Late intrauterine fetal death — structured oral station (12 minutes)

Opening prompt — "The ultrasound confirms the baby has died. Talk me through what you do next."

Model response — say it in this order: ^[1][3]

• "I would confirm the diagnosis with a senior operator on real-time ultrasound, documenting fetal biometry, anatomy where visible, amniotic fluid, placental site, and any signs of maceration or hydrops — and if there is any doubt, a second senior operator reviews before the news is broken."
• "Then I break the news compassionately: eye contact, her name, a private room, her partner, the offer of a support person and cultural or spiritual care. I would say 'I am so sorry, your baby has died' — and avoid 'fetal demise' or 'products'."
• "I would take a focused history for cause and examine the mother for co-existing disease — blood pressure, temperature, signs of preeclampsia, sepsis, or abruption — and stabilise anything I find before planning the birth."
• "Then I would activate the bereavement pathway: a named carer, a specialist perinatal bereavement midwife, and the offer of memory-making — handprints, footprints, photographs, naming — without pressure."^[1][4]

Examiner is listening for: confirmation by a senior, compassionate and specific language, parallel cause-finding and stabilisation, and the bereavement pathway. ^[1]

Probe 1 — "What investigations would you offer, and what is the chance you find a cause?"

• "The investigation bundle has four pillars: maternal blood (full blood count, coagulation with fibrinogen, HbA1c, thyroid function, liver function and bile acids, syphilis and infection screen, and Kleihauer-Betke or flow cytometry for fetomaternal haemorrhage — flow cytometry is more accurate); cytogenetics with array CGH preferred over karyotype, after written consent; perinatal autopsy, the single highest-yield test, offered with care and with limited or MRI options for those who decline; and placental histopathology, which is mandatory and the most commonly abnormal test."^[1]
• "With full investigation including autopsy and placental histology, a possible or probable cause of death is found in up to three-quarters of late intrauterine fetal deaths (GTG 55, Grade B)."^[1]
• "A substantial minority remain unexplained even after full investigation, and I would be honest about that with the parents."^[1]

Probe 2 — "How would you plan the birth?"

• "I counsel on mode and timing without pressure. The recommended first-line induction is mifepristone 200 mg as a single dose followed by a prostaglandin (GTG 55, Grade B), because the combination shortens the induction-to-delivery interval by a mean of 7.86 hours versus misoprostol alone."^[1][2]
• "The misoprostol dose scales with gestation: at 28 weeks and beyond, 25 to 50 micrograms vaginal every 4 hours, or 50 to 100 micrograms oral every 2 hours; at 25 to 28 weeks, 200 micrograms every 4 hours; at 24 weeks, 400 micrograms every 3 hours."^[1]
• "Vaginal birth is recommended for most women. Caesarean is considered for specific indications — for example, more than two lower-segment scars or an atypical scar, where induction safety is unknown."^[1]
• "Regional analgesia is not contraindicated if coagulation is normal, and I would offer the best analgesia available for a labour the family will remember forever."^[1]

Probe 3 — "The parents ask whether this will happen again."

• "The recurrence risk of stillbirth after one stillbirth is increased — approximately two- to five-fold — and it is modified by the cause and by modifiable factors."^[5][6]
• "In the next pregnancy I would optimise the modifiable risks — stop smoking, achieve a healthy weight, side-lying going-to-sleep position — offer low-dose aspirin if a placental cause is identified, institute enhanced surveillance with serial growth scans and doppler, consider earlier birth around 37 to 39 weeks where a placental cause was found, and ensure continuity of carer with active mental-health screening."^[1][5]

Probe 4 — "The mother is terrified and asks what is going to happen to her body."

This is a scored communication domain, not a courtesy. Demonstrate it out loud: ^[3][4]

• Move to her eye level, use her name, and explain plainly: "You will go through labour and birth. We will give you the best pain relief available — you can have an epidural. We will be with you the whole time. You can hold your baby afterwards if you wish, and we can make handprints and photographs for you to keep."
• Acknowledge fear, keep the partner informed, allocate a staff member to support them, and avoid jargon and avoid conducting the conversation standing over the bed.
• Commit to a debrief and a named follow-up at six weeks.^[3][4]

Probe 5 — "What happens after the birth, in the days and weeks that follow?"

• "Immediate postnatal: anti-D within 72 hours if she is rhesus-negative, suppression of lactation offered, debrief, and the offer of memory-making."^[1]
• "Follow-up at around six weeks with both parents: results review, structured postnatal review, mental-health screening for depression, anxiety, and PTSD, and pre-pregnancy counselling for the next pregnancy."^[1][3]
• "Governance: a structured perinatal mortality review and incident reporting, with feedback to the family."^[1]