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OBSTETRICS
REPORT
The Study of Stillbirth
and the “12 Steps”
Toward Prevention
Ruth Fretts, MD, MPH
More can be done to provide for good outcomes in pregnancy. One area that needs attention is stillbirth, to prevent it whenever possible and to bring understanding when loss has occurred.
In the United States, the chance that a pregnancy will end as a stillbirth is about 1 in 200 for white women and 1 in 87 for black women.1 Stillbirth is 10 times more common than sudden infant death syndrome and is more common than infant deaths related to congenital anomalies (Table 1).2-5
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STILLBIRTH RATES AND CAUSES
There have been many roadblocks to the study of stillbirth, including a lack of consistency in reporting, definition, and evaluation.3 There has also been tension when death occurs before birth: Do these losses “count” as much as those deaths that occur after birth, and if we acknowledge the value of these lost lives, will we inadvertently impact a women’s access to abortion? Are stillbirths just “bad luck” or “God’s will,” or can more be done for women and their families?
There are many downstream consequences of stillbirth. Women who experience stillbirth are at increased risk for depression, anxiety, posttraumatic stress disorder, somatization disorder, and family disorganization.6,7 Is there anything we can do to make a difference for these families?
Of stillbirths worldwide, 98% occur in developing countries, with rates estimated to be 5 to 7 times higher than in developed countries. While there are significant differences in the rate and causes of stillbirth in these settings, the study of stillbirth globally gives insight into the interaction between the fetal and maternal conditions in the setting of varying access to healthy food, medical care, treatment of infections, screening of congenital anomalies, education, and antepartum and intrapartum care. We often forget that intrapartum asphyxia, obstructed labor, and preeclampsia are the leading causes of stillbirth globally. Women who have low education, poor nutrition, and no or late prenatal care have worse outcomes, no matter where they live. While social inequities remain a primary driver of obstetric outcome, there are emerging risk factors for stillbirth in developed countries, such as an increased rate of obesity, nulliparity, multiple gestations, use of reproductive technologies, and advanced maternal age (Table 2).
The reduction of specific types of stillbirths has occurred in settings where specific strategies have been developed; eg, screening for congenital anomalies and the availability of pregnancy termination have reduced stillbirths related to anomalies. Intrapartum monitoring, antibiotics, and cesarean delivery have also reduced the risk of intrapartum deaths.3
An estimated 40% of all stillbirths are significantly growth restricted, and the detection of growth restriction remains a major challenge. Preterm stillbirths are more likely to be growth restricted and occur in black women. Risk factors for late unexplained stillbirth are advanced maternal age, obesity, low socioeconomic status, and aberrations of fetal growth (both small babies and those who are large for gestational age) (Table 2).3,8,9
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IMPLICATIONS FROM RESEARCH
There are many complexities in studying stillbirth and many areas where we could do better. First, as a concept, stillbirths need to count and be counted. These losses should not be reviewed in the context of a “tissue committee,” but a perinatal audit needs to occur. The best way to reduce stillbirths is to study them. This includes reviewing the maternal obstetric history, including barriers to seeking care, a detailed description of the finding at birth, and a thorough, focused stillbirth evaluation. Without this, prevention strategies cannot be developed. It is true, after a stillbirth review, that some losses appear to be without known cause, but just as many have areas of care we know could have been managed better.
Some common findings emerge in the review of stillbirth cases. Black women appear to be overrepresented, especially from 20 to 24 weeks of gestation. Also, a fair number of losses between 20 and 24 weeks occur in women with multiple gestations.
After 24 to 28 weeks, the most common type of stillbirth is probably related to placental dysfunction and growth restriction. These are difficult cases indeed, since in most cases the diagnosis of growth restriction occurs at the diagnosis of stillbirth.
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STILLBIRTH REVIEW
While all stillbirths are difficult and have a tremendous impact on families, the late stillbirths feel the worst and are more subject to initiation of a legal request for medical records when parents search for answers. Most cases do not demonstrate blatant malpractice, but careful review will often demonstrate that changes in the fetal or maternal condition were not appreciated by the clinicians.10 This is sometimes related to having multiple providers or frequent urgent care visits that result in lack of continuity in care.
Some reviews find system errors that demonstrate a problem with patient follow-up. Whose job was it to contact the patient who forgot or cancelled her appointment? We have seen abnormal labs overlooked (a lonely elevated uric acid level), an elevation of blood pressure that did not trigger closer follow-up, and bad advice that when the baby’s movement is decreased, it is only because there is “less room to move.”
Without a stillbirth review, the chance for improvement is lost. Audits of stillbirth have found opportunities for improved outcome in 35% to 45% of cases; the most common findings point out failure to diagnose fetal growth restriction, failure to appreciate a change in maternal risk, and failure to adequately manage the complaint of decreased fetal movement.10
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12 STEPS TO STILLBIRTH PREVENTION
1. Stillbirths need to be counted. Many information-collecting systems include information only on live-born infants. Any upgrade in tracking outcome data should include stillbirths with as much data as live births.
2. All perinatal deaths need to be systematically reviewed; ideally, this should occur in a multidisciplinary review that is peer protected. The information from audits should focus not only on quality of care but also on the quality of the documentation, and deficiencies should be reported back to the providers. Trends or “lessons learned” need to be readily shared with obstetric staff.
3. Know your statistics; if you have a higher than average number of stillbirths, you have to ask why. Are there too many higher-order multiples? Too many intrapartum deaths?
4. After the diagnosis of a stillbirth, a woman should be given an opportunity to rally her resources, including a written plan of care with the next steps, and to discuss the stillbirth evaluation and support services.
5. A protocol for the stillbirth evaluation should be readily available, preferably in the “stillbirth package,” so doctors and midwives have easy access to information on the most relevant evaluations (see Table 3).
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TABLE 3. Simplified Protocol for Scenario-Specific Stillbirth Evaluation |
6. If a previous evaluation of chromosomes has not been performed, the woman should be offered an amniocentesis (preferably after the epidural is placed). This will greatly improve the chances that she will be able to obtain living cells for tissue culture. About
8% to 10% of stillbirths have chromosomal abnormalities, and the presence or absence of these abnormalities greatly influences the recurrence risk of stillbirth.4
7. The placenta should be sent for evaluation, preferably with the baby, in all cases. If there is suspicion that the death was the result of a cord accident, take photos of the cord position at birth (even a cell phone can be used if a camera is not available).
8. The autopsy consent should include options for evaluation that can be easily tailored to the parental needs, including a complete autopsy, an autopsy that spares the fetal head, an autopsy that involves leaving the organs
in place but allows biopsies, and an external examination by a perinatal specialist (if available).
9. Providers should be aware of the religious concerns of families; however, parents in general want answers to why their baby died. Most parents will allow an autopsy if they are reassured that the baby will be treated with respect and evaluated in a timely manner.5
10. Nurses need to be educated about the importance of fetal autopsy. Many times the parents are overwhelmed and feeling guilty that they may have done something wrong and are ambivalent about whether they should “subject” their baby to being “cut up.” Parents frequently seek advice from their labor nurses, so education should include a periodic update of the best practice for stillbirth evaluation and support services.5
11. Develop a work flow for evaluating the complaint of decreased fetal movement, including an ultrasound to assess fetal growth. At this visit, maternal and fetal risk factors need to be reviewed; it is not sufficient just to rule out asphyxia with a nonstress test.11
12. Evidence shows that recovery from stillbirth is improved if women and families receive support from multiple sources (spouse, family, friends) and a stillbirth support network, so resources
for families need to be made available.7
For a thorough review of the management of stillbirth, see ACOG’s recent practice bulletin “Management of Stillbirth.”8
The author reports no actual or potential conflict of interest in relation to this article.
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Ruth Fretts, MD, MPH, is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Harvard Vanguard Medical Associates, Wellesley, MA
References
- Willinger M, Ko CW, Reddy UM. Racial disparities in stillbirth risk across gestation in the United States. Am J Obstet Gynecol. 2009;201(5):469.e1-e8.
- Fretts RC. The study of stillbirth. Am J Obstet Gynecol. 2009;201(5):429-430.
- Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol. 2005;193(6):1923-1935.
- Korteweg FJ, Bouman K, Erwich JJ, et al. Cytogenetic analysis after evaluation of 750 fetal deaths: proposal for diagnostic workup. Obstet Gynecol. 2008;111(4):865-874.
- Chichester M. Requesting perinatal autopsy: multicultural considerations. MCN Am J Matern Child Nurs. 2007; 32(2):81-86.
- Turton P, Evans C, Hughes P. Long-term psychological sequelae of stillbirth: phase II of a nested case-control cohort study. Arch Womens Ment Health. 2009;12(1): 35-41.
- Cacciatore J, Schnebly S, Froen JF. The effects of social support on maternal anxiety and depression after stillbirth. Health Soc Care Community. 2009;17(2):167-176.
- ACOG Practice Bulletin No. 102: management of stillbirth. Obstet Gynecol. 2009;113(3):748-761.
- Huang DY, Usher RH, Kramer MS, Yang H, Morin L, Fretts RC. Determinants of unexplained antepartum fetal deaths. Obstet Gynecol. 2000;95(2):215-221.
- Saastad E, Vangen S, Froen JF. Suboptimal care in stillbirths—a retrospective audit study. Acta Obstet Gynecol Scand. 2007;86(4):444-450.
- Tveit JV, Saastad E, Stray-Pedersen B, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines—a clinical quality improvement. BMC Pregnancy Childbirth. 2009;9:32.
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