Please sign in or sign up for a March of Dimes account to proceed. Some women are more likely than others to have a stillbirth. Reducing your risk factors for stillbirth may help you have a healthy baby. Common causes include infections, birth defects and pregnancy complications, like preeclampsia. Most women who have a stillbirth and get pregnant again have a healthy pregnancy and a healthy baby.
You've saved this page It's been added to your dashboard. BMJ ;— Ozone is a gas that comes from car exhaust, gasoline and fumes from factories and chemicals. Reduction in stillbirths at term after new Stillbirths not reducing pregnancies induction paradigm: results of a national intervention. So far this has been well-received. The aim is to reduce stillbirths for women at or redkcing the end of the pregnancy, while not increasing unnecessary intervention. There is a clear reducinf urgent need for well-designed trials addressing this research question.
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The reduced rates of induction of labour are of interest and require further trials reporting labour induction rates with sufficient power to detect differences in subsequent perinatal outcomes. High Stillbirths not reducing pregnancies risk: Others include cramps, pain or bleeding from the vagina. Compared the impact on perinatal mortality of antenatal day care units intervention vs. Component studies in Empson et al. The fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Prospective, family cohort study. Pergnancies statistical significance measures were provided [LOE: 1-]. Pregnandies with the findings of the studies we reviewed, the Lancet Maternal and Child Undernutrition Series recommends deworming during pregnancy in specific, Stillbirhts contexts i. Table 4 Impact of use of routine ultrasound scanning on stillbirth and perinatal mortality. The impact of pregnancie agents on risk of stillbirths is less convincing, although the analysis shows a slight trend in the Sam bond hard images of benefit.
Conceiving within a year of stillbirth is common and is not associated with increased risk of stillbirth, preterm birth, or small-for-gestational-age birth in the following pregnancy, compared with an interpregnancy interval of at least two years.
- An estimated two-thirds of the world's 3.
- Screening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies.
- Stillbirths are deaths of unborn babies after the 24th week of pregnancy.
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Despite advances in healthcare, stillbirth rates remain relatively unchanged. We conducted a systematic review to quantify the risks of stillbirth and neonatal death at term from 37 weeks gestation according to gestational age. We searched the major electronic databases Medline, Embase, and Google Scholar January —October without language restrictions. We included cohort studies on term pregnancies that provided estimates of stillbirths or neonatal deaths by gestation week.
We estimated the additional weekly risk of stillbirth in term pregnancies that continued versus delivered at various gestational ages. We compared week-specific neonatal mortality rates by gestational age at delivery. Thirteen studies 15 million pregnancies, 17, stillbirths were included. All studies were from high-income countries. Four studies provided the risks of stillbirth in mothers of White and Black race, 2 in mothers of White and Asian race, 5 in mothers of White race only, and 2 in mothers of Black race only.
The prospective risk of stillbirth increased with gestational age from 0. Neonatal mortality increased when pregnancies continued beyond 41 weeks; the risk increased significantly for deliveries at 42 versus 41 weeks gestation RR 1. Limitations include variations in the definition of low-risk pregnancy, the wide time span of the studies, the use of registry-based data, and potential confounders affecting the outcome.
Our findings suggest there is a significant additional risk of stillbirth, with no corresponding reduction in neonatal mortality, when term pregnancies continue to 41 weeks compared to delivery at 40 weeks. PLoS Med 16 7 : e This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests: The authors have declared that no competing interests exist. Despite advances in antenatal and intrapartum care, stillbirth continues to be a major burden [ 1 ]. More than 3, babies are stillborn every year in the UK—with a third of them considered to be apparently healthy term infants 37 weeks gestation or beyond [ 2 ].
Stillbirth at term in an otherwise low-risk pregnancy [ 3 , 4 ] devastates parents with its unexpectedness. Such an effort requires an understanding of the magnitude of the problem through collation of large datasets, particularly for key factors like gestational age, for which existing information is imprecise [ 6 ].
Prolonged pregnancy is a known risk factor for stillbirth. To avoid this adverse outcome, women are routinely offered induction of labour after 41 weeks gestation [ 6 — 8 ]. This recommendation is based on evidence of increased stillbirth risk beyond 41 weeks [ 9 ].
However, 1 in 3 stillbirths occur prior to 41 weeks gestation [ 2 — 4 ]. The stillbirth risks before 41 weeks are not routinely discussed with women who have no clinical indication for delivery. Individual studies on the risk of stillbirth in what is considered as normal term gestation vary in the magnitude and consistency of findings by gestational week [ 12 — 14 ].
Corresponding neonatal mortality estimates are imprecise [ 13 , 15 , 16 ]. We undertook a systematic review to evaluate the additional weekly risks of stillbirth in term pregnancies that continue versus deliver at various gestational ages. We also assessed the week-specific risks of neonatal death by gestational age at birth. Ethics approval was not needed. There were no language restrictions. We manually searched the reference lists of relevant studies for more relevant data, and contacted the authors and researchers in the field for additional studies or relevant information where required.
We selected the studies in a 2-stage process. First 2 independent reviewers JM and HR screened the titles and abstracts to identify eligible studies, and then they retrieved the relevant full texts for detailed assessment.
Any disagreements on the eligibility of the studies were resolved with a third reviewer ST. We included cohort studies including those nested within randomised trials on pregnant women at term gestation without a prespecified indication for early delivery, if they provided weekly estimates of stillbirths. We excluded abstracts, letters, case reports, case series, and animal studies, and studies that only included women with pre-existing medical conditions, congenital fetal malformations, complications such as preeclampsia, gestational diabetes, or small-for-gestational-age fetuses, or women who needed planned delivery before 37 weeks for maternal or fetal reasons.
We defined term pregnancies as pregnancies with a gestational age of 37 completed weeks or beyond [ 18 ]. Stillbirth was defined as the death of a baby before birth, which included both antenatal and intrapartum deaths [ 19 ]. Any newborn death before 28 days of age was classed as a neonatal death [ 20 ]. We defined a low-risk pregnancy as that in which a healthy woman with apparently uncomplicated pregnancy enters labour with a low risk of developing intrapartum complications [ 21 ].
Two independent reviewers JM and HR assessed the quality of the individual studies, both for internal risk of bias and external the representativeness of the population validity [ 22 ].
For internal validity, we studied the individual features of the study such as the design, method of sampling, ascertainment of the outcome, appropriate determination of gestational age, and adequacy of follow-up [ 23 ]. For external validity, we considered a population to be clearly defined as representative of low-risk pregnancy if it met the following criteria: a clear definition of low-risk pregnancy, exclusion of pregnancies with congenital fetal malformations, and exclusion of multiple pregnancies.
Any discrepancies were resolved after discussion with a third reviewer ST. Data were extracted in duplicate by 2 reviewers JM and HR. We extracted the number of ongoing pregnancies, number of deliveries, and number of events stillbirths or neonatal deaths per week.
In the first step, for each study we calculated the gestation-week-specific prospective risk of stillbirth from the number of stillbirths that occurred in that week divided by the number of pregnancies that were considered to be at risk. We obtained pooled week-specific risks by using a multilevel studies and women mixed-effects logistic regression model without covariates and with random intercepts [ 25 ].
The overall week-specific rates of neonatal death were calculated using the same model: The number of neonatal deaths that occurred in a particular week were divided by the number of deliveries in that period. In the next step, we compared the change in overall week-specific risk of the event either stillbirth or neonatal death between 2 consecutive weeks by calculating the risk ratio RR.
We calculated the RR by dividing week-specific risks that were obtained after fitting the corresponding logistic models. After calculating the distribution of RRs for all gestational ages, we chose the 2. For each gestational week, we also estimated the number of pregnancies at risk, i.
We planned subgroup and sensitivity analyses a priori to determine whether the risks of stillbirth and neonatal death at term varied according to maternal characteristics such as race White, Black, Asian, Other , body mass index normal, overweight, obese , and age; study characteristics such as quality risk of bias , country income status low, middle, high , and time period; or restriction of assessments to those studies that excluded fetuses with congenital malformations and studies that used a strict definition criterion of low-risk pregnancy.
For subgroup analysis, we compared the week-specific risks of stillbirth in women of Black versus White race by including race as a covariate in the logistic model, with White race as reference.
We estimated the heterogeneity using the tau-squared statistic, with a value of 0 indicating no between-study variance. Publication bias and small study effect were assessed with funnel plots representing weekly event rate logit scale versus its standard error.
All analyses were carried out in Stata version From 10, citations, we included 13 studies 15,, pregnancies , which reported 17, stillbirths and 2, neonatal deaths Fig 1. Ten of the 13 studies included only singleton pregnancies [ 12 , 14 , 30 — 35 ], 6 studies excluded pregnancies complicated by congenital fetal malformations [ 14 , 32 — 35 ], and 4 included women without any medical complications [ 30 , 35 ].
Twelve studies provided weekly rates of stillbirth only [ 12 — 14 , 30 — 35 ], 1 provided rates of neonatal death only [ 36 ], and 4 provided rates of both stillbirth and neonatal death [ 13 , 30 , 34 ]. Four studies provided data to compare the weekly risks of stillbirth for women of White versus Black race [ 12 , 31 , 33 ], and 2 for White versus Asian race [ 33 ]. There were no major differences between the studies in the definitions of stillbirth and neonatal mortality. Ten studies provided clear definitions of stillbirth and neonatal death [ 13 , 14 , 30 , 31 — 37 ].
Three studies used registry entry data on stillbirth and neonatal death for analysis Table 1. The risk of stillbirth at term in the studies varied from 1. The overall gestation-week-specific prospective risk of stillbirth steadily increased with gestational age, from 0. Stillbirth risk solid back line ; neonatal death risk solid red line. S2 Appendix provides individual study estimates on week-specific risks of stillbirth for 40 weeks and 41 weeks.
Our sensitivity analyses restricted to studies with a strict definition of low-risk pregnancy Table 3 , pregnancies without congenital fetal malformations Table 3 , last participant recruitment after S3 Appendix , and a low risk of bias S4 Appendix showed a consistent increase in risk of stillbirth at each gestational week after 37 weeks. Subgroup analyses by race showed that compared to White women, Black women at term were 1.
The week-specific prospective risks of stillbirth are provided separately for Black and White women in S6 Appendix. There were no statistically significant differences in the odds of stillbirth at any gestational age between Asian and White women, except for a lower risk at 42 weeks in mothers of Asian race RR 0.
There were insufficient data to undertake other planned subgroup analyses on maternal body mass index, age, and country income status. The risk of neonatal death was unchanged for births between 38 and 41 weeks of gestation; the risk increased beyond 41 weeks RR 1. Table 2 provides the estimates of week-specific risk of neonatal death for births at various gestational ages at term.
Sensitivity analysis performed by only including studies on singleton pregnancies uncomplicated by congenital fetal malformations S8 Appendix , and only high-quality studies S9 Appendix , showed a similar pattern, with increased risks observed for births beyond 42 weeks compared to the previous week. We found that the prospective risk of stillbirth increased with gestational age in pregnancies at term; neonatal mortality risk remained unchanged until 41 weeks, but increased beyond this gestation.
Pregnancies that continued to 41 weeks—currently still considered normal term gestation—had a small but significant increase in the risk of stillbirth compared to those delivered at 40 weeks, with no differences in neonatal mortality.
To our knowledge, ours is the largest review to date on risks of stillbirth and neonatal death at various gestational ages in term pregnancies. The review was based on a prospective protocol with predefined inclusion criteria.
We contacted the individual authors for relevant data when it was required for the analysis and where it was possible. When we included unpublished data, the relevant researchers were not involved in the data extraction, quality assessment, or analysis to minimise bias. The large sample size achieved with these efforts allowed us to generate results with high precision.
By reporting both relative and absolute increases in the risks, our findings provide the appropriate context for interpretation. We assessed the qualities of the included studies and the validity of the evidence.
Our sensitivity analyses demonstrated that our findings were not sensitive to the assumptions made. Unlike previous studies in this area, our robust analytical approach [ 38 , 39 ] avoided the inappropriate use of Kaplan—Meier method [ 40 , 41 ]. The inclusion criteria varied between studies. But all studies included women whose pregnancy continued to term and beyond, an indication of their low-risk status in that early delivery was not required [ 42 , 43 ].
But continuation of such pregnancies to term is in line with current practice, where there is no routine ultrasound monitoring of fetal growth [ 43 ]. Some of the included cohorts extended before , and the risk of outcomes might have changed over time. We consider the effect of study time span on our stillbirth estimates to be minimal for the following reasons.
Second, evidence behind the current recommendations on the timing of delivery in term pregnancies with no obvious reasons for early delivery stem from both recent and past data [ 6 , 46 ] Third, in apparently low-risk pregnancies at term, the standard of antenatal care, including regular blood pressure checks and auscultation of fetal heart, has not changed over time [ 44 ]. Lastly, we observed very little between-study variance in the reported risks of stillbirth for various gestational ages, irrespective of the year of data collection or inclusion criteria.
Although the database registries are prone to biases, we expect the outcome of death to be well recorded [ 47 ]. It is possible that an intrauterine death recorded as being in a particular gestational week may have occurred in the previous week.
But in women who undergo weekly monitoring of fetal heart rate at term gestation, the time interval from fetal demise to birth is considered about 2 days on average [ 48 ].
Influence of antenatal screening on perinatal mortality caused by syphilis in Swaziland. Compared the impact of 2 g of elemental calcium intervention vs. Binder et al. Multicentre RCT. Various versions of the partograph are marked by different slope and position of the action line, which is likely to impact labour augmentation interventions, Caesarean section rates, and maternal satisfaction.
Stillbirths not reducing pregnancies. Complications & Loss
Although there are several RCTs and a Cochrane review evaluating vibroacoustic stimulation during pregnancy Grade B evidence , the non-significant impact on perinatal mortality does not support including this intervention presently. Further RCTs are needed to determine optimal intensity, frequency, duration and position of vibroacoustic stimulation, as well as efficacy, predictive reliability, safety in terms of fetal hearing impairment and neurological development and perinatal outcome.
Amniotic fluid protects and supports the fetus during pregnancy. Both low amniotic fluid oligohydramnios and high amniotic fluid polyhydramnios are abnormal and potentially place the fetus at risk of adverse outcomes.
Oligohydramnios can be associated with maternal conditions including pre-eclampsia, or with placental membrane rupture, fetal growth restriction, post-term pregnancy, fetal kidney problems, or fetal or placental abnormalities [ , ]. Until ultrasound became available, the invasive nature of amniotic fluid testing limited its clinical usefulness [ ].
Using ultrasound, multiple methods for measuring amniotic fluid have been developed and are used to identify at-risk pregnancies. The amniotic fluid index AFI is a measure of the amount of amniotic fluid which is calculated by summing centimeters of depth of 4 different pockets of fluid; alternatively, the single deepest vertical pocket or maximum pool depth may be used.
At term, many clinicians will induce labour or perform Caesarean section after diagnosis of decreased amniotic fluid volume to prevent an adverse pregnancy outcome. However, using assessments of amniotic fluid volume to predict fetal complications is controversial, and the utility of amniotic fluid assessment is different when used prior to versus after the onset of labour.
Here, we examine the potential for assessment of amniotic fluid volume, or interventions to achieve normal amniotic fluid volume, to effectively detect high-risk pregnancy or fetal distress and subsequent adverse perinatal outcomes. We also examined the impact of interventions to achieve normal amniotic fluid volume on perinatal outcomes. Impact of amniotic fluid assessment for polyhydramnios on stillbirth and perinatal mortality.
Impact of amniotic fluid volume assessment for oligohydramnios and associated interventions on stillbirth and perinatal outcomes.
Several observational studies explored the association of polyhydramnios with perinatal mortality, with inconsistent findings. Several observational studies [ ] observed that polyhydroamnios was an independent risk factor for both perinatal mortality and intrapartum morbidity [LOE: 2-].
A retrospective cohort study by Dashe et al. Magann et al. The association may not apply to certain subsets of high-risk pregnancies, as a similar study among women with gestational diabetes who had AFI performed antenatally found no elevated risk of perinatal morbidity or mortality among pregnancies complicated by polyhydramnios compared to gestational diabetics without polyhydramnios [LOE: 2-].
No intervention studies subsequent to diagnosis of polyhydramnios were identified. Observational studies of oligohydramnios cases demonstrated a consistent elevated risk of poor perinatal outcomes. Anandakumar et al. In Italy, Locatelli et al. One study found that in addition to the absolute volume of AFI, the distribution of amniotic fluid by intrauterine quadrants is predictive of fetal outcome.
Myles et al. A number of observational studies, RCTs and a systematic review compared AFI measurement to other methods of measuring amniotic fluid in ability to predict poor perinatal outcome.
In an observational study in Egypt, Youssef et al. Morris et al. A Cochrane review [ ] compared the evidence for the predictive value of 2 methods of amniotic fluid assessment AFI versus single deepest vertical pocket on adverse pregnancy outcomes Additional file They recommended that the single deepest vertical pocket measurement be used because AFI resulted in increased diagnoses of oligohydramnios and rates of labour induction with no improvement in perinatal outcomes compared to single deepest vertical pocket, suggesting better predictive value of single deepest vertical pocket.
An RCT by Alfirevic et al [ ] randomised women to fetal monitoring by either AFI with computerised cardiotocography, or maximum pool depth determined by computerised cardiotocography, but found no statistically significant difference in perinatal outcome in the 2 groups.
Measurement of maximal amniotic fluid vertical pocket proved slightly better than AFI in identifying post-term pregnancies with abnormal perinatal outcomes.
One intervention strategy to improve perinatal outcomes is to augment amniotic fluid volume in cases of oligohydroamnios. Polyhydramnios is a clear risk factor for perinatal mortality, whether associated with congenital malformations, placental insufficiency, or of idiopathic origin. However, no studies reported the impact of interventions subsequent to a diagnosis of polyhydramnios after amniotic fluid assessment, so the impact on stillbirth of amniotic fluid screening for polyhydramnios remains unclear.
Although robust RCTs are limited, very low AFI values oligohydramnios are frequently associated with poor pregnancy outcomes, and in these cases a reactive NST loses its usual reassuring value Grade C evidence. Where feasible, amniotic fluid volume estimation may be helpful for identifying severe oligohydramnios, but further research is needed to document subsequent intervention and perinatal mortality outcomes to determine the cost-benefit ratio of utilizing amniotic fluid assessment procedures.
Amniotic fluid assessment is complicated by high variability of sequential measurements and use of different measurement methods, which can compromise the accuracy of the test. No particular method of amniotic fluid volume assessment appears superior to another [ , ], though using maximum vertical pool depth rather than AFI appears to limit unnecessary inductions of labour and Caesarean section by reducing diagnoses of oligohydramnios.
There is a need for further research to test the impact of interventions to prevent or treat oligohydroamnios, particularly in the antepartum period with intact membranes, on perinatal outcomes. Women with high-risk pregnancies, especially multiple pregnancies and pregnancies complicated by hypertensive disorders, are frequently admitted to hospital for bed rest and monitoring.
However, in some instances, more limited monitoring in facilities and home-based bed rest or reduced physical activity may be as effective as hospital-based monitoring.
Home-based activity modification, accompanied by outpatient surveillance and hospital admissions only for complications, would offer cost savings over hospital admission, reduced burden on hospital resources and personnel, and reduced disruption to the life of the mother posed by lengthy hospital stays. Impact of home versus hospital-based bed rest and monitoring in high-risk pregnancy on stillbirth and perinatal mortality.
Both perinatal mortality and fetal deaths were lower among the self-monitoring group perinatal mortality: 6. The limited evidence available Grade D evidence suggests that home-based care for certain subsets of women with uncomplicated high-risk pregnancy has no apparent disadvantage compared with hospital-based bed rest and monitoring in terms of impact on stillbirths and perinatal mortality. The number of studies on this subject is small, however, and limited to the conditions of multiple gestation and hypertensive disorders of pregnancy, exclusively in high-resource settings.
As one RCT above indicated, bed rest in hospital for non-proteinuric hypertension may be superior to home-based care [ ], but insufficient evidence exists to recommend hospitalization in this case, as the study was underpowered. The Cochrane review found that in multiple pregnancy, bed rest in hospital appears to confer little advantage over no modification of physical activity; bed rest had no impact on rates of perinatal mortality, stillbirth, or pre-term birth, but may improve fetal growth [ ].
The potential cost savings and increased convenience to women of home-based bed rest and monitoring indicates that further large studies of the efficacy of bed rest as an intervention as well as monitoring at home versus in hospital are needed, particularly studies that include economic analyses of costs to mothers and hospitals. A fetal surveillance unit provides a wide range of maternal and fetal diagnostic tests, often on an outpatient basis, of particular benefit in identifying and monitoring high-risk pregnancies.
Antenatal fetal surveillance protocols, which may include multiple surveillance methods at a specified frequency, have the potential to impact perinatal mortality, neonatal morbidity, birth weight in cases of fetal growth problems, rates of prematurity, and length of hospital admission.
Assessment of fetal condition can usually be performed on an outpatient basis, with admission reserved for delivery, which is usually less disruptive to the pregnant woman's family [ ]. Specially designated antenatal surveillance units that offer predominantly outpatient services also offer operating cost savings compared with standard hospital admission.
Day care unit assessment for non-proteinuric hypertension reduced subsequent inpatient stay difference in mean stay: 4. The Cochrane protocol, for a review currently in progress, proposes to assess the impact of different specified regimens of fetal surveillance for impaired fetal growth on maternal and perinatal outcomes and length of hospital admission [ ].
The 2 intervention studies adopted different approaches. Soothill et al [ ] conducted a before-after intervention study comparing the number and length of antenatal admissions in the 5 months after the opening of a perinatal care unit providing largely outpatient-based services to records from the 6 months prior to the opening. Menzies et al. If patients could be consistently monitored on an outpatient basis, obstetricians would be more willing to admit patients only for delivery, and to perform more fetal assessments and maternal tests as outpatient services.
Outpatient fetal surveillance offers benefits in terms of cost and convenience, and could improve health facility organisation, and improved record-keeping would streamline obstetric and perinatal audit, data quality for research, and teaching opportunities [ ]. However, the evidence base for the benefits of outpatient surveillance of high-risk pregnancies is relatively limited, as the single Cochrane review on the subject included 1 small RCT that reported no perinatal deaths Grade C evidence.
The reduced rates of induction of labour are of interest and require further trials reporting labour induction rates with sufficient power to detect differences in subsequent perinatal outcomes. At this time, even in high-resource settings, in-hospital fetal surveillance units cannot be recommended as an intervention to prevent stillbirths.
A partograph, alternatively called a partogram, is a simple pre-printed paper form on which midwives and obstetricians record labour observations. The tool provides a continuous pictorial overview of the progress of labour, while monitoring maternal and fetal well-being. The partograph distinguishes between the latent and active phases of labour. The active labour section has 2 straight lines called the alert and action lines. Slower progress than this crosses the alert line on the partograph, which may prompt initiation of the process of transfer to a facility with emergency obstetric capacity in preparation for intervention for prolonged labour.
Depending on the partograph version, the 'action line' is 2 to 4 hours to the right of the alert line. Labour crossing this line suggests primary inefficient uterine activity and prompts immediate appropriate management of slow progress of labour, usually via amniotomy, oxytocin infusion, or both. Some evidence suggests that midwives and physicians find the partograph practical in terms of ease of use, time resourcefulness, continuity of care and educational assistance [ ], which may contribute to positive maternal and fetal outcomes.
Partographs are also inexpensive and relatively simple to use, making their use attractive in low-resource settings where other intrapartum monitoring technologies are unavailable or prohibitively expensive. In higher-resource settings, the partograph can be implemented alongside other fetal surveillance tests such as cardiotocography to provide more information for decision-making. However, some practitioners view the partograph as inappropriately restrictive and formulaic, prompting intervention prematurely [ ], factors which could impact both clinical and maternal psychological outcomes.
Various versions of the partograph are marked by different slope and position of the action line, which is likely to impact labour augmentation interventions, Caesarean section rates, and maternal satisfaction.
The Cochrane review [ ] compared the impact of use of the partograph in comparison with no partograph, as well as different versions of the partograph, for monitoring the progress of spontaneous labour at term Additional file None of the included studies reported intrapartum stillbirth rates, though several reported neonatal outcomes.
The Cochrane review [ ] also compared the impact of different versions of the partograph with different action line placement on labour outcomes. There was no difference in neonatal outcomes. The review also pooled the results from 3 RCTs to compare shorter 2-hour action line or alert line only versus longer time-to-intervention 4-hour action line or alert plus action lines and found no differences between the groups for Caesarean section rate, Apgar score or instrumental delivery, but early intervention in the low-resource setting reduced the Caesarean section rate.
The reported stillbirth rate was 0. A sub-study using the same WHO dataset of breech birth management using the partograph [ ] found a non-significant decrease in intrapartum stillbirth after the introduction of the partograph compared with before 1. In Indonesia, Fahdhy et al [ ] compared the use of midwives trained to employ the partograph versus standard midwifery care without the partograph.
Overall, there were no significant differences in maternal or perinatal outcomes with the use of partograph versus no partograph, and no evidence that any particular version of the partograph is better than another in preventing perinatal mortality. Partographs may be comparatively more effective in low-resource settings, as the studies from Africa and Mexico in the Lavender review [ ], as well as data from Southeast Asia [ ] that showed reduced Caesarean section rates with use of the partograph and early intervention for slow progress of labour.
The data from Southeast Asia and Indonesia also showed trends toward improved birth outcomes [ ]. Our overall assessment of the grade of evidence of studies of partograph is Grade C. Given the limitations of the studies included and the potential impact of organisational issues, e.
Methods to assess fetal heart rate and levels of oxygenation of fetal blood are monitoring strategies intended to identify early signs of fetal compromise as a result of oxygen shortage, or fetal hypoxia [ 2 ].
Severe and prolonged hypoxia is associated with stillbirth, early neonatal death, and long-term physical or mental disability, including cerebral palsy, if the baby survives. Fetal heart rate patterns are classified as either reassuring, nonreassuring or abnormal, considering heart rate baseline, variability, and decelerations. While nonreassuring tests may become reassuring with simple change in maternal position, abnormal fetal heart rate alterations or low blood oxygen levels are a frequent indication for Caesarean or instrumental delivery [ ].
In many hospitals in high-income countries including the US and Canada, cardiotocography is widely used to monitor fetal heart rate in labour, though intermittent auscultation periodic listening to the fetal heart rate using a stethoscope or handheld Doppler device is occasionally performed. In addition to external cardiotocography, which can be employed continuously or intermittently during labour, internal cardiotocography can be performed by attaching a sensor to the fetal presenting part, usually its head.
This can be done only if the membranes are ruptured, as electrode must be embedded in the baby's scalp. Intermittent auscultation via stethoscope or handheld Doppler is more common than electronic fetal monitoring methods in low-resource settings where fetal heart rate monitoring is available.
Currently, cardiotocography is recommended in high-risk pregnancy and labours induced or augmented with oxytocin [ ]. Because of the poor ability of cardiotocography alone to detect true fetal distress, the practice of pulse oximetry is thought to provide additional helpful information to corroborate cardiotocographic traces.
Pulse oximetry is intended as a follow-up procedure in the presence of a nonassuring cardiotocographic test, and is intended to improve the accuracy of the assessment of fetal well-being in the intrapartum period [ ]. While non-reassuring tests may become reassuring with simple change in maternal position, abnormal fetal heart rate alterations are a frequent indication for Caesarean or instrumental delivery [ ]. There is some danger that improper interpretation of cardiotocographic tracings can lead to inappropriate intervention, or false reassurance that delays necessary intervention.
There is a need for sensitive and specific methods of using cardiotocography, potentially in conjunction with pulse oximetry, to improve detection of fetal compromise due to hypoxia. Improved detection of hypoxia, primarily by expediting delivery, could improve outcomes and prevent stillbirth in these instances.
A new Cochrane review assessing cardiotocography versus intermittent auscultation of fetal heart for assessment of fetal well-being is in progress [ ]. Impact of intrapartum cardiotocography with or without pulse oximetry on stillbirth and perinatal outcomes.
A third Cochrane review [ ] assessed RCTs that comparied maternal and fetal outcomes after fetal pulse oximetry was used in labour with or without concurrent use of cardiotocography or auscultation , compared with cardiotocography alone Additional file Although there are several studies of fetal pulse oximetry and intrapartum cardiotocography, few reported stillbirth or perinatal mortality as outcomes. The available results show no statistically significant impact on stillbirths or perinatal mortality, whether cardiotocography is used alone or in conjunction with fetal pulse oximetry in labour.
Continuous cardiotocography appears associated with increased rates of operative delivery and lower rates of neonatal seizures compared to no or intermittent cardiotocography, but has no demonstrated impact on rates of perinatal mortality acidosis, dystocia, or long-term physical or developmental outcomes.
There is currently no evidence of benefit from randomised or quasi-randomised studies for intrapartum cardiotocography alone or in conjunction with electrocardiogram or fetal pulse oximetry in preventing stillbirth. One drawback of intrapartum cardiotocography is that its poor predictive value of true fetal distress and hypoxia is not sufficiently enhanced by any adjunctive technologies at this time. Pulse oximetry appears safe, though long-term developmental studies have not been performed, but it does not have any clear impact on stillbirths or perinatal mortality [ ].
Adjunctive electrocardiogram possibly reduces neonatal encephalopathy, academia, and instrumental delivery, but these findings need additional research to verify. Minimally invasive technologies and tests are needed in addition to intrapartum cardiotocography to more accurately identify intrapartum hypoxia and dystocia. There are robust studies and Cochrane reviews on fetal pulse oximetry and intrapartum cardiotocography Grade B evidence.
In high-income countries, documented stillbirth rates, particularly stillbirths associated with intrauterine asphyxia, in high-income countries have followed increasing prevalence of cardiotocographic fetal monitoring with Caesarean section for fetal distress [ - ], though this association may be confounded. Electronic fetal monitoring with access to operative delivery may an important tool in the arsenal of strategies to prevent stillbirth, though this is unproven.
More precise tests for fetal distress and indications for Caesarean section are needed. Although a reasonable number of Cochrane reviews and RCTs were available which assessed the impact of one or more implementation strategies for many screening and monitoring interventions, none of the interventions we reviewed demonstrated convincing evidence of impact on stillbirths or perinatal mortality.
Of the range of monitoring interventions evaluated, fetal movement counting and Doppler monitoring were promising for further evaluation in high-risk pregnancies in low-resource settings. Low amniotic fluid measurements were strongly predictive of stillbirth, but interventions to restore adequate amniotic fluid volume or to deliver the baby based on identification of oligohydramnios have not been systematically tested to conclude whether amniotic fluid assessment is a useful diagnostic tool that leads to actions which prevent stillbirth.
Collective grading of evidence for impact of monitoring interventions in pregnancy on stillbirth and related perinatal outcomes. Despite the existence of many tools, devices, and techniques for monitoring pregnancy for complications, there is a dearth of rigorous evidence that any screening and monitoring intervention has a direct impact on stillbirth rates in unselected and low-risk populations.
This stems from several common shortcomings in the design and interpretation of studies investigating the use of screening and monitoring techniques. First, the small size and insufficient rigor of many screening and monitoring studies to date renders them underpowered to detect significant differences in perinatal mortality subsequent to their implementation.
Many studies assessing the impact of the interventions covered in this review did not report stillbirths or perinatal mortality at all. For virtually all the interventions included in this review with the exception of x-ray pelvimetry , there is a need for RCTs sufficiently powered to detect statistically significant impact on stillbirth or perinatal mortality, if such differences exist. Second, for screening and monitoring interventions to reduce stillbirth incidence, they must effectively identify women at higher risk of stillbirth in time for an appropriate and effective intervention to be provided.
Most studies we reviewed limited their analysis to the first step of successful screening or monitoring: detection of women at increased risk of stillbirth or perinatal death.
A number of studies showed that positive test results corresponded fairly well with increased risk of adverse pregnancy outcome. However, a trial of an otherwise effective screening method will show no impact on stillbirths if the subsequent intervention fails to prevent stillbirth, either because intervention is ineffective or provided too late.
In most of the studies we reviewed, few women who screened positive were treated according to an established protocol. This flaw precludes assessment of whether the lack of impact of any given screening technique is attributable to a failed screening method or a failed intervention.
This fact highlights the need for time-to-decision and time-to-intervention studies, as well as analyses that consider which interventions are employed, and protocols for employing them, subsequent to adverse findings of screening and monitoring studies. The quality, appropriateness, and timeliness of the intervention care provided must also be considered along with the effectiveness of screening or monitoring in detecting true complications.
In high-income countries, there is a particular need for better understanding of placental pathophysiology, as up to half of unexplained stillbirths show signs of growth restriction, much of which is attributed to placental insufficiency [ ]. Placental dysfunction is often observed in other major known causes of stillbirth including pre-eclampsia and abruption, suggesting the need for accurate placental function or placental biomarker screening tests, especially those appropriate for use in unselected populations.
One such test in early pregnancy which measures pregnancy associated plasma protein-A has been associated with a 40—fold increase in risk of stillbirth due to placental dysfunction in a selected population, but it is unclear what interventions could prevent stillbirth among women with such positive test results [ ].
Screening and monitoring are often technology-dependent, as illustrated by the cardiotocographic machine required for the BPP, CST, and NST; and the use of video ultrasound machines for amniotic fluid assessment. This makes some of these interventions impractical or unaffordable in low-resource or remote settings at the present time. However, certain technologies, such as handheld Doppler ultrasound and video ultrasound scanning machines, are increasingly available in low-resource settings; there is a need for studies to define the most cost-effective ways of using these and other available technologies to identify high-risk pregnancies.
Additionally, other techniques, such as fetal movement monitoring and the partograph, require little investment other than training of midwives or mothers, and may be appropriate for use in high-risk pregnancies, if these pregnancies can be identified and if the use of these techniques result in improved outcomes, which has not yet been conclusively demonstrated.
Additionally, there is some potentially promising evidence that fetal surveillance typically provided on an inpatient basis, often with bed rest, for high-risk pregnancies can be offered on an outpatient basis with bed rest or reduced activity at home without deleterious impact on pregnancy outcomes; this evidence requires confirmatory effectiveness trials in low-resource settings before programmatic adoption of this approach could be recommended. Practicality, logistical feasibility, and cost-effectiveness are chief concerns in many low-resource areas.
Where ANC services are available and widely utilised, the prospects for identifying and monitoring high-risk pregnancy improve. Unfortunately, in areas where ANC attendance is poor, few of these screening and monitoring techniques are likely to be implementable.
A few monitoring approaches showed promise for use in high-risk pregnancies, including fetal movement monitoring and umbilical Doppler velocimetry. Before recommending these interventions for widespread use, further large RCTs of sufficient rigour to detect differences in stillbirth and perinatal outcomes are needed to determine the utility and effectiveness of these monitoring approaches and interventions used after positive tests.
This review identified several interventions — for example, amniotic fluid measurement for signs of oligohydramnios, especially as pregnancy approaches or exceeds term; routine ultrasound scanning, and intrapartum cardiotocography — that are in widespread use in high-resource settings, but for which rigorous evidence is lacking.
For these interventions, their continued use is reasonable even though the evidence base for impact on stillbirths is lacking. Intrapartum cardiotocography in particular has been shown in RCTs to elevate the risk of operative delivery.
Prevailing wisdom credits cardiotocography and available Caesarean section with the diminution of stillbirth rates in high-income countries in recent decades; however, the role of cardiotocography in reducing stillbirth should be confirmed with more rigorous evidence.
Efforts to achieve glycaemic control in cases of maternal diabetes mellitus are also encouraged, despite the lack of strong evidence showing an impact of such interventions on stillbirth, on the grounds that women with good glycaemic control experience fewer complications and negative outcomes of pregnancy. Particularly in pregnancies deemed high-risk based on screening test results, clinical progression of pregnancy, or reproductive history, multiple antepartum testing modalities can minimise deficiencies in sensitivity and predictive value when used in combination to assess fetal well-being and abnormalities.
The BPP reflects one standardised strategy by which tests of fetal well-being have been packaged to permit a more comprehensive assessment of fetal well-being. In cases where one test raises the possibility that a pregnancy is high-risk, multiple tests of fetal well-being should be considered if time allows, along with the patient's overall clinical history, to determine the appropriateness of intervention. Multiple tests are recommended in many protocols for identifying and making clinical decisions about management of pregnancies with suspected fetal growth restriction [ ].
In these cases the collective results of a battery of tests including all the components of the BPP and Doppler velocimetry, as well as ultrasound biometry, can be informative in decision-making to maximise gestational age and inform the strategic timing of corticosteroid administration and early delivery via induction or Caesarean section.
However, conflicting test results — a recent study showed only Resource constraints preclude the implementation of many of the interventions reviewed in this paper. The interventions requiring the lowest investment in resources and training — fetal movement monitoring and the partograph — show some evidence of benefit in high-risk pregnancies, but more studies are needed.
Where safe Caesarean section is available, ensuring that intermittent or continuous intrapartum fetal heart rate monitoring is performed may improve targeting of Caesarean section while improving birth outcomes. Screening and monitoring interventions cannot be effective without responsive, quality care and careful clinical management, particularly for high-risk pregnancies. Health systems quality improvement activities, including boosting provider skill in interpreting test results and determining appropriate intervention, timely response including swift referral, and evaluative strategies to document outcomes after intervention are essential complementary activities to ensure that an effective screening or monitoring technique translates to measurable improvements in perinatal mortality outcomes.
Screening pregnancies to identify risk factors, complications, or indications of fetal distress and providing appropriate surveillance for identified risk factors theoretically encourages appropriate use of interventions, including induction of labour, Caesarean section, and pharmacological treatment, to prevent fetal loss and adverse maternal or neonatal outcomes.
Screening and monitoring are futile, however, in the absence of effective interventions to act promptly and appropriately to manage identified risk factors and complications. The weak evidence in this review for impact of screening and monitoring interventions on stillbirth incidence is due at least in part to limitations in study designs that result in uninterpretable data.
Screening tests may be ineffective, inappropriate, or occur too late to prevent adverse outcomes, but more problematically, most studies did not report the impact of intervention particularly standardised intervention following positive screening test results.
Effective interventions exist to prevent stillbirth associated with many maternal infections or conditions e. Because screening and monitoring techniques during pregnancy also pose the risk of inappropriate or unnecessary use of drugs, induction of labour, iatrogenic preterm birth, or Caesarean section, it is practically, ethically, and economically important to validate the sensitivity, specificity, and positive predictive value of available screening and monitoring techniques to protect women and their babies from iatrogenic harm; and to ensure the wise use of scarce medical resources in low- and middle-income settings.
Web Table 1. Component studies in Mangesi et al. Web Table 2. Component studies in Neilson meta-analysis: Impact of routine ultrasound in pregnancy.
Web Table 3. Component studies in Bricker et al. Web Table 4. Component studies in Papageorghiou et al. Web Table 5. Component studies in Baschat impact of Doppler velocimetry on stillbirth and perinatal mortality in pre-term growth-restricted fetuses. Web Table 6. Component studies in Neilson et al. Web Table 7. Component studies in Pattinson et al.
Web Table 8. Component studies in Russell et al. Web Table 9. Component studies in Mukhopadhyay et al. Web Table Component studies in Boulvain et al. Component studies in Pattison and McCowan meta-analysis: Impact of cardiotocography for antepartum fetal assessment on perinatal mortality. Component studies in Lalor et al. Component studies in Tan et al. Component studies in Magann et al review: impact of idiopathic polyhydramnios on stillbirth and perinatal mortality.
Component studies in Magann et al. Component studies in Nabhan and Abdelmoula [ ] meta-analysis: comparison of single deepest vertical pocket vs. AFI in predicting perinatal outcome. Component studies in Hofmeyr and Gulmezoglu [ ] meta-analysis: impact of maternal hydration on amniotic fluid volume and perinatal outcomes. Component studies in Crowther meta-analysis: Impact of hospitalisation for bed rest for women with a multiple pregnancy on stillbirth and perinatal mortality.
Component studies in Meher et al. Component studies in Kroner et al. Component studies in Lavender et al. Component studies in Alfirevic and Devane meta-analysis: Impact of continuous cardiotocography on stillbirth and perinatal mortality. Component studies in Neilson meta-analysis: Impact of fetal electrocardiogram ECG on perinatal mortality. Component studies in East et al.
This article has been published as part of BMC Pregnancy and Childbirth Volume 9 Supplement 1, Stillbirths — the global picture and evidence-based solutions. National Center for Biotechnology Information , U. BMC Pregnancy Childbirth.
Published online May 7. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Rachel A Haws: ude. Supplement Stillbirths — the global picture and evidence-based solutions. Guest review editor: Robert L Goldenberg. This article has been cited by other articles in PMC.
Additional file 2 Web Table 2. Additional file 3 Web Table 3. Additional file 4 Web Table 4. Additional file 5 Web Table 5. Additional file 6 Web Table 6. Additional file 7 Web Table 7. Additional file 8 Web Table 8.
Additional file 9 Web Table 9. Additional file 10 Web Table Additional file 11 Web Table Additional file 12 Web Table Additional file 13 Web Table Additional file 14 Web Table Additional file 15 Web Table Additional file 16 Web Table Additional file 17 Web Table Additional file 18 Web Table Additional file 19 Component studies in Kroner et al.
Additional file 20 Web Table Additional file 21 Web Table Additional file 22 Web Table Additional file 23 Web Table Abstract Background Screening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies.
Methods The fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour.
Results We found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Conclusion There are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered.
Introduction Although most pregnancies progress normally, some are more complex because of antenatal or intrapartum conditions that place the mother, the developing fetus, or both at a higher risk for complications than pregnancies without these conditions. Methods This is the fourth in a series of papers on the evidence for interventions that impact stillbirths.
Table 1 Screening and monitoring interventions reviewed in this paper. Identification and care of high-risk pregnancies Pregnancy risk screening Fetal movement counting Routine ultrasound scanning Doppler velocimetry Pelvimetry Detection and management of maternal diabetes mellitus Advanced monitoring in pregnancy Antenatal fetal heart rate monitoring using cardiotocography Fetal biophysical profile test scoring Vibroacoustic stimulation Amniotic fluid volume assessment Home versus hospital-based bed rest and monitoring in high-risk pregnancy In-hospital fetal surveillance unit Monitoring during the intrapartum period Use of the partograph Cardiotocography with or without pulse oximetry.
Open in a separate window. Results Identification and care of high-risk pregnancies Pregnancy risk screening Background Early identification of high-risk pregnancies can theoretically facilitate monitoring, referral and prompt initiation of therapy.
Table 2 Impact of pregnancy risk screening on stillbirth and perinatal mortality. Health centre setting. Prospective cohort study. Assessed the association of perinatal mortality with risk factors recorded on a home-based mother's card to pregnant women on which risk factors and ANC attendance were documented. Weighted risk factor method clearly superior to unweighted risk factor method in primiparae. No difference in multiparae. Cho et al. Chung Ang Medical Center. Cross-sectional study to test scoring system.
Assessed the utility of Edwards' scoring system adapted to a Korean setting in identifying high-risk pregnancy. Risk scoring included demographic, obstetric, medical, and miscellaneous factors. Lefevre et al. Rural primary care setting. Prospective study. There was a clear relationship between risk score and probability of adverse outcome.
Good sensitivity could be achieved only at the expense of a very high false-positive rate, however. Risk scoring no more effective than a policy that would refer all women with standard obstetric risk factors; majority of adverse outcomes occurred in women identified as low-risk. Majoko et al. Rural setting. Evaluation of screening test; sub-study of ANC trial.
Used traditional risk scoring at ANC booking to group women into low- and high-risk groups. High-risk women were encouraged to deliver in facilities. Complications: Mikulandra [ ] Croatia. Assessed the associations of a risk factor scale low, moderate, and high risk for pregnancy and delivery on perinatal outcomes. High pregnancy risk: High intrapartum risk: SBR: 0. Retrospective analysis. Morrison [ 11 ] USA. Women scored during pregnancy using a simplified, numerical form for antepartum risk scoring.
Tested the predictive value of a simplified risk scoring system in anticipating the risk of perinatal mortality. Talsania et al. Women scored as no, mild, moderate, or severe risk based on sociodemographic and obstetric data. Assessed association of risk factors and risk scoring with perinatal mortality. PMR: Statistically significant. PM sensitivity, specificity, PPV were Assessed the association of risk factors with perinatal mortality. Conclusion A number of studies reviewed were able to successfully identify women at high risk of obstetric complications.
Fetal movement counting Background Monitoring fetal movements using counting strategies is an indirect measure of central nervous system integrity and fetal responsiveness. Table 3 Impact of fetal movement counting on stillbirth and perinatal mortality.
Meta-analysis Cochrane. Routine fetal movement counting intervention versus mixed or undefined fetal movement counting controls. Intervention studies Gomez et al. Hospital setting. Grant et al. Cluster RCT. Compared the impact on birth outcomes of asking mothers to keep routine kick charts intervention vs. Moore [ 27 ] USA. Assessed the impact of introducing formal fetal movement assessment intervention compared to no monitoring before the intervention controls.
Compared the obstetrical outcome among the patients with a normal kick chart unexposed , compared to those with an abnormal count exposed. SBR: Urban hospital setting. Compared birth outcomes among women with good fetal movements vs. No statistical significance data. Sinha et al. Retrospective cohort study. Compared the impact of reduced fetal movements exposed to women without reduced fetal movements unexposed on PMR.
PMR: RR not estimable. Compared the impact of decreased fetal movement exposed vs. Routine use of ultrasound scanning Background Ultrasound scans during pregnancy are widely used, even in many resource-poor settings, but availability and quality of ultrasound machines vary, and ultrasound operators in some settings may lack the ability to accurately interpret imaging. Table 4 Impact of use of routine ultrasound scanning on stillbirth and perinatal mortality. Assessed the effects of routine ultrasound intervention vs.
Open cluster RCT. Compared the impact of ultrasound screening intervention vs. Observational studies Cristina et al. Retrospective case-control review of all obstetric ultrasounds. Compared the impact of having a single umbilical artery cases vs. Mahran et al. Tertiary care setting. Comparison of diagnostic tests. Compared the effectiveness of diagnostic ultrasound intervention vs.
Growth restriction: Sylvan et al. University clinics. Observational cohort study. Compared the impact of routine ultrasound screening exposed group vs.
Observational study. To assess the ability of grayscale placental ultrasound to detect pathological lesions in the placentas of pre-term pregnancies. Figure 1. Conclusion There is no clear evidence that ultrasound examination during pregnancy is harmful [ 31 ], and its assumed benefits include 1 better gestational age assessment; 2 earlier detection of multiple pregnancies; 3 determination of placental location to rule out placenta praevia; 4 detection of clinically unsuspected fetal malformation when termination of pregnancy is more feasible, and 5 monitoring of fetal growth for pregnancies at increased risk of fetal growth restriction or macrosomia.
Doppler velocimetry Background In many high-income countries, Doppler ultrasound studies are used as a non-invasive means to assess the sufficiency of uterine and umbilical cord blood flow. Table 5 Impact of uterine artery Doppler velocimetry on stillbirth and perinatal mortality. Sought to relate the risk of antepartum stillbirth to uterine artery Doppler flow velocimetry at 22—24 weeks. Fetal growth restriction and perinatal death associated with impeded uterine artery flow.
Multicentre RCT. Compared the impact of uterine Doppler intervention versus placebo controls on PMR. Women with abnormal Doppler waveforms received mg of aspirin daily from Doppler exam until 36 wks. Observational studies Smith et al. Studied the relationship between abnormal mean pulsatility index in the top decile and a bilateral notch vs.
Antepartum SBR: adj. Unexplained SBR: adj. No association between Doppler with a bilateral notch and SB. Table 6 Impact of umbilical artery and ductus venosus Doppler velocimetry on stillbirth and perinatal mortality. Assessed association of umbilical artery Doppler and ductus venosus Doppler with perinatal outcome in preterm growth-restricted fetuses. Assessed the effects of Doppler umbilical artery waveform analysis intervention vs.
Intervention studies Baschat et al. Prospective cohort. Used logistic regression to assess the predictive ability of Doppler diagnosis of absent or reversed umbilical artery end-diastolic velocity, absence or reversal of atrial systolic blood flow velocity in the ductus venosus and pulsatile flow in the umbilical vein to predict stillbirth and perinatal mortality.
In cases of abnormal or reversed end-diastolic umbilical artery flow, venous pulsatility improved prediction of stillbirth. Tertiary level referral hospitals. Multi-centre RCT. Compared the impact of Doppler ultrasound umbilical artery flow velocity waveform analysis intervention vs. Standard ultrasound biometric assessment in both arms. Compared the impact of umbilical Doppler 28—34 wks gestation intervention vs.
Davies et al. Single centre; unselected population. Compared the impact of routine umbilical and uterine artery Doppler ultrasound to assess placental perfusion intervention vs.
Standard ANC in both arms. Whittle et al. Doppler ultrasound at 26—30 wks and 34—36 wks gestation in all women. Compared the impact of umbilical artery Doppler ultrasound revealed to clinician intervention vs.
Secondary hospital. Case series. Investigated the use of a personal computer- based, continuous-wave Doppler machine by a trained midwife to assess umbilical artery flow velocity waveforms with respect to the resistance indices RIs.
Compared the impact of poor Doppler flow velocimetry of umbilical artery exposed with normal flow unexposed. Torres et al. Hospital Clinic. Prospective observational study over a 2-year period.
Assessed the use of umbilical artery Doppler in predicting SB. Compared the impact of absent exposed vs. Uterine artery Doppler waveform analysis Several studies assessed whether uterine artery Doppler velocimetry in unselected populations could identify high-risk pregnancies, particularly those at risk of stillbirth.
Conclusion Doppler ultrasound is a relatively new technique that has been applied to the study of fetal, placental and uterine circulatory dynamics. Pelvimetry Background Pelvimetry, or pelvic measurement in pregnant women with the intention of predicting likely cephalopelvic disproproportion of cephalic presentations and thus their subsequent need for Caesarean section , can be performed by clinical manual examination, or with imaging techniques including conventional x-ray, computerised tomography scanning, or magnetic resonance imaging.
Table 7 Impact of pelvimetry on stillbirth and perinatal outcomes. Assessed the effects of pelvimetry performed antenatally, intrapartum or postpartum intervention vs. Observational studies Fine et al. Compared the Thoms method of interpretation to the modified Ball technique for x-ray pelvimetry comparing both to manual assessment of the pelvis as prognostic indicators for safe vaginal delivery.
Uneventful nonoperative vaginal deliveries: Prediction of obstetric outcome: Neither technique significantly more accurate than manual assessment, or than the other. Conclusion There is little support for the use of pelvimetry to predict the need for Caesarean section in women with fetuses with cephalic presentations, as the dynamic and individual nature of maternal tissue changes during labour and fetal head moulding in the birth canal make antenatal pelvimetry a poor predictor of cephalopelvic disproportion.
Detection and management of maternal diabetes mellitus Background In pregnant women, pre-existing diabetes mellitus can cause severe complications for both mother and child during pregnancy and delivery, including congenital malformations, hypertension, pre-eclampsia, macrosomia and intrauterine fetal death [ 60 - 63 ].
Table 8 Impact of detection and management of maternal diabetes mellitus on stillbirth and perinatal mortality.
Assessed the impact of treatment of gestational diabetes on perinatal outcomes. US, UK. Review Cochrane. PMR: Insufficient data to assess.
Assessed the effects of a policy of elective delivery intervention vs. Review non-Cochrane. Intervention studies Hod et al. Open-label RCT. Assessed the impact of mealtime insulin Aspart IAsp intervention with human insulin HI controls , both in combination with basal neutral protamine Hagedorn NPH insulin. SBR: one in each group. PMR: 14 vs. For women under 20, the rate is 6. Black and Asian women are up to twice as likely to have a stillborn baby when compared with white women, the report said.
Known causes of stillbirth include congenital malformations, where a baby's brain, heart or other organ have failed to develop properly; maternal haemorrhage; or asphyxiation during childbirth.
Unplanned home births also carry a risk, the report said. The researchers say that the quality of research into the causes of stillbirth has been affected by a fall in the number of post mortem examinations.
The report also called for better targeting of women at risk of their baby dying, including those who are socially deprived and from ethnic backgrounds. The report said: "Given the steadily increasing average maternal age in the UK, maintaining perinatal mortality at current rates may be a challenge in the years ahead.
Low graphics Accessibility help. News services Your news when you want it. News Front Page. E-mail this to a friend Printable version. A third of stillbirths occur at the end of pregnancy. We need to know more about why stillbirths happen. Royal College of Obstetrics and Gynaecology. The BBC is not responsible for the content of external internet sites.
Conceiving within a year of stillbirth does not increase risks for next pregnancy -- ScienceDaily
Please sign in or sign up for a March of Dimes account to proceed. Some women are more likely than others to have a stillbirth.
Reducing your risk factors for stillbirth may help you have a healthy baby. Common causes include infections, birth defects and pregnancy complications, like preeclampsia. Most women who have a stillbirth and get pregnant again have a healthy pregnancy and a healthy baby.
Stillbirth is when a baby dies in the womb after 20 weeks of pregnancy. Most stillbirths happen before a woman goes into labor, but a small number happen during labor and birth. Stillbirth affects about 1 in pregnancies each year in the United States; this is about 1 percent of all pregnancies and about 24, babies.
Stillbirth can happen in any family. Researchers are working to learn more about risk factors for stillbirth. Risk factors are things that make you at risk for more likely than others to have a condition. But knowing about and reducing your risk factors may help prevent stillbirth from happening to your baby. Other risk factors are things you can do something about, like quitting smoking. Talk to your health care provider about what you can do to help reduce your risk factors for stillbirth.
Other possible risk factor: A recent study says that being exposed to certain kinds of air pollution mainly ozone may increase your risk for stillbirth. Ozone is a gas that comes from car exhaust, gasoline and fumes from factories and chemicals. To find out about ozone in your area, visit airnow.
We need more research to find out how ozone and other air pollution affects pregnancy and stillbirth. The most common symptom of stillbirth is when you stop feeling your baby moving and kicking.
Others include cramps, pain or bleeding from the vagina. Call your health care provider right away or go to the emergency room if you have any of these conditions. An ultrasound uses sound waves and a computer screen to show a picture of your baby in the womb. If your baby is stillborn, your provider talks with you about options for giving birth.
When and how you give birth depends on how far along you are in your pregnancy, your medical condition and what you think is best for you and your family. Labor usually starts within 2 weeks after a baby dies in the womb.
Your provider checks your baby, the placenta and the umbilical cord to try to find out why your baby died. The placenta grows in your uterus and supplies the baby with food and oxygen through the umbilical cord. Your provider may ask to do certain tests to try find out what caused the stillbirth. Tests may include:. In addition to checking your baby for medical and genetic conditions, your provider reviews your family health history and any problems or illnesses you had during pregnancy.
Your family health history is a record of any health conditions you, your partner and members of both your families have had. Your provider may want to test you for infections, genetic conditions and other medical conditions, like lupus or thyroid problems. If you have questions about the tests, including their cost, talk to your health care provider. For most women, the chances of having another stillbirth are very low.
If you had a stillbirth and are thinking about having another baby, give yourself time to heal physically and emotionally.
Your provider may recommend that you have medical tests to try to find out more about what caused your stillbirth. If you had a stillbirth that was caused by a genetic condition, a genetic counselor can help you understand the condition and the chances of you having another stillbirth. Your health care provider can help you find a genetic counselor.
If you get pregnant again, your provider monitors you and your baby closely. At around 32 weeks of pregnancy, she may ask you to do kick counts to help you keep track of how often your baby moves. Infections in the mother or baby. Some infections may not cause signs or symptoms and may not be diagnosed until they cause serious complications, like premature birth or stillbirth.
Infections that can cause stillbirth include:. Problems with the placenta or umbilical cord. Placental problems include infections, blood clots, inflammation redness, pain and swelling , problems with blood vessels and other conditions, like placental abruption. Placental abruption is a serious condition in which the placenta separates from the wall of the uterus before birth.
Placental problems cause about 24 in stillbirths 24 percent. Problems with the umbilical cord may lead to about 10 in stillbirths 10 percent. Grief is all the feelings you have when someone close to you dies. Having a stillborn baby is a painful loss for a family. But there are things you can do to help you grieve, heal and remember your baby. After birth, do what feels right for you and your family. You may want to spend time alone with your baby and other family members.
You can name your baby, hold your baby, bathe and clothe her and take part in cultural or religious traditions, like baptism. Some families take pictures of their baby, make footprints or save locks of hair. You may be able to keep things from the hospital, like blankets, that were used with your baby. Keepsakes like these can help you and your family remember your baby. Parents who have a stillbirth need time to grieve.
You and your partner may cope with grief in different ways, and you may need help dealing with others as you grieve. You may need help learning how to deal with these situations and the feelings they create.
Or your hospital may have a loss and grief program for families. Getting counseling can be really helpful to you and your family. Talking about your feelings with other parents who have had a stillbirth may help you deal with your grief.
Visit shareyourstory. Sharing your story may ease your pain and help you heal. Having a stillbirth may make you at risk for postpartum depression also called PPD.
PPD is a kind of depression that some women get after having a baby. Tell your provider if you have signs or symptoms of PPD, like feeling depressed most of the day every day, having little interest in things you normally like to do, or having trouble eating or sleeping.
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In This Topic View More. What is stillbirth? What are the risk factors for stillbirth? BMI is a measure of body fat based on your height and weight. To find out your BMI, go to www. Diabetes is a condition in which your body has too much sugar called glucose in the blood.
High blood pressure.