Oxford Handbook of Midwifery (103 page)

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:

Unexplained antepartum deaths were then described using the obstetric classification, with the largest identifiable causes being:

•
APH (13.9%)

Half of all the stillbirths reported remained unexplained.

Neonatal deaths are those occurring during the first month of life. CEMACH (2004)
¹
reported that the leading causes of neonatal death were:

The leading causes of post-neonatal death were:

The CEMACH report (2009) that reviewed perinatal mortality noted some positive key findings:
²

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

Management of care

experienced ultrasonographer and a registrar to assess by ultrasound whether or not the FHR is present.

When giving bad news note that:

Induction of labour

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