Intrauterine Fetal Death
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Induction, labour and delivery
Typical clinical findings of intrauterine fetal death (IUFD) include:
- Absent fetal movements
- Disappearance of symptoms of pregnancy
- Symphysis-fundal height not increasing as expected
- Fetal heart not heard
The diagnosis is confirmed by ultrasound scan. Be compassionate, offer a repeat scan by a second health care worker. Take a good history to help establish the cause of fetal death. Offer induction of labour, although the woman may choose to go home & return later.
Investigations
Take blood for FBC, urea & electrolytes, INR & screen for antiphospholipid syndrome (Antinuclear factor, Anticardiolipin antibody, Lupus anticoagulant & anti-B2 glycoprotein 1 antibody). Check RPR, Rh & HIV if not done previously.
INDUCTION, LABOUR AND DELIVERY
- Oxytocin infusion may be used if the cervix is favourable
- Intravaginal misoprostol may be used:
- At 20-24 weeks, give 100 mcg 6 hourly, up to 4 doses
- At ≥26 weeks: 25-50 mcg 4-6 hourly, up to 6 doses
- Alternatively from 26 weeks onwards, dissolve 200 mcg misoprostol in 200 mL water, & give 20 mL (20 mcg) every 2 hours orally
- Do not use misoprostol with parity ≥5 or previous caesarean section beyond 24 weeks gestation
- Do not infuse oxytocin <6 hours after the last dose of intravaginal misoprostol
- Bulb induction using a Foley catheter is a safe alternative to misoprostol – inflate a 30 mL Foley catheter bulb with 50 mL water, place above the internal os & strap the catheter to the thigh
- If induction fails, consider the possibility of extrauterine pregnancy
- Give analgesia – morphine 0.1 mg/kg IM (maximum 10 mg) with metoclopramide 10 mg IM 4 hourly if necessary
- Avoid artificial rupture of membranes, except with abruptio placentae
- Labour management follows the same principles as for normal labour: enter all observations, fluids & medications on a partogram, & treat labour abnormalities appropriately
POSTPARTUM CARE
- Encourage the parents to hold & name at their baby
- Be sympathetic & supportive at all times, note the normal grief responses
- Explain the cause of the stillbirth (if known) to the parents
- Offer the parents the opportunity to take photographs of their baby
- Advise on lactation suppression (give carbegoline 1 mg stat, oral)
- Transfer the mother to a gynaecology ward, or a separate area in the postnatal ward
Investigations following an unexplained IUFD
- Examine the placenta & make appropriate notes
- A paediatric doctor must examine the baby & make appropriate notes
- The mother must not be discharged without Rhesus group & RPR results
- Further investigations & autopsy, if needed