Dr Ibanda using RCOG guidelines describes how a woman with intrauterine foetal death(IUFD) can be managed.

1. Management of IUFD Protocol
Presenters
Dr Sabiiti Edgar
Dr Gwazo Mathias
Dr Ibanda Hood
Tutors
Dr Tabuley J
Dr Namagembe I
Dr Namusoke F
Prof Byamugisha J

2. Scope
• The guideline apply to the Dept of MFM/Labour suite
• It addresses the Dx and Mgt of IUFD
• The protocol is meant to be used by MSWNH & Kawempe NRRH

3. Purpose
• To provide guidance to all;(midwives,doctors,laboratory
technicians,students,administrative staff at Kawempe NRH &MSWNH
• Describe the roles of the healthcare team in evaluating, managing,
and improving care for patients diagnosed with stillbirth.
• It is meant for those working in ANC clinic ,MFM ward ,severe PET
ward,Labour suite ,laboratory/blood bank and Post natal ward.

4. Introduction
• Fetal death is a tragedy that causes severe distress to both
parents and care givers.
• Intrauterine fetal death refers to babies with no sign of life in
utero(WHO,2004;RCOG,2010).
• Many countries define fetal death according to gestational age for
legislation and statistical purposes.

5. Introduction(ctd)
• Stillbirth" has replaced "intrauterine fetal demise" as the terminology
of choice based on the opinions of parent groups
• WHO recommends national reporting of fetal death as fetal death
after 22WOG or ≥500g or crown heel length ≥25cm (WHO,2004).
• Threshold for Uganda is 28w or >1000g

6. Introduction(ctd)
• The Every Newborn Action Plan (ENAP) targets national stillbirth rates
(SBRs) of 12 or fewer stillbirths per 1000 births by 2030.
• Estimated 2.6 million still births with global estimate at 2%
(Blencowe,2015)
18.4/1000 births in 2015 from 24.7/1000 births in 2000[25.5%↓]
98% occurs in LMICs.
• Globally, unexplained stillbirth is reported in 76% of
cases(Lawn,2016).

7. Introduction(ctd)
• Half of the world's stillbirths are linked to intrapartum
complications(Lawn,2016)
• A study conducted in Madagascar found an annual incidence of
5.22%(Akolekar,2016).
• Still birth rate in Uganda was 21 per 1000births in 2015(WHO,2016).

8. Impact of IUFD (Psychological)
PSYCHOLOGICAL SEQUELEA
• depression
• posttraumatic stress disorder,
anxiety
• These conditions may adversely
affect a subsequent pregnancy
Other complications
• sadness
• Despair
• confusion
• loss of a desired child,
• loss of self-esteem as a parent,
• Loss of confidence in the ability
to produce a healthy child

9. Risk Factors of IUFD

10. Risk factors for intrauterine fetal death
A study in Stockholm ( Wolffkerstin, et al. 2002 ),identified the
following risk factors-
• infections (24%) –malaria, syphilis, toxoplasmosis, other TORCHES
• Placental insufficiency (22%),
• Placental abruption(19%) –partial or complete
• Intercurrent maternal conditions (12%), such as diabetes mellitus
• congenital malformations (10%)

11. Risk factors
• Umbilical cord complications (9%)
• Thrombophilias - ( acquired form)- Antipholilipid syndrome (APS),SLE
• IUGR
• Oligohydramnios
• Post maturity
• Cholestasis
• Obesity
• Smoking>10cigarretes per day or other forms of substance abuse

12. DIAGNOSIS
Diagnosis of IUFD
Finding out the cause(s) of IUFD

13. Diagnosis of IUFD
•Real-time ultrasound scan is essential for accurate
diagnosis of IUFD
•Ideally, real-time USS should be available all time
•Get a second opinion when it is possible
•If a woman is informed of USS findings of IUFD, but she
feels Foetal movement, a second real-time USS should
be offered.

14. Discussing the diagnosis and subsequent care
• If a woman is unaccompanied, an immediate offer should be
made to call her partner, relatives, or friends.
• Discussion should aim to support maternal/parental choice
• Parents should be offered written information to supplement
discussions.

15. Finding out the cause of IUFD
What women should know/be told.
• Clinical assessment and laboratory tests help to know: maternal
condition, cause of IUFD, chances of recurrence, and if we can
prevent other complications of pregnancy
• No cause is found in at least 50% of IUFD
• If cause is found, recurrent of IUFD may be prevented
• Abnormal tests may not really be the cause of IUFD

16. Tests for to determine cause of IUFD
TEST RATIONALE
CBC + CRP + ABO compatibility Rule out PET, DIC(low platelets),
Leukocytosis(Neutrophilia)-Sepsis
Anaemia, Hydrops,
Liver function tests Bile salts-Obstetric cholestasis
Liver enzymes (HELLP syndrome)
Kleihauer Lethal maternofoetal haemorrhage
Determine how much anti-D to give if
needed
Maternal coagulation times and Tests for thrombophilia DIC, if IUGR or placental disease
Thyroid function tests, Random blood sugars +/- HBA1c Thyroid disorders, DM, GDM
Infection screen
Blood cultures, Malaria tests, Midstream urine culture and sensitivity,
Vaginal and cervical swabs, Screen for syphilis, viral, Fetal placental,
blood, or microbiology
Screen for malaria, Parvovirus, TORCHES
and other causes of IUFD
Foetal Tissue for Karyotyping Do detect genetic disorders, if PM is
rejected

17. Postmortem examination
• Postmortem examination should not be done if parents reject it
• External examination should include weight, length, because IUGR is
common among stillbirths
• The following exams are done:
• External examination
• Autopsy
• Microscopy
• X-ray
• Placenta and cord detailed examination

18. TREATMENT
Labour and Birth, intrapartum care, postnatal care, Grief counselling, Diagnosis of
cause, and Future reproductive plans

19. Labour and Birth
When to deliver
 Birth plan depends on mother’s wishes, medical condition, and past
obstetric history
 Delivery should offered immediately if there is sepsis, preeclampsia,
Membrane rupture, Antepartum Haemorrhage. A more flexible
approach is discussed if these conditions are not present.

20. When to deliver (ct’d)
• Women without DIC should be advised that delaying birth by a short
period will not cause harm, but may suffer medical complications and
anxiety. Test for DIC twice a week if delivery is to be delayed by
>48hours.
• If a woman returns home before delivery, she should get phone
number for support.
• Women should know that a postmortem becomes more difficult if
they delay birth.
• Women should know that the baby’s appearance chances if they
delay birth

21. Where to deliver from
At Facilities with Emergency obstetric care (Basic and comprehensive)
Aim at getting special labour rooms for mothers/couples with IUFD.
Care in labour should be given by an experienced midwife.

22. Mode of Delivery (Birth)
• Vaginal birth is the recommended mode unless there is need for
caesarean delivery.
Induction of Labour
• Mifepristone-Misoprostol combination is first line.
• Misoprostol should preferred to Prostaglandin E2, because it is safe,
effective, and cheaper
• Advise women that vaginal misoprostol is as effective as oral
misoprostol but with less side effects

23. Induction of labour in women with previous
lower segment uterine scar
• Specialist should discuss the safety and benefits of induction of
labour
• Mifepristone used alone increases the chances of labour within 72
hours
• Avoid prostaglandins
• Mechanical methods of induction of labour in women with an IUFD
with guidance from/by a specialist
• No induction for 2 or more previous LS or 1 upper segment scars.

24. Other intrapartum care
• Antibiotics: used only if patient has sepsis
• Analgesia
• Prefer Diamorphine to Pethidine
• Spinal or epidural can be used in patients without sepsis or DIC
• Offer women to meet anaesthetist
• Monitor women with Previous scar for features of rupture
• Augmentation: only specialists can decide to augment previous scar

25. CARE DURING PUERPERIUM
• Inform all staff who cared for the woman about the birth outcome.
• Lactation suppression
• This is best done using Cabergoline or Bromocriptine(Dopamine agonist).
Cabergoline > Bromocriptine
• Avoid these drugs if a woman has hypertension/Preeclampsia
Dose
Bromocriptine (2.5mg bd for 14/7)
Cabergoline 1mg single dose

26. Psychological support
• Know and respond to variation in individual/cultural approaches to death.
• Offer counselling to all women and their partners
• Consider other family members for counselling
• If a woman has symptoms of psychiatric disease, don’t talk to them in
isolation
• Advise the couple about support groups.
• If couple wants to touch, hold, take pictures, or name their body/baby
allow them, but don’t persuade them to.
• If the baby is given a name, use that name in subsequent meetings.
• Allow, but don’t persuade, parents to retain artefacts of remembrance.
• Get verbal consent from the parents if you want to take pictures

27. Pregnancy after IUFD
Antenatal care
• Clearly indicate on a woman’s file that she had IUFD
• Staff in care should read file fully before meeting the woman
• Women with a previous unexplained IUFD should have an obstetric
Antenatal care.
• Serial growth monitoring, using an Ultrasound scan is recommended
for a woman who gets an IUFD of a baby who has no anomalies but is
small for age

28. Future labour and Birth
• Future births should be at specialist maternity unity/Hospital
• If mother request for scheduled birth, we must consider the gestation
of the previous IUFDD, previous intrapartum history, and safety of
induction of labour

29. ALGORITHM FOR MANAGEMENT OF IUFD
Is it IUFD
(from History & Exam)
Do US
scan
Dead
Baby
1. Appropriately Break the
news,
2. counsel her
3. Prepare her for TOP
Birth/TOP
1. Counsel,
2. consent for TOP plan
3. Prepare for TOP (e.g. CBC, Clotting profile)
4. Conduct TOP(see algorithm 2)
5. Give intrapartum care(e.g. Analgesia,
prevent PPH, treat cause if known )
Postpartum care
1. Grief counseling
2. Emotional support
3. Lactation suppression
(Cabergoline 1mg start
or Bromocriptine
2.5mg bd for 14 days
4. Consent for Postmortem
& other test for knowing
cause of IUFD
5. test for cause
Review at 6weeks
postpartum
• Communicate PM/Test
results.
• Consult specialized
psychosocial care if
depressive symptoms
still exist.
• Offer treatment of any
identifiable cause(s) of
IUFD found on tests.
• Suggest another meeting
to discuss future
reproductive plans and
prevention of IUFD
Live baby
Resume ANC and
surveillance if
needed
Read for
TOP?
Yes
No
Allow her home to return
when ready
OR
Offer admission for tests and
more counseling before TOP
Review at 3/12
• Discuss prevention of
IUFD recurrence
• Discuss future fertility
needs
• Offer family planning if
it’s needed
• If she/they want to
conceive again,
support their choice
• Discuss how
preconception, ANC,
intrapartum(Birth),
and postnatal care will
be done(see chart 3)

30. Algorithm for Termination of pregnancy in IUFD
TOP: Termination Of Pregnancy
Decided to
do TOP in
IUFD
Is fetal
size
>24/40
No
Plan A: Counsel her, get consent, prepare, Do
Ultrasound scan for placenta location and placental
volume. Then Terminate using Dilatation and
Curettage. Give Postabortal care.
OR
Plan B: Do Ultrasound as in plan A. Give
Misoprostol 200-600µg every 6 hours, until
expulsion. Then, Examine Products of conception
for completion or Repeat ultrasound scan. If Retain
products, do curettage. Then Give Postabortal care
Yes
Is there
uterine
scar?
Yes
Mifepristone alone
(200mg start)
OR
Consult specialists
OR
Catheter induction
AND
Monitor for features
of uterine rupture
No
Modes of Termination
If foetus is <28/40, induce labor.
• Use misoprostol 200-600µg
6hourly
OR
• Mifepristone(200mg, then
600µg Misoprostol 24/48hr
later
OR
• High dose oxytocin if cervix
favors (Bishop score≥6)
If foetus > 28/40
• Follow obstetric protocols of
misoprostol. That is: 25µg
vaginal/oral every 2 hours till
labour is established OR
• Vaginal Dinoprostone 3mg 6
hourly with/without adding
oxytocin
• Monitor for features of
uterine rupture

31. MANAGING A WOMAN WITH HISTORY OF IUFD
(PREPREGNANCY, and ANTENATAL CARE)
Is IUFD
cause
recurrent
No
• Advise to conceive
only after the couple
is emotionally ready
to have another
baby. Its about 6-
12months
May
recur
Is cause
genetic?Yes
Preconception
Genetic
counseling
OR
Preimplantatio
n genetic
testing
Medical condition like
DM, Thyroid disease,
SLE, or Placental
insufficiency
No
• Work with respective specialist(s) to optimally
manage the condition
• Folate supplementation if NTD is a concern
• Screen and treat infections like syphilis, CMV
• Smocking, Alcohol, & drug cessation
• Control obesity
• Ensure cessation of depressive symptoms of IUFD
After
conceiving
Antenatal care
• Attends ANC under
specialist care
• Testing for Gestational
Diabetes
• Testing for Gestational HTN
• Serial Doppler studies if she
has Hx of placental
insufficiency
• Growth monitoring from
24/40 onwards if IUGR was
noticed in previous IUFD(s)
• Plan to deliver in hospital
with specialist care

32. Managing IUFD in special
situations
Multiple pregnancy with one/more foetus alive
Placenta praevia with/without previous scar

33. Multiple pregnancy with a live and dead
foetus
• Demise of one twin in second or third trimester occurs in 2.4-6.8% of twin
pregnancies. With triplet, IUFD incidence ranges 4.3-17%
• It can have severe sequelae on surviving twin
• Example, 3-15% IUFD affects second twin, highest in monochorionics
• Preterm birth occurs 57%-68%
• Brain injury in surviving twin (20%)
• Multicystic encephalomalacia
• If IUFD occurs ≥34/40, deliver
• Aim at avoiding unnecessary prematurity, but also don’t prolong pregnancy
which can affect surviving twin.
• Vaginal delivery is optimal, C-section is for obstetric reason

34. IUFD with placenta praevia
• If the Foetus is small, it can be delivered vaginally
• But a foetus >24 weeks, for mother’s safety, Hysterotomy is better

35. CLINICAL GOVERNANCE

36. Risk management and standards for
documentation
• Maternity units should be aware of specific standards for IUFD and
stillbirth
• Have a standardized checklist to ensure that all appropriate care
options are offered and the response to each is recorded.
• Consent for perinatal postmortem examination should be
documented using a nationally recommended form
• Perinatal Death Review meeting should be conducted.
• Results of MPDR meeting should be used for preventing future
stillbirths.

37. Care for staff
• Clinical staff dealing with IUFD should get psychological support when
it is needed.

38. Some auditable standards
• Proportion of IUFD reported as a clinical incident
• Completion of investigation for cause of IUFD
• Proportion of patient offered postmortem examination
• Proportion of parents who were offered alternative tests after refusing
Postmortem exam
• Proportion of consent for postmortem exam sought by a specialist
obstetrician or midwife
• Proportion of women offered lactation suppression
• Proportion of women given fertility and contraceptive advise
• Proportion of parents offered follow-up with a senior obstetrician
• Proportion of women and families offered counselling follow-up.

39. Important aspects of Training
• Seminars on causes and care of late IUFD
• Skills training for the ultrasound diagnosis of IUFD
• Training for discussion with parents about late IUFD
• Training on postmortem examination, including consent.
• Additional training in IUFD for bereavement counsellors
• Quarterly multidisciplinary clinical-pathology meetings for critical
analysis of stillbirth
• Role play of follow-up appointments for obstetric trainees.

40. References
Akolekar R, Tokunaka M, Ortega N. Prediction of stillbirth from maternal factors, fœtal biometry and utérine artery
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regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob
Heal. 2016;4(2):98-108.
Bode Williams and Sujata Datta. Previous fetal death.GLOWN https://www.glowm.com/pdf/section3_chapter18.pdf
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Jassir FB, You D, McClure EM, Mathai M, Cousens S., Lancet Ending Preventable Stillbirths Series study group. Lancet Stillbirth
Epidemiology investigator group. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016 Feb
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Royal College of Obstetricians and Gynaecologist. 2010. green to guideline No:55, late intrauterine Foetal death
ACOG guidelines 2020