Stillbirth

Overview

A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy.

If the baby dies before 24 completed weeks, it's known as a miscarriage or late foetal loss.

Contact your midwife or doctor straightaway if you're pregnant and worried about your baby - for example, if you've noticed your baby moving less than usual. Don't wait until the next day. If your baby is moving less, it can be a sign that something's wrong and needs to be checked out.

What causes stillbirth?

Some stillbirths are linked to complications with the placenta, a birth defect or with the mother's health. For others, no cause is found.

What happens when a baby dies before they're born?

If your baby has died, you may be able to wait for labour to start naturally or your labour may be induced. If your health is at risk, the baby may need to be delivered as soon as possible. It's rare for a stillborn baby to be delivered by caesarean section.

After a stillbirth

After a stillbirth, decisions about what to do are very personal. There's no right or wrong way to respond.

A specialist midwife will talk with you about what you want to do - for example, holding the baby or taking photographs. They can also discuss the tests you may be offered to find out why your baby died and give you information about registering the birth.

Can stillbirths be prevented?

Not all stillbirths can be prevented, but there are some things you can do to reduce your risk of having a stillbirth, such as:

• not smoking
• avoiding alcohol and drugs during pregnancy – these can seriously affect your baby's development, and increase the risk of miscarriage and stillbirth
• not going to sleep on your back after 28 weeks - don't worry if you wake up on your back, just turn onto your side before you go back to sleep
• attending all your antenatal appointments so that midwives can monitor the growth and wellbeing of your baby

Causes

A large proportion of stillbirths happen in otherwise healthy babies, and the reason often can't be explained. But there are some causes we do know about.

Complications with the placenta

Many stillbirths are linked to complications with the placenta. The placenta is the organ that links the baby's blood supply to the mother's and nourishes the baby in the womb.

If there have been problems with the placenta, stillborn babies are usually born perfectly formed, although often small.

With more research, it's hoped that placental causes may be better understood, leading to improved detection and better care for these babies.

Other causes of stillbirth

Other conditions that can cause or may be associated with stillbirth include:

• bleeding (haemorrhage) before or during labour
• placental abruption - where the placenta separates form the womb before the baby is born (there may be bleeding or abdominal pain)
• pre-eclampsia - a condition that causes high blood pressure in the mother
• a problem with the umbilical cord, which attaches the placenta to the baby's tummy button - the cord can slip down through the entrance of the womb before the baby is born (cord prolapse) or can be wrapped around the baby and become knotted
• intrahepatic cholestasis of pregnancy (ICP) or obstetric cholestasis - a liver disorder associated with severe itching during pregnancy
• a genetic physical defect in the baby
• pre-existing diabetes
• an infection in the mother that also affects the baby

Infections

Usually this will be a bacterial infection that travels from the vagina into the womb (uterus). These bacteria include group B streptococcus, E.coli, klebsiella, enterococcus, Haemophilus influenza, chlamydia, and mycoplasma or ureaplasma.

Some bacterial infections, such as chlamydia and mycoplasma or ureaplasma, which are sexually transmitted infections, can be prevented by using condoms during sex.

Other infections that can cause stillbirths include:

• rubella - commonly known as German measles
• flu - it's recommended that all pregnant women have the seasonal flu vaccine, regardless of stage of pregnancy
• parvovirus B19 - this causes slapped cheek syndrome, a common childhood infection that's dangerous for pregnant women
• coxsackie virus - this can cause hand, foot and mouth disease in humans
• cytomegalovirus - a common virus spread through bodily fluids, such as saliva or urine, which often causes few symptoms in the mother
• herpes simplex - the virus that causes genital herpes and cold sores
• listeriosis - an infection that usually develops after eating food contaminated by listeria bacteria
• leptospirosis - a bacterial infection spread by animals such as mice and rats
• Lyme disease - a bacterial infection spread by infected ticks
• Q fever - a bacterial infection caught from animals such as sheep, goats and cows
• toxoplasmosis - an infection caused by a parasite found in soil and cat faeces
• malaria - a serious tropical disease spread by mosquitoes

Increased risk

There are also a number of things that may increase your risk of having a stillborn baby, including:

• having twins or a multiple pregnancy
• having a baby who doesn't grow as they should in the womb
• being over 35 years of age
• smoking, drinking alcohol or misusing drugs while pregnant
• being obese - having a body mass index above 30
• having a pre-existing physical health condition, such as epilepsy

Your baby's growth

Your midwife will check the growth and wellbeing of your baby at each antenatal appointment and plot the baby's growth on a chart.

Every baby is different and should grow to the size that's normal for them. Some babies are naturally small, but all babies should continue to grow steadily throughout pregnancy.

If a baby is smaller than expected or their growth pattern tails off as the pregnancy continues, it may be because the placenta isn't working properly. This increases the risk of stillbirth.

Problems with a baby's growth should be picked up during antenatal appointments.

Your baby's movements

It's important to be aware of your baby's movements and know what's normal for your baby.

Tell your midwife immediately if you notice the baby's movements slowing down or stopping. Don't wait until the next day.

What happens?

Your baby's wellbeing will be monitored during your antenatal appointments, so any problems will usually be picked up before labour starts.

Confirming the baby has died

If it's suspected that your baby may have died, a midwife or doctor may initially listen for the baby’s heartbeat with a handheld Doppler device. You'll also be offered an ultrasound scan to check your baby's heartbeat.

Sometimes a mother may still feel her baby moving after the death has been confirmed. This can happen when the mother changes position. In this case, the mother may be offered another ultrasound scan.

Finding out your baby has died is devastating. You should be offered support and have your options explained to you. If you're alone in hospital, ask the staff to contact someone close to you to come in and be with you.

Before the birth, a person with skills and experience with parents who have lost a baby should be available to talk with you about whether you would like to see a photograph of your baby, have a memento such as a lock of hair, or see or hold your baby.

Giving birth if your baby has died

If a woman's baby dies before labour starts, she will usually be offered medicine to help induce labour. This is safer for the mother than having a Caesarean section.

If there's no medical reason for the baby to be born straightaway, it may be possible to wait for labour to start naturally. This decision doesn't usually need to be made immediately, and it may be possible to go home for a day or two first.

In some cases, medicine that prepares a woman’s body for the induction process may be recommended. This medication can take up to 48 hours to work.

Natural labour

While waiting for labour to begin naturally, regular blood tests are needed after 48 hours.

Waiting for labour to begin naturally increases the chance of the baby deteriorating in the womb. This can affect how the baby looks when he or she is born, and can make it more difficult to find out what caused the death.

Induced labour

If the health of the mother is at risk, labour is nearly always induced using medication. This may been done immediately if:

• the mother has severe pre-eclampsia
• the mother has a serious infection
• the bag of water around the baby (the amniotic sac) has broken

Labour can be induced by inserting a pessary tablet or gel into the vagina, or by swallowing a tablet. Sometimes, medicine is given through a drip into a vein in the arm.

After the baby is stillborn

After a stillbirth, many parents want to see and hold their baby. It's entirely up to you whether you wish to do so. You'll be given some quiet time with your baby if this is what you want.

You can also take photographs of your baby and collect mementos, such as a lock of hair, foot prints or hand prints, or the blanket your baby was wrapped in at birth.

If you're not sure whether you want to take any mementos of your baby home, it's usually possible for them to be stored with your hospital records. If your hospital doesn't keep paper records, you may be given these mementos in a sealed envelope to store at home. This means you'll be able to look at them if you ever decide you want to.

You may also want to name your baby, but not everyone does this and it's entirely your choice.

Decisions about what to do after a stillbirth are very personal, and there's no right or wrong way to respond.

Breast milk

After a stillbirth, your body may start producing breast milk, which can cause discomfort and distress. Medicines (dopamine agonists) can stop your breasts producing milk. They cause few side effects and may also help you feel better emotionally, but they aren't suitable if you have pre-eclampsia.

Some mothers prefer to let their milk supply dry up without medication. Your doctor or midwife can discuss your options with you.

Finding the cause

You'll be offered tests to find the cause of the stillbirth. You don't need to have these, but the results may help to avoid problems in any future pregnancies.

The tests you're offered may include:

• blood tests - these can show whether the mother has pre-eclampsia, obstetric cholestasis or, rarely, diabetes
• specialist examination of the umbilical cord, membranes and placenta - the tissues that attach you to your baby and support your baby in pregnancy
• testing for infection - a sample of urine, blood or cells from the vagina or cervix (neck of the womb) can be tested
• thyroid function test - to see whether the mother has a condition that affects her thyroid gland
• genetic tests - usually carried out on a small sample of umbilical cord, to determine whether your baby had problems such as Down's syndrome

More in-depth tests can also be carried out on your baby to try to establish the cause of death or whether there are any conditions that might have contributed to it. This is called a post-mortem.

Post-mortem

A post-mortem is an examination of your baby's body. The examination can provide more information about why your baby died, which may be particularly important if you plan to become pregnant in the future.

A post-mortem can't go ahead without your written permission (consent), and you'll be asked if you want your baby to have one. The procedure can involve examining your baby's organs in detail, looking at blood and tissue samples, and carrying out genetic testing to see whether your baby had a genetic disease.

The healthcare professional asking for your permission should explain the different options to help you decide whether you want your baby to have a post-mortem

Follow-up care

You'll usually have a follow-up appointment a few weeks after you leave hospital to check your health, and discuss the post-mortem and test results (if carried out).

This appointment is also an opportunity to talk with your doctor about possible future pregnancies. Before attending your follow-up appointment, you may find it helpful to write down any questions you have for your doctor.

Bereavement support

A stillbirth can be emotionally traumatic for both parents, as well as other family members. Help and support is available.

You may be introduced to a bereavement support officer or a bereavement midwife. They usually work in hospitals or for the local council. They can help with any paperwork that needs to be completed and explain choices you can make about your baby's funeral. They'll also act as a point of contact for other healthcare professionals.

Many people experience feelings of guilt or anxiety following the loss of their baby. Some parents experience depression or post-traumatic stress disorder (PTSD).

You may find it helpful to discuss your feelings with your GP, community midwife or health visitor, or other parents who have lost a baby.

Support groups

Sands, a stillbirth and neonatal death charity, provides support for anyone affected by the death of a baby. You can:

• call the Sands confidential helpline on 020 7436 5881 - 9.30am to 5.30pm Monday to Friday, plus 6pm to 10pm Tuesday and Thursday
• email helpline@uk-sands.org

There are many other self-help groups in the UK for bereaved parents and their families. You can search for bereavement support services in your area.

These groups are usually run by healthcare professionals, such as baby-loss support workers or specialist midwives, and parents who have experienced stillbirth.

Some support groups are for women whose stillbirth has a specific cause. For example:

• Action on pre-eclampsia (APEC)
• ICP support (obstetric cholestasis, or OC)
• Group B strep support

Registering a stillbirth

By law, stillborn babies have to be formally registered. In England and Wales, this must be done within 42 days of your baby's birth, within 21 days in Scotland.

You don't have to register a stillbirth in Northern Ireland, but you can if you want to as long as it's within a year of the birth.

See GOV.UK for more information about registering a stillbirth.

Prevention

Not all stillbirths can be prevented, but there are some things you can do to reduce your risk.

These include:

• not smoking
• avoiding alcohol and drugs during pregnancy – these can seriously affect your baby's development, as well as increasing the risk of miscarriage and stillbirth
• attending all your antenatal appointments so that midwives can monitor the growth and wellbeing of your baby
• making sure you're a healthy weight before trying to get pregnant
• protecting yourself against infections and avoiding certain foods
• reporting any tummy pain or vaginal bleeding that you have to your midwife on the same day
• being aware of your baby's movements and reporting any concerns you have to your midwife straight away
• reporting any itching to your midwife
• going to sleep on your side, not on your back

Some of these are discussed in more detail below.

Your weight

Obesity increases the risk of stillbirth. The best way to protect your health and your baby's wellbeing is to lose weight before becoming pregnant. By reaching a healthy weight, you cut your risk of all the problems associated with obesity in pregnancy.

If you're obese when you become pregnant, your midwife or GP can give you advice about improving your health while pregnant.

Eating healthily and activities such as walking and swimming are good for all pregnant women. Talk to your midwife or doctor before starting a new exercise programme if you weren't active before you got pregnant.

Monitoring your baby's movements

You'll usually start feeling some movement between weeks 16 and 20 of your pregnancy, although it can sometimes be later than this. These movements may be felt as a kick, flutter, swish or roll. You should continue to feel your baby move up to and during labour.

If you notice your baby is moving less than usual, or there's a change in the pattern of movements, it may be the first sign your baby is unwell. You should contact your midwife or local maternity unit immediately so your baby's wellbeing can be assessed.

There's no specific number of movements that's considered to be normal. What's important is noticing and telling your midwife about any reduction or change in your baby's typical movements.

The Royal College of Obstetricians and Gynaecologists has produced a leaflet called Your baby's movements in pregnancy (PDF, 138kb) that you may find useful.

Avoiding certain foods

There are some foods you should avoid during pregnancy. For example, you shouldn't eat some types of fish or cheese, and you should make sure all meat and poultry is thoroughly cooked.

Read more about the foods to avoid during pregnancy.

Going to sleep on your side, not your back

Research suggests that going to sleep on your back after 28 weeks of pregnancy can double the risk of stillbirth. It's thought this may be to do with the flow of blood and oxygen to the baby.

The safest position to fall asleep in is on your side, either left or right. Don't worry if you wake up on your back – just turn onto your side before going back to sleep.

Attending antenatal appointments and reporting any concerns

During your antenatal appointments, your midwife or GP will monitor your baby's development, growth and position.

You'll also be offered tests, including blood pressure tests and urine tests. These are used to detect any illnesses or conditions, such as pre-eclampsia, that may cause complications for you or your baby. Any necessary treatment can be provided promptly and efficiently.

Read more about antenatal care.

Selected links

NHS 111 Wales links

Antenatal health and care

Counselling

Miscarriage

Local support services search

External links

Sands

Tommy's

The Miscarriage Association