WK8: Unexpected outcomes and diverse populations Flashcards
Define stillbirth.
the birth of a baby with no signs of life from 20 weeks gestation or more, or weighing at least 400g or more if the gestation is unknown.
Define neonatal death
the birth of a live baby from 20 weeks gestation or more, or weighing at least 400g or more if the gestation is unknown, who dies within 28 days of birth.
What is the requirements for babys born prior to 20 weeks so less than 400g with an unknown gestation?
Births of babies weighing less than 400g or prior to 20 weeks gestation do not need to be registered, nor do they have to be legally buried or cremated.
Define abortion
Abortion is a medical procedure to end a pregnancy that involves the use of medicines or surgery to remove the embryo or fetus and placenta from the uterus
What are some reasons for abortion?
- A personal decision based on individual circumstances
- In all circumstances, the woman must be treated with respect, empathy and understanding in the context of ethical and professional healthcare.
Some reasons may be (not all though!)
- Unexpected pregnancy
- The unexpected news of fetal abnormality
- Maternal medical reasons
What are the two types of abortions?
Medical abortions
- Uses medications rather than surgery.
- Mifepristone (a synthetic anti-progesterone) in combination with misoprostol (a prostaglandin analogue) is the best available regimen for medical abortion.
- Alternative regimens are reported but are generally less effective and take longer to work.
RANZCOG (2019).
Surgical abortions
- Involves the removal of the pregnancy (sometimes referred to as ‘contents of the uterus’) via the vagina by surgical means.
- To have a surgical abortion, the cervix must be wide enough to allow for surgical instruments into the uterus.
- Pregnancy <12 weeks may involve suction aspiration
- Pregnancy >12 weeks requires the combined use of medical and surgical abortion.
What are some unexpected findings?
- Suspect findings on ultrasound (maybe at the 20 week Morph e.g. structure of the heart, smaller limbs, missing limb that may be indicative of syndrome or incompatibility with life)
- low PAPP-A= pregnancy associated plasma protein A
- PAPP-A assists in the recognition of the fetus by the maternal immune system (stop mother not attack baby)
- Can be an independent risk factor for adverse outcomes. Increased risk of fetal death in utero after 24 weeks, spontaneous misscarriage before 24 weeks, pre term birth, gestational hypertension, maternal preeclampsia - increased MSS indicative of downs syndrome
- mater illness e.g. PE, GDM
- fetal concerns e.g. IUGR
- Miscarriage (up to 20 weeks gestation)
- Stillbirth
- Prematurity
- Neonatal illness caused by (e.g.)
- infection
- hypoxia
- Congenital abnormality - Neonatal death
- Infertility
- Termination for fetal abnormality
- Baby with a disability from birth injury
Define early pregnancy loss
The spontaneous abortion of pregnancy prior to 20/40
- risk increases with maternal age
Define perinatal death
either a still birth or neonatal death (400mg/20 weeks gestation)
What are some common reactions to death of a baby?
Grief
Numbness and emptiness
Disbelief and denial
Shock
Physical pain
Loss
Regret
Anger
Profound sadness
Guilt
relationship conflict
lack of acknowledgement
Mother may question whether she did anything to cause death and my blame herself
Family feeling isolated (as friends +fam don’t know how to help, happens before they have told people, grandparents may also be greving)
What are some factors that can effect the grief process
- early pregnancy loss
- later pregnancy loss
- importance and meaning of pregnancy
- a social support network
- personality style
- culture
- women at greater risk of depression and PTSD
How can you help with the grief process?
- Understand the stages of grief
- Listening to the woman and her family and being present
- Respect for individual reactions
- Assist with creating memories/honouring the baby
- E.g. a song, blanket or sent (essential smell to diffuse while birthing or holding) that can take you back to a time in life - The giving of time
- To enable parents to
- Explore
- Discuss
- Clarify
Explain some medical acre needs for perinatal loss
- Information giving
- Plan for induction of labour if stillbirth/TOP for congenital abnormality
- If termination or death in utero
- Trauma related to being in labour with dead baby and hearing a live baby and mother birthing is very traumatic - Assisting with birth if operative delivery
- At the increased likelihood
- Also increased likelihood of retained placenta and PPH - Discussion with parents about the reasons for the baby’s death
- Baby’s appearance after birth
- Discuss what it may look like when born - Sometimes no explanation for death
- Raise the issue of postmortem examination and investigation(s)
- Seeing the parents again at later time to discuss impact on successive pregnancy
What may a still born appear like?
- Autolysis begins within 12-24 hours of death= Autolysis: breakdown of cells or tissues
Maceration
- Colour-pink, pale, livid
- Blisters
- breaking and skin slippage exposing red/livid subcutaneous tissue
- Skull collapse
After birth
- Increasing paleness
- Darkening of lips, abdomen, dependent areas
- Increasing skin fragility
- Fluid leakage
- Possibly blood-stained
- Mouth, nose, umbilicus, skin
Prepare the couple as much as possible about what the baby will look like.
- Be honest and explain how difficult it is to predict especially if uncertain of time since death
- It is important to prepare for maceration
Parents will be guided by what you do and say.
- If you hold the baby and notice the ‘good features’ (good eye lashes)
- Hold the baby like it is live
- Talk to the baby like it is live
- Tell them they can hold and kiss their baby
- Use its name
- Talk to the baby using his/her name
