Stillborn

Stillborn also known as stillbirth, intrauterine fetal death or demise, is when a baby dies in the womb after 20 weeks of pregnancy before or during delivery ¹. Both miscarriage and stillbirth describe pregnancy loss, but they differ according to when the loss occurs. In the United States, a miscarriage is usually defined as loss of a baby before the 20th week of pregnancy, and a stillbirth is loss of a baby after 20 weeks of pregnancy ². Most stillbirths happen before a woman goes into labor, but a small number happen during labor and birth. Stillbirth affects about 1 in 100 pregnancies each year in the United States; this is about 1 percent of all pregnancies and about 24,000 babies ³. That is about the same number of babies that die during the first year of life and it is more than 10 times as many deaths as the number that occur from Sudden Infant Death Syndrome (SIDS) ⁴.

Stillbirth is further classified as either early, late, or term ²:

• An early stillbirth is a fetal death occurring between 20 and 27 completed weeks of pregnancy.
• A late stillbirth occurs between 28 and 36 completed pregnancy weeks.
• A term stillbirth occurs between 37 or more completed pregnancy weeks.

Because of advances in medical technology over the last 30 years, prenatal care (medical care during pregnancy) has improved, which has dramatically reduced the number of late and term stillbirth ⁵. However, the rate of early stillbirth has remained about the same over time ⁵.

Common causes of stillbirth may include the following:

• Mother with diabetes or high blood pressure
• Infection in the mother or in the fetal tissues
• Congenital abnormalities
• Rh disease. A blood incompatibility problem between the mother and fetus.
• Cord problems including knots, tightened cord, cord wrapped around fetal body or neck, cord prolapse (falling down through the open cervix during labor)
• Placental problems including poor circulation, twin-to-twin transfusion (when twin circulations connect in a shared placenta).

Stillbirth with an unknown cause is called “unexplained stillbirth”  ². Having an unexplained stillbirth is more likely to occur the further along a woman is in her pregnancy. Having an autopsy on the baby and other laboratory tests is important in trying to understand why the baby died before birth. Your health care provider can share more information about this.

Stillbirth occurs in families of all races, ethnicities, and income levels, and to women of all ages. However, stillbirth occurs more commonly among certain groups of people including women who:

• are of black race
• are 35 years of age or older
• are of low socioeconomic status
• smoke cigarettes during pregnancy
• have certain medical conditions, such as high blood pressure, diabetes and obesity
• have multiple pregnancies such as triplets or quadruplets
• have had a previous pregnancy loss

This does not mean that every individual of black race or older age is at higher risk for having a stillbirth. It simply means that overall as a group, more stillbirths occur among all mothers of black race or older age when compared to white mothers and mothers under 35 years of age. Differences in factors such as maternal health, income, access to quality health care, stress, social and emotional support resources and cultural factors may explain how these factors are related to having a stillbirth. More research is needed to determine the underlying cause of stillbirths in these populations.

Treatment of stillbirth depends on many factors such as the number of weeks gestation, the size of the fetus, and how long since the fetal heartbeat stopped. Treatment may include the following:

• Waiting until the mother goes into labor on her own
• Dilation and evacuation also called D&E. Dilation and evacuation involves dilating the cervix and using instruments to deliver the fetus and tissues
• Induction of labor using medications to open the cervix and make the uterus contract and push out the fetus and tissues.

Stillbirth is often very difficult for parents and other family members. Stillbirth is sometimes harder than an earlier miscarriage because it happens later in pregnancy when the fetus has developed and the mother has felt movement. Often, the fetus is fully formed and is delivered just as any baby. It may be very hard emotionally for a woman to go through labor, yet not have a baby to take home. Counseling is important for all parents with a stillbirth to help them understand their feelings and begin the work of grieving.

Stillbirth key points

• Some women are more likely than others to have a stillbirth. Reducing your risk factors for stillbirth may help you have a healthy baby.
• Scientists don’t know what causes all stillbirths. Common causes include infections, birth defects and pregnancy complications, like preeclampsia.
• You can have tests to try to find out what caused your baby’s death and prevent another stillbirth in your next pregnancy.
• Most women who have a stillbirth and get pregnant again have a healthy pregnancy and a healthy baby.

Successful pregnancy after stillbirth

For most women, the chances of having another stillbirth are very low. Less than 1 in 100 women (less than 1 percent) who’ve had a stillbirth go on to have another stillbirth ⁶.

If you had a stillbirth and are thinking about having another baby, give yourself time to heal physically and emotionally. Your doctor may recommend that you have medical tests to try to find out more about what caused your stillbirth. You may need to wait until after you’ve had these tests to try to get pregnant again.

If you had a stillbirth that was caused by a genetic condition, a genetic counselor can help you understand the condition and the chances of you having another stillbirth. A genetic counselor is a person who is trained to help you understand about how genes, birth defects and other medical conditions run in families, and how they can affect your health and your baby’s health. Your health care provider can help you find a genetic counselor.

Here’s what you can do help to lower your risk of having a stillbirth in another pregnancy:

• Get a preconception checkup. This is a medical checkup you get before pregnancy. It helps make sure you’re healthy when you get pregnant.
• Get treatment for any medical conditions you have.
• Get to a healthy weight before getting pregnant. Your provider can recommend ways to get to a weight that’s right for you.
• Don’t smoke, drink alcohol, use marijuana or other drugs that can be harmful to your pregnancy. Tell your provider if you need help to quit.
• If you have any pain or bleeding from the vagina during pregnancy, call your doctor right away.

If you get pregnant again, your doctor monitors you and your baby closely. At around 32 weeks of pregnancy, she may ask you to do kick counts to help you keep track of how often your baby moves. Your doctor also may do medical tests to check your baby’s heart rate and movements.

Causes of stillbirth

Stillbirth can happen in any family. Scientists don’t know what causes all stillbirths including why stillbirth affects certain women more than others. Common causes of stillbirth include infections, birth defects and pregnancy complications, like preeclampsia. Researchers are working to learn more about risk factors for stillbirth.

Infections in the mother or baby

Some infections may not cause signs or symptoms and may not be diagnosed until they cause serious complications, like premature birth or stillbirth. Infections that can cause stillbirth include:

• Cytomegalovirus (CMV). This is a kind of herpes virus that you can get by coming in contact with body fluid (like saliva, semen, mucus, urine or blood) from a person who carries the virus. It’s a common infection in young children, but if you get it during pregnancy, it can cause serious problems, like stillbirth.
• Fifth disease. This is a common childhood illness that’s caused by a virus called parvovirus B19. It usually spreads through the air from an infected person’s cough or sneeze.
• Genital and urinary tract infections. These infections affect the urinary tract and genitals (also called sex organs), like the vagina or ovaries. The urinary tract is the system of organs (like the kidneys and bladder) that helps your body get rid of waste and extra fluids. Getting infected with genital herpes for the first time during pregnancy can lead to stillbirth. Genital herpes is a sexually transmitted infection (STI) you can get from having sex with someone who’s infected.
• Listeriosis. This is a type of food poisoning.
• Syphilis. This is an sexually transmitted infection.
• Toxoplasmosis. This is an infection you can get from eating undercooked meat or touching cat poop.

Problems with the placenta or umbilical cord

Placental problems include infections, blood clots, inflammation (redness, pain and swelling), problems with blood vessels and other conditions, like placental abruption. Placental abruption is a serious condition in which the placenta separates from the wall of the uterus before birth. Placental problems cause about 24 in 100 stillbirths (24 percent). Problems with the umbilical cord include having a knot in the cord or the cord being pinched so that your baby doesn’t get enough oxygen. Problems with the umbilical cord may lead to about 10 in 100 stillbirths (10 percent).

Complications during pregnancy, including:

• Being pregnant longer than 42 weeks
• Diabetes, obesity, high blood pressure and preeclampsia
• Health conditions like lupus, thrombophilias and thryroid disorders. Lupus is an autoimmune disorder. Autoimmune disorders are health conditions that happen when antibodies (cells in the body that fight off infections) attack healthy tissue just about anywhere in the body by mistake. Thyroid disorders affect your thyroid, a gland in your neck that makes hormones that help your body store and use energy from food. Thrombophilias increase your chances of making abnormal blood clots.
• Preterm labor and preterm premature rupture of the membranes (also called PPROM). Preterm labor is labor that begins early, before 37 weeks of pregnancy. Preterm premature rupture of the membranes (PPROM) is when the sac around the baby breaks early, causing labor to start.
• Fetomaternal hemorrhage. This is when your baby’s blood mixes with your blood during pregnancy or birth.
• Trauma or injuries (like from a car accident)

Conditions in the baby

Conditions in the baby, including:

• Birth defects and genetic conditions. About 14 in 100 stillborn babies (14 percent) have one or more birth defects, including genetic conditions like Down syndrome.
• Fetal growth restriction
• Not getting enough oxygen during labor and birth
• Rh disease. Rh factor is a protein on the surface of red blood cells. Rh disease happens when a woman who doesn’t have the protein (called Rh-negative) is pregnant with a baby who does have the protein (called Rh-positive). Rh disease can be prevented.

Risk factors for stillbirth

Risk factors are things that make you at risk for (more likely than others to have) a condition. Having a risk factor for stillbirth doesn’t mean for sure that you will have stillbirth. But knowing about and reducing your risk factors may help prevent stillbirth from happening to your baby. Some risk factors are things you can’t change, such as having a stillbirth in a previous pregnancy. Other risk factors are things you can do something about, like quitting smoking. Talk to your health care provider about what you can do to help reduce your risk factors for stillbirth.

According to the Centers for Disease Control and Prevention (CDC) and other experts, risk factors for stillbirth include:

Medical conditions

• Being obese. If you’re obese, you have an excess amount of body fat and your body mass index (also called BMI) is 30 or higher. BMI is a measure of body fat based on your height and weight.
• Diabetes. Diabetes is a condition in which your body has too much sugar (called glucose) in the blood.
• High blood pressure. Blood pressure is the force of blood that pushes against the walls of your arteries. Arteries are blood vessels that carry blood away from your heart to other parts of the body.

Pregnancy conditions and pregnancy history

• You’re pregnant with multiples (twins, triplets or more).
• You have intrahepatic cholestasis of pregnancy. This is the most common liver condition that happens during pregnancy.
• You had complications in a previous pregnancy, like premature birth, preeclampsia or fetal growth restriction. Premature birth is birth that happens too early, before 37 weeks of pregnancy. Preeclampsia is a condition that can happen after the 20th week of pregnancy or right after pregnancy. It’s when a pregnant woman has high blood pressure and signs that some of her organs, like her kidneys and liver, may not be working properly. Fetal growth restriction is when a baby doesn’t gain enough weight in the womb before birth.
• You’ve never given birth before.
• You had a miscarriage or stillbirth in a previous pregnancy. Miscarriage is when a baby dies in the womb before 20 weeks of pregnancy.

Age, race and social factors

• You’re younger than 20 or older than 35.
• You’re black. Black women have a higher risk for stillbirth compared to other women.
• You smoke, drink alcohol or use street drugs or prescription painkillers, like opioids.
• You’re not married.

Other possible risk factor

A recent study says that being exposed to certain kinds of air pollution (mainly ozone) may increase your risk for stillbirth. Ozone is a gas that comes from car exhaust, gasoline and fumes from factories and chemicals. Scientists need more research to find out how ozone and other air pollution affects pregnancy and stillbirth. If you’re worried about air pollution and your pregnancy, talk to your doctor.

How do you know if your baby is stillborn?

Signs of a condition are things someone else can see or know about you, like you have a rash or you’re coughing. Symptoms are things you feel yourself that others can’t see, like having a sore throat or feeling dizzy.

The most common symptom of stillbirth is when you stop feeling your baby moving and kicking. Others include cramps, pain or bleeding from the vagina. Call your health care provider right away or go to the emergency room if you have any of these conditions.

Your provider uses ultrasound to see if your baby’s heart has stopped beating. An ultrasound uses sound waves and a computer screen to show a picture of your baby in the womb.

What are the symptoms of stillbirth?

The following are the most common symptoms of stillbirth. However, each woman may experience symptoms differently. Symptoms may include:

• Stopping of fetal movement and kicks
• Spotting or bleeding
• No fetal heartbeat heard with stethoscope or Doppler
• No fetal movement or heartbeat seen on ultrasound, which makes the definitive diagnosis that a baby is stillborn. Other symptoms may or may not be linked to stillbirth.

The symptoms of stillbirth may resemble other medical conditions. Always consult your doctor for a diagnosis.

What are your options for giving birth if your baby is stillborn?

If your baby is stillborn, your doctor talks with you about options for giving birth. When and how you give birth depends on how far along you are in your pregnancy, your medical condition and what you think is best for you and your family. Some women need to give birth right away for medical reasons, but it’s often safe to wait until you go into labor on your own. Labor usually starts within 2 weeks after a baby dies in the womb.

Your doctor may recommend:

1. Inducing labor. This is when your doctor gives you medicine or breaks your water (amniotic sac) to make your labor start. Most women with a stillbirth have their doctors induce labor soon after they learn of their baby’s death. If you decide to wait to go into labor on your own and it doesn’t happen by 2 weeks after your baby’s death, your doctor may induce labor to help prevent dangerous blood clots from developing.
2. Dilation and evacuation also called D&E. During this surgical procedure, your doctor dilates (opens) the cervix to remove tissue from the lining of the uterus. The cervix is the opening to the uterus (womb) that sits at the top of the vagina. Having a D&E may limit the information your doctor can get about your baby’s condition. For example, if you have a D&E, your baby’s doctor can’t do an autopsy on your baby.
3. Cesarean birth (also called c-section). This is surgery in which your doctor makes a cut in your belly and uterus to deliver your baby.

What tests do you get after a stillbirth?

Your doctor checks your baby, the placenta and the umbilical cord to try to find out why your baby died. The placenta grows in your uterus and supplies the baby with food and oxygen through the umbilical cord. Your doctor may ask to do certain tests to try find out what caused the stillbirth. Tests may include:

• Amniocentesis (also called amnio). In this test, your doctor takes some amniotic fluid from around your baby in the uterus. If your doctor thinks a genetic condition or an infection in your baby may have caused the stillbirth, she may recommend an amnio before you give birth. Genetic conditions are health conditions that are passed from parents to children through genes.
• Autopsy. This is a physical exam of your baby’s body after death. During an autopsy, a doctor checks your baby’s organs for signs of birth defects or other conditions. This may help your doctor find out what caused your baby’s death and if you may be at risk of having another stillbirth in the future. Birth defects are health conditions that are present at birth. They change the shape or function of one or more parts of the body. Birth defects can cause problems in overall health, how the body develops or how the body works.
• Genetic tests to check for genetic conditions in your baby
• Tests for infections on your baby or on the placenta

In addition to checking your baby for medical and genetic conditions, your doctor reviews your family health history and any problems or illnesses you had during pregnancy. Your family health history is a record of any health conditions you, your partner and members of both your families have had. Your doctor may want to test you for infections, genetic conditions and other medical conditions, like lupus or thyroid problems.

Information from tests on you and your baby may help you if you’re thinking about getting pregnant again. Test results may help your doctor find out if there’s a chance that you could have another stillbirth. Even if your doctor doesn’t find out what caused your stillbirth, having the tests may help you better understand and cope with your baby’s death. If you have questions about the tests, including their cost, talk to your health care provider.

How can you deal with feelings of grief after a stillbirth?

Grief is all the feelings you have when someone close to you dies. Having a stillborn baby is a painful loss for a family. But there are things you can do to help you grieve, heal and remember your baby.

After birth, do what feels right for you and your family. You may want to spend time alone with your baby and other family members. You can name your baby, hold your baby, bathe and clothe her and take part in cultural or religious traditions, like baptism. Some families take pictures of their baby, make footprints or save locks of hair. You may be able to keep things from the hospital, like blankets, that were used with your baby. Keepsakes like these can help you and your family remember your baby.

Parents who have a stillbirth need time to grieve. You and your partner may cope with grief in different ways, and you may need help dealing with others as you grieve.

After you leave the hospital, certain things, like hearing names you were thinking of for your baby, seeing the baby’s nursery at home or having your breast milk come in can be painful reminders of your loss. You may need help learning how to deal with these situations and the feelings they create. Ask your health care provider to help you find a grief counselor to help you cope with your baby’s death. Or your hospital may have a loss and grief program for families. Getting counseling can be really helpful to you and your family.

Talking about your feelings with other parents who have had a stillbirth may help you deal with your grief. Visit https://share.marchofdimes.org/, the March of Dimes online community where families who have lost a baby can talk to and support each other. Sharing your story may ease your pain and help you heal.

Having a stillbirth may make you at risk for postpartum depression. Postpartum depression is a kind of depression that some women get after having a baby. Tell your doctor if you have signs or symptoms of postpartum depression, like feeling depressed most of the day every day, having little interest in things you normally like to do, or having trouble eating or sleeping.

Grieving the loss of your child

Mementos of the baby often help in the grieving process. Holding and touching the baby are important steps. In a private room, a nurse or counselor brings the baby to the parents wrapped in a blanket. This helps parents understand that the baby has really died and gives them a real, not imagined memory. Seeing the baby is especially helpful when a baby has a birth defect. Often, parents’ imagination of the defect is much worse than the real problem. Photographs of the baby may be helpful, too, as well as a lock of hair or footprints. Many parents wish to remember their baby with a memorial or funeral service. This can also help friends and other family members understand the loss that the parents have experienced.

Some parents may wish to learn more about the cause of their baby’s death, especially if there are no clear factors. An autopsy or special genetic and chromosomal testing are often available. Results can be shared with the parents at a meeting with your doctor several weeks afterwards. Autopsy does not prevent the parents from being able to see or hold the baby, and the autopsy can be performed before a funeral, if the parents wish.

References

1. Stillbirth. https://www.chop.edu/conditions-diseases/stillbirth
2. What is Stillbirth? https://www.cdc.gov/ncbddd/stillbirth/facts.html
3. Hoyert DL, Gregory ECW. Cause of fetal death: Data from the fetal death report, 2014. National vital statistics reports; vol 65 no 7. Hyattsville, MD: National Center for Health Statistics. 2016. https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_07.pdf
4. Xu JQ, Kochanek KD, Murphy SL, Arias E. Mortality in the United States, 2012. NCHS data brief, no 168. Hyattsville, MD: National Center for Health Statistics. 2014. https://www.cdc.gov/nchs/data/databriefs/db168.pdf
5. MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National vital statistics reports; vol 60 no 8. Hyattsville, MD: National Center for Health Statistics. 2012. https://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_08.pdf
6. Stillbirth. https://www.marchofdimes.org/complications/stillbirth.aspx