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Nursing Care of an Intrauterine Fetal Demise Patient: Clinical Exemplar

Brooke Fortner

University of South Florida

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Nursing Care of an Intrauterine Fetal Demise Patient: Clinical Exemplar

Clinical exemplars are important tools that enable nurses to demonstrate the critical

thinking used to make decisions during the delivery of patient care (Black, 1997). A clinical

exemplar can be used to demonstrate the decision-making that resulted in whether or not an

intervention was performed, and allows the nurse to reflect on the responsiveness and ethical

responsibility to the patient care experience (Pollard, 2015). This clinical exemplar will

demonstrate my reflection on the actions and rationales of providing competent care to a patient

experiencing complications of pregnancy.

Nursing Care

The patient presented to the Labor and Delivery unit for induction of labor at 15 weeks

gestation due to intrauterine fetal demise (IUFD). The 19-year-old patient had gone to her

prenatal appointment earlier that morning and was told to promptly go to the hospital, as no fetal

heart tones were found. Upon arrival to the unit, the provider performed an ultrasound and

confirmed the lack of fetal heart tones. An assessment was performed with no other abnormal

findings and stable vital signs. Prenatal records were available. The patient reported no vaginal

bleeding and no leakage of fluid. Additionally, the patient denied cramping and contractions. The

patient was given 800 mcg of Cytotec to ripen the cervix for vaginal delivery of the passed fetus.

External fetal monitoring was not indicated. A urine sample was taken and tested on the unit,

testing positive for cannabinoids. The patient admitted to the use of marijuana prior to hospital

admission, following the news of the loss of her fetus.

On admission and initial assessments, the patient was exhibiting the expected behavior of

a young adult who just received the news of the loss of her fetus. She cycled through various

stages of loss: anger, denial, bargaining. However, as the patient’s stay in the hospital continued,
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and the pain of induced labor began to set in, the patient’s demeanor suddenly changed. During

my initial assessment, I had noticed old scars along her wrists and forearms. She admitted to

causing self-harm a few years ago, but said that it was just “[her] being young and stupid.” It was

when emotional changes occurred that this assessment finding became crucial. When I went back

in to the patient’s room to get another set of vital signs, change the IV fluids, and provide

emotional support, the patient told me that she was depressed and really having trouble coping. I

sat with her for a bit, listening to her talk about various emotions. She then said that she felt

pressure in her rectum, so I went to notify my preceptor so that she could confirm the need for a

sterile vaginal exam and the change in coping. As we continued to talk with our patient, the

patient’s face suddenly dropped, and almost without emotion- only two tears falling down her

face- she verbalized the need to be Baker Acted as she said “I want to die with my baby.”

Information needed to make a decision include assessment of emotional state, stability,

and the emergent need for a 1:1 sitter and legal action. The administrator on duty (AOD)

provided us with the steps we needed to take to Baker Act the patient. The patient’s provider was

notified after safety was ensured in order to get an order for a 1:1 sitter and to initiate the Baker

Act. While the patient did not have an immediate plan for how she would carry out suicide, the

expressed wish to kill herself created a critically emergent situation. Safety was the priority in

this situation and the appropriate measures were taken in order to prevent the death of the

mother.

The best decision was made based on evidence and research in the area of care of patients

at risk for self-harm, grieving, and loss. Long-term outcomes include improved coping

mechanisms, decreased suicidal ideation, and the maintenance of safety. Interventions that can

be delegated include the request for a 1:1 sitter so that as the nurse, we can still provide care to
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other patients in our assignment, rather than remaining in the room with the patient to observe

her.

A study by Kondrat and Teater (2012) discusses the importance of nurses in the initial

recognition of suicidality in a patient. While this study focused on ER nurses, it is relevant to

L&D nurses as critical care is provided and IUFD puts the patient at risk for suicidal ideation. A

significant risk factor that this article described that a nurse should be able to recognize is

hopelessness (Kondrat & Teater, 2012). This risk factor was present in the patient as she

described how she felt that she did not feel hopeful for her future. This article also describes the

use of solution-focused therapy approach that can positively impact hopelessness and allow for

the appropriate assessment of suicide risk (Kondrat & Teater, 2012). Solution-focused therapy

provides a brief avenue for assessing risk and for increasing hope (Kondrat & Teater, 2012). This

approach can be adapted by nurses working with those who present with suicidal ideation and

psychiatric emergencies (Kondrat & Teater, 2012). Therefore, in a time of hopelessness, the

nurse helping a patient through a fetal demise can allow grieving to occur, but also help the

mother to recognize her strengths and hopes for the future.

Conclusion

As a team, my preceptor and I made the right decision and achieved the desired outcome,

as the patient remained safe from self-harm. I recognized there was something abnormal in the

patient’s emotional state, a risk to safety, and the need for further assessment and help from my

preceptor. As an opportunity for improving my patient care, I should have sought further

information about the cut marks on the patient’s arms in the initial assessment, instead of

allowing her to dismiss them as a part of her past that were irrelevant. Therefore, more practice

in empathetic interviewing skills that evoke deeper responses will be beneficial.

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References

Black, P. J. (1997). Use of the clinical exemplar in performance appraisals. Neonatal Network,

16(5), 73-78. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/9325873

Kondrat, D. C., & Teater, B. (2012). Solution-focused therapy in an emergency room setting:

Increasing hope in persons presenting with suicidal ideation. Journal Of Social Work,

12(1), 3-15. doi:10.1177/1468017310379756

Pollard, C. L. (2015). What is the right thing to do: Use of a relational ethic framework to guide

clinical decision-making. International Journal Of Caring Sciences, 8(2), 362-358.