Question: Intrauterine fetal death is diagnosed at 28 weeks. At 32 weeks, prostaglandins fail to induce labour. What are the alternatives to caesarean delivery?
Help us improve clinical query answers - just fill in a survey after reading this page
Please note: the search for this response was carried out over 1 year ago. Eligible users may request an update of the evidence by submitting a new Clinical Query here.
Answer: RCOG Green-top Guideline 55, Late Intrauterine Fetal Death and Stillbirth1, makes the following recommendations for induction of labour in women with an unscarred uterus:
A combination of mifepristone and prostaglandin preparation should usually be recommended as the first-line intervention for induction of labour. D
Misoprostol can be used in preference to prostaglandin E2 because of equivalent safety and efficacy with lower cost but at doses not currently marketed in the UK. B
Women should be advised that vaginal misoprostol is as effective as oral therapy but associated with fewer adverse effects. A
The guideline also gives advice on induction of labour in women with a scarred uterus and outlines a range of tests that should be offered to the mother.
An American College of Obstetricians and Gynecologists Practice Bulletin2 on the Management of Stillbirth suggests:
“Before 28 weeks of gestation, vaginal misoprostol appears to be the most efficient method of induction, regardless of cervical Bishop scopre, although high-dose oxytocin infusion also is an acceptable choice. Typical dosages for misoprostol use are 200-400 mcg vaginally every 4-12 hours. After 28 weeks of gestation, induction of labor should be managed according to usual obstetric protocols.”
This publication goes on to say that:
“In patients after 28 weeks of gestation, cervical ripening with a transcervical Foley catheter has been associtated with uterine rupture rates comparable to spontaneous labor and this may be a helpful adjunct in patients with an unfavourable cervical examination.”
References:
- 1. RCOG Green-top Guideline 55. Late Intrauterine Fetal Death and Stillbirth. London: RCOG, 2010. http://www.rcog.org.uk/files/rcog-corp/GTG%2055%20Late%20Intrauterine%20fetal%20death%20and%20stillbirth%2010%2011%2010.pdf
- 2. ACOG Practice Bulletin 102. Management of Stillbrith. Washington: ACOG, 2009
- Search date: 12 January 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
This clinical query answer was produced following the clinical query protocol as described here.
The RCOG will not be liable for any special or consequential damages arising from the use or reliance on information contained within the Query Bank.
