Intra-uterine Foetal Death

The curriculum doesn't explicitly mention IUFD, though it is included because it appeared as an SAQ topic in both 2012 (50% pass rate) and 2017 (removed from exam due to ambiguous wording of the question).

In both SAQs, the bulk of the marks related to the impact of the condition on analgesic choices.

Resources

Late Intra-Uterine Foetal Death and Stillbirth (Green-top Guideline No. 55) (BJOG, 2010)
IUFD & Anaesthesia for non-obstetric surgery in pregnancy (Final FRCA Teaching, 2020)

Intra-uterine foetal death occurs in 0.6% of pregnancies

50% occur before 28 weeks' gestation
20% occur at, or near, full term

Ante-partum causes include:

Congenital malformation
Infection
Ante-partum haemorrhage
Pre-eclampsia
Gestational diabetes

Intra-partum causes include:

Severe maternal or foetal infection
Major obstetric haemorrhage
Cord prolapse
Idiopathic hypoxia-acidosis

Non-clinical aspects

The aim is to minimise the psychological distress endured by the patient
Patients should be managed in a quiet room, isolated from normal labour ward activity
Free access to patient for family members and partner can stay over
Psychological support service referral

Midwifery care

Mandatory 1:1 midwifery care
Experienced midwife
L1 care with regular MEOWS monitoring
Low threshold for escalation to L2 care if demonstrating signs of coagulopathy or sepsis

Obstetric care

Current practice is to induce early labour in order to:

Reduce risk of developing DIC or sepsis
Reduce psychological distress

The lack of need for concern over foetal welfare means high infusion rates of oxytocic drugs may be used, which risks overstimulation and uterine rupture
Occasionally require LSCS
No need for routine antibiotic prophylaxis, although careful monitoring for signs of sepsis
No need for routine chemical VTE prophylaxis

All patients should be offered the opportunity to meet with an Obstetric Anaesthetist to discuss analgesic options if they would like (RCoG Guidelines)
Initial anaesthetic assessment should involve excluding sepsis or coagulopathy via the presence of clinical features and blood tests

Coagulopathy

Standard rules of engagement apply with regards to neuraxial interventions
Normal FBC and clotting profile within 6hrs implies lower risk, though DIC can develop rapidly
Platelets <80x10⁹/L, an INR >1.4, an APTT >45s or an abnormal TEG should raise suspicion

Analgesia

Analgesic option	Example(s)	Advantages	Disadvantages	Notes
Inhaled analgesia	Entonox	Easily & rapidly accessible No effect on labour No need for procedure	Nausea Light-headedness Only moderately efficacious
Simple analgesia	IV paracetamol	Easily administered No effect on labour Safe	Only mildly efficacious Requires IV access Non-titratable
IM opioids	Diamorphine IM 5 - 10mg	No effect on labour Lasts a few hours Minimally invasive	Moderate analgesia only Opioid side-effects	RCoG Guideline recommends diamorphine over pethidine
IV opioids	Morphine PCA 1mg bolus/5min lockout Fentanyl PCA 10μg bolus/5min lockout	Effective pain relief Titratable	Requires IV access Requires SpO₂ monitoring ↑ Rate forceps delivery Opioid side-effects	Remifentanil PCA not suitable - better alternatives available
Neuraxial analgesia	Epidural or CSE	Effective pain relief Titratable	Requires IV access ↓ pushing ability Delayed onset vs. others Standard risks apply	↑ Risk of epidural haematoma (DIC) or abscess (sepsis) formation