What is stillbirth? Doctors answer questions about this unfortunate occurrence

What is stillbirth? And why does it occur?

You carry your precious child in your womb for nine long months. But when you go into labour and finally deliver your baby, there is no life. No heartbeat, sound or movement. Even worse, the reason for your child's death is unknown, leaving you baffled beyond belief, wondering why such a crushing and cruel thing could happen and if you are to blame for your baby's untimely demise.

Stillbirth statistics

Yes, stillbirth happens, even in seemingly normal pregnancies, and not always with a clear-cut reason. According to the World Health Organisation (WHO), an estimated 2.6 million stillbirths occur annually around the world, with 98 per cent of them taking place in low- and middle-income countries. 40 per cent of all stillbirths occur during labour and delivery, WHO also reported.

There are an estimated 80 to 120 stillbirth cases in Singapore annually or an average of two to three out of every 1000 pregnancies. In 2020, there were 38,590 occurred live births and 78 registered stillbirths.

Unfortunately, why stillbirth happens is not always explainable. It is a devastating loss that hits unexpectedly, says the American Pregnancy Association, and the cause cannot be determined in about one-third of stillbirths despite extensive tests and efforts to find out why.

The good news is the chances of having another stillbirth are minuscule, and most women who have experienced it will go on to deliver healthy babies.

Stillbirth meaning: Defined and classified

What is stillbirth? What is the difference between a stillbirth and a miscarriage?

Dr Katleen del Prado, a perinatologist and a high-risk pregnancy specialist, defines stillbirth as "the delivery of a baby without a heartbeat beyond five months of pregnancy. Less than five months or a foetus less than 500 grammes, we classify as a miscarriage".

Stillbirth can be early, late or term, depending on when it happens. It's an early stillbirth if the foetal death occurs between weeks 20 and 27 of the pregnancy, a late stillbirth if it occurs between weeks 28 and 36 of the pregnancy, and a term stillbirth if it occurs during week 37 or beyond of the pregnancy.

Causes of stillbirth

There are many possible causes of stillbirth, said Dr del Prado. It is any problem or condition that keeps the mother, the foetus and the placenta (including the umbilical cord that connects them) from being healthy and functioning well. These three are essential to maintaining life.

Some of the known causes of stillbirth are:

• complications during labour and delivery
• maternal conditions (like high blood pressure or diabetes)
• birth defects or abnormalities
• placental problems (like placental abruption or when the placenta separates from the womb)
• infections
• problems with the umbilical cord
• growth restriction (baby's growth slows or stops during pregnancy)
• trauma
• postdate pregnancy (when a pregnancy lasts longer than 42 weeks)

Stillbirth – what are the risk factors?

There are certain factors that increase the risk of stillbirth and other adverse pregnancy outcomes. These are:

• inadequate prenatal care
• previous stillbirth or pregnancy loss
• malnutrition
• obesity
• smoking
• alcohol and drug abuse
• age of the pregnant woman (being under 15 or over 35)

Does one stillbirth increase the risk of future stillbirths?

According to Professor Tan Kok Hian, head and senior consultant, Perinatal Audit and Epidemiology Unit, Division of Obstetrics and Gynaecology at KKH, the vast majority of couples experience healthy pregnancies after stillbirth, although parents with genetic defects or maternal diseases (e.g. diabetes or hypertension) may be at increased risk for subsequent stillbirths.

"While the overall risk for having a stillborn is low for most couples, the risk is a bit higher for couples who have already had one such experience.

If the previous stillbirth was due to genetic defects, couples who have had a stillbirth should consider undergoing genetic counselling before trying to conceive another child," he said.

A genetic counsellor can advise couples about the risks of recurrent stillbirth and complications associated with a second conception and pregnancy. There may be some steps that can be taken to reduce a woman's risk during subsequent pregnancies.

If the stillbirth was due to a maternal illness such as diabetes or high blood pressure, for instance, steps can be taken to make sure the condition is well under control before the woman tries to conceive again.

Detecting stillbirth

Confirming the occurrence of stillbirth or pregnancy loss requires a specialised ultrasound scan to assess the condition of the baby within the womb. This procedure aims to provide a clear understanding of the situation and guide subsequent actions.

In the unfortunate event that pregnancy loss is confirmed, the subsequent course of action depends on the stage of pregnancy. Options may include inducing labour, opting for caesarean delivery, or allowing natural labour to progress.

Once the baby is delivered, further investigations are conducted to determine the cause of death. These assessments may involve:

1. Amniocentesis: This test can reveal whether a genetic condition or infection contributed to the stillbirth.
2. Autopsy: A thorough examination of the baby's organs can help identify any birth defects or underlying medical conditions that might have led to the tragedy.

Experiencing pregnancy loss is an incredibly challenging ordeal, and support from loved ones is essential for physical and emotional recovery. Women need the backing of those around them to navigate this difficult time and gradually move forward.

It's worth noting that despite such a heart-wrenching experience, the possibility of future healthy pregnancies remains.

Women who have experienced stillbirth should communicate openly with their healthcare providers to ensure proper precautions are taken to prevent a recurrence.

How to prevent stillbirth

With increased knowledge and better treatment of maternal conditions, the number of stillbirths has decreased. To help decrease the risk of experiencing a stillbirth even further, follow these recommendations:

Attend all antenatal appointments

Go for antenatal care early (in the first trimester). It is important to attend regular antenatal appointments throughout your pregnancy. During these appointments, your doctor will check to make sure your baby is developing properly and that your placenta is healthy and of normal size. Regular prenatal appointments can also help to identify any additional health problems early on

Avoid infection

Many infections responsible for stillbirth are preventable during pregnancy. Practice proper hygiene and stay away from sick people. Avoid handling cat litter during pregnancy, and do not eat raw or improperly cooked foods. Get tested for syphilis, early in pregnancy.

Report pain, bleeding or irregular symptoms

Monitor for any abnormal bleeding or pains during pregnancy. Report any of these symptoms, no matter how minor, to your doctor

Avoid alcohol, smoking and drugs all throughout your pregnancy

It doesn't take an expert to know that these unhealthy practices will put you and your baby's safety at risk.

Listen to your doctor

Patients with medical conditions should follow their doctor's advice, for example, to have good control of hypertension and diabetes which will reduce the risk of stillbirths. Take all prescribed medication and heed your doctor's orders.

Sleep on your side, and not on your back, especially from week 28 of your pregnancy and onwards

Studies show sleeping on your side from 28 weeks of pregnancy cuts the risk of stillbirth by half, compared to sleeping on your back.

Have a child at an earlier maternal age

When to get pregnant is definitely up to you. But you should know that maternal age is a factor in reducing the risk of stillbirth.

Monitoring foetal movement reduces the risk of stillbirth

In addition, it would be wise to familiarise yourself with the way your baby moves.

"The most important initial sign is for the mother to monitor the foetal movements," explained Dr del Prado.

"Normally, the foetus sleeps but it can easily be awakened by stimulation such as a voice, touching the abdomen, after coughing and after eating."

Sense and observe, for example, what time of the day your baby is most active and how many times he/she moves in an hour. Do this repeatedly until you get a good feel of how your baby moves. If the movements suddenly stop, slow down significantly or there is no reaction even after stimulation, inform your doctor immediately.

Another reason to contact your doctor without delay is when there is vaginal bleeding or vaginal discharge that is not normal for you, particularly when it's late into the pregnancy. This could indicate an infection, problems with the placenta, or the start of labour.

Getting pregnant again after stillbirth

Dr del Prado urges mums who have had stillborn babies to know and understand why their baby died. This could help them with closure and moving on, and at the same time, help doctors respond better when faced with a similar situation in the future.

"Your babies have become your angels in heaven. Your role does not stop there. Whether you want another child or no longer, we have to investigate the cause of your baby dying inside.

Ideally, an autopsy of the stillborn baby and an examination of the placenta would be done. Ask your doctor about the possible cause of death because we can do something if these conditions can be resolved before or during pregnancy," she said.

To those who want to try again and get pregnant despite experiencing stillbirth, Dr del Prado highly recommends preconception counselling with a maternal-foetal medicine specialist (also called a perinatologist) or a high-risk pregnancy expert while still in the planning stage of pregnancy.

This way, there will be ample time to prepare the body, address all pregnancy-related concerns, manage existing health problems and risk factors, and reduce the chances of poor perinatal (before and after birth) outcomes.

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This article was first published in theAsianparent.