—————— Critical Care Nursing Technique Traumatic Fetal Death Janet C. Howard, RN, MSN, CCRN, and Diane M. Nyari, RN, MSN Co Trauma during pregnancy increases the mortality risk to both victims: mother and child, The critical care nurse assumes a major role in assess- ing needs from both the trauma and obstetric perspec- tives. Collaboration between the critical care and obstetric nurse is essential to meet the complex physical, emotional, social, and spiritual needs of the entire family. A bereave- ment protocol can be helpful insuggesting specific interven- tons for long-term follow-up of the family suffering fetal Toss. Cc) Providing the optimallevel of care to the traumatized preg- nant woman requires the co- ordinated skills of nursing spe- cialists, The critical care nurse working in the emergency de- partment (ED) initiates nursing care of the traumatized preg- nant woman by rapidly assess- ing the vietim todetermine life- threatening injuries. Later, the intensive care unit (ICU) staff manage the varied needs of the seriously injured patient and monitor for possible compli- cations. In collaboration with the ED and ICU nurses, the obstetric nurse assists in per- forming an evaluation of fetal well-being. In particular, the obstetric nurse offers skills in fetal monitoring and in prepar- ing the family for premature delivery. Exploring the mean- ing of fetal loss and supporting healthy coping methods in the family is aresponsibility shared by the nursing professionals. Recognizing the Causes of Fetal Death Traumatic deaths relatively rare but ranks as one of the most common nonobstetric causes of fetal death. Although few statistics appear in the literature, one retrospective review reported onefetal death resulting from trauma in 12 pregnant women (8%).! Failure to recognize the effect of the anatomic and physiologic changes of pregnancy can increase mortality. During the first trimester, the uterus is protected within the bony pel- vis, and the increases in mater- nal blood volume and cardiac output are minimal. However, during the second and third trimesters, theenlarging uterus extends beyond the pelvis and displaces abdominal organs? A peak cardiac output of 7L/ minis achieved by week 24 and is maintained until term; total blood volume increases by 50%? Direct injury to the fetus occurs by means of penetrating orblunt mechanisms. Penetrat- ing trauma, including gunshot and stab wounds to the uterus, can cause fetal death, even with minimal maternal injury Because of the associated en- ergy, tissue destruction result- ing from gunshot wounds is greater than that caused by stab wounds, Penetrating injur- ies are often intentional, the result of increased stress and marital conflict during preg- nancy’ Alcohol and drug use are common factors contribut- ing to this type of injury. Maintaining an active life style throughout pregnancy predisposes a woman to blunt injuries suffered in motor vehi- cle accidents (MVA), falls, and sporting accidents. Commonly in an MVA, the protuberant I) Janet C. Howard, RN, MSN, CCRN, is a Trauma Clinical Nurse Specialist at Memorial Hospital in South Bend, Indi- ana. She was instrumental in the implementation ofa trauma response team at the hospital. Diane M. Nyari, RN, MSN, is currently the Head Nurse of the Pediatric Intensive Care Unit at ‘Memorial Hospital in South Bend, Indiana. Diane formerly held the position of Clinical Nurse Specialist in the regional neonatal intensive care unit at ‘Memorial VOL. 8, NO. 4, JULY-AUGUST 1989217a ical Care Nursing Technique abdomen is contused by the quate oxygenation, defined as tation. The pregnancy was un- steering wheeloranimproperly Po? greater than 60 mmHg, is complicated until the time of worn seatbelt. The fetus is needed to maximize fetal sur- the accident. While moving at somewhat protected by the vival.” Likewise, carbon diox- approximately 40 miles/hr, her amniotic fluid, which acts asa ide levels are evaluated in rela- car slid on an icy road ‘and shock absorber? However, if tion to expected levels. During came to a stop in a snow the pelvis is disrupted by frac- the second and third trimes- embankment. She was wearing tures, direct fetal trauma, in- ters, the expected Pco, aver- a seatbelt at the time. cluding skull fractures and ages 30 mmHg; anormal PCO: Onarrivalin the ED, M.C. was intracranial hemorrhage, is of 40 mmHG may be harmful conscious and complained of more likely. to the fetus.!! chest, abdominal, and low back Although the most common Maternal hypovolemia cre- pain. The emergency nurse cause of fetal death is death of ates: similar dangers for the completed aninitialassessment the mother, fetal loss some- developingfetus.Becausepreg- with the following findings: The times occurs without obvious _nancyincreasesthe vascularity airway was patent and the tra- maternal trauma because of _ of the pelvis, lower abdominal _cheamidline. Spontaneous res- abruptio placentae.’ This pre-and pelvic injuries are often _pirations, regular but shallow, mature separation of a nor- accompanied by alarge blood occurred at a rate of 32 per mally implanted placenta, ac- loss. To compensate for the minute. Paradoxical excursion counts for themajority of fetal acute blood loss, the sympa- _of an anterior flail segment on deaths in accidents in which thetic response shunts blood —_therightsidewasnoted. Breath themothersurvives*The rapid from the uterus to maintain sounds were diminished from compression of organs and perfusion of the vital organs? the nipple line to the costal shearing forcesthat occur dur- A vascular shunt of 20% may margin on thesameside. There ing deceleration cause the occurbeforesignsof shock are was no evidence of external abruption. In contrast to the evident in the mother. Fur- hemorrhage. Heart tones were muscular uterus, the nonelas- thermore, eventransient hypo- clearly audible without mur- tic placenta does not easily tension can precipitate fetal mur, gallop, or rub, and neck rebound from decelerative hypoxiaanddeath.""Decreased —_veins were flat in the supine forces.’ A placental separation cardiac outputrelated to hypo- _ position. Peripheralpulses were of 25% to 50% can cause fetal volemia may be aggravated by weak but equal and capillary distress, whereas abruption the venacavalsyndrome, Ven- refill was delayed to 5 seconds. greater than 50% can result in ous return to the right side of | Cardiac monitoring showed fetal death* the heart is impaired because _ sinus tachycardia at a rate of Fetal death also occurs sec thevenacavaiscompressedby 130; blood pressure was re- ondarilyasaresultofmaternal the uterus when the mother is corded at 100/80. hypoxia and/or hypovolemia. in a supine position? The complete neurologic Trauma creates an additional evaluation was unremarkable; stress that tipsthedelicatephys-- Case Study* the Glascow Coma score was iologicbalancebetween mother 15, There was a seatbelt contu- “MC. was a 25-year-old, grav- and fetus, Because compensa- i429 para I ferale whewes Sion noted over the lower ab- tory mechanisms protect the mother at the expense of the imvolved in a motor vehicle omen. The abdomen, was fetus, the effects of physiologic °¢ident during her seventh eae eeenicaie eect imbalances are magnified in Month of pregnancy. The date ith’ ocking of the pelvis and the fetus? of jher last menstrual period hen q urine specimen, Was Maternal hypoxia and/or a” serial examinations were Optained by catheterization, it hypercapnia result directly Consistent with a 29-week ges- oo rossi Bloody, . from thoracic injuries or in- Because of the site of her directly from central nervous _, “Thenameand nonessential charac. pain, M.C. repeatedly expressed ‘ ration? teristics of the case have been changed a system injuries or aspiration’ fErcunftlemisiig ay obeicnees, concern about her baby's con- Inthetraumatizedwoman,ade- actual person is coincdental. dition. The emergency nurse 218 DIMENSIONS OF CRITICAL CARE NURSING6 al Care Nursing Technique frequently reported and inter- ing staff, assumed the coordi _ After delivery, M.C. was re- preted assessment findings, nation of the care. Over the admitted to the ICU. Once which indicated the well-being next 12 hours respirations be- recovered from anesthesia, the ofthe baby. These werereports came less rapid, and follow-up _ mother was asked whether she of active fetal movement with- ABGs on 40% oxygen showed and the father would like to out contractions, absence of an; saturation of 100% witha view and hold the baby. The vaginal bleeding, absence of | pH7.45, PCO, 35, and Po, of 88. nurse prepared the parents by amniotic fluid leakage, and — M.C. continued to complain of explaining the infant's color, maintenance of fundal height, —_generalizedpainoverher chest, temperature, and appearance. measured at 29cm. Thefather, abdomen, and lower back. Thenurse brought the infant to who had arrived at the hospital Pulse was 90, respiratory rate _ theparentsand remained avail- by this time, eagerly accepted 24, and blood pressure 120/80. _able for questions and reassur- the suggestion to be with his The parents were reassured by _ ance, The nurse pointed out the wife during further evaluation. the continuous external fetal _infant'snormal features. Photo- Fetal monitoring revealed a monitoring, which revealed a graphs and footprints of the normal pattern with arate of normal fetal heart rate pattern _infant were takenand accepted 160 beats per minute. Portable with a beat-to-beat variability by theparents. Attheirrequest, ultrasound confirmed gesta- averaging 6 beats. the pastor of their church was tional age and showed anante- At 18 hours postadmission, _calledand asked tocome tothe riorly placed placenta without M,C. began experiencing ab. - hospital. evidenceof previaor abruption. —_ dominal cramping, which inten- Physically, M.C. made rapid The diagnostic workup was sified to severe abdominal pain _ progress. Oxygen therapy was completed as quickly as possi- without overt vaginal bleeding. gradually weaned as her pul- ble. The laboratory work re- She became pale, restless, monary status improved. She vealed abnormalarterial blood tachycardic, and tachypneic. required additional transfusion gases (ABGs); pH was 7.30,Pco, The uterus was rigid with an of packed cells. Coagulation was 45,andPo,was68onroom increased fundal height. Fetal studies, which were closely air and there wasa positiveRh _heartrateshowedfrequent late monitored, returned tonormal. factor. The x-ray films showed —_decelerations without variabil- She was transferred to a pri- multiple fractures of the sixth, __ity.Astheoxygenwasincreased _ vate room on a medical-surgi- seventh, and eighth ribs on the —_to 100% and M.C. was positioned cal unit, from which she was right side and probable pulmo- on her left side, the primary discharged several dayslaterto nary contusion, as well as two nurse provided brief explana- further convalesce at home. nondisplaced pelvic fractures. tions in a calm voice. After The primary nurse made a Oxygen wasstartedat 60% by —_repeatlaboratoryworkshowed follow-up phone call several partialrebreathermask.Aftera a metabolic acidosis and ade- days after discharge to offer total fluid intake of 3,000 cc, veloping coagulopathy, fresh the parents continued help in including crystalloids and two _ frozen plasma was given. adjusting to the loss. units of packed red blood cells, The obstetrician discussed the heart rate fell to 100 beats the risk of maternal hemor- per minute and blood pressure . rhage and recommended im- Retforming « Comprehensive increased to 130/70.Thefamily mediate delivery. The nurse was informed of the need to recognized the parents’ con- _—As illustrated in the case admit M.C.totheICUforobser- _ cernforthe baby’ssurvivaland study, the performance of a vation of her cardiopulmonary informed them of the availabil- comprehensive evaluation of and obstetric status. A grand- ity of neonatal intensive care. _ the physical and psychosocial mother offered to watch the An emergency cesarean sec- _ needs is afforded high priority couple's other child so that the tion was quickly performed, in the emergency setting. The father could remain at the but attempts toresuscitate the nurse considersthemechanism hospital. infant were unsuccessful. A ofiinjury,physicaland obstetric ‘A primary nurse, with con- concealed abruption of 50% — findings, and psychologic clues sultation of the obstetric nurs- was diagnosed at delivery. in developing a plan of care. VOL. 8, NO. 4, JULY-AUGUST 1989219= Critical Care Nu 1g Technique The history of the accident ety, the nurse asks direct, spe- the uterus for fetal size, move- from emergency medical ser- cific questions in completing ment, resting tone, and pres- vice (EMS) personnel provides the assessment. ence or absence of contrac- importantcluesconcerningthe Despite mutual concern for tions. After the 25th week, the mechanism ofinjury.Invehicu- the well-being of the fetus, the height of the fundus is mea- lar accidents, the nurse ascer- critical care nurse recognizes _ sured in centimeters above the tains details such as the time theimportanceofmaternalcar- symphysis pubisto confirm the and location of the accident, diopulmonary function to the gestational age. The nurse thelocation ofthe victim within survival of both mother and inspects the perineum fre- thevehicle, anyrestraints used, fetus. A physical assessment of quently for evidence of vaginal andtheapproximatespeedand the traumatized pregnant bleeding or leaking amniotic point of impact. In penetrating woman is carried out accord- fluid. Documentation includes trauma, itis important to note ing to established protocols. the amount and color of the thetypeandcaliberof weapon, Thenurse assessesfor patency _dischargeand any tissue passed itsdistance and trajectory, and of the airway and quality of — with it. any intervening materials. respirations, and high-flow oxy- Secondly, the nurse com- — genisstarted. The nurse evalu- pletes an obstetric history by ates the adequacy of cardiac Soe interviewing themother, if pos- output and tissue perfusion. ‘atient sible. Theinformationgathered . Mental status, vital signs, and Once the mother's physical includes date of the last men- urine output are closely moni- injuries have been determined strual period (LMP), number tored to identify trends that and her condition stabilized, and route of previous deliver- warn of early shock-restless- further attention is focused on ies, and any obstetric complica- ness, pallor, tachypnea, tachy- the well-being of the fetus. tions. The gestationalageofthe cardia, decreased pulse pres- Commonly, assessment of the fetus is estimated in weeks sure, or oliguria. In particular, —_fetusis accomplished with fetal from the date of the LMP; nor- the nurse evaluates the effect heart rate (FHR) monitoring mal gestation is 40 weeks, yet of the supine position on car- and ultrasonography. viability is possible at 24 weeks diac output. If possible, the _Thecritical carenurserecog. with neonatal intensive care. nurse places the patient ina _nizes the value of FHR moni: Ahistory of previous cesarean _left-side-lying position or man- toring as a routine method of sections should alert the nurse ually displaces the uterus to fetal assessment. Following an tothe possibility of uterinerup- _preventpositionalhypotension. accident, however, the mother ture, whereas previous abor- Inaddition tostandard trauma _ and father oftenfearthat some- tion or abruption predisposes laboratory work, the type and thing is wrong. Because of the the mother to repeated obstet- crossmatch includes a deter- parents’ anxiety, itis important ric problems." minationofmaternalRhfactor that the nurse's approach pro- While completing the inter- to plan for administration of vide reassurance.'® view, the critical care nurse Rho (D) immune globulin Before beginning, the nurse assesses the level of maternal (RhoGAM) to the Rh-negative provides a simple explanation anxiety and its effect on data woman following delivery or of the-purpose, technique, and collection. The mother com- fetal loss." X-ray films are expected findings of fetal mon- monly focusesher attentionon taken, as needed, to identify itoring, Additionally, the nurse the well-being of the baby and injuries. The nurse anticipates maintains an awareness of her needs frequent reports con- the couple's concerns about facial expressions and strives cerning his or her status. The irradiation during pregnancy to maintain eye contact father is escorted into the andprovidesinformationabout throughout the procedure. trauma room as soon as possi- its purpose and reassurance Questions by the parents are ble to observe the condition of that appropriate shielding will answered simply but honestly; the mother and share in the be used, the nurse and physician fre- necessary decision making. Continuingwiththeobstetric quently report findings but Because of the couple's anx- examination, thenursepalpates avoid giving false reassurances 220 DIMENSIONS OF CRITICAL CARE NURSINGa | 0 such as “everything will be just fine.” Auscultation should be per- formed quickly but carefully by a nurse experienced in the technique. Initially, the nurse auscultates fetal heart tones using a Doppler ultrasound instrument. Fetal heart tones, possibly audible by the 10th to 12th gestational week, range from 120 to'160 beats per minute.'® In the high-risk mother, the initial doppler auscultation is followed by continuous moni- toring with an external or in- ternal electrode, Each method has distinct advantages and disadvantages, and the nurse should be aware of these. Monitoring via an externally placed electrode is easily ac- complished in most trauma- tized women but is subject to artifacts such as those caused by client movement." At times, the ultrasound tocodynamom- eter also produces false in- formation by miscounting the FHR. External monitoring works best when the belt fits snugly, which may cause dis- comfort, To detect erroneous counting, the nurse should periodically verify the moni- tored rate by auscultating the FHR with a Doppler. Despite the disadvantages, continuous monitoring alerts the nurse to intermittent changes in heart rate and its response to fetal movement or uterine contractions. Sustained tachycardia, a heart rate ex- ceeding 160 beats per minute for several minutes, can be an early warning sign of mild or chronic fetal hypoxia.'* How- ever, the nurse must rule out an increased heart rate result- ing from other reasons includ- ing maternal fever, anxiety, fetal infection, or prematurity On the other hand, fetal brady- cardia, a rate of less than 100, may indicate progressive hy- poxia, acidosis, or decreased placental blood flow.'* A dis- played rate of less than 100 should also be checked to be sureitisnot thematernal heart, rate. Variability, which refers to the expected fluctuation in fetal heart rate, is one of the most important parameters of fetal well-being." If variability de- creases, the nurse is warned that fetal reserve is depleted and that the fetus may be in jeopardy. Finally, any slowing of the heart rate during uterine con- tractions is noted. Depending on the timing during the con- traction, the slowing of the heartrateislabeledeither early or late deceleration. Early de- celerations, beginning at the onset of the contraction and ending as the contraction ends, are considered benign and are usually the result of compres- sion of the fetal head.'* Con- versely, late decelerations, which tend tooccur at the peak orlaterineachcontraction and donot return to baseline before the end of the contraction, can be an ominous sign.!* They are usually a result of decreased blood flow and oxygen transfer tothe fetus. Despitethe appear- ance of late decelerations, de- livery of the fetus may be delayed if the FHR exhibits adequate variability. In certain circumstances, in- ternal FHR monitoring may be initiated in the traumatized patient. Monitoring via an in- termally placed electrode is more accurate and eliminates many of the disadvantages of the external method. However, because placement of the elec- trode requires cervical dilation and rupture of the membranes, itis reserved for use only when delivery is imminent."* When placental abnormali ties are suspected, ultrasonog- raphy is often used to identify the problem and observe the cardiac activity of the fetus. Fetal death is confirmed by the Jack of heart beat onareal-time scan.!” In ultrasonography, sound waves are bounced off tissues and converted into a visual image. Thenurseinforms the couple who are unfamiliar with the technique that scan- ning does notinvolve radiation, Therefore, the father is per- mitted in the room to share the results and provide support to the mother. Supporting the Family During the Intrapartum Perlod Based on the information obtained through fetal moni- toring and the sonogram, the critical care nurse further plans carein preparation for delivery. If the fetus is not distressed despite a minor placental sepa- ration, the nurse continues to monitor the mother and fetus closely.'* If, however, the fetus shows distress, physical and emotional preparations for delivery begin, Vaginal delivery ispreferred unless further prob- lemsnecessitaterapid delivery.” When significant abruption is accompanied by fetal dis- tress, immediate cesarean sec- tion is preferred to maximize infant survival and minimize maternal complications.’ A sec- tion allows rapid delivery and hysterectomy, if necessary. Severe placental separation VOL. 8, NO. 4, JULY-AUGUST 1989221= Critical Care Nursing Technique Table 1. A Bereavement Protocol During and Immediately Within Need Preceding Birth After Birth 24 Hours 2 Weeks Later Long Term To experience Maintain frequent Provide private Koop infant’s Primary nurse to bonding with contact with and quiet longings make follow-up the infant mother father, atmosper with parents visit (f mother and sibiings—_forbirth——Askparents to still hospital Eneoura Handle baby share ized) or phone arents to talk gontly experiences of cal about their Allow parents ‘birth ("momoryEncourago infant to touch and making”) verbalization Emphasize the _ hold infant about normaley ‘peciainess of Refer to the of pregnancy, the infant by infant by baby's referring tothe _ namo appearance, baby by name Emphasize that ete, based on andastheir the infant family’s baby was loved readiness Prepare parents Take picture, for the footorints, birth/death and lock of hai. Offer to parents or keop with chart To have privacy Make consistent Offer choice of Allow parents to 6-8 wocks: Mako ‘protected and caragiver private room expross. follow-up phone stress ‘assignments Limit vistors as feelings (about call or visit to ‘minimized Eliminate family requests -aocident, encourage ‘unnecassary Support healthy hospitalization, _rememboring persons from coping birth, ote.) and a oversedation ‘ask questions Make other staff Assist with (ebout reason ‘aware of ratification of howto inform for baby’s. ‘grieving family family siblings, family, oath, future Eliminate Screen visitors friends pregnancies, ‘unnecessary ete.) teste, procedures treatments Inform family of ‘availabilty of support staff To have Share information Offer an ‘Arrange parent 6-8 weeks: Share information with all team autopsy conference further autopsy concerning _- members. Offer funer with M.O. results death and Provide informa options, Discuss autopsy/ 6-8 wer burial tion as known Encourage and stating pathologic Emphasize facts, about cause of input of concerns findings not conjecture death (Copyright © 1986, Memorial Hospital of South Bend) 222 DIMENSIONS OF CRITICAL CARE NURSINGDuring and 24 Hours Need Preceding Birth 2 Weeks Later Long Term Continue to Help with funeral Remind paronts Ascoss offer of various ‘expectations of information support groups ‘and provide: opportunity to cy ‘parents to ask Offer ‘questions went possible Answer questions pamphlet ‘about burial/ cremation Encourage decision-making about care To receive Offer to notify Show Make consistent Discuss effects of 6-8 weeks: Contact ‘emotional clergy of choice, willingness to caregiver ef on health, and spiritual or chaplain cry assignments —_-marriago, support Offer ritual of Arrange for _—Discuss feelings family blessing and of doubt/guilt Assess for dadication, _Acknowled ‘abnormal grief Offer to pray with if eppropriate tional pain reactions family and a normal Suggest montal friends Offer to contact health couns support ing for persons abnormal grief death through Offer literature reactions phone call or note » Compas: slonate Friends by primary nurse and hemorrhage damage the uterine wall, leading to release of large amounts of thrombo- plastin into the maternal blood supply? The hypofibrinogene- mia and disseminated intra- vasular coagulation (DIC) that frequently result are corrected through administration of fresh frozen plasma or cryoprecipi- tate? Parental anxiety related to the unknown condition of the baby is continually addressed. The nurse takes time during physical preparationsto answer questions and explore any con- cerns. Informationis relayed in small frequent discussions with the parents; information pro- vided to the parents should include a description of the press feelings of guilt over “kill- delivery/operating room, and _ ing the baby” in the accident. the appearance of and possible _After fetal deathis confirmed, resuscitative measures for the _ thecouple ofteninquires about infant, delivery of the dead infant. When fetal demise is con- _Relyingon theinformation pro- firmed by the sonogram, the vided to the couple by the couple is informed as soon as _ obstetrician, thenurse prepares possible of the baby's death? them fordelivery. Spontaneous ‘The obstetrician, accompanied vaginal delivery, which often bytheprimarynurse,relaysthe follows fetal death, may be information ina private setting. ‘An honest approach such as — nurseacknowledgesthe pain of 'm very sorry your baby is _ facinglaborandthe delivery of dead” is recommended. ‘A variety of responses by explores the couple's choice of both mother andfather canbe anesthesia for delivery, de- anticipated. Responses can scribes the appearance and rangefrom quietacceptanceto temperature of the fetus at denial, anger, or guilt. The delivery, and reassures them mother, in particular, may ex- that they will be able to touch delayed by several days. The adead baby. Further, thenurse VOL. 8, NO. 4, JULY-AUGUST 1989 223————1 Critical Care Nursing Technique and hold the baby if they wish. following the fetal death. Insti- in the care must not be over- After delivery, the opportun- tutions vary in their available’ looked. Many of thesameneeds ity tohold theinfant and call it staff resources, but commonly for information, for input into by name emphasizes the spe- the primary nurse, obstetrician decisions, and for emotional cialness ofthe baby.Eveninthe and/orprimarycarephysician, support are present. Recogniz- presence of obvious external social worker, and chaplain are _ingeach other's stress and offer- trauma, the actual appearance _ involved. ing support are crucial during of the infant is less disturbing A coordinating person, re- the difficult time. Small group then the parents might imag- sponsible forimplementingthe discussions, or “debriefings” ine." If they choosenot to view _protocolandassuring year-long — mayhelpin resolving thestaff’s the body, a photograph and follow-up, is identified to all grief.“ footprints are saved and kept team members. Without clear _ In the role as primary nurse, with the chart for the future." communication, an omission the critical care nurse assumes ‘As the mother’s condition al- or a duplication of efforts can responsibility for identifying, lows,thenursefacilitatesbond- easily occur. Inmostsituations, planning, implementing, and ing by allowing the parents tothe primary nurse or social evaluating interventions to be with the baby for aslongas —_ worker assumes the coordina- meet the holistic needs of the they desire. tor role. family suffering fetal loss. The The parents will have ques- Another factor in the suc- nurse incorporates knowledge tions about the disposition of céssful implementation of the of potential causes of fetal the infant's body. Local health bereavement protocol is accu- death into the assessment of regulations usuallyrequirereg- rate record keeping. An index maternal and fetal condition. istration of thedeathand burial card that includes the parents’ During the diagnostic phase or cremation after a particular names,addressandphonenum- —_and preparations for delivery, gestational age or weight. In- ber, infant name, date of death, _thenurseprovideshonest infor- vestigatingthelocalregulations details of thecase,andinvolved mation and emotional support. prior to the delivery prepares _professionalsishelpfulindocu- Finally, the critical care nurse the nurse to answer the ques- menting the implementation of implements the bereavement tions she is asked. Burial or the protocol. The card may be protocol with interdisciplinary cremationnotonly satisfiesthe kept in a small file box on the collaboration to meet the long- health statutes, but makes the unit orsome other place thatis term needs of the family. loss a reality for the family.” accessible to the persons in- The nurse suggests the post. volved. The card should be Clinical Research Questions ponementoffuneralplansuntil filed by date to serve as @ thefellowingquestionsneed further themotherisabletoparticipate reminder of the follow-up investigation: after anesthesia. Some funeral _dates—2 weeks, 6 to 8 weeks, _® What criteria should be used to homes senda representativeto 1 year. inate the nee for continuous FAR the hospital to meet with the The protocol serves as_a monitoring in the traumatized preg: family. guideline by suggesting specific “"s Does severe abdominal trauma approachestomeet the family’s reduce the accuracy of external fetal ds, The family's adjustment monitoring? Assisting the Grieving tol i © What i the impact of collabora Family—A Bereavement to the loss must be viewed 28 9. cetweencriicalcareandobteic dynamic process, in which Protocol as ‘nurses on the hospital outcome for vie . some needs take priority over tims of trauma during pregnancy? Its essential that the entire others at certain times. A pro- “"e What specific interventions. in- healthteamrecognizeandsup- —_tocol that recognizes variations _ cluded in a bereavement protocol are port thefamily inthe early grief inthe family’sneedsandallows cited by families as helpful in the work. A bereavement protocol flexibility initsimplementation _*“/ustment to fetal loss? (Table 1) has been developed —_ is recommended. by some institutions to outline _—_Althoughnotincludedaspart Key Words the intradisciplinary responsi of the bereavement protocol, Trauma, pregnancy, fetal death, Fetal bilities during the first year the needs of the staff involved demise, bereavement, 224 DIMENSIONS OF CRITICAL CARE NURSINGCritical Care Nursing Technique ——— References 1983;26:902-912. 8, Golan A, Sandbank O, Teare AJ. ‘Trauma in late pregnancy. South Afr 1. Sorensen VJ, et al. Trauma in pregnancy. Henry Ford Hosp Med J 1986;34:101-104. 2. Haycock CE. Emergency care of the pregnant traumatized pati Emerg Med Clin North Am 1984; 343-851, 3, Baker DP, Traumain the pregnant patient. Surg Clin North Am 1982362; 275-289, 4, VanderVeer JB, Trauma during pregnancy, Topics Emerg Med 1984; 672-77. ', Hillard PIA. Physical abuse in pregnancy. OB Gyn 1985;66:185-190. 6. Haycock CE. Injuries during preg- nancy: Saving both mother and fetus. Consultant 1982;22:269-274. 7. Crosby WM. Traum: Med 1980;57:161 63:108-125. Mosby, 1984 101:683-691, 101-127. ic injuries during pregnancy. Clin Obstet Gynecol 9. Higgins SD, Garite TJ. Late abrup- tio placenta in trauma patients: Impli- t. cations for monitoring. OB Gyn 1984, 10, Bobak IM, Jensen MD, Essent of Maternity Nursing. St, Louis, CV 11, Barron WM. The pregnant surgi- cal patient: Medical evaluation and ‘management, Ann Intern Med 1984; 12, Crosby WM. Automobile injuries and blunt abdominal trauma, baum HJ (ed). Trauma Philadelphia, WB Saunders, 1979, ‘Nursing: Care of the Growing Family, ‘ed. 3. Boston, Little, Brown & Com- pany, 1985. 14, Newkirk EJ, Fry ME. Trauma during pregnancy: Nursing assessment in the emergency department. Focus Crit Care 1985;1230-39, 15, Whitaker CM, Death before birth. ‘Am J Nurs 198686:157-158. s__16, Olds SB, Condon ML, Lade- wig PA. Maternal Newborn Nursing— A Family.Centered Approach, ed 2. Reading, Massachusetts, Addison- Wesley, 1980. 17, Stack JM, Barnas K. Stillbirth, ‘AFP 1987;35:117-124. 18, Kowalski. When birth becomes death. AORN J 198338557-64, 19, Hildebrand WL. Helping parents cope with perinatal death. AFP 1980; 22:121-125, Buchs- Pregnancy. 13, Pillitteri_ A. MaternalNewborn Book Reviews Critical Care of the Newborn (2nd edition). WA Hodson and WE Truog. Philadelphia: W.B, Saunders Company, 1989, 206 page Beginning with chapters on fetal monitoring, maternal drug effects, and delivery room management and resuscita- tion, the book covers the many diverse problems which may plague the pre-term or term newborn, either at birth or shortly thereafter. The focus of the book is on diagnostic approaches, initial treatment, and stabilization of the infant, ‘The book is organized around the medical model and includes chapters about disorders of the various body sys- tems, as well as chapters on asphyxia, apnea, assessment of gestational age, temperature regulation, nutrition, fluids and electrolytes, and infants of diabetic mothers. The chapter on infectious disorders is very comprehensive for a handbook ofthis size and includes a section on neonatal AIDS, Congen- ital malformations are also discussed in surprising detail. ‘Neonatal critical care nurses will find this handbook most useful asa quick, ready reference about disorders and immediate care of the newborn, Nursing care and practice issues are not addressed, nor are some topics of interest to nursing, specifically ethical issues and working with Families. —Reviewed by Dawn L. Johnson, RN, MN, CCRN, Patient Care Manager, ICU, Children's Hospital of Wisco Milwaukee, Wisconsin. Cutial Care Medicine, John M, Luce and David J. Plerson. Philadelphia: W.B. Saunders Company, 1988, 634 pages Critical Care Medicine was written “to help physicians, nirses and respiratory therapists manage critically il patients." The authors address the concept of critical care medicine through a systems approach, In addition, sections on drug overdosage and withdrawal, environmental di orders and nutrition are included. ‘Common to all disease processes, whatever degree, is the problem of tissue oxygenation. The opening section of the ‘book sts the stage for the remainder ofthe text by present- {ng the most common underlying abnormality of organ sys- tem failure, tissue oxygenation. ‘This book provides a succinct overview of many com- monly encountered critical care problems; however, it ‘Would be useful tothe ertical care nurse only as a supple- mental reference since few nursing books or journals are cited in the recommended reading section—Noncy Stark, MSN, CCRN, Nurse Educator for Critical Care, Medical College of Georgia, Augusta, Georgia. VOL. 8,NO, 4, JULY-AUGUST 1989225