Understanding Stillbirth

When a baby dies in utero at 20 weeks of pregnancy or later, it’s called a stillbirth. (When a pregnancy is lost before 20 weeks, it’s called a miscarriage.) About 1 in 160 pregnancies ends in stillbirth in the United States. Most stillbirths happen before labor begins, but a small number occur during labor and delivery.

If you’ve recently received the heartbreaking news that your baby has died in the womb, your grief may be overwhelming. To find support, see the last section of this article or see our articles on coping with pregnancy loss and honoring a baby who dies in pregnancy.
How is stillbirth diagnosed?

A pregnant woman may notice that her baby is no longer moving and visit her healthcare provider, or she may find out at a regular prenatal visit. The provider listens for the baby’s heartbeat using a handheld ultrasound device called a Doppler. If there’s no heartbeat, an ultrasound is done to confirm that the heart has stopped beating and the baby has died.

Sometimes the ultrasound provides information that helps explain why the baby died. The practitioner also does blood tests to help determine – or rule out – potential causes. In addition, you may opt to have an amniocentesis to check for chromosomal problems that might have caused or contributed to the stillbirth. (You’re likely to get more complete information about your baby’s chromosomes from an amnio than from tissue samples after delivery.)
How is a stillborn child delivered?

Some women need to deliver without delay for medical reasons, but others may be allowed to wait a while, to prepare for delivery or give labor a chance to begin on its own. During this time, their provider follows them closely to make sure they’re not developing an infection or blood clotting problems.

Most women, though, choose to have labor induced soon after they learn of their baby’s death, either through labor and delivery or through a procedure performed under local or general anesthesia.

Labor and delivery

If a woman’s cervix has not begun to dilate in preparation for labor, her caregiver may insert medicine into her vagina to start that process. Then she gets an IV infusion of the hormone oxytocin (Pitocin) to stimulate uterine contractions. The vast majority of women are able to deliver vaginally.

Dilation and evacuation (D&E)

If a woman is still in her second trimester and she has access to an experienced practitioner, she may be able to have the baby’s body removed in a procedure known as dilation and evacuation (D&E). During the D&E, she’s put under general anesthesia or given IV sedation and local anesthesia while the doctor dilates her cervix and removes her baby.

For women who have a choice between these two delivery options, here are a few factors to consider:

The D&E may be a better choice for women who prefer a rapid, more detached procedure. And in experienced hands, women are less likely to have complications from a D&E than from an induction, though the risk of complications is low for both procedures.

Induction may be a better choice for women who want to experience birth as part of their grieving process and who want the option of seeing and holding their child. In addition, an autopsy of the baby after an induction may provide more clues about the cause of the stillbirth than one done after a D&E.

What happens after the baby is delivered?

Patients and their healthcare providers should discuss beforehand what will happen. Patients can let their provider know if they want to hold their baby or perform cultural or religious rituals soon after birth.

The medical team can do tests to try to determine the cause of the stillbirth. First they examine the placenta, membranes, and umbilical cord right after delivery. Then they ask permission to have these tissues thoroughly analyzed in the lab and to do genetic testing and an autopsy on the baby.

This may be difficult for parents who are grieving for their child. And even a thorough evaluation may not answer the question of why the baby died.

On the other hand, parents may learn valuable information. For example, if the stillbirth was the result of a genetic problem, the mother can be on the lookout for it in her next pregnancy. Or she may find out that the cause is something that’s unlikely to recur, such as an infection or a random birth defect, which may be reassuring if she wants to become pregnant again.

Providers can explain to parents what might be learned from an autopsy, how it’s done, and what it would cost. (Autopsies aren’t always covered by insurance and can cost up to $1,500.) For parents who decide not to have a complete autopsy done, there are less invasive tests that may provide some useful information. These include X-rays, MRI, ultrasound, and tissue sampling.

Tests are also done on the mother, along with a thorough evaluation of her medical, obstetric, and family history for clues to the cause of the stillbirth.
What are the causes of stillbirth?

In many cases, the cause of death is never discovered, even after a thorough investigation. And sometimes more than one cause contributes to a baby’s death.

Common causes include:

Poor fetal growth. Babies who are growing too slowly have a significantly increased risk of stillbirth, especially those whose growth is severely affected.
Placental abruption. Placental abruption, when the placenta starts to separate from the uterus before a baby is delivered, is another common cause of stillbirth.
Birth defects. Chromosomal and genetic abnormalities, as well as structural defects, may result in stillbirth. Some stillborn babies have multiple birth defects.
Infections. Infections involving the mother, baby, or placenta are another significant cause of stillbirth, particularly when they occur before 28 weeks of pregnancy. Infections known to contribute to stillbirth include fifth disease, cytomegalovirus, listeriosis, and syphilis.
Umbilical cord accidents. Accidents involving the umbilical cord may contribute to a small number of stillbirths. When there’s a knot in the cord or when the cord is not attached to the placenta properly, the baby may be deprived of oxygen. Cord abnormalities are common among healthy babies, however, and are rarely the primary cause of stillbirth.
Other events, such as lack of oxygen during a difficult delivery or trauma (from a car accident, for instance), can also cause stillbirth.

What puts some women at higher risk for stillbirth?

Anyone can have a stillbirth, but some women are more at risk than others. The odds of having a stillborn baby are higher if the mother:

Had a previous stillbirth or intrauterine growth restriction in a previous pregnancy. A history of preterm birth, pregnancy-induced hypertension, or preeclampsia increases the risk, too.
Has a chronic medical condition such as lupus, hypertension, diabetes, kidney disease, thrombophilia (a blood clotting disorder), or thyroid disease.
Develops complications in this pregnancy, such as intrauterine growth restriction, pregnancy-induced hypertension, preeclampsia, or cholestasis of pregnancy.
Smokes, drinks, or uses certain street drugs during pregnancy.
Is carrying twins or more.
Is obese.

Other factors come into play, too. African American women are about twice as likely as other American women to have a stillborn baby. Women who haven’t had a baby are also at higher risk.

There’s some evidence suggesting that women who become pregnant as a result of in vitro fertilization (IVF) or a procedure called intracytoplasmic sperm injection (ICSI) have a higher risk of stillbirth, even if they aren’t carrying multiples.

Age – at either end of the spectrum – affects risk as well. Both teens and older pregnant women are more likely to have a stillbirth than women in their 20s and early 30s. The increase in risk is most marked in teens under 15 years old and women age 40 and older.

For teens, experts suspect both physical immaturity and lifestyle choices may contribute to the higher risk. Older women are more likely to conceive a baby with lethal chromosomal or congenital abnormalities, to have chronic conditions like diabetes and high blood pressure, and to be carrying twins, all of which are risk factors for stillbirth.