I vote epidural. Check labs if available but if afebrile, hemodynamically stable and no other disease process (pre-eclampsia, abruption, rupture) I would just proceed.
CanGas
Quick google search pulls up references below:
http://www.soap.org/FAQ.htm
FAQ 12: Neuraxial Analgesia in the Parturient with Fetal Demise
Does SOAP have recommendations for labor epidural placement in parturients with an intrauterine fetal demise?
SOAP does not have specific guidelines. Please refer to the following reference: Maslow AD, Breen TW, et. al. Prevalence of coagulation abnormalities associated with intrauterine fetal death. Can J Anaesth. 1996; 43:1237-43.
Additional information about platelet counts can be found in the ASA Practice Guidelines for Obstetric Anesthesia:
http://www.asahq.org/publicationsAndServices/practiceparam.htm#ob
Prevalence of coagulation abnormalities associated with intrauterine fetal death
AD Maslow, TW Breen, MC Sarna, AK Soni, J Watkins and NE Oriol
Department of Anesthesia and Critical Care, Beth Israel Hospital, Harvard Medical School, Boston, MA 02215, USA.
PURPOSE: The purpose of this study was to determine factors associated with abnormal coagulation in the setting of intrauterine fetal death (IUFD). METHODS: We reviewed the charts of 238 patients diagnosed with IUFD over ten years. Data included demographics, co-existing obstetric disease and coagulation studies. A coagulation score was assigned based on the platelet count, prothrombin time, activated partial thromboplastin time and plasma fibrinogen concentration. Approximately 90% of the study population had coagulation scores < 4. A score of > or = 4 was considered abnormal. RESULTS: Complete coagulation analysis was available in 183/238 patients (77%) within 24 hr of delivery. One hundred and sixty-four of these (89.6%) had a coagulation score, < 4 and 19 had a score > or = 4 (10.4%). No relationship between the coagulation score and age, parity, gestational age at delivery, and number of days the dead fetus remained in utero was found. A coagulation score > = or 4 was associated with the presence of a pregnancy-related disease (P < 0.05), notably abruption (P < 0.001) and uterine perforation (P < 0.05). Four patients without co-existing disease (3.2%), had a coagulation score > or = 4. CONCLUSION: In most pregnancies complicated by fetal demise, the fetus and placenta are delivered within one week of fetal demise. The previously reported severe coagulation disturbances are largely eliminated by early delivery. Our study shows that coagulation abnormalities occur in some patients with uncomplicated IUFDs (3.2%) and that this number rises in the presence of abruption or uterine perforation.
Influence of Epidural Anaesthesia on the Course of Labour in Patients with Antepartum Fetal Death
Samuel Lurie MD* , 1 , Isaac Blickstein MD*, Michael Feinstein MD*, Avi Matzkel MD*, Tiberiu Ezri MD David Soroker MD
*Departments of Obstetrics and Gynaecology, Kaplan Hospital, Rehovot, Israel (Affiliated to the Medical School of the Hebrew University and Hadassah, Jerusalem) Departments of Anaesthesiology, Kaplan Hospital, Rehovot, Israel (Affiliated to the Medical School of the Hebrew University and Hadassah, Jerusalem)
Correspondence to 1 Department Obstetrics and Gynecology, Kaplan Hospital, 76100 Rehovot, Israel.
Copyright 1991 Royal Australian and New Zealand College of Obstetricians and Gynaecologists
ABSTRACT
Summary: The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for parity and gestational age, who received narcotic pain relief. Both groups had similar preinduction cervical dilatation and the induction was performed by amniotomy and oxytocin infusion. The mean first stage of labour was 5.4 hours in the epidural group, and 8.7 hours in the controls (p = 0.0192). The mean cervical dilatation rate was 3.3 cm/hour and 1.0 cm/hour respectively (p = 0.0142). The second stage was similar in both groups. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus.
