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Fetal death
1 Introduction
2 Choosing between active and expectant care
3 Choice of methods for inducing labor
4 Conclusions
1 Introduction
The interval between a diagnosis of antepartum fetal death and birth
is a time of great distress. When the diagnosis of fetal death has been
made and confirmed by ultrasound examination, women require the
time and opportunity to adjust. Rushed decisions are unnecessary,
except for complications such as placental abruption or severe hyper-
tension. Women should be made aware of the options available to
them, given time to consider these options and to decide what they
want. They must be allowed the time to start to grieve, and to make
decisions in an environment in which they feel secure. Many women
will want to return home, even if only for a brief period. It is impor-
tant to remember to ask the woman how she came to the hospital or
clinic. It may be preferable for her not to drive at such a time, or go
home unaccompanied.
2 Choosing between active and expectant care
From the physical standpoint, given appropriate means to induce
labor after fetal death, there are no overwhelming benefits or hazards
for induction of labor over expectant care. The advantages and the
disadvantages of both these approaches relate almost exclusively to
their emotional and psychological effects. The woman herself is the
best judge of these, and she is the one who should make the choice.
Her caregivers should assist her by providing her with the information
needed to make an informed choice. They should ensure that what-
ever option she chooses is provided in an empathetic environment
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SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise website at www.maternitywise.org/prof/
Oxford University Press 2000
with as little psychological and physical discomfort as possible (see
Chapter 49).
It is wrong to assume that all women desire the most rapid method
of delivery when their babies have died in utero. For some women, the
uncertainty and the learning of the death are the worst moments;
carrying the dead fetus still permits them a feeling of closeness to the
baby, that will be lost once it is born.
Many women, on the other hand, are anxious to give birth as quickly
as possible. Some may even suggest that this should be done by
cesarean section. Discussing the facts and alternatives with the woman
and her partner conveys compassion and understanding. Often it will
help to defuse initial feelings of anger, suspicion, inadequacy, and guilt,
which are typically felt by all, caregivers and women alike, after the sad
diagnosis is made.
The main advantage of the expectant option is the absence of any
need for intervention. The woman can stay at home, and she will avoid
procedures that might turn out to be less effective and more risky than
anticipated.
The disadvantages of expectant care are mainly psychological, and
relate to the unpredictable and usually long time during which the
woman may have to carry the dead baby. Sometimes, she or her rela-
tives may be under the impression that the baby will rot inside her and
exude toxins that can poison her. It is important to dispel such fears,
although this may not always be successful.
The only physical hazard of the expectant policy relates to a possible
increase in the risk of disturbances in blood coagulation. These are
most likely to occur when fetal death has been caused by placental
abruption. Disorders of coagulation in association with other causes of
fetal death are rare. The hypofibrinogenemia that is held responsible
for these disorders occurs very slowly and is rarely clinically significant
in the first 45 weeks after fetal death. By the time that clinically signif-
icant alterations in coagulation mechanisms could arise, the chances
are that birth will have occurred.
The main advantages of an active policy to effect delivery in the care
of women with a dead fetus are that it offers the option of ending a
pregnancy that has lost its purpose and that a post-mortem diagnosis
may be easier to achieve in the absence of maceration. The disadvan-
tages of an active policy relate to the means through which it is effected.
If labor is induced, the efficacy and safety of the method used will
be the most influential factor in considering the relative merits of the
policy.
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3 Choice of methods for inducing labor
A variety of agents and methods have been used for inducing labor
after antepartum fetal death. Agents used include saline, oxytocin, the
natural prostaglandins, prostaglandin analogs such as 15-methyl-
prostaglandin F
2,
sulprostone, and misoprostol, and the progesterone
antagonist mifepristone. Consideration must be given to the route of
administration, the choice of prostaglandin, and the choice of other
agents where prostaglandins are not readily available.
When intra-uterine fetal death occurs in late pregnancy it is usually
possible to induce labor with any of the prostaglandin regimens that
are employed for other inductions (see Chapter 40). Methods with
which one is thoroughly familiar tend to perform better than those that
are only rarely needed and require careful study before being applied.
These methods may be less effective, however, at the earlier gestational
ages when the sensitivity of the uterus to prostaglandins is lower than
it is at term.
Intravenous administration of natural prostaglandins has been
superseded because of a high incidence of side-effects compared with
local routes. The intra-amniotic route of administration has also been
largely superseded by local preparations.
Vaginal administration of prostaglandins or prostaglandin analogs in
the form of suppositories, gels, or pessaries, is widely used at present
because of its convenience and ease of administration. Prostaglandin
E
1
(gemeprost, Cervagem) and PGE
2
analogs, such as sulprostone, are
often used.
When prostaglandins are not available, extra-amniotic infusion of
saline, or simply placement of an extra-amniotic balloon without any
infusion may be used.
The prostaglandin E
1
analog misoprostol has been shown to be effec-
tive for the induction of labor at all stages of pregnancy, administered
orally or vaginally. As it is not registered for use in obstetrics and
gynecology, no manufacturers guidelines for route of administration
or dosage are available. The main problem is uterine hyperstimulation,
which may even result in uterine rupture. Its use at present should
be restricted to research protocols to determine optimum and safe
regimens
Mifepristone, a steroid compound that antagonizes progesterone
action, has shown promise for induction of labor after fetal death,
possibly in combination with prostaglandins to further enhance the
success rate. With improvements in techniques with prostaglandins
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and prostaglandin analogs alone, the place of mifepristone appears to
be limited.
4 Conclusions
In the case of fetal death, the decision whether or not to induce labor
should be made on psychological or social grounds, and the woman
herself is the best judge of these. Should induction be chosen, the most
effective method in the later weeks of pregnancy is likely to be one with
which the caregiver has adequate experience from inducing labor in
other pregnancies. Earlier in gestation, vaginal administration of
prostaglandin analogs appears to be the treatment of choice. Methods
employing an extra-amniotic catheter bulb may be considered when
prostaglandin analogs are unavailable, unaffordable, or ineffective. In
the future, misoprostol may become a useful alternative.
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Effective care in pregnancy and childbirth
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