1. Simpson, Kathleen Rice PhD, RN, FAAN

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Consider the following recent cases. Case 1: After several hours of a nonreassuring fetal heart rate pattern during labor, a decision was made for an emergent cesarean birth. The team was assembled and birth occurred 27 minutes after the decision. The baby was slow to respond to simulation; eventually Apgar scores of 2, 4, and 9 were recorded at 1, 5, and 10 minutes of life. Case 2: A woman had a cesarean birth after prolonged labor without cervical change. When the baby was born approximately 45 minutes later, he was limp, blue, and without spontaneous respirations. Since a depressed baby was unexpected, the neonatal team was not asked to attend the birth. Resuscitation was difficult and the Apgar score at 10 minutes was 4. The baby was transferred to the NICU, requiring ventilator support for several hours. Case 3: A woman was admitted for a planned repeat cesarean birth. She was prepped and in the surgical suite within the hour. A macerated dead fetus was noted at birth to the complete surprise of the members of the surgical team as well as the mother and her support person.

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In each of these cases, the condition of the fetus prior to birth was not known to the members of the perinatal team. In the first case, the fetal monitor was removed after the decision to proceed during the abdominal prep in the labor room. There was no attempt to assess fetal status after the woman was moved to the OR. In the second case, the fetal monitor was removed in anticipation of an imminent transfer from the labor room to the OR; however, a more emergent case took priory, which caused a delay. Fetal monitoring was not reinitiated, nor was fetal status assessed in the OR. In the third case, it was not routine for women who were scheduled for repeat cesarean birth to have fetal monitoring prior to surgery; there was an assumption of fetal well-being unless the physician indicated the pregnancy was high risk.


After each of these cases a team debriefing and case review was conducted. Based on discussions with team members, it became apparent that routine care did not involve fetal assessment prior to cesarean birth despite recommendations to do so from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) in their Guidelines for Perinatal Care: "For women requiring cesarean [birth], fetal surveillance should be continued until abdominal sterile preparation has begun; if internal fetal monitoring is in use, it should be continued until the abdominal sterile preparation is complete" (p .148). The following responses by team members indicated a lack of knowledge of current standards and guidelines and/or the inability to incorporate them into clinical practice:


Is this something new that we should be doing now? What is the "Guidelines for Perinatal Care?" We don't have a fetal monitor in our OR. We don't bother getting a strip in the OR since there is no connection to our electronic strip archiving system. Our physicians are in too much of a hurry in the OR to let us listen to the baby's heart rate or get a fetal monitoring strip, so we've given up on trying to do that.


Fetal status prior to birth has direct implications for the baby's condition at birth and the ability to plan for neonatal resuscitation. This assessment is a component of basic perinatal nursing care. In the first two cases, advance planning for neonatal resuscitation could have improved the outcome for the baby. In the last case, the mother and her family could have been emotionally prepared for the stillbirth and options could have been discussed with them before proceeding with the surgery. The AAP & ACOG (2002) recommendations for fetal assessment prior to cesarean birth are based on clinical common sense supportive of safe care for mothers and babies and should be operational in every labor unit. Members of the perinatal team should be up-to-date on all recommendations for clinical care outlined in the Guidelines for Perinatal Care (2002). Take the time to fully review this valuable resource to ensure that unit practices are consistent with their recommendations. An unexpectedly depressed baby at birth should be an unusual occurrence.


Fetal Assessment Prior to Cesarean Birth


* Assess fetal status prior to cesarean birth via electronic fetal monitoring in the labor room and in the OR. Include the fetal monitoring strip from the labor room as part of the handoff communication to the surgical team.


* For women requiring cesarean birth, fetal surveillance should be continued until abdominal sterile preparation has begun; if internal fetal monitoring is in use, it should be continued until the abdominal sterile preparation is complete. Communicate fetal status to the surgeon immediately prior to surgery.


* Insure that members of the neonatal resuscitation team are in attendance when birth of a depressed baby is anticipated. One member of this team should able to perform a complete resuscitation including endotracheal intubation and medication administration (AAP & American Heart Association, 2006).




AAP & ACOG. (2002). Guidelines for perinatal care. Elk Grove Village, IL: Author. [Context Link]


AAP & AHA. (2006). Textbook of neonatal resuscitation (5th ed.). Elk Grove Village, IL: Author. [Context Link]