Review
Intrauterine fetal death
Farah Siddiqui
Lucy Kean
Abstract
Sadly, the death of a fetus may occur at any stage of a pregnancy, includ-
ing during the labour process. A pregnancy loss will be devastating for
the expectant parents. Obstetricians should be familiar with the manage-
ment of intrauterine fetal death as prompt and appropriate counselling
will aid the couple’s grief process. Understandably, couples wish to know
the cause and chances of recurrence; thus, the full investigation of possi-
ble aetiological factors using a pragmatic approach will help in the post-
natal counselling and management of future pregnancies. This review
also explores the legal and ethical aspects of postmortem consent.
Keywords bereavement; intrauterine fetal death; stillbirth; postmortem;
viral infections are often
Introduction
Many definitions exist for intrauterine fetal death (IUFD); older
definitions use a gestational age of 28 weeks, and the WHO clas-
sification includes a birthweight of greater than 500 g. The legal
definition which is used by the Confidential Enquiry into Mater-
nal and Child Death (CEMACH) is ‘a child that has issued forth
from its mother after the 24th week of pregnancy and which did
not at any time after being completely expelled from its mother
breathe or show any other signs of life’ [Section 41 of the Births
and Deaths Registration Act (1953), as amended by the Stillbirth
Definition Act (1992)]. CEMACH reported the incidence of IUFD
in England and Wales to be 5.3 per 1000 births in 2006.
Mortality in singleton pregnancies has declined from 51.5 per
10 000 births in 1982–1990 to 42.0 in 1991–2000 (RR 0.82, 95%
CI 0.76–0.87). During these periods there was a greater decline
in mortalities from multiple pregnancies, from 197.9 to 128.0 per
10 000 (RR 0.65, 95% CI 0.51–0.83). In singletons, the largest
reductions occurred in intrapartum-related deaths and deaths
due to congenital anomalies, antepartum haemorrhage and pre-
eclampsia. There was little change in the rate of unexplained
antepartum death occurring at term (RR 0.97, 95% CI 0.84–1.11)
or preterm (RR 0.94, 95% CI 0.82–1.07); these account for about
half of all late fetal deaths.
Farah Siddiqui MB ChB DM MRCOG is a Sub Specialty specialist Registrar at
the Fetal and Maternal Medicine, Nottingham NHS trust, City campus,
Nottingham, UK.
Lucy Kean BM BCh DM FRCOG is a Consultant at the Fetal and Maternal
Medicine, Nottingham NHS trust, City campus, Nottingham, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:1
Aetiology
Chromosomal abnormalities
These account for 30−60% of early fetal demise. The incidence
increases with maternal age. Approximately 7% of fetuses with
chromosomal abnormalities will survive to term. The ­commonest
chromosomal abnormality is autosomal trisomy.
Genetic anomalies affect the development of the fetus and the
placenta. One recent study found an increase in apoptosis and a
decrease in cell proliferation in chromosomally abnormal placen-
tae compared to chromosomally normal placentae, implying that
genetic abnormalities can lead to changes that affect trophoblast
development and proliferation.
Karyotype analysis often fails from the placenta, fetal blood
(via an intracardiac sample) and fetal skin post delivery. Where
there are specific concerns, the genetics laboratory may be able
to help with specific diagnoses by utilizing other techniques such
as fluorescent in-situ hybridization. Fetal chondrocytes have
the most prolonged cell viability, and a small sample from the
iliac crest can sometimes provide a diagnosis. Performing a fetal
karyotype by transabdominal chorionic villus sampling before
delivery avoids the problems associated with delay and infec-
tion of the placenta during delivery, although this is often not
­acceptable to the woman.
Fetal structural anomalies
These account for 35% of fetal deaths, and commonly include
cardiac anomalies and renal abnormalities.
Infection
This is a significant risk for the fetus. The infection is often an
ascending bacterial infection, such as Escherichia coli or Group B
streptococcus, which triggers a cytokine cascade leading to fetal
damage, preterm labour and intrauterine fetal death.
Viral infections are often asymptomatic in adults but can be
devastating to the fetus. For example, transplacental transmis-
sion of parvovirus B19 can result in fetal anaemia, hydrops and
fetal death. Parasitic infections such as malaria and toxoplasmo-
sis are also associated with fetal death.
Typically infections are classed as a non recurring cause of
fetal death.
Maternal diabetes
Prior to the introduction of insulin, the life-expectancy of a dia-
betic was short; women who reached childbearing age were faced
with infertility, recurrent miscarriages, congenital malformations
and a stillbirth rate of almost 100%. The introduction of insulin
has increased life-expectancy. However, despite insulin treat-
ment and apparent good glycaemic control, a diabetic pregnancy
is still associated with increased risks to the fetus and newborn
compared to the non-diabetic pregnancy. Spontaneous miscar-
riages may be as high as 17%; congenital malformation rates are
4−10 times greater than in the non-diabetic population; stillbirth
and perinatal mortality rates are five times greater; neonatal and
infant mortality rates are 15 and 3 times greater, respectively.
Gestational diabetes is associated with an increased risk of
fetal death. However, maternal glucose metabolism returns to
normal almost as soon as the fetus dies. Blood sugar estima-
tion is generally unhelpful. Also, as the derangement is generally
 © 2008 Elsevier Ltd. All rights reserved.
 Review
mild, HbA1c measurements are usually normal. Women with
unexplained stillbirth have a four-fold increase in glucose abnor-
malities in subsequent pregnancies. Therefore, if this diagnosis
is suspected, formal glucose testing should be undertaken in the
next pregnancy.
Maternal age
The effect of maternal age on perinatal deaths is described by a
U-shaped curve with the highest death rates in very young and
older mothers. Mothers younger than 20 and those older than
40 have the highest rates of stillbirth (5.6 and 8.1 per 1000 total
births, respectively). The cumulative risk of IUFD at 38 weeks
of gestation in an uncomplicated patient aged 40 or over is simi-
lar to the risk of IUFD at 41 weeks in an uncomplicated patient
younger than age 35. These data raise the suggestion that routine
antenatal testing beginning at maternal age 40 and at 38 weeks’
gestation should be considered.
Maternal body mass index
The CEMACH report of 2006 showed that among the women
who had a stillbirth and a recorded body mass index (BMI), 26%
(761/2924) were obese (BMI> 30). Other studies have demon-
strated that nulliparous women with a BMI greater than 30 have
a four-fold increase in the risk of IUFD compared with women
with a BMI between 20 and 25. This may reflect a higher inci-
dence of hypertensive disease and abnormal glycaemic control
in these women.
Cord complications
A nuchal cord is found in 23% of all deliveries, both live and
stillborn infants. Multiple nuchal loops are found in 3.7% of
stillborns. A pathological examination is important to determine
whether the finding is a postmortem event, as the demised fetus
can become entangled in the cord during delivery. The inci-
dence of true umbilical knots is 1% and is associated with a
mortality rate of 2.7%. Again, the mere presence of knot does
not predict fetal death; if the knot is loose, fetal circulation can
be ­maintained.
Decreased Wharton’s jelly in certain areas of the cord, most
notably the fetal and placental insertions, can result in occlusion
of fetal blood flow if the vessels are twisted sufficiently. It is
vital not to attribute fetal death to a knot or nuchal cord without
postmortem confirmation as this can deny parents knowledge of
the real cause of death.
Placental complications
If the umbilical cord inserts into the placenta abnormally, this
can be associated with fetal death. Marginal insertions are pres-
ent in 5–7% of pregnancies and can lead to fetal death if these
vessels rupture or are compressed. Velamentous insertions,
where the cord inserts into the external membranes of the pla-
centa, are more common in monochorionic twins, but also occur
in 1% of singleton pregnancies. The cord vessels in this case are
not surrounded by Wharton’s jelly and thus are prone to torsion,
rupture (vasa previa) and inflammation if they cross the cervix.
Placental abruption, the premature separation of the placenta
from the uterus, has an incidence of 1% and leads to fetal death
in 0.12%. Symptoms may include bleeding, abdominal pain or
reduced fetal movements. The cause of the abruption is often
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:1
not known; however, risk factors include smoking, cocaine use,
trauma, pre-eclampsia, hypertension, thrombophilia and pro-
longed rupture of membranes.
Thrombophilias
Thrombophilias associated with placental abruption include
factor V Leiden mutations, prothrombin gene mutations, hyper-
homocysteinaemia, activated protein C resistance, antithrombin
III deficiency and anticardiolipin antibodies. These thrombo-
philias are also associated with intrauterine growth restriction
and pre-eclampsia.
Antiphospholipid syndrome can lead to IUFD. There is evi-
dence that low-dose aspirin and low-molecular-weight heparin
improve pregnancy outcome amongst those who present with
recurrent miscarriage. Women with unexplained stillbirth are
also more likely to be heterozygous for factor V Leiden mutation,
and to be protein S or C deficient. Interestingly, these fetuses
may not be growth restricted, although there may be placental
features that point to an underlying thrombophilia.
Obstetric cholestasis
The development of intense pruritis with no rash after 24 weeks’
gestation in association with abnormal liver function tests which
improve after delivery suggests obstetric cholestasis. The condi-
tion is poorly understood although it is associated with a peri-
natal mortality rate (PMNR) which is improving with active
management; from 13.4 in 1984 to 8.4 in 2002. The cause of
the fetal death is thought to be anoxia, possibly related to the
placental passage of bile salts. Fetal assessments with umbilical
artery Doppler and cardiotocography (CTG) are not predictive of
fetal death.
Diagnosis
Women often present with a history of reduced fetal movements.
The absence of a fetal heart beat on auscultation should always
be confirmed by an ultrasound scan by experienced personnel,
which can be challenging, especially if the woman presents in
labour.
On ultrasound examination, a four chamber view of the fetal
heart should be obtained and watched for 1 minute for cardiac
pulsations. Colour flow mapping can be useful in obese women.
At the time of the ultrasound scan, the presence of skin oedema,
hydrops, overlapping of the skull bones (Spalding sign) and the
amount of liquor is useful in determining the timing of death; the
femur length is useful for estimation of the gestation.
Management
Prevention of Rhesus (D) isoimmunization
Changes in the uteroplacental blood flow dynamics rapidly result
in maternal transfusion of fetal blood; thus, Rhesus D-negative
women should be administered anti-D; a Kleihauer test will con-
firm whether a further dosage is required.
Providing choice and establishing safety of the mother
Patient safety should be a prime concern:
• Ensure the maternal blood pressure is not raised and there is
no proteinuria, in order to exclude significant pre-eclampsia;
 © 2008 Elsevier Ltd. All rights reserved.
 Review
• Exclude the possibility of an abruption which is usually pos-
sible from the history and examination;
• When it is thought that the baby died some time prior to pres-
entation (especially over a month), check a clotting screen
to exclude the development of disseminating intravascular
­coagulopathy (DIC).
Once the diagnosis has been confirmed, the woman should
be informed clearly of the fetal death and condolences given.
The woman should be encouraged to notify a friend or relative
for support and given the time to digest the information. If her
partner is present, allowing the couple time to console each other
is important. Once ready, the options for delivery should be dis-
cussed. Overall, 80–90% of patients enter spontaneous labour
within 2 weeks of fetal death. However, if labour is delayed the
risk of developing DIC increases.
How to deliver
After 13 weeks’ gestation, the general advice is to aim for a vagi-
nal delivery, although risk factors in the woman’s medical and
obstetric history should be explored. A common request from
bereaving mothers is for a surgical management either with
a dilatation and evacuation or caesarean section. Both these
methods are associated with significant maternal morbidity and
increased risk of developing DIC. Recent studies suggest that
vaginal delivery is associated with increased acceptance and a
quicker recovery in grief reaction times. However, 10% of term
vaginal deliveries are complicated by perineal, vaginal or cervi-
cal lacerations necessitating surgical repair. Third- and fourth-
degree lacerations are commoner when the fetus weighs over
4 kg, but can be reduced by good management in labour, keeping
the need for assisted delivery to a minimum. These pregnancies
can also be complicated by severe shoulder dystocia. It is impor-
tant to ensure a senior practitioner is present for delivery and, in
a few exceptional circumstances where labour does not progress,
abdominal delivery may be warranted.
Circumstances where a caesarean section is appropriate
include:
• Where there is a high risk of uterine rupture, or suspected scar
dehiscence or failed induction;
• In cases of major placenta previa;
• In women who cannot bear the concept of a vaginal delivery.
Abdominal delivery is associated with a 50% risk of
­endomyometritis.
Delivery
Most units have a dedicated area on the labour ward where these
women are managed, with access to the labour ward if emergency
treatment is required, adequate analgesia and a place where their
partner and relatives can stay. The women should be offered the
choice as to whether to delay treatment or to start it immediately.
Analgesia should be discussed and encouraged; analgesics
such as diamorphine and oromorphine are more effective than
codeine and pethidine. If the clotting is normal, the woman may
wish for an epidural. If an epidural is contraindicated, patient-
controlled analgesia should be considered.
Induction of labour
When planning induction of labour, it is important to remember
that complications such as uterine rupture and shoulder dystocia
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:1
can occur, and management must be safe. Common choices for
induction are:
• prostaglandin E2 preparations/oxytocin;
• mifepristone and misoprostol.
The standard prostaglandin E2 protocols have a good safety
record in relation to uterine rupture. However, mifepristone and
misoprostol have been used to good effect with low complication
rates. The advantage of this second protocol is that the induc-
tion to delivery time is shorter (median: 8.5 h). In order for the
process to work efficiently, mifepristone needs to be given 24–48
h before starting misoprostol. Although this time can be spent at
home, many women do not wish to delay starting, and misopro-
stol alone or prostaglandin E2 may be used, accepting a longer
induction to delivery interval in these women. Extra-amniotic
saline has been shown to be reasonably effective as an alterna-
tive to the above methods.
Other points to bear in mind during delivery are:
• Hyperstimulation is particularly dangerous in women with a
scar on the uterus;
• Membranes should be left intact for as long as possible, as
ascending infection can rapidly occur;
• Postpartum haemorrhage is common, especially with pre-
­eclampsia, abruption, prolonged fetal death or infection;
• Prolonged chorioamnionitis and repeated small abruptions
predispose to retained placenta and occasionally placenta
­accrete;
• There should be a low threshold for antibiotic prophylaxis.
Investigations
The investigations listed in Table 1 should be considered, but
each woman must be individually assessed as not all investiga-
tions will be relevant to her.
Postmortem
The CEMACH reports a decline in the uptake of autopsies, with a
postmortem being performed in only 38% of perinatal deaths in
England and Wales, although there is marked regional variation.
A recent report suggests that a lack of perinatal pathologists is
the main reason that medical teams do not seek consent for post-
mortem. Although seeking consent for postmortem is perceived
as difficult when the couple has just lost a child, valuable infor-
mation may be obtained which would help in the planning of
future pregnancies. A study of 400 stillborn fetuses and infants in
Wales reported that, even when a likely prenatal diagnosis was
reached, the autopsy significantly changed the cause of death in
12% and found new information in 26% of cases.
The recent enquiry into perinatal pathology, including organ
retention, has had an impact on public confidence. This has
increased the need for practitioners to remain regularly updated
on postmortem consent issues and for access to bereavement or
pathology liaison midwives.
Postmortem procedure
It is important to explain to the couple that the postmortem will
be performed by a dedicated perinatal pathologist, and that this
may therefore require the baby being moved to another hospital.
The baby will be returned once the postmortem is complete. The
baby is treated with dignity and respect at all times. Incisions
 © 2008 Elsevier Ltd. All rights reserved.
 Review

Where there is a suspected central nervous system (CNS)

Investigations to consider in the event of fetal death abnormality, the brain should be fixed before examination. This
can take many days, especially in a large, term fetus. If this is an
Investigation To detect important aspect of the postmortem examination, parents have
three options:
Kleihauer Fetal-maternal haemorrhage • To forgo this extra information;
Full blood count with Need baseline in case of • To delay funeral arrangements until this process is complete; or
platelets bleeding; abnormalities point • To allow the pathologist to retain the fetal brain and to proeed
to pre-eclampsia, disseminated with funeral arrangements without the brain being returned.
intravascular coagulation screen
Blood group, antibody screen Isoimmunization Human Tissues Act (2004)
and Coombs’ test In the past fetuses of less than 28 weeks gestation were not rec-
Antinuclear antibody Lupus, other autoimmune ognizable in law and were often disposed of by burial or incin-
disorders eration, even after 28 week when the registration of the stillbirth
Anticardiolipin antibodies Thrombophilia was mandatory, without the involvement of the parents. Since
(IgG, IgM), lupus the Human Tissues act 2004, the potential of the fetus for human
anticoagulant screen, factor life was recognized and any products of conceptus are treated
V Leiden, antithrombin III, with respect and the parent wishes for cremation or burial are
factor C, factor S respected. Stringent controls are now in place for the retention
HbA1C Diabetes of fetal tissue.
Creatinine Renal disease
The Human Fertilization and Embryology Act (1990) reduced
Liver function tests, uric acid Pre-eclampsia
the age of viability to 24 weeks; however, it was not until 1992
Bile acids Obstetric cholestasis
that the definition was changed in the Stillbirth Act. Autopsies
VDRL, parvovirus antibody, Transplacental transmission of
were still being performed with the retention of organs as part of
CMV, IgM and IgG viral or parasitic infection
the routine examination of the fetus, and it was only in the late
High vaginal swab Transcervical ascending
1990s that the Bristol and Liverpool enquiries highlighted the
infection (especially Group B
need for the mother’s informed consent for this practice.
streptococcus)
The Human Tissues Act (2004) recognized the fetus as the
Postmortem examination of Structural or syndromic fetal
potential for human life. Stringent controls are now in place for
fetus and placenta including abnormalities and detects
the retention of fetal tissue.
samples for cytogenetics. inflammatory of infective causes
Prior written consent required
What can be offered to parents who do not wish to have a
postmortem?
Table 1 In cases where a genetic syndrome is suspected and the parents
decline a postmortem, they may accept fetal imaging with MRI or
are needed to the scalp, abdomen and chest but not to the face skeletal X-rays; in some cases, a geneticist may be able to exam-
and limbs; the organs are examined and then returned to the ine the fetus externally for dysmorphic features. Couples usu-
body and the incision closed. Closure may not be possible in very ally consent to histological examinations of the placenta which
macerated fetuses; however, in these circumstances the baby is often offers valuable information on inflammatory or infective
wrapped and once the baby is dressed, the appearance should causes. Placental abnormalities such as a circumvallate placenta
be the same as before the postmortem. In cases of known fetal or infarcts involving more than 20% of the placental surface may
cardiac, renal or brain abnormality, the parents may wish to limit cause or be associated with fetal demise. Placental tissue can also
the postmortem to a specific organ; however, less information is be sent for karyotyping and cytogenetics.
obtained in this way as abnormalities in one organ may be linked
to others (in the case of VACTERAL or VATER). The parents’
After delivery
wishes must be respected and their consent should clearly docu-
ment which organs or systems the pathologist should examine. During the labour the couple should be asked whether they
would like to see the baby. Studies have shown that seeing and
What tissues are kept? holding the baby facilitates an adequate grief response, with ear-
All organs are returned to the body; although it may not be pos- lier acceptance. It is well established that 90% of couples accept
sible to return the organ to its original position. The organs are an offer to see and hold the child and that no mother regrets the
weighed, photographed and examined macroscopically; small decision; many often speak fondly of the experience. However,
samples are then taken to make up tissue slides for a microscopic the couple’s wishes should be respected and if they choose not
examination. These tissue slides then make up part of the medical to see the baby, the option of taking photographs and keeping
record so that they can be re-examined if the diagnosis is unclear. them in the medical records if the couple wishes to view them
At early gestations small tissue samples may in fact comprise a at a later date should be suggested. The maternity department
whole organ. This must be clearly stated in the consent form. The often provides a memento box where hand and foot prints of
parents may wish for the slides to be cremated or buried with the the baby and a lock of the baby’s hair can be collected and
baby; once again this should be specified in the consent. presented.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:1  © 2008 Elsevier Ltd. All rights reserved.
 Review
The parents often wish to know the sex of the baby for iden-
tity and naming. Sexing the baby is difficult in earlier gestations
and in the presence of dysmorphology. Wrong assignment of
fetal sex can be very distressing. It is often better to await the
results of the postmortem or karyotype.
Most couples appreciate the option of having the baby blessed,
anointed or baptized.
The couple should be given information regarding the options
for cremation or burial; most hospitals arrange a cremation, with
the relatives being invited to a committal service. Some couples
may wish to arrange the funeral themselves and the bereavement
team can aid the couple in planning their own service. Bereavement
teams are aware of differing cultural requirements and provide an
important liaison between the pathologist and parents. Emotional
support can be more easily accepted if it includes help with practi-
cal issues such as registration and funeral arrangements.
Legal issues
The Royal College of Obstetricians and Gynaecologists and the
Office for National Statistics highlighted the need for a statement
on the interpretation and implementation of the registration law
when it is known that one or more fetuses has died in utero,
either naturally or through a medical intervention such as selec-
tive reduction. It can be said that the pregnancy of that fetus (or
fetuses) has ended prior to 24 weeks gestation. It may be that
there are other continuing pregnancies in the same womb but
the pregnancy of the dead fetus (or fetuses) is no longer continu-
ing. This means that in a number of situations where it is known
that one or more fetuses has died prior to the 24th week of preg-
nancy (e.g. where there has been a delay between a diagnosed
intrauterine death and delivery, vanishing twins or selective or
multifetal pregnancy reduction in multiple pregnancies), those
fetuses known to have died prior to the 24th week of pregnancy
would not be registered as stillbirths. In all of these cases, there
would have to be evidence that it was known that the fetus (or
fetuses) had died prior to the 24th week of pregnancy and this
evidence, usually based on ultrasound imaging, would need to
be clearly detailed in the mother’s notes in case any queries arose
at a later date.
The law does not recognize fetal deaths before 24 weeks. The
lack of legal recognition means that parents will not have a death
certificate for these early fetal losses. It does not mean that they
cannot arrange a funeral or cremation if they wish.
It is necessary for parents to register the birth of any baby
born after 24 weeks’ gestation. This is often a traumatic time for
parents and the bereavement team can be helpful in assisting
with this.
It is extremely difficult to have death certificates changed, and
parents can be deeply upset to find that a baby has a registered
cause of death that is not accurate. When writing the stillbirth
certificate:
• Do not use abbreviations;
• Do not guess the cause of death;
• Sign and print your name clearly;
• Write your GMC registered qualifications clearly; and
• Write a contact or bleep number under your name.
The coroner does not have any legal jurisdiction in cases
of stillbirth (even intrapartum), and cases should not need to
become the remit of the coroner.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:1
Suppression of lactation
The physiological reaction to the postpartum period can be dis-
tressing, especially with lactation as the body is preparing to feed
a baby, but there is no baby to care for. Often all that is required
is a supportive bra and non-steroidal analgesia. Carbergoline (a
long-acting dopamine agonist) is effective; however, this should
not be used in women with pre-eclampsia or those with a strong
personal or family history of thromboembolic disease.
Contraception
There is a possibility of the mother conceiving prior to the next
period, which may delay the grieving process. Parents should be
aware of this but a detailed discussion of options will need to
wait until the appropriate time.
Going home
The couple will want early discharge, which is reasonable once
the woman is medically fit. It is important to ensure that the
bleeding is not heavy, the uterus is well contracted and the pla-
centa and membranes are complete. The woman should be hae-
modynamically stable and not in need of intravenous antibiotics.
It is less disruptive for the woman to stay in hospital an extra
day rather than be readmitted with fulminating pre-eclampsia
or sepsis.
Both the midwife and GP should be alerted of the loss. Many
midwives do not work from GP surgeries and it cannot be
assumed that one will automatically inform the other. Often the
GP or the community midwife arranges a home visit. All antena-
tal clinic and scan appointments should be cancelled.
The woman should be informed of who to call if she is having
problems. Contact numbers of support groups such as SANDS
(Stillbirths and Neonatal Deaths) are a useful resource, offering
contact or web-based forums with other parents who have faced
similar experiences.
Bereavement care
Loss of a child during pregnancy is generally accepted as a seri-
ously distressing life event, leading to a grief reaction in the
majority of mothers for 6–9 months, although this may be unrec-
ognized for a lifetime.
As traditional support systems diminish, parents may now
look towards healthcare professionals for guidance and emotional
support following the death of their baby. The grief process fol-
lowing a stillbirth involves prospective rather than retrospective
grieving. It also involves the difficulty of recognizing a life and
often simultaneously mourning a death. Parental grief is often
secret and unrecognized by both relatives and healthcare profes-
sionals. Not all bereaved parents will need or accept professional
counselling. However, bereaved parents should be given the
choice whether or not to take up the offer of counselling.
Follow-up
The following points should be noted:
• The venue should be as neutral as possible and a home visit
may be appropriate is some cases.
• The baby’s name and sex should be ascertained before the
consultation if possible.
 © 2008 Elsevier Ltd. All rights reserved.
 Review
• There should be enough time for the parents to talk about the
experience and their concerns, and for any questions to be
answered honestly.
• The results of the postmortem examination should be dis-
cussed and the couple offered a copy of the report.
• When a cause is found on postmortem, the findings should be
clearly discussed and a referral to clinical genetics considered.
• If an investigation is positive, discuss management in future
pregnancies and recurrence risks.
• If no cause is found, a clear plan for the next pregnancy should
be laid out.
• Specific behaviours such as folic acid supplementation, stop-
ping smoking and adequate blood glucose control in diabetics
should be considered.
• The patient’s grief response should be assessed to diagnose
possible depression.
• Clear documentation, including a letter to GP should be pre-
pared. It may be helpful to write to the parents to summarize
findings and management in future pregnancies, in case they
chose to book elsewhere in future pregnancies.
• The couple should be offered a further appointment to discuss
certain aspects, or a preconceptual visit.
Management of the next pregnancy
It is very important for parents that future professionals adhere to
the plans that were formulated after the loss of the baby. There
may be minor differences of opinion in future management, but
it is better to put these aside in the interests of maintaining the
faith of the parents in their care when at all possible. When the
plan needs to be changed (such as may occur when new infor-
mation comes to light), it is important to explain clearly why the
changes need to be made and how this will improve the pros-
pects of a healthy pregnancy. After the birth of the next child,
parents may require much reassurance that the baby is healthy.
An examination by a senior paediatrician can help.
Conclusion
Intrauterine fetal death is sadly a common occurrence and one
which all labour ward personnel should be trained to manage.
Recent advances have improved the likelihood of identifying a
cause. The key to this is a logical and methodical approach to
investigation. Postmortem examination remains a critical aspect
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:1
of investigation and labour ward teams require a clear under-
standing of its legal aspects. Sympathetic and supportive care of
parents should respect parental wishes and allow choice wher-
ever possible. However, maternal safety should also be a central
aspect of care. ◆
Further reading
Bahtiyar M, Funai E, Norwitz E, Buhimschi C, Rosenberg V. Advanced
maternal age is an independent predictor of intrauterine fetal death
at term. Am J Obstet Gynecol 2006; 195: 209.
Bristol Royal Infirmary Inquiry. Bristol heart inquiry interim report.
Available from: www.bristol-inquiry.org.uk/interim_report/index.htm,
May, 2000.
British Medical Association. Interim BMA guidelines on retention of
human tissue at post mortem examination for the purposes of
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