Stillbirth and Late Fetal Loss Bereavement Care (658)

There is no agreed national recommended regime for induction of labour for stillbirth. The method and timing of delivery needs to be patient centred considering their clinical presentation and previous obstetric/medical history. Best practice recommendations within this guideline have been used evidence from Dodd et al Cochrane review 2010, NICE 207 Induction of labour and RCOG GTOP guideline 55.

Following confirmation of stillbirth, the couple should be offered time alone should they wish. While most couples wish to know the next step in their management, some may wish time away from hospital. An initial assessment must ensure there are no signs of sepsis, abruption/antepartum haemorrhage (APH), severe pre-eclampsia that would require URGENT DELIVERY.

Baseline observations should be taken with consent and recorded on MEOWS chart. Offer to take baseline bloods including FBC, U&E, LFT, CRP, COAG, Khleihauer, HBA1c (see list below) to investigate possible causes and ensure all management options are appropriate.

Should the above clinical situations be excluded, a discussion should occur between the woman and senior clinician around the method and timing of birth. This discussion should be customised to the presenting condition and other individual factors including past obstetric and past medical history.

Vaginal birth is the recommended mode of delivery for most women with an intrauterine death, as this decreases morbidity and will have fewer implications for future pregnancies over caesarean section. However, a caesarean birth may be required or be the chosen mode of birth due to past obstetric or medical history as well as emotional and psychological factors. Given this complexity the decision regarding mode of birth should be discussed with a consultant in all cases. Discussion directly between the couple and a consultant is required if caesarean section is being considered.

If a woman opts for birth by Caesarean section this should be supported and arranged as soon as possible. Daytime delivery should be aimed for unless clinical circumstances deem otherwise. Consideration should be given where waiting would contribute to psychological stress, providing it is safe to continue in line with other clinical priorities.

Most parents will opt for induction of labour (IOL) but in the event that expectant management is chosen, women should be advised that 85% of women will labour spontaneously within 3 weeks of an IUD being diagnosed but there is a small risk (10%) of disseminated intravascular coagulation (DIC) developing within the first 4 weeks of IUD. The risk of DIC increases to 30% after 4 weeks. Please be cautious if there are any concerns in the history that might suggest IUD may have occurred sometime earlier. Those wishing expectant management should be offered a coagulation screen and FBC performed at least twice weekly.

Ensure that the GENERAL PRACTITIONER and the COMMUNITY MIDWIVES are informed of the IUD on the day it has been confirmed.

Ensure that all ANC appointments and scans are cancelled.

Offer the woman and her partner the ‘Following confirmation of pregnancy loss’ leaflet MI351552

In order to establish or exclude a cause of death, the following investigations should be offered. These should be performed when the woman feels ready. In certain situations, where the cause of the stillbirth is obvious (known fetal anomaly) some of these investigations may not be required. Please check with a senior clinician/consultant if there are any queries.

• FBC
• G&S
• Khleihauer (irrespective of maternal blood group as this is to assess for fetomaternal haemorrhage).
• U&E/LFT’s/Urates
• Coagulation screen (if abruption suspected)
• Maternal serology for Toxoplasmosis, CMV, Herpes & Parvovirus (if indicated)
• Maternal HbA1c
• TFT
• Lupus Cardiolipins (taken at consultant follow up at least 6 weeks postnatally)
• Low Vaginal Swab for C & S and listeria (if indicated)
• MSSU + dipstick (if indicated)
• Urine for toxicology (if indicated)

Following, the MBRRACE report, we recommend CO testing antenatally, on all women, including non-smokers.

Women who are Rhesus negative, due to the possibility of a fetomaternal haemorrhage, should receive an appropriate dose of Anti-D at the initial presentation. A further dose will need to be administered after delivery.

There are no agreed regimes nationally for induction of labour in women with a stillbirth. RCOG recommendations are for mifepristone/misoprostol as the first line method of induction. In certain cases, oxytocin can and should be consider. Please discuss with the consultant on call. 

The NHSGGC agreed recommendations are:

• Use of misoprostol over oxytocin
• If previous 1-2 CB, IOL is safe but rupture risk (0.8%-1.1%)
• If 3 cs or atypical scars the safety of IOL is unknown.

Should the decision be for medical management, it is encouraged to observe the optimal mifepristone-misoprostol route of 36-48 hrs to reduce the dose of misoprostol required and therefore reducing the rupture risk. A population-based study that evaluated the rupture risk of women undergoing induction of labour for a live fetus reported rupture rates of 0.8% and 1.1%, respectively, with the use of misoprostol and oxytocin.

Vaginal delivery is contraindicated on all women with a previous classical incision on their uterus.

Contraindication to misoprostol administration: allergy to prostaglandins. Cautions in women with inflammatory bowel disease and conditions that can exacerbated by hypotension (cardiovascular and cerebrovascular).

Contraindications to mifepristone: acute porphyria, chronic adrenal failure, uncontrolled severe asthma.

Previous caesarean birth

There is little evidence in the literature on the safety and efficacy of medical management of late fetal death in the presence of a previous caesarean birth. These women need careful counselling on risks and benefits of the different options available to them on the risks and consequences of CB both short and long term morbidity and particularly the impact on future pregnancies. A recent review of evidence by NICE has resulted in no recommended regimes for medical management of induction in this situation due to the marketing on the uses for misoprostol. In addition, a high dose mifepristone regime (600mg daily for 2 days) was likely to lead to a prolonged delivery time and therefore adding too much undue distress for the woman. NICE have recommended mechanical methods for IOL (cook balloon), and this should be discussed and offered to woman. Most of these women will then need oxytocin use as per current hospital regime.

> 2 previous CB OR atypical uterine scars

The safety regarding the induction of labour in this group is unknown. A cook balloon may be associated with a lower risk of rupture over prostaglandins and can be considered. The rupture risk is still greater than for 1 CB, but thought to be the same as the risk associated with spontaneous labour. Mode of delivery should therefore be discussed with a Consultant Obstetrician and plan made on an individual basis. Due to the lack of evidence consider a category 3 CB.

 These recommendations relate only to gestations of ≥24 weeks. Where size of baby at time of diagnosis of stillbirth measures less than 24 weeks but the gestation as measured from their 12 week scan is ≥24 weeks these recommendations apply. Where women present with no previous antenatal care and stillbirth is diagnosed, senior medical opinion should be sought to determine if these recommendations or those for late miscarriage apply based on clinical history and ultrasound.

Induction of labour in an unscarred uterus:

Step 1 - Administer 200mg Mifepristone.

 Ideally parents should be asked to return 24-48 hours later for Misoprostol treatment but if there is evidence of abruption, sepsis, elevated BP or SROM women should be advised to remain as an in-patient. In cases where the woman does not wish to wait and Misoprostol is to be started immediately, still administer Mifepristone 200 mg. This will be active at 24-48 hours and will be of benefit in those cases where a second course of Misoprostol is required.  Women should be advised to avoid non steroidal analgesics.

Those who are able/willing to be discharged home following the Mifepristone should be discharged with a 24 hour contact number for information and support and must be advised to contact their hospital if labour starts or there is evidence of rupture of the membranes. If the woman is contracting, a VE should be performed – in these cases the woman should be advised to remain in hospital.

 Step 2 24+0-24+6  Administer Misoprostol 400 microgram every 3 hours (SL/PV/oral/buccal).

            25+0-27+6 Administer misoprostal 200 micrograms (bucal/SL/PV/oral) every 4 hours

            From 28+0 weeks 25-50micrograms PV every 4 hours or 50-100 micrograms oral every 2                hours

We recommend administering misoprostol vaginally allowing a sustained release with fewer side effects. Alternative administration routes (oral or sublingual) can be considered (maternal choice, vaginal bleeding, and infection). For the sublingual route the tablet should be held under the tongue or between the teeth and cheek for 30 minutes with the remnants swallowed after this time.

Misoprostol regime:

On readmission to labour ward record T, P, BP and RR on MEOWS chart.  Care should be provided by an experienced midwife in a private room where partners can stay overnight.

All medications should be prescribed on HEPMA. Please site IV access and obtain bloods, FBC etc.

If the woman wishes to have the oral route of medication beyond the first dose this is acceptable as the absorption rate for both the PV and oral route are similar. However, the incidence of systemic side effects (nausea, vomiting, diarrhoea, and mild pyrexia) is significantly increased with the oral route of administration and there may be a longer induction to birth interval time.

All women should have T, P, BP and RR recorded each time Misoprostol is due on the MEOWS chart.

Once labour is established the birth partogram should be commenced and hourly observations should be recorded until delivery.

Vaginal examinations may be performed to assess progress following discussion with the woman, although it is not necessary to be carried out every 4 hrs. Cervical dilatation and any vaginal loss (e.g. SROM/PV bleeding) should be recorded on the partogram .

Following delivery of the baby, Syntometrine should be given intramuscularly unless contra-indicated and controlled cord traction should be used to deliver the placenta. Oxytocinon 5IU IM can be used as an alternative. If undelivered after 1 hour, follow routine guidance for MROP in theatre.

PLEASE OBSERVE FOR HYPERTONIC UTERUS AT ALL TIMES UNTIL COMPLETION OF THE THIRD STAGE. IF NECESSARY WITHHOLD MISOPROSTOL, OR REDUCE SUBSEQUENT DOSE TO **25 MICROGRAMS, ESPECIALLY IN THOSE OVER 32 WEEKS.

If the first course of Misoprostol is unsuccessful, there should be a break of twelve hours after the last dose, following which a second course can be administered starting with the appropriate vaginal dose. Prior to starting the second course an assessment should be made by senior medical staff (both clinically and/or ultrasound) to ensure that the pregnancy is still within the uterus and there is no evidence of uterine rupture. There is no indication to give a further course of mifepristone at this stage.

GGC current practice in this case is after 1^st round for pelvic exam and consultant to advise of subsequent plan which is either to repeat miso regime or 3mg prostin PV and repeat 6 hours later. If then still undelivered further discussion with consultant, labour to be actively managed at this point including 2^nd and 3^rd stages.

ARM should NOT be performed unless discussed with senior obstetrician and very rarely before 4cm dilated. Potential exemption may be in case of massive abruption and IUD where ARM may hasten the process. If there is delay in the 2^nd stage consultant involvement should be considered as the lack of tone may make delivery of the baby more difficult. Active management of the 3^rd stage should occur in line with PPH risk assessment.

After 2 failed courses of Misoprostol a repeat scan MUST be performed to exclude uterine rupture and a consultant decision on further management recorded.

If a plan is then made for a CB, this should be carried out as a category 3 emergency CB. Be mindful of the noises that can be heard as a woman is transferred to and from theatre. Liaise with anaesthetic staff regarding repeating of blood tests based on chosen anaesthesia method.

Induction of labour in a scarred uterus (previous caesarean birth)

Previous caesarean birth (1-2)

Step 1 - Administer 200mg Mifepristone.

 As above, administer 200mg mifepristone and ideally wait 24-48 before administrating misoprostol. Highlight that allowing this time interval may reduce the need for repeated misoprostol dosages, reducing rupture risk.

**Step 2 Administer Misoprostol 25 microgram every 4 hours (PV) to a maximum of 5 doses. (This is a lower dose than that for an unscarred uterus)

On readmission to labour ward record T, P, BP and RR on MEOWS chart

We recommend administering misoprostol vaginally allowing a sustained release with fewer side effects. Alternative administration routes (oral or sublingual) can be considered (maternal choice, vaginal bleeding, and infection). For the sublingual route the tablet should be held under the tongue or between the teeth and cheek for 30 minutes with the remnants swallowed after this time.

Misoprostol regime:

All women should have T, P, BP and RR recorded each time Misoprostol (every 4 hours) is due on the MEOWS chart.

Once labour is established the birth partogram should be commenced and hourly observations should be recorded until delivery.

Vaginal examinations may be performed to assess progress following discussion with the woman, although not rigid in timings. Cervical dilation and any vaginal loss (e.g. SROM/PV bleeding) should be recorded on the partogram. Please remember these women are high risk for uterine rupture.

Following delivery of the baby, Syntometrine should be given intramuscularly unless contra-indicated and controlled cord traction should be used to deliver the placenta. If undelivered after 1 hr, follow routine guidance for MROP in theatre.

PLEASE OBSERVE FOR HYPERTONIC UTERUS AND IF NECESSARY WITHHOLD MISOPROSTOL.

If the first course of Misoprostol is unsuccessful, there should be a break of twelve hours after the last dose, following which a second course can be administered starting with the appropriate vaginal dose. Prior to starting the second course an assessment should be made by medical staff (both clinically and ultrasound) to ensure that the pregnancy is still within the uterus and there is no evidence of uterine rupture. There is no indication to give a further course of mifepristone at this stage.

After 2 failed courses of Misoprostol a repeat scan MUST be performed to exclude uterine rupture. Delivery by caesarean birth is recommended and a consultant discussion on further management recorded.

Caesarean birth

Timing of the caesarean birth should be completed within 24-48 hrs if this is the primary decision on mode of delivery. For those where caesarean birth is required following failed medical treatment, every attempt should be made to complete ASAP/ within 12 hrs, keeping in mind the wishes of the couple.

Written consent should be obtained using the NHSGGC consent form for CB.  On call anaesthetist should be informed and asked to review. Depending on clinical situation/ woman’s wishes, this should be performed under spinal anaesthetic. Repeat bloods (FBC, CRP) will need to be obtained if > 24 hr since admission. Please be guided by anaesthetic staff for changes to this.

Please be mindful of the noise of labouring women on transfer of women to and from theatre.

Expectant management

If delivery is delayed >48 hours repeat FBC and clotting screen twice weekly. Also advise that if expectant management is performed then:

• The value of some information from post mortem may be reduced
• The appearance of the baby may deteriorate

Spontaneous labour and augmentation of active labour

For women presenting in spontaneous labour with confirmation of stillbirth.

Commence partogram and continue with hourly observations until delivery.

An initial sterile examination should be performed.

1:1 Intrapartum care should be commenced.

Vaginal examinations may be performed to assess progress taking into consideration the women’s wishes. If contractions stop, this must prompt a medical review to ensure no signs of uterine rupture. Misoprostol can be given in women with unscarred uterus in doses as described above. Senior clinical input is required in those women with a scarred uterus and a personalised plan made. Consideration of oxytocin or misoprostol in doses above can be given. This should be discussed with senior medical staff. Use of oxytocin for stillbirth labour should be in line with current NHSGGC local guideline in terms of escalation and dosage should be considered where labour is not progressing providing there are no concerns of uterine rupture.

Alternatives

Mechanical method

Induction of labour using mife/miso remains our chosen method for inducing labour after diagnosis of IUD from 24 weeks gestation. However, mechanical methods using Cook® Cervical Ripening Balloons can be used in patients where misoprostol is contraindicated or individualised care. Women have the option of staying or going home with this in (depending on location to hospital). As per current hospital guidance, the balloon should be removed after 12 hrs up to maximum of 24 hrs. They must be counselled to contact the ward should it fall out, contractions begin or there is SRM. Unless in active labour, on removal, they will need to be transferred to LW for ARM and augmentation using oxytocin.

Twins

The timing and mode of delivery for multiple pregnancies in the case of a single fetal demise will depend on the chorionicity, gestation, position of the fetuses and the wellbeing of the remaining baby/babies.

DO NOT CONFIRM THE SEX OF THE BABY unless already known.

• Complete stillbirth investigations (see checklist – of note placental swab for virology and piece of placenta for genetics).
• Offer photos and memory box.
• Perform a thromboprophylaxis risk assessment
• Check rhesus status and ensure anti-D given if appropriate
• Arrange for IDL, appropriate venous thromoembolism risk assessment, pain relief and iron if required
• The womans named consultant/community midwife/GP and HV should be informed
• Ensure all antenatal appointments have been cancelled
• Offer counselling services and support group information from the bereavement pack including SANDS/ARC/CBUK/Miscarriage Association and the bereavement midwife's details
• Discuss contraception
• Clear contact details for labour ward and bereavement midwives should be given to parents in case of any postnatal concerns/questions
• If over 22 weeks then they should be given written information, leaflet MI351551-Understanding what happened-the perinatal mortality review process so that they can contribute any specific questions they wish addressed
• A datix should be completed for all losses over 22 weeks
• Discuss suppression of lactation (see below).
• Discuss post mortem (see below).
• Complete still birth certificate. Ensure parents are aware of need for birth registration (within 21 days). This now is done via telephone and not in person.
• Inform women they will be contacted by our bereavement specialist midwives within 2-6 weeks of discharge.
• Complete both the maternal and fetal 'Bereavement Pathway' on badgernet.

Suppression of Lactation

See guideline GGC – Breast care/lactation management when you baby has died

Consent for a Post mortem Examination

All women should be given an information leaflet – ‘Post mortem examination of a child’, NHS Scotland publication. A consultant should discuss PM with couples. If wishing to proceed, full or limited, woman must complete an ‘Authorisation of hospital postmortem examination of a child under 12 yrs of age’ form. A copy of this must go in the envelope with the baby. Please note, that a copy of the authorisation form goes to the woman and another is placed in their notes.

Parents should be advised that PM examination provides more information that other (less invasive) tests and this can sometimes be crucial to the management of future pregnancies.

Attempts to persuade parents to choose PM must be avoided, individual, cultural and religious beliefs must be respected.

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.

Pregnant women and people contemplating prolonged expectant management should be advised that the value of PM may be reduced.

Parents should be informed that PM results normally take at least 12 weeks and occasionally over 12 weeks to be available.

The placenta should be sent for histology whether or not PM examination of the baby is requested. Where a PM is requested, the placenta should be sent to the mortuary with the baby. If a PM is declined or parents are undecided the placenta should be sent to histopathology.

A piece of placenta from the fetal side should be taken and placed in the tissue medium sample tube kept in the labour ward fridge and sent with the genetics request form.

This should be arranged by the named consultant. It should normally take place 8-12 weeks following the event. Management plans for future pregnancies should be documented in the patients notes.