CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

INVESTIGATION AND MANAGEMENT OF

LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

CLINICAL PRACTICE GUIDELINE

Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland

and

Directorate of Strategy and Clinical Programmes, Health Service Executive

Version 1.0

Guideline No. 4

Date of publication - October 2011

Revision date - October 2013

CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Table of contents

1. Key Recommendations .................................................................................................. 3

2. Purpose and Scope ......................................................................................................... 4
3. Background ..................................................................................................................... 5
4. Methodology .................................................................................................................... 9
5. Glossary ........................................................................................................................ 10
6. Clinical Guideline ............................................................................................................. 11
6.1 Terminology ............................................................................................................ 11
6.2 Diagnosis ................................................................................................................ 12
6.3 Investigation ........................................................................................................... 13
6.4 Labour and delivery ................................................................................................ 26
6.5 Post-natal care........................................................................................................ 31
6.6 Supportive Care ...................................................................................................... 33
6.7 Follow up ................................................................................................................ 34
6.8 Pregnancy after stillbirth ......................................................................................... 35
6.9 Perinatal Death Notification Form ........................................................................... 37
6.10 Legal requirements, Registration and the Role of the Coroner ............................ 38
6.11 Clinical Governance ................................................................................................. 41
6.12 Future Research .................................................................................................. 43
7 Key performance indicators ........................................................................................... 45
8. References and Recommended Reading ..................................................................... 46
9. Useful resources ........................................................................................................... 51
10. Qualifying statements ................................................................................................ 52
11. Implementation Strategy ............................................................................................ 53
12. Appendix List ............................................................................................................. 54
Appendix 1 ........................................................................................................................... 55
Appendix 2 ........................................................................................................................... 56
Appendix 3 ........................................................................................................................... 57
Appendix 4 ........................................................................................................................... 59
Appendix 5 ........................................................................................................................... 60
Appendix 6 ........................................................................................................................... 63

2
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

1. Key Recommendations

 Real-time ultrasonography is essential for the accurate diagnosis of Intra-uterine Fetal

Death (IUFD).
 Discussions aim to support maternal/parental choice.
 Supportive care should be made available to all bereaved parents
 Recommendations about labour and birth should take into account the mother‟s
preferences, her medical condition and previous intra-partum history.
 Management of IUFD may involve awaiting spontaneous labour or planned medical
induction.
 Vaginal birth is the recommended mode of delivery for most women, but caesarean birth
may need to be considered in individual cases.
 A combination of mifepristone and a prostaglandin preparation should be the first-line
intervention for induction of labour.
 If a woman has had a previous caesarean section, a discussion as to the safety and
benefits of induction of labour needs to be undertaken by a consultant obstetrician.
 Clinical assessment and evaluation is recommended to assess maternal wellbeing and
to determine the cause of death, the chance of recurrence and of avoiding further
pregnancy complications.
 Laboratory tests are recommended to rule out any maternal disease or risk factor that
may have contributed to the IUFD / stillbirth.
 Fetal karyotyping should be considered in all cases.
 Parents should be offered a full postmortem examination of the baby.
 Postmortem examination should include external examination with birth weight, histology
of relevant tissues and plain radiography (skeletal survey)
 Pathological examination of the cord, membranes and placenta is recommended in all
cases of IUFD / stillbirth.
 Standardised checklists should be used to ensure that all appropriate care options are
offered and that each response mark is recorded.
 A standardised dataset should be collected for all stillbirths.
 All stillbirths should be reviewed in a multi-professional meeting using a standardised
approach.
 All term intra-partum deaths with no evidence of a major congenital anomaly should be
investigated locally.
 Staff working with bereaved parents should be provided with an opportunity to develop
their knowledge and understanding of perinatal loss, together with development of skills
in working in this area.
 A system should be in place to give clinical and psychological support for staff involved
with an IUFD/stillbirth.
 A follow-up appointment with the consultant obstetrician should be arranged and it
should be clear who is responsible for making these arrangements.
 Women with a history of IUFD should attend a consultant-led hospital-based antenatal
clinic in their next pregnancy and undergo increased antenatal surveillance.

3
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

2. Purpose and Scope

The purpose of this guideline is to assist all healthcare professionals in the diagnosis,
investigation and management of late fetal intrauterine death (IUFD) and stillbirth.

The guidance is primarily intended as a resource for obstetricians and midwives but might
also be useful for women and their partners, general practitioners and commissioners of
healthcare.

The objectives of the guideline are:

 To standardise management of IUFD and stillbirth based on an evidence

based best practice approach
 To provide an investigation protocol to help health care providers determine the
cause of fetal death
 To incorporate information on general care before, during and after birth as
well as care in future pregnancies

 To ensure best practice with respect to the treatment given to bereaved

parents

The guideline does not include:

 Management of multiple pregnancies with a surviving fetus

 Late delivery of fetus papyraceous
 Management of specific medical conditions associated with an increased risk of stillbirth
or late IUFD

These guidelines are designed to guide clinical judgment and not replace it. In individual
cases a healthcare professional may, after careful consideration, decide not to follow a
guideline if it is deemed to be in the best interests of the woman.

4
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

3. Background
The scale of the problem

In the developed world, one in 200 infants is stillborn. This is a devastating outcome of
pregnancy for parents and clinicians. Despite improvements in antenatal care, stillbirth
remains 10 times more common than sudden infant death syndrome. More than 3.2 million
stillbirths occur globally each year, yet stillbirths are largely invisible in global health
indicators, policies and programmes [Stanton et al., 2006]. In 2009, the stillbirth rate in
England, Wales and Northern Ireland was 5.2 per 1000 total births, a rate that shows only a
slight downward trend since 2000 [CMACE, 2011]. In Ireland, around 350 stillbirths are
registered every year. The Irish Perinatal Statistics Report from 2008 notes that of the
75,587 births recorded, there were 358 stillbirths [ESRI, 2010; Appendix 1].

Management of labour and delivery

When a baby dies before birth, the options for care are either to wait for labour to start
spontaneously or to induce labour. Most women (over 90%) begin to contract and labour
within three weeks of IUFD, but if labour does not begin, there is a risk of developing a
disseminated intravascular coagulopathy (DIC) [Weiner, 1999], as well as intra-uterine
infection if the membranes are ruptured. Other disadvantages of a long interval between
fetal death and birth relate to greater emotional distress, and to the degree of information
that can be obtained from a postmortem examination. It is usual clinical practice therefore to
recommend medical induction, provided this can be safely undertaken.

Inducing labour in cases of IUFD may involve the use of oxytocin or prostaglandins. The
issues related to the type and dosage of induction agents are a little different for women
who are having labour induced after IUFD compared to induction of labour at term in the
presence of a live fetus. While side effects (including uterine hyper-stimulation, nausea,
vomiting, and diarrhoea) and safety (particularly rare complications such as uterine rupture)
are important considerations for the woman, issues related to fetal wellbeing are not.
Furthermore, it is necessary to consider the receptivity of the uterus to prostaglandin
medication, especially at early gestational ages, where the use of low doses may be
ineffective in inducing labour, or be associated with a long induction to delivery interval
[Dodd and Crowther, 2010].

Misoprostol, a prostaglandin E1 analogue, is probably the most preferred agent because of

its low cost, stability in room temperature and ease of administration. Mifepristone is a
steroid compound, which competes with progesterone at the receptor level and is also
widely used for termination of pregnancy. Mifepristone, administered before misoprostol,
increases the sensitivity of the uterus to prostaglandins and ripens the cervix, thereby
allowing lower doses of misoprostol to induce expulsion of the fetus. However, the optimum
combination of mifepristone and misoprostol has not been established for induction of late
intrauterine deaths [Dodd and Crowther, 2010, Wagaarachchi et al, 2002].

5
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Psychological aspects of late IUFD / Stillbirth

The recognition of perinatal loss as a significant bereavement is relatively new [Badenhorst

and Hughes, 2007]. The substantial psychological impact of perinatal death on mothers and
families has been extensively studied over the past 30 years, when it first became clear that
the normal grief reactions to perinatal death did not differ greatly from those observed in
other bereavement situations [Kennell, 1970]. The death of an infant is now recognised as
one of the most stressful life events that an adult may experience [Fish, 1986]. A wide range
of short and long-term negative outcomes for parents has been reported as a result of infant
death [Hughes, 2003, Badenhorst and Hughes, 2007]. Factors which have been reported to
increase the risk of adverse psychological outcomes for parents after a perinatal death
include: perceived inadequate social support, traumatic circumstances surrounding the
death, difficulties in coping with a crisis in the past, problematic relationships and the
presence of other life crises.

Research has suggested that the role of practitioners in the handling of death and their
interaction with the bereaved person following a loved one‟s death influences the intensity of
grief. It is proposed that skilled, sensitive and caring treatment in the time surrounding
pregnancy loss positively impacts on the grief experience of bereaved parents [Corbet-
Owen and Kruger, 2001]. A number of studies have examined the factors considered to be
important to bereaved parents following the death of their child, as well as aspects of care
that they considered to be lacking. These findings implicate the importance of validation and
acknowledgement of the physical and emotional aspects of their experience, empowerment
and safety, collaborative decision--making, the sharing of knowledge, creation of memories
and sensitive care [PSANZ, 2009].

Provision of an empathetic caring environment, and strategies to enable the mother, father
and family to accept the reality of perinatal death, are now an accepted part of standard
nursing/midwifery and social support in most of the developed world. Provision of
interventions such as psychological support or counselling, or both, has been suggested to
improve outcomes for families after a perinatal death

Evaluation of causes of stillbirth

Stillbirths deserve the same systematic evaluation as adult deaths. However, the optimal
evaluation of stillbirth is controversial and is influenced by several medical factors, including
the availability of perinatal pathology, as well as by personal beliefs and public concerns
regarding fetal autopsy. The study of specific causes of stillbirth is also hindered by the
absence of uniform protocols of investigation and lack of agreement on a definitive
classification system.

The primary method for classification of stillbirth is according to the presumed cause of
death or associated obstetric disorder. There are numerous classification systems and none
is universally accepted [Silver et al., 2007]. Original versions consisted of categories of
congenital malformation and birth asphyxia, while more recent approaches have attempted
to include abnormal fetal growth and placenta pathology, although it is controversial whether
these conditions are causes of or risk factors for stillbirth [Fretts 2005; Smith and Fretts,
2007; Silver et al., 2007].

6
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Unexplained stillbirths account for 25 to 60% of total stillbirths. This wide variation in rates is
both a reflection of the classification systems used to define stillbirth and the extent of
postmortem assessment performed in each case [Fretts, 2005, Silver et al, 2007]. Further,
an unexplained stillbirth may in fact be an un-investigated one. Postmortem examination
may not be undertaken and the decision not to investigate can either be doctor or patient-
mediated. Parents may have cultural or religious beliefs why autopsy is impermissible or
doctors may feel that the clinical scenario or antenatal diagnosis suffices as an adequate
explanation. These difficulties are further compounded by a lack of consensus regarding the
number of tests needed and by the scarcity of uniform protocols of investigation [Silver et
al., 2007; Corabian et al., 2007].

Investigation of stillbirth

The optimal evaluation of stillbirth is controversial. There is often debate regarding the
attribution of a stillbirth to a particular underlying pathology, and lack of parental consent
can restrict procedures such as autopsy. The cost of testing also has to be considered in
most clinical settings. In general, the most common causes of stillbirth are investigated, as
well as those conditions that might predispose couples to recurrent stillbirth. However, even
identifying a sporadic cause has merit as it can bring closure for the parents and provide
reassurance for the future [Silver et al., 2007].

Histopathological examination of the fetus and placenta remain the most relevant
investigations in understanding the events leading to intrauterine death. Evaluation of the
placenta, membranes and umbilical cord can yield insight into different possible aetiologies
of stillbirth [Silver et al., 2007]. In addition, many of the broad categories of cause of death,
including unexplained stillbirth, are thought to be related to placental function [Smith and
Fretts, 2007]. About half of unexplained stillbirths have a birth weight less than the tenth
percentile corrected for gestational age and parental characteristics [Froen et al., 2004].

Following stillbirth, postmortem examination can reveal important information and findings at
perinatal autopsy change the presumptive cause of death or yield additional information in
22-76% of cases [Gordijin et al., 2002]. However, in the last decade, autopsy rates have
fallen to around 40-50% of all stillbirths. While evidence supports all perinatal autopsies
being performed by specialist perinatal pathologists, the majority of hospitals in the UK and
Ireland do not have access to this. Concerns into the removal, retention and storage of fetal
organs at postmortem examination in both the UK and Ireland have led to a significant
change in public opinion about fetal autopsy. An Irish 25-year retrospective analysis from
1979 to 2003 reported a drop-off in postmortem rates from 90% in first half of the study to
50% by 2003 [Walsh et al., 2008]. This has led to a search for alternatives to autopsy,
including postmortem radiological imaging.

“Stillbirths: the way forward in high income countries”

The Lancet‟s Stillbirths Series steering committee [Flenady et al., 2011] concluded that:-

 Stillbirths in many high-income countries are potentially preventable.

 The proportion of unexplained stillbirths without adequate investigation is high.
 All parents should be offered a thorough investigation including a high quality autopsy
and placental histopathology.

7
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

 Improvements in investigation and reporting practices, including consensus of definition

and classification systems, is needed.
 Future research should focus on screening and interventions to reduce stillbirth
associated with preterm birth, as well as a results of placental dysfunction.
 Parents have the greatest stake of all in the wellbeing of their baby, and must be part of
the drive to reduce stillbirth.

8
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

4. Methodology

The literature reviewed during the development of this guideline included current local and
national guidelines and their reference lists from the UK, Canada, USA, Australia and New
Zealand.

A search was conducted of current international guidelines in the UK, USA, Canada, New
Zealand and Australia.

In addition, Medline and the Cochrane Library were searched for literature published
between 2000 and 2010. Articles were restricted to those published in English. The search
words used were stillbirth, late fetal death, intra-uterine death, investigation, and
management.

The principal guideline developer was Dr. Keelin O‟Donoghue, Senior Lecturer, Obstetrics
and Gynaecology, University College Cork and Cork University Maternity Hospital (CUMH).
Ms. Anna Maria Verling (Chairperson, Miscarriage, Stillbirth and Neonatal Death
Committee, CUMH) and Dr. Roisin O‟Loughlin (SHO, CUMH) are acknowledged for their
development of local guidelines and for assisting with review of this guideline.

The guideline was peer-reviewed by Dr. Michael Gannon (Mullingar), Dr. Emma Kilgarriff
(GP), Dr Eddie O‟Donnell (Waterford) and Professor Michael Turner (HSE Obstetrics and
Gynaecology Programme), the Institute of Obstetricians and Gynaecologists‟ Clinical
Advisory Group, the HSE Obstetrics and Gynaecology Programme Working Group.

The guidelines were also reviewed by Féileacáin (Stillbirth and Neonatal Death Association
of Ireland).

9
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

5. Glossary
Live birth
Delivery of an infant, which, after complete separation from its mother, shows sign of life.
Evidence of life includes breathing movements, presence of a heartbeat, pulsation of the
cord or definite movement of voluntary muscles.

Neonatal death (NND)

Death of a live born baby occurring before 28 completed days after birth.
Early 0-6 completed days.
Late 7-27 completed days.

Perinatal death
Death of a fetus or a newborn in the perinatal period that commences at 24 completed
weeks‟ gestation and ends before seven completed days after birth.

Stillbirth (SB)
A baby delivered without signs of life after 23+6 weeks of pregnancy.

Intra-uterine death (IUD)

A baby who dies in utero

10
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6. Clinical Guideline
6.1 Terminology

The World Health Organization (WHO) defines stillbirth as a "fetal death late in pregnancy"
and allows each country to define the gestational age at which a fetal death is considered a
stillbirth for reporting purposes. As a result, some countries define stillbirth as early as 16
weeks of gestation, whereas others use a threshold as late as 28 weeks.

According to the International Classification of Diseases, revision 10 (ICD-10), an early fetal

death is death of a fetus weighing at least 500g (or if birth weight is unavailable then after
22 weeks gestation or with a crown-heel length of 25cm or more). A late fetal death is
defined as death of a fetus weighing at least 1000g (or a gestational age of 28 weeks or a
crown heel length of 35cm or more). Late fetal deaths are recommended by the WHO as
the measure for international comparison.

The Perinatal Mortality Surveillance Report [CEMACE, 2011] defines stillbirth as „a baby
delivered without signs of life after 23+6 completed weeks of pregnancy‟. This definition was
accepted by the Royal College of Obstetricians and Gynaecologists in their 2010 Green-top
Guideline [RCOG Green-top Guideline No. 55, November 2010].

The National Perinatal Epidemiology Centre‟s perinatal death notification form defines
stillbirth as “a baby delivered without signs of life from 24 weeks gestation and/or >500g”.

The Stillbirths Registration Act (1994) applies “in relation to a child born weighing 500
grammes or more or having a gestational age of 24 weeks or more who shows no sign of
life”.

ACOG defines stillbirth as fetal death occurring during pregnancy at 20 weeks of gestation
or later.

Intrauterine fetal death refers to babies with no signs of life in utero. There is general
agreement between the above bodies on this definition.

In this guideline, stillbirth is taken to refer to a baby delivered without signs of life from 24
weeks gestation and IUFD is taken to refer to death in utero after 24 weeks gestation.

11
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.2 Diagnosis

Diagnosis

Real-time ultrasonography is essential for an accurate diagnosis of IUFD. This allows direct
visualisation of the fetal heart, and views can be supplemented with colour Doppler of the
heart and umbilical cord. Use of ultrasound also facilitates visualisation of other secondary
features such as fetal hydrops, polyhydramnios, anhydramnios, overlapping skull bones and
skin oedema [RCOG, 2010].

Auscultation of the fetal heart by Pinard Stethoscope or Doppler is inaccurate and this
together with cardiotocography should not be used to investigate suspected IUFD.

Ideally, a second opinion should be obtained to confirm the diagnosis of IUFD. In addition,
mothers ought to be prepared for the possibility of passive fetal movement, and where this
is reported, a repeat ultrasound scan should be offered [RCOG, 2010].

When a diagnosis is confirmed, if a woman is unaccompanied, an offer should be made to

call her partner/family/friends.

Breaking the news

Once a diagnosis has been firmly established the parents are told in a timely and unhurried
manner in a private space. A doctor should advise parents of the death, with a midwife
present.

Those giving the news should acknowledge the baby‟s death. If the parents have decided
on a name for the baby it is important to use it. Staff should also be careful in using overly
medicalised terminology when speaking to parents about their loss.

Parents need to be given the opportunity and space to talk about their loss. It has been
shown that parents value acceptance and recognition of their emotions highly [McCreight,
2008]. Further guidance for staff to support them in their relationship with bereaved parents
is available [SANDS, 2007].

Follow-up

Parents who experience adverse events value continuity of the caregiver. Discussions on
further management should aim to support maternal/parental choice. Written information
should be given to parents to supplement these discussions.

Supportive care for the parents and family should be made available. The general
practitioner (GP) should be informed of the IUFD as soon as practicable after diagnosis.

The doctor / midwife dealing with the parents during initial diagnosis should give an
appropriate contact number for the hospital. The parents need to be reassured that they can
make contact at any time, if they need any further information or clarification.

12
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.3 Investigation

Clinical assessment and laboratory tests should be recommended to assess maternal

wellbeing and to determine the cause of death, the chance of recurrence and possible
means of avoiding further pregnancy complications [RCOG, 2010; PSANZ, 2009, BC
Reproductive Care Program, 2000]. Even identification of a sporadic cause can bring
emotional closure and facilitate parental recovery.

Parents should be made aware that:

1. No specific cause is found in almost half of stillbirths.
2. When a cause is found it can crucially influence care in a future pregnancy.
3. An abnormal test result is not necessarily related to the IUFD, so correlation between
blood tests and postmortem examination should be sought.
4. Sometimes further investigation is necessary.

Investigations recommended for all stillbirths (Appendix 2)

 At the time of diagnosis

o Maternal and family history
o Ultrasound scan +/- Amniocentesis
o Maternal blood tests
o Maternal toxicology
o Maternal microbiology

 After delivery
o External examination
o Infant blood tests
o Infant microbiology
o Placenta, membrane and cord histopathology
o Cytogenetic investigations
o Postmortem examination
o Postmortem Radiological imaging

Maternal and family history

A detailed family history should be sought to identify a possible inherited cause to explain
the stillbirth. A comprehensive maternal medical and social history should be taken.
This should explore:
 Previous fetal losses
 Elevated blood pressure
 History of bleeding
 Recent illness or viral exposure
 Medications during pregnancy
 Substance use
 History of fetal movements
 Antenatal investigations
 Fetal ultrasounds and fetal growth

13
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Ultrasound +/- Amniocentesis

At the time of ultrasound confirmation of IUFD, the ultrasound should include examination
for possible fetal abnormalities, fetal biometry and assessment of amniotic fluid volume
[PSANZ, 2009].

The option of amniocentesis after IUFD should be discussed. Parents will need to be given
time to consider this, and supported through the procedure. Amniocentesis can provide
cytogenetic results, especially if the mother chooses expectant management, but patient
acceptability and safety (i.e. infection) of amniocentesis has not been specifically
investigated in the setting of IUFD [Saal et al., 1987; Khare et al., 2005]. A report on a large
series of third-trimester amniocentesis suggested this is an acceptable option, with a low
complication rate, although a 10% cytogenetic culture failure rate was reported
[O‟Donoghue et al., 2005].

Amniotic fluid collected by amniocentesis prior to the onset of labour can provide an
uncontaminated specimen for microbiological assessment. It is the only sample where the
detection of pathogens such as E-Coli will be of value, especially if no autopsy is performed.
This is due to potential contamination during vaginal birth where findings from cultures of
natural orifices and the placenta/membranes are often discredited [PSANZ, 2009].

Maternal blood tests

Laboratory tests should be recommended to out rule any maternal disease or risk factor that
may have contributed to the IUFD / stillbirth.

Full blood examination

A full blood examination can assist in detection of: infection as a cause of the fetal death;
maternal anaemia which may indicate conditions such as thalassemia; low platelet levels - a
marker for pre-eclampsia; autoimmune diseases such as systemic lupus erythematosus
(SLE) and Idiopathic Thrombocytopenia Purpura (ITP); and elevated platelet levels may
indicate thrombocythemia [PSANZ, 2009].

Maternal coagulation testing

Testing maternal coagulation and plasma fibrinogen are not indicated to find a cause for the
IUFD, but rather because of the association between IUFD and maternal coagulopathy.
Maternal sepsis, placental abruption and pre-eclampsia, all possible causes of IUFD,
increase the chance of maternal DIC. These tests are also relevant if regional anaesthesia
is requested during labour [RCOG, 2010].

Serology for Cytomegalovirus, Toxoplasma, Parvovirus B19, Rubella and Syphilis

Serology for Cytomegalovirus, Toxoplasma and Parvovirus B19 should be undertaken

following an IUFD. Rubella and Syphilis should also be included if they have not already
been undertaken during the antenatal period. Where test results are positive, a
microbiologist or infectious disease specialist should be consulted regarding further testing
and treatment required [PSANZ, 2009].
Maternal-fetal transmission of Toxoplasmosis is dependent on the time of maternal
infection. The earlier the fetus acquires the infection the more severe the consequences,

14
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

however maternal-fetal transmission is more likely to occur later in pregnancy.

Disseminated Toxoplasma may cause fetal death [Goldenberg RL and Thompson C, 2003].

Parvovirus (B19) causes severe fetal anaemia, non-immune hydrops and fetal death
[Goldenberg RL and Thompson C, 2003; Tolfvenstam et al., 2001]. It was found to be the
cause of death in 10% of all non-malformed fetal deaths occurring between 10 and 24
weeks of gestation referred for pathological examination [Wright et al., 1996]. 1%-3% of
susceptible pregnant women will develop serologic evidence of infection in pregnancy, of
which the transmission rate to the fetus is 17%-33% (16-18). The spontaneous loss rate of
fetuses affected by Parvovirus B19 after 20 weeks gestation is 2.3% [Crane et al., 2002]. Of
note, hydrops is not necessarily a feature of parvovirus related late IUFD [RCOG, 2010].

Rubella is associated with a wide variety of fetal abnormalities and also infects the placenta,
enhancing the risk of stillbirth. However due to widespread vaccination, congenital rubella
infection in developed countries is extremely rare [Goldenberg RL and Thompson C, 2003].

Whether CMV actually causes stillbirth and, if so, the mechanism by which it does so is not
clear [Goldenberg RL and Thompson C, 2003]. However, a prospective study of more than
10,000 women found an increase in fetal loss associated with infection in early pregnancy
[Griffiths PD and Baboonian C, 1984].

Blood group and antibody screen

A blood group and antibody screen should be performed to exclude haemolytic disease due
to maternal sensitisation to red cell antigens, for example Rh D and Kell [Moise, 2004].

Kleihauer-Betke test

A Kleihauer-Betke test to detect fetomaternal haemorrhage should be performed following

the diagnosis of an IUFD, and preferably prior to delivery. Limited evidence suggests that
post delivery Kleihauer may still be useful [RCOG, 2010; PSANZ, 2009, Biankin et al.,
2003].

The incidence of massive fetomaternal haemorrhage is <0.1%. However the incidence in

otherwise unexplained cases of fetal death has been estimated to be as high as 14%
[Laube DW and Schauberger CW, 1982]. The diagnosis of a significant fetomaternal
haemorrhage is confirmed by quantification of fetal erythrocytes in maternal blood
performed by the Kleihauer test. The general consensus is that 50ml constitutes a
significant haemorrhage, with various studies using limits ranging from 30- 150ml; these
levels are gestation dependent [PSANZ, 2009].

The time period over which the haemorrhage occurs will have a direct impact upon the
mortality associated with it, according to whether the fetus was able to compensate for the
loss in blood volume. However, as it is not currently possible to assess this, a loss of 20% of
total fetal blood volume should be considered severe enough to cause fetal mortality
[WiSSP, 2004].

Renal Function Tests including Uric Acid

Elevated uric acid levels early in the third trimester in pre-eclamptic women have been

15
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

associated with perinatal death and it is therefore recommended to evaluate the contribution
of pre-eclampsia to the death [PSANZ, 2009].

Abnormal renal function is an indicator of possible SLE, which is associated with a

significant increase in fetal morbidity and mortality. Uric acid is the most sensitive laboratory
indicator of pre-eclampsia and is a better predictor of perinatal outcome than blood pressure
[PSANZ, 2009; Redman et al., 1976].

Liver Function and Bile acid Tests

Mild liver test abnormalities are a possible marker for obstetric cholestasis. Obstetric
cholestasis (OC) was initially associated with a significant increase in the perinatal mortality
rate, ranging from 3%-20%, as well as a five-fold increased incidence in intra-partum fetal
distress and pre-term labour [Fisk NM and Storey GN, 1988]. When more recent studies
are considered, the perinatal mortality rate from OC is 11/1000, and the additional risk of
stillbirth from OC over the general population remains undetermined [RCOG, 2011]

Abnormalities in liver function are also a marker for viral hepatitis, cytomegalovirus, and
toxoplasmosis. Abnormal liver function has also been associated with acute fatty liver of
pregnancy and HELLP syndrome (Haemolysis, Elevated Liver function, Low Platelets)
[PSANZ, 2009].

Thyroid Function Tests

Pregnancy is associated with physiological changes in the thyroid function, which may result
in thyroid disorders. Thyroid disorders during pregnancy have been associated with adverse
health outcomes for both the mother and child, including increased risk of miscarriage,
gestational hypertension, low birth weight and fetal death [Feki et al., 2008]. Recent reports
have focused on the correlation of subclinical hypothyroidism and adverse pregnancy
outcome [Benhadi et al., 2000].

HbA1c

The increased risk of fetal morbidity and mortality with maternal diabetes is well known
[Engel et al., 2008]. A stillbirth rate of 35 per 1000 births to type 2 diabetic mothers has
been reported [Cundy et al., 2000]. Gestational diabetes mellitus (GDM) is defined as
carbohydrate intolerance of variable severity with the onset or first recognition during
pregnancy. There is some evidence to indicate that uncontrolled GDM is associated with
increased perinatal mortality; however the majority of women with GDM have a normal
HbA1c [Aberg et al., 1997; RCOG, 2010]. HbA1c monitors glycaemia over the previous 3
months by reflecting the average glucose concentration over the life of the red cells and
therefore may provide information to aid in the consideration of the contribution of diabetes
to the fetal death. If the HbA1c level is raised, fasting blood glucose should be tested and if
abnormal a Glucose Tolerance Test performed 6-8 weeks postnatally [PSANZ, 2009].

Investigation for Thrombophilia

Testing for Anticardiolipin antibodies, Lupus anticoagulant and APC resistance are
recommended for all women at the time of IUFD.

16
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Ideally, further investigation for thrombophilia should be undertaken 8-12 weeks postnatally
where a fetal death is associated with fetal growth restriction, pre-eclampsia, maternal
thrombosis and/or maternal family history of thrombosis, remains unexplained following the
core investigations or where tests for thrombophilia were positive at the time of the IUFD.
These tests include fasting homocysteine levels, Protein C and S deficiency, the
Prothrombin gene mutation and the anti-thrombin II deficiency [PSANZ, 2009; RCOG 2010].
Local protocols may apply regarding the timing of testing for thrombophilia.

Anticardiolipin antibodies and Lupus anticoagulant should be repeated postnatally if found

to be positive at the time of the IUFD and the Factor V Leiden mutation should be tested if
APC resistance was positive at birth.

Thrombophilias are multigenic disorders caused by inherited and acquired defects resulting
in a predisposition to thrombosis [Alonos et al., 2002]. Antiphospholipid antibodies are the
most important causes of acquired thrombophilias. In pregnancy, thrombophilic disorders
are associated with an increased risk of venous thromboembolism, pre-eclampsia, placental
abruption, early and late fetal demise, recurrent pregnancy loss and fetal growth restriction
[Alfirevic et al., 2002; Saade GR and McLintock C, 2002]. However, accurate estimates of
strength of the associations for adverse pregnancy outcome and inherited thrombophilic
disorders are problematic due to small numbers and heterogeneity of the available studies
[Alfirevic et al., 2002]. Recent systematic reviews have demonstrated a statistically
significant increase in the risk of stillbirth associated with APC resistance, Factor V Leiden
mutation, Protein C deficiency, Protein S deficiency, Prothrombin G20210 mutation and
MTHFR [Saade GR and McLintock C, 2002; Rey et al., 2003; Dudding TE and Attia J, 2004,
PSANZ, 2009].

Ideally the identification of thrombophilia following an unexplained stillbirth would result in

intervention in future pregnancies to reduce the risk. Although the evidence is unclear, there
is some evidence to suggest that antithrombotic therapy may reduce adverse pregnancy
outcome for women with thrombophilia [McLintock et al., 2001].

Parental karyotypes

Parental bloods for karyotype are indicated if a fetal balanced translocation is identified.
These tests should also be performed if fetal genetic testing fails and there is a history
suggestive of fetal aneuploidy e.g fetal abnormality or a history of a previous unexplained
IUFD or recurrent pregnancy loss {RCOG, 2010; Sikkema-Raddatz et al., 2000].

Maternal autoantibody testing

Testing for occult maternal autoimmune disease may be indicated in certain circumstances.
These include where fetal hydrops is evident clinically or at postmortem (test anti-red cell
antibody serology), or where endomyocardial fibroelastosis or AV node calcification is found
at postmortem (test maternal anti-Ro or anti-La antibodies). Maternal alloimmune
antiplatelet antibodies should be tested where fetal intracranial haemorrhage is found or
fetal thrombocytopaenia detected [RCOG, 2010].

17
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Maternal Toxicology

Illicit drug use accounts for a proportion of stillbirths [Silver et al., 2007]. Maternal urine
should be analysed for cocaine metabolites, if the history or presentation are suggestive
[Lutiger et al., 1991]. The RCOG Green-top guideline lists a maternal toxicology screen as a
recommended test - as long as maternal consent is obtained and where history and/or
presentation are suggestive [RCOG, 2010].

Maternal microbiology

Infectious and microbiological investigation should be performed where infection is

suspected as an aetiology (maternal fever, abnormal liquor, flu-like symptoms, prolonged
rupture of membranes) or where the cause of stillbirth is not obvious [RCOG, 2010, Moyo et
al., 1996]. Tests to be performed include maternal blood cultures, mid-stream urine
analysis, vaginal and cervical swabs [RCOG, 2010].

McDonald et al identified that although 70% of women with mid-gestation spontaneous

abortions were asymptomatic for infection, micro-organisms were identified from the
placenta and/or fetus in 62% of women studied and histological chorioamnionitis was
present in 69%. Among 51 women with intact membranes, 28 were culture-positive, with the
most frequent isolate being Group B Streptococcus (GBS). In this study, GBS was the most
significant pathogen associated with the fetal deaths, and was often the sole pathogen
recovered [McDonald HM and Chambers HM, 2000]. The detection of GBS is optimised
with the use of a perianal swab in conjunction with a low vaginal swab and the use of
specific culture media [Jones et al., 2004].

External examination

A perinatal pathologist, neonatologist or paediatrician should perform a detailed external

examination of the baby where possible, irrespective of whether a postmortem is being
performed or not. A comprehensive external examination of the baby is an essential
component of the investigation of a stillbirth [PSANZ, 2009, BC Reproductive Care
Program, 2000; Magee 2001]. A report on a large case series suggested that approximately
25% of stillborn infants were found on clinical examination to have demonstrable
abnormalities and also indicated that lack of external examination would have resulted in
approximately 4% of diagnoses being missed [WiSSP, 2004].

A detailed external examination of the baby is also a component of a full postmortem. As

the perinatal pathologist is the most appropriate person to carry out the external
examination, parents who have declined a full postmortem should be asked to consent for
the baby to be examined by a pathologist. In circumstances where it is not possible for a
pathologist to perform the examination, or where a perinatal pathologist is not available,
then a neonatologist or paediatrician should conduct the examination [PSANZ, 2009].

The external examination should aim to answer at least three questions [Magee, 2001]:
1. Does the infant display a detectable anomaly?
2. Is growth appropriate?
3. Is maceration present, and if so, how severe?

18
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Infant blood tests

A blood sample should be collected from the infant for investigation of the presence of
infection, to assess other haematological parameters for karyotyping (if not already
performed) and a routine Guthrie test [PSANZ, 2009].

A cord blood sample should be collected after delivery where possible; if this is not possible,
cardiac puncture can be performed. This blood sample will provide a potentially
uncontaminated sample for microbiological culture and assessment of fetal inflammatory
response. If a sample of blood is obtained it should also be sent for chromosomal analysis,
and haematological assessment (full blood count, nucleated red cell count, group and
antibody screen).

Infant microbiology

Surface swabs for aerobic and anaerobic bacterial culture cultures should be taken from the
ear and throat of all stillbirths. Intrauterine infections have been reported to represent the
cause of death in 15%-24% of cases of stillbirths when premature rupture of membranes is
included. Infection may be subclinical in the mother, hence the importance of investigating
all incidences of fetal death where a cause is not obvious [PSANZ, 2009]. Fetal
microbiological investigations may be more informative than maternal serology for detecting
viral infections. [RCOG, 2010]

Analysis of the placenta, cord and membranes

At time of delivery, the clinician should undertake:

 A detailed macroscopic examination of the placenta and cord and should document the
findings
 Placental swabs between the amnion and chorion using aseptic technique for aerobic
and anaerobic bacterial cultures
 Sampling of amnion and placental tissue for karyotyping if required.

Pathological examination of the cord, membranes and placenta should be recommended

whether or not postmortem examination of the baby is requested. Following a stillbirth, the
placenta, membrane and cord should be sent to the perinatal pathologist fresh and unfixed
for macroscopic and histological examination.

The placenta should be examined in all cases of intrauterine death. Examination of the
placenta reduces the proportion of unexplained stillbirths [Heazell and Martindael, 2009]. In
one review of 146 autopsies performed on macerated and non-macerated stillbirths,
significant findings were identified in the placenta in 53% of cases [Magee, 2001]. Another
review of placentas from stillbirths identified histologic abnormalities in 98% of cases (the
findings supporting the prior clinical impression in 77% of cases, being contradictory to prior
impressions in 11% of cases, and being the sole contributor to explaining death in a further
11% of cases) [Rayburn et al., 1985]. In addition to a probable cause of death, placental
examination in cases of stillbirth may provide an audit of antenatal clinical judgment by
providing clinic-pathologic correlation and/or lead to an improved management of
subsequent pregnancies by diagnosing conditions that may recur or be preventable or
treatable in subsequent pregnancies [Magee, 2001].

19
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Cytogenetic investigations

Karyotyping is important as about 6% of stillborn babies will have a chromosomal

abnormality [Genest et al., 1992]. Some abnormalities are potentially recurrent and can be
tested for in future pregnancies. Written consent should be taken for any fetal samples used
for karyotyping [RCOG, 2010].

Culture potentially provides the greatest range of genetic information (trisomies,

monosomies, translocations, major deletions and marker chromosomes). Microdeletions
have to be requested specifically, usually according to the result of any postmortem
examination. If all cultures fail, QF-PCR can be performed on extracted DNA, but this
provides less detailed genetic information.

Ideally, more than one cytogenetic technique should be available to maximise the chance of
informative results [RCOG, 2010; PSANZ, 2009]. Cytogenetic investigation of pregnancy
loss can now be routinely performed by MLPA (multiplex ligation-dependent probe
amplification). This technique has a higher success rate than karyotyping – 85-95% - as well
as reduced reporting time (12 days). Karyotyping will still be performed where this can
provide relevant information that investigation by MLPA may not provide. Parental follow up
will be required in a proportion of cases. Local guidelines and laboratory service
agreements will determine the technique used, the laboratory involved, the sample
requirements and the reporting times.

A range of tissue types can be used, but all cell cultures can fail. Samples from multiple
tissues should be used to increase the chance of culture [RCOG, 2010]. Perinatal
specimens suitable for karyotyping include skin, cartilage and placenta. Skin specimens are
associated with a higher rate of culture failure, twice that of other tissues, including
placenta. Placenta usually has the advantages of being the most viable tissue and of more
rapid cell culture, but the disadvantages of maternal contamination and placental
pseudomosaicism [Schreck et al., 1990].

Placental biopsy (approximately 1 cm diameter) should be taken from the fetal surface close
to the cord insertion (to avoid tissue of maternal origin). Skin biopsy should be deep to
include underlying muscle (about 1 cm in length from the upper fleshy part of the thigh). The
skin can be closed with wound adhesive strips and tissue adhesives, but this is less
successful when the baby is severely macerated [RCOG, 2010].

The rate of successful chromosome analysis using amniocentesis in cases of IUFD ranges
from 82%-92%. In contrast, the success rate for placental chromosome analysis is
approximately 60% and approximately 30% for skin. The total time from fetal death until
biopsies can be processed is often long, and the chances of succeeding with a
chromosomal analysis decreases with time. Amniocentesis reduces the elapsed time
between fetal death and sample collection, and the samples are easier to handle and for the
laboratory to process Ahlenius et al., 1995; Neiger R and Croom CS, 1990].

Postmortem examination

Parents should be offered a full postmortem examination of the stillborn infant to help
explain the cause of an IUFD / stillbirth. The value of post-mortem examination after stillbirth
is well documented. It provides additional information in up to 65% of cases of IUFD and

20
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

may also alleviate parental anxiety about antenatal care, as well as being essential for
research to investigate the aetiology of stillbirth [Stock et al., 2010; Gordijin et al., 2002].

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. Parents should be given time to make this decision. However, attempts to
persuade parents to choose postmortem must be avoided; individual, cultural and religious
beliefs must be respected [RCOG, 2010].

The examination should ideally be undertaken by a specialist perinatal pathologist [RCOG,

2010].

Postmortem examination should include external examination with birth weight, histology of
relevant tissues and skeletal X-rays. Parents can also be offered a limited postmortem
examination, sparing certain parts of the body e.g. the brain.

Each pathology department should have a stillbirth postmortem protocol to include

consideration of the following: external examination, internal examination (dissection
procedure), weights and measurements, tissue histology (special stains and frozen
sections), ancillary studies (cytogenetic studies, molecular and biochemical studies,
viral/bacterial studies) and placental examination [Magee, 2001].

Consent

What should be discussed in seeking consent for a postmortem examination

1. Why the postmortem examination is required and why it would be helpful to the
clinicians and to the family.
2. That the examination will be carried out according to best practice guidelines and
professional standards with care and respect for the body of the infant.
3. Parents have the right to refuse a postmortem examination.
4. What a postmortem examination entails. Parents have the option to decline
detailed - as opposed to general – information.
5. That hospital postmortem examinations can be full or limited, and that a limited
postmortem may lead to an incomplete assessment or not clarify a diagnosis.
6. The possibility of removal and retention of organs and tissues and the reasons
why this may be required.
7. What happens to organs and tissues that have been removed and retained.
8. Storage of organs and tissues retained at postmortem examination.
9. Other uses to which retained organs and tissues can be put – e.g. research,
education and training.
10. Where and when the postmortem will take place, and an estimation of how long it
will take.
11. Implications of postmortem examination on funeral arrangements.
12. Options for the ultimate disposition of organs not returned to the body prior to the
funeral.
13. When the postmortem results may be available.
14. Options in relation to communication of the postmortem results.

[Adapted from the Code of Practice for Post Mortem Services, 2010].

21
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Written consent must be obtained for any invasive procedure on the baby including tissues
taken for genetic analysis (Appendix 3).

The way in which the postmortem examination is discussed with the parents is extremely
important. In all cases postmortem examination of the baby should be discussed with
parents by senior medical staff (Consultant and/or Registrar) in a sensitive manner. The
medical staff seeking consent must have knowledge of the procedures involved. An
improvement in postmortem rates has been demonstrated when senior staff are involved in
counselling [Stock et al., 2010].

Parents should be given clear, honest and objective information [Code of Practice for Post
Mortem Services, 2010]. 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 – but parents should be
advised that they may find the terminology distressing [RCOG, 2010].

Parents should be given time to receive information and make decisions, the opportunity to
ask questions, and should be allowed privacy for discussion between themselves. Parents
need to feel comfortable to discuss their fears around the procedure and have the
confidence to ask staff for guidance. Emotional or psychological support during this time
may also be helpful [Code of Practice for Post Mortem Services, 2010].

The possible retention or organs and /or tissues must be discussed, along with the reasons
why organs/tissues may be retained. The various options in relation to the sensitive disposal
of organs/tissues after examination should be explored. Specific consent must be obtained
for the removal and /or retention or organs or tissues for any reason [Madden, 2005; Code
of Practice for Post Mortem Services, 2010].

If, after discussion, parents decline postmortem examination this decision should be
documented in the maternal chart.

If, after discussion, including provision of an explanatory leaflet outlining postmortem

examination, parents agree to a postmortem examination, written consent is obtained and
the „request for postmortem‟ form completed in full. If possible, the mother should be
encouraged to sign, particularly where her surname differs from the father, as discrepancies
in surnames can lead to difficulties in the carrying out of the postmortem.

The postmortem consent form outlines the exact nature of a postmortem examination, any
limitations made by the parents are recorded and then a parent and one of the senior
medical staff sign it. If the Consultant or Registrar has specific issues to be dealt with in the
post-mortem, they should bring these to the attention of the relevant Pathologist.

Making arrangements

Parents should be advised of the local arrangements for postmortem examination. In some
hospitals, this will involved the baby being transported to another hospital for the procedure,
and this must be made clear to the parents.

Following consent for postmortem examination, the mortician is contacted to arrange a time

22
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

of examination in the Pathology Department.

If X- rays have been carried out they should be sent with the baby when being sent for
postmortem. In some units, the skeletal survey will be performed in the radiology
department en route to the pathology department.

The completed postmortem request form with clinical details and signed, fully completed
postmortem consent form accompany the baby‟s body to the Pathology Department.

Detailed local arrangements should exist to confirm the baby‟s identity, ensure the remains
are transported with dignity, and to confirm the baby‟s return to the parents after the
postmortem. Parents should be advised of baby‟s return as early as possible, and can be
given time with baby after the return from the postmortem examination.

Communication

Postmortem and placental examinations are performed to uncover a cause of death and/or
identify factors that could influence the management of future pregnancies. It is necessary
therefore that the pathologist (a) generate a timely and informative report; (b) communicate
autopsy findings to health care providers; and (c) participate in a regular review of stillbirths
[Magee, 2001].

A preliminary autopsy report (comprising a short but relevant history, a list of gross findings
in infant and/or placenta, a list of tests whose results are awaited, such as cytogenetics and
viral studies), and an estimated date for release of the final report should be issued within
48 hours of the autopsy procedure. Guidelines for turnaround times for the full report are
available, with 3 months being the suggested maximum [Magee, 2001].

Postmortem radiological imaging

Parents who decline an autopsy should be asked for consent to undertake a full body X-ray.
A skeletal survey (plain radiography) may detect abnormalities (mainly skeletal), which may
not be detected on an external examination. The Wisconsin Stillbirth Service Program
estimated that approximately 20% of unselected stillborn infants had abnormalities
detectable on X-Ray [WiSSP, 2004].

Ultrasound and magnetic resonance imaging (MRI) should not yet be offered as a substitute
for conventional postmortem examination [RCOG, 2010].

Magnetic resonance imaging (MRI) can be a useful adjunct to conventional postmortem for
the evaluation of stillborn fetuses [Griffiths et al., 2005; Cohen et al., 2008]. MRI was chosen
for its excellent soft tissue contrast and representation of the central nervous system (CNS),
an area that presents problems for pathologists. Initial studies reported detailed anatomical
depiction of most organ systems, but the depiction of abnormalities outside the CNS was
inferior to formal autopsy. Other problems include limited availability of MR in many centres
and the length of time per scan.

Computerised tomography (CT) represents another non-invasive alternative to fetal

autopsy. To date, postmortem CT has been confined to use in adult forensic examination,
where it gives excellent spatial resolution for most organs, particularly skeletal views, and is

23
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

better at forensic reconstruction than MRI [Dirnhofer et al., 2006]. The proposed advantages of
CT over MR postmortem imaging include depiction of fractures and gross tissue injury, as well
as the fast acquisition time (5-10 minutes for whole-body CT) which leads to minimal
intrusion on the working schedule of a clinical radiology department. Further, with the use of
multi-detector CT (MDCT), images can be reconstructed in any plane, which helps to
elucidate complex anatomical structures.

A recent study confirmed the feasibility of MDCT in the investigation of third trimester
stillbirth. MDCT image quality was acceptable and the examination demonstrated a range of
anatomic and pathologic findings. Initially, the value of CT may also be as an important
adjunct to conventional postmortem examination, especially where postmortem rates are
low, in the setting of congenital malformation, and where the resource of MRI is not
available. [O‟Donoghue et al, 2011]. Targeted biopsy under imaging control may add to the
sensitivity and specificity of postmortem imaging and allow histological diagnosis.

24
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Status of Current Evaluation for the Cause of Stillbirth

Generally
Useful in Uncertain Developing
accepted
some cases utility technologies
tests
• Medical and • Lupus • Thyroid • Comparative
obstetric anticoagulant function tests, genomic
history • Anti-cardiolipin TSH hybridisation
• Maternal antibodies • TORCH • Testing for
haematology • Factor V Leiden serology single-gene
and mutation • Placental disorders
biochemistry • Prothrombin cultures • Nucleic acid
• Post-mortem G20210A • Testing for based testing
examination mutation other for infection
• Radiological • Screen for thrombophilias • MR and CT
investigations Protein C, • Glyco- imaging
• Placental Protein S and haemoglobin
evaluation Anti-thrombin (HbA1c)
• Maternal III deficiency
bacteriology • Rubella and
• Karyotype Syphilis testing
• Kleihauer- (if not done
Betke test antenatally)
• Blood group • Maternal
and antibody autoantibodies
screen • Parental
• Liver function karyotypes
and bile acid
testing
• Parvovirus
serology
• Toxicology
screen

[From Silver et al., 2007; PSANZ, 2009; RCOG, 2010]

25
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.4 Labour and delivery

Management

The management of the birth is discussed as soon after diagnosis as feasible, and options
are explored with parents regarding timing of the birth. Recommendations about labour and
birth should take into account the mother‟s preferences as well as her medical condition and
previous intra-partum history. Clear explanations of procedures should be communicated to
the parents in a sensitive manner.

Management may involve awaiting spontaneous labour or planned induction.

Women should be strongly advised to take immediate steps towards delivery if there is
sepsis, pre-eclampsia, placental abruption or membrane rupture, but a more flexible
approach can be discussed if these factors are not present [RCOG, 2010].

The management plan should be clearly documented in the chart in consultation with the
parents. This should include their wishes with regard to the bereavement and loss team.
The midwife who is dealing with the family should inform Bed Management, Delivery Suite
and the relevant ward, to ensure that an appropriate space is made available.

Expectant management

More than 85% of women with an IUFD labour spontaneously within three weeks of
diagnosis. If the woman is physically well, her membranes are intact and there is no
evidence of pre-eclampsia, infection or bleeding, the risk of expectant management for 48
hours is low [NICE, 2008].

However, there is a 10% chance of maternal DIC within 4 weeks from the date of fetal death
and an increasing chance thereafter [Parasnis et al., 1992]. Women who delay labour for
periods longer than 48 hours should therefore be advised to have testing for DIC twice
weekly. They should also be advised that they could develop severe medical complications
and suffer greater anxiety with prolonged intervals [RCOG, 2010].

Women contemplating prolonged expectant management should be advised that the value
of subsequent postmortem examination might be reduced and that the appearance of the
baby might deteriorate [RCOG, 2010].

Medical induction

Vaginal birth is the recommended mode of delivery for most women, but caesarean section
will need to be considered in some cases [RCOG, 2010].

Vaginal birth can be achieved within 24 hours of induction of labour for IUFD in about 90%
of women [Wagaarachchi. et al., 2002]. Vaginal birth carries the potential advantages of
immediate recovery and quicker return to home.

A combination of mifepristone and a prostaglandin is recommended as the 1 st line

intervention for induction of labour. Wagaarachchi et al found that the combined use of

26
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

mifepristone and misoprostol was not only safe but also had an average time to delivery
interval less than any of the other induction regimes in use.

A single 200mg dose of mifepristone is appropriate for induction after IUFD.

Misoprostol can be used in preference to prostaglandin E2 because of equivalent safety and

efficacy with lower cost [RCOG, 2010]. The use of vaginal misoprostol in the termination of
second and third trimester of pregnancy is as effective as other prostaglandin preparations
(including cervagem, prostaglandin E2 and prostaglandin F2alpha), and more effective than
oral administration of misoprostol. [Dodd and Crowther, 2010].

A review of misoprostol use for late IUFD recommended that the dose should be adjusted
according to gestational age (100 micrograms 6-hourly before 26 weeks; 25–50 micrograms
4-hourly at 27 weeks or more) [Gómez Ponce de León, 2007]. The National Institute has
endorsed this recommendation for Health and Clinical Excellence [NICE, 2008], although
the 2010 Cochrane Review on the use of Misoprostol in IUFD concluded that the differing
treatment regimens analysed appeared comparable for the common reported outcomes.

There remains wide variation in the dose, frequency and route of administration of
misoprostol used in the setting of IUFD. While concerns about fetal safety are not relevant,
issues of side effects for the mother remain. In addition, important information regarding
maternal safety, and in particular the occurrence of rare outcomes such as uterine rupture,
remains limited [Dodd and Crowther, 2010].

A suggested protocol for medical induction of labour after IUFD is set out in Appendix 4.

Caesarean birth might occasionally be clinically indicated by virtue of the maternal

condition. The woman herself might request caesarean section because of previous
experiences or a wish to avoid vaginal birth of a dead baby. This demands a careful and
sensitive discussion and joint decision-making [RCOG, 2010]. The implications of
caesarean delivery for future childbearing should be discussed [NICE, 2004].

Previous caesarean section

If a woman has had a previous caesarean section, a discussion as to the safety and
benefits of induction of labour needs to be undertaken by a consultant obstetrician [RCOG,
2010].

Mifepristone can be used alone (at a dose of 600mg) to increase the chance of labour
significantly within 72 hours (avoiding the use of prostaglandin).

Women with a single lower segment scar should be advised that, in general, induction of
labour with prostaglandin is safe but not without risk. The RCOG Green-top guideline (2010)
concludes that misoprostol can be „safely‟ used for induction of labour in women with a
single previous CS and an IUFD, while acknowledging the paucity of studies on the safety
and effectiveness of induction of labour after IUFD in women with a single caesarean
section scar. The RCOG Green-top Guideline on VBAC recommends that women should be
informed that there is a higher risk of uterine rupture with induction of labour with
prostaglandins [RCOG, 2007].

27
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

In contrast, the Society of Obstetricians and Gynaecologists of Canada recommended that

misoprostol be contraindicated in women with previous caesarean delivery because of a
high rate of uterine rupture [SOGC, 2005]. A more recent review of induction of labour for
late IUFD concluded that misoprostol could be used safely at lower doses for women with a
previous caesarean (25–50 micrograms) [Gómez Ponce de León, 2007]. This latter
recommendation has been endorsed by NICE [NICE, 2008]. Misoprostol is not currently
marketed at these lower doses.

Women with two previous CS 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 CS [RCOG, 2010]. Women with more than two CS deliveries or atypical scars
should be advised that the safety of induction of labour is unknown [RCOG, 2010]. Unless
there is a pressing need to induce labour, caution should be exercised in using oxytocic
agents in the presence of a uterine scar.

Care on admission to the hospital

The admission should be planned and the parents prioritised on their arrival and taken
directly to the relevant ward or clinical area. The parents should be accommodated in a
room on their own - where possible in a location within the hospital away from antenatal or
postnatal wards.

An individual midwife should be allocated to the family. This midwife should welcome the
family, orientate them to the ward and provide additional supportive care during their stay in
the hospital. The consultant or registrar should then reassess the woman, and review the
care plan with the couple and the allocated midwife.

Appropriate support services should be contacted in relation to the parents‟ admission,

including members of the hospital bereavement and loss team (personnel involved will vary
locally). Pastoral care is also offered to the family.

Unnecessary disruption should be avoided during the time on the ward and contact with
additional staff minimised.

Care on admission to the Labour Ward

The midwife on ward should liaise with Labour Ward prior to transfer. On arrival, the
parents should be introduced to the Midwifery and Medical Team and the Care Plan is
reviewed with the parents.

Staff should try to ensure a quiet environment for the parents during this time. 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 [RCOG, 2010].

Intra-partum management

An experienced midwife should give care in labour. During labour the parents should have
the opportunity to spend time on their own if that is what they wish.

28
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Routine antibiotic prophylaxis should not be used. Women with sepsis should be treated
with intravenous broad-spectrum antibiotic therapy. Intra-partum antibiotic prophylaxis for
women colonised with group B streptococcus is not indicated. Infection is a common
association of late IUFD and the mother can develop severe sepsis from a wide range of
bacteria. Regardless of the primary cause of death, the fetus can act as a focus for severe
secondary sepsis, which can result in DIC. In one study, 3.1% of women with an IUFD
developed signs of sepsis during induction of labour [Wagaarachchi et al, 2002]. There are
no data on the routine use of intra-partum antibiotics for the prevention of maternal infection
in the setting of IUFD [RCOG, 2010].

Analgesia in labour is particularly important for women with an IUFD. All usual modalities
should be available including regional anaesthesia and patient-controlled anaesthesia
[RCOG, 2010]. Diamorphine should be used in preference to pethidine. Regional
anaesthesia should be available for women with an IUFD; however, assessment for DIC
and sepsis should be undertaken before administering regional anaesthesia. Women should
be offered an opportunity to meet with an obstetric anaesthetist [ROCG, 2010].

Women undergoing VBAC should be closely monitored for features of scar rupture.
Oxytocin augmentation can be used for VBAC, but a consultant obstetrician should make
the decision [RCOG, 2010]. Fetal heart rate abnormality, usually the most common early
sign of scar dehiscence, does not apply in this circumstance. Other clinical features include
maternal tachycardia, atypical pain, vaginal bleeding, haematuria on catheter specimen and
maternal collapse [RCOG, 2007]. There are no reports on the safety and effectiveness of
oxytocin augmentation in VBAC with IUFD.

Birth

The parents will never forget this time, and the aim is to sensitively ensure it is as positive
an experience as possible. If an assisted delivery is required, the obstetrician must handle
this sensitively, and adequate analgesia should be maintained throughout.

Certain fetal scenarios e.g. macrosomia or hydrops may increase the time spent in labour
and increase the risk of dystocia. It is estimated that around 3% of stillborn babies weigh
more than 4kg [CMACE, 2009]. Because of this, a longer passive second stage of labour
has been advocated in the setting of IUFD. This aims to ensure good descent of the fetal
head and prevent CS at full dilatation. Destructive procedures such as craniotomy,
decapitation, and cleidectomy were common many years ago to enable vaginal delivery of a
dead baby that had become obstructed in the pelvis during labour. These procedures have
almost completely disappeared from obstetrics in the developed world, although are still
rarely carried out in the developing world, where abdominal delivery poses a significant risk
to the mother. However, some authors make the case for skilled practitioners to continue to
perform these operations in certain cases [Steel et al., 2009].

Post partum haemorrhage also needs to be anticipated, particularly where there was pre-
existing polyhydramnios or where labour has been either precipitate or prolonged. A senior
obstetrician should therefore be either available or in attendance at delivery. Active
management of the third stage of labour, using oxytocics to ensure adequate uterine tone,
should also be advocated.

At birth, the parents should be provided the opportunity if appropriate to:

29
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

 Cut the cord

 Have the baby delivered into mother‟s arms
 Spend time alone with the baby
 Get to know their baby
 Facilitate mother and baby skin to skin contact
 Take and have a variety of photographs taken

Parents are often ill-prepared for the appearance of their baby, especaily where death
occurred several days before delivery. Staff should gently explain to the parents what their
baby might look like after birth.

The parents may need to be gently guided in carrying out these tasks for their baby. The
midwife will also facilitate this in the way she models the care of the baby as she would with
a living baby. The way in which the midwife interacts with the baby using the same respect
and importance that she would with a living baby will have a profound influence on the
parent‟s reaction to their baby.

30
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.5 Post-natal care

Care on the ward after delivery

One midwife should be allocated to care for the parents and the baby.

Parents should be allocated a room on their own after delivery. The partner should be
offered open visiting and facilitated to stay with the mother at night.

Parents need to be advised in relation to rooming with the baby and the need for the baby to
be placed occasionally in quiet room.

Lactation

Mothers need to be advised on what to expect regarding lactation and how to suppress or
manage this. Suppression of lactation is of psychological importance for some women
following IUFD. One third of those who choose non-pharmacological measures to achieve
this are troubled by excessive discomfort.

If suppression is necessary, dopamine agonists are 1st line agents to suppress lactation.
Cabergoline is superior to bromocriptine (Cabergoline 1mg od for 14 days). Dopamine
agonists should not be given to women with hypertension or pre-eclampsia. Oestrogens
should not be used to suppress lactation [RCOG, 2010].

Thromboprophylaxis

Women should be routinely assessed for thromboprophylaxis as per local protocols and
established guidelines, but IUFD is not a risk factor on its own [RCOG, 2010].

Who should be informed of the stillbirth?

 General Practitioner
 Hospital chaplain
 Social worker
 Public health nurse
 Bereavement officer
 All existing antenatal appointments should be cancelled
Ideally, a telephone call should be made to the GP as soon as reasonable after the
diagnosis of IUFD and after stillbirth - a letter or email from the hospital may not be received
in time prior to a bereaved mother or father presenting to their GP.

Discharge

Before discharge, the woman should be reviewed by a senior obstetrician.

Parents should be provided with written information on supportive care (from support groups
as well as local pregnancy loss services) and contact information for follow-up.

31
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

The chart should be retained in the hospital and safely stored. Results of postmortem
examination and placental pathology, and results of blood tests should be filed in a timely
manner. The chart will be needed for review at the hospital multi-disciplinary meeting and
for perinatal audit, as well as for completion of perinatal death notification forms.

In some units, it is practice to attach a sticker to the chart to indicate that a perinatal death
has occurred and alert staff to the patients‟ history. This is a discreet way of ensuring that
health care professionals who come into contact with the bereaved parents are aware of the
previous stillbirth and treat the couple with sensitivity.

The parents should be aware that a follow-up appointment with the consultant obstetrician
will be arranged and it should be clear who is responsible for making these arrangements.
Subsequent clinic appointments should take place in a quiet and undisturbed location within
the hospital, for example at the end of a gynaecology clinic.

Follow up arrangements are also made with the GP.

Birth registration

Parents are advised on the registration requirements and procedure before discharge.

The medical certificate is an essential requirement but if a postmortem examination is to be

carried out, the medical certificate cannot be completed until those results are available and
this may take several months.

When the parents attend for follow up to receive the results, the medical certificate may then
be completed by the obstetrician and given to the registrar so that the parents may apply for
registration of their stillborn baby.

Burial / Cremation

Parents should be given information regarding burial and cremation and be allowed to make
choices. Some parents will make their own burial arrangements at a family plot or choose
cremation.

If parents are considering a hospital burial they need to be made aware that shared plots
are used, and should be given information on the relevant cemetery. If parents decide on
hospital burial, or cremation, the services of the hospital‟s Undertakers are offered. Written
consent for hospital burial is completed and placed in the chart, while a copy is also given to
the parents. Local guidelines apply regarding this process.

Pastoral Care is offered to all families by the Hospital Chaplains. Parents are offered a
Religious Service in conjunction with the Hospital Chaplain or their chosen Religious
Leader, which the Chaplain will assist in facilitating.

32
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.6 Supportive Care

Ideally, a bereavement officer / team should be appointed to coordinate services for parents
who have experienced an IUFD. The midwife caring for the parents should link with
appropriate services including Funeral Director, Chaplain, bereavement and loss officer /
team.

Parents should be invited to meet with Chaplain or their chosen religious leader.

Staff should gently support parents‟ wishes in having contact with their stillborn baby.

Parents are to be supported in parenting their baby, e.g. holding, dressing, bathing, and
getting to know their baby.

Parents should be helped to retain artefacts of remembrance.

Maternity units should have facilities for producing photographs, palm and foot prints and
locks of hair with presentation frames.

Photographs are precious to bereaved parents, especially those taken soon after birth.
Guidance on taking pictures at this difficult time is available from support groups.

Footprints, handprints and lock of hair (if available) are then taken for a memories booklet,
with the parents‟ consent.

Counselling should be offered to all women and partners. Other family members should be
considered for counselling. Posttraumatic stress disorder is prevalent in parents in this
situation. Perinatal death is also associated with increased rates of admission with post-
natal depression. Women with poor social support are particularly vulnerable. Parental
relations have a 40% higher risk of dissolving after stillbirth compared with a live birth.

Parents should be advised about local and national support groups (e.g. A Little Lifetime
Foundation, Feileacain, etc.).

Finally, excellence in clinical care needs to be matched with the same attention to emotional
support. Ancillary guidelines for staff in appropriately communicating with bereaved parents
are available [SANDS, 2007].

33
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.7 Follow up

It has been shown that parents value [Badenhorst and Hughes, 2007]:

 Efforts to find out how they are coping

 Full and frank information given sensitively to enable them to build up a cohesive picture
of what happened and assess their future options.
 Reassurance where possible.

A follow-up appointment with the consultant obstetrician should be organised when results
of postmortem tests are available.

Parents should have an appropriate contact number for the obstetric team during this time.
The parents need to be reassured that they can make contact at any time.

At follow-up, parents should be advised about the cause of late IUFD, chance of recurrence
and any specific means of preventing further pregnancy loss.

General pre-pregnancy advice should also be included in the consultation: smoking

cessation, weight loss as appropriate, pre-conceptual folic acid therapy.

Support services including pastoral care and bereavement counselling should also be
offered. Parents may choose to make contact with these services at their discretion over
time.

Mothers who suffer perinatal death may not have the same access to routine care where
they can discuss their physical needs in the postnatal period. Close liaison between
hospital, general practice and support services is important. Relevant issues of care include
suppression of lactation, contraception, gynaecological complications and sexual difficulties
[Badenhorst and Hughes, 2007].

34
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.8 Pregnancy after stillbirth

Recurrence of stillbirth

In Ireland in 2008, 98.3% of total births to multiparous women recorded no previous

stillbirths – but 1.7% recorded at least at 1 previous stillbirth, consistent with data from other
years [ESRI 2010].

Small studies have shown no difference in stillbirth recurrence, but a large retrospective
study of 947 women and 261384 controls showed that women with a history of stillbirth (but
otherwise low-risk) had a 12-fold increased risk of intra-partum stillbirth (95% CI 4.5–33.7)
[Sharma et al., 2007]. A study that compared outcomes in the second pregnancy for 364
women with previous stillbirth versus 33 715 with previous live birth showed an increased
risk of pre-eclampsia (OR 3.1, 95% CI 1.7–5.7) and placental abruption (OR 9.4, 95% CI
4.5–19.7) [Black et al., 2008].

The ACOG Practice Bulletin reports the risk of recurrent stillbirth after 20 weeks of gestation
as 7.8 to 10.5 per 1000 births. Most of this risk occurs before 37 weeks of gestation.
However, the risk for subsequent stillbirth for women with a previous live born, growth-
restricted infant delivered before 32 weeks of gestation is double the risk for women with a
previous stillbirth [ACOG, 2009].

An observational study of 316 consecutive pregnancies in women with a history of

unexplained stillbirth revealed a rate of gestational diabetes four times higher than expected
[Robson et al., 2001]. A significant proportion of unexplained IUFDs are reclassified as fetal
growth restriction when customised charts and different classification systems are used
[Gardosi et al., 2005].

Management of pregnancy after stillbirth

The history of stillbirth should be clearly marked in the case record and caregivers should
ensure they read all the previous notes thoroughly before seeing the woman at the booking
visit.

Women with this history should attend a consultant-led hospital-based antenatal clinic -
[RCOG, 2010] and should have early access to combined antenatal care [Monari and
Facchinetti, 2009].

Women should be advised about smoking cessation; ceasing smoking in the first trimester
seems sufficient to reduce the risk of stillbirth [Monari and Facchinetti, 2009].

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 (e.g. 4 weekly from 24 weeks) [Monari and
Facchinetti, 2009].

Screening should be carried out for gestational diabetes [Monari and Facchinetti, 2009].
Maternal request for scheduled birth should take into account the gestational age of the
previous IUFD, previous intra-partum history and the safety of induction of labour.

35
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Caregivers should be vigilant for postpartum depression in women with a previous IUFD.
The birth of a healthy baby does not compensate for a previous loss and can trigger a
resurgence of grief.

Carers should be aware that maternal bonding in a pregnancy after stillbirth could be
adversely affected. Depression in the third trimester is highly predictive of depression one
year after subsequent birth, particularly for women who conceive within less than 12 months
from an IUFD. Unresolved maternal grief may result in disorganisation of attachment with
future babies [Badenhorst and Hughes, 2007].

36
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.9 Perinatal Death Notification Form

From 2011, perinatal death notification forms should be completed for all cases of stillbirth
[Appendix 5]. These should be filled out using the information available in the maternity
case notes, the postmortem report and the placental histology report, and submitted
(electronically) to the National Perinatal Epidemiology Centre (NPEC).

Queries regarding the Perinatal Death Notification Form should be addressed to NPEC:-

Tel: (0) 21 4205017

Fax: (0) 21 4205025
E-mail: npec@ucc.ie

37
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.10 Legal requirements, Registration and the Role of the Coroner

The legal definition of stillbirth is “any child expelled or issued forth from its mother after the
24th week of pregnancy that did not breathe or show any signs of life”.

Fetal deaths delivered later than 24 weeks that had clearly occurred before the end of the
24th week do not have to be certified or registered.

A Coroner must be contacted if there is a doubt about the status of the birth [Coroners Acts
1962 and 2005].

The relevant authorities should be contacted if there is a suspicion of deliberate action to

cause stillbirth.

The parents are responsible in law for registering the birth but can delegate the task to a
healthcare professional.

Stillbirths Registration Act (1994)

This Act applies in relation to a child born weighing 500 grammes or more or having a
gestational age of 24 weeks or more who shows no sign of life.

The functions of an tArd-Chláraitheoir, superintendent-registrars and registrars under the

Births and Deaths Registration Acts, 1863 to 1987, include the registration of stillbirths.

Each Registrar is obliged to establish and maintain a register of stillbirths.

The Information recorded in the register is set out as follows:-

 Date and Place of Birth.

 Sex of Child
 Weight.
 Gestational Age
 Forename and Surname of Child.
 Mother's Forename and Surname, Address and Occupation.
 Any former Surname(s) of Mother.
 Father's Forename and Surname, Address and Occupation.
 Any former Surname(s) of Father.
 Signature, Qualification and Address of Informant.
 When Registered.

The Act sets out the legal requirements for notification and registration of stillbirths:-

 The mother or the father of a stillborn child may, within forty-two days after the birth, give
the registrar of the district in which the stillbirth occurred the information specified and
sign the register in the presence of the registrar, and the registrar shall register the
stillbirth accordingly and sign the register.
 The required particulars shall comprise the details indicated in the Schedule to this Act
and a medical certificate signed by a registered medical practitioner, who has attended

38
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

the birth or has examined the child, stating, in the opinion of the medical practitioner, the
weight and gestational age of the child and naming, where applicable, the hospital in
which the birth occurred or which had care of the mother following the birth.

 Where the registration takes place as the result of particulars provided by the mother or
the father of the child, the registrar shall, within two weeks of registration, notify the
hospital named in the certificate or the medical practitioner who signed it, where no
hospital is named, that such registration has taken place.

 Where no such notification is received by the hospital or by the medical practitioner

within three months of the stillbirth, it shall be the duty of the hospital (by an authorised
member of its staff) or, where no hospital is involved, of the medical practitioner who
attended the birth or examined the child to give to the registrar within four months of the
stillbirth, the required particulars of the stillbirth and sign the register in the presence of
the registrar, and the registrar shall register the stillbirth accordingly and sign the
register.

 A medical practitioner who attends a stillbirth or examines the child shall provide the
required medical certificate to the mother or the father of the stillborn child, where either
parent expresses a wish to inform the registrar of a stillbirth.

 Where a medical certificate is provided to the mother or the father of the child and the
hospital or the medical practitioner is not notified that registration has taken place as the
result of information given to the registrar by the parents, a duplicate of that certificate
may be used for registration purposes.

 If the medical practitioner is not fully satisfied that the birth was a stillbirth, the medical
practitioner shall refer the matter to the Coroner.

 If, in the course of duty, a Coroner finds that a body is that of a stillborn child, the
Coroner shall, within one month of so finding, notify the registrar of the details, so far as
the Coroner can ascertain them, of the stillbirth indicated in the Schedule, and the
registrar shall register the stillbirth accordingly and sign the register.

Coroner’s post-mortem examination

A Coroner in Ireland is an independent office holder charged with the legal responsibility
[Coroners Acts 1962 and 2005] for the investigation of sudden, unexplained, violent and
unnatural deaths in his or her district. This may require a post mortem examination,
sometimes followed by an inquest.

A Coroner‟s postmortem examination is compulsory under the law and consent is not
required. Parents should therefore not be approached for consent.

The postmortem is carried out by a pathologist, who acts as the Coroner's agent for this
purpose. Pathologists and /or facilities at hospitals operated or funded by the HSE may be
used for the purpose of Coroners‟ post mortems. Coroners are entitled and obliged by law
to direct the retention of organs and ante-mortem samples in the context of establishing the
cause of death.

39
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

No doctor may certify a death which is due directly or indirectly to any unnatural cause. The
Coroner's inquiry is concerned with establishing whether or not the death was due to natural
or unnatural causes. The general rule is that all sudden, unexplained, violent deaths and
any death which is due directly or indirectly to any unnatural cause must be reported to the
Coroner. If a doctor has any doubt in the matter, he or she should contact the District
Coroner.

The Dublin City Coroner has also determined that the following deaths are reportable by
Maternity Hospitals in Dublin City. Local requirements should be ascertained by other
hospitals by contacting the Coroner for the district in which the hospital or institution is
located [Code of Practice for Postmortem Services, 2010].

 All maternal deaths

 Infant death occurring as either stillbirth / intrapartum / neonatal / post- neonatal
death where any of the following arise:
o Questions of criminal offence
o Concealment of birth
o Want of attention at birth / possible infanticide
o Procured abortion
 Trauma (accidental / non-accidental)
 Allegation of malpractice (which may have contributed to the cause of death) or any
concerns relating to death
 Certain stillbirths (where the medical practitioner is not fully satisfied that the birth
was a stillbirth or there are any other concerns)
 Certain deaths in hospital
o Post diagnostic/therapeutic/instrumental procedure (where the procedure may
be a factor in the causation of death.)
o Adverse drug reaction
o Certain healthcare acquired infections
 Maternal drug addiction (that may have contributed to death)
 Unnatural death (antepartum, intrapartum, neonatal, post neonatal)
 Domiciliary delivery

40
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.11 Clinical Governance

Maternity units should be aware of specific standards for diagnosis, management,

investigation and follow-up of cases of IUFD / stillbirth

Standardised checklists are recommended to ensure that all appropriate care options are
offered and that each response mark is recorded. An example is shown in Appendix 6.

Parents should be provided with written information leaflets on the following issues:-
 Postmortem examination
 Expectations for physical recovery
 Lactation suppression
 Birth registration
 Details of local and national support groups
 Plan for follow-up
Consent for postmortem examination should be documented using the nationally
recommended form.

A standardised dataset should be collected for all stillbirths.

Perinatal death notification forms should be completed for all cases of stillbirth and cases
reported to the National Perinatal Epidemiology Centre.

All stillbirths should be reviewed in a multi-professional meeting using a standardised

approach to analysis for substandard care and means of future prevention.

All term intra-partum deaths with no evidence of a major congenital anomaly should be fully
investigated locally with a view to identifying whether there were avoidable factors and to
identify any areas where future care can be improved. The rate of intrapartum fetal death is
a perinatal outcome, which is particularly sensitive to the standard of intrapartum
management [Walsh et al., 2008].

Staff working with bereaved parents should be provided with an opportunity to develop their
knowledge and understanding of perinatal loss, together with development of skills in
working in this area.

A system should be in place to give clinical and psychological support for staff involved with
an IUFD.

Perinatal Audit

Perinatal audit has been described as: “The systematic, critical analysis of the quality of
perinatal care, including the procedures used for diagnosis and treatment, the use of
resources and the resultant outcome and quality of life for women and their babies”
[Flennady et al., 2011].

Although high-level evidence is not available, a review of before-and-after studies in low-

income and middle-income countries showed a 30% reduction in perinatal mortality

41
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

associated with the introduction of perinatal audit [Pattinson et al., 2005]. Studies in high-
income countries also indicate benefit.

The Lancet‟s Stillbirths Series steering committee [Flenady et al., 2011] recommended
these essentials for high quality perinatal audit:-

• Complete registration and comprehensive documentation for each stillbirth

• Allocated motivated multidisciplinary personnel
• Training in audit methodology and communication skills for participants
• An independent chairperson
• Analysis of what went well
• Analysis of what should have been done differently
• Analysis of the substandard care factor
• Definition of improvements in care that need to be made
• Implementation of improvements
• Checking that change has occurred
• Keeping the goal in mind: to improve the quality of care

42
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

6.12 Future Research

The RCOG Green-top guideline No.55 lists recommendations for future research:

 The optimal system for classification of stillbirth.

 Safety and efficacy of methods for induction of labour with a previous caesarean section.
 The optimal dose of misoprostol for induction of labour according to gestational age.
 The diagnostic power and accuracy of MRI for postmortem investigation.
 The optimal psychological care of women and their partners.
 A comparison of hospital and home follow-up appointments.

The Lancet‟s Stillbirths Series steering committee [Flenady et al., 2011] lists stillbirth
research priorities in discovery science, epidemiology, and development and delivery:

Research priorities in discovery science

 The effects of peri-conceptual environment, including nutrition and micronutrient status,

on embryonic development
 Development of repositories of well phenotyped human samples from stillbirths or other
related conditions and matched controls, with clear arrangements for access, and
appropriate ethical and other legal permissions in place
 Characterising the fetal response to an adverse intrauterine environment to develop
improved means of clinical assessment of fetal wellbeing
 Defining pathophysiological pathways leading to stillbirth associated with maternal
disease, in particular type 1 and type 2 diabetes mellitus
 Defining pathophysiological pathways leading to increased rates of growth restriction
and decreased rates of pre-eclampsia among smokers
 Development of improved statistical, biometric, and bioinformatic technologies for data
interpretation and clinical prediction of outcome
 The effect of maternal obesity, with or without insulin resistance, on fetal and placental
development
 The role of normal and abnormal coagulation in normal and abnormal pregnancy
 Understanding the fetal or placental function and control of the timing of parturition in
post-dates pregnancy
 Discovery-based analysis (expression array or high throughput sequencing, proteomics,
and metabolomics) of samples from well characterised complicated pregnancies and
matched control
Research priorities in epidemiology

 What factors contribute to the excess in stillbirth rates in minority populations?

 What maternal lifestyle consumptions (caffeine, alcohol, cannabis) are associated with
stillbirth and what are their relation with other relevant disorders and causes of stillbirth?
 What care factors relating to health-care professional practice, care setting, and the
mother and family are associated with potentially avoidable stillbirth?
 How relevant is antenatal detection of fetal growth restriction to the prevention of
stillbirth?
 What is the contribution of other maternal bacterial infections in pregnancy (e.g., group B
streptococcal infection, bacterial vaginosis) to stillbirth?

43
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

 What is the optimum investigation protocol for stillbirth to identify causes and relevant
conditions in terms of yield, utility, and costs?
 What approaches can be used to enhance accuracy of data on stillbirth rates using
existing health systems datasets?
 What is the optimum model for clinical perinatal mortality audit and how can this be
implemented on a population-based scale?
 Can a universal shortlist of less than ten categories of cause of stillbirth be used while
linking to the present complex systems for stillbirth cause-of-death classification in high
income countries? Would such a classification system meet the needs for comparability
globally and still be useful for surveillance and public health decision-making in varying
settings?
 What factors affect under-reporting of stillbirth in disadvantaged communities and can
these be reduced?
Research priorities in development and delivery

 How can smoking cessation programmes be most effectively implemented as part of

routine antenatal care?
 In pregnancies with established intrauterine growth restriction, what is the optimum
mode and timing of birth to reduce stillbirth and neonatal and infant mortality and severe
morbidity?
 In high-risk pregnancies, does fetal umbilical artery Doppler ultrasound reduce the risk of
stillbirth, neonatal and infant mortality, and major morbidity?
 What is the role of fetal growth monitoring with growth curves adjusted according to
individual characteristics in detection of abnormalities in fetal growth and reduction of
stillbirth, neonatal and infant mortality, and morbidity; and which characteristics, if any,
result in optimal performance of such an approach?
 For disadvantaged populations, how can access to optimum antepartum and birthing
care be improved?
 How can perinatal audit and facility quality improvement be most effectively undertaken
to reduce stillbirth rates?
 What is the role of screening in early pregnancy with markers of placental function in
reduction of the risk of stillbirth, neonatal and infant death, and major morbidity?
 For women who report decreased fetal movements, what is the optimum management to
reduce the risk of stillbirth in term and preterm pregnancies?
 What characteristics of antenatal care are associated with a reduction in the risk of
stillbirth?
 In pregnancies with impaired fetal growth, what regimens of fetal surveillance are
associated with a reduction in adverse pregnancy outcome including stillbirth, neonatal
and infant mortality, and major morbidity?

44
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

7 Key performance indicators

1. Completion of investigations for the cause of late IUFD

2. Proportion of parents offered postmortem examination

3. Proportion of parents declining postmortem who were offered alternative tests

4. Proportion of parents who have postmortem consent undertaken by an appropriately

trained senior obstetrician

5. Proportion of women offered follow-up with a senior obstetrician

6. Proportion of women and families offered counselling follow-up

45
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

8. References and Recommended Reading

Reports, Policies & Guidelines

1. Best Practice Guidance for the care of a family when their baby or child dies in the Neo-
natal, Paediatric or the Accident and Emergency Units. Child Bereavement Trust, UK,
2000
2. Code of Practice for Postmortem Services. Health Service Executive 2010.
3. Fetal and perinatal pathology. Report of a Joint Working Party. Royal College of
Obstetricians and Gynaecologists and Royal College of Pathologists. London: RCOG
Press; 2001
4. Grief Counselling and grief therapy: a handbook for the mental health practitioner.
Worden, JW (2003) 3rd Edition, Guilford Press, New York.
5. Guidelines for Investigating Stillbirths. An update of a systematic review. Journal of
Obstetrics and Gynaecology Canada; 2007
6. Investigation and Assessment of Stillbirths. British Colombia Reproductive Care
Program: Perinatal Mortality Guideline 5. 2000
7. Late Intrauterine and fetal death. Green-top Guideline No.55. Royal College of
Obstetricians and Gynaecologists; 2010
8. Management of Stillbirth. National Guideline Clearinghouse. American College of
Obstetricians and Gynaecologists; 2009.
9. National Collaborating Centre for Women‟s and Children‟s Health. Clinical guideline:
Caesarean section. London: RCOG Press; 2004.
10. National Institute for Health and Clinical Excellence. Clinical guideline no.70: Induction of
labour. London: National Institute for Health and Clinical Excellence; 2008.
11. Perinatal Mortality 2009. Centre for Maternal and Child Enquiries (CMACE): United
Kingdom. CMACE: London, 2011.
12. Perinatal Statistics Report. Health Research and Information Division, ESRI, December
2010
13. Policy and procedure on caring for and supporting parents experiencing an intra-uterine
death or stillbirth in Cork University Maternity Hospital. Miscarriage, Stillbirth and
Neonatal Death Committee, CUMH, 2011
14. Pregnancy Loss and the Death of a Baby. Guidelines for professionals. Schott J, Henley
A, Kohner N. 3rd ed. London: Bosun Press, on behalf of SANDS; 2007.
15. PSANZ Clinical Practice Guideline for Perinatal Mortality. Perinatal Society of Australia
and New Zealand – Perinatal Mortality Special Interest Group; 2009
16. Report of Dr. Deirdre Madden on Post Mortem Practice and Procedures. Dublin, 2006
17. Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 45: Birth
after previous caesarean birth. London: RCOG; 2007
18. Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 43:
Obstetric Cholestasis. London: RCOG; 2011
19. SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean
birth. Society of Obstetricians and Gynaecologists of Canada. Number 155, February
2005. Int J Gynaecol Obstet 2005; 89:319–31.
20. Stillbirth and Bereavement: Guidelines for Stillbirth Investigation. Society of Obstetricians
and Gynaecologists Canada - Clinical Practice Guidelines; 2006
21. Stillbirths Registration Act, 1994

46
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

22. Wisconsin Stillbirth Service Program UoW. Guide to etiologic evaluation of the stillborn
infant: The WiSSP Protocol. Wisconsin: Wisconsin Stillbirth Service Program; 2004.

Peer-reviewed articles

1. Aberg A, Rydhström H, Källén B, Källén K. Impaired glucose tolerance during pregnancy

is associated with increased fetal mortality in preceding sibs. Acta Obstet Gynecol
Scand 1997;76:212–7.
2. Ahlenius I, Floberg J, Thomassen P. Sixty-six cases of intrauterine fetal death. A
prospective study with an extensive test protocol. Acta Obstet Gynecol Scand.
1995;74(2):109-17.
3. Alfirevic Z, Roberts D, Martlew V. How strong is the association between maternal
thrombophilia and adverse pregnancy outcome? A systematic review. Eur J Obstet
Gynecol Reprod Biol 2002;101:6–14.
4. Alonso A, Soto I, Urgelles MF, Corte JR, Rodriguez MJ, Pinto CR. Acquired and
inherited thrombophilia in women with unexplained fetal losses. Am J Obstet Gynecol.
2002 Nov;187(5):1337-42.
5. Badenhorst W and Hughes P. Psychological aspects of perinatal loss. Best Pract Res
Clin Obstet Gynaecol 2007; 21 (2): 249-259
6. Benhadi N, Wiersinga WM, Reitsma JB, Vrijkotte TG, Bonsel GJ: Higher maternal TSH
levels in pregnancy are associated with increased risk for miscarriage, fetal or neonatal
death. Eur J Endocrinol 2009, 160(6):985-991.
7. Biankin SA, Arbuckle SM, Graf NS. Autopsy findings in a series of five cases of
fetomaternal haemorrhages. Pathology 2003;35:319–24
8. Black M, Shetty A, Bhattacharya S. Obstetric outcomes subsequent to intrauterine death
in the first pregnancy. BJOG 2008;115:269–74.
9. Cohen MC, Paley MN, Griffiths PD, Whitby EH. Less invasive autopsy: benefits and
limitations of the use of magnetic resonance imaging in the perinatal postmortem.
Pediatr Dev Pathol 2008;11:1–9.
10. Corabian P, Scott NA, Lane C, Guyon G. Guidelines for investigating stillbirth: an update
of a systematic review. J Obstet Gynaecol Can 2007; Jul; 29(7): 560-7
11. Corbet-Owen C and Kruger M. The health system and emotional care: validating the
many meanings of spontaneous pregnancy loss. Families, Systems and Health 2001; 19
:411-427
12. Cundy T, Gamble G, Townend K, Henley PG, MacPherson P, Roberts AB. Perinatal
mortality in Type 2 diabetes mellitus. Diabet Med. 2000 Jan;17(1):33-9.
13. Dirnhofer R, Jackowski C, Vock P, Potter K, Thali M. Virtopsy: Minimally Invasive,
Imaging-guided virtual autopsy. Radiographics 2006; 26: 1305-1333
14. Dodd JM, Crowther CA. Misoprostol for induction of labour to terminate pregnancy in the
second or third trimester for women with a fetal anomaly or after intrauterine fetal death.
Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD004901.
15. Dudding TE, Attia J. The association between adverse pregnancy outcomes and
maternal factor V Leiden genotype: a meta-analysis. Thromb Haemost. 2004
Apr;91(4):700-11.
16. Engel PJ, Smith R, Brinsmead MW, Bowe SJ, Clifton VL. Male sex and pre-existing
diabetes are independent risk factors for stillbirth. Aust N Z J Obstet Gynaecol
2008;48:375–83
17. Feki M, Omar S, Menif O, Tanfous NB, Slimane H, Zouari F, et al. Thyroid disorders in
pregnancy: frequency and association with selected diseases and obstetrical
complications in Tunisian women. Clin Biochem. 2008 Aug;41(12):927-31.

47
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

18. Fish W. Differences in grief intensity in bereaved parents. Champaigne, IL: Research
Press Company, 1986.
19. Fisk NM, Storey GN. Fetal outcome in obstetric cholestasis. Br J Obstet Gynaecol. 1988
Nov;95(11):1137-43.
20. Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY et al. Stillbirths: the
way forward in high income countries. Lancet 2011; published online April 14
21. Flenady V, Wilson T. Support for mothers, fathers and families after perinatal death.
Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000452.
22. Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol 2005: 193: 1923-35
23. Gardosi J, Kady SM, McGeown P, Francis A,Tonks A. Classification of stillbirth by
relevant condition at death (ReCoDe): population based cohort study. BMJ
2005;331:1113–7.
24. Genest DR, Singer DB. Estimating the time of death in stillborn fetuses: III. External fetal
examination; a study of 86 stillborns. Obstet Gynecol 1992;80:593–600
25. Genest DR. Estimating the time of death in stillborn fetuses: II. Histologic evaluation of
the placenta; a study of 71 stillborns. Obstet Gynecol 1992;80:585–92.
26. Goldenberg RL, Thompson C. The infectious origins of stillbirth. Am J Obstet Gynecol.
2003 Sep;189(3):861-73.
27. Gómez Ponce de León R,Wing D, Fiala C. Misoprostol for intrauterine fetal death. Int J
Gynaecol Obstet 2007;99 Suppl 2:S190–S193.
28. Gordijin SJ, Erwich JJ, Khong TY. The value of perinatal autopsy: critique. Pediatr Dev
Pathol 2002; 5: 480-6
29. Griffiths PD, Baboonian C. A prospective study of primary cytomegalovirus infection
during pregnancy: final report. Br J Obstet Gynaecol. 1984 Apr;91(4):307-15.
30. Griffiths PD, Paley MN, Whitby EH. Postmortem MRI as an adjunct to fetal or neonatal
autopsy. Lancet 2005; 365 (9466): 1271-3
31. Heazell AE, Martindale EA. Can postmortem examination of the placenta help determine
the cause of stillbirth? J Obstet Gynaecol 2009;29:225–8.
32. Hughes P, Riches S. Psychological aspects of perinatal loss. Current Opinion in
Obstetrics and Gynecology 2003;15:107–11.
33. Jansen Lachine J. Bereavement Model for the Intensive Care Nursery. Neo-natal
Network 2003; Vol 22 (3): 17-23.
34. Jones S, Athan E, Viggers J. Prevention of recurrent fetal death in utero due to group B
streptococcal chorioamnionitis. Aust N Z J Obstet Gynaecol. 2004 Aug;44(4):356-7.
35. Kennell JH, Slyter J, Klaus MH. The mourning responses of parents to the death of a
newborn infant. New England Journal of Medicine 1970; 283:344–9
36. Khare M, Howarth E, Sadler J, Healey K, Konje JC.A comparison of prenatal versus
postnatal karyotyping for the investigation of intrauterine fetal death after the first
trimester of pregnancy. Prenat Diagn 2005;25:1192–5.
37. Laube DW, Schauberger CW. Fetomaternal bleeding as a cause for "unexplained" fetal
death. Obstet Gynecol. 1982;60(5):649-51.
38. Leon, IG. Perinatal loss: A critique of current hospital practices. Clinical Paediatrician
1992; Vol 31, 366-374.
39. Lutiger B, Graham K, Einarson TR, Koren G. Relationship between gestational cocaine
use and pregnancy outcome: a meta-analysis. Teratology 1991;44:405–14.
40. Magee JF. Investigation of Stillbirth. Pediatric and Developmental Pathology 2001; 4 (1):
1-22
41. McCreight BS. Perinatal loss: a qualitative study in Northern Ireland. Omega (Westport)
2008; 57:1–19.

48
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

42. McDonald HM, Chambers HM. Intrauterine infection and spontaneous midgestation
abortion: is the spectrum of microorganisms similar to that in preterm labor? Infect Dis
Obstet Gynecol. 2000;8(5- 6):220-7.
43. McLintock C, North R, Dekker G. Inherited thrombophilias: Implications for pregnacy
associated venous thromboembolism and obstetric complications. Curr Probl Obstet
Gynecol Fertili. 2001 July/August 2001:115-49.
44. Moise K. Hemolytic disease of the fetus and newborn. In: Creasy RK, Resnik R, editors.
Maternal- Fetal Medicine: Principles and Practice. 5th Edition ed. Philidelphia: Saunders;
2004. p. 537-61.
45. Monari F and Facchinetti F. Management of subsequent pregnancy after antepartum
stillbirth; a review. J Matern Fet Neonat Med 2010; 23 (10): 1073-84
46. Moyo SR, Hägerstrand I, Nyström L,Tswana SA, Blomberg J, Bergström S, et al.
Stillbirths and intrauterine infection, histologic chorioamnionitis and microbiological
findings. Int J Gynaecol Obstet 1996;54:115–23.
47. Neiger R, Croom CS. Cytogenetic study of amniotic fluid in the evaluation of fetal death.
J Perinatol. 1990 Mar;10(1):32-4.
48. O'Donoghue K, et al. Investigation of the role of computed tomography as an adjunct to
autopsy in the evaluation of stillbirth. Eur J Radiol. 2011 Apr 29. [Epub ahead of print]
49. Parasnis H, Raje B, Hinduja IN. Relevance of plasma fibrinogen estimation in obstetric
complications. J Postgrad Med 1992;38:183–5.
50. Pattinson RC, Say L, Makin JD, Bastos MH. Critical incident audit and feedback to
improve perinatal and maternal mortality and morbidity. Cochrane Database Syst Rev
2005; 4: CD002961.
51. Rayburn W, Sander C, Barr M, Rygiel R. The stillborn fetus: placental histologic
examination in determining a cause. Obstet Gynecol 1985; 65:637–640
52. Redman CW, Beilin LJ, Bonnar J, Wilkinson RH. Plasma-urate measurements in
predicting fetal death in hypertensive pregnancy. Lancet. 1976 Jun 26;1(7974):1370-3.
53. Rey E, Kahn SR, David M, Shrier I. Thrombophilic disorders and fetal loss: a meta-
analysis. Lancet. 2003 Mar 15;361(9361):901-8. 61.
54. Robson S, Chan A, Keane RJ, Luke CG. Subsequent birth outcomes after an
unexplained stillbirth: preliminary population-based retrospective cohort study. Aus N Z J
Obstet Gynaecol 2001;41:29–35.
55. Saade GR, McLintock C. Inherited thrombophilia and stillbirth. Semin Perinatol 2002
Feb;26(1):51-69.
56. Saal HM, Rodis J, Weinbaum PJ, DiMaggio R, Landrey TM. Cytogenetic evaluation of
fetal death: the role of amniocentesis. Obstet Gynecol 1987;70:601–3.
57. Schreck RR, Falik-Borenstein Z, Hirata G. Chromosomal mosaicism in chorionic villus
sampling. Clin Perinatol 1990;17:867–88.
58. Sharma PP, Salihu HM, Kirby RS. Stillbirth recurrence in a population of relatively low-
risk mothers. Paediatr Perinat Epidemiol 2007;21 Suppl 1:24–30.
59. Sikkema-Raddatz B, Bouman K,Verschuuren-Bemelmans CC, Stoepker M, Mantingh A,
Beekhuis JR, et al. Four years‟ cytogenetic experience with the culture of chorionic villi.
Prenat Diagn 2000; 20: 950–5.
60. Silver RM, Varner MW, Reddy U, Goldenbery R, Pinar H, Conway D et al. Work-up of
stillbirth: a review of the evidence. Am J Obstet Gynecol 2007; 5: 433-44
61. Smith A, Bannatyne P, Russell P, Ellwood D, den Dulk G. Cytogenetic studies in
perinatal death. Aust N Z J Obstet Gynaecol 1990; 30: 206–10.
62. Smith GCS and Fretts RC. Stillbirth. Lancet 2007; 370: 1715-1725
63. Stanton C, Lawn JE, Rahman H, Wilczynka-Ketende K, Hill K. Stillbirth rates: delivering
estimates in 190 countries. Lancet 2006; 367: 1487-94.

49
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

64. Steel A, Fakokunde A and Yoong W. Management of complicated second stage of

labour in stillbirths: review of the literature and lessons learnt. J Obstet Gynaecol 2009;
29 (6): 464-66
65. Stock SJ, Goldsmith L, Evans MJ and Laing IA. Interventions to improve rates of post-
mortem examination after stillbirth. Eur J Obstet Gynecol 2010; 153: 148-150
66. Tolfvenstam T, Papadogiannakis N, Norbeck O, Petersson K, Broliden K. Frequency of
human parvovirus B19 infection in intrauterine fetal death. Lancet 2001; 357:1494–7.
67. Trulsson, O, Radestad, I. The silent child- mothers experiences before during and after
stillbirth, Birth 2004; 31(3) 189-195.
68. Wagaarachchi PT,Ashok PW, Narvekar NN, Smith NC, Templeton A. Medical
management of late intrauterine death using a combination of mifepristone and
misoprostol. Br J Obstet Gynaecol 2002; 109: 443–7.
69. Walsh CA, McMenamin MB, Foley ME, Daly SF, Robson MS, Geary MP. Trends in
intrapartum fetal death, 1979-2003. Am J Obstet Gynecol 2008; 198:47.e1-47.e7
70. Weiner CP. Fetal Death. In: James DK, Steer PJ, Weiner CP, Gonik B editor(s). High
risk pregnancy management options. Second Edition. London: WB Saunders, 1999.
71. Wright C, Hinchliffe SA, Taylor C. Fetal pathology in intrauterine death due to parvovirus
B19 infection. Br J Obstet Gynaecol. 1996 Feb; 103 (2) :133-6.

50
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

9. Useful resources
A Little Lifetime Foundation

A Little Lifetime Foundation (formerly ISands), providing information and support to

bereaved parents and families since 1983. Working with Health Care Professionals and
Others to develop good practices in the area of Infant death. A Little Lifetime Foundation is
a registered charity with support and services provided by volunteers.
Website: www.isands.ie

Féileacáin

Féileacáin (Stillbirth and Neonatal Death Association of Ireland – SANDAI) is a newly

formed organisation (charitable status pending) that aims to offer support to anyone affected
by the death of a baby during pregnancy or shortly after. The organisation was formed by a
group of bereaved parents who have now come together to formally offer support to other
parents and families who find themselves in a similar situation.
Website: www.feileacain.ie

Stillbirth and Neonatal Death Society (SANDS)

The UK Stillbirth and Neonatal Death Charity, established by bereaved parents in 1981. The
core aims are (1) To support anyone affected by the death of a baby; (2) To work in
partnership with health professionals to improve the quality of care and services offered to
bereaved families; and (3) To promote research and changes in practice that could help to
reduce the loss of babies' lives.
Website: www.uk-sands.org

Child Bereavement Trust (CBT)

The UK‟s leading charity that supports families and educates professionals, both when a
child dies and when a child is bereaved.
Website: www.childbereavement.org.uk

International Stillbirth Alliance (ISA)

A non-profit coalition of organizations dedicated to understanding the causes and

prevention of stillbirth. ISA‟s mission raise awareness of stillbirth and to promote global
collaboration in the prevention of stillbirth and provision of appropriate care for parents
whose baby is stillborn.
Website: www.stillbirthalliance.org

51
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

10. Qualifying statements

These guidelines have been prepared to promote and facilitate standardisation and
consistency of practice, using a multidisciplinary approach. Clinical material offered in this
guideline does not replace or remove clinical judgment or the professional care and duty
necessary for each pregnant woman. Clinical care carried out in accordance with this
guideline should be provided within the context of locally available resources and expertise.

This Guideline does not address all elements of standard practice and assumes that
individual clinicians are responsible to:

 Discuss care with women in an environment that is appropriate and which enables
respectful confidential discussion.
 Advise women of their choices and ensure informed consent is obtained.
 Meet all legislative requirements and maintain standards of professional conduct.
 Apply standard precautions and additional precautions as necessary, when delivering
care.
 Document all care in accordance with local and mandatory requirements.

52
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

11. Implementation Strategy

 Distribution of guideline to all members of the Institute and to all maternity units.

 Implementation through the HSE Obstetric and Gynaecological Programme‟s local

implementation boards.

 Distribution to other interested parties, including general practitioners, parent and

support groups, regulatory and educational training bodies.

53
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

12. Appendix List

1. Stillbirth, early neonatal and perinatal mortality rates, Ireland 1999-2008

2. Checklist for investigation of IUFD/ stillbirth
3. Consent to postmortem form
4. Suggested algorithm for induction of labour after IUFD
5. Perinatal death notification manual, NPEC, 2011
6. Checklist for management of IUFD / stillbirth

54
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Appendix 1
Stillbirth, early neonatal and perinatal mortality rates, Ireland 1999-2008
ESRI, 2010

55
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Appendix 2

Algorithm for investigation of stillbirth

Stillbirth

Maternal and family Stillbirth Placental examination

history examination and investigations

Maternal External Cytogenetic Cord

investigations examination investigations examination

Cytogenetic and
Radiological Post-mortem
Microbiology
studies examination
investigations

56
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Appendix 3

57
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

58
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Appendix 4
Medical Induction of labour after IUFD

On the day of diagnosis of IUFD

Mifepristone 200mg PO

36-48 hours after diagnosis

24-34 weeks Misoprostol 200mcg PV followed by 200mcg PO 3 hourly x 4 doses

>34 weeks Misoprostol 100mcg PV followed by 100mcg PO 3 hourly x 4 doses

A second course may be started after 24 hours and with medical review

NB: Particular caution needs to be taken when considering induction of labour in women with a previous
uterine scar.

59
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Appendix 5

60
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

61
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

62
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

Appendix 6

63
CLINICAL PRACTICE GUIDELINE INVESTIGATION AND MANAGEMENT OF LATE FETAL INTRAUTERINE DEATH AND STILLBIRTH

64