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Intrauterine death

Intrauterine fetal death refers to babies with no signs of life in utero. Stillbirth is defined as a baby delivered with no signs of life, known to have died after 24 completed weeks of pregnancy. In the UK, 1 in 200 babies are stillborn each year. In 28% of stillbirths, the cause remains unknown. Twelve per cent of stillbirths are attributed to placental conditions, 11 per cent to antepartum/intrapartum haemorrhage and 9 per cent to major congenital abnormality. Eight per cent of stillbirth deaths occur during labour or delivery.

Diagnosis

The mother may be aware of a decrease in fetal movements in many cases; others may be discovered at a routine antenatal check. Diagnosis is confirmed by ultrasound examination, which will reveal a lack of a visible heartbeat. Auscultation is insufficiently accurate for diagnosis, and may give false reassurance.

Delivery

Where the death is diagnosed antenatally, labour is induced using a combination of mifepristone and prostaglandin. While induction does not have to be immediate, it should take place within 2-3 days. Vaginal birth can be achieved within 24 hours of induction of labour in about 90 per cent of women, but is often emotionally distressing, and the woman may opt for a caesarean birth. The implications of a caesarean section for future childbearing should be discussed. The mother who has to deliver a stillborn baby requires significant psychological support. She may request substantial amount of pain relief, not realising that later she may wish she could fully remember the birth of the baby. Intrauterine death is a risk factor for the development of disseminated intravascular coagulation (DIC), which increases from low at 48 hours to 10 per cent within 4 weeks. The woman's condition should be monitored carefully. After delivery blood should be taken for FBC, clotting screen, Kleihauer test, HBA1c, cultures, serology and cytogenetics.

After the birth

After the baby is born, it is important to provide the mother and her partner with time - away from the normal postnatal ward - to spend with their baby and the opportunity to hold it, to wash and dress the baby if they wish or to watch while a member of staff does so, and to enable the parents to have mementoes of the baby, which may include photographs, the baby's name-band, foot and hand prints, a lock of hair. Parents should be offered full post-mortem examination to help explain the cause of an intrauterine fetal death, but should not be persuaded to accept the offer against their wishes or cultural or religious beliefs. Consent must be obtained, even for less invasive tests. Women should also be offered pharmacological measures to suppress lactation, to avoid physical discomfort and emotional distress. All key staff groups must be informed to ensure cancellation of existing appointments and continuity of follow-up. Carers must be alert to the fact that women (and their partners and other children) are at risk of prolonged severe psychological reactions, including post-traumatic stress disorder. Stillbirth must be medically certified by the doctor or midwife present at the birth or who examined the baby after birth, and the Coroner must be contacted if there is doubt about the status of the birth. Fetal deaths delivered later than 24 weeks that had clearly occurred before the end of the 24th week do not have to be certified or registered. Caring for a woman with a stillbirth can take a heavy emotional toll on the midwife and midwives also need effective support systems.

Further reading

Royal College of Obstetricians & Gynaecologists (2010). Late intrauterine Fetal Death and Stillbirth. Green-top guideline No 55. Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_55.pdf

SANDS (Stillbirth and neonatal death charity) Resources for professionals. http://www.uk-sands.org/professionals

Harding M. (2014) Stillbirth and neonatal death (Professional reference). Available at: http://patient.info/doctor/stillbirth-and-neonatal-death

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