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Chorioamnionitis is a serious complication during labor at term and is associated with adverse neonatal outcome affecting approximately 10% of pregnancies. It is diagnosed clinically or microbiologically or by histopathologic examination of the placenta and umbilical cord. The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. These subjective findings are neither sensitive nor specific. However, clinical chorioamnionitis requires a high index of suspicion, timely diagnosis, prompt antibiotic treatment, and delivery, which may help reduce the potentially devastating outcome of maternal and neonatal infections. This article focuses on clinical chorioamnionitis and presents the physiologic immune response during pregnancy, the definition of chorioamnionitis, clinical diagnostic criteria, and implications for practice.

A better understanding of why women die during pregnancy, childbirth, or postpartum offers valuable insight into strategies aimed at preventing maternal deaths and arresting the progression in the severity of a complication. The rate of severe maternal morbidity and maternal mortality in the United States has been trending upward in recent years and has garnered national attention with concentration on bolstering reviews of maternal deaths and implementing patient safety initiatives. The obstetric nurse is in a unique position to improve maternal outcomes through the anticipation, recognition, and communication of the early warning signs of impending deterioration in maternal condition. Presented in the context of the conceptual model of Stephen Covey's Circle of Influence, the professional nurse can proactively influence maternal outcomes directly, with actions defined by the scope of professional nursing practice or indirectly through professional interactions with others. Advancing one's education, knowledge, and technical skills broadens the influential capacity.

Early recognition and treatment of sepsis are key to decreasing maternal and fetal morbidity and mortality. Timing is critical, and early intervention is associated with improved outcomes. The perinatal provider is in a unique position to identify risk factors, perform assessments, and implement the first 3 hours of the sepsis bundle. Early detection and management combined with careful assessment can assist in providing evidence-based care and moving the patient to a higher level of care when warranted.

There are many interventions performed as a part of the active management of labor and birth that have remained unchanged over the years. Separating ritual from beneficial nursing care can guide the development of a research agenda. The agenda for the next 10 years can address some of the gaps remaining in the evidence-based foundation for routine interventions used during labor and birth. The gaps identify areas where unanswered questions prevent optimal care from occurring. These unanswered questions include optimal time for epidural administration; management of maternal movement during labor when routine interventions make this difficult; changing the practice of immediate, closed glottis coached pushing at 10 cm; continuous electronic fetal monitoring; routine administration of intravenous fluids; and finally, the use of oxytocin as augmentation or induction of labor.

Anesthetic complications require immediate recognition and intervention. With the many options and high anesthesia rates among laboring women, today's perinatal nurses need education not only in the choices of anesthesia but also in the complications that can result from these choices. Most orientation programs briefly discuss the subject, leaving the amount of information and training insufficient for the nurses to feel confident in their understanding of the complications and competent to respond. This educational need could also extend to experienced staff who lack current knowledge and appropriate competence in responding to obstetric anesthesia emergencies. The purpose of this article is to address the major complications of obstetric anesthesia and how nurses need to respond, with the goal of improving patient safety in these rare but high-risk situations. Recommendations in didactic content are presented to assist hospital educators in achieving this goal.

Substantial scientific evidence supports spontaneous maternal bearing down for its associated maternal and fetal physiologic benefits. Imposing specific directions for Valsalva pushing does not result in optimal outcomes but continues to be widely used, particularly when labor progress is less than optimal. However, there are numerous evidence-based approaches that can be used to avoid reverting to directed, prolonged Valsalva bearing down. Nursing care challenges may be encountered when using physiologic approaches; therefore, strategies are detailed to alleviate a variety of problems including ways to promote physiological descent and effectively support women's spontaneous efforts. For example, maternal postural interventions are suggested for asynclitic and occiput posterior fetal positions. When fetal heart rate abnormalities present and the fetus may be compromised, modifications to spontaneous bearing down are suggested as alternatives to longer and stronger Valsalva pushing, such as encouraging the women to use short pushes or breath through contractions until the fetus recovers. Open knee-chest maternal positioning can help to diminish a premature urge to push, while the closed knee-chest position may be more useful if cervical edema occurs. Even with clinical challenges, evidence-based care can help achieve the improved outcomes documented from women's spontaneous bearing-down efforts during the second stage.

Perinatal nurses are at higher risk for involvement in a malpractice suit than are their colleagues in other medical specialties. That risk can be minimized. A review of selected obstetrical malpractice claims reveals that key issues for perinatal nurses who want to avoid litigation include sound and current education in the interpretation of fetal heart rate tracings, the adoption of well-designed policies for the administration of oxytocin, ability and willingness to use the chain of command, comprehensive and objective documentation, and awareness of the fact that making the patient's well-being the focus of every nursing action is the perinatal nurse's best defense.

An increasing number of women receive epidurals during labor and birth. Although the incidence of adverse reactions remains very low, the potential for life-threatening complications still exists. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) states that the safety of women undergoing procedures, such as the administration of epidural analgesia/anesthesia, depends significantly on the competence, attentiveness, and experience of those responsible for their care. The purpose of this article is to review the significant complications related to obstetric epidural. Recommendations are presented to aid the nurse in preparing for and managing epidural emergencies. Specific responsibilities of nurse managers and educators in competency training, evaluation, and guidance of nurses are also discussed.