Stillbirth

Stillbirth
Ultrasonography is often used to diagnose stillbirth or medical conditions that raise the risk of stillbirth.
Classification and external resources
Specialty	Obstetrics
ICD-10	P95
OMIM	614389
DiseasesDB	6890
MedlinePlus	002304
eMedicine	topic list
MeSH	D050497

Stillbirth is often defined as fetal death after 20 weeks of gestation,^[1] but a fetus greater than any combination of 16, 20, 22, 24, or 28 weeks gestational age and 350g, 400g, 500g, or 1000g birth weight may be considered stillborn depending on local law.^[2] Once the fetus has died, the mother may or may not have contractions and undergo childbirth or in some cases, a Caesarean section. Most stillbirths occur in full-term pregnancies. The cause is often unknown.^[1]

In the U.S., the Born-Alive Infants Protection Act of 2002 specifies that any breathing, heartbeat, pulsating umbilical cord, or confirmed voluntary muscle movement indicate live birth rather than stillbirth.^[3]

The term is often used in distinction to live birth (the baby was born alive, even if it died shortly thereafter) or miscarriage (early pregnancy loss). The word miscarriage is often used incorrectly to describe stillbirths.

Causes

The causes of a large percentage of human stillbirths remain unknown, even in cases where extensive testing and autopsy have been performed. A rarely used term to describe these is "sudden antenatal death syndrome" or SADS, a phrase coined by Cacciatore & Collins in 2000.^[4] Many stillbirths occur at full term to apparently healthy mothers, and a postmortem evaluation reveals a cause of death in only about 40% of autopsied cases.^[5]

In cases where the cause is known, some possibilities of the cause of death are:

• bacterial infection
• birth defects, especially pulmonary hypoplasia
• chromosomal aberrations
• growth retardation
• Induced Fetal Demise
• intrahepatic cholestasis of pregnancy
• maternal diabetes
• high blood pressure, including preeclampsia
• maternal consumption of recreational drugs (such as alcohol, nicotine, etc.) or pharmaceutical drugs contraindicated in pregnancy
• postdate pregnancy
• placental abruptions
• physical trauma
• radiation poisoning
• Rh disease
• celiac disease^[6]
• female genital mutilation^[7]

Entanglement of cord in twin pregnancy at the time of Caesarean Section

• umbilical cord accidents^[8]
  • Prolapsed umbilical cord – Prolapse of the umbilical cord happens when the fetus is not in a correct position in the pelvis. Membranes rupture and the cord is pushed out through the cervix. When the fetus pushes on the cervix, the cord is compressed and blocks blood and oxygen flow to the fetus. The mother has approximately 10 minutes to get to a doctor before there is any harm done to the fetus.
  • Monoamniotic twins – These twins share the same placenta and the same amniotic sac and therefore can interfere with each other's umbilical cords. When entanglement of the cords is detected, it is highly recommended to deliver the fetuses as early as 31 weeks.
  • Umbilical cord length - A short umbilical cord (<30 cm) can affect the fetus in that fetal movements can cause cord compression, constriction and ruptures. A long umbilical cord (>72 cm) can affect the fetus depending on the way the fetus interacts with the cord. Some fetuses grasp the umbilical cord but it is yet unknown as to whether a fetus is strong enough to compress and stop blood flow through the cord. Also, an active fetus, one that frequently repositions itself in the uterus can cause entanglement with the cord. A hyperactive fetus should be evaluated with ultrasound to rule out cord entanglement.
  • Cord entanglement - The umbilical cord can wrap around an extremity, the body or the neck of the fetus. When the cord is wrapped around the neck of the fetus, it is called a nuchal cord. These entanglements can cause constriction of blood flow to the fetus. These entanglements can be visualized with ultrasound.
  • Torsion – This term refers to the twisting of the umbilical around itself. Torsion of the umbilical cord is very common (especially in equine stillbirths) but it is not a natural state of the umbilical cord. The umbilical cord can be untwisted at delivery. The average cord has 3 twists.

After a stillbirth there is a 2.5% risk of another stillbirth in the next pregnancy (an increase from 0.4%).^[9]

Diagnosis

It is unknown how much time is needed for a fetus to die. Fetal behavior is consistent and a change in the fetus' movements or sleep-wake cycles can indicate fetal distress.^[8] A decrease or cessation in sensations of fetal activity may be an indication of fetal distress or death, though it is not entirely uncommon for a healthy fetus to exhibit such changes, particularly near the end of a pregnancy when there is considerably less space in the uterus than earlier in pregnancy for the fetus to move about. Still, medical examination, including a nonstress test, is recommended in the event of any type of any change in the strength or frequency of fetal movement, especially a complete cease; most midwives and obstetricians recommend the use of a kick chart to assist in detecting any changes. Fetal distress or death can be confirmed or ruled out via fetoscopy/doptone, ultrasound, and/or electronic fetal monitoring. If the fetus is alive but inactive, extra attention will be given to the placenta and umbilical cord during ultrasound examination to ensure that there is no compromise of oxygen and nutrient delivery.

Constricted umbilical cord

When the umbilical cord is constricted (q.v. "accidents" above), the fetus experiences periods of hypoxia, and may respond by unusually high periods of kicking or struggling, to free the umbilical cord. These are sporadic if constriction is due to a change in the fetus' or mother's position, and may become worse or more frequent as the fetus grows. Extra attention should be given if mothers experience large increases in kicking from previous childbirths, especially when increases correspond to position changes.^[8]

Regulating High blood pressure, diabetes and drug use may reduce the risk of a stillbirth. Umbilical cord constriction may be identified and observed by ultrasound, if requested.

Some maternal factors are associated with stillbirth, including being age 40 or older, having diabetes, having a history of addiction to illegal drugs, being overweight or obese, and smoking cigarettes in the three months before getting pregnant.^[10]

Treatment

Fetal death in utero does not present an immediate health risk to the woman, and labour will usually begin spontaneously after two weeks, so the woman may choose to wait and bear the fetal remains vaginally. After two weeks, the woman is at risk of developing blood clotting problems, and labor induction is recommended at this point. In many cases, the woman will find the idea of carrying the dead fetus emotionally traumatizing and will elect to have labor induced. Caesarean birth is not recommended unless complications develop during vaginal birth. Women need to heal physically after a stillbirth just as they do emotionally. They will go through the healing process afterwards just as they would after a normal healthy birth.^[11]

Epidemiology

The average stillbirth rate in the United States is approximately 1 in 160 births, which is roughly 26,000 stillbirths each year.^[12] In Australia,^[13] England, Wales,^[14][15] and Northern Ireland, the rate is approximately 1 in every 200 births; in Scotland, 1 in 167.

In developing countries, where medical care can be of low quality or unavailable, the stillbirth rate is much higher.

Society and culture

The way people view stillbirths has changed dramatically over time. Years ago, parents were expected to recover from the loss of a fetus just months after it happened. In the early 20th century, when a stillbirth occurred, the baby was taken and discarded and the parents were expected to immediately let go of the attachment and try for another baby.^[16]

Legal definitions

In Japan, statues of Jizo, a Buddhist patron deity of children, memorialize stillborn babies.

Australia

In Australia any stillborn weighing more than 400 grams, or more than 20 weeks in gestation, must have its birth registered.^[17]

Austria

In Austria a stillbirth is defined as birth of a child of at least 500 g weight without vital signs, e.g. blood circulation, breath or muscle movements.

Canada

Beginning in 1959, "the definition of a stillbirth was revised to conform, in substance, to the definition of fetal death recommended by the World Health Organization."^[18] The definition of "fetal death" promulgated by the World Health Organization in 1950 is as follows:

"Fetal death" means death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps.^[19]

Germany

Monument to stillborn babies in Germany

In Germany a stillbirth is defined as birth of a child of at least 500g weight without blood circulation or breath. Details for burial vary amongst the federal states.^[20]

Ireland

At one time, this Angels' Plot was one of the few burial grounds for stillborn babies that was consecrated by the Catholic Church in Ireland.

Since 1 Jan 1995 stillbirths occurring in the Republic of Ireland must be registered; stillbirths which occurred before that date can also be registered but evidence is required.^[21] For the purposes of civil registration, s.1 of the Stillbirths Registration Act 1994 refers to :-

"...a child weighing at least 500 grammes, or having reached a gestational age of at least 24 weeks who shows no signs of life."

The Netherlands

In the Netherlands, stillbirth is defined differently by the central bureau of statistics (CBS) and the Dutch perinatal registry (Stichting PRN). The birth and mortality numbers from the CBS include all liveborn children, regardless of gestational duration and all stillbirths from 24 weeks of gestation and onwards. In the Perinatal Registry, gestational duration of both liveborn and stillborn children is available. They register all liveborn and stillborn children from 22, 24 or 28 weeks of gestation and onwards (dependent on the report: fetal, neonatal or perinatal mortality). Therefore, data from these institutions on (still)births can not simply be compared one-on-one.

United Kingdom

The registration of still-births has been required in England and Wales from 1927, in Scotland from 1939 but is not required in Northern Ireland.^[22] Sometimes a pregnancy is terminated deliberately during a late phase, for example for congenital anomaly. UK law requires these procedures to be registered as "stillbirths".^[23]

England and Wales

For the purposes of the Births and Deaths Registration Act 1926 (as amended), section 12 contains the definition that :-

"still-born" and "still-birth" shall apply to any child which has issued forth from its mother after the twenty fourth week of pregnancy and which did not at any time after being completely expelled from its mother, breathe or show any other signs of life.

A similar definition is applied within the Births and Deaths Registration Act 1953 (as amended), contained in s.41.

The above definitions apply within those Acts thus other legislation will not necessarily be in identical terms.

s.2 of the 1953 Act requires that registration of a birth takes place within 42 days of the birth except where an inquest takes place or the child has been "found exposed" in which latter case the time limit runs from the time of finding.

Extracts from the register of still-births are restricted to those who have obtained consent from the Registrar General for England and Wales.

Scotland

Section 56(1) of the Registration of Births, Deaths and Marriages (Scotland) Act 1965 (as amended) contains the definition that :-

"still-born child" means a child which has issued forth from its mother after the twenty-fourth week of pregnancy and which did not at any time after being completely expelled from its mother breathe or show any other signs of life, and the expression "still-birth" shall be construed accordingly

s.21(1) of the same Act requires that :-

Except so far as otherwise provided by this section or as may be prescribed, the provisions of this Part of this Act shall, so far as applicable, apply to still-births in like manner as they apply to births of children born alive.

In the general case, s.14 of the Act requires that a birth has to be registered within 21 days of the birth or of the child being found.

Unlike the registers for births, marriages, civil partnerships and deaths, the register of still-births is not open to public access and issue of extracts requires the permission of the Registrar General for Scotland.

Northern Ireland

In Northern Ireland the Births and Deaths Registration (Northern Ireland) Order 1976,^[24] as amended contains the definition :-

"still-birth" means the complete expulsion or extraction from its mother after the twenty-fourth week of pregnancy of a child which did not at any time after being completely expelled or extracted breathe or show any other evidence of life.

Registration of still-births can be made by a relative or certain other persons involved with the still-birth but it is not compulsory to do so. Registration takes place with the District Registrar for the Registration District where the still-birth occurred or for the District in which the mother is resident. A still-birth certificate will be issued to the registrant with further copies only available to those obtaining official consent for their issue. Registration may be made within three months of the still-birth^[25]

United States

In the United States, there is no standard definition of the term 'stillbirth'.^[19] The Centers for Disease Control and Prevention collects statistical information on "live births, fetal deaths, and induced termination of pregnancy" from 57 reporting areas in the United States. Each reporting area has different guidelines and definitions for what is being reported; many do not use the term "stillbirth" at all. The federal guidelines suggests (at page 1) that fetal death and stillbirth can be interchangeable terms. The CDC definition of "fetal death" is based on the definition promulgated by the World Health Organization in 1950 (see section above on Canada). Researchers are learning more about the long term psychiatric sequelae of traumatic birth and believe the effects may be intergenerational^[26]

The federal guidelines recommend reporting those fetal deaths whose birth weight is over 12.5 oz (350g), or those more than 20 weeks gestation. Forty-one areas use a definition very similar to the federal definition, thirteen areas use a shortened definition of fetal death, and three areas have no formal definition of fetal death. Only 11 areas specifically use the term 'stillbirth', often synonymously with late fetal death, however they are split between whether stillbirths are "irrespective of the duration of pregnancy", or whether some age or weight constraint is applied. A movement in the U.S. has changed the way that stillbirths are documented through vital records. Previously, only the deaths were reported. However 27 states have enacted legislation that offers some variation of a birth certificate as an option for parents who choose to pay for one. Parents may not claim a tax exemption for stillborn infants, even if a birth certificate is offered. To claim an exemption, the birth must be certified as live, even if the infant only lives for a very brief period.

See also

• Coffin birth
• Perinatal death
• Smoking and pregnancy
• Stillbirth and Neonatal Death Society

References

Further reading

• G. J. Barker-Benfield, "Stillbirth and Sensibility The Case of Abigail and John Adams," Early American Studies, An Interdisciplinary Journal, Spring 2012, Vol. 10 Issue 1, pp 2–29.
• the Lancet series on stillbirth highlights the rates and causes of stillbirth globally, explores cost-effective interventions to prevent stillbirths (as well as maternal and neonatal deaths) and sets key actions to halve stillbirth rates by 2020. Also included are Comments from professional organizations and parent groups, the latter demonstrating the unique tragedy for families of the birth of a baby bearing no signs of life. www.thelancet.com/series/stillbirth

External links

• The Wisconsin Stillbirth Service Program (WiSSP), a branch of the University of Wisconsin-Madison's Clinical Genetics Center. One of the foremost authorities on the causes of stillbirth and responsible for many stillbirth evaluation protocols, including the widespread use of the Kleihauer-Betke test in deciding whether Rh disease is to blame for a stillbirth.