16.3 IUFD

Question 1

a) What are the implications of managing a patient with an intrauterine fetal death (IUFD) at 36-weeks
gestation? (55%)

Answer 1

1. > > Delivery decision:

induction, expectant or
occasionally caesarean due
to previous obstetric history
or patient preference or because underlying
cause necessitates this (e.g. uterine rupture).

2. > > Psychological:

senior midwife experienced in
caring for women with IUFD,
early conversation with obstetric anaesthetist, dedicated room for care of women experiencing
fetal loss away from the noise of labour
ward but still with the facilities
to provide level of care required.

Good communication among all involved healthcare professionals to avoid the possibility of lack of awareness of the situation and subsequent
insensitivity.

3. > > Pain relief options:
   more detail in (b)
4. > > Level of care:
   complications may have caused the
   IUFD or result from it.
   Obstetrician-led management
   and one-to-one midwifery care,
   MEOWS charting.
   Delivery suite is level 1 care,
   ward is level 0.
   May need to stay in level 1 care post-delivery. M
   ay require level 2 or even 3 care,
   depending
   on circumstances.

5&raquo_space; Implications of underlying cause:
may remain occult, may have major
implications on delivery management.

Abruption, pre-eclampsia, uterine
rupture, thrombophilia, sepsis,
maternal diabetes will all impact on
Intrapartum care and delivery mode.

Question 2

b) How does the presence of an IUFD influence the choice in the method of pain relief in labour? (20%)

Answer 2

> > Early consultation with the
obstetric anaesthetist should be facilitated to
discuss expectations and wishes.

> > Maternal pain experience might
be greater due to psychological distress
and also if induction is necessary.
There is therefore greater need for
effective pain relief, and epidural may be optimal.

> > Need not consideruteroplacental transfer:
better pain-relieving opioids
such as morphine and diamorphine may therefore be used instead of pethidine. May be given as PCA.

> > Cause or consequence of IUFD may contraindicate regional technique: sepsis; pre-eclampsia with deranged clotting or thrombocytopaenia;
haemorrhage or IUFD resulting in DIC.

> > Remifentanil PCA contraindicated according to protocols, lack of experience and recent adverse incidents associated with use in presence of IUFD.

Question 3

c) Which abnormal haematological results would contraindicate epidural analgesia? (25%)

Answer 3

> > Raised white cell count:

• Maternal sepsis (cause or effect of the IUFD).

> > Low platelets:
• May be present in severe pre-eclampsia
or HELLP syndrome.

> > Deranged coagulation, low fibrinogen:
• May accompany low platelets
in the presence of DIC due to abruption,
uterine rupture or occasionally as
a result of the IUFD itself.

• May also occur in pre-eclampsia
or HELLP syndrome.

• Abnormal coagulation may also be
present in maternal thrombophilias.

Question 4

c) If this patient requires a
caesarean section what are the
advantages of using regional
anaesthesia, other than the
avoidance of the effects of general
anaesthesia? (3 marks)

Answer 4

> > Offers optimum pain relief postoperatively.

> > Facilitates early contact with the baby.

> > Permits clearer recollection of events that may be important to the woman.

> > Facilitates presence of partner at delivery.

Question 5

a) Describe the important
non-clinical aspects of her
management. (4 marks

Answer 5

> > One-to-one senior midwifery care,
trained in caring for women with IUFD.

> > Good communication between all involved healthcare professionals to avoid possibility of lack of awareness of situation and subsequent
insensitivity.

> > Clear discussions with the woman regarding expectations and wishes for the delivery: pain relief, presence of friends or family,
contact with the baby after birth,
arrangement for mementoes to be created
(photos, hair cuttings, footprints).

> > Dedicated suite/room away from the noise of delivery suite, ideally with provision of non-clinical area where the woman may be with her birth
partner/family/friends before delivery and may spend time with her baby, if desired, after birth. However, location for delivery is ultimately determined by maternal condition