Stillbirth: A Health Professional’s Role

About Stillbirth

Clinical Considerations & Stillbirth Management

ACOG Guidance

• ACOG’s “Management of Stillbirth” document outlines clinical considerations and management of stillbirth, including essential components of evaluation and documentation (Management of Stillbirth)
• Full documentation of the events surrounding the stillbirth, maternal health conditions, and relevant lab tests are critical to help parents understand as much as possible about what happened to their baby

Stillbirth Prevention

The loss of a baby due to stillbirth is a devastating reality for many families and takes a serious toll on their health and well-being. Healthcare providers play an important role in preventing stillbirths through proactive care and education. Here is how you can help.

Reduce Racism and Bias in Pregnancy Care

• Stillbirths happen more often among people that give birth who are American Indian/Alaska Native, Black, and Native Hawaiian/Pacific Islander compared to other racial and ethnic groups.
• Pregnant people of color are more likely to experience poor quality of care from their providers, insufficient appointment time, low decision-making involvement, and births for which they received late or no prenatal care compared to White women.
• Studies have shown that medical staff consciously or unconsciously dismiss or downplay the concerns of Black women and express skepticism about reported symptoms.
• Preventing poor perinatal outcomes, like stillbirth, begins by listening to your patients concerns, believing their experience, and recognizing that racism and subconscious bias is directly associated with adverse outcomes.
• Healthcare providers have an obligation to provide quality care to every patient that is respectful of the patient’s values and beliefs, no matter their race, ethnicity, sexual identity, or religious background.

Resources and Trainings: Many resources exist to recognize and address implicit bias, including trainings from the Dignity in Pregnancy and Childbirth Project, March of Dimes, and National Institute for Children’s Health Quality.

Provide Comprehensive Prenatal Care

• By providing comprehensive prenatal care, you can closely monitor the health and development of both the expectant parent and the fetus to notice if there's a risk.
• Regular check-ups, ultrasounds, and screenings allow you to identify potential risk factors or complications early on.
• Evidence indicates that adequate prenatal care protects against stillbirth, neonatal death and infant death.

Support the Elimination or Reduction of Drug Use/Motivational Interviewing

• Reducing/eliminating alcohol and drug use is one of the best ways to protect the pregnant person and their baby.
• Drug use and smoking is a risk factor for both stillbirth and sudden unexpected infant death (SUID).
• Motivational Interviewing (MI) is a tool that can help you navigate these conversations and look for solutions with the patient.

Resources: Pregnancy and Substance Use: A Harm Reduction Toolkit - National Harm Reduction Coalition; Getting Help to Quit Tobacco; 2Morrow Health; Quit for Two; Tobacco and Nicotine Cessation During Pregnancy

Educate on Fetal Movement Counting

• Inform your patients about counting fetal kicks (or movements). A change in the typical pattern could indicate the fetus is stressed.
• Notably, few studies have been conducted on the clinical management of reduced fetal movements. Guidelines do exist, however, from the UK, Australia and New Zealand.
• StatPearls which instructs providers to conduct a non-stress test for any reported decrease in fetal movement; if the test is non-reactive, a biophysical profile may be conducted, and if that is not reassuring, to consider delivery.

Educate on Immunization & Infection Prevention

• Vaccinations recommended during pregnancy can help protect against infections that harm the pregnant person and their baby.
• Research suggests there’s a higher risk of stillbirth among pregnant persons with COVID. This protection is especially strong against the Delta variant, which was prominent in 2021, but it still helps with other variants. The COVID-19 vaccination was associated with a 15% (OR 0.85, 0.73-0.99) decrease in stillbirth risk.

Resources: Pregnancy and Vaccination; Pregnancy and Vaccination

Manage Gestational and Pre-existing Diabetes

• Gestational diabetes is associated with stillbirth, plausibly through impacts on placental development and function.
• Share information with your patient on why it’s important to be screening and treated for diabetes during pregnancy.
• Follow best practices related to screening and management of gestational and pre-existing diabetes during pregnancy. Options include Management of Diabetes in Pregnancy, Gestational Diabetes Mellitus (available only to members/subscribers), Current guidelines on the management of gestational diabetes mellitus

Manage Hypertension and Hypertensive Disorders

• Chronic hypertension, superimposed preeclampsia, and preeclampsia are all associated with increased risk for stillbirth, preterm delivery, low birth weight, neonatal intensive care unit (NICU) admission, and cesarean delivery.
• Evidence indicates that prophylactic aspirin, 50-150 mg/day initiated at ≤16 weeks gestational age can prevent pre-eclampsia, fetal growth restriction and perinatal mortality for patients with hypertensive disorders or pre-eclampsia risk factors with few apparent downsides.
• Share information with your patient on the importance of managing hypertension during pregnancy
• Follow best practices related to management of hypertension and hypertensive disorder during pregnancy (options listed in the resources below).

Resources: Washington State Blue Band Initiative; Hypertension in pregnancy care process model; Postpartum Follow up Care Schedule; Hypertension in pregnancy: diagnosis and management - NCBI Bookshelf; Managing Chronic Hypertension in Pregnant Women: ACOG Releases Updated Practice Bulletin

Caring for a Family who Experienced Stillbirth

The kindness and empathy you show a family going through perinatal loss will be remembered for a lifetime. Help parents understand as much as possible about what happened to their baby – this can be an essential part of the grieving process.

Be sensitive

• Family members are often devastated and bewildered following such tragic and unexpected loss. Be sensitive to their experience while explaining the next steps. This will help the family make informed decisions.
• Often, the time in the hospital is the only moment a family has with their baby. As their healthcare provider, you can gently support the family so they can create memories, engage in rituals, and create an environment that lessens regrets and future trauma.

Hurtful language

• At least…
• Everything happens for a reason
• Time heals all wounds
• It’s going to be okay
• God has a plan
• You are young, you can have more children
• At least you can get pregnant
• Be thankful you have other children
• Let go, move on

Helpful language

• I am so sorry
• I/we will walk through this with you
• This is what is going to happen (describe the process; you will need to repeat yourself)
• I would do anything to take this pain away
• If you would like to talk about how you are feeling, I’m here to listen

L&D/Postpartum

• Slow things down – there is no rush unless medically necessary
• Educate the parents and prepare them for what to expect
• Use the term “baby” rather than fetus
• If the parents have named their baby, use their name
• Treat the deceased baby as you would a live baby
• Give parents as much time as they want with their child. This may be the only time they have.

Explain next steps:

• Talking with the family about the importance of a thorough evaluation of the stillborn child can often provide valuable answers that help in the healing process. Every family deserves the opportunity to discuss the specifics of their loss to help them decide which, if any, tests they would like done.
• Many stillbirth evaluation protocols have been published, all of which include a careful medical history, a post-mortem autopsy, an evaluation of the placenta, and genetic testing (typically a chromosomal microarray).

Coordinate Follow-up Care

• Parents who have experienced stillbirth have heightened short-and long-term levels of depression, anxiety, and PTSD compared to those of parents with live birth; notify their care team of the stillbirth to increase screening and awareness of perinatal mood and anxiety disorders (PMADs).
• Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.
• Link families to resources that can offer grief and bereavement support.