About 85 percent of stillbirths occur before labor begins (2). The pregnant woman may suspect that something is wrong with her baby if the fetus suddenly stops moving around and kicking. A small number of stillbirths occur during labor and delivery.
How is fetal death diagnosed?
An ultrasound examination (a test that uses sound waves to take a picture of the fetus) can confirm that the fetus has died by showing that the fetus's heart has stopped beating. It sometimes can help explain why the fetus died. The health care provider will do some blood tests on the pregnant woman to help determine why the fetus died.
How is the pregnant woman treated?
The health care provider will discuss options for delivering the fetus. Some women may need to deliver immediately for medical reasons. However, many couples can decide when they want to deliver the fetus. Some choose to wait until the woman goes into labor. Labor usually starts within two weeks after the fetus dies. Waiting for labor generally poses little risk to a woman's health. If labor has not begun after two weeks, doctors recommend inducing labor because there is a small risk of dangerous blood clots after this time.
Most couples choose to have labor induced soon after they learn of their baby's death. If the woman's cervix has not begun to dilate in preparation for labor, the provider may use vaginal suppositories to help prepare her cervix. She is then treated with the hormone oxytocin (also called Pitocin), which is given through a vein. Oxytocin stimulates uterine contractions. Generally, a woman does not need a cesarean unless she develops problems with labor and delivery.
What tests are done after the fetus is delivered?
After delivery, the fetus, placenta and umbilical cord are examined carefully to determine why the fetus died. The provider often recommends an autopsy. In some cases, the provider recommends tests for genetic or chromosomal birth defects or various infections.
These tests cannot determine the cause of stillbirth in up to half of all cases (1, 3). However, the information from these tests often is useful in helping couples plan a future pregnancy, even if the cause of the stillbirth remains unknown.
What are the causes of stillbirth?
There are a number of known causes of stillbirth. Sometimes more than one of these causes may contribute to the baby's death. Common causes include:
- Birth defects: About 15 to 20 percent of stillborn babies have one or more birth defects (4). Nearly half of these have chromosomal abnormalities, such as Down syndrome (4). Others have birth defects resulting from genetic, environmental or unknown causes.
- Placental problems: Placental problems cause between 10 and 20 percent of stillbirths (3). One of the most common placental problems is placental abruption. In this condition, the placenta peels away, partly to almost completely, from the uterine wall before delivery. It results in heavy bleeding that can threaten the life of mother and baby. Sometimes it can cause the fetus to die from lack of oxygen. Women who smoke cigarettes or use cocaine during pregnancy are at increased risk of placental abruption.
- Poor fetal growth: Fetuses who are growing too slowly are at increased risk of stillbirth, sometimes from asphyxia (lack of oxygen). About 20 percent of stillborn babies have poor growth (3). Women with preeclampsia, a pregnancy-related form of high blood pressure, are at increased risk of having a growth-restricted baby. Smoking also increases the risk. An ultrasound examination during pregnancy can show that the fetus is growing poorly, allowing health care providers to carefully monitor the pregnancy.
- Infections: Infections involving the mother, fetus or placenta appear to cause about 10 to 25 percent of stillbirths (3). Infections are an important cause of fetal deaths before 28 weeks of pregnancy (3). Some infections may cause no symptoms in the pregnant woman. These may include genital and urinary tract infections and certain viruses, such as fifth disease (parvovirus infection). These infections may go undiagnosed until they cause serious complications, such as fetal death or preterm birth (before 37 completed weeks of pregnancy).
- Chronic health conditions in the pregnant woman: About 10 percent of stillbirths are related to chronic health conditions in the mother, such as high blood pressure, diabetes and kidney disease (3). These conditions may contribute to poor fetal growth or placental abruption. Due to improvements in medical care, fetal deaths due to maternal health conditions have greatly decreased (3).
- Umbilical cord accidents: Accidents involving the umbilical cord may contribute to about 15 percent of stillbirths (3). These may include a knot in the cord or abnormal placement of the cord into the placenta. These can deprive the fetus of oxygen.
Other causes of stillbirth include trauma (such as car accidents), postdate pregnancy (a pregnancy that lasts longer than 42 weeks), Rh disease (an incompatibility between the blood of mother and baby), and lack of oxygen (asphyxia) during a difficult delivery. These causes are uncommon.
Can stillbirths be prevented?
Over the past 30 years, stillbirths have declined by about 50 percent (3). This is largely due to better treatment of certain conditions, such as maternal high blood pressure and diabetes, which can increase the risk of stillbirth. Today, women with well-controlled diabetes and high blood pressure face little increased risk of stillbirth (3). Rh disease was an important cause of stillbirth until the 1960s. Now it usually can be prevented by giving an Rh-negative woman an injection of immune globulin at 28 weeks of pregnancy, and again after the birth of an Rh-positive baby.
Women with high-risk pregnancies are carefully monitored during late pregnancy, usually starting by about 32 weeks (3). Tests that monitor the fetal heart rate often can tell if the fetus is in trouble. This can allow treatment, sometimes including early delivery, which can be lifesaving. Premature babies are at increased risk of health problems in the newborn period and of lasting disabilities. However, with advances in medical care, the outlook for premature babies has greatly improved.
Health care providers often suggest that high-risk pregnant women do a daily “kick count” starting around 28 weeks of pregnancy (5). One approach is to record how long it takes a fetus to make ten movements. It is reassuring if a fetus makes ten movements within two hours. If a woman counts fewer than ten kicks in two hours, or if she feels that the baby is moving less than usual, she should contact her health care provider. Her provider may recommend tests, such as fetal heart rate monitoring and ultrasound.
Women should not smoke, drink alcohol or use street drugs during pregnancy. All of these can increase the risk of stillbirth and other pregnancy complications. Pregnant women also should discuss all prescription, over-the-counter and herbal medications with their health care provider because some medications can pose a risk to the fetus.
Pregnant women should report any vaginal bleeding to their health care provider immediately. Vaginal bleeding during the second half of pregnancy can be a sign of placental abruption. Often, a prompt cesarean delivery can save the baby.
Women who are obese appear to be at increased risk of having a stillborn baby (6). Women who are obese should consider losing weight before they attempt to conceive. Their health care provider can discuss their ideal weight and how they can achieve it. A woman should never try to lose weight during pregnancy. However, women who are obese should not gain as much weight during pregnancy as women who are not overweight.
A woman who has had a stillbirth in a previous pregnancy should be monitored carefully for any signs of fetal difficulties. This will help assure that all necessary steps can be taken to prevent another fetal death.
What is the risk of stillbirth happening again in another pregnancy?
Parents who have had a stillbirth are often worried about this tragedy happening again. Fortunately, the risk is low for most couples. For example, chromosomal birth defects or cord accidents are unlikely to occur again in another pregnancy.
However, the risk may be higher if a maternal health condition (such as diabetes) or a genetic disorder caused the stillbirth. In such cases, the couple would benefit from genetic counseling. A genetic counselor can advise the couple about the risk of stillbirth or other pregnancy complications in another pregnancy.
A couple should discuss their risk of stillbirth with their health care provider before another pregnancy. In some cases, the woman and her health care provider can take steps to reduce her risk in another pregnancy. For example, if a woman has diabetes, she can get the condition under good control before she tries to conceive.
How do parents cope with their grief?
A couple who has had a stillbirth needs time to grieve. Parents form a bond with their child long before birth, so it is normal to feel intense loss when their unborn baby dies. Each person experiences loss differently. Parents may experience many emotions, including shock, numbness, denial, deep sadness, guilt, anger and depression.
A woman and her partner may cope with their grief in different ways. This sometimes creates tension between them when they need each other most. It may be helpful to ask a health care provider for a referral to a counselor who is experienced in dealing with pregnancy loss. Some couples also find it helpful to join a support group for parents who have experienced pregnancy loss. In such a group, they can share their feelings with others who truly understand what they are going through. This often helps them feel less alone.
Resources
Parents or other family members who have experienced the loss of a baby may want to read the bereavement information provided on this Web site.
For additional information, contact the International Stillbirth Alliance
References
1. National Institutes of Health (NIH). NICHD Funds Major Effort to Determine Extent and Causes of Stillbirth. NIH News, Nov. 19, 2003.
2. Smith, G.C.S., et al. First-Trimester Placentation and the Risk of Antepartum Stillbirth. Journal of the American Medical Association, volume 292, number 18, November 10, 2004, pages 2249-2254.
3. Goldenberg, R.L., et al. Stillbirth: A Review. Journal of Maternal-Fetal and Neonatal Medicine, 2004, volume 16, pages 79-94.
4. American College of Obstetricians and Gynecologists (ACOG). Genetic Evaluation of Stillbirths and Neonatal Deaths. ACOG Committee Opinion, number 257, May 2001.
5. American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), Guidelines for Perinatal Care, Fifth Edition. AAP, Elk Grove, IL and ACOG, Washington, DC: 2002.
6. Nohr, E.A., et al. Prepregnancy Obesity and Fetal Death. Obstetrics and Gynecology, August 2005, volume 106, pages 250-259.
November 2005
