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March 2025 newsletter now available - see below.

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

IUD (Intrauterine Fetal Death) (658)

Please report any inaccuracies or issues with this guideline using our online form

This aim of this guideline is to standardise care of those women presenting to maternity triage with an intrauterine death. It should be used to counsel women sensitively about her options and identify those at risk of medical complications in whom immediate intervention may be required. 

Definitions1:

  • Late fetal losses – the baby is delivered between 22+0 and 23+6 weeks of pregnancy showing no signs of life, irrespective of when the death occurred.

  • Stillbirths – the baby is delivered from 24+0 weeks gestation showing no signs of life. If Intrauterine death had been diagnosed (usually by ultrasound) prior to 24 weeks and delivery does not take place until 24 weeks this should be classified as a late fetal loss or miscarriage as appropriate.

  • Early neonatal deaths – death of a live born baby (born at 20 weeks gestation of pregnancy or later or ≥ 400g where an accurate estimate of gestation is not available) occurring before 7 completed days after birth.

  • Miscarriage: The spontaneous expulsion from the uterus of a fetus that shows no signs of life before 24 weeks gestation

Diagnosis

  • Take a full history

  • Enquire about fetal movements noting that passive movements after IUD can be felt.

  • Perform basic maternal observations and an antenatal check including maternal heart rate, respiratory rate, blood pressure, temperature, urinalysis and abdominal palpation

  • Diagnosis should be made by real time ultrasound assessment of fetal cardiac pulsation.

  • A second person trained in ultrasound scanning should be present where possible.

  • Where views are difficult to obtain colour doppler and umbilical cord doppler can be used

  • If possible and confident to do so perform a single measurement such as head circumference HC/ abdominal circumference AC or  femur length FL to date pregnancy at this stage 

  • Fetal hydrops, intra-fetal gas or overlapping skull bones may be seen and evidence of these should be documented.

  • If possible try to have support with patient at the time of USS  – if not, once the diagnosis is confirmed offer to call a relative or friend for support

  • Ensure that serious pathology has been excluded such as chorioamnionitis, pre-eclampsia, coagulopathy and abruption

  • Women should be strongly advised to take immediate steps towards delivery if there is sepsis, pre- eclampsia, placental abruption or membrane rupture

  • Take urgent bloods for Full blood count,  group and save and coagulation, CRP and baseline UE/LFT

  • All women should have a have Kleihauer undertaken as soon as possible after presentation as the haemorrhage may have occurred some time before presentation. This allows diagnosis of any feto-maternal haemorrhage as possible cause of the IUD and allows timely administration of Anti-D should the woman be Rhesus negative.

  • Where feto-materal haemorrhage has occurred the dose of Anti-D should be altered and a repeat Kleihauer should be performed at 48 hours to ensure fetal cells have been cleared.

Management

Vaginal delivery

  • A vaginal delivery can be achieved in 90% of women in 24hours following induction of labour with an IUD

  • Benefits include recovery time and less time to discharge as well as reduced risks for future pregnancies.

  • Those with group-B strep do not need intrapartum antibiotic prophylaxis

  • If concerns regarding sepsis and infection follow appropriate antibiotic therapy guidance

Caesarean section

  • On occasions maternal request for c-section can be considered along with her previous medical and obstetric history

  • Those with a previous c-section should be discussed with the obstetric consultant on call and arrangements made to see an obstetric consultant to discuss delivery options.

  • Those with 1 or 2 c-sections can be advised that IOL is safe but does come with a risk of uterine rupture.

  • Those with 3 c-section scars or atypical scars should be advised that the safety of IOL is unknown

Expectant management

  • 85% of women with a confirmed IUD will labour spontaneously within 3 weeks

  • This is an uncommon management option

  • Women who choose expectant management should be warned about the increasing risk of medical complications with prolonged expectant management and should be seen twice a week to exclude DIC and sepsis. The risk of DIC is 10% within the first 4 weeks and 30% thereafter. 

  • Women should also be warned that the appearance of the baby may deteriorate and the value of post mortem examination can be affected with prolonged expectant management.

Investigations following IUD (following admission to Labour ward)

Reasons for intrauterine death will include congenital malformation, congenital fetal infection, antepartum haemorrhage, pre eclampsia and maternal diabetes mellitus. Intrapartum causes will be secondary to placental abruption, maternal and fetal infection, cord prolapse, uterine rupture and hypoxia-acidosis.

Directing investigations to detect causes and their indications are listed below

  • Full blood count FBC, urea and electrolytes UE, liver function tests LFT’s , coagulation screen , Creactive protein CRP 
    To detect pre eclampsia, sepsis and it’s complications such as multi organ failure and disseminated intravascular coagulopathy DIC. 

  • Kleihauer
    To detect late feto-maternal haemorrhage – in all women, not just rhesus negative. Where feasible this should be carried out as soon as possible to diagnosis of IUFD in all women. 

  • Bacteriology , maternal blood cultures, mid stream urine specimen, high vaginal swab , cervical swab 
    Indicated if maternal fever and sepsis, flu like symptoms or abnormal liquor including prolonged rupture of membranes.

  • Maternal serology 
    If maternal fetal infection suspected  e.g fetal hydrops can use booking serum for baseline serology. Parvovirus B19. rubella, CMV herpes and toxoplasma gondii . Treponemal serology can be checked on booking bloods. Consider checking other virus’ if the woman has travelled abroad to endemic areas.

  • Maternal HBA1c
    May indicate type 1 or 2 DM. GDM patients may still have a normal HBA1c

  • Thrombophilia screening
    Lupus anticoagulant and anticardiolipin antibodies should be performed at a later date (e.g post natal follow up) as pregnancy may affect the results

  • Fetal and Placental swabs for microbiology
    Fetal ear and maternal and fetal surfaces of placenta should be swabbed.

  • Placental tissue for karyotyping 
    Offer to all women - written consent is required . Cultures can sometimes fail.
  • Post mortem examination

    We would encourage all women to have a full post mortem. This may lead to changes in future pregnancy management in up to 20% of cases. 

    Ideally this should be discussed by the on call consultant. If a full post mortem is not wished then the pros and cons of a limited post mortem should be discussed. Written consent is required. 

    If PM is declined, the baby should be examined by the on-call obstetrician and the findings documented.

Management after 24 weeks

The majority of women are suitable for vaginal delivery

Those with active bleeding, evidence of abruption or sepsis should be admitted. 

 Where no indications for admission and observation exist 

Administer Mifepristone 200mg orally + arrange admission to LABOUR SUITE 24-48 hours later

 

  • Care should be provided by an experienced midwife in a private room where partners can stay overnight

  • Prescribe all medications on a kardex to avoid delays on admission

  • Side effects of mifepristone include abdominal cramp, rashes and headaches

  • Contraindications include severe asthma, porphyria, renal or liver failure.

  • Benefits include reduced time spent in hospital, reduced number of misoprostol doses and reduced risk of retained placenta

  • Women should be encouraged to attend the department sooner if they have a fever, bleeding, pain or feel otherwise unwell – give contact number for labour suit directly. They will need support during this time

  • If any concerns regarding sepsis initiate appropriate therapy- see antibiotic guideline

  • If there are any patient concerns these women should be brought to labour suite immediately

  • Women should be advised to avoid non steroidal analgesics

  • Women should be warned about the possibility of feeling passive fetal movements

Labour suite

  • 4 hourly observations to be completed either on a MEWS chart or the partogram from admission to labour suite.

  • Partogram to be used and fully completed once labour commenced

Administer Misoprostol 50micrograms every 4 hours per vagina (5 doses)

 

  • If after the 1st round of misoprostol (all 5 doses) delivery has not occurred inform the obstetric registrar who should perform a pelvic examination

    The obstetric consultant should advise a subsequent plan

    Repeat Misoprostol regime

    OR

    3mg prostin per vagina and repeat at 6 hours. If still undelivered / not in established labour a further discussion with the obstetric consultant should occur
  • Labour should be actively managed and this includes the second and third stages

  • ARM should not be performed unless discussed with senior obstetrician and very rarely before 4cm dilation as this may slow progress and increase the risk of infection. A potential exemption may be in the case of massive abruption and IUD where ARM may hasten the process.

  • If there is delay in the second stage there should be a low threshold for consultant involvement as the lack of tone may make delivery of the baby more difficult.

  • Active management of the third stage should occur in line with PPH risk assessment

  • If the placenta appears incomplete and bleeding is ongoing evacuation of retained products of conception should be performed under anaesthetic.

  • Care should be tailored to individual requests and needs where feasible.

Determining sex of baby

This can be potentially difficult due to hydrops or maceration. Advise parents about this potential difficulty when appropriate

2 experienced healthcare professionals (midwives, obstetricians, neonatologists or pathologists ) should examine the baby if determination of sex is difficult. In some cases determination of sex may not be possible and pathology / karyotype will have to be awaited.  

Prior to discharge

  • Post mortem examination should be discussed by the consultant on duty where possible – if not a senior doctor comfortable in discussing PM could take consent. Parents should be given written information by their midwife prior to a final discussion. Parental consent for PM must be documented in notes – also if declined.

  • Perform a thromboprophylaxis risk assessment.

  • Check rhesus status and ensure anti-D given if appropriate.

  • Offer lactation suppression with cabergoline 1mg single dose - contraindicated in hypertensive women.

  • Arrange for immediate discharge letter, appropriate venous thromboembolism risk assessment, pain relief and iron if required.

  • Inform the community midwife / general practitioner and the woman’s lead consultant.

  • Ensure all antenatal appointments have been cancelled

  • Offer counselling services and support group information ( family bereavement service). The Child Bereavement Service will see families ≥23 weeks. Before this gestation referral should be made to SANDS or the Miscarriage Association.

  • Discussion regarding contraception should occur before discharge

  • Clear contact details for MAU or Labour Ward should be given to the parents in case of any postnatal concerns.

  • Written information should be given to the parents to let them know a review of their pregnancy and delivery will take place. They should be given written information on how to contribute if they have specific questions they wish addressed.

  • A Datix should be completed for all losses ≥22 weeks

Follow up

This should be arranged by the lead consultant for that patient. On occasions a consultant colleague with significant involvement in the case may take over this responsibility.  

Follow up normally occurs 8-12 weeks following the event but patients should be informed that this can be re-arranged if they do not feel able to attend at that stage. 

Management plans for future pregnancies should be documented in the patient’s notes  

Editorial Information

Last reviewed: 04/12/2018

Next review date: 01/12/2023

Author(s): Laurie Anderson.

Approved By: Obstetrics Clinical Governance Group

Document Id: 658

References
  • Late intrauterine Fetal Death and Stillbirth, RCOG Green Top Guideline 55, October 2010.

  • MBRRACE-UK Mothers and Babies- reducing Risk through audits and Confidential enquiries across the UK