At 38 weeks gestation with a history of fetal demise and late decelerations on a non-stress test (NST), should induction of labor be performed or a biophysical profile (BPP) be done?

Management of Late Decelerations at 38 Weeks with History of Fetal Demise

For a patient at 38 weeks gestation with a history of fetal demise and late decelerations on non-stress test (NST), immediate induction of labor is strongly recommended rather than proceeding with a biophysical profile (BPP). 1, 2

Rationale for Immediate Induction

• Late decelerations on NST represent a significant warning sign of potential uteroplacental insufficiency, which is particularly concerning in a patient with history of prior fetal demise 1
• The presence of late decelerations on NST, regardless of NST reactivity, should be viewed with alarm and warrants immediate delivery at term (38 weeks) 2
• Studies show that patients with late decelerations during antepartum testing have significantly higher rates of fetal distress during labor and potential adverse outcomes 1

Risk Assessment

• History of fetal demise represents a major risk factor for recurrent adverse outcomes
• Late decelerations indicate potential ongoing fetal compromise that could rapidly deteriorate
• At 38 weeks, the fetus is considered term with minimal risk from delivery compared to the risks of continued monitoring

Evidence Supporting Immediate Action

• According to ACR guidelines, abnormal results at term generally warrant delivery rather than continued monitoring 3
• Research shows that even with reactive NSTs, fetal death can occur within a short time frame (24-48 hours) when decelerations are present 2
• Studies demonstrate that 25% of cases with decelerations during NST resulted in fetal death during observation periods of 36-48 hours, despite negative contraction stress tests 2

Why BPP Is Not Preferred in This Scenario

• While BPP is valuable for high-risk pregnancy monitoring, the presence of late decelerations at term with history of fetal demise represents an acute finding requiring immediate intervention 4, 3
• Waiting for BPP results could delay necessary intervention in a situation where time is critical
• Even normal BPP results cannot completely eliminate the risk of sudden fetal demise, particularly with the combination of risk factors present 5

Common Pitfalls to Avoid

• Overreliance on reassuring tests: Unexpected fetal demise can occur despite previously reassuring test results 5
• Delayed intervention: At term with concerning findings, delaying delivery increases risk without significant benefit
• Ignoring the significance of late decelerations: Late decelerations represent a serious finding that should prompt immediate action at term 1, 2

Special Considerations

• If delivery cannot be accomplished immediately, continuous fetal monitoring should be maintained until delivery
• The mode of delivery should be determined based on obstetrical factors and the urgency of the situation
• Preparation for potential neonatal resuscitation should be made given the concerning fetal status

At 38 weeks with late decelerations and history of fetal demise, the safest approach is immediate delivery rather than further testing with BPP, as this represents the best strategy to prevent potential fetal mortality.