can have a profound effect on fetal status.It is essential that the fetus be consideredas the second patient when developing theplan of care. Gestational age of the fetus is asignificant factor determining how the fetuswill be affected by maternal interventions aswell as the type of fetal surveillance that isappropriate.6

PROMOTING FETAL WELL-BEING

Fetal well-being requires a hemodynami-cally stable, well-oxygenated mother and awell-oxygenated fetus. To promote fetal oxy-genation, essential clinical criteria must bemet, including adequate maternal cardiac out-put, blood pressure, hemoglobin levels, andoxygen saturation; adequate blood flow tothe uterus and placenta; adequate placentalfunction; normal uterine activity (in ICU pa-tients, this usually implies no uterine con-tractions); and uninterrupted umbilical bloodflow to the fetus (ie, absence of umbilicalcord compression). While many patients inthe ICU are supine with the head of the bedelevated slightly, this position is not ideal forpregnant women because it results in aorto-caval compression and decreased cardiac


22 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2006

output and blood pressure, leading to a de-crease in blood flow to the uterus and pla-centa and ultimately a negative effect on ex-change of oxygen between the mother andthe fetus. Aorto-caval compression effectivelydecreases venous return and increases cardiacafterload, which can result in a decrement ofup to 30% in ejection fraction.7 A lateral po-sition works best to promote maternal-fetaloxygen exchange; however, if this is not fea-sible given the patient’s condition, at mini-mum a left or right hip wedge should be used.Maternal hemoglobin levels should be main-tained at least to 10 g/dL to be adequate tocarry oxygen to the placenta to be transferredto the fetus via passive diffusion. Maternaloxygen saturation should be maintained at atleast 95% in order to promote adequate fetaloxygenation. Uterine activity should be mini-mized and can be controlled with intravenous(IV) fluid volume, terbutaline, or magnesiumsulfate as the patient’s condition allows. Um-bilical cord compression may be treated withmaternal position changes as appropriate tothe patient’s condition.

FETAL ASSESSMENT

The following information about fetal as-sessment is presented to familiarize criticalcare providers with various methods to as-sess fetal status, terminology used to de-scribe characteristics of FHR tracings, and ap-propriate interventions based on FHR data.This brief overview is not meant to provideenough information for ICU providers to in-terpret FHR tracings, but rather to promotecommunication with perinatal care providerswhen caring for a critically ill pregnantwoman.

Electronic fetal monitoring

Assessment of fetal well-being at 24 weeksor more of gestation is usually accomplishedvia EFM. Gestational age of the fetus andthe mother’s condition are determinants ofwhether monitoring is intermittent or contin-uous. Data can be obtained via external ul-

trasound or internal fetal spiral electrode, al-though most women in the ICU will have ex-ternal monitoring. Internal monitoring is re-served for women in labor with ruptured am-niotic membranes. They may require this typeof invasive monitoring because of inadequateor equivocal data from external monitoring.Fetal heart rate tracings provide informationabout ongoing fetal status. Four componentsof the FHR tracings are included in routineevaluation. These include the baseline rate,baseline variability, and presence or absenceof FHR accelerations and FHR decelerations.In 1997, the National Institute of Child Healthand Human Development Research PlanningWorkshop8 recommended the use of standardterminology to improve agreement in FHRinterpretation among members of the perina-tal team and researchers studying fetal status.The Association of Women’s Health, Obstet-ric and Neonatal Nurses9 and the AmericanCollege of Obstetricians and Gynecologists10

recently supported adoption of these recom-mendations. This terminology includes defini-tions for common FHR patterns (Table 1).

FHR patterns

The normal baseline FHR is between 110beats per minute (bpm) and 160 bpm. Thebaseline rate is evaluated over at least a 10-minute period and is determined by the meanrate rounded to increments of 5 bpm, eg, 130bpm or 135 bpm (Fig 1). An FHR of less than110 bpm for 10 minutes or more is consid-ered bradycardia, while an FHR of greater than160 bpm for 10 minutes or more is consid-ered tachycardia. Fetal heart rate variabilityis visually assessed by evaluating fluctuationsfrom the baseline (Fig 1). There are 4 cat-egories of variability: absent (amplitude un-detectable), minimal (amplitude greater thanundetectable but ≤5 bpm), moderate (ampli-tude 6–25 bpm), and marked (amplitude >

25 bpm) (Fig 2). Moderate variability is con-sidered normal. Periodic increases or acceler-ations of the FHR above the baseline rate areindications of fetal well-being. If the fetus isat term, an acceleration ≥15 bpm above the



Table 1. Fetal heart rate characteristics and patterns∗,†

Term Definition

Baseline rate Approximate mean FHR rounded to increments of 5 beats per minute (bpm)during a 10-min segment excluding periodic or episodic changes, periodsof marked variability, and segments of baseline that differ by >25 bpm. Inany 10-min window, the minimum baseline duration must be at least 2 minor the baseline for that period is indeterminate. In this case, one may needto refer to the previous 10-min segment for determination of the baseline.

Bradycardia Baseline rate of <110 bpm.Tachycardia Baseline rate of >160 bpm.Baseline variability Fluctuations of 2 cycles/min or greater in the baseline FHR. These

fluctuations are irregular in amplitude and frequency and are visuallyquantified as the amplitude of the peak to trough in bpm.

Absent variability Amplitude range undetectable.Minimal variability Amplitude range > undetectable and ≤5 bpm.Moderate variability Amplitude range 6–25 bpm.Marked variability Amplitude range >25 bpm.

Acceleration Visually apparent abrupt increase (onset to peak is <30 s) in FHR abovebaseline. The increase is calculated from the most recently determinedportion of the baseline. Acme is ≥15 bpm above the baseline and lasts≥15 s and <2 min from the onset to return to baseline.

Before 32 weeks of gestation, an acme ≥10 bpm above the baseline andduration of ≥10 s is an acceleration.

Prolonged acceleration Acceleration ≥2 min and <10 min duration.Early deceleration Visually apparent gradual decrease (onset to nadir is ≥30 s) of the FHR and

return to baseline associated with a uterine contraction. This decrease iscalculated from the most recently determined portion of the baseline. It iscoincident in timing, with the nadir of deceleration occurring at the sametime as the peak of the contraction. In most cases, the onset, nadir, andrecovery of the deceleration are coincident with the beginning, peak, andending of the contraction, respectively.

Late deceleration Visually apparent gradual decrease (onset to nadir is ≥30 s) of the FHR andreturn to baseline associated with a uterine contraction. This decrease iscalculated from the most recently determined portion of the baseline. It isdelayed in timing, with the nadir of deceleration occurring after the peakof the contraction. In most cases, the onset, nadir, and recovery of thedeceleration occur after the onset, peak, and ending of the contractionrespectively.

Variable deceleration Visually apparent abrupt decrease (onset to beginning of nadir is <30 s) inFHR below baseline. The decrease is calculated from the most recentlydetermined portion of the baseline. Decrease is ≥15 bpm, lasting ≥15 sand <2 min from onset to return to baseline. When variable decelerationsare associated with uterine contractions, their onset, depth, and durationvary with successive uterine contractions.

Prolonged deceleration Visually apparent decrease in FHR below baseline. The decrease is calculatedfrom the most recently determined portion of the baseline. Decrease is≥15 bpm, lasting ≥2 min but <10 min from onset to return to baseline.

Recurrent decelerations Occurring with ≥50% of uterine contractions in any 20-min segment.

∗Adapted from National Institute of Child Health and Human Development Research Planning Workshop.8†FHR indicates fetal heart rate.



Figure 1. Fetal heart rate (FHR) baseline and variability determination. Mean FHR rounded to incrementsof 5 beats per minute (bpm) (135). Fluctuations upward and downward from the baseline rate (moderate,6–25 bpm). This is a reassuring FHR tracing (normal baseline rate and variability; presence of accelerations;absence of decelerations).

baseline rate for ≥15 seconds is consideredreassuring, while in the preterm fetus (<32weeks’ gestation) an acceleration of ≥10 bpmlasting ≥10 seconds is considered reassuring.

Decelerations or decreases in the FHR be-low the baseline rate can suggest fetal com-promise. There are 4 types of decelerations:early, late, variable, and prolonged, each withspecific defining criteria and clinical implica-tions. Early and late decelerations are iden-tified on the basis of their relationship touterine contractions. Early decelerations aregradual (≥30 seconds from onset to nadir) de-creases in the FHR from the baseline rate thatoccur in synchrony with contractions and aregenerally considered to be benign. Late de-celerations are also gradual decreases in theFHR from the baseline rate; however, the tim-ing is late with respect to the contraction.Late decelerations usually begin around thepeak of the contraction with the nadir andreturn to baseline occurring after the con-traction. These types of decelerations may bea reflex central nervous system response totransient or mild hypoxemia or the result ofdirect myocardial depression related to ongo-ing or sustained hypoxemia. Variable decel-erations vary in shape, depth, duration, andtiming. The decrease in FHR is abrupt (on-set to beginning of nadir <30 seconds), ≥15

bpm from the baseline, and lasting ≥15 secand <2 min from onset to return to baseline.Variable decelerations are usually associatedwith umbilical cord compression. Prolongeddecelerations are also abrupt; however, theylast longer (≥2 min but <10 min) from on-set to return to baseline than do variabledecelerations.

The FHR is interpreted relative to uterineactivity. Therefore, interpretation of FHR pat-terns includes a complete assessment of the 4components of uterine contractions: (1) fre-quency, (2) duration, (3) intensity, and (4) theuterine resting tone between contractions.These assessments can be made by palpa-tion, the use of an external tocodynamome-ter, or the use of an intrauterine pressurecatheter (IUPC). Assessment of uterine activ-ity begins with palpation. Contraction fre-quency is measured from the beginning ofone contraction to the beginning of the nextand is described in minutes. Duration is thelength of the contraction and is described inseconds. Intensity refers to the strength of thecontraction. It is described as mild, moder-ate, or strong by palpation or in millimeters ofmercury (mm Hg) if an IUPC is used. Uterineresting tone is assessed in the absence of con-tractions or between contractions. By directpalpation, resting tone is described as soft or



Figure 2. Fetal heart rate (FHR) variability. bpm indicates beats per minute.

hard, and via IUPC in terms of mm Hg. As withany procedure, the least invasive approachis preferred unless there is need for moreobjective data. An IUPC requires ruptured

membranes and is reserved for women in la-bor for whom adequate data regarding uter-ine activity cannot be obtained via externalmonitoring.



When the FHR is normal, the term reassur-ing is often used. A reassuring FHR tracinghas a baseline rate within normal limits, ac-celerations, moderate variability, and no late,variable, or prolonged decelerations (Fig 1).A normal baseline rate with moderate vari-ability, accelerations, and no deceleration ishighly predictive of a well-oxygenated fetus.8

At the other end of the spectrum from nor-mality there are several FHR patterns that arepredictive of current or impending fetal as-phyxia so severe that the fetus is at risk forneurologic and other fetal damage, or death.8

These FHR patterns include recurrent lateor variable decelerations or substantial brady-cardia, with absent FHR variability. Many fe-tuses have FHR tracings that are somewherebetween these 2 extremes, and there is noconsensus among perinatal experts regard-ing the presumed fetal condition and clin-ical management.8 Abnormal characteristicsof the FHR include tachycardia, bradycardia,minimal or absent variability, and recurrentlate, variable, or prolonged decelerations. Thepresence of one or more of these character-istics may not necessarily indicate fetal com-promise. It is estimated that even the mostominous FHR patterns are associated with at

Figure 3. Nonreassuring fetal heart rate (FHR) tracing (tachycardia; minimal to absent variability, latedecelerations; no accelerations). bpm indicates beats per minute.

most a 50% to 65% incidence of neonataldepression.11 Electronic fetal monitoring sen-sitivity (the ability to detect a healthy fetuswhen it is indeed healthy) is high, while speci-ficity (the ability to detect a compromised fe-tus when it is compromised and not includehealthy fetuses in the criteria) is low.12 Never-theless, abnormal FHR tracings require inter-ventions as appropriate and careful ongoingevaluation. When the FHR has characteristicsthat are persistently abnormal, the term non-reassuring is often used (Fig 3).

Clinical implications of nonreassuringFHR patterns

Fetal bradycardia may be caused by fetalconditions such as hypoxemia secondary toan acute decrease in oxygen flow to the fetus,vagal stimulation, and rarely, cardiac anoma-lies or hypothermia. The duration and pres-ence or absence of baseline FHR variabilityare critical components in making a clinicalassociation between bradycardia and possi-ble fetal hypoxemia. Fetal tachycardia may becaused by fetal conditions such as infection,hypoxemia, anemia, prematurity (<26–28weeks’ gestation), cardiac tachyarrhythmias,



and congenital anomalies or by maternalconditions such as fever, dehydration, infec-tion, or medical problems as in thyroid dis-ease. If fetal bradycardia is noted via EFM,it is important to confirm that the origin ofthe heart rate being traced is fetal rather thanmaternal by checking the mother’s pulse. Incases of fetal death, the fetal monitor can de-tect and erroneously trace the maternal heartrate.

The most common causes of minimal vari-ability not associated with acidemia are cen-trally acting drugs such as narcotics, tranquil-izers, magnesium sulfate, and other analgesicsadministered to the mother. Minimal (but notabsent) variability is also seen in fetuses <26to 28 weeks’ gestation and during fetal sleepcycles. Loss of variability, especially in thepresence of recurrent late or variable deceler-ations or bradycardia, is a sensitive indicatorof fetal metabolic acidemia.

Late decelerations should be evaluated inthe context of FHR variability. For exam-ple, late decelerations with moderate baselinevariability and a stable rate with accelerationsare less concerning than are late decelerationsin the presence of an abnormal baseline rate,minimal variability, and absence of accelera-tions. If the FHR pattern had been reassuringprior to the onset of decelerations, an iatro-genic cause, such as maternal hypotension,can be frequently determined. Conversely,late decelerations with absent variability arepossible secondary to fetal hypoxemia13–15

and are likely to occur when there is chronicplacental insufficiency that cannot supportthe transient hypoxia episodes that occur dur-ing normal labor.16 Variable decelerations maybe caused by a uterine contraction pressingthe cord against the fetus, by a short or nuchalcord, or by intense vagal stimulation in thesecond stage of labor. In the case of oligo-hydramnios (low amniotic fluid volume), thecord is more vulnerable to compression be-cause of the lack of cushioning provided bythe amniotic fluid.17 Prolonged decelerationsmay be the result of an isolated episode of um-bilical cord compression, maternal hypoten-sion, excessive uterine activity, vagal stimula-

tion, and rarely, maternal seizures or maternalrespiratory or cardiac arrest.

Interventions for nonreassuring FHRpatterns

When the FHR is nonreassuring, interven-tions are based on the physiologic basis ofthe patterns’ characteristics. The usual in-trauterine resuscitation techniques includelateral position changes, administration of anIV fluid bolus, and administration of oxy-gen at 10 L/min via a nonrebreather facemask.10,18 These interventions promote fetalwell-being by maximizing intravascular vol-ume, uterine perfusion, placental exchange,and ultimately, oxygen delivery to the fetus.19

When a woman is critically ill, oxygen admin-istration may be accomplished by methodsother than the nonrebreather face mask de-pending on the individual’s clinical situation.While it is important to maintain adequate in-travascular volume to maximize oxygen deliv-ery to the fetus, IV fluid boluses may be con-traindicated in selected clinical conditions. Topromote fetal oxygenation, a lateral maternalposition is recommended. At times, the clin-ical condition of the pregnant woman in theICU may not allow a complete lateral position.In this case, a left or right hip wedge shouldbe used to avoid aorto-caval compression.

Using the FHR to assess fetal status anddetermine the need for clinical interven-tions

Experienced perinatal nurses assess FHRtracings for evidence of fetal well-being us-ing a mental checklist that includes thefollowing20:• What is the baseline FHR?• Is it within normal limits for this fetus?• If not, what clinical factors could be con-

tributing to this baseline rate?• Is there evidence of baseline variability?• If not, does fetal stimulation elicit an acceler-

ation of the FHR appropriate for gestationalage?

• What clinical factors could be contributingto this baseline variability?

• Are there accelerations or decelerations?



• If so, what type and what are the appropri-ate interventions (if any)?

• Does the FHR pattern suggest a chronic oracute maternal-fetal condition?

• Is uterine activity normal in frequency, dura-tion, intensity, and resting tone?

• What is the relationship between the FHRand uterine activity?

• If the FHR pattern is nonreassuring, dothe appropriate interventions resolve thesituation?

• If not, are further interventions needed?• Is the FHR pattern such that notification of

the primary care provider is warranted?

Ancillary methods to assess fetal status

Occasionally, as the patient’s condition al-lows, ancillary methods, including real-timeultrasound evaluation, nonstress test (NST),biophysical profile, and umbilical arteryDoppler velocimetry, are used to assess fe-tal status. These methods may be used whendata obtained via EFM are inadequate to de-termine fetal well-being or the data are equiv-ocal. Real-time ultrasonography may be usedfor a general visualization of the fetus, to mea-sure and compare fetal growth parameterswith expected values, to estimate fetal gesta-tional age, to rule out gross fetal abnormali-ties, and as a component of the biophysicalprofile.

The NST is based on the premise that theheart rate of a fetus who is not acidotic orneurologically depressed will temporarily ac-celerate with fetal movement.21 Electronic fe-tal monitoring is used for the NST. Nonstresstest results are defined as reactive or nonreac-tive, with reactive being considered normal.Generally, to meet criteria for reactive, theremust be 2 accelerations of the FHR that peakat least 15 bpm above the baseline for at least15 seconds within a 20-minute period withor without discernable fetal movement by themother.21 A nonreactive NST is one that lackssufficient FHR accelerations over a 40-minuteperiod.21

The biophysical profile consists of 5 vari-ables, including fetal breathing movements(one or more episodes of rhythmic fetal

breathing movements of 30 seconds or morewithin 30 minutes), fetal movement (3 ormore discrete body or limb movementswithin 30 minutes), fetal tone (one or moreepisodes of extension of a fetal extremity withreturn to flexion, or opening or closing of ahand), amniotic fluid volume (a single verti-cal pocket of amniotic fluid exceeding 2 cm),and the NST.21 Each of these variables are as-signed a score (2 if previously described crite-ria are met, 0 if criteria are not met) for a totalpossible score of 10. A total score of 8 to 10 isconsidered normal, a score of 6 is consideredequivocal, and a score of 4 or less is consid-ered abnormal. Presence of oligohydramnios,regardless of the overall score, is a concern-ing finding because low amniotic fluid levelsare often suggestive of fetal compromise. Dur-ing periods of fetal hypoxemia, blood flow isredirected to the fetal brain, heart, and adrenalglands. This redistribution of fetal blood flowcan result in decreased renal perfusion, lead-ing to oligohydramnios. Thus, oligohydram-nios can be a sensitive sign of uteroplacentalreserve and evolving fetal deterioration.16

Umbilical artery Doppler velocimetry isa noninvasive technique used to assessthe hemodynamic components of vascularimpedance.21 In a normal, healthy preg-nancy, physiologic conditions of the placentapresent an area of low vascular impedancethat allows continued blood flow throughoutthe cardiac cycle. With increases in placentalimpedance, the most passive blood flow indiastole in the umbilical artery decreases tolow, absent, or reversed end-diastolic flow.16

The basis for the test is that flow velocitywaveforms in the umbilical artery of normallygrowing fetuses differ from those of growth-restricted fetuses. Umbilical artery Dopplervelocimetry is more of a placental test thana test of fetal well-being; however, it is help-ful in identifying fetuses at risk for perinatalmorbidity and mortality.16

Special considerations for the pretermfetus

Pregnancy is expected to last approxi-mately 40 weeks (term pregnancy range is



38–42 completed weeks of gestation). Theage of a preterm fetus then is less than 37completed weeks of gestation. Fetal viabil-ity (the ability to survive if born) is gener-ally thought to be 24 weeks’ gestation, al-though there have been cases where youngerfetuses have survived. The younger the fetus,the greater the risk of perinatal morbidity andmortality.16 While the principles of EFM arethe same for the preterm fetus as for the termfetuses, there are differences in FHR patternsof preterm fetuses when compared to thoseof term fetuses and there are unique clini-cal implications for interpreting EFM data.6

Perinatal complications such as preeclamp-sia, intraamniotic infection, oligohydramnios,umbilical cord compression, placental abrup-tion, intrauterine growth restriction, utero-placental insufficiency, and multiple gestationare more common during preterm labor.6

These complications are often associated withnonreassuring FHR patterns. There is evi-dence to suggest that nonreassuring FHR pat-terns have greater significance for outcomesfor the preterm fetus.22 At term, approxi-mately only 20% of infants with nonreassur-ing FHR patterns will be neurologically de-pressed, whereas in preterm infants less than33 weeks’ gestation, approximately 70% to80% of infants with nonreassuring FHR pat-terns will be neurologically depressed, hypox-emic, or acidemic16

The preterm fetus is more susceptible tohypoxic insults and more likely to developand die from complications of prematurity ifborn depressed, hypoxemic, or acidemic.16

An abnormal or nonreassuring FHR pattern(minimal to absent variability, late decelera-tions, recurrent variable decelerations, tachy-cardia) is predictive of perinatal asphyxiaand long-term neurological outcome for thepreterm fetus.22–28 Compared to the term fe-tus, the progression from reassuring to nonre-assuring status occurs more often and morequickly.16 Thus, timeliness of identificationand initiation of interventions for nonreas-suring FHR patterns is more critical and ofmore lasting consequences when the fetus ispreterm.5,6

MEDICAL RECORD DOCUMENTATION

Because the fetus is a distinct patient re-quiring assessments, interventions, and eval-uation, documentation of nursing care isrequired. A separate medical record is not nec-essary; fetal data is included in the mother’smedical record. Ideally, the medical recordcomponent for the fetus should have cues andadequate space to prompt documentation ofcomprehensive care, including characteristicsof the FHR tracing, uterine activity, and nurs-ing interventions directed at promoting fetalwell-being. If the critically ill pregnant womanis cared for in the ICU setting, it is unlikelythat the electronic surveillance and documen-tation system used in the labor unit is avail-able. A stand-alone electronic fetal monitor isusually borrowed from the labor unit. There-fore, the paper version of selected medicalrecord forms, usually reserved for the elec-tronic system “downtime,” may be required.Data from the fetal monitor is not likely to bedisplayed in the ICU monitoring system avail-able for viewing remote from the patient’sroom. If continuous EFM is used, the labornurse should remain at the bedside to evalu-ate the FHR.

Care should be taken to save the originalfetal monitoring tracing as part of the medi-cal record if it is not downloaded to the elec-tronic archival system. The ink on most fetalmonitoring tracings is at risk for fading overtime. To prevent deterioration of this impor-tant component of the medical record, theoriginal paper tracing should be stored in azip-lock plastic bag within an opaque enve-lope in a cool place to deter damage fromheat, light, and air. Alternatively, a copy or mi-crofilm of the tracing may be made and storedwith the mother’s medical record.

When collaborating with perinatal careproviders, it is helpful to be familiar withthe language used to describe maternal-fetalstatus and the normal parameters of FHRtracings. Common abbreviations used in doc-umenting care of pregnant women are in-cluded in Table 2. This list may be help-ful in deciphering portions of the patient’s



Table 2. Common terms and abbreviations used to describe maternal-fetal status in the medicalrecord∗

AB Abortions (elective or spontaneous)AFI Amniotic fluid index (measurement of amniotic fluid in each of 4 abdominal quadrants)AFV Amniotic fluid volume (measurement of single vertical pocket of amniotic fluid)AROM Artificial rupture of membranesBOW Bag of waterBBOW Bulging bag of waterBPD Biparital diameter (fetal head measurement by ultrasound)BPP Biophysical profile (test of fetal well-being)CST Contraction stress test (test of fetal well-being)C/S Cesarean section (cesarean birth)EDC Estimated date of confinement (due date)EDD Estimated date of delivery (due date)EDB Estimated date of birth (due date)EFM Electronic fetal monitoringEFW Estimated fetal weightEGA Estimated gestational ageFHR Fetal heart rateFSE Fetal spiral electrodeG Gravida/Gravidity (number of times the woman has been pregnant)IUFD Intrauterine fetal deathIUP Intrauterine pregnancyIUPC Intrauterine pressure catheterLGA Large for gestational ageLMP Last menstrual periodLBW Low birth weightNST Nonstress test (test of fetal well-being)NVD Normal vaginal delivery (vaginal birth without complications)P Para/Parity (the number of pregnancies that resulted in birth after 20 weeks’ gestation,

whether alive or stillborn; not the number of babies)PIH Pregnancy-induced hypertensionPROM Premature rupture of membranesPPROM Preterm premature rupture of membranesPTB Preterm birth (before 37 completed weeks of gestation)PTL Preterm labor (before 37 completed weeks of gestation)ROM Rupture of membranesSGA Small for gestational ageSROM Spontaneous rupture of membranesUC Uterine contractionsVE Vaginal examinationVLBW Very low birth weight

∗Adapted from Simpson.20

medical record that were documented byperinatal care providers.

SUMMARY

A collaborative approach between perina-tal and ICU nurses and physicians to caring

for critically ill pregnant women works bestto promote the best possible outcomes formothers and babies. The fetus must beconsidered as the second patient since thematernal condition and treatments havethe potential to profoundly affect fetalstatus.



REFERENCES

1. Panchal S, Arria AM, Harris AP. Intensive care utiliza-tion during hospitalization for delivery: prevalence,risk factors, and outcomes in a statewide population.Anesthesiology. 2000;92(6):1537–1544.

2. Demirkiran O, Dikmen Y, Utku T, Urkmez S. Criticallyill obstetric patients in the intensive care unit. Int JObstet Anesth. 2003;12(4):266–270.

3. Mirghani HM, Hamed M, Ezimokhai M, WeerasingheDS. Pregnancy-related admissions to the intensivecare unit. Int J Obstet Anesth. 2004;13(2):82–85.

4. Selo-Ojeme DO, Omosaiye M, Battacharjee P, KadirRA. Risk factors for obstetric admissions to the in-tensive care unit in a tertiary hospital: a case controlstudy. Arch Gynecol Obstet. 2005;272(3):207–210.

5. Simpson KR. Fetal assessment in the adult inten-sive care unit. Crit Care Nurs Clin North Am.2004;16(2):223–242.

6. Simpson KR. Monitoring the preterm fetus during la-bor. MCN Am J Matern Child Nurs. 2004;29(6):380–390.

7. Naylor DF, Olson MM. Critical care obstetrics and gy-necology. Crit Care Clin. 2003;19(1):127–149.

8. National Institute of Child Health and HumanDevelopment Research Planning Workshop.Electronic fetal heart rate monitoring: researchguidelines for interpretation. Am J Obstet Gynecol.1997;177(6):1385–1390 and J Obstet GynecolNeonatal Nurs. 1997;26(6):635–640.

9. Association of Women’s Health, Obstetric, andNeonatal Nurses. Fetal Heart Monitoring Princi-ples and Practices. Washington, DC: Association ofWomen’s Health, Obstetric, and Neonatal Nurses;2005.

10. American College of Obstetricians and Gynecolo-gists. Intrapartum Fetal Heart Rate Monitoring.Washington, DC: American College of Obstetriciansand Gynecologists; 2005. Practice Bulletin No. 62.

11. Martin CB Jr. Electronic fetal monitoring: a brief sum-mary of its development, problems and prospects.Eur J Obstet Gynecol Reprod Biol. 1998;78(2):133–140.

12. Simpson KR, Knox GE. Risk management and EFM:decreasing risk of adverse outcomes and liability ex-posure. J Perinat Neonatal Nurs. 2000;14(3):45–58.

13. Beard RW, Filshie GM, Knight CA, Roberts GM. Thesignificance of the changes in the continuous fetalheart rate in the first stage of labour. J Obstet Gy-naecol Br Commonwealth. 1971;78(10):865–881.

14. Berkus MD, Langer O, Samueloff A, Xernaxis EM,Field NT. Electronic fetal monitoring: what’s reassur-ing? Acta Obstet Gynecol Scand. 1999;78(1):15–21.

15. Clark SL, Gimovsky ML, Miller FC. The scalp stimu-lation test: a clinical alternative to fetal scalp blood

sampling. Am J Obstet Gynecol. 1984;148(3):274–277.

16. Freeman RK, Garite TJ, Nageotte MP. Fetal HeartRate Monitoring. 3rd ed. Philadelphia, Pa: LippincottWilliams & Wilkins; 2003.

17. Galvan BJ, Van Mullem C, Broekhuizen FF. Using am-nioinfusion for the relief of repetitive variable de-celerations during labor. J Obstet Gynecol NeonatalNurs. 1989;18(3):222–229.

18. Simpson KR, James DC. Efficacy of intrauterine re-suscitation techniques in improving fetal oxygen sta-tus during labor. Obstet Gynecol. 2005;105(6):1362–1368.

19. King TL, Simpson KR. Fetal assessment during labor.In Simpson KR, Creehan PA, eds. AWHONN’s Peri-natal Nursing. 2nd ed. Philadelphia, Pa: LippincottWilliams & Wilkins; 2001: 378–416.

20. Simpson KR. Electronic fetal heart rate monitoring: aprimer for the critical care nurse. AACN Clin Issues.1997;8(4):516–523.

21. American College of Obstetricians and Gynecolo-gists. Antepartum Fetal Surveillance. Washington,DC: American College of Obstetricians and Gynecol-ogists; 1999. Practice Bulletin No. 9.

22. Matsuda Y, Maeda T, Kouno S. The critical pe-riod of non-reassuring fetal heart rate patterns inpreterm gestation. Eur J Gynecol Reprod Biol.2003;106(1):36–39.

23. Braithwaite ND, Milligan JE, Shennan AT. Fetalheart rate monitoring and neonatal mortality inthe very preterm infant. Am J Obstet Gynecol.1986;154(2):250–254.

24. Douvas SG, Meeks GR, Graves G, Walsh DA, MorrisonJC. Intrapartum fetal heart rate monitoring as a pre-dictor of fetal distress and immediate neonatal con-dition in low-birth weight (less than 1800 grams) in-fants. Am J Obstet Gynecol. 1984;148(3):300–302.

25. Low JA, Galbraith RS, Muir DW, Killen HL, PaterEA, Karchmar EJ. Mortality and morbidity after in-trapartum asphyxia in the preterm fetus. Obstet Gy-necol. 1992;80(1):57–61.

26. Low JA, Killen H, Derrick EJ. The predictionand prevention of intrapartum fetal asphyxiain preterm pregnancies. Am J Obstet Gynecol.2002;186(2):270–282.

27. Shy KK, Luthy DA, Bennett FC, et al. Effects ofelectronic fetal heart rate monitoring, as comparedto periodic auscultation, on the neurologic devel-opment of premature infants. New Engl J Med.1990;322(9):588–593.

28. Westgren LM, Malcus P, Svenningsen NW. Intrauter-ine asphyxia and long-term outcome in preterm fe-tuses. Obstet Gynecol.1986;67(4):512–516.

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Crit Care Nurs Q Vol. 29, No. 1, pp. 20–31 c 2006