Stillbirth and Infant Death Flashcards
what is a stillbirth
when a baby dies after 24 weeks gestation and before/ during birth
what is a miscarriage
loss of baby before 24 weeks
what is a late miscarriage
loss of baby at 22-24 weeks
how common is a stillbirth
1 in 250 pregnancies (8 every day, 1/3rd of these over 37 weeks gestation)
rate of stillbirth reducing
what can cause a still birth
placental causes IUGR congenital abnormalities placental abruption maternal or fetal infection cord prolapse idiopathic hypoxia-acidosis uterine rupture nutrition lifestyle- extremes of maternal age, obesity, smoking ethnic minorities lower socioeconomic class pre eclampsia/eclampsia diabetes obstetric cholestasis multiple pregnancy- TTTT prolonged pregnancies previous stillbirth maternal antibodies-rhesus etc
what increases your risk of stillbirth
twins
black/asian
mothers aged 40 or over or teenage mothers
mothers living in poverty
why is education about a babies movements in pregnancy important
half of women who had still births felt their baby move less before hand
what advice should you give mothers to prevent still birth
sleep on you side in the third trimester quit smoking stay healthy weight avoid alcohol and drugs go to every antenatal appointment report any symptoms: bleeding, stomach pains, itching, leaking fluid/ discharge get vaccinations (flu) start folic acid before conception vit d for whole pregnancy (esp if obese)
what is the immediate management for a patient who has had a stillbirth
assess maternal wellbeing- prompt tx of any life threatening condition
take detailed Hx of eventsduring pregnancy and clinical examination for preclampsia/ chorioamnionitis /placental abruption
kleihauer test for rhesus -ve women
Anti-RhD gammaglobulin
what is a kleihauer test
detects large fet0-maternal haemorrhage by measuring how much fetal blood has mixed with mothers
what are the options for labour in a stillbirth
consider mothers preference and her medical condition + previous Hx
advise for immediate delivery is sepsis, pre eclampsia, placenta abruption or membrane rupture
vaginal delivery recommended for most, c section for some
test for disseminated intravascular coagulation (clotting studies, blood platelets count and fibrinogen)
delay of labour with intact membranes and no evidence of DIC has no immediate risk but may develop comps/ anxiety is delayed for a long time (if over 48 hours DIC testing twice weekly)
prolonged labour also makes autopsy less effective and babies appearance deteriorates. increases risk of DIC and sepsis
mifipristone and misoprostol to indice labour
Care in labour should given by an experienced midwife
analgesia should be offered and available
what investigations are done after stillbirth
maternal bacteriology (blood cultures, urine, vaginal and cervical swabs)
serology (viral screen, syphilis, tropical infections)
maternal random blood glucose and HBA1C (for gestation or diabetes mellitus)
maternal thyroid function
thrombophilia screen (if +ve get fragmin in next pregnancy)
anti body screen
parental bloods for karotype
toxicology
fetal and placental microbiology
fetal tissues for karotype
post mortem- external, autopsy, microscopy, x ray, placenta and cord
advice for next pregnancy after still birth
stop smoking, reduce weight or manage medical condition better
Continuity
Frequent contact
Parent led and agreed decision making
Likely to involve more frequent fetal surveillance/tests NIPT, scanning
Likely to involve more frequent maternal surveillance e.g GTT, more BP checks
May involve medication Aspirin/ fragmin if thrombophilia screen or PET
Likely Early delivery by IOL
what mental health conditions are common after a stillbirth
depression
post traumatic stress disorder
what is SUDI
sudden unexplained death of an infant
for which there is no apparent reason
what is SIDS
sudden infant death syndrome: when there is no pathology or risk factors to explain death
what is cot death
can be caused by either SUDI or SIDS
what is correlated to SUDI
social depravity
ethnic minority
what causes the largest number of infant deaths ages 2-6
SUDI
is SUDI common after 12 months
no v rare
what are the contributors to SIDs
aged 2-4 months (critical development period)
vulnerable infant- preterm birth maternal smoking
exogenous stress- prone position, overheating, head covering, co sleeping, infection
what are the risks facts for SIDS that are intrinsic to the child
Acute illness (URTI, otitis media) with symptoms present at time of death but not significant cause of death
Pre-term before 37 weeks (internal homeostatic mechanisms not fully formed)
Congenital abnormality not causing death
Multiple births
Previous unexpected infant death
Small for gestational age
Male infant
what are the risks facts for SIDS that are extrinsic to the child
Symptomatic depression in mother/ primary care giver at time of death
Alcohol use by mother >2 units in last 24 hrs
Substance misuse by parent
Smoking by mother in pregnancy or postnatally
Poor housing / overcrowding
Domestic violence
Co sleeping
Sleeping on pillow or other soft surface (adult duvet)
Sleeping prone or side sleeping
why is swaddeling associated with SIDS
overheating
what should be in the cot with a baby
nothing expect blanket tucked under their arms
should you fall asleep holding baby in chair
no
what is the approach in scotland to SUDI
joint agency- involves police and social work as unexpected death
Most occur at home – ambulance/ A&E team have responsibility to call the police
After reported to the police procurator fiscal investigation and post mortem
how long till get result result from post mortem
3-4 months
what are common causes of SUDI on autopsy
Infections (pneumonia, gastroenteritis, CMV, HSV, myocarditis, RSV pneumonitis, meningitis, septicaemia)
Congenital abnormalities
Other natural deaths
Accidents
NAI- usually head trauma: shaking, head injury
what are the components of a infant post mortem
clinical Hx, macroscopic examination, histology, microbiology, toxicology
how likely are you to find a cause on post mortem after SUDI
around 50%
increases as child gets older
what can you offer for next pregnancies after SUDI
CPR training
what are the components of bereavement support after SUDI
Once death has been confirmed:
Explain what will happens next
Find private space
Give time to make plan
Ensure family time to spend with the baby
Start memory making
Parent led care when possible
Plan going home, documentation and notification
Police/ procurator fiscal- cant take out ant venflons etc until consent from police and procurator fiscal
Express sympathy
ALWAYS use babys name- even if stillbirth ask if they had a name in mind
Listening and responding to parents
Sensitive parent led care
Appropriate envrinoment
Memory building
Cultural and spiritual support
Understanding the loss and the grief process
Support from family, friends and community
Get counselling
Memory boxes
Memorial services with other families
what is incongruent grieving
mothers and fathers will grieve very differently and at different times- relationship difficulties and separation
what can happen to parents when grieving
PTSD
incongruent grieving
Preoccupied with grief and other children are overlooked
Child envy of others
Withdrawal from society and friends
Silent grief
Invalidation of their loss
Subsequent pregnancies full of anxiety and fear
Phenomenon of the replacement child/ vulnerable child
