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MRCOG PART 2 SBAs and EMQs

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ESSAY 338 - IUD

Posted by GULSHAN R.
Assesment include history taking, examination and relevant investigations.
History of any trauma,P/V/B should be asertain.Any intercurrent illness such as-fever,diarrhoea or deterioration of medical disorder such as -pre eclampsia,GDM & preexisting diabetes melitus,heart disease etc should be taken.
On examination-general condition of the patient should be assesed.Anaemia,dehydration,pulse ,blood pressure should be measure as these condition may cause fetal distress & reduced fetal movement.
P/A/E should be done to observe fetal movement,liquor volume and auscultate fetal heart rate.
If any doubt about movement or fetal heart sound-auscultate by doppler or reffer to USG to confirm viability.

(b)Patient will have to inform the diagnosis in a clear, sensitive manner.Partner and family should be inform.She may need time to react.Next step will be to discuss the available options about mode of delivery,investigations before and after delivery which may help to identify cause of death & which may help in management of subsequent pregnancy.
Investigations include-FBC to check Hb & WBC count to identify infections.Blood group & Rh typing should be done to see incompability and save blood.HbA1c & random blood glucose to screen diabetes melitus.Screen for infections-TORCH & Parvovirus,VDRL.Thyroid function test as thyroid dysfunction is a recognised cause of IUD.Lupus anticoagulant,anticardilipin antibody toidentify autoimmune cause.Thrombophilia screening should be done.Fetal karyotype should be done--amniotic fluid ,placental tissue or fetal blood.placental or feal swab for culture should be done.Patient should be counsell & consent taken for postmortem examination.Sensitive counselling if no cause is identify.
Baseline cloting function should be done for management purpose as there is chance of DIC in prolong IUD,placental abruption and in severe preeclampsia.
If any underlying cause is identify such as-conceled abruption or severe PE -treat.
Discussion regarding delivery-if there is no life threatening condition patient may go home & wait for spontaneous delivery with regular follow up by FBC & clotting. Otherwise IOL by unit protocol.Multidisciplinary team should be involve-senior obstetrician,midwife,psycologist& haematologist.
Adequate intrapartum analgesia should be maintain.Keep membrane intact as long as possible.Take precaution to manage PPH if any.
Encourage patient to hold the baby if she wish.obtain photograph ,hand & foot print.Arrange postmortem investigations if they give consent.
Arrange for resistration & funeral.
Inform GP & cancell any pending appoinment.
Manage breast engorgement by simple analgesia & firm support.if fail cabergoline is an alternative.
Arrange postnatal follow up to discuss the result of investigations &about contraception & future pregnancy.
Posted by Penelope T.
a) I would acknowledge this lady\'s anxiety. I would clarify further history including any antenatal problems to date. I would check the results of her Down\'s screening, antenatal bloods, anomaly scan and GCT. I would ask about recent vaginal bleeding or loss, pain or contractions, symptoms of infection and pre-eclampsia, and abdominal trauma.
Examination would include maternal pulse, temperature and blood pressure. I would then check the fundal height, lie and presentation. I would check for uterine tenseness or tenderness.
I would then attempt a CTG. If unable to find the fetal heart I would get a bedside ultrasound. If unable to see the fetal heart I would explain my concerns sensitively but would get a formal ultrasound immediately. Midwife and/or family member should accompany the patient in this setting.
b) I would arrange a private quiet room to counsel this lady and would ensure she had a supportive partner, family member or midwife presnt. I would explain the ultrasound findings gently and offer sympathy. I would use empathy, and allow time for grief, anger and questions. The patient and family may want time alone prior to further discussion. Some women feel guilt so it is important to emphasise that this is not her fault. When she is ready, I would go on to discuss delivery and investigation.
We should aim for vaginal delivery with induction usually by prostaglandins (although depending on cervical findings). Timing would be dependent on the mother\'s wishes, although it is advisable not to delay indefinitely due to the risk of developing a coagulopathy. During the induction and labour privacy should be ensured and one-to-one midwifery care employed. She should be allowed standard analgesia including epidural if wished. An active third stage should occur, and after birth, time to spend with her baby. The bereavement services and social worker should be notified and should see her prior to birth to make contact.
Maternal investigations should include HbA1C, Full blood count and Antibody screen. Serology for Syphilis, Parvovirus B19, TORCH should be taken. Additionally Kleihauer and antiphospholipid antibodies (anticardiolipin antibody and lupus anticoagulant) should be done. Follwing delivery maternal and fetal surface placental swabs should be sent for microscopy and culture. The placenta itself should be checked and sent for histological examination. The baby should be examined. Postmortem examination (full, external only or limited) shoudl be discussed with the parents and written informed consent obtained if they agree. Fetal karyotype should be performed.
I would review the lady postpartum to check her physical symptoms and answer any questions. I would offer lactation suppression with firm support/cold compress or cabergoline (needs to be given within 24hrs, rare side effects of liver abnormality or myelosuppression). I would discuss contraception and symptoms of postnatal depression.
Social worker and/or bereavement midwife should see the woman to discuss funeral arrangements, and should make regualr contact following her discharge from hospital. She should be given telephone numbers for these services and information regarding any support groups locally.
A follow up appointment would be made with the consultant to discuss investigations and possible cause and debrief the patient further. Her mental and physical state should be assessd at this visit. Future pregnancy should be managed as high risk, with specific risk of fetal death dependent on investigation results.
Posted by Im F.
a) Initial assessment for this healthy woman will include history regarding any PV bleeding or vaginal losses. Any history of viral infection in past few days should be explored. Her hand held notes should be seen to find out her detailed USG anomaly scan report and her first trimester screeing results.i would also inquire history of trauma and any recent history of nausea, headache and abdominal pain to rule out preeclampsia. Pysical examination should be done to see pulse, blood pressure temperature and any signs of anaemia. Abdominal examination to see tender uterus to rule out chorio,SFH(fundal height),whether co correlates well with pregnancy or not to rule out polyhydramnios or IUGR. A CTG should be done to see whether reactive or not? USG should be done for fetal well being, fetal heart and subplacental clots to rule out concealed haemorrhage. Doppler umbilical artery should be performed to rule out IUGR. Speculum examination should be done to see vaginal losses,bleeding and discharge. Swabs can be taken at the same time. She should be given support all the while.

b) This is a very distressing event for the patient. So, she should be approached sensitively. Possibly the diagnosis should be explored in a separate room in the presence of her partner if possible or in presence of some special midwife. Identification of underlying cause may help with grief and her future planning of pregnancy. The counseling should be sensitive as no cause can be found in most of the cases.
Investigations of IUD should be done according to unit protocol after counseling the patient and her partner. Fetal investigations will include detailed USG to find out any structural anomaly, polyhydramnios and hydropic changes. Fetal karyotype can be offered by amniocentesis. Maternal investigations will include routine FBC, U&E, LFT’s, coagulation profile,GTT, blood group and any abnormal antibodies (to rule out alloimmunization). Viral infection screening should be offered to rule out rubella, CMV, toxoplasmosis and syphilis. Thrombophilia screen should also be done to rule out antiphospholipid syndrome which is associated with adverse fetal outcome. After delivery, placental swabs should be taken as well.
Once the patient is emotionally stable, method of induction should be discussed with patient giving all the risks and benefits of each method. Induction should be done according to unit protocol on a suitable time acceptable to patient. DIC screen (though rare) should be done before IOL. She should be offered either prostaglandin (vaginal) followed by oxytocin or mifepristone and prostaglandin plus oxytocin according to unit protocol. Good analgesia should be given all the while with best support from midwife. Membranes should be kept intact as long as possible. Avoid operative delivery and perineal lacerations. Encourage mother to hold the baby. Photograph can be taken. Hand and foot prints of baby should be obtained.
Bereavement counseling, funeral and registration should be arranged. Breast engorgement should be managed with carbogolline. Her GP should be informed. Postmortem should be arranged if the couple agrees for it. Incident forms should be filled up. Postnatal appointment should be arranged (away from obstetric outdoor) to discuss postmortem and other investigations results. Plan for subsequent pregnancy should be made accordingly. Contraception should be discussed.
Posted by H H.
H
A healthy 25 year old primigravida presents at 36 weeks gestation with a 48 hour history of reduced fetal movements. (a) Discuss your assessment [5 marks]

Reduced fetal movement (RFM)should be considered seriously ,but in most of the cases the fetus is ok and this is just a subjective feeling. I would look at her notes for LMP , early dating scan to confirm dates , screening tests done for chromosomal or structural abnormalities or infections, symphysial fundal heights(SFH) and growth scans. I would measure her SFH ,as 1/3rd of patients with RFM have growth restricted feoti, and do a CTG. Should the SFH be ok and CTG is reactive I would reassure the patient. Should the SFH be reduced, I would ask for ultrasound fetal biometry (abdominal circumference AC and expected fetal weight EFW ) and amniotic fluid index AFI or deepest vertical pool DVP. Should the AC/EFW be below 10th centile or AFI less than 5th centile or DVP cord free ,less than 2 cm , I would do umbilical artery Doppler blood flow ,should the latter be also abnormal ,would necessitate more monitoring and might need intervention if CTG is also non reassuring or abnormal.
(b) Intra-uterine death is confirmed by ultrasound scan. Discuss your subsequent management
I would a sympathetic attitude in breaking the bad news. I would tell her that nothing she could have done or omitted ,would have caused this. I will give her time to pull her self up. I would tell her that there ae investigations that will be done to seek for a cause to reduce its recurrence, but in most of the cases no cause is found. I would explain what need to be done next. She can either opt to wait till spontaneous labour starts, this usually takes some weeks with no danger on her but she is followed up with weekly coagulation screen , or opt to have her labour be induced and this will include the use of prostaglandins. Privacy will be ensured during her delivery.
Investigations to detect the cause would include ultrasound which would have shown hydrops, structural abnormalities or evidence of intracranial calcification denoting infection. Maternal blood for group, red cell antibodies, kleihauer test if suspect feto maternal hemorrhage, hemoglobin electrophoresis if ethnic origin, IgG and I gM antibodies for TORCH infection. Lupus anticoagulant and antinuclear antibodies done 6 wk after delivery to avoid false positive results.
Patient is counseled regarding postmortem examination PM( aim,to detect a cause, types full,limited,externalexamination, procedure incisions, macroscopic exam fetus and placenta ,microscopic exam, organs will be replaced again parts might be kept for research, photographs and radiology pictures will be taken for future keeping, PM will not interfere with funeral arrangements, PM might not detect a cause and so recurrence of the condition would be minimal, PM will not interfere with her later holding and seeing her baby, written information given)
Patient will need bereavement counseling after delivery and taken through the whole process of mourning and grief and be sure she overcome grief. Social worker will help.She is given address of support groups like SANDs.
I would discuss with her funeral arrangements and will arrange with her an appointement with the consultant.


Posted by sonu P.
a) The patient must be very anxious, so should be seen without delay. I will ascertain if she is had any antenatal care or not.If she is booked,I will review her notes to look for any high risk factor like DM, PET, associated medical condition and the course of pregnancy till date. Also, I will ask her about SROM, PVB and abdominal pain. On examination, systemic review is only needed if she has pre-existing conditions or system specific complaints. A note of BMI is made. I will check her BP and urinalysis result. I will measure the SFH and plot it on a customised growth chart which takes ethnicity, age, parity into account to minimise errors. I will ascertain the lie of the fetus. A cardiotocography is done after ascertaining the heart beat with a pinard. An USS is requested in case of failure to locate fetal heart.

b) A diagnosis of intrauterine death in a healthy young patient is associated with significant distress. The patient should be seen promptly and approached in a sensitive and empathetic manner. It is advisable to see the patient in an room dedicated for the purpose with no interruptions; preferably with a family member or a midwife attending with the physician in order to give emotional support after the consultation. I will explain the diagnosis to her.It is likely to be followed by various responses to bad news-like sadness, anger, denial and blaming herself. I will tell her that she has not done anything that has caused this. I will give her the option to discuss further management immediately or allow her time, if she wants.I will tell her the process of induction of labour in the form of mifepristone followed by misoprostol 48 hours later or with vaginal prostaglandin, as per unit protocol. I will reassure her that a short delay in induction is not likely to harm her physical health in any way. I will involve the unit bereavement midwife for counselling and support. I will alert the patient about the detailed investigations to find out the cause of death and also initiate the talk about post-mortem, to be discussed in detail later on. When in labour ward, patient should be supported adequately and informed all the time. Patient’s wishes of seeing the baby, taking footprint and pictures and other requests should be respected. Lactation suppression should be offered with bromocriptine or cabergoline. The patient is offered a postnatal follow up appointment with consultant to discuss the investigation and plan for future pregnancy.
Posted by Syamala H.
syamalah
ansa:patient is likely to be anxious, a sympathetic attitude is required.assesment of presenting complain to know whether decreased fetal movement present through out the day or only during certain hours of the day which might be just due to fetal sleep cycle.also her activityduring the last 2 days as a busy mother maynot be able to concentrate on fetal activity. any h/o abdominal trauma, association with pain and tightness in abdomen or vaginal bleeding that will indicate abruption,any h/o pv loss,fever as pprom with chorioamnionitis can lead to similar complain. h/o headach visual symptoms and epigastic discomfort will indicate preecclampsia. h/o fever rash and flu like illness which indicate viral infection.itching in palm sole associated pale stool and dark urine will indicate cholestasis.ask about family h/o sickle cell anemia or thalssemia and inborn errors of metabolism. will also take h/o illicit drug abuse ,smoking and alcohol intake.also review her antenatal records to see for her screening for an aneuploidy and anamoly scan.to know whether she had been screened for diabetes. her growth scans including the last scan and see for fetal growth and IUGR ,liqour volume and any placental grading. and her blood report for group Rh and antibodyscreen to identify risk of isoimmunisation.
examination will include her BMI and BP. see for pallor jaundice lymphadenopathy and edema.per abdomen palpation for fundal height including symphysiofundal height measurement to see for intruterine growth restriction.auscultation of fetal heart and ctg. ctg is useful for acute hypoxia and she should have and ultrasound for confirmation of fetal heart activity, liqour volume to see for oligoamnios and fetal biometry to see for presence of growth restriction.further managment will depend on the finding of ultrasound and womens perception of fetal activity.
ansb
patient has to be sensitivity told about fetal death preferably in presence of partner or family member as fetal loss is devastating experience for expectant parents. there might be initial anger reaction or feeling of guilt which should be appropriatly delt. they should be given some time to come in terms with the condition. she should be told that it is important to identify the cause of fetal death as it will effect her future pregnancy managment. this would require for her to undergo battery of test and tests would be done for baby and the placenta. also it is advisable that an autopsy and cytogenetic analysis is done for baby after delivery.
mother should be tested for blood group and Rh status and antibody screen to identify alloimmunisation, kliehauer betkes test to see for fetomaternal hemmorhage. Hb electrophoresis for hemoglobinopathies.coagulation study. infectious screen for TORCH,parvovirus,listeriossis and syphlis. liver function and bile salts to look for hepatisis and cholestasis. blood sugar and HbA1c for diabetes. lupus anticoagulant anticardiolipin antibody and APTT for APS. screening for thrombophilia. anti Ro antibodies if fetus is hydropic. urine for tested for protienuria. urine for drug screening if h/o is suggestive.anti D should be given for Rh negative with kleihauer testing.
planning for delivery should be done in consultation with the mother. indications for immediate delivery include signs of sepsis. if condition of the mother stable with no signs of sepsis and if she`s willing expectentant managment can be done. 80% will have spontanous onset of labour in 2 wks. indication for cesarean are major degree placenta previa or other contraindication for vaginal delivery.induction of labour by PGE2 or mifepristone and misoprostol can be done. later regime reduces induction delivery interval but dose of misoprostol should be reduced to 100 mg. care during labour should be given in a seperate dedicated area in labour room and allow partner or family member to stay.provide adequate analgesia in form os diamorphin or epidural if coagulation normal.
memberane should be left intact to aviod ascending infection. low threshold for antibiotic is recommendated. active managment of third stage as increased risk of PPH.retained placenta can occur due to either choriamnionitis or recurrent small abruption.
after delivery fetal blood/skin/sample from iliac crest can be sent for karyotype. blood for infectious screen. and full fetal x-ray. fetus should be send for a autopsy after consent. placental swabs is taken for infection and it should be send for histopathology. counselling by bereavement team and arrangment for funeral can be made dependindg on parents wishes.arrangement for death cetificate and registration of baby has to be done.
adequate analgesia for mother after delivery and suppression of lactation by single dose cabergoline. dopamine agonist avoided in preecclampsia and personal or family history of thromboembolism.
contraceptive need should be discussed. if no medical illness complicating pregnancy she can concieve before first period. early conception delays the grieving process. support group like SAND can offer some solace to grieving parents. folow up can be arranged after2 wks as provisional report of postmortem would be available and this can be discussed.it is important that grieving is complete before she concieves again. plan for future pregnancy can be made depending on the identified cause of dearh.
Posted by Kiran  J.
A healthy 25 year old primigravida presents at 36 weeks gestation with a 48 hour history of reduced fetal movements. (a) Discuss your assessment [5 marks]. (b) Intra-uterine death is confirmed by ultrasound scan. Discuss your subsequent management


A:I will take history of vaginal bleeding and pain abdomen/uterine contractions to rule out abruptio placental APH .History of pyrexia,dizziness or feeling unwell,offensive vaginal discharge and leakage of amniotic fluid.Any history of trauma.History of non specific upper respiratory tract symptoms such as cough,soar throat,fever generalized muscular aches and pains with +- rash/lymphadenopathy as viral infections can present like this. Any symptoms hinting of pre-eclampsia ie headache,epigastric pain or visual symptoms.I will ask her any history of recent onset of itching(particulary on palmer surface of hands and soles of feet) without rash .Important to know history of smoking,alcohol binging or use of illicit drugs.I will check her hand held notes for records regarding Down screening and booking bloods for Hepatitis B/vdrl ,Blood group and Rh factor and any fetal abnormalities detected on dating and 20 week scan.Examination constitutes bp check to detect hypertension,abdominal examination to look for tenderness,palpable fetal\\parts and fundal hieght as 29% cases of reduced fetal movements can be associated with IUGR.I will check her for pedal edema ,brisk reflexes and clonus.I will attach a CTG on for an EFM tracing and if not detected an USS to detect fetal heart,fetal biometry and liqour volume including Dopplers if the former present.

B.I will assist her in a private room and sensitively inform her of the sad diagnosis.Offer her my condolenses,if her partner/family not present ,offer her a chance to call them to be with her in this difficult time.Give her time for the news to be accepted and provided she is well with no acute problems like Pre-eclampsia/abruption can go home and return for consultation.
She can be managed expectantly or by Induction of labour.If she is well with no history of trauma,PET,abruption,,placenta previa ,she can be managed expectantly if she wishes with a community midwife to check every 2 days and she should be aware of risk of DIC difficulty gross examining fetus due to advanced maceration.
if she decides for induction of labour than mifepristone can be given as cervical priming agent followed by misoprostol 36-48 hours later for which she can return.verbal and written information is provided by trained staff and follow standard operating procedures and protocols of the unit.FBC,Coagulation and blood group check and provide emotional support and pain relief (pca,epidural )during labour process.Staff should be aware of increased risk of PPH nad placental retention so active managemnt of 3rd stage.Membranes should be kept intact as late as possible due to risk of infection.If any signs of chorioamnionitis, give antibiotics I/V.Once baby delivered she is offered the choice to see the baby and cuddle ,momentos including hair lock,foot and hand print and photographs after dressing the baby can be made and given to her. she is provided information regarding investigations and consented for it on formal consent forms.Investigations include FBC,Coagulation ,blood group and Rh factor and antibodies.A Kliehaur Betke test to detect Fetomaternal haemorhage.HbA1c to detect diabetes mellitus of mother,Lupus anticoagulant,anticardiolipin antibodies and anti nuclear antibodies for Anti phospholipid antibodies.IgG and IgM by Enzyme immunassay for CMV,Toxoplasmosis,Rubella and Parvo virus.Screening for thrombophillias can be done if family history in which case Factor V leidin,Anti thrombin 3 ,factor C and factor S levels.LFTS and Bile acids if suspicion of Obstetric cholestasis.
She is informed verbally and written information vise regarding post mortem examination that it can be helpful in diagnosing the cause but in small percentage cause may not be found .Her baby will be returned to her in the same way at the time of birth.A standard consent form needs to be signed by the parents if they agree for a post mortem.All body organs will be returned to the baby and no organ shall be retained.In case a CNS abnormality is suspected the brain may take long time to fix,in this situation she can either forego the postmortem or delay the funeral services or arrange funeral without the fetal brain which can be either returned or sensitively disposed according to familys wishes.Her wishes for a private funeral/cremeation or a hospital arrangements are enquired and consented for.In case she doesnt wish a post mortem then she is offered and taken consent for photographs,Body Xrays,Babys skin biopsy ,placental cytogenetics karyotype and culture and sensitivity test.If parents wish arrange for a blessing/prayer/Baptism by the hospital pastor/religious needs inchage. Information is imparted regarding Charities like SANDS which can be helpful in bereavement period.
She can go home when feeling well and no medical indication to stay in hospital.Inform GP and midwife to cancel her antenatal follow up.A death certificate has to be issued for all still births above 24 weeks.Important issues are supression of lactation which can be done by Bromocriptine and contraception adviceif requesting.
Clear plan should be documented in her notes and arrange follow up once all the investigation results are ready and plan of care( for her next pregnancy.
Posted by R v P.
RVP

A healthy 25 year old primigravida presents at 36 weeks gestation with a 48 hour history of reduced fetal movements. (a) Discuss your assessment [5 marks].
She should be attended to without delay as she could be very worried as well as the reduced fetal movements may indicate impending fetal demise.
Checking her hand held and hospital records to findout recurrent episodes of reduced fetal movements (RFM) is important as she may need further investigations such as an obstetric ultrasound scan even if the fetal movements are felt by the mother. Her notes will also reveal previous abnormal scan findings such as presence of anomalies in the 20 week scan that may increase risk of IUD. In addition, IUGR and reduced liquor may have already been detected if she has had subsequent scans after 20 week scan. Abnormal doppler such as absent end diastolic pattern may already have been diagnosed but in such cases it is likely patient would have already been admitted.

Recent fever, malaise may indicate maternal infection. She may give a history of PV loss suggestive of SROM. She may also give a history of bleeding recently which could be an indication of abruption.
Maternal observations including pulse BP and temperature should be noted to to exclude infection and raised blood pressure. Urine should be checked for protein, lecocytes and nitrites.
Fetal heart rate should be located with a portable doppler or CTG probe. Maternal pulse could be palpated to distinguish between the two. Once the fetal heart rate is picked up, a formal CTG should be completed according to the unit protocol (ie if a computerised CTG is used, until the Dowes /Redman criteria is met and the mother has felt movements during the CTG which could be documented on the CTG by pressing the device). If this is the first presentation, the CTG is reassuring and the mother felt plenty of movements, then she could be reassured. If the fetal heart could not be located with CTG, real time USS should be performend urgently. A four chamber view of the heart should be obtained and observed for at least two minutes. If heart pulsations are absent, colour doppler could be applied to detect any blood flow with in the chambers to confirm asystole. If the heart beat is located with USS, then monitoring should continue with the CTG.

(b) Intra-uterine death is confirmed by ultrasound scan. Discuss your subsequent management

This should be explained to the mother and family. The news is very distressful to them and therefore the approach should be sympathetic. They might want some privacy to absorb the news and this should be respected. It is appropriate to move the patient to a dedicated private room if this is available. The oncall consultant should be informed. The unit protocol for the management of IUD should be followed. Mother and family should be offered bereavement counselling.
Further management including delivery and maternal and fetal investigations should be discussed with the patient and family when they are ready.
Written information should be provided to support clear verbal advice to make an informed decision. With regards to delivery both expectant management and immidiate induction of labour (IOL) should be offered to the patient. Advantages of expectant management include less interventions and less pain during labour. Disadvantages include risk of infection and DIC especially with prolonged delay of onset of labour. If she choose IOL, oral mifeprestone (400mcg)should be given to her follwed by prostaglandins or misoprostol 48hrs later according to the unit protocol. Pain relief during labour should be offered to her. If she choose expected management, home management may be appropriate with clear instructions to return if signs of infection, bleeding or once she is in labour. Regular follow up should be arranged to all patients on expectant management.
Investigations to explore possible cause of IUD should be offered to her. Maternal investigations include FBC, group, Rh and anti bodies, baseline renal and liver functions. In addition baseline clotting studies and thyroid functions should also be performed. Thrombophilia screening should also be offered to her. For anti phospholipid syndrome, ANA and cardiolipin antibodies should be repeated 12 weeks later.
Parents shoud be offered karyotyping. Placenta should be sent for histology. External examination of the fetus should be completed and photographic evidence included in the case notes. Swabs from placenta and fetus should be sent for microbiology. If the parents wish, foot and hand prints, lock of hair and photographs of the fetus should be provided to them.
Hospital post mortem should be discussed with the parents as it may help to find the cause of death. They should be informed that no cause may be found on PM. If the parents agree, written consent should be obtained for either limited or full PM.
Brest milk suppression should be offered to her with cabergoline. .
Death certificate should be provided to the family without undue delay to help with the registration and funeral arrangements. Hospital chaplaincy services should be offered to her.
Her community midwife and GP should be informed before the patient is discharged to the community. Prior to discharge, patient should be given a follow up appointment with the consultant responsible typically around 6-8 weeks time to discuss test results and plans for future pregnancy. Contraceptive advise should also be provided to her prior to discharge.
Posted by Mohamed D.
Mohamed
(A) Check her handheld maternity notes for dating scan, anomaly scan or any further scans for any congenital problems in the fetus, placental site or growth restriction. Also check if there are any events during the antenatal care like infections, bleeding or reduced fetal movements earlier. Any history of rupture of the fetal membranes should be checked. Any history of feeling unwell as it may indicate infection.
Examination for temperature if there is a possibility of infection. BP, Pulse and her general condition should be checked, as maternal infection could be suspected. Abdominal examination to check fundal height, as FGR could be a cause for the condition and warrant further follow up. Any abdominal tenderness as she may be in labour, having abruption or intra uterine infection. Check FHS with a Doppler for reassurance. CTG should be done for reassurance and ultrasound if FHS could not be found on listening with Doppler.

(b) Explain the findings to her in a sensitive manner in quite area. Give her time to absorb the situation and ask her if she would like her partner to be present or any family member. Support the partner as well as he has lost his baby. Reassure her that this not something related to her fault. She should be counselled for either to start induction of labour or to wait for some time as she may enter into spontaneous labour. If she opt to wait, send blood for group and serum save, FBC for lucocytosis and CRP as both may indicate an ongoing inflammation and treatment. Check her clotting parameters if the fetal death is not recent, as this may lead to DIC.
Induction of labour she be offered using mifepristone oral 200mg then misoprostol after 24 hours or as the unit protocol. Written information should be provided for the whole process. Pain relief should be offered once she is in labour as epidural or morphine derivatives. Patient wishes should be respected. Active management of the third stage to guard against post partum haemorrhage. Caesarean delivery only for obstetric indications as palcenta previa or transverse lie in labour. In case of suspected infection or chorioamnionitis, antibiotics should be started. After delivery offer her time with the baby and offer photos, footprints, and hair, if she decides for that. Offer her advice about post mortum examination to identify the cause of death if possible and provide he with written information to make an informed decision. Swab the placenta for any infection and send it for histology to identify any cause of death. Bloods should be sent to check for fetmaternal haemorrgae as Kleihauer test. Send maternal bloods for thrombophilia screening and repeat again in 6 weeks. Offer her cabergoline to suppress breast milk production. Offer a postnatal appointment with the consultant to discuss the results of investigations, and advise about future pregnancy.
Posted by Bee N.
A healthy 25 year old primigravida presents at 36 weeks gestation with a 48 hour history of reduced fetal movements. (a) Discuss your assessment [5 marks]. (b) Intra-uterine death is confirmed by ultrasound scan. Discuss your subsequent management

(Bee)
A) I will start by ask if she has had any associated abdominal tenderness or per vaginal bleeding which may signify possible abruption. I will ask id she has had any fluid draining from her vagina( ? Liquor). I will ask if she has had any previous or recent flu like illness that may signify viral infection which may have affected the baby. I will ask if she has taken any drug or medication such as opiods or sedatives that may have sedated the baby. I will ask if she had anomaly scan and if any abnormality(congenital anomaly). If any abnormality in anomaly scan, I will review the results. I will ask if she has has any growth scans in this pregnancy and if so review the result to exclude small for gestational age.
I will examine for anaemia, jaundice/oedema which may be recent developments. This will indicate possibility of anaemia and HELLP/pre eclamsia respectively. I will take her BP which is high in pre eclampsia, Pulse and temperature which is high in infection. I will palpate her abdomen to estimate uterine size and measure symphysiofundal height to detect small for gestational age. I will check for lie and presentation in case delivery is needed.
I will commence a cardiotocograph to detect fetal distress, noting that cardiotocograph is very sensitive in detecting acute fetal distress but no so sensitive for detecting chronic hypoxia.
I will take urine for urinalysis which may detect glycosuria (diabetes) or proteinuria( pre eclampsia)
I will take bloods for FBC to detect anaemia, CRP to detect any infection, LFT, U&E which may be deranged in HELLP or pre eclampsia.
Often patients beginning to feel movements once reassured by CTG but if not I will want to arrange for USS to check for growth and liquor volume while informing patient that this is not a sensitive test to detect fetal distress in low risk pregnancies but may detect SGA.

B)I will inform consultant obstetrician on call and approach patient preferrably with a midwife .I will choose a quiet room and discuss findings with patient and her partner in a sensitive and sympathetic manner. I will give then a short time together afterwards to assimilate diagnosis and grieve.
I will inform patient of the possible cause if known and inform her that investigations can be carried out to find the cause if not known but often no cause is found. I will then inform her that process of induction can be started off immediately if labour ward is able to accommodate it or it can be scheduled for the next day or two depending on her wish. I will inform her that short delays her usually not detrimental but long delays can cause disseminated intravascular coagulation. When she comes in for induction,I will take bloods in not already taken for FBC, group and save and coagulation screening and kleihauer( isoimmunisation). I will follow the unit protocol of management which may include use of prostaglandin and oxytocin. I will ensure adequate analgesia throughout induction. I will try to avoid early rupture of membrane. I will also try to avoid operative delivery as much as possible. I will manage third stage avtively to minimise blood loss and administer anti D prophylaxis if appropriate.
Afetr delivery I will allow mother to handle baby if she wishes and to take photographs and hand/leg prints. I will examine baby immediate to see if any obvious physical abnormality. Before discharge from hospital, I will discuss post mortem with patient. I will tell her this may help find out cause of death but may show no positive results. I will inform her of registration of death and fill incident form.I will infrom her that the hospital may help with burial or she may choose to do it herself if she wishes. I will arrange follow up to discuss cause of death and management of next pregnancy which should be in a consultant led unit. I will offer medication to suppress lactation and discuss contraception if she wishes. I will inform her of bereavement groups which she may attend for further help and ensure follow up to make sure she is able to cope with the process. There must be a clear documentation of all discussions and plans made.
Posted by A A.
. AA (SA)
(a) I will assess her general condition and ask more about symptoms associated with reduced fetal movements. Pain abdomen or contraction associated with vaginal bleeding in placental abruption. History of watery vaginal discharge. History of itching to rule out obstetrics cholestasis. History of alcohol, smoking, or any sedating drugs can lead to this problem. I will ask about her job and daily activities as she is very busy not concentrating on fetal activity. I will review her antenatal record, anomaly scan and if any serum screening done early in pregnancy. Any recent ultrasound in third trimester. EXAMINATION includes checking BMI, BP, pulse rate and temperature. Urinanalysis for protein, blood, nitrite and glucose. P/A abdominal palpation for contration to feel, any tenderness, lie and presentation of fetus. Symphysial fundal height (SFH) and to plot on customized chart. Auscultation of fetal heart beat and to advice for CTG for 20 mins. Ultrasound for fetal biometry, liquor volume and placental localization. Doppler studies in case of SGA/IUGR. Vaginal examination if complaining of contractions or vaginal loss. If any none reassuring maternal or fetal condition than I will deal accordingly. She will need admission in case of abruption, pre eclampsia and IUGR. If maternal and fetal conditions are reassuring I will discharge her home and advice to return if any concerns. Provide her written information about her condition and follow up appointment.
(b) This condition is associated with maternal emotional distress. Explain the finding in supportive and sympathetic way. Ask if she want to call her partner or any friend to be with her. Give her time to believe the finding. Reassure her that nothing she has done or omitted for this condition. Treat cause if found like abruption or pre eclampsia. She needs sensitive counseling as cause is unknown in majority of cases. I will follow up unit protocol for routine investigations for intrauterine death. Investigation included maternal blood and detailed fetal ultrasound before delivery. Fetal and placental investigations after delivery. If she is not in labour advice for induction of labour with prostaglandin and oxytocin as unit protocol. Provide adequate intrapartum analgesia in labour. Keep membrane intact as long as possible. Avoid delivery by C/S and operative vaginal delivery. In case of macrosomic fetus delivery should be by experienced person to avoid perineal lacerations if at all possible. After delivery consider maternal wish if she want to see baby or not. Baby should be seen by neonatologist to find any abnormal appearance or any specific syndrome. Discuss with parents about postmortem to make diagnosis and complete investigations. Postmortem may not identify cause in all cases. Breast engorgement by simple analgesia. Provide cabergoline if suppression of lactation needed. Arrange post natal follow up to discuss postmortem report if done and all other investigations done and plan for subsequent pregnancy. I will discuss contraception with her. Inform her GP and cancel any pending antenatal appointment .Provide support group detail and their contact numbers
Posted by S P.
will ask if the movements are less throughout the day or at certain times , her activity in the past two days. any associated h/o pain , if present its nature . any bleeding or loss of liquor . will ask if any h/o trauma will also take h/o any febrile /flu like illness during present pregnancy . any symptoms suggestive of PET such as head ache / nausea / epigastric pain. any features of OC i.e itching , pale stool / dark urine .H?O drug abuse / alcohol and smoking .F?H - thombophelia . Ethnic origin to be noted. confirm gestation from lmp.. her antenatal records need to checked , if anomaly scan was done .Examination would includeBP , BMI .urine dip stick abdominal examination to assess SFH , lie presentation , tenderness, any palpable contraction, check fetal heart . speculum examination if history suggestive of loss of liquor. if fetal heart heard , do bpp and ctg to acertain fetal wellbeing. investigation would include scan to assess fetal welbeing . doppler umlical artery if iugr/ any other anomaly and in case suspecting iud detail scan to confirm diagnosis and look for any fetal anomaly.
B the findings should be sympathetically explained to the women if possible in the presence of partner / family member.Will give her time to come in terms with the loss . further advice her to have certain tests which will help identify the cause of death and help in the grieving process.these would include blood tests , FBC blood gr- antibody titre , kleihaur test [ r/o fetomaternal bleed - to be done immediately rather than waitinf g for delivery ] , HbAic , test for APS - lupus anticoagulant , anti cardiolipin antibody ,screening for thrombophelia ,screening for infection - TORCH , EBV , Shyphilus , LFT , Coagulation profile ,HVS and urine for microscopy and culture. further information can be attained if, placental swabs , HPE , karotyping done and babies swabs, karyotype ,postmortem are done following birth , meeting with pathologist should be arranged and prior consent taken for the above procedures.she should be informed after all these test there is possibility of not finding the cause if there is no maternal indication for delivery such as APH , PET , Coagulopathy she should be offered expectant management /active management aiming for vaginal delivery , c/s for obstretic indications only such as major placenta previa. usually spontaneous labour will occur within 2-4 weeks , however weekly monitoring of coagulation profile will be needed , she can revert to active m/m anytime during this period . or she can be induced on a day suitable to her , mefiprestone orally can be given 24-48hrs prior to the day of induction followed by PGE2/Misoprotol as per unit protocol , this reduces the induction to delivery interval , oral mifeprestone can be omitted if she wishes immediate induction .risks and benefits of both methods should be explained , informed consent to be taken . analgesia during labour should be discussed , epidural can be provided if coagulation profile is within normal.Labour should be managed by senior obstretician , partner support during labour should be encouraged . 1:1 midwife to look after the women.adequate analgesia should be provided. Amniotomy to be delayed as long as possible to prevent acending infection .perineal trauma , instrumental deklivery avoided as far as possible Increased risk of Pph , active management of 3rd stage with uterotonics as per unit protocol , possibility of adherent placenta due to chorioamnionitis to be kept in mind. after delivery women should be allowed to hold the babby if she wants. adequate analgesia , milk supression with - cabergoline/ bromocriptine, antibiotics if indicated. arange postmortem if consented for . help from socail workers /support team to help in arrangement for registeration /funeral and breaving process. contacts of local supprt groups to be given. Gp to be informed . future ANC appointments cancelled , contraceptive advise given and follow up for investigation results and clear plan for next pregenancy documented in the postnal visit
Posted by Chitra.s M.
A.History of leak/bleed pv and abdominal pain is enquired about.History of materal smoking,alcohol or recreational drug use is noted.Records are reviewed for presence of fetal anomalies or growth restriction.The woman is examined to note her BMI,pulse, temparature and BP.Abdominal examination is done for uterine size, contractions and tenderness.Presence of fetal heart sounds are checked with hand held doppler. Simultaneous palpation of maternel pulse is done to rule out maternal recording.If fetal heart sounds are localised,CTG is done for fetal well being.IF the CTG is normal and mother appreciates good fetal movements, she is reassured. If the fetal heart cannot be localised with doppler,request for immediate USS is made for confirmation of viability.
B.A sympathetic approach is adopted and the woman is informed about the fetal death inutero in a private room preferably in the presence of her family/partner.Time is given for them to take in the news.Discussion of further management is done when they are ready.Immediate labour and delivery is recommended in the context of ruptured membranes,evidence of infection and active pv bleed.If the woman is well ,choice of expectant management is discussed with the information that weekly screening for DIC is needed.Mode of delivery is discussed with the information that vaginal delivery can be achieved in majority of the cases.The couple are counselled about the postmortem examination of the baby as it can help identify the cause of death and help in prognosis and management of future pregnancies.Written information is provided and maternal wishes regarding the timing , mode of delivery and views on postmortem examination of the baby are recorded and she is supported in her choice.Maternal investigations include FBC for evidence of infection and platelet counts,Kliehauer test for fetomaternal haemorrhage and guiding anti D dose if the woman is Rh negative.Coagulation screen is done for DIC.Infection screen for syphilis and TORCH is done.Blood sugars and HbA1c are done for diabetes.LFT and bile acids are done for evidence of obstetric cholestasis.Screening is done for heriditary thrombophilia and antiphospholipid antibodies.Parental karyotyping is done for evidence of balanced translocations.Labour is induced by oral mifepristone followed by oral or vaginal prostaglandins(E1/E2) according to unit protocols.She is cared for in an area away from the sounds of other women and their babies.Supportive one to one care is provided .Analgesic needs are assessed and regional analgesia can be provided if coagulation studies are normal.Membranes are left intact to minimise infection.Antibiotics are given according to unit protocols.Active management of third stage of labour is done.cesarean section may be required for obstetric indications or maternal request.Mother is supported in her choice regarding holding the baby.Baby ,placenta and cord are sent for postmortem examination after taking consent.fetal and placental swabs are sent for infection screen.Lactation supression is provided with cabergoline.Psychological support and counselling is provided to the parents with the involvement of bereavement officers.Funeral arrangements are discussed.Support group details like SANDS is offered.Medical certificate of still birth is issued to enable birth to be registered.Information about contraception is offered before discharge from the hospital.All antenatal appointments are cancelled and the community midwife and GP informed.A follow up appointment is made to discuss results of the investigations, identify any psychological issues and for planning of future pregnancy.
Posted by Ir A.
If
a) I will ask her whether she has any abdominal pain or contractions, leaking liquour or bleeding from the vagina. I will take history of any symptoms suggestive of preeclampsia, ie headache, blurring of vision or epigastric pain. I will take her blood pressure and check urine for proteinuria. I will ask for any generalised pruritus which may be suggestive of cholestasis. I will also review her antenatal records and last ultrasound scan for fetal growth parameters. I will do an abdominal examination for fundal height, fetal lie and presentation, palpable contractions, uterine tenderness and auscultate the fetal heart. I will do a CTG to assess fetal wellbeing.

b) I will explain the diagnosis to the mother in a sensitive and empathic manner and offer her my condolence. This is bound to cause significant distress to her and I will encourage her to inform her partner or family. If she is accompanied by her partner, i\'ll give them time to come to terms with the diagnosis and console eachother.
Once they are ready, I will explain that she will require some investigations and discuss the options of induction of labour versus awaiting spontaneous labour. 80-90% of women with IUD will go into spontaneous labour within 2 weeks; however there is risk of disseminated intravascular coagulopathy (DIC). I will do a full blood count, platelet count and coagulation screen. An indirect coomb\'s test and kleihauer test should be done for atypical antibodies and fetomaternal haemorrhage. A thrombophilia screen including antiphospholipid antibody, lupus anticoagulant, factor V Leiden mutation and protein C and S should be done. HbA1c should also be done but is unlikely to be abnormal in a healthy 25 year old. Liver function test, blood urea and serum creatinine will provide information about obstetric cholestasis, preeclampsia or occult renal disease. A high vaginal swab should be done for group B streptococcus. On ultrasound, one should look for spalding\'s sign, fetal hydrops, AFI and estimated fetal weight.
If she agrees for induction of labour, options include prostaglandin E2 or oral mifepristone followed by vaginal misoprostol after 48 hours. She should be managed in a separate dedicated space in the labour ward where her partner or family member may accompany her. She should be offered adequate pain relief. She can take epidural if coagulation profile is normal and platelet count is more than 85 thousand. Membranes should be left intact as near delivery as possible to minimise risk of infection. Syntocinon may be used for augmentation of labour if needed. A low threshold for giving prophylactic antibiotics should be kept. Care should be taken to preempt and avoid perineal trauma with adequate perineal support and avoidance of instrumental delivery. She is at high risk of PPH and third stage should be managed actively. The parents should be allowed to hold the baby after deliver and encouraged to take photographs or keep mementos. Postmortem of the baby should be sensitively discussed with the parents assuring them that the baby will be dealt with dignity and respect and informed consent obtained. Placenta should be sent for histopathology and cytogenetics. The services of the bereavement staff of the hospital should be offered which will help the couple in arranging funeral services. The mother should be given cabergoline 0.5 mg single dose for lactation suppression. They should be given contact information of support groups like SANDS (stillbirth and neonatal death support group). A further appointment should be given to discuss the findings of the investigations and postmortem and planning future pregnancy. Contraception should be discussed.
Posted by A- N.
AA
a) The intial assessment includes a taking a detailed history and review of the antenatal notes to identify the risk factors such as Small for gestational age, intra uterine growth ristriction and evidence of placental insufficiency by looking into the records of serial symphysio fundal height recordings.
I would look into the 20 week anomoly scan results to check for placental position as with anterior placenta, the patient may be less receptive to foetal movements.
In the history I would ask about any previous history of similar episode, any history suggestive of preeclampsia including headaches, bluring of vision. Any history suggestive of antepartum haemorrhage including sudden onset of abdominal pain or bleeding pervaginum is enquired to.
I shall enquire about history of smoking which may cause IUGR, alcohol abuse and any history of substance abuse or using precription drugs as benzodiazapenes as these may cause decreased fetal movements or pre dispose to IUGR and abruptio placentae leading to decreased fetal movements as in the case of substance abuse.
I would also enquire about her employment history to check if she is too busy to have time to spare time to feel foetal movements.
In general examination I would check for blood pressure to identify pre eclampsia. Abdomional examination to check for epigastric or hypochondrial tenderness to identify imminent preeclampsia.
I would measure the sympyso fundal height and plot on coustumised growth chart to identify for suggestion of iugr. I would feel for any uterine tenderness which may suggest abruptio placentae.
then i would check for the foetal lie and presentation which in non cephalic presentations may present for decreased foetal movements.
Next I would check for foetal heart sounds if present patient is reassured
If this is a reccurrent episode or doppler examination does not detect foetal heart sounds then an ultrasound examination performed to check weather the foetus is alive, if alive an amniotic fluid volume ios extimated and to check for foetal growth.
A umbilical artery doppler is performed if Small for gestational age baby is identified.
The role of cardio tocogram is only to identify acute hypoxia and not chronic hypoxic episode.
Abdominal circumference is to be plotted on costumised growth charts.

b) I would ensure that the patient is in a quiet room and with her family or partner if she wishes prior to breaking her news about the death of foetus.
I would inform her regarding IUD in a clear manner explaining that the foetus has died in womb in a sympathetitic and emathetic manner.
At this stage I will explain that I was not sure about the cause of foetal death and further investigations may help in identifing the cause of death.
I wil give her time to understand the implications of the news and to react.
Then I shall discuss with her regarding further management including delivery options, investigations and postmortom.
I would then take maternal blood to check for full blood count to check for haemoglobin levels to check for anaemia, platelet count to suggest preeclampsia and white cell count for evidence of infection.
Blood group and antibody screen to chech for iso immunisation.
Kleuihaure test is requested to identify feto-maternal bleeding.
Blood for infection screen including for CMV, toxoplasma, parvo virus B, rubella, syphilis screen. Hb1AC to check for gylcaemic control over last 6-8 weeks will suggest if there were to be undiagnosed gestational diabetis millitus that has caused IUD.
LFT\'s including for bile salts to identify obstetric cholestasis,, maternal genital swabs taken if infection is suspected.
The options for delivery are discussed including expectant management or induction of labour. I will explain in 80% women spontaneous onset of labour will occur in 2 weeks.If she prefers expectant management then regular full blood count and cougulation profile is done as there is an increased risk of dissaminated intravascular coagulation if IUD is more than 4 weeks in particular.
Induction of labour may be offered when the patient requests either immediately or at the time of her choice with either syntocinon or with mefipristone and prostaglandinsx as per local protocols.
Caeserean section may be required if there are absolute contraindication for vaginal delivery as placenta prevea.
evidence has suggested caring for the woman in a seperate family room with one to one care by midwife will help in berivement process.
She should be offered adequate analgesia either with PCA or an epidural.
Artificial rupture of membranes is avoided to reuce risk of introducing infection.
Antibiotic prophylaxis if infection is suspected.
active management of 3rd stage to reduce risk of PPH.
postmortom examination is to be discussed and she is to be given written information about postmortom, if she declines full postmortom then a partial postmortom is to be offered or a placental histology is offered.
She is given a chance to discuss regarding postmortom with her partner and if posible with a pathologist.
Cord blood is to be taken for infection screen, chromosomal analysis.
After delivery she should be offered to spend time alone with baby if she so wishes as this will help in brevement process.
She is offered the memantos in the form of photographs, foot prints lock of hair, if she declines then thes are to be kept in notes to give her if she requests at a future date.
funeral arrangements are to be discussed.
Baby birth registration may be done by hospital or byu partents if they so wish.
Early discharge arrangements is to be made and done if medically fit.
Bereavement team is to be involved as psychological support is vital at this stagew.
Breast milk supression with carbergalone is effective.
contraception is discussed.
Further antenatal appointments is to be cancelled and G.P and community midwife is to be informed.
Information regarding the sup[port groups as SANDS is given.
Appointments for follow up in postnatal clinic in 6-8 weeks to see and discuss with consultant regarding the possible causes including the results from investigations and postmortom report to be made and arrangements to check for anti phospholipid antibodies. Plan for management of future pregnancies is made at this appointment.


Posted by L S.
LS:
(a) Discuss your assessment [5 marks].
I would ask from her history about risk and causes for reduced fetal movement. The first cause is whether she noticed it after a history of fall or trauma to her abdomen. Whether she is in labour with uterine contractions, leaking liquor or has show. Risk of hypertension in pregnancy checked. Other maternal causes of reduced fetal movement like diabetes and rhesus alloimmunisation are enquired. Her antenatal records and follow up is checked to see if she has had any detailed anomaly scan and if she is suspected to have a fetus with an anomaly causing her fetus not to be as active. Any history of intra uterine growth restricted checked and enquired.
Her blood pressure and vital signs checked. Her abdomen checked to see if it is irritable and the symphysis fundus height is correlating to her gestational age. Fetal wellbeing is checked with daptone to confirm fetal heart beat and a cardiotocogram arranged if present. An ultrasonography of fetal wellbeing is carried out to reassure both the patient and the attending health care professional.

(b) Intra-uterine death is confirmed by ultrasound scan. Discuss your subsequent management
The news should be broken in a quiet place in the presence of her family and an experience midwife to provide adequate support for her bereavement. Initial response can vary from anger, disbelief, and extreme grief and is important to be skilful and have adequate empathy to handle the situation. She should be sensitively counselled that no cause is found in majority of cases but some investigations can be carried out which include maternal blood investigation and later a post mortem of the unborn fetus will help in finding out a cause. Some time is given for both the parents to come to terms with their loss. Sensitively talk about delivery plan, timing and mode of delivery of the unborn child and if all goes as planned she can go home the same day after delivery. Timing should be when she is prepared to undergo the process of induction with prostaglandins with or without oxytocin depends on unit protocol after cervical assessment or if she wants to await spontaneous labour which can be an option but should be informed it is unpredictable on timing, might take weeks and maybe be more distressful. Vaginal delivery with adequate analgesia during the delivery process is desirable. During labour membranes are kept intact as long possible. Close observation of complications like obstructed delivery and perineal trauma. Encourage the parents to hold the baby if they wish. Obtain photograph or hand and foot prints of child. Rediscuss post mortem and other investigations like fetal tissue removal for finding out cause of death. Arrangement for registration and funeral should be organised as per unit protocol. Provide the couple with bereavement counselling and local support groups to help them get through the difficult period. Her lactation should be suppressed with carbegolline and simple analgesia given for breast engorgement. Her GP should be informed and all pending appointments cancelled. Follow up arranged to discuss the results of all investigations and device a plan for subsequent pregnancy. Contraception should be discussed and encouraged to plan subsequent pregnancy once mentally and physically ready.
Posted by F N.
healthy 25 year old primigravida presents at 36 weeks gestation with a 48 hour history of reduced fetal movements. (a) Discuss your assessment [5 marks]. (b) Intra-uterine death is confirmed by ultrasound scan,discuss further menagement.

She should be approached with great sympathy as she will be extreamly anxious.history of previous episodes of reduced fetal movements should be noted,history of vaginal bleeding and abdominal pain may be associated with APH,history of rupture of membranes and uterine activity should be obtained.History of headache,visual disturbences and pain epigestrium is important to assess for recent onset PET.

Examination should include monitering of blood pressure and pulse and temprature.Abdominal examination should be done to palpate the lie and presentation. Tense and tender abdomen may be associated with APH/chorioamniotis.reduced symphysiofundal height may be suggestive of IUGR.
speculam and digital examination can be considered if there is history of vaginal bleeding and rupture membranes and to exclude labour.
Urinalysis should be done to check for protienuria.Fetal heart can be auscaltated with a hand held doppler or CTG can be done.
It is important to realize that the history,examination and investigation should not cause much delay in auscaltation of fetal heart rate to allevieate the lady\'s anxiety.And any required examination and investigations can be done after auscaltation of fetal heart.
Bloods for FBC,U&Es,LFTs,Uric Acid,Crp can be sent if there is suggestion of PET or chorioamnioitis.
USS for fetal growth and doppler can be requested if IUGR is suspected.

B:
She should be approcahed with extream sensitivity and empathy. She should be seen in quite room without interruption idealy with her partner or a family member.If she is unaccompanied offer to call for family if she wishes.Condolenses should be offered and give her and family some time together before discussing the further management plan.
She can offered the option of expectant management to await the onset of spontanous labour.However the uncertanity about the timing of onset of spontanous labour,risk of DIC,and prescence of any clinical condition like PET/choriamnioitis may exclude this option.
The other option is induction of labour.The timing should be confirmed with the lady.The induction regiemns for IUD differ in each maternity unit. In Most units oral dose of 200 mg of mifepristone is administered followed 24-36 hrs later by misoprostol (oral/vaginal) or using prostaglandins gel or tablets.

She should be looked after in a separate room preferably away from the rest of labour ward.Adequtae pain reief should be ensured in labour.Avoid to rupture membrane and operative deliveryif possible.
bloods should be taken to screen for diabetes,and thyroid disorders,TORCH,antiphospholipid syndrome and thrombophilia.Blood and urine cultures should be sent.Vaginal swabs should be sent to exclude infection.
swabs from the fetal and maternal side of the placenta should be sent.placenta should be sent for histology.Fetal karyotype can be requested.
Baby\'s Postmartum should be offfered with written information about it.Consent form should be signed if she wishes PM.
Option to hold the baby,and to take baby\'s photographs should be given.
The lady\'s religious and ethinic values should be respected regarding the baby funeral/cremation.Blessing by the hospital priest can be arranged.Hospital coronar may need to be informed.
Gp and community midwife should be informed.
Adequate postnatal anagesia should be prescribed.
Bromocriptine/cabrgoline can be given for lactattion suppression,however advised on tight fitting garments may help without need for medication.
Information about support groups given at discharge.
Followup appointment should be arranged with the lady;s consultant in 4-6 weeks,making sure that the results of the investigations are available.
Posted by Bgk H.
bgk

a. Reduce fetal movement may cause anxiety and concern to both mother and obstetricians. It could be due to intrauterine death or growth restriction. It can also be normal in cases of maternal unawareness and fetal sleep cycle. I need to know that she formally counting her fetal movement using fetal movement chart or just informally count and feel her fetal movement. I will ask about abdominal pain, abdominal trauma and PV bleeding that may suggest placental abruption and need urgent attention. She might be in labour and this may cause reduce fetal movement. I will review her antenatal record to look at any underlying medical problem such as gestational diabetes or hypertension. Any viral illnesses that occur during this pregnancy need to be check. Her previous scan including anomaly and growth scan if available need to be reviewed to look for evidence of fetal anomaly or intrauterine growth restriction (IUGR). I will examine her abdominal and measure her symphysial fundal height and plot in the graph to look for evidence of fetal growth restriction. A vaginal examination is indicated if patient in labour. A cardiotocogram need to assess fetal wellbeing. I will arrange an ultrasound if the is suspicious of IUGR. This may further adjunct by uterine artery Doppler.

b. This may cause significant distress to patient. I will explain in sensitive manner regarding the finding with the presence of her partner. The aim of the management is to identify the cause and deliver the fetal safely avoiding significant morbidity to the mother. If there is any antepartum haemorrhage suggesting placental abruption may need urgent delivery. But any coagulation defect needs to be ruled out. Full blood count and coagulation profile need to be sent. Any coagulation defect need to be corrected before induction of labour.

I will investigate the cause of the IUD by sending maternal serum for check of abnormal antibodies. A seroconversion of a pared sera for specific infection may suggest fetal infection. I will perform and send Klaeihauer test to detect any fetomaternal haemorrhage. A random blood sugar and HbA1C may indicate the sugar control.

If patient is haemodynamically stable I will discuss regarding management of labour. She may request immediate induction of labour. This need to be respected and arranged. Induction of labour can be done using misoprostol or prostaglandin according to local protocol. This may give patient some control on her management but it is associated with the side effects of induction of labour. Patient can await spontaneous labour. This have the advantage of avoiding side effect of induction but this may take a few weeks and may cause psychological morbidity to patient. Labour needs to be manage by one to one midwife care. Adequate pain relief should be offered. Preferably she should be manage in dedicated room and away from other labouring mother. Episiotomy need to be avoided if possible. Patient will be given options to see and hold the dead baby if she wishes following the delivery. Post mortem on the baby can be discussed. Karyotyping of the fetus can be perform if consented. On discharge, patient need to be given an appointment in bereavement clinic. Patient psychological well being and all investigation result can be reviewed . I will arrange investigation for antiphospholipid screening for future pregnancy management . Patient information sheet and support group need to be given. Incident report form should be filled.
Posted by zara A.
a]The reduced fetal movements are cause of concern because could be associated with intrauterine hypoxia ,but could be physiological related to fetal sleep or mother could be busy and could not note movements.She should be inquired that any previous episode of reduced fetal movements.HEr antenatal record should be reviewed for anamoly scan AND placenta at20 weeks.,results of serum screening reviewed ,blood group and atypical antibodies ,Any evidence of IUGR.She should asked about any family history of congenital anomoly and metabolic disorders .History of any flu like illness and fever.SHE should inquired about any vaginal loss and bleeding,and ask about abdominal pain andABDOMINALtrauma.Social history inquired about smoking , alcohal and use of any recreational drugs .Her BMI and blood pressure recorded.Urinanalysis carried out for protienuria.Abdominal examination carried out ,abdominal palpation and symphysiofundal height recorded and plotted on customised charts to detect SGA. CTG should be recorded for 20 minutes to assess foetal wellbeing .ULTRASOUND for foetal biometry recorded for estimated fetal weight and abdominal cicumference if suspicion of SGA .AMNIOTIC fluid volume recorded by AFI or or measuring deepest pool.B]THE patient should be approached empathetically and involve partener and family .She should explained about diagnosis .FURTHER management would depend on cause of iud and maternal wishes taken into account.The options are immediate delivery by induction of labour and expectant management awaiting spontaneous onset of labour .The indication for immediate delivery are chorioamniotis ,preeclampsia ,placental abruption DIC,AND maternal wishes .The induction should be done with COMBINATION OF mifepristone and prostaglandins . THE INDICATION OF CSECTION ARE OBSTETRIC LIKE major placenta previa.Mother should explained about the further investigations to detect the cause of IUD and plan for future pregnancy.The maternal investigations planned dependingon suspected cause are blood tests for coagulation screen and platelets; HBAIC LFTS,bile salts[obstetric cholestasis],infection screen [listeria ,toxoplasmosis,syphilis,parvovirus,HERPES SIMPLEX ,RUBELLA],antibodies antiR0 and lupus anticoagulant [antiphospholipid syndrome]AND THROMBOPHILIA SCREENINGIn pregnancy and repeat after 3 months.THYRIOD FUNCTION TESTS.MAternal genital swabs for infection screen if infection suspected.MATERNAL URINE fordrug screening[with consent]Fetal investigation are postmartum examination [with parents consent ],any dysmorphic fetures,fetal xray ,weight and sex noted .FETal karyotyping by taking fetal skin or blood .FETAL infection screening .PLACENTA SENT FOR PATHOLOGY .if expectant management planned moniter maternal blood for coagulation and platelets.DURING labour mother provided good analgesia PCA OR DIAMORPHINE,REGIONAL analgesia if coagulopathy ruled out.MEMBRANES should kept intact .BereavemeNT counselling offered to mother and family.Lactation should supperresed by carbagoline .OFFER her to hold baby ,oppurtunity to take photographs and foot and hand prints.PROvide parents contact details of support organization SANDS .FUNERAL ARRANGEMENT should made.GIVE stillbirth certificate andASk parents to register death of baby with in 42 days.OFFER CONTRACEPTION .INFORM GP and provide information leaflets .FOLLOw up arranged to discuss result s of investigation and to make management plan for next pregnancy.
Posted by Bobey B.
Assessment should include a detailed history of the reduced fetal movements and associated symptoms as abdominal pain or vaginal bleeding . History of flu-like illness should be asked. History of alcohol intake, smoking that may be risk factors. Drug history such as sedatives (benzodiazepine, barbiturates and narcotics), and corticosteroids for enhancement of fetal lung maturity are conditions that may be associated with reduced fetal movements. Clinical examination BP, pulse rate, temperature reading and BMI.
Abdominal palpation and measurement of symphyseal fundal height is, as reduced fetal movements can requests a warning sign that the baby is small for gestation or unwell. Auscultation of fetal heart should be done to look for fetal bradycardia. Non-stressed test at least for 15-20 min. should be performed. Loss of variability may be associated with fetal sleep, sedation, central nervous system depression including fetal acidosis. The absence of accelerations or presence of decelerations may indicate fetal hypoxia. CTG is useful in detection of acute hypoxia but is poor for chronic hypoxia. If reduced fetal movements persist ultrasound should be performed to rule out small for gestational age, structural anomalies and oligo- or polyhydramnios.
b) The first and ongoing priority of management is emotional and psychological support of the parents and family.
Identification of potential causes and to find explanation may help with grief, however the majority of cases no cause is found. The underlying cause for fetal death may be obvious clinically, however, a detailed maternal history and examination is recommended e.g. constant abdominal pain and tense uterus, and concealed abruption should be considered. Severe preeclampsia should be managed promptly. The baby needs delivery to avoid the possibility of sepsis or disseminated intravascular coagulopathy developing. The woman should again be counseled appropriately for choice of immediate induction or expectant management. Vaginal delivery should be recommended as the best outcome for her recovery and for future pregnancies.
The options for induction include vaginal prostaglandin followed by oxytocin infusion or oral mifepristone followed 24 to 48 hrs later by misopristol and oxytocin according to unit protocol. In spite of their efficacy, al methods have drawbacks, such as fever, rigors, increased pain and need for analgesia. Adequate intrapartum analgesia is essential. The membranes should be kept intact as long as possible. The partner is encouraged to remain and provide support during delivery. The parents should be encouraged to view and hold the newborn if they wish.
Neonatal footprints and hand prints are made and the parents should be encouraged to name the baby. Photographs should be taken. If the parents decline these, they should be stored in the notes so that they may be retrieved later if the parent wishes. Support groups such as SANDS (Stillbirth and Neonatal Death Society) may prove valuable. Consent for postmortem examination, investigations for possible causes should be discussed, such as karyotyping, thrombophilia screening, Kleihauer (regardless of Rh status), FBC including platelets fasting blood glucose or haemoglobin A1C, anticardiolpin antibody and viral infection screen. Placental pathology can be useful in detection cause of fetal death. Organization of burial and funeral according to the parents\" wishes should be documented. Lactation suppression should be offered. Carbegolline is better than bromocryptine if medical treatment is required. Contraception should be discussed. The ultimate issue is to implement an appropriate management strategy for future pregnancy. Routine postpartum care is best provided at home by community staff. The general practitioner and the community midwife need to be informed. Visit after 6 weeks to see consultant should be organized before the woman is discharged.
Posted by LK K.
Ask about the actual fetal movements – is she feeling at least 10 a day -when does her baby move the most? Has the change been gradual or sudden (suggestive of an acute event)? For most women movements will be normal but perceived reduced eg due to being very busy and not noticing during the day, thus need reassurance. However one must not be dismissive.
Ask about bleeding or abdominal pain, which may be suggestive of placental abruption. Fever and malaise may be suggestive of a viral infection, or with a history of SROM suggestive of chorioamnionitis. A history of flu like illness or exposure to a child with parvovirus may be a cause of fetal hydrops.
Is there a history of palpitations or cardiac history - this may suggest dysthyroid disease, or palpitations leading directly to fetal distress, and cardiac abnormalities in the fetus are commoner if a family history exists. Take a full antenatal history – does she have peexisting or gestational diabetes mellitus, any itching in palms or soles and pale stool suggestive of obstetric cholestasis (OC), visual symptoms and headache with or without oedema suggestive of preeclampsia (PET).
Does she smoke, drink alcohol or use recreational drugs? Any medication she may be on eg bblockers. Look at her scans – any history of aneuploidy or growth scans suggestive of IUGR? From the booking bloods look at the antenatal screen to exclude syphilis/ HIV/ rubella, chronic anaemia. Also look at the BMI and family history of Diabetes or hypertension.
Must not forget to ask about trauma to the abdomen and consider possibility of domestic abuse.
Investigations include BP and urinalysis to exclude preeclampsia, HR and T to exclude pyrexia, dehydration. Abdominal examination to exclude tenderness, assess symphysis fundal height for small/ large for gestational age fetuses or polyhydramnios in hydrops. Speculum examination is appropriate if history suggestive of SROM/ offensive discharge or bleeding. Check for oedema and abnormal reflexes
Blood tests should include FBC for anaemia, blood group looking for abnormal antibodies, BM and HBA1c for diabetic screen, LFTs and Bile acids if history suggestive of OC and add urates if suspect PET.
Auscultate FH and fetal US/s to assess growth, liquor volume and fetal dopplers.

b) News of an intrauterine death (IUD) at advanced gestation must be given sensitively as they are a big shock to the mother – it should be done in the presence ideally of her partner / next of kin. It may be met with denial/ disbelief, and grief reactions including anger, guilt at not presenting sooner and distress. Always confirm findings with a second senior obstetrician. Always allow the couple time to come to terms with the diagnosis before moving further.
Explain in simple language what has occurred, that it is not their fault, than in a large number of fetuses there may not be an obvious cause as to why the IUD occurred. Explain what the possible course of action would be.
Inform the consultant of the patient.
An IUD at such advanced gestational age would need to be delivered vaginally (unless any absolute contraindications to this such as major placenta praevia). This usually would involve the mother taking mifepristone (an antiprogestogen) 200mg orally and attending 48hours later for induction, by which time she may experience some bleeding or pain and if so should attend labour ward. Induction would then be with vaginal prostaglandins or misoprostol. She does not have to make a decision there and then, providing there are no signs of sepsis.
To investigate the cause of death blood tests will be taken for viral screening, for Toxoplasmosis, Rubella, coxackie virus, CMV and parvovirus. Kleihauer will be sent and a thrombophilia screen (for lupus anticoagulant and APS) with a full screen to follow postnatally. Offer post-mortem (this can be discussed after delivery). A swab is sent from the placenta and a sample of placenta or fetal skin is sent for karyotyping. Discuss appropriate analgesia according to unit protocols such as epidural or PCA. The patient should be cared for by a multidisciplinary team including a bereavement midwife and a pastor or appropriate religious member and burial arrangements and patient wishes met.
Appropriate follow up should be arranged four weeks later in a consultant led clinic.


Posted by MAYURA N.
A healthy 25 year old primigravida presents at 36 weeks gestation with a 48 hour history of reduced fetal movements. (a) Discuss your assessment [5 marks]. (b) Intra-uterine death is confirmed by ultrasound scan. Discuss your subsequent management

a)Patients with reduced fetal movements should be assessed in maternity admission unit .Detailed history regarding how many fetal movements patients has perceived should be taken. Its important to check history of any PV bleeding or contractions.If any history of fever,rigors,vomiting or genrally feelin gunwell in last few days should be noted. Hand held maternity notes should be reviewed for history of diabetes, preeclmpsia and also check whether any recent growth scan result if available.
Afetr routine pulse,blood pressure and urine dipstick,per abdominal examination should be performed to check the size of baby, amount of liqour and presentation. Check ,fetal heart rate by sonicaid or pinard. If difficulty finding fetal heart then portable scanner could be used to locate the fetal heart.
This should be followed by at least 30 minutes CTG and featl movements should be noted during this time .If patient doesn’t perceive fetal moevemnts during this time, then CTG should be continued longer.

b)This patient should be dealt with sensitively and empathetically. The response from the patient could be in the form of anger or denial especially if pregnancy has been uneventful. Enough time should be given to the patient ,her partner and family for discussion.Explain to the patient that we don’t know the cause of IUD yet. Option of immediate induction versus waiting for spontaneous labour should be discussed.If patient agrees further detailed scanning should be performed to check for IUGR ,Hydrops ,retroplacental hematoma or other congenital anamolies. Amniocentesis for Karyotyping can be offered at the same time.Bolldo tests in the form of FBC,Group and save,clotting ,thrombophilia screen and tests for antiphsopholipid antibodies should be done.LFT and urea,elctrolytes should be performed to rule out obstetric cholestasis. Random blood glucose orHBA1C could be done to rule out diabetes.
MSU and HVS should be sent to rule out infection as a cause of IUD. If patients wishes to be induced then prostaglandins follwed by oxytocin infusion can be used. Misoprostol though not licesnsed to use for induction can be used for IUD .Reassure the patient that she will be offered good pain relief. Membranes should be kept intact if possible. Traumatic delivries should be avoided and perineal tears should be stitched under good analgesia. Check whether patient would like to hold the baby after delivery. Once patient is settled discuss options of postmortum. Placenta should be send for histopathology if patient agrees.Check baby thouroughly for obvious congenital malformations and document whether macerated or fresh stillbirth. Arrange follow up in clinic in 6weeks for postnatal debriefing.
Posted by Dr Dyslexia V.
X

a) History of decreased fetal movement including the intensity and frequency of the kics are important. Any associated sinister symptoms such as leaking of liquor, per vaginal bleeding with abdominal pain in abruption placenta, blunt abdominal trauma or fall should be taken. Any presence of itching on palms and soles and abdomen could suggest obstetric cholestasis. Any fever or flu like illness, diarrhea should be taken for cases of lestiriosis. History of substance abuse like cocaine should also be taken tactfully. Her antenatal record should be reviewed for all the serum screening , growth chart and follow up like. Examination should include pulse rate if tachycardic could suggest hypovolumia in abruption, blood pressure to assess for pregnancy induced hypertension and protenuria for preeclampsia. Uterine fundal size assessed to detect small for gestational age fetus, uterine tenderness in abrption or chorioamnitis. Fetal heart rate could be checked with, Doppler sonicaid device and a non stress CTG should be done as well. If any abnormalities in the history or examination should prompt for ultrasound of the fetus for parameters, amniotic fluid index and Doppler of umbilical artery.
b) This is a difficult diagnosis for any mother and it should be approached with a sympathetical manner and handled delicately. She should be counselled with her partner or family member in a private place so she could vent out her emotions. Invetigations to the cause of intrauterine death should be undertaken which include full blood count, coagulation profile which could be deranged in abruption and infection. Renal profile, liver function test and kliheaur test also taken to check for preeclampsia and feto maternal hemorrhage. A random blood sugar or GTT could be done to detect gestational diabetes. Thrombophilic screen such as for APS and factor V Leiden should be taken. Infectious screening such as TORCHE’s listeriosis, and CMV should be taken. Pelvic examination to assess for occult leaking and high vaginal swab taken for group B streptococcus. Ultrasound must be done to assess for fetal anomaly, hydrops, parameter for fetal growth restriction, and placeta localization and abnormality. She could be given the option for expectant management in regard to delivery with weekly coagulation screening or immediate induction of labour with prostaglandin or oxytcin based on cervical asessment. She shoul be given adequate analgesia in labour and even epidural anesthesia if coagulation profile are normal. Option of postmortem and the extent of post mortem and its purpose should be discussed and consent taken after delivery. She should be informed on the undertaking of fetal blood for cultures, skin biopsy for karyotyping, placental culture and biopsy .Lactation could be prevented with carbegoline or bromocriptine if there is no contraindication such severe hypertension. She should be given follow up for bereavement counseling and to review the results of the investigations. She could be referred to bereavement counselors if required and support groups such as SANDS.
Posted by NIRMALA M.
Nirmala
a. Detailed history about reduced fetal movements relating to the frequency of the movements, timing of the day and how is it different is important. History of continuous abdominal pain associated with bleeding per vaginum should be asked to rule out abruption. Her occupation should be noted because busy woman would not notice fetal movements during working hours and when she notices baby might be at sleep. Her notes should be read carefully to assess RH status, rubella status, placental position as anterior placenta with raising BMI > 30 might reduce the maternal perception of fetal movements. Any history of intake of drugs should be noted though she is a healthy woman. She should be enquired whether her antenatal period was uneventful so far in this pregnancy and has she been followed up by midwife since booking. H/o smoking, alcohol, illicit drug history should be ruled out. Any family history H/O congenital anomalies, IUD noted. Her BMI measured to R/O obesity. Her blood pressure and urine protein measured to note preeclampsia. Symphysiofundal height (SFH) measured and plotted on customized chart. If SFH is less than the gestational age, then diagnosis of small for dates or oligohydramnios could be made. Fetal heart should be auscultated using Doppler sonic aid/ Pinards fetoscope followed by CTG. If CTG is normal, then it is reassuring for that point of time. If SFH is less, than USS to assess AFI/ deep vertical pocket measurement to assess liquor volume and fetal biometry to assess EFW, AC, BPD to assess R/O IUGR. If Iugr is confirmed on USS, then umbilical artery dopplers should be done to assess the end diastolic flow, if positive, reassuring. If absent or reversed, then severe IUGR to be delivered immediately.

b. She should be approached sensitively. Before informing her the diagnosis, make sure that she is accompanied by someone especially her partner. She has to be taken to a separate room and the bad news of fetal death is slowly broken down to her. At first, she could not believe or react angrily but later burst into tears. But sympathetically facing her in an unhurried manner, answering her concerns will help her to go through this difficult time. Explain her that the cause of fetal death is unknown and the need for further investigations to find out the cause. Regarding the mode of delivery, options of expectant management and induction of labour should be given to her. If she could not make a decision immediately, she can be offered another appointment to discuss about the mode of delivery options. She should be advised not to wait for a longer time for spontaneous labour. Her wishes should be respected. If she opts for IOL, then IOL should be arranged as per unit protocol. IV cannula and bloods should be done for FBC, CRP, group and save, kleihauver test, clotting, thrombophilia screen, antiphosphplipid antibody screen, Infection screen like toxoplasmosis, rubella if not immune, parvovirus B19, listeria, HVS swab for culture and sensitivity and endo cervical swab for Chlamydia and gonorrhea. Broad spectrum IV antibiotics if she has signs of infection. Once delivered, cord blood taken for karyotyping, infection screen as above, Direct coomb’s test for rhesus and ABO incompatibility, hemoglobin and HCT for fetal anaemia. Placenta and baby should be swabbed and swab sent to culture and sensitivity. Placenta should be sent to histopathology. Parents should be sensitively approached, explained the need for postmortem and counseled appropriately which might give us a clue for the cause of death. If the baby looks morphologically syndromic, karyotyping of parents and involvement of geneticist is necessary. Any breast engorgement should be treated with cabergoline. Information about SANDS support group and leaflet should be given to them. Postnatal follow up appointment should be arranged at 6 weeks to discuss the results and its implications on future pregnancy.
Posted by KWASI RICHARD A.
KRA
A. I would ensure the patient is a quit room with family support if possible before breaking the news. I would inform the patient that tragically her baby\'s heart has stopped and she/he is no longer alive. Counselling in this situation requires skill and empathy, and I would endeavour to provide this with support from the attending midwife. Initially the mother and /or the family usually expres shock, confusion,disbelief and sometimes anger, often ask why the baby has died. I would advise the woman that the cause of her baby dying is unknown at present,but we will try to find the cause in due course. At this stage Iwill offer the mother and her family some time together alone and return later to discuss delivery.

B. I would explain the process of induction labour and the advantage of vaginal delivery,it minimizes postnatal inpatient time and speed up. I would her that she can have an epidural or patient-controlled analgesia early in labour for pain relief and she will have access to dedicatedquiet room/bereavement suite with her partner and family. I would mention post-mortem examination and briefly explain advantages and disadvantages of her permitting her baby to hav an austopy. She does not need to make decision regarding a post-mortem examination until after delivery. I would inform her that once delivered She will be able to go home quickly unless there is unexpected complication.

After delivery the baby should be sent for post-mprtem examination if the patient gives consent. Appropriate investigations include maternal blood tests for full blood count(for haemoglobin, and white-cell count for infection), infection screen (for cytomegalovirus, toxoplasmosis, parvovirus B19 and rubella and syphills if not already taken in pregnanacy), Kleihauer-Betke test for fetomaternal haemorrhage(regardless of blood group), HbA1c (to ascertain glucose control over previous six weeks, anticardiolipin antibodies and lupus anticoagulant (to test for antihospholipid syndrome), bile salts (to exclude obstetric cholestasis) and activated protein C resistance. Maternal genital swabs should be taken if infection is suspected. Blood samples may taken from the umbilical cord for investigations of infection and chromosomal analysis. The placenta should be swabbed for infection and sent for histopathology.
arrange registration and burial.manage breast engorgement with simple analgesics and carbegoline.inform the GP . dicuss contraceptio before discharge and arrange postnatal follow up to discuss investigations
Posted by S P.
Paul you missed marking my essay
it reached on 20 th
please if you could
Posted by LK K.
Sorry Paul I don\'t know if I posted my answer too late to be marked, on the 22nd am?

kind regards,
Louisa
Posted by Ida I.
I.

A) She should be asked regarding the nature, intensity and the frequency of the kicks throughout the day. Handheld antenatal records checked for previous antenatal visits, in particularly her previous scans to ensure that the fetus is growing according to her dates, and to check liquor volume. Excessive liquor volume can give the perception of reduced fetal movement.
Her blood pressure checked to exclude hypertension. Symphysio-fundal height measured to ensure her uterus is corresponding to her dates. Presence of fetal heart checked with Doppler sonicaid or daptone device. CTG should be done to give better reassurance and to look for abnormal fetal heart beats. Ultrasound of the fetus should be done for further reassurance with the visualisation of the fetal heart that could be shown to the mother. Ultrasound can also be done to assess liquor volume.

B) She should be approached in a sensitive and sympathetic manner. Any discussions should be done in a private room, preferably with her partner present. She should be given time to digest the situation. Bereavement counselling should be given. She can be referred to support groups for further counselling and support.
Maternal investigations should include baseline hemoglobin level to exclude anaemia. Coagulation profile done to exclude coagulopathy that is associated with IUDs. Blood group and saved for impending delivery. Screening for toxoplasmosis, syphillis, CMV and parvovirus should be done to exclude maternal infections. Kleihauer test to exclude rhesus isoimmunization. Blood glucose taken to exclude diabetes. Detailed ultrasound of the fetus shold be carried out to look for abnormalities and the placenta should be mapped out to look for evidence of placental abruption.
Timing of delivery should be discussed, to give the patient the option of awaiting spontaneous delivery or for induction of labour. Induction of labour with prostaglandins and oxytocin, as well as its risk has to be discussed with the patient. aim for vaginal delivery and caesarean section reserved for obstetric indications only. Membranes should be kept intact intrapartum. Adequate analgesia should be given during delivery.
Post delivery, baby should be seen by the pathologist. Postmortem should be discussed to ascertain the cause of death, and the option of a full or limited postmortem can be offered. Allow the mother to hold the baby, and funeral arrangements can be made.
Cabergoline and analgesia should be made available postpartum. Arrange for postnatal clinic visit 4 to 6 weeks post delivery to review the patient, particularly to look for signs of postpartum depression. Karyotyping, thrombophilia and antiphospholopid screening should be done at this juncture. Results of the investigations and plans for her future pregnancy can also be discussed during this visits.