What is stillbirth?

Miscarriage and stillbirth both refer to the loss of a foetus during pregnancy. But while a miscarriage is the sudden loss of a foetus during the first 20 weeks of pregnancy, stillbirth is the loss of a foetus after the 20th week of pregnancy.

Read more: Recurrent miscarriage

Apart from this difference in timing, the effects of a miscarriage and stillbirth are similar. For expecting parents, this loss of the foetus can be traumatic. And it should be treated as such. According to the American Psychological Association, such perinatal loss of the foetus is common, and so people often fail to recognize the depth of such a loss and the effects it can have on a woman’s physical as well as mental health. This is the reason why women and their partners who have lost a foetus to a miscarriage or a stillbirth should get adequate therapy and be allowed to grieve their loss properly.

Read more: Postpartum depression

According to the US Centers for Disease Control and Prevention (CDC), stillbirth is further classified on the basis of exactly when after the 20th week of pregnancy it occurs. The following are the three types of stillbirth.

• Early stillbirth: Fetal death occurring between the beginning of the 21st week of pregnancy and the end of the 27th week of pregnancy.
• Late stillbirth: Fetal death occurring between the 28th and 36th completed weeks of pregnancy.
• Term stillbirth: Fetal death occurring after the 37th completed week of pregnancy.

When it comes to experiencing the symptoms of stillbirth, most women have varying experiences. Some women also experience no symptoms of stillbirth before it happens, which is why it may come as a greater shock. The most commonly experienced symptoms of stillbirth may also resemble those of other conditions. The following are some of the symptoms that may show up during stillbirth.

• Foetal movements, which start between 18th and 20th weeks of pregnancy, have stopped.
• Spotting or bleeding.
• Sudden stabbing or cramping abdominal pain during pregnancy
• Stabbing or cramping pain in the womb.
• Excessive headache, dizziness and blurred vision.
• High fever, nausea and exhaustion.
• Absence of foetal heartbeat when a doctor looks for it with a stethoscope or Doppler (one of the types of ultrasound during pregnancy).

Every expectant mother and father wonders the same thing after experiencing a stillbirth: why did this happen? Usually, performing an autopsy on the stillborn baby is the most accurate way of figuring out why stillbirth occurred. However, such autopsies are not performed in every nation and hospital, nor is it deemed sensitive or appropriate by many to ask for it.

However, it must be understood that further in-depth research into causes of stillbirth is the best way to pinpoint the causes of such a tragedy and possibly to avoid it in lakhs of other cases. According to the current research available on stillbirths, the following are the chief causes that have been identified.

• Placental problems: The placenta is the organ that supports the pregnancy by providing oxygen and nutrients to the baby. Any adverse effect on the placenta can cause stillbirth. This can happen if a pregnant woman experiences placental abruption, suffers from pregnancy-induced hypertension, preeclampsia, gestational diabetes, etc. The chorionic membrane is one of the four foetal membranes that protect the baby inside the womb, and also helps form the placenta. A subchorionic haemorrhage or hematoma can therefore also increase the risk of stillbirth.
• Infections: Bacterial infections and viral infections, especially if they occur between the 24th and 27th weeks of pregnancy, can cause stillbirth. This is the reason why pregnant women should be more cautious about infections and take adequate precautions against them. (Read more: What pregnant women need to know about COVID-19)
• Birth defects: According to the American Pregnancy Association, chromosomal defects cause 15-20% of all stillbirths. The causes of these defects can be genetic or environmental leading to structural malformations or any functional abnormalities in the foetus, which in turn can cause the stillbirth to happen. 
• Growth restrictions: Babies who are too small or not developing properly in the womb might experience some complications, which can cause them to die due to asphyxiation or lack of oxygen. Stillbirth due to asphyxia may happen well before or during labour. (Read more: Intrauterine growth retardation)
• Post-term pregnancy: When a pregnant woman is not able to deliver her baby even after 42 weeks of pregnancy, the risk of stillbirth increases exponentially. This is because a post-term baby has probably outgrown the capacity of the womb, which can lead to complications like foetal malnutrition, meconium aspiration syndrome and hence, stillbirth.
• Trauma: A little bump here and there might not affect the foetus much - he or she is protected by the amniotic fluid and sac, after all - but a full-fledged fall or accident experienced by the mother can lead to stillbirth. This type of trauma, especially automobile accidents, can also lead to placental abruption, internal bleeding and other complications in the mother, which can make the sustenance of the foetus impossible.

Stillbirth can occur to women of all ages, races, regions and economic background. Current research, however, suggests that women who have the following risk factors have more chances of experiencing stillbirth.

• The age of the woman is 35 years or older. Ageing can affect the quality of eggs, thereby affecting the way the embryo develops into the foetus, and how the foetus grows.
• If a pregnant woman is malnourished, she may not be able to sustain the pregnancy. Malnutrition can also lead to underdeveloped foetuses.
• If proper prenatal care is not taken - and this includes diet, exercise, physical and mental health - this can also affect the development of the foetus and the mother’s ability to carry the baby to term.
• Smoking cigarettes, consuming alcohol and drug abuse can also lead to complications in pregnancy, which in turn can lead to stillbirth.
• Women with preexisting health conditions like high blood pressure, diabetes, obesity, polycystic ovary syndrome, etc., are at a higher risk of developing complications and experiencing miscarriage or stillbirth if their symptoms are not controlled. (Read more: Can I still get pregnant if I have PCOS?)
• Women carrying twins or multiple foetuses are basically developing more than one baby within a limited space. This can lead to intrauterine growth retardation and other issues, which in turn can lead to stillbirth. 
• Women who have experienced previous miscarriages or stillbirths, or have a history of such loss of pregnancy in the family, are at greater risk for stillbirths. 
• The CDC and the UK’s National Health Service (NHS) have observed that women of African-American or just African descent are at an increased risk of stillbirths.

Most women are able to feel their baby move and kick in the womb by the 20th week of pregnancy. If the mother is unable to feel the movement for a few days, then this should be seen as a red flag. It is recommended that you see your gynaecologist soon, if this happens.

As the pregnancy gets closer to the delivery date, the baby’s activities become more pronounced. In such stages, the mother can notice more easily when the baby is not responding to stimuli like sound, touch, etc., at the usual times. This can also sound the alarm in some cases.

A doctor can check for foetal heartbeat and movement using a stethoscope, and that’s the primary way to check the baby’s health after 20 weeks of pregnancy are done. However, the most accurate way of finding out if stillbirth has occurred is through a foetal ultrasound. A foetal ultrasound can sometimes also reveal the exact reason why the stillbirth occurred.

A decade or two ago, the idea that stillbirths can be prevented would have sounded preposterous and impossible. However, with improvements in medicines, medical research and healthcare systems, stillbirth rates across the world have decreased in recent years. 

Women with high-risk pregnancies are being identified early into their gestation periods, and they are being monitored and taken better care of. Developments in labour and birthing techniques, medicines, neonatal care, etc., have also increased the chances of survival of premature foetuses if preterm labour is indeed induced to save them. 

However, it’s important to note that in developing countries like India, these medical and technological advancements are yet to fully reach the entire population. Not everyone can access proper prenatal care, safe birthing environments and postnatal or neonatal care. Hence, all pregnant women and their loved ones should take the following steps to ensure that they are monitoring their baby while in the womb, so that stillbirth can be prevented.

• Do a kick count, especially starting in the 24th to 28th weeks of pregnancy. What this means is that you should take time out every day to monitor and record your baby’s movements. Once you familiarize yourself with the movements and are aware of their rhythm and timings, you'll immediately be able to tell if there are any changes in them - or if the movement stops completely and suddenly.
• Avoid smoking, alcohol, use of drugs and any risky lifestyle choices during and before pregnancy. 
• Avoid going to sleep on your back. It’s fine if you wake up on your back, which means you probably rolled over in your sleep. Just make sure that you sleep on your side as much as possible, especially after the 28th week of pregnancy.
• If you have experienced a previous miscarriage or stillbirth, the current pregnancy should be more closely monitored so that another pregnancy loss can be avoided.
• Make sure you keep in touch with your obstetrician and attend all your check-up and ultrasound appointments. If you notice any symptoms of any complications during your pregnancy, do not hesitate or delay in making the call to your doctor.

The moment a doctor confirms a stillbirth via ultrasound, a number of assessments will need to be made to determine the immediate course of action. One thing is obvious: a foetus which has passed away will need to be removed from the mother’s body as soon as possible. There are three ways to do this vaginally, which is deemed to be the safest way for most women:

• Waiting for the mother to go into labour on her own and delivering the stillborn baby.
• Dilating the cervix and delivering the foetus as well as associated tissues using instruments.
• Using medications to induce labour, dilate the cervix and make the uterus push out the foetus and associated tissues.
• If these methods for a normal delivery do not work or are deemed to be too risky, then the stillborn baby is removed via C-section.

Many women contract infections after delivering a stillborn foetus, especially if the method of delivery was not vaginal. Heavy bleeding, fever, chills and pain are quite common as well. It’s therefore recommended that women remain under the care of healthcare professionals in a hospital or clinic after stillbirth for a few days at least. Despite there being a stillbirth, lactation will be activated soon after delivery. A discussion with the doctor regarding the management of lactation, medications, etc., should be undertaken. 

As mentioned before, the mental health of both the mother and her partner should also be prioritised during this time. Adequate therapy should be provided to the grieving couple, and funeral arrangements should be made for the stillborn baby to help the couple and their family cope with this adverse outcome. Everybody who goes through this unfortunate experience deserves a healing period.