Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guidelines
  3. Maternity
  4. Back
  5. Common obstetric problems, intrapartum labour ward
  6. Intrauterine Fetal Death (IUFD) and Anaesthesia (618)
Important: please update your RDS app to version 4.7.3

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

 

 

Intrauterine Fetal Death (IUFD) and Anaesthesia (618)

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

Intrauterine fetal death (IUFD) refers to babies with no signs of life in utero1. Late IUFD (>24 weeks gestation) is relatively common with the stillbirth rate in Scotland being approximately 5 in 1000 total births. Most women will be suitable for vaginal delivery and many will have been induced. The main complications relate to coagulopathy and sepsis. Prolonged expectant management carries higher risks. In addition to being a distressing time for the woman and her family, stillbirth is rated more painful than live birth and more analgesia may be utilised.

  • Women should be offered the opportunity to discuss options for analgesia with the duty anaesthetist
  • All analgesia modalities should be available – including regional analgesia (if no contraindications)
  • Blood should be sent for full blood count, coagulation screen (including Fibrinogen), urea and electrolytes and CRP

  • Equanox (Entonox)
  • IM Opioids – Administered in line with midwifery guidelines
  • IV Opioids – Either Morphine or Remifentanil PCA can be considered and delivered in accordance with local guidelines (table gives the advantages and disadvantages of each)
  • Epidural – If bloods satisfactory and no suggestion of coagulopathy or sepsis then epidural analgesia can be administered in accordance with local protocols

Up-to-Date blood results for full blood count, urea and electrolytes, coagulation Screen (including fibrinogen) and CRP should be reviewed prior to epidural. Any abnormalities should be discussed with a consultant anaesthetist. It should always be considered that the complications of epidural abscess or vertebral canal haematoma could be catastrophic. A conservative approach is advised.

There is a widely quoted figure of a 3.1% incidence of signs of sepsis during induction of labour for IUFD2. However, this is a small series of 96 patients and there are no details on the definition of the episode. All labours will have a baseline incidence of sepsis.

In the same series of 96 patients there were no incidences of coagulopathy or haemorrhage. In a retrospective cohort study of coagulopathy 12 of 104 (11%) of patients presenting with IUFD after 24 weeks had a complication of coagulopathy3. However, this appears to have been defined on the need for blood transfusion. In addition, in the majority of cases this was associated with a clinical syndrome (preeclampsia, HELLP, uterine rupture). In the other cases there were statistically significant abnormalities in platelet count, PT, APTT and Fibrinogen at presentation. 

Caesarean Section will occasionally be indicated. General Anaesthesia is usually most appropriate in this context, however circumstances may necessitate an alternative approach (eg morbid obesity). Patients should be recovered in accordance with Association of Anaesthetists of Great Britain and Ireland Safety Guideline on Immediate Post-anaesthesia Recovery. Management of the patient in a single room must not compromise post-anaesthesia monitoring.

Advantages 

Disadvantages

Morphine PCA

Pain relief/sedation will persist between contractions which may be advantageous in the distressed patient 

Pain relief may be inadequate for peak contractions

Analgesia will continue and cover for post-delivery pain relief

Morphine side effects may occur including; nausea, constipation, itch. 

In majority of cases the patient can be left for brief periods by the midwifery team 

Remifentanil PCA

Provides superior analgesia during peak of contractions

Requires constant monitoring by the midwifery team

Any Side effects are quickly eliminated  

Requires more active participation by the mother with less opportunity to sleep/rest between contractions 

Offers no post delivery analgesia. 

Editorial Information

Last reviewed: 17/01/2022

Next review date: 17/01/2025

Author(s): Tom Pettigrew.

Version: 2

Approved By: Obstetric Clinical Governance Group

Document Id: 618

References
  1. Royal College of Obstetricians and Gynaecologists Green-top guideline 55. Late intrauterine death and stillbirth. October 2010 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg55.pdf  
  2. Medical management of late intrauterine death using a combination of mifepristone and misoprostol. - Wagaarachchi PT, Ashok PW, Narvekar NN, Smith NC, Templeton A. 2002 Apr;109(4):443-7.
  3. intrauterine foetal death and delivery complications associated with coagulopathy: a retrospective analysis of 104 cases. -Tempfer, Brunner, Bentz, Langer, Reinthaller, Hefler in J Womens’ Health (Larchmt), 2009 April; 18(4): 469-74.