Stillbirth is typically defined as
fetal death at or after 20 or 28 weeks of
pregnancy
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ...
, depending on the source.
It results in a baby born without
signs of life. A stillbirth can result in the feeling of
guilt or
grief in the mother.
[ The term is in contrast to ]miscarriage
Miscarriage, also known in medical terms as a spontaneous abortion and pregnancy loss, is the death of an embryo or fetus before it is able to survive independently. Miscarriage before 6 weeks of gestation is defined by ESHRE as biochemical ...
, which is an early pregnancy loss, and Sudden Infant Death Syndrome, where the baby dies a short time after being born alive.
Often the cause is unknown.[ Causes may include pregnancy complications such as pre-eclampsia and birth complications, problems with the ]placenta
The placenta is a temporary embryonic and later fetal organ (anatomy), organ that begins embryonic development, developing from the blastocyst shortly after implantation (embryology), implantation. It plays critical roles in facilitating nutrien ...
or umbilical cord, birth defects, infections such as malaria
Malaria is a mosquito-borne infectious disease that affects humans and other animals. Malaria causes symptoms that typically include fever, tiredness, vomiting, and headaches. In severe cases, it can cause jaundice, seizures, coma, or deat ...
and syphilis, and poor health in the mother. Risk factors include a mother's age over 35, smoking, drug use, use of assisted reproductive technology, and first pregnancy. Stillbirth may be suspected when no fetal movement is felt.[ Confirmation is by ]ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...
.
Worldwide prevention of most stillbirths is possible with improved health systems. Around half of stillbirths occur during childbirth
Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births glo ...
, with this being more common in the developing
Development or developing may refer to:
Arts
*Development hell, when a project is stuck in development
*Filmmaking, development phase, including finance and budgeting
*Development (music), the process thematic material is reshaped
* Photograph ...
than developed world
A developed country (or industrialized country, high-income country, more economically developed country (MEDC), advanced country) is a sovereign state that has a high quality of life, developed economy and advanced technological infrastruc ...
.[ Otherwise, depending on how far along the pregnancy is, medications may be used to start labor or a type of surgery known as dilation and evacuation may be carried out.] Following a stillbirth, people are at higher risk of another one; however, most subsequent pregnancies do not have similar problems. Depression, financial loss, and family breakdown
The concept of interpersonal relationship involves social associations, connections, or affiliations between two or more people. Interpersonal relationships vary in their degree of intimacy or self-disclosure, but also in their duration, in t ...
are known complications.[
Worldwide in 2019, there were an estimated 2.0 million stillbirths that occurred after 28 weeks of pregnancy (about 1 for every 72 births). They occur most commonly in low income settings, particularly the ]Middle east
The Middle East ( ar, الشرق الأوسط, ISO 233: ) is a geopolitical region commonly encompassing Arabia (including the Arabian Peninsula and Bahrain), Asia Minor (Asian part of Turkey except Hatay Province), East Thrace (Europ ...
and Sub-Saharan Africa. In the United States, for every 167 births there is one stillbirth. Stillbirth rates have declined, though more slowly since the 2000s.
Causes
As of 2016, there is no international classification system for stillbirth causes. The causes of a large percentage of stillbirths is unknown, even in cases where extensive testing and an autopsy have been performed. A rarely used term to describe these is "sudden antenatal death syndrome", or SADS, a phrase coined in 2000. Many stillbirths occur at full term to apparently healthy mothers, and a postmortem evaluation reveals a cause of death in about 40% of autopsied cases.
About 10% of cases are believed to be due to obesity
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's ...
, high blood pressure
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high b ...
, or diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
.[
Other risk factors include:
*]bacterial infection
Pathogenic bacteria are bacteria that can cause disease. This article focuses on the bacteria that are pathogenic to humans. Most species of bacteria are harmless and are often beneficial but others can cause infectious diseases. The number of th ...
, like syphilis[
*]malaria
Malaria is a mosquito-borne infectious disease that affects humans and other animals. Malaria causes symptoms that typically include fever, tiredness, vomiting, and headaches. In severe cases, it can cause jaundice, seizures, coma, or deat ...
* birth defects, especially pulmonary hypoplasia
Pulmonary hypoplasia is incomplete development of the lungs, resulting in an abnormally low number or size of bronchopulmonary segments or alveoli. A congenital malformation, it most often occurs secondary to other fetal abnormalities that ...
* chromosomal aberrations
* growth restriction
* intrahepatic cholestasis of pregnancy
*maternal diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
*maternal consumption of recreational drugs (such as alcohol, nicotine, etc.) or pharmaceutical drugs contraindicated in pregnancy
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ...
*postdate pregnancy
Postterm pregnancy is when a woman has not yet delivered her baby after 42 weeks of gestation, two weeks beyond the typical 40-week duration of pregnancy. Postmature births carry risks for both the mother and the baby, including fetal malnutrition ...
* placental abruptions
* physical trauma
* radiation poisoning
* Rh disease
* celiac disease
* female genital mutilation
* umbilical cord accidents
**''Prolapsed umbilical cord
Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It us ...
'' – 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 rupture. 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 accidentally entangle itself 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 three twists.
* Smoke Inhalation - If a pregnant woman gets trapped in a building fire, the smoke and fumes can kill an unborn child.
A pregnant woman sleeping on her back after 28 weeks of pregnancy may be a risk factor for stillbirth.
After a stillbirth there is a 2.5% risk of another stillbirth in the next pregnancy (an increase from 0.4%).
In the United States, highest rates of stillbirths happen in pregnant women who:
* are of low socioeconomic status
* are aged 35 years or older
* have chronic medical conditions such as diabetes, high blood pressure, high cholesterol, etc.
* are African-American
* have previously lost a child during pregnancy
* have multiple children at a time (twins, triplets, etc.)
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. A decrease or cessation in sensations of fetal activity
A fetus or foetus (; plural fetuses, feti, foetuses, or foeti) is the unborn offspring that develops from an animal embryo. Following embryonic development the fetal stage of development takes place. In human prenatal development, fetal develo ...
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
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ...
when there is considerably less space in the uterus
The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The ...
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
Frequency is the number of occurrences of a repeating event per unit of time. It is also occasionally referred to as ''temporal frequency'' for clarity, and is distinct from '' angular frequency''. Frequency is measured in hertz (Hz) which is ...
of fetal movement, especially a complete cease; most midwives and obstetrician
Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surg ...
s 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
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...
, and/or electronic fetal monitoring. If the fetus is alive but inactive, extra attention will be given to the placenta
The placenta is a temporary embryonic and later fetal organ (anatomy), organ that begins embryonic development, developing from the blastocyst shortly after implantation (embryology), implantation. It plays critical roles in facilitating nutrien ...
and umbilical cord during ultrasound examination to ensure that there is no compromise of oxygen and nutrient delivery.
Some researchers have tried to develop models to identify, early on, pregnant women who may be at high risk of having a stillbirth.
Definition
There are a number of definitions for stillbirth. To allow comparison, the World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
uses the ICD-10 definitions and recommends that any baby born without signs of life at greater than or equal to 28 completed weeks' gestation be classified as a stillbirth.[ The WHO uses the ICD-10 definitions of "late fetal deaths" as their definition of stillbirth.][ Other organisations recommend that any combination of greater than 16, 20, 22, 24 or 28 weeks gestational age or 350 g, 400 g, 500 g or 1000 g birth weight may be considered a stillbirth.
The term is often used in distinction to live birth (the baby was born alive, even if it died shortly thereafter) or ]miscarriage
Miscarriage, also known in medical terms as a spontaneous abortion and pregnancy loss, is the death of an embryo or fetus before it is able to survive independently. Miscarriage before 6 weeks of gestation is defined by ESHRE as biochemical ...
(early pregnancy loss). The word miscarriage is often used incorrectly to describe stillbirths. The term is mostly used in a human context; however, the same phenomenon can occur in all species of placental mammals.
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.
Regulating high blood pressure
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high b ...
, diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
and drug use may reduce the risk of a stillbirth. Umbilical cord constriction may be identified and observed by ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...
, if requested.
Some maternal factors are associated with stillbirth, including being age 35 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.
Treatment
Fetal death '' in utero'' does not present an immediate health risk to the pregnant woman, and labour will usually begin spontaneously after two weeks, so the pregnant woman may choose to wait and bear the fetal remains vaginally. After two weeks, the pregnant woman is at risk of developing blood clot
A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of c ...
ting problems, and labor induction is recommended at this point. In many cases, the pregnant woman will find the idea of carrying the dead fetus traumatizing
Psychological trauma, mental trauma or psychotrauma is an emotional response to a distressing event or series of events, such as accidents, rape, or natural disasters. Reactions such as psychological shock and psychological denial are typical. ...
and will elect to have labor induced. Caesarean birth is not recommended unless complications develop during vaginal birth. How the diagnosis of stillbirth is communicated by healthcare workers may have a long-lasting and deep impact on parents. People need to heal physically after a stillbirth just as they do emotionally. In Ireland, for example, people are offered a 'cuddle cot', a cooled cot which allows them to spend a number of days with their child before burial or cremation.
Delivery
In single stillbirths, common practice is to induce labor for the health of the mother due to possible complications such as exsanguination. Induction and labor can take 48 hours. In the case of various complications such as preclampsia, infections, multiples(twins), emergency Cesarean may occur.
Epidemiology
The average stillbirth rate
Rate or rates may refer to:
Finance
* Rates (tax), a type of taxation system in the United Kingdom used to fund local government
* Exchange rate, rate at which one currency will be exchanged for another
Mathematics and science
* Rate (mathema ...
in the United States is approximately 1 in 160 births, which is roughly 26,000 stillbirths each year. In Australia, England, Wales, and Northern Ireland, the rate is approximately 1 in every 200 births; in Scotland, 1 in 167. Rates of stillbirth in the United States have decreased by about two-thirds since the 1950s.
The vast majority of stillbirths worldwide (98%) occur in low and middle-income countries
A developing country is a sovereign state with a lesser developed industrial base and a lower Human Development Index (HDI) relative to other countries. However, this definition is not universally agreed upon. There is also no clear agree ...
, where medical
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practi ...
care can be of low quality or unavailable. Reliable estimates calculate that, yearly, about 2.6 million stillbirths occur worldwide during the third trimester. Stillbirths were previously not included in the Global Burden of Disease Study which records worldwide deaths from various causes until 2015.
Society and culture
The way people view stillbirths has changed dramatically over time; however, its economic and psychosocial
The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is ...
impact is often underestimated. 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. In many countries, parents are expected by friends and family members to recover from the loss of an unborn baby very soon after it happens. Societally-mediated complications such as financial hardship and depression are among the more common results. A stillbirth can have significant psychological effects on the parents, notably causing feelings of guilt in the mother. Further psycho-social effects on parents include apprehension, anger, feelings of worthlessness and not wanting to interact with other people, with these reactions sometimes carried over into pregnancies that occur after the stillbirth. Men also suffer psychologically after stillbirth, although they are more likely to hide their grief and feelings and try to act strong, with the focus on supporting their partner.
Legal definitions
Australia
In Australia, stillbirth is defined as a baby born with no signs of life that weighs more than 400 grams, or more than 20 weeks in gestation. They legally must have their birth registered.
Austria
In Austria, a stillbirth is defined as a birth of a child of at least 500g 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
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
". The definition of "fetal death" promulgated by the World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
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.
Germany
In Germany, a stillbirth is defined as the birth of a child of at least 500g weight without blood circulation or breath. Details for burial vary amongst the federal states.
Republic of Ireland
Since 1 January 1995, stillbirths occurring in the Republic of Ireland must be registered; stillbirths that occurred before that date can also be registered but evidence is required. 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."
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 livebirths, 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 stillbirths has been required in England and Wales from 1927 and in Scotland from 1939 but is not required in Northern Ireland. Sometimes a pregnancy is terminated deliberately during a late phase, for example due to congenital anomaly. UK law requires these procedures to be registered as "stillbirths".
=England and Wales
=
For the purposes of the Births and Deaths Registration Act 1926 (as amended), section 12 contains the definition:A similar definition is applied within the Births and Deaths Registration Act 1953
Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiated by hormones which cause the muscular walls of the uterus to contract, expelling the f ...
(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 stillbirths are restricted to those who have obtained consent from the Registrar General for England and Wales
The General Register Office for England and Wales (GRO) is the section of the United Kingdom HM Passport Office responsible for the civil registration of births (including stillbirths), adoptions, marriages, civil partnerships and deaths in Englan ...
.
=Scotland
=
Section 56(1) of the Registration of Births, Deaths and Marriages (Scotland) Act 1965 (as amended) contains the definition:s.21(1) of the same Act requires that: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
Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiated by hormones which cause the muscular walls of the uterus to contract, expelling the f ...
, as amended contains the definition:Registration of stillbirths can be made by a relative or certain other persons involved with the stillbirth 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 stillbirth 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.
United States
In the United States, there is no standard definition of the term 'stillbirth'.
In the U.S., the Born-Alive Infants Protection Act
The Born-Alive Infants Protection Act of 2002 ("BAIPA" , ) is an Act of Congress. It affirms legal protection to an infant born alive after a failed attempt at induced abortion. It was signed by President George W. Bush.
Legislative history
* ...
of 2002 specifies that any breathing, heartbeat, pulsating umbilical cord or confirmed voluntary muscle movement indicate live birth rather than stillbirth.
The Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georg ...
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 suggest (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
The federal guidelines recommend reporting those fetal deaths whose birth weight is over 12.5 oz (350 g), 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
* Sands (charity)
References
External links
*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.
Lancet series on stillbirth 2016
{{Authority control
Pathology of pregnancy, childbirth and the puerperium
Fertility
Medical aspects of death
Midwifery
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