What is Stillbirth?
Stillbirth is the death of an infant in-utero and past 20 completed gestational weeks. In Australia and New Zealand (ANZ) approximately 2500 babies are stillborn each year (over 2000 in Australia alone).
There are several different definitions of stillbirth depending on the number of weeks of gestation and the birth weight of the baby (which is usually required to be at least 400 grams). Some babies die in the uterus (womb) before they are born (called an intra-uterine fetal death). It can happen during the last half of pregnancy or, more rarely, during the labour and birth, when it is known as intrapartum death.
If a baby is born alive, but dies in the first 4 weeks of life, this is called a neonatal death.
What are the causes?
Around 30% of stillbirths are unexplained.
Some of the known causes are:
High blood pressure - Known as pre-eclampsia, high blood pressure may cause abruption of the placenta (where the placenta separates from the uterus) placing the baby in distress. Other conditions may also prevent the placenta from supplying the baby with sufficient oxygen and nutrients.
Chromosomal or structural irregularities - Around 10% of stillborn babies have anomalies that may be identified as genetic or from an unknown cause. Sometimes genetic defects prevent the organs from developing properly.
Bacterial infections – Sometimes these infections cause no symptoms in the mother but increase the likelihood of stillbirths.
Other maternal issues that may result in a stillbirth are diabetes, blood clotting problems, thyroid conditions or the liver condition obstetric cholestasis.
Intra-Uterine Growth Restriction (IUGR) –Infants who are not growing at an appropriate rate for their gestational age are at an increased risk of stillbirth due to hypoxia (oxygen deficiency).
Twin-Twin Transfusion Syndrome (TTTS) - In multiple pregnancies, the main cause of stillbirth is twin-twin transfusion syndrome. This is a condition in which the blood from one twin is transferred to the other twin via the placenta. 15% of identical twin pregnancies are affected by TTTS.
Labour Complications - A complicated labour may result in a stillbirth. This is sometimes the case if the cord passes through the vagina before the baby, disrupting the oxygen flow before the baby can breathe on its own.
It is believed that there is a higher risk of stillbirths with women who:
• are of advanced maternal age (over 35)
• are obese
• smoke during pregnancy,
• abuse drugs or alcohol during pregnancy
• hypertension (high blood pressure)
Sometimes it is determined that there is little chance a baby will survive the full term of pregnancy or live outside the uterus. This may be determined by ultrasound or a process called karyotyping. Karyotyping is a test which can help identify genetic problems by examining chromosomes in a sample of cells. The test can be performed on almost any tissue, including
• Amniotic fluid
• Bone marrow
• Placenta tissue
If the baby has been diagnosed with abnormalities that will prevent it from surviving outside of the uterus, the parents will have to face the difficult decision of when to deliver the baby. Some parents choose to continue with the pregnancy until the baby passes away. Other parents choose to induce labour.
Intra-Uterine Fetal Death
If the baby has died in the uterus and not during the delivery process, it may take up to two weeks for labour after the death. Many women choose to have labour induced rather than waiting for this to occur naturally.
There are a number of birthing options that may be presented to and considered by the parents.
Many mothers find the concept of delivering their stillborn baby naturally to be overwhelming and choose to have a caesarean. For others, a natural delivery feels like the better choice.
Parents may also be given the option of dilation and curettage. However, often parents prefer natural or caesarean delivery in order to have the opportunity to hold their baby and create memories.
Coping after delivery
Stillbirth is devastating for the parents, regardless of the number of weeks of gestation. In many cases, the death occurs unexpectedly towards the end of pregnancy when, had the baby been born alive, the chance of survival would be high.
In the hospital
Ideally you will be offered a choice on where to return after delivery. Many parents wish to return to the maternity ward as they do not wish to be perceived as ‘non-parents’ when their child has died. Some find the sight and sound of other babies quite distressing. It is important to honour your feelings and choose the situation that feels right for you.
Spending time with your baby and creating a lifetime of memories
Many parents choose to spend time with their baby. It is believed that validating the life of their baby assists in the grieving process.
This experience may be enhanced by the creation of memories. It is important not to feel rushed to make these decisions. The baby may be held for you at the hospital for a period of time whilst you determine what feels right for you.
It is a legislative requirement in Australia to hold a funeral for a baby born at 20 weeks gestation or greater. You may choose to arrange a service with the hospital chaplain or a religious representative of your choice. Here are some suggestions on how to hold a funeral for your baby.
If a baby is born late in the third trimester, full lactation will occur. Many mothers are not aware that their milk will still come in following the delivery of a stillborn baby. This experience alone can be both physically and emotionally painful. A lactation consultant will be able to help you manage and decrease milk production.
In NSW, a post-mortem examination of a stillborn baby can only be undertaken with the parent/s written consent. Autopsy rates are very low as it often too distressing for the parents to give consent.
What is an autopsy?
An Autopsy (or post-mortem) is a surgical examination of a body after death, to determine the cause of death or to find out more about factors that might have contributed to the death.
Even if consent is not given for an autopsy, it is recommended that the placenta, membrane and cord should be sent for examination.
Reasons to consent
A full autopsy is the most accurate and detailed method of identifying why a baby is stillborn. The results of an autopsy may:
• help you to understand the cause of your baby’s death and better process your grief.
• help determine risk to future pregnancies or identify potential inherited conditions
• provide information to health professionals that may be important in the management of your future pregnancies and help you successfully carry other babies to full term
• Contribute to the understanding of stillbirths and possibly help other mothers and their babies
Making the decision
Deciding about a post-mortem can be very difficult. The post-mortem can be delayed for a short period, but it is recommended within 48 hours. If you are unable to make this decision at the time, you may complete some forms authorising a friend or family member to choose for you.
After the autopsy
Following a post-mortem, you and your family will be able to see and hold the baby. Usually the effects of the post-mortem are unnoticeable once the baby has been dressed.
The results of the autopsy are usually reported within twelve weeks, sometimes even up to 6 months, although some preliminary findings may be available within a few days.
Stillbirths account for 70% of peri natal deaths. While infant mortality rates have declined in Australia over the past two decades there has been no reduction in the rate of stillbirth. Despite the fact that the rate of unexplained stillbirths is almost ten times that of SIDS (Sudden Infant Death Syndrome), very little research has been done in this area.
There are currently several research areas being explored by the Australian and New Zealand Stillbirth Alliance (ANZSA). The following are the main areas that are being focused on:
• Predicting at risk babies so that they may be monitored and action taken to prevent stillbirth
• Maternal factors that cause stillbirth and awareness campaigns to reduce these factors
• The use of home devices to monitor fetal movement
• Education for health professionals in dealing with parents following a stillbirth.