Late Intrauterine Fetal Death and Stillbirth

Question 1

What is the optimal method for diagnosing late IUFD?

Answer 1

• Auscultation and cardiotocography should not be used to investigate suspected IUFD.
• Real-time ultrasonography is essential for the accurate diagnosis of IUFD.
• Ideally, real-time ultrasonography should be available at all times.
• A second opinion should be obtained whenever practically possible.
• Mothers should be prepared for the possibility of passive fetal movement. If the mother reports passive
  fetal movement after the scan to diagnose IUFD, a repeat scan should be offered.

Question 2

What is the best practice for discussing the diagnosis and subsequent care?

Answer 2

• If the woman is unaccompanied, an immediate offer should be made to call her partner, relatives or friends.
• Discussions should aim to support maternal/parental choice.
• Parents should be offered written information to supplement discussions.

Question 3

What are the general principles of investigation?

Answer 3

• Clinical assessment and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of death, the chance of recurrence and possible means of avoiding further pregnancy complications.
• Parents should be advised that no specific cause is found in almost half of stillbirths.
• Parents should be advised that when a cause is found it can crucially influence care in a future pregnancy.
• Carers should be aware that an abnormal test result is not necessarily related to the IUFD; correlation between blood tests and postmortem examination should be sought. Further tests might be indicated following the results of the postmortem examination.
• Systems that use customised weight charts and capture multiple contributing factors should be used to
  categorise late IUFDs.

Question 4

Are there any special recommendations for women with an IUFD who are rhesus D-negative?

Answer 4

• Women who are rhesus D (RhD)-negative should be advised to have a Kleihauer test undertaken urgently to detect large feto–maternal haemorrhage (FMH) that might have occurred a few days earlier. Anti-RhD gammaglobulin should be administered as soon as possible after presentation.
• If there has been a large FMH, the dose of anti-RhD gammaglobulin should be adjusted upwards and the Kleihauer test should be repeated at 48 hours to ensure the fetal red cells have cleared.
• If it is important to know the baby’s blood group; if no blood sample can be obtained from the baby or
  cord, RhD typing should be undertaken using free fetal DNA (ffDNA) from maternal blood taken shortly
  after birth.

Question 5

What tests should be recommended to identify the cause of late IUFD?

Answer 5

Tests should be directed to identify scientifically proven causes of late IUFD.

Question 6

What precautions should be taken when sexing the baby?

Answer 6

• Parents can be advised before birth about potential difficulty in sexing the baby, when appropriate.
• Two experienced healthcare practitioners (midwives, obstetricians, neonatologists or pathologists) should inspect the baby when examining the external genitalia of extremely preterm, severely macerated or grossly hydropic infants.
• If there is any difficulty or doubt, rapid karyotyping should be offered using quantitative fluorescent polymerase chain reaction (QF-PCR) or fluorescence in situ hybridisation (FISH).

Question 7

What is best practice guidance for cytogenetic analysis of the baby?

Answer 7

• Written consent should be taken for any fetal samples used for karyotyping.
• Samples from multiple tissues should be used to increase the chance of culture.
• More than one cytogenetic technique should be available to maximise the chance of informative results.
• Culture fluid should be stored in a refrigerator and thawed thoroughly before use.

Question 8

What is the guidance on perinatal postmortem examination for maternity clinicians?

Answer 8

• Parents should be offered full postmortem examination to help explain the cause of an IUFD.
• Parents should be advised that postmortem examination provides more information than other (less invasive) tests and this can sometimes be crucial to the management of future pregnancy.
• Attempts to persuade parents to choose postmortem must be avoided; individual, cultural and religious beliefs must be respected.
• Written consent must be obtained for any invasive procedure on the baby including tissues taken for genetic analysis. Consent should be sought or directly supervised by an obstetrician or midwife trained in special consent issues and the nature of perinatal postmortem, including retention of any tissues for clinical investigation, research and teaching.
• Parents should be offered a description of what happens during the procedure and the likely appearance of the baby afterwards. This should include information on how the baby is treated with dignity and any arrangements for transport. Discussions should be supplemented by the offer of a leaflet.
• Postmortem examination should include external examination with birth weight, histology of relevant tissues and skeletal X-rays.
• Pathological examination of the cord, membranes and placenta should be recommended whether or not postmortem examination of the baby is requested.
• The examination should be undertaken by a specialist perinatal pathologist.
• Parents who decline full postmortem might be offered a limited examination (sparing certain organs),
  but this is not straightforward and should be discussed with a perinatal pathologist before being
  offered.
• Less invasive methods such as needle biopsies can be offered, but these are much less informative and reliable than conventional postmortem.
• Ultrasound and MRI should not yet be offered as a substitute for conventional postmortem.
• MRI can be useful adjunct to conventionaLpostmortem.

Question 9

What are the recommendations for timing and mode of birth?

Answer 9

• Recommendations about labour and birth should take into account the mother’s preferences as well as her medical condition and previous intrapartum history.
• Women should be strongly advised to take immediate steps towards delivery if there is sepsis, preeclampsia, placental abruption or membrane rupture, but a more flexible approach can be discussed if these factors are not present.
• Well women with intact membranes and no laboratory evidence of DIC should be advised that they are unlikely to come to physical harm if they delay labour for a short period, but they may develop severe medical complications and suffer greater anxiety with prolonged intervals. Women who delay labour for periods longer than 48 hours should be advised to have testing for DIC twice weekly (Table 1).
• If a woman returns home before labour, she should be given a 24-hour contact number for information and support.
• Women contemplating prolonged expectant MX should be advised that the value of postmortem may be reduced.
• Women contemplating prolonged expectant MX should be advised that the appearance of baby may deteriorate.
• Vaginal birth is the recommended mode of delivery for most women, but caesarean birth will need to be considered with some.

Question 10

How should labour be induced for a woman with an unscarred uterus?

Answer 10

• A combination of mifepristone and a prostaglandin preparation should usually be recommended as first-line intervention for induction of labour.
• Misoprostol can be used in preference to prostaglandin E2 because of equivalent safety & efficacy with lower cost but at doses lower than those currently marketed in the UK.
• Women should be advised that vaginal misoprostol is as effective as oral therapy but associated with fewer adverse effects.

Question 11

What is best practice for induction of labour for a woman with a history of lower segment caesarean section LSCS?

Answer 11

• A discussion of the safety and benefits of induction of labour should be undertaken by a consultant obstetrician.
• Mifepristone can be used alone to increase the chance of labour significantly within 72 hours (avoiding the use of prostaglandin).
• Mechanical methods for induction of labour in women with an IUFD should be used only in the context of a clinical trial.
• Women with a single lower segment scar should be advised that, in general, induction of labour with prostaglandin is safe but not without risk.
• Misoprostol can be safely used for induction of labour in women with a single previous LSCS and an IUFD but with lower doses than those marketed in the UK.
• Women with two previous LSCS should be advised that in general the absolute risk of induction of labour with prostaglandin is only a little higher than for women with a single previous LSCS.
• Women with more than two LSCS deliveries or atypical scars should be advised that the safety of induction of labour is unknown.

Question 12

What are considered suitable facilities for labour?

Answer 12

• Women should be advised to labour in an environment that provides appropriate facilities for emergency care according to their individual circumstances.
• Maternity units should aim to develop a special labour ward room for well women with an otherwise uncomplicated IUFD that pays special heed to emotional and practical needs without compromising safety. This can include a double bed for her partner or other companion to share, away from the sounds of other women and babies.
• Care in labour should given by an experienced midwife.

Question 13

What are the recommendations for intrapartum antimicrobial therapy?

Answer 13

• Women with sepsis should be treated with intravenous broad-spectrum antibiotic therapy (including antichlamydial agents).
• Routine antibiotic prophylaxis should not be used.
  Intrapartum antibiotic prophylaxis for women colonised with group B streptococcus is not indicated.

Question 14

Are there any special recommendations for pain relief in labour?

Answer 14

• Diamorphine should be used in preference to Pethidine.
• Regional anaesthesia should be available for women with an IUFD.
• Assessment for DIC and sepsis should be undertaken before administering regional anaesthesia.
• Women should be offered an opportunity to meet with an obstetric anaesthetist.

Question 15

What are the recommendations for women labouring with a scarred uterus?

Answer 15

• Women undergoing VBAC should be closely monitored for features of scar rupture.
• Oxytocin augmentation can be used for VBAC, but the decision should be made by a consultant obstetrician.

Question 16

Where should women receive care before returning home?

Answer 16

• Women should be cared for in an environment that provides adequate safety according to individual clinical circumstance.
• Women with no critical care needs should ideally be able to choose between facilities which provide adequate privacy

Question 17

What are the criteria for thromboprophylaxis?

Answer 17

• Women should be routinely assessed for thromboprophylaxis, but IUFD is not a risk factor.
• Heparin thromboprophylaxis should be discussed with a haematologist if the woman has DIC.

Question 18

What are the options for suppression of lactation?

Answer 18

• Women should be advised that almost one-third of those that choose nonpharmacological measures are
  troubled by excessive discomfort.
• Women should be advised that dopamine agonists successfully suppress lactation in a very high proportion of women and are well tolerated by a very large majority; cabergoline is superior to bromocriptine.
• Dopamine agonists should not be given to women with hypertension or pre-eclampsia.
• Estrogens should not be used to suppress lactation

Question 19

Who should be informed of events?

Answer 19

• All key staff responsible for care of the woman during pregnancy and afterwards should be informed of events.
• All existing appointments should be cancelled – maternity units should keep a list of likely departments
  that need to be contacted.

Question 20

What psychological problems can follow late IUFD?

Answer 20

• Carers must be alert to the fact that mothers, partners and children are all at risk of prolonged severe psychological reactions including post-traumatic stress disorder but that their reactions might be very different.

Question 21

What is best practice for use of interventions that might aid psychological recovery?

Answer 21

• Carers should be aware of and responsive to possible variations in individual and cultural approaches to death.
• Counselling should be offered to all women and their partners.
• Other family members, especially existing children and grandparents, should also be considered for counselling.
• Debriefing services must not care for women with symptoms of psychiatric disease in isolation.
• Parents should be advised about support groups.
• Bereavement officers should be appointed to coordinate services.

Question 22

What is the evidence for seeing, holding, naming and mementos?

Answer 22

• Carers should avoid persuading parents to have contact with their stillborn baby, but should strongly
  support such desires when expressed.
• Parents who are considering naming their baby should be advised that after registration a name cannot be entered at a later date, nor can it be changed.
• If parents do decide to name their baby, carers should use the name, including at follow–up meetings.
• Parents should be offered, but not persuaded, to retain artefacts of remembrance.
• Maternity units should have the facilities for producing photographs, palm and foot prints and locks of hair with presentation frames.
• Verbal consent should be sought from the parents and information governance regulations should be complied with for clinical photography.
• If the parents do not wish to have mementos, staff should offer to store them securely in the maternal case record for future access.
• It should be explained that clothes on a macerated baby might become stained.

Question 23

What are the legal requirements for medical certification of stillbirth?

Answer 23

• Obstetricians and midwives should be aware of the law related to stillbirth.

Question 24

What are the recommendations for spiritual guidance, burial, cremation and remembrance?

Answer 24

• Maternity units should have arrangements with elders of all common faiths and nonreligious spiritual organisations as a source of guidance and support for parents.
• The legal responsibility for the child’s body rests with the parents but can be delegated to hospital services.
• Parents should be allowed to choose freely about attendance at a funeral service.
• A leaflet about the options should be available.
• Maternity units should provide a book of remembrance for parents, relatives and friends.
• Carers should offer parents the option of leaving toys, pictures and messages in the coffin.

Question 25

What advice should be given about fertility?

Answer 25

- Information about fertility and contraception should be offered to mothers before returning home.

Question 26

What are the options for follow-up meetings?

Answer 26

- The wishes of the woman and her partner should be considered when arranging follow-up. - Before the visit, it is essential to ensure that all available results are readily to hand

Question 27

What are the recommendations for the content of the follow-up appointment?

Answer 27

- Parents should be advised about the cause of late IUFD, chance of recurrence and any specific means of preventing further loss. - Women should be offered general prepregnancy advice, including support for smoking cessation. - Women should be advised to avoid weight gain if they are already overweight (BMI over 25) and to consider weight loss. - An offer should be made to discuss the potential benefit of delaying conception until severe, psychological issues have been resolved. - Carers should be aware that while mothers tend to experience greater anxiety when conception occurs soon after a fetal loss, partners are more likely to suffer anxiety if conception is delayed. - Parents can be advised that the absolute chance of adverse events with a pregnancy interval less than 6 months remains low and is unlikely to be significantly increased compared with conceiving later. - The meeting should be documented for the parents in a letter that includes an agreed outline plan for future pregnancy

Question 28

What recommendations should be made for pregnancy following unexplained late IUFD?

Answer 28

- The history of stillbirth should be clearly marked in the case record and carers should ensure they read all the notes thoroughly before seeing the woman. - Women with a previous unexplained IUFD should be recommended to have obstetric antenatal care. - Women with a previous unexplained IUFD should be recommended to have screening for gestational diabetes. - For women in whom a normally formed stillborn baby had shown evidence of being small for gestational age, serial assessment of growth by ultrasound biometry should be recommended in subsequent pregnancies.

Question 29

What recommendations should be made for the management of future delivery after unexplained stillbirth?

Answer 29

- Previous unexplained IUFD is an indication to recommend birth at a specialist maternity unit. - Previous IUFD related to a known nonrecurrent cause merits individual assessment for place of birth. - Maternal request for scheduled birth should take into account the gestational age of the previous IUFD, previous intrapartum history and the safety of induction of labour.

Question 30

What recommendations should be made for maternal care after the next birth?

Answer 30

- Carers should be vigilant for postpartum depression in women with a previous IUFD. - Carers should be aware that maternal bonding can be adversely affected.

Question 31

Are there any risk management standards for IUFD?

Answer 31

- Maternity units should be aware of specific standards for IUFD and stillbirth

Question 32

What are the standards for documentation?

Answer 32

- Standardised checklists can be used to ensure that all appropriate care options are offered and that response to each is recorded. - Consent for perinatal postmortem examination should be documented using the nationally recommended form. - All stillbirths should be reviewed in a multiprofessional meeting using a standardised approach to analysis for substandard care and means of future prevention. Results of the discussion should be recorded in the mother’s case record and discussed with the parents. - All stillbirths should be reported to the Centre for Maternal and Child Enquiries (CMACE).

Question 33

What is best practice for care of staff?

Answer 33

- A system should be in place to give clinical and psychological support for staff involved with an IUFD. - Occupational Health should be contacted for advice if there are particular concerns about fitness to work.