Stillbirth

Stillbirth is typically defined as death at or after 20 to 28 weeks of  (depending on the source). It results in a baby born without. The World Health Organization (WHO) advocates for the usage of ICD-10 definitions of stillbirth to be able to compare data internationally. The WHO uses the ICD-10 definitions of "late fetal deaths" as their definition of stillbirth. A stillbirth can result in the feeling of or  in the mother. The term is in contrast to, which is an early pregnancy loss, and , where the baby is born alive, even if it dies shortly after.

Often the cause is unknown. Causes may include such as  and, problems with the  or , , infections such as  and , and poor health in the mother. Risk factors include a mother's age over 35, smoking, drug use, use of, and first pregnancy. Stillbirth may be suspected when no fetal movement is felt. Confirmation is by.

Worldwide prevention of most stillbirths is possible with improved health systems. About half of stillbirths occur during, with this being more common in the than. Otherwise depending on how far along the pregnancy is, or a type of surgery known as  may be carried out. Following a stillbirth, women are at higher risk of another one; however, most subsequent pregnancies do not have similar problems. ,, and are known complications.

Worldwide in 2015 there were about 2.6 million stillbirths that occurred after 28 weeks of pregnancy (about 1 for every 45 births). They occur most commonly in the developing world, particularly and. In the United States for every 167 births there is one stillbirth. Although stillbirth rates are declining, they are declining at a slower rate since the 2000s. By 2030, the WHO hopes to hit a goal of only having 12 stillbirths per 1000 births in each country worldwide.

Causes
As of 2016, there is no international classification system for stillbirth causes. The causes of a large percentage of stillbirths is unknown, even in cases where extensive testing and an have been performed. A rarely used term to describe these is "sudden antenatal death syndrome" or SADS, a phrase coined in 2000. Many stillbirths occur at full term to apparently healthy mothers, and a postmortem evaluation reveals a cause of death in about 40% of autopsied cases.

About 10% of cases are believed to be due to, , or.

Other risk factors include:
 * , like
 * , especially
 * maternal
 * maternal consumption of (such as, , etc.) or   in
 * s
 * maternal
 * maternal consumption of (such as, , etc.) or   in
 * s
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 * s
 *  – Prolapse of the umbilical cord happens when the fetus is not in a correct position in the pelvis. Membranes rupture and the cord is pushed out through the cervix. When the fetus pushes on the cervix, the cord is compressed and blocks blood and oxygen flow to the fetus. The mother has approximately 10 minutes to get to a doctor before there is any harm done to the fetus.
 *  – These twins share the same placenta and the same amniotic sac and therefore can interfere with each other's umbilical cords. When entanglement of the cords is detected, it is highly recommended to deliver the fetuses as early as 31 weeks.
 * Umbilical cord length - A short umbilical cord (<30 cm) can affect the fetus in that fetal movements can cause cord compression, constriction and ruptures. A long umbilical cord (>72 cm) can affect the fetus depending on the way the fetus interacts with the cord. Some fetuses grasp the umbilical cord but it is yet unknown as to whether a fetus is strong enough to compress and stop blood flow through the cord. Also, an active fetus, one that frequently repositions itself in the uterus can cause entanglement with the cord. A hyperactive fetus should be evaluated with ultrasound to rule out cord entanglement.
 * Cord entanglement - The umbilical cord can wrap around an extremity, the body or the neck of the fetus. When the cord is wrapped around the neck of the fetus, it is called a nuchal cord. These entanglements can cause constriction of blood flow to the fetus. These entanglements can be visualized with ultrasound.
 * Torsion – This term refers to the twisting of the umbilical around itself. Torsion of the umbilical cord is very common (especially in equine stillbirths) but it is not a natural state of the umbilical cord. The umbilical cord can be untwisted at delivery. The average cord has 3 twists.

A mother sleeping on after 28 weeks of pregnancy may be a risk factor for stillbirth.

After a stillbirth there is a 2.5% risk of another stillbirth in the next pregnancy (an increase from 0.4%).

Diagnosis
It is unknown how much time is needed for a fetus to die. Fetal behavior is consistent and a change in the fetus' movements or sleep-wake cycles can indicate fetal distress. A decrease or cessation in sensations of may be an indication of  or death, though it is not entirely uncommon for a healthy fetus to exhibit such changes, particularly near the end of a  when there is considerably less space in the  than earlier in pregnancy for the fetus to move about. Still,, including a , is recommended in the event of any type of any change in the strength or of fetal movement, especially a complete cease; most  and s recommend the use of a  to assist in detecting any changes. Fetal distress or death can be confirmed or ruled out via /,, and/or. If the fetus is alive but inactive, extra attention will be given to the and  during ultrasound examination to ensure that there is no compromise of oxygen and nutrient delivery.

Some researchers have tried to develop to identify early on pregnant women who may be at high risk of having a stillbirth.

Definition
There are a number of definitions for stillbirth. To allow comparison, the uses the ICD-10 definitions and recommends that any baby born without  at greater than or equal to 28 completed weeks' gestation be classified as a stillbirth. Others use greater than any combination of 16, 20, 22, 24, or 28 weeks gestational age or 350 g, 400 g, 500 g, or 1000 g birth weight may be considered stillborn.

The term is often used in distinction to (the baby was born alive, even if it died shortly thereafter) or  (early pregnancy loss). The word miscarriage is often used incorrectly to describe stillbirths. The term is mostly used in a human context, however the same phenomenon can occur in all species of s.

Constricted umbilical cord
When the umbilical cord is constricted (q.v. "accidents" above), the fetus experiences periods of, and may respond by unusually high periods of kicking or struggling, to free the umbilical cord. These are sporadic if constriction is due to a change in the fetus' or mother's position, and may become worse or more frequent as the fetus grows. Extra attention should be given if mothers experience large increases in kicking from previous childbirths, especially when increases correspond to position changes.

Regulating, and drug use may reduce the risk of a stillbirth. Umbilical cord constriction may be identified and observed by, if requested.

Some maternal factors are associated with stillbirth, including being age 35 or older, having diabetes, having a history of addiction to illegal drugs, being overweight or obese, and smoking cigarettes in the three months before getting pregnant.

Prevalence
Stillbirths can happen to any mother no matter age, race, ethnicity, or religion. The highest rates of stillbirths happen in women who:


 * are low socioeconomic status
 * are 35 years or older
 * have chronic medical conditions such as diabetes, high blood pressure, high cholesterol, etc.
 * are African American
 * have previously lost a child during pregnancy
 * have more than one child at a time (twins, triplets, etc.)

Although these groups have higher prevalence of stillbirths, it does not mean that women who belong to these groups have a higher chance of a stillbirth occurring.

Treatment
Fetal death  does not present an immediate health risk to the woman, and labour will usually begin after two weeks, so the woman may choose to wait and bear the fetal remains. After two weeks, the woman is at risk of developing blood ting problems, and is recommended at this point. In many cases, the woman will find the idea of carrying the dead fetus and will elect to have labor induced. birth is not recommended unless complications develop during. How the diagnosis of stillbirth is communicated by healthcare workers may have a long-lasting and deep impact on parents. Women need to heal physically after a stillbirth just as they do emotionally. In Ireland women are offered a 'cuddle cot', a cooled cot which allows them to spend a number of days with the child before burial or cremation.

Epidemiology
The average stillbirth in the United States is approximately 1 in 160 births, which is roughly 26,000 stillbirths each year. In Australia, England, Wales, and Northern Ireland, the rate is approximately 1 in every 200 births; in Scotland, 1 in 167. Rates of stillbirth in the United States have decreased by about 2/3 since the 1950s.

The vast majority of stillbirths worldwide (98%) happen in, where care can be of low quality or unavailable. Reliable estimates calculate that yearly about 2.6 million stillbirths occur worldwide during the. Stillbirths were previously not included in the that records worldwide deaths from various causes until 2015.

Society and culture
The way people view stillbirths has changed dramatically over time, however its economic and impact is often underestimated. In the early 20th century, when a stillbirth occurred, the baby was taken and discarded and the parents were expected to immediately let go of the attachment and try for another baby. In many countries parents are expected by friends and family members to recover from the loss of an unborn baby very soon after it happens. Societally-mediated complications such as financial hardship and are among the more common results. A stillbirth can have significant psychological effects on the parents, notably causing feelings of in the mother.

Australia
In Australia stillbirth is defined as a baby born with no signs of life that weighs more than 400 grams, or more than 20 weeks in gestation. They legally must have their birth registered.

Austria
In Austria a stillbirth is defined as birth of a child of at least 500 g weight without, e.g. blood circulation, breath or muscle movements.

Canada
Beginning in 1959, "the definition of a stillbirth was revised to conform, in substance, to the definition of fetal death recommended by the ." The definition of "fetal death" promulgated by the in 1950 is as follows:
 * "Fetal death" means death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps.

Germany
In Germany a stillbirth is defined as birth of a child of at least 500 g weight without blood circulation or breath. Details for burial vary amongst the federal states.

Republic of Ireland
Since 1 Jan 1995 stillbirths occurring in the Republic of Ireland must be registered; stillbirths which occurred before that date can also be registered but evidence is required. For the purposes of civil registration, s.1 of the Stillbirths Registration Act 1994 refers to :-

"...a child weighing at least 500 grammes, or having reached a gestational age of at least 24 weeks who shows no signs of life."

The Netherlands
In the Netherlands, stillbirth is defined differently by the central bureau of statistics (CBS) and the Dutch perinatal registry (Stichting PRN). The birth and mortality numbers from the CBS include all liveborn children, regardless of gestational duration and all stillbirths from 24 weeks of gestation and onwards. In the Perinatal Registry, gestational duration of both liveborn and stillborn children is available. They register all liveborn and stillborn children from 22, 24 or 28 weeks of gestation and onwards (dependent on the report: fetal, neonatal or perinatal mortality). Therefore, data from these institutions on (still)births can not simply be compared one-on-one.

United Kingdom
The registration of still-births has been required in England and Wales from 1927, in Scotland from 1939 but is not required in Northern Ireland. Sometimes a pregnancy is terminated deliberately during a late phase, for example for congenital anomaly. UK law requires these procedures to be registered as "stillbirths".

England and Wales
For the purposes of the (as amended), section 12 contains the definition that :-

"still-born" and "still-birth" shall apply to any child which has issued forth from its mother after the twenty fourth week of pregnancy and which did not at any time after being completely expelled from its mother, breathe or show any other signs of life.

A similar definition is applied within the (as amended), contained in s.41.

The above definitions apply within those Acts thus other legislation will not necessarily be in identical terms.

s.2 of the 1953 Act requires that registration of a birth takes place within 42 days of the birth except where an inquest takes place or the child has been "found exposed" in which latter case the time limit runs from the time of finding.

Extracts from the register of still-births are restricted to those who have obtained consent from the.

Scotland
Section 56(1) of the (as amended) contains the definition that :-

"still-born child" means a child which has issued forth from its mother after the twenty-fourth week of pregnancy and which did not at any time after being completely expelled from its mother breathe or show any other signs of life, and the expression "still-birth" shall be construed accordingly

s.21(1) of the same Act requires that :-

Except so far as otherwise provided by this section or as may be prescribed, the provisions of this Part of this Act shall, so far as applicable, apply to still-births in like manner as they apply to births of children born alive.

In the general case, s.14 of the Act requires that a birth has to be registered within 21 days of the birth or of the child being found.

Unlike the registers for births, marriages, civil partnerships and deaths, the register of still-births is not open to public access and issue of extracts requires the permission of the.

Northern Ireland
In Northern Ireland the, as amended contains the definition :-


 * "still-birth" means the complete expulsion or extraction from its mother after the twenty-fourth week of pregnancy of a child which did not at any time after being completely expelled or extracted breathe or show any other evidence of life.

Registration of still-births can be made by a relative or certain other persons involved with the still-birth but it is not compulsory to do so. Registration takes place with the District Registrar for the Registration District where the still-birth occurred or for the District in which the mother is resident. A still-birth certificate will be issued to the registrant with further copies only available to those obtaining official consent for their issue. Registration may be made within three months of the still-birth

United States
In the United States, there is no standard definition of the term 'stillbirth'.

In the U.S., the of 2002 specifies that any breathing, heartbeat, pulsating umbilical cord, or confirmed voluntary muscle movement indicate live birth rather than stillbirth.

The collects statistical information on "live births, fetal deaths, and induced termination of pregnancy" from 57 reporting areas in the United States. Each reporting area has different guidelines and definitions for what is being reported; many do not use the term "stillbirth" at all. The federal guidelines suggest (at page 1) that fetal death and stillbirth can be interchangeable terms. The CDC definition of "fetal death" is based on the definition promulgated by the World Health Organization in 1950 (see ). Researchers are learning more about the long term psychiatric sequelae of traumatic birth and believe the effects may be intergenerational

The federal guidelines recommend reporting those fetal deaths whose birth weight is over 12.5 oz (350 g), or those more than 20 weeks gestation. Forty-one areas use a definition very similar to the federal definition, thirteen areas use a shortened definition of fetal death, and three areas have no formal definition of fetal death. Only 11 areas specifically use the term 'stillbirth', often synonymously with late fetal death, however they are split between whether stillbirths are "irrespective of the duration of pregnancy", or whether some age or weight constraint is applied. A movement in the U.S. has changed the way that stillbirths are documented through vital records. Previously, only the deaths were reported. However 27 states have enacted legislation that offers some variation of a birth certificate as an option for parents who choose to pay for one. Parents may not claim a tax exemption for stillborn infants, even if a birth certificate is offered. To claim an exemption, the birth must be certified as live, even if the infant only lives for a very brief period.