Eduovisual
Pregnancy, Childbirth & Puerperium
Intrauterine fetal demise: workup
— <20 weeks = spontaneous abortion / early pregnancy loss
— Some states use ≥350 g, ≥500 g, or ≥20 weeks for fetal death certificate reporting
— Half occur before 28 weeks; 1/3 are term
— Disparities: non-Hispanic Black women have 2× the rate of non-Hispanic White women — a frequent Step 3 health-equity stem
— Decreased or absent fetal movement reported by patient (most common presenting complaint after 20 weeks)
— Inability to auscultate fetal heart tones on routine prenatal visit
— Fundal height lagging from expected
— Vaginal bleeding or spontaneous labor in 2nd/3rd trimester
— Loss of pregnancy symptoms (breast tenderness, nausea regression)
— Maternal: age ≥35, obesity (BMI ≥30), nulliparity, prior stillbirth (10× recurrence), pregestational diabetes, chronic HTN, SLE/APS, smoking, illicit drug use, low SES
— Pregnancy-related: post-term ≥41 weeks, multiple gestation, IUGR, oligohydramnios, cholestasis of pregnancy, preeclampsia, Rh alloimmunization
— Fetal: congenital anomalies, aneuploidy, infection (parvovirus B19, CMV, syphilis, listeria)
— Placental: abruption, cord accident, vasa previa, placental insufficiency
Board pearl: When a 3rd-trimester patient reports "I haven't felt the baby move all day," the immediate next step is in-office handheld Doppler followed by bedside real-time ultrasound — NST is not the first move if heart tones are absent. Confirmation of demise requires ultrasound visualization of absent cardiac activity, not Doppler alone, because maternal aortic pulsation can mimic FHR.
— Absent fetal movement >12–24 hours in a previously active fetus
— Routine prenatal visit with no audible fetal heart tones by Doppler
— Discordant fundal height (small for dates)
— Spontaneous labor at term with no FHR detected on admission
— Postpartum-style symptoms: breast engorgement regression, weight loss, "deflating" abdomen
— Last definite fetal movement (date/time) and trend over preceding days
— Gestational age confirmation — first-trimester US is gold standard for dating
— Pregnancy course: bleeding, trauma, MVC, falls, abdominal pain, fever, rash, recent infections
— Maternal medical: diabetes (last HbA1c), hypertension, thyroid, SLE, thrombophilia, prior VTE
— Obstetric history: prior stillbirth, recurrent loss, IUGR, preeclampsia
— Medications, supplements, illicit substances (cocaine, methamphetamine → abruption)
— Travel (Zika), occupational exposures, sick contacts (parvovirus from school-age children)
— Immunization status (rubella, varicella), STI screen results
— Domestic violence screen — abdominal trauma is an under-recognized cause
— Painful bleeding + rigid uterus → placental abruption
— Painless bleeding → previa or vasa previa
— Pruritus on palms/soles, RUQ → intrahepatic cholestasis (stillbirth risk ↑ after 36 wks)
— Headache, visual changes, edema → preeclampsia/HELLP
— Fever, flu-like illness, deli meats → listeriosis
— Rash exposure, anemia → parvovirus B19 with hydrops
Step 3 management: Once IUFD is suspected, do not dismiss the patient to return for an outpatient ultrasound the next day. The standard is same-visit confirmatory ultrasound by a clinician credentialed in OB sonography. The diagnosis must be delivered in person, never by phone, with a support person present, and confirmed by a second provider before disclosure when feasible — a recurring patient-safety/communication theme on Step 3.
— BP, HR, RR, SpO2, temperature
— Tachycardia + hypotension in a 3rd-trimester patient with IUFD = abruption with concealed hemorrhage or DIC until proven otherwise
— Fever → consider chorioamnionitis or listeriosis
— Fundal height: often smaller than expected for gestational age; serial measurements may show no interval growth
— Uterine tone: board-like, tender → abruption; soft and nontender → cord accident, anomaly, more chronic process
— Leopold maneuvers: assess fetal lie/position for planned delivery
— No fetal movement appreciated on palpation
— Handheld Doppler: absent FHR — but maternal aortic/uterine artery pulsations can mimic FHR at ~80–100 bpm; if rate matches maternal HR, fetal heart is not what you're hearing
— Confirmation requires real-time 2D ultrasound demonstrating absent cardiac motion for ≥several seconds, ideally by two clinicians or with M-mode through the heart
— Speculum: assess for bleeding, rupture of membranes (ferning, nitrazine, pooling), cervical lesions
— Bimanual: cervical dilation, effacement, station, presenting part
— Defer digital exam if previa suspected until US localizes placenta
— Petechiae, oozing IV sites, gingival bleeding → DIC (Spalding sign and prolonged retention raise DIC risk after ~4 weeks)
— Jaundice, RUQ tenderness → HELLP, acute fatty liver
— Hyperreflexia, clonus → preeclampsia with severe features
Key distinction: Absent FHR on Doppler ≠ diagnosis of IUFD. Diagnosis requires ultrasound confirmation of absent fetal cardiac activity. Doppler alone may pick up maternal vessels; conversely, fetal position or maternal obesity can cause false-negative Doppler in a live fetus. CCS pearl: order "ultrasound, obstetric, real-time" — not "fetal NST" — as the confirmatory study when demise is suspected.
— Absent fetal cardiac activity on real-time 2D imaging — diagnostic
— Supportive findings: Spalding sign (overlapping skull bones), Robert sign (gas in fetal great vessels), scalp edema, maceration, oligohydramnios, hydrops
— Document fetal biometry, placental location, amniotic fluid index, any anomalies
— Doppler of umbilical artery if pre-demise IUGR suspected
— CBC with platelets, type & screen, fibrinogen, PT/PTT/INR — establish DIC baseline
— Comprehensive metabolic panel — hepatic/renal function (rules out HELLP, AFLP, cholestasis)
— HbA1c — undiagnosed diabetes is a common reversible risk factor
— TSH
— Kleihauer-Betke or flow cytometry for fetomaternal hemorrhage — particularly informative in unexplained term IUFD
— Urine drug screen (with consent per state law)
— Urinalysis with protein:creatinine if HTN/preeclampsia suspected
— Syphilis (RPR/VDRL) — universally recommended
— Parvovirus B19 IgM/IgG if hydrops or maternal exposure
— CMV serology if anomalies/IUGR
— TORCH titers are not routinely recommended (low yield); test selectively
— Cervical/vaginal cultures and placental cultures if chorioamnionitis or PPROM
— Repeat fibrinogen and platelets q24–48h if delivery delayed
— Risk of DIC rises substantially after 4 weeks of fetal retention (up to 25%)
Board pearl: A pregnant patient at 38 wks with IUFD, BP 160/110, platelets 88k, AST 220, LDH 900 — the diagnostic workup confirms HELLP-associated IUFD. Step 3 management: initiate magnesium sulfate for seizure prophylaxis, antihypertensives for SBP ≥160/DBP ≥110, and proceed to delivery; do not delay for fetal indications.
— Perinatal autopsy — highest-yield single test; identifies cause in ~30–45%
— Placental pathology — identifies cause in additional ~30%; should be sent in all stillbirths regardless of autopsy decision
— Fetal karyotype or chromosomal microarray — microarray preferred (can be performed on nonviable tissue, detects copy number variants, ~5% additional yield over karyotype)
— Acceptable tissue sources: amniocentesis pre-delivery, fetal blood, placental block near cord insertion, fascia lata, costochondral junction
— Photographs, radiographs, external measurements, gross exam if family declines autopsy
— Antiphospholipid antibodies (lupus anticoagulant, anticardiolipin IgG/IgM, anti-β2-glycoprotein-I) — repeat at ≥12 weeks if initially positive to confirm APS
— Inherited thrombophilia testing: factor V Leiden, prothrombin G20210A only if personal/family hx of VTE or placental infarction on path — routine screening not recommended
— Glucose tolerance testing if not done
— ANA if SLE features
— Hemoglobin electrophoresis in at-risk populations
— MRI of fetus if autopsy declined — "virtual autopsy"
— Maternal imaging only if specific concern (e.g., hepatic US for AFLP)
— Especially with anomalies, consanguinity, recurrent loss, or abnormal microarray
Key distinction: Autopsy + placental pathology + chromosomal microarray is the highest-yield triad. Routine thrombophilia panels are low-yield and not recommended unless clinical features warrant — a frequent Step 3 distractor. Step 3 management: counsel patients pre-delivery that placental pathology requires no additional procedure and should essentially always be obtained; autopsy is offered with informed consent, including limited/external-only options for families with religious or personal objections.
— 1) Maternal hemodynamic and coagulation stability
— 2) Decision on timing and route of delivery
— 3) Emotional support, disclosure, and bereavement planning
— Maternal indications for urgent delivery: preeclampsia with severe features, DIC, abruption with hemorrhage, chorioamnionitis, ruptured membranes, hepatic dysfunction
— Otherwise, delivery may be scheduled in 1–2 days to allow family preparation, support mobilization, and labs to return
— Expectant management >2 weeks raises DIC risk substantially; most patients labor spontaneously within 2 weeks
— Vaginal delivery is first-line regardless of gestational age, even with prior cesarean (most settings allow TOLAC after IUFD with appropriate counseling, though prior classical CD remains contraindication)
— Cesarean reserved for maternal indications (placenta previa, transverse lie at term, refusal of vaginal route after counseling, maternal instability)
— Lower vertical hysterotomy or hysterotomy with extraction in select 2nd-trimester cases when D&E unavailable
— <24 weeks: dilation and evacuation (D&E) by trained provider OR medical induction with mifepristone + misoprostol
— 24–28 weeks: medical induction; misoprostol-based regimens; mifepristone pretreatment shortens induction
— ≥28 weeks: standard induction with cervical ripening (Foley, misoprostol if no prior CD, oxytocin); misoprostol contraindicated with prior cesarean at term — use mechanical methods + oxytocin
CCS pearl: After confirming IUFD on ultrasound, the CCS sequence is: counsel and disclose → labs (CBC, coags, fibrinogen, type & screen) → IV access → admit to L&D → choose induction method based on GA and uterine scar status → bereavement consult and chaplaincy → Rh(D) immune globulin if Rh-negative. Don't forget RhIg even in demise.
— Progesterone receptor antagonist; primes the uterus
— Pretreatment 24–48h before misoprostol shortens induction-to-delivery interval significantly, especially <28 weeks
— Standard of care when available for 2nd-trimester demise
— <28 weeks, no prior CD: 200–400 mcg vaginally or sublingually q4–6h
— 28–32 weeks: 100 mcg q4–6h
— ≥32 weeks: 25–50 mcg vaginally q4h, or transition to oxytocin once cervix favorable
— Prior cesarean delivery at term: avoid misoprostol (uterine rupture risk); use mechanical dilation (Foley balloon) + low-dose oxytocin
— IV infusion per standard induction protocols once cervix favorable (Bishop ≥6)
— Higher doses sometimes required given fetal demise context
— Monitor for water intoxication with prolonged high-dose infusion
— Transcervical Foley catheter — safe with prior CD
— Laminaria — used in D&E preparation
— Rh(D) immune globulin 300 mcg IM within 72h of delivery for all Rh-negative unsensitized patients — including stillbirth and D&E
— Increase dose if Kleihauer-Betke shows large fetomaternal hemorrhage (10 mcg per mL fetal blood, plus 300 mcg baseline)
— Cabergoline 1 mg PO ×1 after delivery for lactation suppression (preferred over bromocriptine); contraindicated in HTN/preeclampsia — use breast binding + cold compresses + analgesia instead
— Pain control: epidural strongly encouraged; opioids; NSAIDs postpartum
— Magnesium sulfate if preeclampsia with severe features
— Empiric antibiotics if chorioamnionitis (ampicillin + gentamicin + clindamycin or metronidazole)
Board pearl: In a patient with one prior low-transverse cesarean and IUFD at 36 weeks, induction is reasonable with mechanical ripening (Foley) + oxytocin; misoprostol is contraindicated at this gestational age due to rupture risk — high-yield distractor.
— Preferred 2nd-trimester option in many US centers when trained providers available
— Lower complication rate than induction in experienced hands
— Cervical preparation: osmotic dilators (laminaria, Dilapan) ± mifepristone 24h prior ± misoprostol 2–4h prior
— Performed under conscious sedation, regional, or general anesthesia
— Limits: provider availability, gestational age cutoff (typically <24 weeks), patient preference for intact fetus for autopsy and grief
— Allows intact delivery — better for autopsy, family viewing, memory-making
— Longer process, more emotionally demanding but often preferred culturally/religiously
— Both options should be offered when feasible; patient choice drives decision
— Retained placenta more common after IUFD induction; manual extraction may be needed
— Examine placenta and cord carefully before sending to pathology
— Cesarean reserved for maternal indication — not for fetal benefit
— Epidural analgesia strongly recommended for induction — both for pain and emotional buffering
— Avoid heavy sedation that impairs patient's ability to participate in memory-making if desired
— Cryoprecipitate to keep fibrinogen >150–200 mg/dL
— FFP for elevated INR with bleeding
— Platelets to maintain >50k with active bleeding or pre-procedure
— Packed RBCs to maintain perfusion; massive transfusion protocol if needed
— Delivery is the definitive treatment — coagulopathy resolves once uterus empty
Step 3 management: Always offer memory-making opportunities — holding the baby, photographs (NILMDTS — Now I Lay Me Down to Sleep volunteer photographers), footprints, locks of hair, naming, blessing/baptism per family wishes. Document offer and patient choice. This is both a quality-of-care metric and a Step 3 communication theme.
— Independent risk factor for stillbirth — relative risk ~1.5–2× at age 35–40, higher beyond
— Mechanism: increased aneuploidy, placental dysfunction, comorbid HTN/diabetes
— Antenatal surveillance is recommended starting at 36 0/7 weeks for AMA ≥35 (twice-weekly NST + AFI or BPP)
— After IUFD, lower threshold for chromosomal microarray and detailed placental pathology
— CKD ↑ stillbirth risk via preeclampsia, IUGR, placental insufficiency
— Adjust misoprostol dosing only minimally — primarily metabolized hepatically with renal excretion of metabolites
— Mifepristone hepatically cleared, no renal adjustment
— Monitor fluid balance during oxytocin infusion — oxytocin antidiuretic effect can precipitate volume overload in CKD/ESRD
— Magnesium sulfate dose reduction required in renal impairment (load 4–6 g, then 1 g/h with frequent levels)
— Often the cause of late-gestation IUFD
— Coagulopathy frequently coexists — check fibrinogen, INR before regional anesthesia
— Avoid misoprostol if severe hepatic dysfunction unclear; in practice still used as benefits outweigh risk
— Acetaminophen safe in modest doses; avoid NSAIDs with renal injury, AKI, or HELLP
— Intrahepatic cholestasis of pregnancy (ICP) with bile acids ≥100 µmol/L confers stillbirth risk markedly elevated — guideline is delivery at 36 0/7 for severe ICP
— Volume shifts in induction and post-delivery diuresis can decompensate stenotic lesions
— MFM and cardiac anesthesia co-management
Key distinction: In AMA, antenatal testing prevents stillbirth and is initiated at 36 weeks per ACOG/SMFM 2021 guidance. In prior stillbirth, surveillance begins at 32 0/7 weeks with delivery typically at 39 0/7 — a frequently tested cadence.
— Stillbirth risk 2–5× baseline; correlates with HbA1c
— Strict glycemic control reduces risk; delivery timing: well-controlled T1/T2DM → 39 0/7–39 6/7; vasculopathy or poor control → 36 0/7–38 6/7
— Antenatal testing twice weekly from 32 wks
— Postpartum: ensure transition to non-pregnancy diabetes management, lactation-compatible meds
— Delivery for preeclampsia with severe features at 34 0/7; without severe features at 37 0/7; chronic HTN well-controlled at 38 0/7–39 6/7
— Magnesium sulfate for seizure prophylaxis
— Aspirin 81 mg starting 12–16 wks in future pregnancies for prevention
— Preconception counseling: optimize BMI, glycemia, BP; smoking cessation
— First-trimester: dating US, screen for diabetes/thyroid, aspirin 81 mg from 12 wks
— Second-trimester: anatomy scan, cervical length
— Third-trimester: antenatal surveillance starting 32 0/7 (twice-weekly NST/BPP), delivery 39 0/7 (or earlier 36–38 wks per individual factors)
— Stillbirth risk elevated; monochorionic-diamniotic > dichorionic
— Single-twin demise in MCDA pregnancy: 25–30% risk of co-twin death or neurologic injury due to acute transfusion through shared circulation; immediate MFM referral, fetal MRI of surviving twin at 3–4 weeks post-demise
— In DCDA single demise, surviving twin is generally not at neurologic risk; expectant management often appropriate
— Monitor maternal coagulation if dead twin retained
— Disproportionate stillbirth burden; address social determinants, transportation, navigator referral
Step 3 management: A patient with prior unexplained 38-week stillbirth presents pregnant again. Plan: aspirin 81 mg from 12 wks, antenatal testing from 32 wks, delivery at 39 0/7 — this cadence is among the most testable on Step 3.
— Risk ~10% if fetus retained 4 weeks, ~25% beyond 5 weeks
— Pathophysiology: thromboplastin release from necrotic fetal/placental tissue
— Monitoring: weekly fibrinogen and platelets if expectant management chosen
— Most modern patients delivered within 24–72h, so DIC is now uncommon at presentation unless concurrent abruption or AFLP/HELLP
— Postpartum hemorrhage rate higher after IUFD induction (uterine atony, retained placenta, DIC, infection)
— Active management of third stage: oxytocin 10 U IM or IV infusion at delivery
— Have second-line uterotonics ready: methergine, carboprost, misoprostol, tranexamic acid
— Chorioamnionitis especially with PPROM or prolonged induction
— Endometritis postpartum
— Sepsis from listeriosis, GBS, or anaerobes
— Manual extraction; if fails, suction curettage under US guidance
— Higher with misoprostol in scarred uterus — avoid at term with prior CD
— Pregnancy + postpartum + bed rest + grief immobility → high VTE risk
— Mechanical prophylaxis intrapartum; pharmacologic prophylaxis postpartum per risk factors (BMI, cesarean, thrombophilia)
— Major depressive disorder, PTSD, complicated grief, anxiety rates substantially elevated in months following stillbirth
— Partners and siblings also affected; screen at every postpartum visit
— Subsequent pregnancy: anxiety often severe; consider perinatal mental health referral
— Engorgement and milk letdown are physically and emotionally painful — anticipate and counsel
— Support binding, cabergoline option, lactation donation if patient desires
Board pearl: A patient 4 weeks after 32-week stillbirth with new SOB, pleuritic chest pain, tachycardia → PE until proven otherwise. CT-PA is appropriate; pregnancy-related VTE risk extends 6–12 weeks postpartum.
— Confirmed IUFD with active bleeding, contractions, ROM, or maternal instability
— Preeclampsia with severe features, suspected HELLP, AFLP, DIC, sepsis
— Suspected abruption — even hemodynamically stable
— Stable patient with confirmed IUFD, normal labs, no bleeding, no labor — allow 24–48h home for family preparation
— Daily fibrinogen/CBC or close follow-up advised; many institutions admit directly for induction
— Maternal-Fetal Medicine for complex cases (multiple gestation, anomalies, maternal medical disease)
— Medical genetics for suspected aneuploidy or syndrome
— Anesthesia early for epidural planning, especially with coagulopathy
— Hematology for DIC management, thrombophilia evaluation post-event
— Pathology — discuss specimen handling in advance
— Social work, chaplaincy, bereavement coordinator — at time of diagnosis
— Lactation consultant for suppression counseling
— Psychiatry / perinatal mental health for high-risk patients (prior depression, suicidality, prior trauma)
— DIC requiring massive transfusion
— Septic shock from chorioamnionitis or listeria
— AFLP with hepatic encephalopathy
— Pulmonary edema from preeclampsia or oxytocin fluid overload
— Acute kidney injury, mechanical ventilation, vasopressor requirement
— Handoffs between OB and ED, between hospitalist and OB, between L&D and postpartum
— Use structured handoff (SBAR/I-PASS); explicitly document grief status, supports, and follow-up plan
— Schedule postpartum visit at 1–2 weeks rather than standard 6 weeks for emotional support and early intervention
CCS pearl: On CCS, when DIC develops: order massive transfusion protocol, fibrinogen, cryoprecipitate, platelets, FFP, pRBCs, OB anesthesia STAT, MFM consult, ICU bed, and proceed with delivery — coagulopathy will not improve until uterus is empty.
— Non-reassuring fetal status from placental insufficiency, IUGR, oligohydramnios — fetus alive but moving less
— Management: NST → BPP → consider delivery if non-reassuring
— Distinguishing feature: present FHR on ultrasound with abnormal tracing or low BPP score
— Normal 20–40 min sleep cycles can mimic decreased movement
— Hydration, glucose intake, position change, stimulation should reawaken movement
— Persistent decreased movement >2 hours despite stimulation warrants NST
— Opioids, benzodiazepines, alcohol cross placenta and reduce fetal movement
— History and toxicology relevant
— Excess fluid dampens perceived fetal movement; baby is moving but mother feels less
— Cushions fetal kicks; movement underperceived but fetus normal
— Rare; arthrogryposis, severe CNS malformation
— Decreased movement chronic, often noted on anatomy scan
— Same pathophysiology but technically not IUFD by US definition
— Management and workup similar but autopsy/microarray yield differs
— Earlier gestation; not typically confused with 3rd-trimester IUFD but appears in early loss differential
Key distinction: Decreased fetal movement = mandatory same-day evaluation. The bedside algorithm is Doppler → if absent FHR, immediate US; if FHR present, NST → if non-reactive, BPP or further evaluation. Sending a patient home to "kick count" after she reports absent movement is a board-classic patient safety error.
— IUFD as consequence of maternal collapse — focus on maternal resuscitation; perimortem cesarean within 4 minutes if mother arrests at ≥20 wks and not responding to ACLS
— Septic shock from pyelonephritis, pneumonia, COVID, listeria, GBS, chorioamnionitis
— Hypoperfusion → fetal demise
— Source control + antibiotics + resuscitation; deliver per maternal/fetal status
— MVCs, intimate partner violence, falls
— Placental abruption can occur with minimal external signs
— Mandatory ≥4 hours of continuous fetal monitoring after trauma at ≥20 wks; longer if contractions, bleeding, or abnormal tracing
— Kleihauer-Betke to detect fetomaternal hemorrhage and guide RhIg dosing
— Even modest DKA carries high fetal mortality
— Fetal acidosis follows maternal acidosis
— Management: fluids, insulin, electrolytes, treat underlying trigger
— Rare but tested; recognize and treat maternal condition
— Cocaine, methamphetamine → vasoconstriction, abruption
— Heavy alcohol, opioids → growth restriction, demise
— Screening and treatment (buprenorphine/methadone for OUD; never abrupt withdrawal in pregnancy)
— Recurrent fetal loss especially at ≥10 weeks, placental insufficiency
— Future pregnancies: aspirin + prophylactic LMWH for obstetric APS
Board pearl: A 28-week pregnant patient after MVC with normal vitals and no obvious injury still requires continuous external fetal monitoring ≥4 hours plus Kleihauer-Betke and RhIg if Rh-negative. Missing occult abruption is the classic trauma-in-pregnancy stillbirth pitfall.
— Rh(D) immune globulin within 72h for all Rh-negative unsensitized patients — dose adjusted for Kleihauer-Betke
— VTE prophylaxis: mechanical in hospital; pharmacologic (LMWH) postpartum for patients with high risk (prior VTE, thrombophilia, cesarean + risk factors, prolonged immobility)
— Update rubella and varicella immunity if non-immune (live vaccines deferred to postpartum)
— Tdap, influenza, COVID vaccines per usual postpartum schedule
— Initiate or resume contraception — most methods acceptable immediately postpartum; LARC (IUD/implant) may be placed at delivery
— Optimize BMI, glycemic control (HbA1c <6.5% pre-conception ideal in diabetes), BP control, smoking cessation, substance use treatment
— Folic acid 400–800 mcg daily; higher if prior NTD
— Review autopsy, placental path, microarray results — counsel on identified vs unidentified cause
— Antiphospholipid syndrome: aspirin + prophylactic LMWH next pregnancy
— Inherited thrombophilia + prior stillbirth: individualized; aspirin ± LMWH per ACOG
— Genetic counseling if heritable cause identified
— Aspirin 81 mg/day from 12–16 wks in patients with prior stillbirth (also reduces preeclampsia)
— First-trimester dating US; anatomy scan; serial growth scans
— Antenatal testing 32 0/7 (twice-weekly NST/BPP)
— Delivery 39 0/7 in absence of other indications; earlier for comorbidities
— Disproportionate burden in Black, Indigenous, low-income communities — connect to home visitation programs, doulas, perinatal navigators
Step 3 management: Don't forget the "small stuff" on discharge — RhIg, contraception counseling, lactation suppression plan, VTE prophylaxis if indicated, bereavement resources, scheduled 1–2 week follow-up, perinatal mental health referral. These checkbox items are exactly the type of item Step 3 tests via "next best step in management" stems.
— Daily check on physical recovery, lochia, fundal involution, breast care
— Screen for depression and acute stress symptoms before discharge
— Discuss autopsy findings timeline — final report typically 6–8 weeks
— Provide written memory packet: footprints, photographs, locks of hair, baby's blanket, hospital bracelet
— Offer chaplaincy and bereavement coordinator visit
— Physical: incision check if cesarean, lochia, BP if preeclamptic, breast care
— Emotional: validated screening with EPDS or PHQ-9; assess for PTSD symptoms
— Review preliminary autopsy and placental pathology if available
— Discuss contraception adherence
— Reinforce VTE warning signs
— Final review of autopsy, placental pathology, microarray results — dedicate adequate time
— Counsel on etiology (or its absence) and recurrence risk
— Address subsequent pregnancy planning — many patients want timeline guidance; no medically required wait beyond physical healing, but emotional readiness varies
— Update problem list with prior stillbirth — flags future pregnancies as high-risk
— Continued mental health screening at 3, 6, 12 months
— Refer to support groups (Share, Compassionate Friends, Star Legacy Foundation, NILMDTS)
— Anniversary reaction counseling — anticipate
— Partners often grieve differently and feel sidelined; explicitly include in counseling
— Siblings need age-appropriate explanations and may benefit from child life or family counseling
Board pearl: Postpartum depression risk after stillbirth is markedly elevated (~30–50% screen positive at some point in first year). PHQ-9 ≥10 or any item 9 positive (suicidality) → urgent mental health referral and safety assessment — same-day evaluation if active suicidal ideation. Don't normalize severe symptoms as "just grief."
— Deliver in person, in a private space, with a support person if possible
— Plain language: "Your baby has died." Avoid euphemisms ("we lost the heartbeat") that create ambiguity
— Allow silence; offer to repeat ultrasound for the patient to see
— Document who was present, what was said, and patient's expressed wishes
— Autopsy is opt-in, not assumed
— Discuss what autopsy can/cannot answer, religious considerations (many faiths permit limited or external autopsy), and that placental pathology requires no additional consent beyond standard surgical specimen handling
— Document patient's choice clearly
— Fetal death certificate required in all US states for ≥20 wks (or ≥350–500 g depending on state)
— Completed by physician, typically within days of delivery
— Birth certificate is NOT issued for stillbirth in most states (separate "Certificate of Birth Resulting in Stillbirth" available on request in many states — emotionally meaningful for families; offer it)
— Suspected criminal trauma or maternal substance use may trigger additional reporting per state law — know your state
— Pregnancy-related substance use reporting varies dramatically by state — some treat as child abuse, others as public health
— Counsel patients honestly about reporting obligations before testing when feasible
— Avoid placing a postpartum stillbirth patient on a unit with healthy newborns when alternatives exist
— Door signage or chart indicators alerting all staff to fetal demise prevents "where's the baby?" trauma
— Handoffs between providers must explicitly transmit the loss
— Providers with religious objection to D&E should ensure prompt referral; emergency stabilization is never optional
— Recognize that Black and Indigenous patients are at higher risk and more likely to report dismissal of symptoms; advocate for same-day evaluation of decreased fetal movement regardless of presentation
Step 3 management: A patient asks why her baby died and the workup is negative. The ethically and clinically correct response is honest disclosure: "In about 25–35% of stillbirths, no cause is found despite thorough evaluation." Fabricating an explanation is harmful; "unknown cause" is a valid diagnostic conclusion.
Board pearl: When a question describes post-term pregnancy at 41 5/7 weeks with decreased fetal movement and unable to find FHR, the answer for "next best step" is bedside ultrasound — not NST, not BPP, not "send home with kick counts." Bedside US confirms or excludes demise.
— "G3P2 at 39 wks, hasn't felt baby move since yesterday. Doppler reveals heart rate of 88 bpm matching maternal pulse." → Next step: real-time obstetric ultrasound (not NST). The matching pulse is the giveaway clue.
— After US confirms absent cardiac activity, "What is the next best step?" → In-person disclosure, baseline labs (CBC, fibrinogen, type & screen, coags), admit for induction, offer autopsy/placental path/microarray. Distractor: "Send home for follow-up in 1 week" — wrong; rising DIC risk.
— "32 wks IUFD, prior low-transverse cesarean × 1." → Foley + oxytocin; misoprostol contraindicated. Distractor: vaginal misoprostol.
— "Which test is most likely to identify a cause?" → Placental pathology + autopsy + chromosomal microarray. Distractors: thrombophilia panel, TORCH titers.
— "Patient with prior 36-week stillbirth, now pregnant again at 10 wks. Best intervention?" → Aspirin 81 mg starting 12–16 wks + antenatal testing starting 32 wks + delivery 39 wks. Distractor: routine LMWH (only with APS or thrombophilia + history).
— "Fetal demise retained 5 weeks, now with petechiae, bleeding gums, fibrinogen 90." → DIC; deliver promptly with cryoprecipitate, FFP, platelets.
— "28-wk pregnant patient post-MVC, hemodynamically stable, no contractions, no bleeding." → Continuous fetal monitoring ≥4 hours + Kleihauer-Betke + RhIg if Rh-neg. Distractor: discharge after 1 hour.
— "Patient asks why her baby died despite negative workup." → Honest acknowledgment that 25–35% remain unexplained; offer continued support. Distractor: attribute to unrelated finding.
— "Postpartum stillbirth, painful engorgement, BP 145/92." → Supportive care (binding, cold, analgesia); avoid cabergoline due to HTN.
— "When to see patient back?" → 1–2 weeks, not 6.
Key distinction: Step 3 frequently tests the management cadence (test timing, drug timing, follow-up timing) rather than diagnosis alone. Memorize the 32 / 36 / 39 rule and the aspirin 12–16 wk start.
Intrauterine fetal demise is fetal death at ≥20 weeks or ≥350 g, confirmed by ultrasound demonstrating absent fetal cardiac activity, managed by stabilizing the mother (coagulation, BP), delivering by vaginal route in nearly all cases with gestational-age-appropriate induction (mifepristone + misoprostol, oxytocin, or Foley if prior cesarean), evaluated with the highest-yield triad of autopsy + placental pathology + chromosomal microarray, and followed by RhIg, lactation suppression, bereavement support, early postpartum follow-up, and in subsequent pregnancies aspirin from 12–16 weeks with antenatal testing from 32 weeks and delivery at 39 weeks.
Board pearl: The three numbers to anchor every IUFD stem on Step 3 — 12–16 weeks (start aspirin), 32 weeks (start antenatal testing after prior stillbirth), 39 weeks (deliver in subsequent uncomplicated pregnancy). Pair them with the three highest-yield investigations — autopsy, placental pathology, chromosomal microarray — and you have answered most of the question bank.