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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (103 page)

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The report shows a rise in the rate of stillbirths from 4.83 to 5.20.
The perinatal death rate for 2002 was 7.87.
The stillbirth rate for multiple pregnancies is 3.5 times higher than for single pregnancies.
Under one type of classification, 70% of the deaths were unexplained antepartum deaths. For those where a diagnosis had been made, the leading causes were:
Congenital malformation (15.7%)
Intrapartum-related events (6.9%).
Unexplained antepartum deaths were then described using the obstetric classification, with the largest identifiable causes being:
•
APH (13.9%)
Maternal disorders (6.7%)
Pre-eclampsia (4.7%).
Half of all the stillbirths reported remained unexplained.
Neonatal deaths are those occurring during the first month of life. CEMACH (2004)
¹reported that the leading causes of neonatal death were:
Immaturity (47.7%)
Congenital malformation (23.6%)
Infection (9.1%).
The leading causes of post-neonatal death were:
Congenital malformation (29.7%)
Sudden infant death, cause unknown (22.9%)
Infection (16%).
The CEMACH report (2009) that reviewed perinatal mortality noted some positive key findings:
²
An improvement in neonatal mortality 3.3 per 1000 livebirths in 2007
A stillbirth rate of 5.2 per 1000 in 2007
A reducing stillbirth rate among twins 12.2 per 1000 livebirths and neonatal mortality rate of 18:1000 livebirths.
The report showed that neonatal mortality was highest amongst teenage mothers: 4.4:1000 compared with other age groups. Extremes of maternal age, non-white ethnicity, and maternal deprivation continue to be risk factors. Maternal obesity could be associated with adverse outcomes.
1. CEMACH (2004).
  Why Mothers Die 2000–2002.
  Available at: M
  www.cemach.org.uk (accessed 25.2.11).
2. CEMACH (2009).
  Perinatal Mortality
  2007. Available at: M
  www.cemach.org.uk (accessed 25.2.11).
  CHAPTER 19
  Emergencies
  460‌‌
  Intrauterine death and stillbirth
  Definition
  - Intrauterine death refers to death of the fetus at any stage in the pregnancy after the first trimester and before the onset of labour.
  - A stillbirth is a baby born after 24 weeks’ gestation which shows no signs of life. A baby born before 24 weeks is defined (from a medical viewpoint) as a spontaneous abortion.
  - The fetus may be retained in the uterus for weeks or be born a few days following intrauterine death.
    Factors associated with intrauterine death
    Maternal
  - Social factors, e.g. low socio-economic status
  - Maternal age (teenagers and >35 years)
  - Smoking, alcohol, and drug misuse
  - Viruses/infection: rubella, cytomegalovirus, toxoplasmosis, listeriosis
  - Exposure to environmental hazards:
    - Lead, cadmium, mercury
    - Air pollution
  - Direct trauma to abdomen
  - Placental dysfunction: abruption, placenta praevia
  - PIH, cholestasis of pregnancy
  - Poor previous obstetric history: abortions, preterm labour, stillbirth
  - Maternal illness: diabetes, renal disease, severe anaemia, epilepsy, antiphospholipid syndrome.
    Fetal
  - Fetal malformation (e.g. associated with diabetes)
  - Fetal anoxia
  - Severe IUGR
  - Rh incompatibility
  - Multiple pregnancy (especially monozygotic twins)
  - Cord accidents, compression, entanglement, true knot
    The cause of intrauterine death and stillbirth is often unknown.
    Complications of intrauterine death
  - DIC may occur if the fetus is retained 3–4 weeks.
  - Induction of labour may be prolonged or difficult.
  - The woman and her partner are at risk of psychological trauma.
    Signs
    Signs will depend on the time lapse since intrauterine death:
  - No fetal movements will be felt by the woman
  - No fetal heart heard with abdominal transducer
  - The uterus may be smaller than expected for dates
  - The woman may experience full breasts and may produce milk
  - Any hypertension may settle
  - There may be a brownish discharge PV.
INTRAUTERINE DEATH AND STILLBIRTH
461
Diagnosis
Ultrasound scan will confirm no heart beat.
Spalding’s sign: overlap and misalignment of fetal skull bones.
Robert’s sign: gas in the great vessels and heart of the fetus (1–2 days).
Fetal curl: there is arching of the fetal spine.
Management of care
The woman who presents with anxieties about reduced or no fetal movements should be seen urgently.
Be sensitive to her anxiety. You may be able to reassure the woman quickly by hearing the fetal heart using the CTG or Sonicaid
^®. When doing this, it is important to differentiate the fetal and the maternal pulse.
If the fetal heart is not heard (or the pregnancy is <20 weeks and the FHR is not easily audible), explain the findings and contact an
experienced ultrasonographer and a registrar to assess by ultrasound whether or not the FHR is present.
The diagnosis of intrauterine death should be confirmed by two experts.
Women booked under midwifery-led care should be transferred to consultant-led care. However, continuity of midwifery care should still be given high priority in order to facilitate adequate support and co-ordination of information throughout the episode. A midwife specializing in bereavement care may be available.
When giving bad news note that:
Support for the woman should be sought from her partner/family/ friend
Information should be clear and honest, given in a way sensitive to individual needs and feelings. Parents will always remember the way the news is delivered and the attitudes of staff
The parents may react with shock or ‘numbness’ or disbelief. Some may experience physical symptoms
Parents need time to receive the information
Any information given may need to be repeated, and distressed clients may need the information to be written down so that they can review it later
Support for staff is also important
The supervisor of midwives, community midwife, health visitor liaison, and GP should be informed of the intrauterine death as soon as possible after diagnosis.
Induction of labour
An obstetric consultant should discuss a plan for care and delivery with the parents.
Once the diagnosis is made, some women will want to wait a day or two, others will request induction of labour as soon as practical.
If the death of the fetus is thought to be related to maternal complications such as placental abruption, PIH, or infection, urgent delivery is indicated.
CHAPTER 19
Emergencies
462
- A full explanation should be given of the procedures, a possible time scale, and how the baby may look at delivery. Obtain consent for treatment. Those close to the couple should be encouraged to stay and give support.
- Ensure that the room for induction of labour is comfortable, and remove any inappropriate items (e.g. fetal monitor).
- Take IV samples of blood to test for FBC/platelets and G&S. Obtain a clotting screen if the intrauterine death occurred more than 3 weeks previously. Other samples may be requested, depending on the clinical picture.
  Induction regimen
- Mifepristone 200mg is given orally and the woman may go home and return in 36–48h.
- On re-admission: misoprostol 800micrograms is given PV.
- Misoprostol 400micrograms is given PV 3h later.
- This is repeated 3h up to five doses. The regimen should be continued even when the cervix dilates, to maintain uterine activity.
- If delivery does not occur, the senior obstetrician should be informed. After 24h it is safe to repeat the five doses of misoprostol.
- ARM should be avoided until delivery is imminent because:
  - There is a risk of infection
  - The fetal skull is cushioned by the waters.
- Choice in analgesia is important. Opiates may be given or an epidural if there is no coagulopathy.
- Syntometrine
  ^®is indicated at delivery. Be aware that PPH may occur.
  Care immediately after delivery
- Support the parents, and, if they are willing, encourage them to look at and hold the baby. They should be left alone with the baby for a period of time if they so wish.
- Acknowledge the parents’ feelings of loss. A few kind words, a clasped hand or hug, or a small posy of flowers from staff can enrich the few memories the couple take away.
- The obstetric registrar or consultant should see the baby and complete a stillbirth certificate. It is important that this is obtained early in the proceedings because the parents will need it to make arrangements for registration and burial.
- Weigh the baby and measure his or her length. The parents may want to help with bathing and dressing the baby. They will wish to give the baby a name. Photographs, a lock of hair, handprints, and footprints are taken and transferred to a card as a keepsake.
- Carefully label the baby with the mother’s identification details.
- Enquire whether the parents would like to see the hospital chaplain or other person who may provide spiritual support.
  Administration
  It is good practice to complete a bereavement checklist and to have a communication book to ensure that all administration is recorded efficiently (see Table 19.9).
  INTRAUTERINE DEATH AND STILLBIRTH
  463
  Investigations into cause of fetal loss