1) Stillbirth refers to the death of a fetus after 22 weeks of gestation or weighing at least 500g, as defined by the WHO. It can occur during delivery (intrapartum) or before delivery (antepartum). 2) Common causes of stillbirth include complications of pregnancy/delivery, fetal growth issues, congenital anomalies, maternal infections, diabetes, hypertension, and unexplained/idiopathic cases. 3) Diagnosis involves assessing the mother's medical history, performing a physical exam to check for fetal movement/heart rate, and conducting imaging like ultrasound to check for fetal abnormalities. Additional tests may include blood tests, amniocentesis, and autopsy.

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