Remote Primary Health Care Manuals

Stillbirth

Stillbirth — any baby 20 or more weeks gestation or weighs 400g or more who doesn't show any sign of life at birth such as breathing, heartbeat or movement

Miscarriage — pregnancy loss at less than 20 weeks gestation or weight less than 400g

  • Stillbirth is a distressing and traumatic event for woman, family and health care providers
  • Grief is an individual emotion and different cultures and language groups react in different ways
    • Women and family members may understand and react to stillbirth in different ways — some younger women may have different cultural values to older family members
    • Listen carefully, be guided by ATSIHPs, woman’s relatives, woman herself

Considerations for health staff, woman and family

  • Be guided by ATSIHPs and family members for language to use
    • 'Passed away', 'lost', 'gone', 'finished' may be better understood and less offensive than 'died'
  • Always treat the mother, her family and the baby with compassion and respect
  • Allow family to spend the time they need with the baby
    • Woman and family members may or may not want to see baby — always ask
    • If family want to see or hold baby — wrap in clean baby rug with face uncovered
  • Family may name baby — check if you should refer to baby by name
    • Tell the woman and her family that every baby born beyond 20 weeks gestation must be registered as a birth and a death and must have a name
    • The birth registration form must be completed
  • Consider continuation of clinical services and how this will be managed
    • It is appropriate for all mothers and babies to be transferred to a maternity unit for continuing care
  • Burial or cremation must be arranged through a funeral director
    • Can have important cultural and spiritual significance
    • Relatives may want formal burial even if baby 'passed away' early in pregnancy
    • Woman may want baby buried in home community
  • Family may believe death was caused by unacceptable behaviour of another person or a series of events — may direct anger or frustration at clinic staff
  • Refer to midwife for continuing advice

Do

Medical consult about

  • Stillbirth — for help following this protocol
  • Medical complications that may need to be managed in hospital
  • Antibiotics if signs of infection
  • Other concerns

Care for mother

  • Look after the woman as the priority — see Care of mother — first 24 hours after the birth
  • Tell woman about the importance of ongoing support and care in hospital — explain that careful management and follow-up is needed to help prevent problems in future pregnancies
    • Autopsy (operation to find cause of death) recommended for same reasons

If mother agrees to go to hospital 

  • Medical consult to send to hospital straight away
  • Talk to senior midwife at receiving maternity unit
  • Talk with retrieval team about options for transporting baby with mother
    • Baby must be identified with name band on each leg
    • Send placenta — very important for autopsy process

If mother refuses hospital transfer

  • Medical/obstetrician consult and talk to local maternity service about continuing plan of care for mother and baby — see Postnatal care of mother
  • Talk later about suppressing lactation (breastfeeding) — milk is usually produced within a few days of birth even if baby stillborn
    • Can use simple measures or take medicine to stop milk production. If mother requests medication — medical consult

Management of deceased baby

  • Baby may be bathed if requested
  • Always wrap the baby and consider dressing the baby
  • Ask if family would like to take mementoes, eg photos, foot/hand prints, lock of hair
  • When not with the family the baby should be placed in the mortuary — or kept cooled
  • If woman doesn't go to hospital — talk with her about autopsy for baby
    • Autopsy strongly recommended —  explain it may help find out why this baby died and help with future pregnancies

If mother consents to autopsy for baby

  • Consult with local maternity service about forms, process and signing of consent
  • Best if mother signs consent form
    • Complete consent form with as much information as possible —will help the pathologist. If situation complicated (eg by family disagreement) — medical consult
  • Write letter/generate health summary which includes
    • Details of any previous pregnancies
    • Details about this pregnancy
    • Details about labour and birth, including birth weight and time of birth
    • Antibiotics or other medicines taken in pregnancy
    • Substance use — smoking, alcohol, petrol sniffing
  • Ask for medical report and autopsy report to be sent to clinic

Transporting autopsy specimens

  • Baby — put name bands on both legs, wrap baby in bluey then put in plastic bag
  • Placenta — put in separate sealed plastic bag
  • Do not use formalin or saline
  • Transport in esky with 4 large ice bricks
    • Seal with sticky tape right around edge of lid
    • If being transported on aircraft (RFDS or other) — put sealed esky inside additional plastic bag and seal bag completely so no leakage
  • Include baby’s cord blood, consent form for autopsy, letter and pathology form
  • Make sure all checks and documentation complete
  • Liaise with the receiving service prior to transfer

If mother doesn't consent to autopsy for baby

  • Check placenta — completeness, texture, cord vessels, knot in cord
    • Photograph any abnormalities in the placenta and include in medical record
  • Take cord blood — may be difficult
    • Collect blood from cord before it is clamped
    • OR perform venipuncture on 1 vessel of cord
  • Carry out basic examination of baby — document findings clearly
    • Check for any obvious abnormalities
    • Record appearance and take photos if parents consent — may help paediatrician diagnose congenital anomalies
    • Document weight, length and head circumference
    • Calculate gestational age based on weight/length and growth chart

Documentation

  • Labour/birth details
  • Birth registration form
  • Medical certificate of cause of perinatal death completed by doctor
  • Perinatal statistics form — send to perinatal statistics unit
  • If woman entitled to stillborn baby payments — contact Centrelink
    • Remind woman to attend Centrelink and have 100 points of identification ready

Follow-up

  • Arrange obstetrician review
  • Give woman the opportunity to talk about what happened and offer referral to perinatal mental health service
  • Talk with woman about available support and counselling services
    • Stillbirth and Neonatal Death Support (SANDS)
    • Pregnancy, Birth and Baby
    • If more support needed — refer woman to social worker
  • Stillbirth or neonatal death can be distressing and traumatic for staff involved and feelings can persist
    • It is important to debrief after these events and support each other in this process
    • CRANAplus Bush Support Service  — 1800 805 391