Still Birth, Intra Uterine Fetal Death, Midwifery - C

1. Still Birth
Intrauterine Fetal Death

2. Introduction:
Death of fetus after the period of viability in utero this death may
during antepartum period and intra partum period.
Antepartum death result in the delivery of the macerated baby.
After death fetal will undergo aseptic necrosis which is known as
maceration.
Intrapartum death result in the delivery of the fresh still birth.

4. Definition:
Still Birth:
Still birth is the birth of newborn after 22th completed week ( weighing
1000 gm or more ) when the baby doesn’t breathe or show any sign of
life after delivery. Such death include ante partum deaths ( macerated)
and intra- partum death ( fresh still birth).
According to WHO – the term stillbirth be applied to a fetus born
dead and weight over 500 gm.

5. Contd...
Intra uterine fetal death ( IUFD):
IUFD refers to the babies with no sign of life in utero.

6. Incidence:
According to NDHS data 2016
Total still birth cases: 96 cases
According to sex:
• Male: 62.3%
• Female: 37.7%
Residence:
• Urban: 52.5%
• Rural: 47.5%
Province:
Province 1 : 17.7%
Province 2 : 29.2%
Province 3 : 16.1%
Province 4 : 6.5%
Province 5 : 15.3%
Province 6 : 7.1%
Province 7 : 8.0%

7. Causes according to NDHS:
• Complication of pregnancy, labor, and delivery: 41.0%
• Disorder related to length of gestation and fetal growth: 4.3%
• Congenital malformation and deformations: 0.9%
• Unspecified cause: 53.9%
Place of delivery:
- Home: 42.4%
- Private health facility: 11.9%
- Government health facility: 34.4%
- Others: 11.3%

8. Causes:
1. Idiopathic 25 – 35 %
2. Maternal
3. Fetal
4. placental

9. Maternal:
• Prolonged pregnancy: greater than 42 WOG
• Diabetic (poorly controlled): the exact cause is unknown. Possibly due
to hypoxia, polyhydramnios etc.
• Maternal infection: TORCH
• Hypertensive disorder: spasm of the uteroplacental circulation leads to
placental insufficiency, fetal death
• Severe anemia: due to maternal hypoxia

10. Contd...
• Anti phospholipid syndrome: in SLE two antiphospholipid antibodies
e.g., lupus anticoagulant and anti-cardiolipin antibodies are important.
They cause dysregulation of coagulation pathway, thrombosis of
utero-placental vessels and poor placental perfusion may lead to fetal
death.
• Hyperpyrexia: acute fever of mother over 39.4°c can kill fetus
directly (placental insufficiency)
• Antepartum hemorrhage: both placenta previa and abruptio cause
actual placental insufficiency.
• Maternal death

11. Fetal:
• Multiple pregnancy
• Intra uterine growth restriction
• Fetal infection
• Rh – incompatibility: excessive hemolysis of fetal blood by antibody
formed in the mother produce fetal anemia and hypoxia and death.

12. Placental:
• Cord accident: true knot, cord around the neck,
• Abruptio placenta
• Premature rupture of membrane
• Placental insufficiency

13. Important causes of still birth:
• Birth asphyxia and trauma
• Pregnancy complication ( placental abruptio, pre eclampsia, diabetes
mellitus)
• Fetal chromosomal anomalies
• infection

14. Sign and symptoms of IUFD :
• Bleeding or spotting during pregnancy.
• Absence of fetal movement.
• Dark brown vaginal discharge.
• Absence of FHS during auscultation.
• Decrease the size of breast and change.
• Fundal height is less.

15. Diagnosis:
• History taking
- Previous history of IUFD
- Absence of fetal movement history
- Disease condition/ infection
• Physical examination:
- Monitor FHS
- Abdominal palpation

16. Contd...
• findings:
- Gradual retrogression of the fundal height.
- Uterine tone is diminished.
- Fetal movement are not felt during palpation.
- Fetal heart sound is absent.
- Cardiotocography flat trace
- Egg shell crackling feel of the fetal head is a late feature.

17. Investigation:
• Sonography (USG)
1. Lack of fetal movement ( including cardiac) during a 10 minutes
period of careful observation.
2. Later sign:
- oligohydramnios
- Collapsed cranial bone

18. Contd...
• Straight X- ray:
(Rarely done at present )
-Spalding sign: irregular overlapping of the cranial bone due to
liquefaction of brain ( usually appears 7 days after death)
- Hyper flexion of spine in some case hyper extension of neck seen
- Crowding of the ribs shadow
- Robert’s sign : Appearance of gas shadow in chamber of heart and
great vessels may appear

19. Contd...
• Hematological investigation:
ABO and Rh grouping, VDRL, post prandial blood sugar, HbA1C,
TORCH screening, lupus anticoagulant and anti cardiolipin antibodies.]
• Urine examination for casts and pus.
• Karyotyping study in congenital malformation
• Naked eye examination of placenta (abnormalities) and cord(
knot, vessels)

20. Prevention:
• Pre- conceptional counselling
• Regular antenatal check up and care with advice regarding health, diet,
and rest.
• Screen out the ‘at risk mother’ those of poor socio economic or high
parity, extremes of age and twins etc.. And encourage for mandatory
hospital delivery.
• Detection and correction of anemia and prevention of pre- eclampsia
and TD vaccination should be done as routine.
• Careful monitoring in labour and avoidance of traumatic vaginal
delivery.
• Skilled birth attendant – at delivery

21. Contd...
• ‘6 clean’ methods to minimize sepsis.
• Provision of referral neonatal services especially to look after the
preterm.
• Health care education to mother about the care of newborn early and
exclusive breast feeding, prevention of hypothermia.
• Educating the community to utilize family planning ( FP) services and
to utilize the available maternity services.
• Autopsy study( forensic study) of perinatal death.

22. Assignment:
• Write down the diagnostic investigation of IUFD/ Still Birth.

23. References:
• Ranabhat R. D. Niraula H. Textbook of Midwifery & Reproductive
Health Professions Education, IOM, TU
• Dutta DC. Textbook of Obstetrics, 8th ed. New Central Book Agency
(P). Ltd. Calcutta, India
• Bennet, V.R. & Brown, L.K.(2001). Myles Textbook For Midwives.
13th ed. Churchill Livingstone; Sydney Toronto
• Bruce, E., & Schultz, C. (2001). Noninfinite Loss and Grief. London:
Jessica Kingsley.
• Bobac, Jensen.(1985). Maternity and gynecologic care: the nurse and
family . 3rd edition , the C.V. Mosby company, St. Louis, Missouri