Stillbirths

Stillborn babies are babies born dead after 24 weeks of pregnancy. Intrauterine death of the fetus can occur at any stage of pregnancy or during labor. Stillbirth causes great emotional stress for both the mother and the obstetric staff, so the pain and the process of delivery in these circumstances may seem useless and futile, and the mothers themselves may feel guilty and consider that what happened is in some way a punishment for them.

A few hours after intrauterine death of the fetus, its skin begins to peel. In such fetuses, the skin has a characteristic macerated appearance (the so-called macerated stillborn), which is not observed in the birth of a fetus that has just died in the womb (the so-called fresh stillborn). In case of intrauterine death of the fetus, its spontaneous delivery occurs (in 80% of cases this is observed within the next 2 weeks, in 90% - within 3 weeks), however, as a rule, labor is induced immediately after the death of the fetus is diagnosed in order to prevent the mother from waiting for a long time for spontaneous labor, as well as to minimize the risk of coagulopathy. The development of DIC syndrome is quite rare, with the exception of cases when the pregnancy period exceeds 20 weeks, and its postmortem stay in the womb of the fetus lasts more than 4 weeks; however, the presence of coagulopathy is very undesirable for the onset of labor.

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Causes of stillbirth

Toxemia, chronic hypertension, chronic kidney disease, diabetes mellitus, infection, fever (with body temperature over 39.4 °C), fetal malformations (11% of macerated stillbirths and 4% of fresh stillbirths are due to chromosomal abnormalities), jaundice, postmaturity. Placental abruption and umbilical cord torsion may be causes of fetal death during labor. In 20% of cases, no apparent cause for stillbirth is found.

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Recognition

Mothers usually report to the doctor that the fetus has stopped moving. The fetal heartbeat is not heard (using a Pinard stethoscope or cardiotocography). Also, it is not possible to detect fetal heartbeats during ultrasound examination.

Tactics of management

Labor is induced using vaginal prostaglandins or by administering them in a manner that does not penetrate the amnion (the dose varies depending on the uterine response). Intravenous oxytocin carries a risk of secondary uterine or cervical trauma and is therefore recommended only after discontinuation of prostaglandin infusion. Oxytocin infusion alone may be used to induce labor when the cervix is ripe (Bishop score greater than 4, gestational age greater than 35 weeks). Amniotomy is contraindicated because of the risk of infection.

Provide adequate analgesia during labor (tests are performed to monitor the hemostasis system during epidural anesthesia). It is desirable for a loved one to be present during labor for moral support. After the birth of a stillborn child, it should be swaddled like any other newborn and allowed to be looked at and held in the mother's arms (if she so wishes). A photograph of the child may be taken and given to the mother at home. Giving a name to a stillborn child and conducting a full funeral ceremony with the help of funeral services can also help to alleviate the grief of the loss.

A procedure for monitoring stillbirth (in order to establish a possible cause of stillbirth). A case of stillbirth is thoroughly analyzed, clinical photographs are studied. An autopsy and histological examination of the placenta are performed. Smears are taken from the upper sections of the vagina for bacteriological examination. The blood of the mother and fetus is tested for infections, which are united in English-language medical terminology under the abbreviation TORCH infections: T - toxoplasmosis, O - others (for example, AIDS, syphilis), R - rubella, C - cytomegalovirus, herpes (and hepatitis). The mother's blood is tested for the Kleihauher-Betke acid test (to identify the exchange of blood between the mother and fetus as a possible cause of unexplained stillbirth), as well as to identify the lupus anticoagulant. A chromosome analysis of the blood and skin of the fetus is performed.

The mother is offered lactation suppression (bromocriptine 2.5 mg orally on the first day, then 2.5 mg every 12 hours orally for 14 days). After receiving the test results, the parents are scheduled to meet to discuss the causes of stillbirth. If necessary, the parents are referred for genetic counseling.

Measures to help parents with stillbirths (in the UK)

• In the event of a stillbirth after the 24th week of pregnancy, a stillbirth certificate must be issued (by an obstetrician), which the parents must submit to the birth and death registrar within 42 days from the date of birth. The father's surname is recorded in the register only if the parents are married or if both parents register.
• The archivist-registrar issues a burial or cremation certificate, which the parents must present to the funeral home or hospital administration. If the parents have chosen a private funeral, they must pay for it themselves; if they have chosen a "hospital" funeral, the hospital administration will pay for it. The registration certificate must indicate the name of the stillborn child (if it was given a name), the name of the registrar, and the date of the stillbirth.
• Hospitals, based on documents signed by both parents, offer "hospital" funerals for stillborns (under conditions agreed upon with the funeral service). If the parents wish to pay for the "hospital" funeral themselves, the hospital administration has the right to accept this payment. The administration must notify the parents in advance of the date and time of the funeral so that they can attend it if they wish. A coffin is provided for "hospital" funerals, and the burial is often carried out in multiple graves located in sections of cemeteries specially designated for children. The hospital administration must inform the parents of the location of the grave. The graves are not marked, so if the parents did not attend the funeral but wish to visit the cemetery later, they are advised to contact the responsible cemetery employee so that temporary markings can be placed on the appropriate grave. If desired, the parents can purchase a single grave on which to subsequently install a tombstone. The hospital can arrange cremation, but this procedure is paid for by the parents.
• Parents of a stillborn baby should contact their local bereavement counselling and support organisation, such as SANDS (Stillbirth and Infant Death Support Society). The grief of loss can last a very long time and parents may find it difficult to communicate with health professionals because of constant apologies.

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