This document discusses the management of stillbirth, including both expectant and active management options. It explains that expectant management involves non-interference and allowing spontaneous expulsion, while active management includes inducing labor through medications if the cervix is unfavorable or proceeding with a c-section as a last resort. It also covers supporting the family through the grieving process, presenting the baby to the parents, managing lactation and future pregnancies.

1. Management of Still Birth
Intrauterine Fetal Death
Prepared by:
Prativa Kafle
Roll no. 17
BNS 2nd year
Chitwan Medical College

2. General Objective:
• At the end of the teaching learning session the BSc. Nursing 3rd year
students will be able to explain about the management of still
birth/IUFD.

3. Specific objectives:
At the end of the session BSc. Nursing 3rd year students will be able to:
• explain the management of still birth/IUFD.
• state the complication of still birth/IUFD.

4. Management of Still Birth/ IUFD:
Explain the problem to the mother and her family. Discuss with them
the option of expectant or active management:
1. Non-interference (expectant management):
The patient and her relatives are likely to be upset psychologically but
they should be assured of safety of non interference.
In about 80% cases, spontaneous expulsion occurs with in 2 weeks of
death.
Sometime needs interference in following condition;
• Psychological upset of the patient.
• Manifestation of uterine infection.

5. Contd...
• Falling fibrinogen level (2-3 g/L)
• If expected management is planned:
• await spontaneous onset of labor during next four weeks.
• Reassure the women that in 90% of cases the fetus is spontaneously
expelled during the waiting period with no complication.
If platelets are decreasing, four weeks have passed without
spontaneous labor, (if fibrinogen levels are low or the women request
it, consider active management; induction of labor)

6. Contd...
[ interference] If induction of labor is planned, assess the cervix
• If the cervix is favorable( soft, thin, partly dilated), induced labor by
using oxytocin 5 to 10 Units of oxytocin in 500 ml RL through IV.
• If cervix is unfavorable ( firm, thick, closed), ripen the cervix by using
prostaglandins.
- combination of mifepristone and prostaglandin can be given a single
dose of 200mg oral mifepristone and misoprostol intravaginal 25µg 4
hourly are safe, effective and low cost.
- Misoprostol( PGE1) 25 to 50 µg either vaginally or orally can be
repeated at every 4 hourly.
- Vaginal administration of prostaglandin (PGE2) gel is also effective
for induction where the cervix is unfavorable ( 6 to 8 hourly).

7. • Delivery by caesarean section only as last resort.
• Do not rupture membranes due to risk of infection.
Management of puperium
At the time of event:
• Inform the parents as soon as possible after the baby's death.
• Avoid using sedation to help the women cope. Sedation may delay
acceptance of the death and may make reliving the experience later-part of
the process of emotional healing more difficult.
• Explain in simple terms about the possible cause of fetal death.
• Allow the parents to see the efforts made by the care givers to revive their
baby
Contd...

8. • Encourage the woman/couple to see and hold the baby to facilitate
grieving.
• Prepare the parents for the possible disturbing or unexpected
appearance of the baby( red, wrinkled, peeling skin). It necessary,
wrap the baby so that it looks as normal as possible.
• Avoid separating the woman and baby too soon, as this can interfere
with and delay the grieving process.
Contd...

9. After the event
• Allow women / family to continue to spend time with the baby.
• People grieve in different ways, but for many remembrance is
important. Offer the women/ family small mementos such as a lock of
hair, a cot label or a name tag.
• Allow the woman/ family to prepare the baby for the funeral if they
wish.
• Encourage locally accepted burial practices and ensure that medical
procedures do not preclude them.
• Arrange a discussion with both the woman and her partner to discuss
the event and possible preventive measures for the future.

10. • Give supportive care.
• Offer the parents and family to be with the dead baby in privacy as
long as they need.
• Discuss with them the events before the death and the possible causes
of death.
• Manage for lactation suppress.
• Avoid stimulating the breast.
Contd...

11. • Support breasts with a well- fitting bra or cloth. Do not bind the
breasts tightly as this may increase her discomfort
• Apply a compress. Warmth is comfortable tor some mothers; others
prefer a cold compress to reduce swelling.
• Relive pain, an analgesic such as ibuprofen or paracetamol may be
used.
• Advise to seek care if breasts become painful, swollen, and red, if she
feels ill or temperature greater than 38˚C.
• Lactation is suppressed with bromocriptine 2.5 mg twice daily for 10
days.
Contd...

12. • Counsel on appropriate family planning method: Appropriate family
planning can be used immediately in postpartum.
(copper T immediately following expulsion of placenta or with in 48 hours).
(Norplant with in 7 days or delay 6 weeks)
• Regular PNC visit should be needed.
• The investigation reports are reviewed and counseling on future pregnancy is
done.
Contd...

13. Grief counselling following IUFD/Still Birth:
Grief:
When someone is bereaved, they usually experience an intense feeling
of sorrow or grief. People grieve in order to accept a deep loss and carry
on with their life. Experts believe that if person do not grieve at the time
of death or shortly after, the grief may stay up inside them. This can
cause emotional problems or physical illness later on. Working through
the grief can be a painful process, but it is often necessary to ensure the
future emotional and physical well-being.
The grieving process can take time and should not be hurried. It depends
on person and their situation. In general, it takes most people one to two
years to recover.

14. Sign / symptoms of grief:
Physical effects:
• Exhaustion
• Blurred vision
• Breathlessness
• Lack of strength
• Restlessness
• Loss of appetite
• Sleeping problems
• Palpitations
• headache

15. Emotional or psychological effects:
• Denial
• Sense of failure
• Resentment
• Irritability
• Anger
• Guilt
• Sadness
• Problems on concentration
• Failure to accept realities
• Depression
Contd...

16. Social effects:
• Withdrawal from normal activity
• Isolation (emotional & physical) from spouse, family or friends.

17. Grieving process: (Kubler 1978)
First phase:
Shock, denial and numbness are certain signs of grief. The woman
who has just given birth who told that her baby is dead may react by
shouting 'no, no, my baby can not be dead, this cant be happening
to me.
Sometimes a woman will 'act out distress but the reality of the loss has
not reached her innermost feeling.
Second phase:
Pining, anger, guilt, bargaining depression, emptiness: or all of these
may experienced as part of the emotional working forwards acceptance
of the situation.

18. • Pinning: As the shock & numbness wear off, the pain of loss emerges
a women whose baby has died may experience physical pain in her
breasts or arms as she hold & feed baby.
• Anger: “why is this happening? Who is to blame?”is a very common
emotion in grief and is usually misplaced & directed against the
service or the care provider. The midwife needs to understand that
although the anger may be directed at her is not usually meant to be
personal attack.
• Bargaining: “ make this not happen and in return I will....” is usually
with god or with oneself.
Contd...

19. • Depression & emptiness: may show in physical as well as in
psychological behavior
• The parents of a dead or dying baby may feel similarly too depressed
or exhausted to care for themselves. For example, the particular
difficulty for the woman who has been delivered of a stillborn baby is
that the physiological squealer of birth continues her breasts fill with
milk but she has no baby to feed; her perineum may be sore or
uncomfortable but she has no live baby to show for the discomfort.
Contd...

20. Third Phase
• This is a phase of acceptance & readjustment.
Breaking the news:
• Parents are usually informed immediately a diagnosis of death or
abnormality is confirmed. It may be the first time in their lives that
they have faced such a devastating experience either alone or together.
• The shock of bad news often people to forget what has been explained
to them and it is helpful to have more than one person at the time. The
midwives may need to repeat information on several occasion before
the parents are able to accept or understand.
Contd...

21. • Breaking bad news requires all the skill and support that midwife can
give even though she herself may feel afraid and distressed at the
situation. Counselling skills, particularly the skill of attending and
listening, are extremely useful. Touch may also be an appropriate
empathetic response.
Contd...

22. Special needs
• Sometimes the needs of the husband may be missed as the focus of
attention is on his wife. It is important for the midwife to observe his
behavior & be sensitive to his needs.
• He may wish to stay with his wife; many units provide suitable
facilities such as a double room. If he is at home he may wish to walk
outside for a little while to escape from the intensity of the situation.
Contd...

23. Presentation of the baby
• In the event of stillbirth or neonatal death, parents may wish to see &
hold their dead baby.
• Some parents will wish to see their baby immediately, whilst other will
wish to delay the event & a few may not wish to see or hold the baby
at all.
• Parents need to be given time in this situation to come to the point of
being able to look at & touch their baby
• It is suggested that the midwife shows the parents the normal parts of
the baby first & then helps them to explore further if they wish.
• The parents are likely to watch the midwife s behaviour towards their
baby. The midwife should handle the baby of the baby respectfully as
though he was alive

24. Management of future pregnancy
• If a particularly medical problem is identified in the mother, it should
be addressed prior of conception. For example, tight control of blood
glucose prior to conception can substantially reduce the risk of
congenital anomalies in the fetus.
• Preconceptionally counseling is helpful if congenital anomalies or
genetic abnormalities are found.
• Genetic screening and detailed ultrasound can evaluate future
pregnancies. In some cases, such as cord occlusion, the patient can be
assured that recurrence is very unlikely.
• ANC follow up should be done monthly.

27. • Psychological upset
• Infection :as long as the membrane are intact , infection is unlikely but
once the membrane rupture, infection.
• Blood coagulation disorder are rare: if the fetus is retained for more
than 4 weeks there is possibility of defibrination from disseminated
intravascular coagulopathy (DIC). It is due to gradual absorption of
thromboplastin , liberated from the dead placenta and decidua into the
maternal circulation.
• During labor: retained placenta, post partum hemorrhage.
Complication:

28. Disseminated intravascular coagulopathy
DIC( disseminated intravascular coagulopathy
Uncontrolled thrombin generation
Fibrin deposition In the microcirculation consumption of platelets and coagulation factors
Ischemic tissue
damage
Secondary fibrinolysis RBC damage and hemolysis
Failure of multiple
organ
Vessels patency Diffuse bleeding

29. Feature of DIC:

30. • Write down the nursing management of IUFD/Still birth.
Assignment

31. • Ranabhat R. D. Niraula H. Textbook of Midwifery & Reproductive
Health Professions Education, IOM, TU
• Dutta DC. Textbook of Obstetrics, 8th ed. New Central Book Agency
(P). Ltd. Calcutta, India
• Tuitui R. , Manual of Midwifery- C. 4th edition. Kathmandu: Vidyarthi
Pustak Bhandar
• Subedi D., Midwifery Nursing-II ,(2016) 3rd edition. Kathmandu:
Medhavi Publication
References