Synopsis
Confirm fetal death sensitively, identify maternal illness and potentially informative investigations, and provide safe birth planning and continuing bereavement care.
- Confirm absent fetal cardiac activity with real-time ultrasound by a suitably trained clinician; difficulty hearing a heartbeat alone is insufficient.
- Use clear compassionate language, allow time and privacy, and offer a support person and professional interpreter where needed.
- Evaluate maternal wellbeing and treat sepsis, abruption or hypertensive disease promptly; fetal death does not remove obstetric urgency.
- Offer investigations directed at cause and recurrence, including placental histology, consented genetic assessment and postmortem options.
- Repeat treponemal serology at presentation with IUFD regardless of booking status, as specified in the published correction to RCOG Green-top 55.
- Vaginal birth is recommended for most patients, with induction method and timing tailored to gestation, uterine scars, clinical condition and preferences.
- Offer lactation advice, VTE assessment, bereavement support and a named follow-up contact, and cancel routine pregnancy communications sensitively.
Key red flags
Fever, haemodynamic deterioration, severe abdominal pain, heavy bleeding or severe hypertension requires urgent assessment and treatment rather than routine bereavement-only follow-up.
After discharge, suicidal thoughts, inability to remain safe, chest pain, breathlessness, heavy bleeding or systemic illness needs immediate clinical help.
Investigation priorities
Demonstrate absent fetal cardiac activity and resolve any diagnostic uncertainty before birth planning.
Management branches
Assessment raises concern that the fetus may have died before birth.
- Arrange ultrasound confirmation while assessing maternal observations, pain, bleeding and possible infection or hypertensive disease.
- Communicate the diagnosis clearly in private, allow silence and questions, and offer chosen support and a professional interpreter when required.
- Provide a named maternity contact and begin time-sensitive maternal and causal investigations without overwhelming the patient with every decision at once.
Key medicines
Mifepristone before induction after late IUFDFor the RCOG combination induction approach, give mifepristone 200 mg orally as a single dose, followed by the gestation-appropriate prostaglandin regimen at the interval specified in the consultant-led induction protocol.Assess uterine scars, maternal stability, adrenal insufficiency, long-term corticosteroid treatment and product-specific contraindications; do not delay urgent birth simply to follow an elective interval.
Misoprostol for an unscarred uterus after late IUFDRCOG regimens after mifepristone are: at 24+0–24+6 weeks, 400 micrograms buccally, sublingually, vaginally or orally every 3 hours; at 25+0–27+6, 200 micrograms by those routes every 4 hours; from 28+0, 25–50 micrograms vaginally every 4 hours or 50–100 micrograms orally every 2 hours. Stop or withhold for established adequate labour, hyperstimulation or concern, using the unit's specified review and maximum-dose rules.This indication is off label in the UK. Do not apply these schedules automatically to a previous caesarean or transmural scar, particularly from 28 weeks; pharmacy preparation and accurate microgram dosing are essential.