Intrauterine death: Intrauterine fetal death (IUFD) refers to the death of the fetus at any stage in the pregnancy after the first trimester and before the onset of labour. The fetus may be retained in the uterus for weeks or be born a few days following intrauterine death.
A stillbirth is a baby born after 24 weeks’ gestation which shows no signs of life. A baby born before 24 weeks is defined (from a medical viewpoint) as a spontaneous abortion.
Causes associated with intrauterine death
Parents should be advised that no specific cause is found in 25–60% of IUFDs.18
Maternal
• Social factors, e.g. low socioeconomic status.
• Maternal age (teenagers and >35 years).
• Less formal education.
• Lack of antenatal care.
• Smoking, alcohol, and drug misuse.
• Obesity/excessive weight gain in pregnancy.
• Viruses/infection: rubella, CMV, toxoplasmosis, listeriosis.
• Exposure to environmental hazards:
• Lead, cadmium, mercury
• Air pollution.
• Direct trauma to the abdomen.
• Placental dysfunction: abruption, placenta praevia.
• PIH, cholestasis of pregnancy.
• Poor previous obstetric history: abortions, preterm labour, stillbirth.
• Maternal illness: diabetes, renal disease, severe anaemia, epilepsy,
antiphospholipid syndrome.
Fetal
• Fetal malformation (e.g. associated with diabetes).
• Fetal anoxia.
• Severe IUGR.
• Rh incompatibility.
• Multiple pregnancy (especially monozygotic twins).
• Cord accidents, compression, entanglement, true knot.
Complications of intrauterine death
• DIC may occur if the fetus is retained >3–4 weeks.
• Induction of labour may be prolonged or difficult.
• The woman and her partner are at risk of psychological trauma.
Signs of Intrauterine death and stillbirth
Signs will depend on the time lapse since intrauterine death:
• No fetal movements will be felt by the woman
• No fetal heart heard with the abdominal transducer
• The uterus may be smaller than expected for dates
• The woman may experience full breasts and may produce milk
• Any hypertension may settle
• There may be a brownish discharge PV.
Diagnosis of Intrauterine death and stillbirth
• Ultrasound scan will confirm no heartbeat.
• Spalding’s sign: overlap and misalignment of fetal skull bones.
• Robert’s sign: gas in the great vessels and heart of the fetus (1–2 days).
• Fetal curl: there is arching of the fetal spine.
Management of Intrauterine death and stillbirth
• The woman who presents with anxieties about reduced or no fetal movements should be seen urgently.
• Be sensitive to her anxiety. You may be able to reassure the woman quickly by hearing the fetal heart using the CTG or Sonicaid®. When doing this, it is important to differentiate the fetal and maternal pulses. Caution must be used, as auscultation of the fetal heart with a Pinard stethoscope or Doppler ultrasound is insufficiently accurate and should not be used to diagnose a suspected IUFD. Auscultation can give false reassurance; maternal pelvic blood flow can result in an apparently ‘normal’ FHR pattern with an external Doppler.
• Ideally, real-time ultrasonography should be available at all times; this is essential for the accurate diagnosis of IUFD. If the fetal heart is not heard (or the pregnancy is <20 weeks and the FHR is not easily audible), explain the findings and contact an experienced ultrasonographer and a registrar to assess by ultrasound whether or not the FHR is present.
• The diagnosis of intrauterine death should be confirmed by two experts.
• Women booked under midwifery-led care should be transferred to consultant-led care. However, continuity of midwifery care should still be given high priority in order to facilitate adequate support and coordination of information throughout the episode. A midwife specializing in bereavement care may be available. When giving bad news note that:
• Support for the woman should be sought from her partner/family/friends.
• Health-care professionals should offer support to help the women and their partners and/or family cope with the emotional and physical consequences of the death. This should include offering information about specialist support.
• Information should be clear and honest, given in a way sensitive to individual needs and feelings. Parents will always remember the way the news is delivered and the attitudes of staff.
• The parents may react with shock or ‘numbness’ or disbelief. Some may experience physical symptoms. Mothers should be prepared for the possibility of passive fetal movement after the scan to diagnose IUFD; a repeat scan should be offered.
• Parents need time to receive the information.
• Any information given may need to be repeated, and distressed clients may need the information to be written down so that they can review it later.
• Support for staff is also important.
• The SoM, community midwife, health visitor liaison, and GP should be informed of the intrauterine death as soon as possible after diagnosis.
Induction of labour
• An obstetric consultant should discuss a plan for care and delivery with the parents.
• Once the diagnosis is made, in the event of an IUFD, if the woman appears to be physically well, her membranes are intact, and there is no evidence of infection or bleeding, she should be offered a choice of immediate induction of labour or expectant management. Some women will want to wait a day or two; others will request induction of labour as soon as practical.
• Immediate induction of labour is the preferred management option if the death of the fetus is thought to be related to maternal complications such as placental abruption, PIH, or infection, or there is evidence of ruptured membranes or bleeding.20
• A full explanation should be given of the procedures, a possible time scale, and how the baby may look at delivery. Obtain consent for treatment. Those close to the couple should be encouraged to stay and give support.
• Ensure that the room for induction of labour is comfortable, and remove any inappropriate items (e.g. fetal monitor).
• Take IV samples of blood to test for FBC/platelets and G&S. Obtain a clotting screen if the intrauterine death occurred >3 weeks previously. Other samples may be requested, depending on the clinical picture.
Induction regimen
• Mifepristone 200mg is given orally and the woman may go home and return in 36–48h.
• On readmission: the choice of vaginal PGE2 or vaginal misoprostol 800 micrograms given PV should be offered. The choice and dose of vaginal prostaglandin should take into account the clinical circumstances, the availability of preparations, and the local protocol; for women who have had a previous Caesarean section, the risk of uterine rupture is increased. The dose of vaginal prostaglandin should be reduced accordingly, particularly in the third trimester.20
• Misoprostol 400 micrograms is given PV 3h later.
• This is repeated 3h with up to five doses. The regimen should be continued even when the cervix dilates, to maintain uterine activity.
• If delivery does not occur, the senior obstetrician should be informed.
After 24h, it is safe to repeat the five doses of misoprostol.
• ARM should be avoided until delivery is imminent because:
• There is a risk of infection
• The fetal skull is cushioned by the waters.
• Choice in analgesia is important. Opiates may be given or an epidural if there is no coagulopathy.
• Syntometrine® is indicated at delivery. Be aware that PPH may occur.
Care immediately after birth
• Support the parents, and, if they are willing, encourage them to look at and hold the baby. They should be left alone with the baby for a period of time if they so wish.
• Acknowledge the parents’ feelings of loss. A few kind words, a clasped hand or a hug, or a small posy of flowers from staff can enrich the few memories the couple take away.
• The obstetric registrar or consultant should see the baby and complete a stillbirth certificate. It is important that this is obtained early in the proceedings because the parents will need it to make arrangements for registration and burial.
• Weigh the baby and measure his or her length. The parents may want to help with bathing and dressing the baby. They will wish to give the baby a name. Photographs, a lock of hair, handprints, and footprints are taken and transferred to a card as a keepsake.
• Carefully label the baby with the mother’s identification details.
• Enquire whether the parents would like to see the hospital chaplain or other persons who may provide spiritual support.
Administration
It is good practice to complete a bereavement checklist and to have a communication book to ensure that all administration is recorded efficiently.
Investigations into the cause of fetal loss
• To complete the process of grieving for their baby, the parents often need to know the cause of death.
• Certain blood, tissue samples, and swabs may be requested from the mother, fetus, and placenta, and are important for obtaining accurate information for counselling the parents at a later date.
• The placenta may be sent to histology for examination.
• A post-mortem may be indicated. A senior obstetrician or midwife should obtain consent after a full, but sensitive, explanation of the procedure. The parents should be given written information about the examination and have an opportunity to read it before consent.
• Photographs of the baby may be required and can be requested from medical photography.
• An appointment with the consultant should be arranged 4–6 weeks after the stillbirth to discuss any findings.