How do you manage a fetal demise at 29 weeks with a prior Lower Transverse Cesarean Delivery (LTCD)?

Management of Fetal Demise at 29 Weeks with Prior LTCD

Vaginal birth after cesarean (VBAC) is the recommended approach for managing fetal demise at 29 weeks in a patient with prior lower transverse cesarean delivery (LTCD), as it offers better maternal outcomes with acceptable safety when properly managed.

Assessment and Preparation

• Confirm fetal demise via ultrasound and document gestational age
• Review prior cesarean operative report to confirm lower transverse uterine incision type
• Assess for contraindications to vaginal delivery:
  • Prior classical or T-incision cesarean
  • Prior uterine rupture
  • Prior hysterotomy or extensive myomectomy
  • Placenta accreta spectrum disorder

Management Approach

Labor Induction Considerations

• Avoid misoprostol (Cytotec) - contraindicated due to 13% risk of uterine rupture in women with prior cesarean 1, 2
• Preferred induction methods:
  1. Mechanical cervical ripening with Foley catheter (safest option with no reported ruptures) 1
  2. Oxytocin (associated with 1.1% uterine rupture risk) 1
  3. Avoid prostaglandin E2 if possible (2% uterine rupture risk) 1

Intrapartum Management

• Continuous electronic fetal monitoring is not needed due to fetal demise
• Close monitoring of maternal vital signs and uterine activity
• Epidural analgesia is recommended for pain management
• Active phase of labor should not exceed 3 hours without progress 3
• Maintain vigilance for signs of uterine rupture:
  • Sudden abdominal pain
  • Vaginal bleeding
  • Maternal tachycardia or hypotension
  • Abnormal uterine contraction pattern

Success Rates and Complications

• VBAC success rate in fetal demise cases is approximately 86.7% 4
• Trial of labor rate in women with prior CD and IUFD is 75.6% 4
• Uterine rupture risk is approximately 2.4% overall in IUFD with prior cesarean 4
• Risk increases significantly with multiple prior cesareans:
  • One prior cesarean: Similar complication rate to no prior cesarean
  • Two or more prior cesareans: Significantly higher complication risk (adjusted odds ratio 3.00) 5

Special Considerations

• Patients with prior vaginal delivery have higher VBAC success rates 1
• If induction is needed, mechanical methods are preferred over pharmacological methods
• Maternal safety is the primary concern in this setting
• If labor fails to progress or complications develop, proceed to repeat cesarean delivery

Pitfalls to Avoid

1. Using misoprostol for induction (13% uterine rupture risk) 1, 2
2. Prolonged induction without progress (>24 hours)
3. Failure to recognize early signs of uterine rupture
4. Delaying cesarean delivery when labor fails to progress
5. Inadequate pain management during labor induction

The evidence strongly supports that in the setting of fetal demise at 29 weeks with a prior LTCD, a trial of labor with appropriate induction methods is the safest approach for maternal outcomes, with high success rates and acceptable complication risks when properly managed.