The Fetus as Patient


  • The author reports no conflict of interest or relevant financial relationships.

Throughout much of human history the fetus, unseen and largely imagined, has been looked upon with marvel and mysticism. The idea of the fetus as an entity, different from the pregnant woman, with conditions that are amenable to medical intervention and treatment is fairly recent. In the early 1900s the experimental observation of human and animal fetuses contributed to an understanding of embryonic and fetal development, and during the 1930s and 1940s the first successful fetal operations were performed on a guinea pig. However, the human fetus could not be thought of as a patient until its ailments could be diagnosed, a process that has evolved slowly (Harrison, 2001).

During the middle of the 20th century, the use of ultrasound for the obstetric population finally allowed for an accurate and detailed determination of normal versus abnormal fetal anatomy. Within the same time frame, interventions such as intrauterine transfusions for life-threatening fetal disorders were first being performed. Over the last 20 years, additional imaging modalities such as ultrafast magnetic resonance imaging (MRI) and computed tomography have been introduced to more specifically diagnose fetal anomalies, and new and improved techniques, including open fetal surgery and devices for fetal surgical intervention, have been developed. Certain fetal interventions have now become standard of care, and the number of physicians and hospitals performing these procedures is increasing.

Although the fetus may be considered a patient, treating the fetus independent of the pregnant woman is impossible. The welfare of the fetus is largely dependent on the health and safety of the pregnant woman who must remain the primary priority throughout the process. Ultimately, all fetal interventions are performed on the pregnant woman's body and potentially incur significant risks to her. Nurses involved in the care of these women and fetuses must be knowledgeable about the fetal diagnoses and options for fetal intervention as they are ideally positioned to affect maternal, fetal, and neonatal outcomes.

In this In Focus series, my colleagues and I discuss the advent of fetal therapy, specific fetal diagnoses responsive to fetal intervention, the different surgical procedures involved in treating a fetus, and the perioperative and perinatal nursing care of the maternal/fetal dyad.

In the first article Farrell and Howell review the history of fetal therapy from its inception in the animal laboratory to the present day. They also discuss a fetal surgical procedure that failed to improve the outcomes of fetuses with severe congenital diaphragmatic hernia but resulted in the development of the ex utero intrapartum treatment (EXIT) procedure, a unique, complex type of delivery.

Gregory, Wright, Schwarz, and Rakowski review placement of fetal shunts in the second article of this series. Shunt placement is considered for the treatment of lower urinary tract obstruction, pleural effusions, or macrocystic lung lesions in the fetus. The authors provide detailed information about ultrasound findings in the fetus, the fetal intervention, and the perioperative care of the pregnant woman.

Monochorionic, diamniotic twin gestations may present with several different complications that may be responsive to fetal therapy. Moise, Kugler, and Jones examine the various diagnoses that affect these gestations and the specific ultrasound findings that occur with each diagnosis. Options for fetal intervention, potential complications, and pregnancy outcomes are discussed. In addition, the authors highlight the need for bereavement services in the case of fetal loss.

The final article in the series introduces the findings of a recently published clinical study of fetal spina bifida closure. Spinner, Koh, Howell, and I review the procedure with emphasis on the perioperative and perinatal care of the mother as well as the care of the neonate. The importance of the nurse's role in the coordination and provision of care to women, fetuses, and children is stressed.

As the field of fetal therapy expands around the globe and the numbers of fetal treatment innovations grow, a consistent need remains for well-informed nurses to be involved in the care of these women and their fetuses. In the past, nursing research on prenatal diagnosis has mainly focused on the family's reaction to an abnormal diagnosis. Currently no published nursing research is available on the safest and best way to care for women who have undergone a fetal surgical intervention. Scientific nursing research to establish best practices is mandatory so evidence-based care can be provided to this population.


  • Susan R. Miesnik, RNC, MSN, CRNP, is a perinatal nurse practitioner at the Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA.