Stillbirth and Neonatal Mortality

Introduction

The death of a baby and the loss of all the potential of a human life can be a devastating event for women, their partners, families and society. The grief and anguish is often life-changing. The human reactions to grief of disbelief, denial, negotiation and anger can all be seen by those caring for affected women and families. Care of women suffering such loss should be compassionate and professional. The burden on those providing such care, especially on a regular basis, should not be underestimated.

Whilst major improvements in medical care in well-resourced countries have seen reductions in perinatal mortality of around 10-fold in the last 150 years, the incidence in under-resourced countries remains as high as 5%. Despite major efforts in the last 2 decades, the rate of fall in the incidence of perinatal mortality has slowed since the mid 1990s, and the incidence in the United Kingdom remains higher than many other well-resourced countries ( Fig. 37.1 ).

Fig. 37.1, Stillbirths in England and Wales, 1927 to 2019. (From Office for National Statistics, licensed under the Open Government Licence v.3.0.)

Definitions

The following definitions are used in the United Kingdom.

Stillbirth : This is a legal definition, confirmed in UK legislation by the Still-Birth (Definition) Act (1992) as the death of a fetus in utero after 24 weeks of gestation.
- This is a baby born with no signs of life, when death is known (or believed) to have occurred after 24 weeks. The timing of the death is important – for example, in an originally twin pregnancy in which there had been a fetal reduction at 12 weeks to a singleton, it would not be appropriate to describe the delivery as a stillbirth. Where death occurs in utero before 24 weeks, the term ‘miscarriage’ or ‘late fetal loss’ can be used. Death after 20 weeks is sometimes classed as a late fetal loss, but there is no accepted specific definition of such a situation.
  
  Stillbirth can be subclassified as those occurring before labour (antepartum) and during labour (intrapartum), in which the fetus was known to be alive at the onset of labour.
Neonatal death : A baby born alive (at any gestation) who subsequently dies within 28 days of the birth. If the death is within the first week, it is termed ‘early’. After the first week, it can be termed ‘late’.
Perinatal mortality: This is the combination of stillbirth and early neonatal deaths. The perinatal mortality rate is defined as stillbirth and early neonatal deaths per 1000 births.

Other definitions are used in different countries. The World Health Organization (WHO) continues to use 28 weeks rather than 24 weeks (this was also the UK definition before 1992) as its gestational cut-off or a birthweight less than 1 kg. This reflects the limited availability of advanced neonatal care globally. Adopting this later gestation lowers the apparent incidence of stillbirth. Despite this, the WHO reported 2.6 million stillbirths globally per year or one every 16 seconds. The large majority of these deaths are in low-resource countries, where around half of all stillbirths occur in the intrapartum period, representing the greatest time of risk. The estimated proportion of stillbirths that are intrapartum varies from 10% in well-resourced countries to 60% in under-resourced countries.

Historically, the rate of stillbirths fell dramatically through the second half of the 20th century, from over 40 in 1000 births before the Second World War to around 10 in 1000 by the mid-1970s. This was believed to be largely a result of improved antenatal care and better nutrition, which mirrored reductions in infant mortality and increased life expectancy generally. The change in definition from 28 to 24 should be taken into account when comparing data before and after 1992. The fall in the stillbirth rate since the mid-1990s has been much slower than the reduction in neonatal mortality during the same period.

In 2019, there were 2346 stillbirths in England, generating a stillbirth rate of 3.6 per 1000 births (a record low). This was a significant fall from a rate of 5.1 in 2010. While this compares relatively well with some global regions (e.g., in sub-Saharan Africa where, even using the narrower WHO definition, the rate was 29 per 1000 births in 2015), the UK government has set a target of continuing to lower this rate. In 2014, the target of halving the number of stillbirths in England by 2025 was announced. This would require a continued reduction to approximately 1600 by 2025, which represents a further decrease of around 750 stillbirths. A recent national review of stillbirths in the United Kingdom concluded that the majority of stillbirths are preventable, particularly by addressing improvements in health care.

Stillbirth

Causes

Whilst some stillbirths can be clearly ascribed to a specific cause (such as placental abruption) – even following extensive investigations, including autopsy – a cause is not identifiable in up to 50% of cases. There are a number of classifications of causes. One useful nomenclature is to divide causes into: maternal, fetal, placental, structural, and intrapartum. There may be an overlap of contributory causes. When no specific cause can be established, factors associated with an increased chance of stillbirth – such as maternal obesity, smoking, or advanced age – may be considered to be contributory, though the precise cause of death may remain unclear. The presence of maternal characteristics associated with stillbirth has changed over the last few decades, with an incidence of maternal obesity being 10% in the 1970s, rising to around 30% today. Maternal age has also increased over the same time frame. The principal causes of stillbirth appear in Table 37.1 .

Table 37.1

Principal Associations With and Causes of Stillbirth

Maternal associations

Smoking – dose dependent
Obesity
Diabetes
Age over 40 years
Black ethnicity
Illicit drug use – especially cocaine
Pre-eclampsia/hypertension
Poor maternal mental health or low educational attainment
Previous stillbirth
Hypovolaemia – hypotension and underperfusion
Antiphospholipid syndrome
Antibody production e.g. haemolytic disease

Placental causes of stillbirth

Placental insufficiency – failure of adequate trophoblastic invasion
Fetal growth restriction
Placental thrombosis/infarction
Placental abruption
Vasa praevia – fetal haemorrhage
Chorioamnionitis – membrane rupture

Fetal causes of stillbirth

Fetal abnormality – aneuploidies
Multiple pregnancy, including twin-to-twin transfusion
Infection, for example, parvovirus B19
Fetomaternal haemorrhage
Cord compression

Care of women with a stillbirth

In some cases, the immediate well-being of the mother is the principal concern. Where a woman is haemodynamically unstable (e.g., massive haemorrhage, trauma, or severe pre-eclampsia), the priorities of resuscitation and life support must be addressed without delay. However, in many cases, there is no immediate maternal physical compromise. In that situation, obstetric and midwifery staff will be able to focus on emotional support and sensitive care.

The diagnosis of stillbirth should be made by the most senior clinician available. It is best practice for real-time ultrasound by a trained operator to be performed for at least 1 minute to confirm asystole. Whenever possible, the diagnosis should be confirmed by a second trained operator. In addition to asystole, there may be other features which can give some indication of the duration of death, such as alteration in the brain tissue leading to overlap of the cranial bones (Spalding sign).

The manner in which the fact of death is communicated to the woman and partner is important and must be done sensitively but unambiguously. Terms such as ‘sleeping’ or ‘passed away’ should be avoided and a clear but tactful use of the words ‘death’ or ‘has died’ will avoid ambiguity. Staff required to communicate such information should have training in how to break bad news. Reiterating the message may also be important in some circumstances. Sometimes, another ultrasound examination will be requested if the woman or her family remain in any doubt about what has happened.

In some cases, the woman will have no suspicion of the baby’s death, and it may be a chance finding on a scheduled ultrasound scan. In other scenarios, the woman will be worried about her baby’s welfare (often, a lack of fetal movements) and will have attended hospital for an antenatal assessment. Typically, one or more midwives will have attempted unsuccessfully to auscultate the fetal heart before calling for medical assistance. In such cases, there will already be anxiety and fear before the bad news is broken.

This news causes emotional numbness and shock to the woman, in which case further detailed information may not be readily absorbed. A period of privacy and comfort from a partner, family member, or friend is important and should be offered. The reaction will vary from one person to another; staff should accommodate each individual woman’s needs as much as possible. It is important to perform basic clinical observations to exclude undiagnosed pre-eclampsia. If it is likely that the fetus died more than 48 hours ago, blood samples taken from the mother to exclude coagulopathy should be considered. An estimation of any fetomaternal haemorrhage by the Kleihauer test is appropriate, especially if the woman is rhesus negative.

After a period of contemplating the bad news, there will come a time when a woman is ready to discuss and plan what happens next. Unless there is maternal physical compromise, this should be avoided until the woman is ready. The fundamental need to deliver the baby should be discussed sensitively with the woman and her family. In most cases, vaginal birth by induction of labour is safer than caesarean birth, though each case will be different and there may be a relative contraindication to induction of labour (such as multiple previous caesareans) or an urgent need to deliver, which cannot wait for birth by induction of labour (e.g., haemorrhage or uncontrolled pre-eclampsia). For some women, when there is no medical indication for caesarean birth, this can seem initially preferable. A careful discussion of the pros and cons of induction versus caesarean should be conducted by a senior clinician.

When there is no maternal physical compromise, many women will choose to leave the hospital to spend some time with family and loved ones at home. Whilst generally a day or two will make little difference, women should be advised that longer prolongation of the pregnancy may lead to additional complications, such as coagulopathy, and can result in deterioration of the baby’s physical appearance and a reduction of information available at autopsy. The possibility of passive fetal movements should be discussed – this is the sensation of movement caused by the baby moving inertly within the amniotic sac because of maternal movements.

Whilst standard induction agents and techniques can be used, mifepristone followed by misoprostol (although unlicensed in the United Kingdom for this indication) is effective and safe as an induction technique. The combination of mifepristone and misoprostol gives an average duration of labour of 8 hours (the addition of mifepristone reduces the time interval by about 7 hours over using misoprostol alone). The dose of misoprostol should be tailored to the gestation. Lower doses of misoprostol are used at more advanced gestations, and caution is required when there is a history of caesarean section. Women should be offered as wide a range of analgesia as is safely possible, including epidural anaesthesia (unless there is evidence of coagulopathy or another specific contraindication). There is no indication for the routine use of antibiotics. Women undergoing vaginal birth after caesarean (VBAC) should be monitored for features of scar rupture, such as persistent suprapubic pain and vaginal bleeding.

Many UK obstetric units have a dedicated facility to care for women who are experiencing a stillbirth. Furnishings may be more evocative of home and a television or radio is typically provided. Facilities may include a bathroom and simple kitchen to allow self-contained consumption of meals and hot drinks. Ideally, this will have a separate entrance to the main delivery area to minimise contact with other women and partners. Care should be led by a consultant obstetrician and one-to-one care provided by an experienced midwife. Many units have midwives specially trained in bereavement care in order to provide continuity of contact and support for women and their partner. Many women will already know the gender of the baby and may already have chosen a name. If the gender cannot be determined with certainty at birth, genetic analysis will determine gender within a few working days.

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