Anaesthesia and Analgesia in Late Intrauterine Fetal Death (IUFD) (618)

• Vaginal birth is recommended for most patients presenting with a late IUFD. However, caesarean section may be offered.¹
• Patients presenting with a late IUFD should be offered a discussion with an anaesthetist regarding analgesia. This patient population may have greater analgesic requirements.¹
• All analgesic options are available including regional analgesia. This is supported by the Royal College of Obstetricians & Gynaecologists (RCOG) Green Top Guideline No. 55 (2024).
• Contraindications to analgesic options may exist, especially with regards to regional analgesia. Most significantly, this includes Disseminated Intravascular Coagulation (DIC) with or without sepsis.
• The decision to provide patient controlled analgesia (PCA) or regional analgesia requires anaesthetic assessment.
• Bloods must be sent for Full Blood Count, Coagulation Studies, Fibrinogen, Urea & Electrolytes, Liver Function Tests and C-Reactive Protein. Regional analgesia should not be considered until recent blood results are available.
• Regional analgesia is an option for this patient population. However, due to the potential risks of DIC and sepsis, if regional analgesia is being considered by a non-consultant anaesthetist, this should be discussed with a consultant anaesthetist before being performed.
• DIC and sepsis can develop in the post-natal period. Clinical follow-up should assess for this. If considering regional analgesia, the potential for post-natal complications should be discussed with the patient during the consent process.
• Late IUFD is a devastating experience for the patient and their family. All care should be undertaken with compassion and sensitivity to this.

• Non-Pharmacological Analgesia^1,3
  • Transcutaneous Electrical Nerve Stimulation (TENS) Machine
  • Water Birth
  • Complimentary Therapies
• Pharmacological Analgesia
  • Entonox
  • IM Morphine (administered per local midwifery guidelines)
  • Either Morphine or Remifentanil (administered following anaesthetist assessment with reference to local guidelines)
• Regional Analgesia
  • Lumbar Epidural (a consultant anaesthetist should be involved in the decision making process)

DIC (Disseminated Intravascular Coagulation) and sepsis are potential complications of late IUFD

• Data on the prevalence of DIC and sepsis in late IUFD is lacking. However, a comprehensive assessment for both DIC and sepsis should be carried out.
• Patients presenting with a late IUFD may also have additional risk factors for developing DIC. These risk factors include (but are not limited to) antepartum or postpartum haemorrhage, placental abruption, sepsis, pre-eclampsia/HELLP syndrome, acute fatty liver of pregnancy and amniotic fluid embolism.^4,5
• Patients presenting with a late IUFD and additional risk factors for DIC should be considered high risk for developing DIC, although this is not quantifiable.
• DIC and Sepsis can develop in the post-natal period too.

• Patients presenting with a late IUFD may be offered a caesarean section.¹
• The choice between regional or general anaesthesia is guided by the preference of the anaesthetist and patient, taking into account the clinical situation. A consultant anaesthetist should be involved in the decision making process.
• If regional anaesthesia is being considered, the potential risks of DIC and sepsis outlined above should be taken into account.
• This patient population is potentially at increased risk of postpartum haemorrhage.⁶
• Recovery care should be in accordance with the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines.⁷ While sensitivity to the clinical situation is important, this should not compromise the post-operative monitoring period (for example, managing the patient in an isolated single room post-operatively).