IUFD / Stillbirth — Inpatient / L&D Order Set (Example)

For use by OB/GYN, MFM, L&D nursing, ED, anesthesia, pathology, and bereavement teams. Print-optimized for chart inclusion; each bullet can be mapped to discrete EHR orders.

Population: confirmed or suspected IUFD / stillbirth Goals: maternal safety + compassionate care + targeted evaluation Site-adaptable checklist + orders

Patient Name / MRN: ___________________________

Gestational age GA: _______ w _______ d

Date/Time Dx: ____/____/_____ ________

Clinician ___________________________

Safety note: This is an educational template. Verify medication choices/doses and local orderable names. Tailor to patient factors (GA, prior uterine surgery, infection/abruption, preeclampsia, bleeding, Rh status) and institutional policy.

1. Confirmation, Triage & Immediate Support

Confirm diagnosis with ultrasound documentation of absent fetal cardiac activity (per institutional standard; consider second confirmation if needed).
Document: GA, presentation, placenta location, estimated interval since demise (if known), and maternal symptoms.
Offer private room / quiet environment; allow support person(s) per policy.
Bereavement & support consults:
- ☐ Social Work / Bereavement Coordinator
- ☐ Chaplain / Spiritual Care
- ☐ Interpreter (if needed)
- ☐ Mental health (psychology/psychiatry) if acute distress or history of severe depression/anxiety
Discuss options & preferences early (labor vs D&E where appropriate; viewing/holding, photos, keepsakes, religious/cultural practices, disposition).

2. Location, Monitoring, IV Access

Admit to: ☐ L&D ☐ Antepartum ☐ ED observation ☐ ICU (if unstable)
Vitals: ☐ q15–30 min until stable then q4h ☐ per unit protocol
IV access: ☐ 1 peripheral ☐ 2 large-bore IVs (if bleeding/abruption risk) ☐ consider arterial line/central access if ICU
Strict I&O: ☐ yes ☐ no; Foley catheter: ☐ yes ☐ no (if indicated)
Fetal monitoring: not applicable; consider maternal uterine activity monitoring during induction per protocol.

3. Maternal Labs & Diagnostic Studies

Admission / STAT (common)

☐ CBC with platelets
☐ Type & screen (or type & crossmatch ____ units PRBCs if high hemorrhage risk)
☐ CMP (electrolytes, renal function, LFTs as indicated)
☐ Urinalysis ± culture (if infection suspected)

Coagulopathy / abruption / severe features (select as indicated)

☐ PT/INR, aPTT
☐ Fibrinogen
☐ D-dimer (if part of local DIC panel)
Consider baseline coagulation testing when there is significant bleeding, suspected abruption, sepsis, severe preeclampsia/HELLP, or prolonged retention per local practice.

Recommended maternal evaluation at time of demise (ACOG/SMFM OCC #10)

☐ Fetomaternal hemorrhage screen: Kleihauer–Betke or flow cytometry (send as soon as possible after diagnosis)
☐ Syphilis testing
☐ Antiphospholipid antibody testing:
- ☐ Lupus anticoagulant
- ☐ Anticardiolipin IgG/IgM
- ☐ Anti–β2-glycoprotein I IgG/IgM
Do not order routine inherited thrombophilia testing as part of stillbirth evaluation (unless specific clinical indication).

Additional tests only if indicated by history/presentation

☐ Glucose screen / HbA1c (if not known or LGA/macrosomia concern)
☐ Toxicology screen (if abruption or substance use suspected)
☐ Preeclampsia evaluation (as indicated): urine protein/creatinine, uric acid, etc.
Routine TORCH serologies are generally not recommended unless specific suspicion; consult MFM/pathology for targeted infectious testing.

4. Delivery Planning (Shared Decision Making)

Discuss timing: most patients prefer prompt delivery; timing is usually not critical if mother is stable.
Discuss method options (dependent on GA, cervical status, prior uterine surgery, patient preference, and institutional expertise):
☐ Induction of labor
☐ Dilation & evacuation (if appropriate GA and experienced provider available)
- Counsel: D&E may limit full autopsy evaluation and may reduce opportunities to see/hold the fetus, but can reduce certain maternal morbidity in some 2nd-trimester scenarios.
Consults:
- ☐ MFM
- ☐ Anesthesia (early epidural planning or high-risk comorbidity)
- ☐ Family Planning / D&E team (if considering D&E)
- ☐ Pathology (placenta/autopsy/genetic specimen planning)

5. Induction Orders (Select Local Protocol Defaults)

Uterotonic / cervical ripening options

☐ Misoprostol regimen per GA and local protocol
- ACOG/SMFM OCC #10 notes that before 28 weeks, typical misoprostol dosing for stillbirth induction has been 400–600 micrograms vaginally every 3–6 hours; after 28 weeks, manage per usual obstetric induction protocols.
- If prior uterine scar and 24–28 weeks, consider lower-dose strategy per local protocol; after 28 weeks with prior hysterotomy, follow TOLAC induction protocols (avoid routine misoprostol).
☐ High-dose oxytocin infusion per local protocol (acceptable alternative in some cases)
☐ Mechanical ripening (e.g., transcervical balloon) per local protocol (especially ≥28 weeks or prior scar per policy)
☐ Consider mifepristone adjunct (where available) per local protocol (commonly given 24–48 hours before misoprostol in some pathways)

Rupture of membranes

☐ AROM when appropriate and safe (per cervical exam, presentation, and provider judgment)

Antibiotics (only if indicated)

☐ No antibiotics (routine prophylaxis not indicated)
☐ Start antibiotics for suspected/confirmed infection (chorioamnionitis, sepsis, etc.) per local pregnancy-safe regimen
☐ GBS prophylaxis: ☐ not indicated ☐ per local policy (rare scenarios)

Hemorrhage preparedness (select as indicated)

☐ Hemorrhage cart available / PPH protocol awareness
☐ TXA availability per local protocol
☐ Uterotonics available postpartum per standard practice
☐ Active management of 3rd stage per protocol

6. Analgesia, Sedation & Supportive Care

Diet: ☐ regular ☐ clear liquids ☐ NPO (if anesthesia planned)
IV fluids: ☐ saline lock ☐ maintenance IVF ____________
Antiemetics PRN per protocol.
Analgesia options:
- ☐ Neuraxial anesthesia (epidural) when desired/available
- ☐ IV opioid PRN per local order set
- ☐ NSAID/acetaminophen postpartum as appropriate
Anxiolysis / sleep support: ☐ per local protocol

7. Rh, Blood Bank, and Post-Delivery Maternal Care

Rh status:
- ☐ Confirm maternal ABO/Rh
- ☐ If Rh-negative and not alloimmunized: administer Rh(D) immune globulin per policy (dose per GA and fetomaternal hemorrhage assessment)
Postpartum monitoring: vitals, bleeding, uterine tone per unit protocol.
Contraception counseling & plan:
- ☐ Discuss immediate postpartum options (if desired) ☐ defer to follow-up
Lactation:
- ☐ Provide lactation counseling (suppression guidance and comfort measures) per local policy
- ☐ Lactation consult if desired

8. Fetal/Placental Evaluation & Specimen Handling

Placenta: ☐ Send placenta/cord/membranes for gross & histologic pathology (routine core component).
Fetal exam: prompt external exam; document dysmorphic features; record measurements (weight/length/HC) and consider foot length if very early GA.
Photography (with consent): ☐ whole body ☐ face (frontal/profile) ☐ hands/feet ☐ any anomalies.
Autopsy: ☐ Offer full autopsy ☐ partial/limited autopsy ☐ external exam only ☐ decline
- If autopsy declined, consider alternatives per local availability (e.g., imaging, limited tissue sampling) and consult pathology.
Genetic evaluation: ☐ Amniocentesis for microarray/karyotype (if delivery not imminent and patient consents) ☐ Placental block/cord segment/internal fetal tissue per pathology guidance.
Additional testing guided by clinical scenario and pathology/MFM recommendations.

9. Documentation, Legal/Reporting, Disposition

Document: time of diagnosis, counseling, patient preferences, plan for delivery, consent decisions (autopsy/genetics/photos/disposition).
Birth/fetal death certificate requirements per state/institution: ☐ initiate paperwork ☐ notify unit clerk/social work.
Disposition of remains:
- ☐ Hospital disposition per policy
- ☐ Family-selected funeral home/mortuary: ___________________________
- ☐ Cultural/religious requests accommodated (as feasible): __________________
Memory-making/keepsakes (if desired): ☐ footprints/handprints ☐ lock of hair ☐ blanket/hat ☐ photos

10. Discharge Planning & Follow-Up

Provide written discharge instructions (bleeding, fever, severe pain, breast symptoms, mood warning signs).
Schedule follow-up visit: ☐ 1–2 weeks ☐ 2–6 weeks (review results, grief support, future pregnancy planning).
Results tracking: ensure placenta pathology, genetic testing, and autopsy (if performed) are routed to ordering clinician and communicated to family.
Support resources: bereavement counseling, peer support groups, mental health referral as indicated.

References (Key Sources)

ACOG/SMFM Obstetric Care Consensus #10: Management of Stillbirth (2020). (SMFM-hosted PDF) — https://s3.amazonaws.com/cdn.smfm.org/attachments/707/c9b1a8b5ba9d32b57d8af8af6fd33ef3.pdf
SMFM Special Statement (2025): Checklists for management of pregnancies complicated by stillbirth. — https://publications.smfm.org/publications/612-society-for-maternal-fetal-medicine-special-statement-checklists/
Perinatology.com template style reference: Thyroid Storm in Pregnancy — Inpatient Order Set (Example). — https://www.perinatology.com/protocols/Thyroidset.htm
RCOG Green-top Guideline No. 55: Care of late intrauterine fetal death and stillbirth (UK; updated publication available). — https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/care-of-late-intrauterine-fetal-death-and-stillbirth-green-top-guideline-no-55/