Fetal and maternal misadventure

Chapter 23 Fetal and maternal misadventure



David T Y. Liu, Mentor: Charles Rodeck



CHAPTER CONTANTS


Fetal abnormalities 207

Fetal trauma 208
Procedure 208

Fetal death 208

Death of a co-twin 208
Management 208
Dichorionic twins – more than 34 weeks 208

Dichorionic twins – before 34 weeks 208

Monochorionic twins 208

Fetal/neonatal death at margin of viability 211

Maternal trauma 211
Procedure 211

Maternal death 211
Procedure 212

It is a sad but undeniable fact that, despite the best intentions, fetal and maternal damage or death occasionally complicate labour. The maternal mortality rate in England and Wales is around 1 per 10 000 live births (see Chapter 3). This can mean a tragedy about every two years in an obstetric department subserving 5000 pregnancies annually. The corrected perinatal mortality of around 1 per 100 births is 100 times higher than the maternal mortality rate. When misfortune presents itself appropriate counselling is essential. In most units a risk management form must be completed.



FETAL ABNORMALITIES



• The mother and her partner should be informed at the earliest opportunity of any major abnormality found at birth. Minor defects, which are detected, can be discussed later, at an appropriate time. Monstrosities are best not shown to parents unless explicitly requested and only after sensitive preparation.

• Discuss fully the likely cause and consequence of the abnormality. If appropriate arrange paediatric and genetic counselling for the couple.

• 3% of births are associated with an abnormality of some sort. Parents naturally want to identify a possible cause. Discuss all queries or suggestions and discourage any feelings of guilt.

• Rejection of the abnormal baby is a natural first reaction. Frequent discussion and counselling in the postnatal period is essential.

• All congenital abnormalities incompatible with life should be photographed, X-rayed and karyotyped to enhance subsequent genetic counselling.

• In contemporary practice most abnormalities are detected antenatally by ultrasound scan to allow proper care after birth.


FETAL TRAUMA


Fetal injuries can range from minor trauma, such as bruising or forceps marks, to major damage, such as fractures.



Procedure



• Inform the parents.

• Attend to the trauma if necessary.

• Discuss fully the likely cause and consequence of the trauma. Where appropriate offer an apology when the cause is clearly iatrogenic (e.g. skin incision to baby at caesarean section).

• Investigate fully where the cause is uncertain and inform the parents of the direction of the enquiry and its subsequent verdict.

• Document all proceedings in detail for medicolegal reasons.


FETAL DEATH


The stillbirth rate is around 5 per 1000 total births. Most stillbirths (80%) are unexplained fetal deaths where antepartum asphyxia is considered a direct cause (80%). In some 20% there may be a history of antepartum haemorrhage. Bleeding after 20 weeks and hypertensive disease remain as fetal risk factors.


Intrapartum asphyxia or trauma accounts for 10–15% of stillbirths. Failure to recognise a problem, inappropriate management and poor communication contribute to the adverse outcome.


Apart from the obvious disappointment facing all concerned, the response evoked in an individual can only be fully appreciated when the psychological background is considered. Medical personnel involved and a senior obstetrician should interview the couple jointly or on planned separate occasions. A tragedy such as this can greatly distress the staff as well as the couple concerned. Before counselling we must examine:


• our attitudes towards fetal loss

• our sense of guilt in terms of personal failure and the reasons why the obstetric system may have failed

• our ability to assess the aetiology objectively and identify avoidable factors

• our ability to detect pathological grief in the parents necessitating referral for psychiatric or social support

• our competency to conduct counselling.

Do not discourage discussion of the death or over-reassure and gloss over the tragedy. Too often clinicians have been viewed by parents as insensitive, unsympathetic and unconcerned. A suggested approach is shown in Box 23.1.



Box 23.1 Stillbirth or fetal death protocol



• Confirm fetal death or stillbirth has occurred – inform the mother immediately.

• Allow ample time for both the mother and her partner to ventilate their feelings and seek causes.

• Do not make excuses. Adopt an accepting attitude. Guilt feelings in mothers are common. Expression of anger is therapeutic, allowing a mother to offload some of her guilt feelings.

• Remember fetal death or stillbirth may be viewed by the mother as further evidence of her failings and inadequacies. It can also be felt as the loss of part of herself and stimulate fantasies analogous to that of phantom limbs after amputation. The birth of a child may hold symbolic significance as a means of redeeming some of the mother’s shortcomings in life. Search for these background factors in the discussion to understand the mother’s responses and to assist in subsequent counselling. Existing children can be affected by the tragedy and may need help and counsel. Support for the couple must extend into the next pregnancy and next birth.


Management



• Confirm suspicion of fetal death by auscultation, cardiotocography and ultrasound scanning.

• Obtain detailed history. This may help determine the cause and is important for the management of subsequent pregnancies.

• Note condition of the mother, clinical assessment, blood pressure, urinalysis, vaginal bleeding.

• Take blood from the mother for haemoglobin, full blood count, cross-matching, clotting screen and Kleihauer count.

• Consider delivery. Women seldom wish to continue pregnancy once fetal death is confirmed. A quarter to a third may develop disseminated intravascular coagulation if the fetus is not delivered within 3–4 weeks.

• Transfusion or resuscitation may be necessary if fetal death followed placental separation. Problems with clotting may need to be corrected.

• Avoid caesarean section unless there are mechanical problems such as transverse lie. Aim for a delivery with minimum intervention, discomfort or surgical intervention.

• Allow labour to continue if contractions are present; otherwise if there is no contraindication induce labour at a time acceptable to the mother. The most effective method is the combination of the anti-progesterone agent mifepristone (600 mg) followed 36–48 hours later by oral or vaginal misoprostol (50 μg).

Related posts:

  1. Maternal and perinatal mortality
  2. Abnormal labour
  3. Episiotomy and tears
  4. Assisted vaginal delivery and shoulder dystocia

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Mar 16, 2017 | Posted by in NURSING | Comments Off on Fetal and maternal misadventure

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