Intrauterine Fetal Death — Diagnosis, Delivery & Bereavement Care
Intrauterine fetal death (IUFD) is death of the fetus before the onset of labour; when the baby is born without signs of life it is called a stillbirth
Definitions differ: ACOG ≥ 20 weeks; RCOG/UK ≥ 24 weeks; WHO international comparison and many Indian reports ≥ 28 weeks (or ≥ 1000 g). Always state the definition you use
Early 20–27 weeks · late 28–36 weeks · term ≥ 37 weeks
About 2 million stillbirths a year worldwide, the majority in low- and middle-income countries including South Asia; many are preventable, especially late in pregnancy
Hypertension and pre-eclampsia, diabetes, thyroid disease
Obesity, smoking, alcohol, and advanced age
Antiphospholipid syndrome, SLE, cholestasis of pregnancy
Severe anaemia and malaria
Placental abruption and infarction
Fetal growth restriction and post-term pregnancy
Cord accidents (true knots, prolapse, entanglement)
Fetomaternal haemorrhage, twin-twin transfusion
Congenital anomalies and chromosomal disorders (about 10–15%)
Alloimmunisation (Rh disease) and hydrops
Single-gene and metabolic disorders
Syphilis, malaria, listeria, GBS, E. coli
CMV, toxoplasma, parvovirus B19, rubella, herpes
Chorioamnionitis and ascending infection after PPROM
Previous stillbirth, fetal growth restriction or small-for-gestational-age fetus, and post-term pregnancy
Reduced fetal movements — a warning sign that must always be acted on the same day
Maternal age ≥ 35, obesity, smoking, nulliparity, low socio-economic status, and a long interpregnancy interval
Multiple pregnancy, diabetes, chronic hypertension, and poor access to antenatal care
Typical story: the mother stops feeling fetal movement; there may be no other symptoms. Later: regression of pregnancy symptoms and breast softening, and sometimes a brown vaginal discharge
Examination: no fetal heart on Doppler or Pinard, and fundal height smaller than expected
Confirm by real-time ultrasound showing no cardiac activity — ideally with a second experienced operator — and tell the mother clearly and gently
Late signs (days after death): Spalding's sign (overriding skull bones), Robert's sign (gas in the great vessels), a hyperflexed spine, scalp oedema, and maceration of the skin
Maceration suggests how long ago death occurred — it supports the timeline but cannot give a precise time
| Test | What it looks for |
|---|---|
| Full blood count, CRP | Anaemia, infection, thrombocytopenia (HELLP) |
| Coagulation, fibrinogen | DIC — baseline, and weekly if delivery is delayed |
| Blood group, Rh, antibody screen; Kleihauer–Betke | Rh disease, fetomaternal haemorrhage; guides anti-D dose |
| Glucose, HbA1c; TSH | Diabetes, thyroid disease |
| Liver function, bile acids, renal function, urine protein | Pre-eclampsia, cholestasis of pregnancy |
| Syphilis (VDRL/TPHA), HIV, hepatitis B, malaria smear (endemic areas) | Congenital and perinatal infection |
| CMV, toxoplasma, parvovirus B19 serology; high vaginal swab; blood culture if febrile | Infective causes, listeria, GBS |
| Lupus anticoagulant, anticardiolipin, anti-β2-glycoprotein I | Antiphospholipid syndrome — treatable in the next pregnancy |
Post-mortem (autopsy) is the single most informative test — discuss it sensitively and obtain written consent; less invasive options such as post-mortem MRI or X-ray are possible if full autopsy is declined
Placental histology, with membranes and cord, in formalin — often shows infarction, abruption, or chorioamnionitis
Genetic testing: chromosomal microarray or karyotype on placental or cord tissue (sent in culture medium, not formalin); a skin or deep-tissue sample if cells are not viable
Document and photograph the baby and placenta; weigh, measure, and record any external anomalies; take surface swabs if infection is suspected
Offer a short period to decide unless she is unwell — about 90% start labour spontaneously within 2 weeks, but waiting is a choice, not a duty
Vaginal birth is preferred; caesarean section only for obstetric reasons (for example, complete placenta praevia or a transverse lie with risk to the mother)
Induction regimen: mifepristone 200 mg orally, then misoprostol 24–48 hours later — mifepristone shortens the induction-to-delivery interval
Prior caesarean scar: use a lower misoprostol dose or a mechanical method (Foley balloon) with close observation — the risk of uterine rupture rises with higher gestation and dose
Analgesia is available: epidural, opioids, or paracetamol; give antiemetics; offer a labour companion; do not leave her alone
| Gestation | Typical dose | Interval |
|---|---|---|
| 13–17 weeks | 200 µg | Every 6 h |
| 18–26 weeks | 100 µg | Every 6 h |
| ≥ 27 weeks | 25–50 µg | Every 4–6 h |
A retained dead fetus can release thromboplastin and cause consumptive coagulopathy
Risk rises after 3–4 weeks of retention, with about one in four developing DIC if left much longer
Check fibrinogen and platelets weekly while waiting; a falling fibrinogen (< 2 g/L) means deliver with blood-product cover
Have blood and fresh frozen plasma ready; manage the third stage actively because of postpartum haemorrhage risk
Offer her the choice to see and hold the baby, to name and dress the baby, and to take photographs, hand and foot prints, and a lock of hair — memories matter, and parents rarely regret making them
Place her in a separate room away from the sounds of newborns, with a bereavement midwife or counsellor and support for her partner
Rh-negative mothers: anti-D immunoglobulin within 72 hours; send the Kleihauer–Betke test first
Suppress lactation if she wishes: cabergoline 1 mg once (or 0.25 mg twice daily for 2 days), a supportive bra, and clear advice
Respect religious and cultural rites and help with the paperwork: stillbirth certificate and burial or cremation arrangements
“I am so sorry. Your baby has died.” Use clear, plain words
Use the baby's name, if she has one
“There is no rush; we will take this at your pace”
“This is not your fault”
“At least you can have another one”
“It was for the best”, or “Everything happens for a reason”
Hurrying her out of the ward
Blame-laden questions about her behaviour
Book a review with a senior clinician to give results (autopsy, histology, genetics) and discuss causes and recurrence risk
Screen for depression, anxiety and post-traumatic stress; refer for counselling early — and include her partner
Offer contraception if desired and advise on physical recovery; review any medical condition found (diabetes, hypertension, APS)
Give written information and contact details for a bereavement support service
Pre-conception counselling: optimise weight, blood sugar, blood pressure, and thyroid; stop smoking; folic acid
Book early, with a named consultant and continuity of care; recurrence risk is higher than baseline but, in unexplained cases, most women have a live baby
Treat the cause: aspirin 75–150 mg for pre-eclampsia risk; aspirin and LMWH for antiphospholipid syndrome; tight diabetic control; anti-D if Rh-negative
Surveillance: early dating scan, growth scans, Doppler if FGR is suspected, and fetal-movement awareness
Timing of birth is individualised — often by 39 weeks if unexplained, and earlier if FGR or hypertension; offer extra emotional support through the pregnancy
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