The loss of a pregnancy is always a tragedy, but late stillbirth between 28 and 36 completed weeks of pregnancy (CDC 2020) can seem particularly cruel.
With this in mind, what can midwives and maternity care staff do to help parents through this distressing period?
Causes of Stillbirth
In about 22% of cases, stillbirth occurs with no known cause (AIHW 2021).
However, there are some common risk factors that are known to be associated with adverse pregnancy outcomes. These include:
Smoking during pregnancy
Consuming alcohol during pregnancy
Certain maternal conditions including diabetes, pre-eclampsia and renal failure
High blood pressure
Being above the healthy weight range
Maternal age of over 35
Pregnancy lasting longer than 41 weeks
Certain sleep positions during late pregnancy (e.g. sleeping on the back)
Complications during labour
Fetal developmental abnormalities or birth defects
Injuries due to vehicle accidents, abuse or family violence.
(The Women’s 2020; Raising Children Network 2020)
The overall rate of stillbirths in Australia has remained fairly constant since 1999. However, the rate of late stillbirth has decreased from 3.5 deaths per 1000 births in 1999 to 2.2 deaths per 1000 births (AIHW 2021).
It is important to note that only 7.4% of stillbirths are caused by congenital anomalies, meaning that many are preventable (Storey et al. 2016). Late stillbirths are the most likely to be preventable (Flenady et al., as cited in AIHW 2021).
Paternal Age is a Risk Factor
Another more unusual risk factor that is currently under-researched is the impact of paternal age on the wellbeing of the fetus (Khandwala et al. 2018).
Research conducted by Nybo Andersen et al. (2004) suggested that pregnancies fathered by a man aged 50 or older have almost twice the risk of ending in fetal loss, compared with pregnancies fathered by younger men.
Interestingly, it was also shown that the paternal age-related risk of late stillbirth was higher than the risk of early stillbirth, with the incidence of loss starting to increase from the age of 45 years onwards.
Diagnosing Late Stillbirth
As soon as stillbirth is suspected, the diagnosis needs to be either confirmed or refuted through urgent ultrasound imaging to assess for fetal heart activity. This must be performed by an appropriately qualified clinician (Queensland Health 2018).
From here, a diagnosis of stillbirth will be made if there is no fetal cardiac activity, no signs of fetal movement and no signs of blood flow in the fetus (Queensland Health 2018).
Throughout the diagnostic process, it is crucial to be sensitive and empathetic. The following are best practice guidelines for communicating fetal death to the parents:
Be honest and transparent about the baby’s status before confirming death (e.g. avoid negating the parents’ instincts that something is wrong)
Avoid preventable or unexplained delays in delivering information
Use clear, empathetic and understandable language when communicating that the baby has died. Avoid medical terms and ambiguous statements
Once communicating that the baby has died, ask the parents whether they would like the healthcare professional to stay and answer questions or provide support, or if they would rather be left alone
Provide verbal, electronic and written information. Repeat information and details if required
Allow adequate time for the parents to discuss the situation with healthcare professionals
Ensure continuity of carer where possible
Offer support services (e.g. social worker, bereavement midwife, Indigenous liaison officer, pastoral care worker)
Reassure the parents that every effort will be made to determine the cause of death. However, avoid speculating about the cause of death before investigations have been performed
Prepare the mother for the possibility of experiencing passive fetal movements.
(Joanna Briggs Institute 2014; Queensland Health 2018)
Management of Labour
Once an intrauterine death has been confirmed, options for labour and birth should be discussed with the parents, and the mother’s wishes should be honoured if safe to do so (Queensland Health 2018).
Many women wish to wait for natural labour to begin and evidence suggests that most mothers will go into spontaneous labour within three weeks of a stillbirth diagnosis (Queensland Health 2018).
Providing that the mother is physically well, the membranes are intact and there is no evidence of pre-eclampsia, infection or bleeding, the risk of expectant management remains low and a policy of watchful waiting and careful monitoring can be adopted (Queensland Health 2018).
However, note that the risk of disseminated intravascular coagulation (DIC) increases if the fetus is retained for more than four weeks from the date of stillbirth (Queensland Health 2018).
Delaying labour is also associated with an increased risk of the mother developing moderate to severe anxiety (RCOG 2010).
If the mother already has ruptured membranes, infection or bleeding, then induction of labour is the preferred option (Queensland Health 2018).
Supporting Psychological Recovery
For many parents, spending time with their deceased baby is key to their long-term recovery. Respecting their wishes to engage in simple activities such as bathing and dressing their baby should be supported whenever possible, as should allowing parents as much time as they feel they need to spend with their baby, including allowing extended family visits if the parents request this (University Hospitals of Leicester 2021).
Another important aspect of the recovery process is honouring, as much as possible, the cultural and religious views of the parents, and offering appropriate follow-up counselling, de-briefing services and support groups to both the mother and her partner (Joanna Briggs Institute 2014).
Grief can be profound and long-lasting following a late miscarriage, stillbirth or neonatal death, and can permeate all aspects of day-to-day living. Feelings of isolation and possibly guilt may run deep and require long-term support, especially during subsequent pregnancies (Schott and Henley 2010).
“I spent nine months imagining life with baby, all the experiences of baby moving. Then to give birth when baby had died is so difficult” (COPE 2021).
Communicating With the Parents
For the midwifery and primary care teams who support grieving parents, using appropriate terminology and reflecting the parent’s language preferences are important parts of providing compassionate bereavement care, healing and recovery (Smith et al. 2020).
During your interactions with the parents, you should:
Use respectful language when talking about their baby. Use the baby’s name and gender if these are known
Answer their questions honestly. If you don’t know something, don’t guess
Use clear and straightforward language
Be comfortable showing emotion
Listen to what the parents have to say, and talk about their baby if they wish to do so
Give them time.
(Queensland Health 2018)
Examples of what you could say to the parents include:
“I’m so very sorry. I can’t begin to imagine what you’re going through but I want you to know I’m here to support you.”
“I wish things could have ended differently/could be different.”
“I am here to support you and help you through this very difficult time”.
“Other parents have sometimes found it helpful to ...”
“What can I help you with or would you like me to wash/dress/wrap/show you how...?”
“Do you have any questions?”
“We can talk again later.”
Given that the incidence of stillbirth has remained largely unchanged for many years (AIHW 2021) while the rates of maternal and child mortality are declining (Lawn et al. 2016), there is still significant progress that needs to be made.
It is possible to reduce the rates of stillbirth in the future, however, in order to move forward, the collection and measurement of stillbirth data must improve, and a singular, global system to identify the causes of stillbirth should be established (Storey et al. 2016).
Until then, being able to provide sensitive and empathetic care to families who experience this tragic event is of utmost importance.
Khandwala, Y S, Baker, V L, Shaw, G M, Stevenson, D K, Lu, Y & Eisenberg, M L 2018, ‘Association of Paternal Age With Perinatal Outcomes Between 2007 and 2016 in the United States: Population Based Cohort Study’, BMJ, viewed 3 June 2021, https://www.bmj.com/content/363/bmj.k4372
Smith, L K, Dickens, J, Bender Atik, R, Bevan, C, Fisher, J & Hinton, L 2020, ‘Parents’ Experiences of Care Following the Loss of a Baby at the Margins Between Miscarriage, Stillbirth and Neonatal Death: A UK Qualitative Study’, BJOG: An International Journal of Obstetrics & Gynaecology, vol. 127, no. 7, pp.868-874, https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.16113