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Stillbirth: Maternal care

Stillbirth: Maternal care
Amos Grunebaum, MD, FACOG
Frank A Chervenak, MD
Section Editor:
Charles J Lockwood, MD, MHCM
Deputy Editor:
Vanessa A Barss, MD, FACOG
Literature review current through: Dec 2022. | This topic last updated: Aug 10, 2021.

INTRODUCTION — Stillbirth refers to an antepartum or intrapartum fetal death occurring after 20 weeks of gestation. It is one of the most stressful life events.

This topic will discuss maternal care upon diagnosis of stillbirth, including parental support and counseling, birth, and postpartum management. Other issues related to stillbirth are reviewed separately:

(See "Stillbirth: Incidence, risk factors, etiology, and prevention".)

(See "Stillbirth: Maternal and fetal evaluation".)


Parents are unprepared and in distress – Almost one-half of late fetal deaths occur in apparently uncomplicated pregnancies. Most occur before labor begins, but a minority occur intrapartum. Regardless of the timing, most parents are unprepared when told that the fetus has died. The family's anticipation of a joyous birth is supplanted by sadness, despair, confusion, and loss, including loss of a desired child, loss of self-esteem as a parent, and loss of confidence in the ability to produce a healthy child [1]. Psychological sequelae include depression, posttraumatic stress disorder, and anxiety, which may adversely affect their relationship and a subsequent pregnancy [2].

Parental needs – Parents of stillborns describe several components of what they want from their caregivers [3-5]:

Good communication (clear, respectful, and kind with adequate time with providers who listen and take concerns seriously)

Recognition of parenthood (eg, using the baby's name, creating memories [eg, footprint and handprints])

Support in meeting with and separating from the baby

Support in their personal chaotic state

Support in bereavement

Explanation of the cause of stillbirth

Organized care among providers

Shared decision-making

Understanding the nature of grief

Clinicians should be aware of these issues when they approach parents during the stressful situation of a stillbirth, and they should be able to provide patient-centered, compassionate, psychosocial care (table 1) [6-9]. Supporting parents and creating a trusting relationship can affect how they respond to bereavement [10-13]. However, the best approach is unclear, as the effectiveness of various forms of intervention has not been evaluated rigorously, particularly in comparative trials [14].

Counseling across the process – Stillbirth counseling has several chronologically distinct stages, which are discussed in detail in the text below.

At the time of diagnosis

When making plans for delivery

At birth and immediately postpartum

During the weeks after discharge and at the first postpartum visit

At a "wrap-up" meeting when all laboratory and pathology results are available

When the patient is considering another pregnancy

During the first and subsequent prenatal visits during subsequent pregnancies


Antepartum — An antepartum fetal death is usually defined as fetal death occurring before the onset of labor. The diagnosis is often initially based on the absence of a fetal heart beat by auscultation, often followed by an ultrasound examination that documents absence of fetal cardiac activity. Where ultrasound is readily available, most physicians will not make a definitive diagnosis of fetal death until ultrasound has confirmed the absence of fetal heart movements.

Once fetal death has been confirmed by ultrasound (ie, the fetal heart is visualized without any activity), the parent(s) should be informed in person, expeditiously, in an empathetic and straightforward manner, in surroundings where they can react privately. Staying with the patient after delivering the diagnosis, possibly holding their hand, and spending as much time with them as they need, is important. (See "Discussing serious news" and 'Emotional support' below.)

The moment of diagnosis is often a very painful event for the prospective parent(s), as well as for the person conveying the information. Beginning at the time of diagnosis, parents who lose a baby may experience the same five stages of grief (denial, anger, bargaining, depression, acceptance) experienced by individuals when told that they have a terminal illness. (See "Bereavement and grief in adults: Clinical features", section on 'Presentation'.)

Parent(s) usually ask the following: why did the death happen?, what do we do now?, and will it happen again? Unless the cause of fetal death is known, the answers to "why" and "will it happen again" cannot be given. The parent(s) should be told that the provider will attempt to answer these questions when the necessary examinations have been completed and when all relevant information has been reviewed, but this will take time, possibly weeks or even months, depending upon the specific examinations performed.

Communicating bad news is a skill that can be learned and for which training must be provided, because it is not a natural ability and does not necessarily improve with experience [15]. Important aspects of giving bad news to parents include [15,16]:

Be well-informed about the information that is to be communicated.

Set up an interview with them and any others that they choose to include.

Attempt to communicate the information as a team.

Have the discussion in an appropriate comfortable, quiet, and private environment.

Assess their perception of the situation, understand the amount of information that they want to receive, and give the information gradually, in understandable and patient-sensitive terms so they can absorb it.

Address their emotions with empathetic verbal and nonverbal support.

Summarize the information.

Develop a plan for follow-up.

Intrapartum — An intrapartum stillbirth can be defined as a fetal death after the onset of labor, usually after admission to the labor and delivery unit and prior to birth, but definitions vary. The etiology of intrapartum stillbirths is often different from those that occur antepartum and often requires a different approach for counseling the parent(s) and evaluating its cause.

Globally, fetal asphyxia is likely the most common reason for stillbirth. In high-income countries, placental abnormalities are the most common associations, while in low- and middle-income countries, conditions such as prolonged or obstructed labor, placental abruption, preeclampsia/eclampsia, fetal growth restriction, fetal distress, breech and other abnormal presentations, and multiple births are associated with stillbirth [17].

Because intrapartum events are the cause of a large percentage of intrapartum stillbirths, likely more so when there was no electronic fetal heart rate monitoring, the parent(s) may have different questions than if the stillbirth happened prior to labor. In addition, there may be medicolegal questions related to the cause of the intrapartum stillbirth and concerns about liability and prevention in future pregnancies.


Treat acute medical and obstetric disorders – Late fetal death may occur in the setting of a maternal medical illness or obstetric complications, which should be managed, as appropriate.

Begin to work-up for cause of stillbirth – The work-up of the patient with a stillbirth is guided by several factors, including the gestational age at occurrence and the circumstances and timing of the stillbirth, whether it occurred antepartum or intrapartum. A thorough medical history is essential to check for known conditions associated with risks of stillbirth, and a comprehensive review of the circumstances leading to the stillbirth should be performed, especially if it occurred intrapartum. (See "Stillbirth: Incidence, risk factors, etiology, and prevention", section on 'Potential etiologies'.)

Maternal laboratory evaluation – The optimal laboratory evaluation of patients who have had a stillbirth is controversial and depends on the maternal and obstetric history. Many lists have been proposed, but the most cost-effective approach has not been determined [7,18-26].

In general, the approach should be guided by clinical data, timing of the death, the mother's medical history, whether fetal growth restriction was present, and sonographic and histopathologic findings. Details of this evaluation are reviewed separately. (See "Stillbirth: Maternal and fetal evaluation", section on 'Maternal laboratory evaluation'.)

Fetal genetic studies – We agree with guidance from the American College of Obstetricians and Gynecologists, which recommends genetic analysis of all stillborns [26]. Microarray is the preferred technique and yields results on nondividing cells, which are common in stillborns. Sample collection for genetic studies and indications for ordering special tests are discussed separately. (See "Stillbirth: Maternal and fetal evaluation", section on 'Additional tests'.)


Timing — It often takes time to fully accept the death of a baby. The parent(s) do not have to be rushed into making any decisions about birth during a chaotic period in the absence of serious maternal medical concerns (eg, disseminated coagulopathy, preeclampsia with severe features, infection). When the parent(s) have accepted the diagnosis and are ready to discuss it further, a discussion about the timing of, and procedure for, birth can ensue.

Intervention should be guided by parental desires, as well as other considerations such as cervical status (Bishop score). Some patients may want to be admitted to the hospital immediately, which is reasonable. It is also medically appropriate, and possibly psychologically desirable [13,27], for the patient to go home and take time in deciding the next step, unless there are serious maternal medical issues that need to be addressed.

The patient who is a candidate for a vaginal birth should be told that if they are not induced, spontaneous labor begins in the majority of cases within one to two weeks of fetal death. Waiting for spontaneous labor to begin is an option and may avoid issues associated with induction; however, waiting also increases the risk of developing coagulation abnormalities, particularly if the dead fetus is retained for several weeks [28]. Coagulation abnormalities are uncommon and due to the gradual release of tissue factor (also called thromboplastin) from the placenta into the maternal circulation [28,29]. In two series including 92 and 123 surgical evacuation procedures performed for second-trimester fetal demise, disseminated intravascular coagulation occurred in a total of four patients (1.9 percent) [30,31].

Available data on outcomes related to timing of induction are sparse. In one of the few studies, patients who were induced >24 hours after the diagnosis of stillbirth had an increased risk of anxiety years after the loss compared with those whose labors were induced within six hours [32].

Route — Unless there are absolute contraindications to a vaginal birth, this type of birth is desirable because it is generally safer for the mother than cesarean birth, including after a previous lower uterine segment cesarean (see 'Previous cesarean birth' below). However, some patients may insist on a primary or repeat cesarean birth so they can avoid the experience of labor and vaginal birth of a fetal demise. They should be thoroughly counseled about the benefits and risks of vaginal versus cesarean birth to ensure they provide fully informed consent.

A study of patients with an obstetric fistula giving birth to a stillborn in resource-limited areas observed that 64 percent were delivered by cesarean because of prolonged obstructed labor, despite the lack of neonatal benefit [33]. The authors emphasized the use of alternatives (vacuum extraction, forceps, and, if unsuccessful, then destructive delivery) and the need for providers to learn these skills to avoid potential complications related to hysterotomy in subsequent pregnancies. These complications (eg, uterine rupture, placental attachment disorders) are even more life-threatening in resource-limited areas.

Our approach to induction or evacuation

Fetal death before 24 weeks — We consider dilation and evacuation (D&E) the best option for management of fetal death before approximately 24 weeks if a clinician with appropriate technical expertise is available [34,35]. A fetal size less than 24 weeks is more important than the gestational age at the time of diagnosis so in individual circumstances a D&E should be considered even if pregnancy dating suggests a gestational age slightly over 24 weeks. In a retrospective cohort study, D&E between 14 and 24 weeks of gestation was less morbid than induction of labor (overall morbidity 11 versus 44 percent); this finding was largely driven by a lower risk for infection requiring intravenous antibiotic therapy (3.7 versus 33.3 percent) [35]. (See "Second-trimester pregnancy termination: Dilation and evacuation".)

If technical expertise for D&E is not available, induction can be performed with misoprostol preferably with mifepristone. The induction regimen is the same as in pregnancies undergoing medical termination without a fetal demise [35,36]. The procedure and outcome is reviewed separately. (See "Second-trimester pregnancy termination: Induction (medication) termination", section on 'Protocol'.)

Fetal death after 24 weeks

Favorable cervix – For patients with a favorable cervix after 24 weeks, labor is induced with standard doses of oxytocin. (Most obstetricians consider a Bishop score ≥6 as favorable and a score ≤3 as unfavorable; scores of 4 or 5 are in a gray zone (table 2)).

Unfavorable cervix – For patients with an unfavorable cervix after 24 weeks and no previous hysterotomy scar, misoprostol is the preferred drug for cervical preparation and induction of labor.

We suggest an initial dose of 50 mcg misoprostol vaginally

If effective contractions with cervical changes occur, then the dose is repeated every four hours for a maximum of six doses [37]. Uterine contraction frequency can be monitored manually; we do not routinely use electronic uterine monitoring when inducing patients with a fetal demise.

If the first dose of 50 mcg does not lead to effective contractions (≥2 contractions in 10 minutes) or cervical changes within four hours, then the second dose can be doubled to 100 mcg and then again to 200 mcg vaginally four hours after the 100 mcg dose.

The mean expulsion time is 10 to 11 hours, but if expulsion does not occur in the first 24 hours of induction, the misoprostol regimen can be repeated a second time.

Oxytocin can be initiated four hours after administration of the last misoprostol dose if needed for further augmentation of labor, especially once the cervix has dilated to 3 to 4 cm.

Success has been reported for a wide variety of misoprostol doses (50 to 400 mcg but sometimes more), routes of administration (oral, vaginal, sublingual, buccal), and frequencies of administration (every 3 to 12 hours) [38]. The optimum regimen has not been established. Although a Cochrane review suggested vaginal administration was more effective than oral administration for pregnancy termination in the second or third trimester for patients with a fetal anomaly or after fetal death [39], another systematic review limited to patients with fetal death concluded vaginal misoprostol was less effective than oral misoprostol for effecting birth within 24 hours, but not within 48 hours [38]. In the latter review, misoprostol (all routes) was 100 percent effective in achieving uterine evacuation within 48 hours; the majority of the 14 trials was performed in the second trimester.

Alternative approaches — The following regimens are examples of reasonable alternative medical approaches to induction of late fetal demise:

A guideline developed for a misoprostol expert meeting suggested the following [37]:

18 to 26 weeks

-Vaginal misoprostol 100 mcg every 6 to 12 hours for a total of 4 doses.

-If the first dose does not lead to effective contractions, double the subsequent dose to 200 mcg. Maximum daily misoprostol dosing should not exceed 800 mcg.

Over 26 weeks

-Favorable cervix: either oxytocin or misoprostol can be used based on the setting and availability of the drugs.

-Unfavorable cervix: vaginal misoprostol 25 to 50 mcg every 4 hours (up to 6 doses). If the first misoprostol dose does not lead to effective contractions, double the subsequent dose. Maximum daily misoprostol dosing should not exceed 600 mcg.

If ≥2 contractions occur in 10 minutes, the dose is not repeated because of the risk of hyperstimulation. A repeat dose may be given if the contraction frequency diminishes.

If the uterine contraction frequency persists or cervical dilation progresses, intravenous oxytocin can be administered if at least 4 hours have elapsed since the last misoprostol dose.

A guideline developed for the Society of Family Planning fellows suggests either a misoprostol-only or mifepristone-misoprostol regimen for pregnancies at 24 to 28 weeks [40]. One approach is not clearly superior to the other, but in several studies, use of mifepristone shortened the induction-to-birth time, especially at earlier gestational ages [41-44]:

Misoprostol only – Misoprostol 100 mcg or 200 mcg vaginally every four hours.

Mifepristone-misoprostolMifepristone 200 mg or 600 mg, followed by misoprostol 24 to 48 hours later.

High dose oxytocin is also effective if other options are unavailable [45,46]. One dosing option is to begin at 6 milliunits/min and increase the dose by 6 milliunits/min at 45 minute intervals until contractions are effective, but not exceeding 40 milliunits/min [45].

At some institutions, a transcervical balloon or bladder catheter is used to aid in cervical ripening and induction.

Special populations

Placenta previa — Placenta previa in early pregnancy does not preclude vaginal birth by standard medical and surgical techniques, although data are limited to a few studies [40]. We believe cesarean birth is safer for the mother in selected second trimester pregnancies over 24 weeks and all third trimester pregnancies. (See "Placenta previa: Management", section on 'Pregnancy termination in women with placenta previa'.)

Previous cesarean birth — We encourage patients with a fetal demise and previous lower uterine segment transverse cesarean birth to attempt a vaginal birth. However, it has been our practice to perform a repeat cesarean if the patient so chooses after being counseled about the risks and benefits of both approaches.

Patients who have had a previous cesarean birth are informed that they are at higher risk of intrapartum uterine rupture than those with an unscarred uterus, and the risk is higher if they are induced than if they enter labor spontaneously [47-49]. In addition, one of the two major clinical signs of uterine rupture, fetal heart rate abnormalities, is unavailable, while the other sign, abdominal pain, is obscured with epidural anesthesia. However, the absolute risk of serious maternal morbidity is low with a prior low segment transverse uterine incision, and there are no fetal benefits to cesarean birth.

Patients with a prior history of a high vertical or classical cesarean should be informed about the significantly increased risk of uterine rupture and should be offered a cesarean birth, although a trial of vaginal birth is not absolutely contraindicated with a late fetal demise. If the cervix is favorable, we use oxytocin in standard doses for patients who choose to be induced. (See "Uterine rupture: After previous cesarean birth".)

In a series of 209 patients with a prior cesarean birth and a fetal demise (average gestational age 30.2±6.6 weeks), 76 percent attempted a trial of labor and 87 percent achieved a vaginal birth [50]. Five patients had a uterine rupture (2.4 percent). Four of these patients had a previous low transverse incision and underwent labor induction (uterine rupture rate with induction: 3.4 percent [4 of 116]). The fifth patients had a previous classical incision and had a repeat cesarean birth before the onset of labor. Of note, uterine rupture in this study was defined as "a disruption or tear of the uterine muscle and visceral peritoneum or a separation of the uterine muscle with extension to the bladder or broad ligament." This may explain why none of the patients with uterine rupture required blood transfusion, hysterectomy, or admission to an intensive care unit.

Drug regimen

For patients with a prior cesarean and third-trimester fetal demise, labor is induced with oxytocin if the cervix is favorable. If the cervix is unfavorable, our preference is to use a mechanical method of cervical ripening (eg, transcervical balloon or bladder catheter) followed by oxytocin for induction.

However, we believe that a history of a prior low segment cesarean birth is not an absolute contraindication to using vaginal misoprostol to induce labor in patients with a fetal demise. (See "Cervical ripening and induction of labor after a prior cesarean birth".)

For patients with a prior cesarean and a late second-trimester fetal demise, labor is induced with oxytocin if the cervix is favorable. If the cervix is unfavorable, a mechanical method of cervical ripening is one option. Misoprostol is an acceptable alternative because the risk of rupture, although increased over baseline, is low [40,51,52].

A guideline developed for Society of Family Planning fellows suggests a misoprostol dose ≤200 mcg vaginally every four hours [40]. Misoprostol 400 mcg vaginally every six hours has been used in patients with a stillbirth between 24 and 28 weeks of gestation, but a more prudent approach is to reserve this dose for pregnancies under 24 weeks and use 200 mcg for those ≥24 weeks [26].

In a systematic review of studies of second-trimester misoprostol-induced abortion, the risk of uterine rupture in patients with a previous cesarean birth was 0.28 percent (95% CI 0.08-1.00) versus 0.04 percent (95% CI 0.01-0.20) in similar patients with no history of previous cesarean; there were only two uterine ruptures among the 722 patients with prior cesarean and one uterine rupture among the 2834 patients without this history [53].

For patients with a prior cesarean and second trimester fetal demise before approximately 24 weeks, dilation and evacuation is an option if a clinician with appropriate technical expertise is available [54].

Fetal-pelvic disproportion — Fetal-pelvic disproportion is rarely an issue during the birth of a nonmacrosomic fetal demise in cephalic or breech presentation. Overlapping skull bones (Spaulding sign), collapse of the fetal body, and maceration often allow pelvic passage of even a large fetus. However, vaginal birth without intervention may be impossible in some situations, such as a shoulder presentation, persistent transverse lie, or in the setting of large external fetal abnormalities (eg, sacral tumor). The major goal in these cases is to minimize the risk of maternal complications due to an obstructed labor and its management.

External or internal podalic version of transverse lie or shoulder presentation is an effective approach with low maternal morbidity when performed by obstetricians with experience with these maneuvers [55,56]. Uterine relaxation with nitroglycerin or general anesthesia is necessary, and an adequate volume of amniotic fluid is desirable [55]. The procedures for internal and external version are described separately. (See "Transverse fetal lie" and "External cephalic version".)

If version is not possible or unsuccessful and vaginal birth is contraindicated, then cesarean birth is recommended. In resource-poor areas where cesarean birth is not an available option, a destructive fetal procedure can be considered to potentially save the life of the mother [57].

Placental examination — The placenta is a crucial part of the evaluation to help determine the cause of the stillbirth. First, it should be carefully examined in the delivery room and then sent for further pathologic examination. The pathologist should be informed that this placenta was from a fetal demise/stillbirth to better evaluate the histopathology. (See "Stillbirth: Maternal and fetal evaluation", section on 'Routine basic placental and noninvasive fetal evaluation'.)


Delivery room — At birth, if a name has been chosen, the baby should be referred to by name. A gross examination of the fetus and placenta should be performed and the parents informed of the findings. If there is a clear finding, such as a tight knot in the umbilical cord, a tight nuchal cord, a thrombosed umbilical cord, or cord disruption, then this should be communicated. Otherwise, clinicians and parents should wait until all tests and examinations have been completed before speculating about the cause of death.

Helping parents connect with and separate from their child — Contact between the parent(s) and stillborn is important because the quality of the attachment (ie, the process that establishes an emotional bond) to a deceased person can affect how the living deal with their loss. Developing a connection with the baby makes the death real, helps prevent emotional withdrawal from the loss, and helps in the transition to parenthood [3].

Parents generally appreciate provider support in viewing, holding, and then separating from their child. If there are significant malformations or advanced maceration and they prefer to view only the parts of the baby that are less upsetting, the baby can be appropriately swaddled with a blanket before being handed over.

We offer parents choices about viewing and holding their baby and avoid biasing their choice or making presumptions that limit their choices. We also offer placing a diaper on the baby and clothing the baby. In a prospective study over 12 years, most parents wanted contact with their baby to personalize the event and information about the death and follow-up from their health care providers, but they chose different options and no single option was chosen by all parents [58]. Some parents want to have other family members or friends meet the baby [4].

Although 21 of 23 studies in a systematic review suggested that viewing and holding the stillborn facilitates healthy grieving and mourning and reduces the risk of long-term psychological problems [59], this belief has been challenged. Some studies have reported that encouraging parents to view and hold the stillborn can cause psychological morbidity in the subsequent pregnancy and increases the risk of clinically significant posttraumatic stress, anxiety, and depression [60,61]. This discordance may be related to how well the parents were prepared for seeing and holding their baby, the support they received, and their sense of control of the decision.

Whether or not the parent(s) view and/or hold the baby, they may appreciate receiving "keepsakes" such as a lock of hair or footprint, if possible, or a blanket or photograph [62].

Coordinating postpartum care — The patient's primary provider (eg, obstetrician-gynecologist, midwife, family practitioner) is usually responsible for coordinating care after a stillbirth, but may not be the primary person providing counseling. The counselor may be one person or part of a team with specific expertise: obstetrician, maternal-fetal medicine specialist, family practitioner, neonatologist, pathologist, genetics counselor, nurse practitioner, social worker, and/or clergy. Social workers often assist the family in making arrangements for burial or disposition of the body. Referral for genetics consultation is usually helpful when congenital malformations have been identified.

Discussing autopsy — Determining the cause of death is important because sooner or later the parent(s) will want to know "why did this happen?" and "will it happen again?" Answers to these questions may be impossible without information gained from an initial evaluation of medical records, visual inspection of the newborn, and a pathologic examination. Therefore, all parents should be offered the option of autopsy examination [63].

The medical staff involved in consent for postmortem examination should be fully trained in how to ask for parental consent and in explaining the postmortem examination procedure; what is gained by this examination and its limitations; the cost, which is usually covered by insurance; and potential findings [64]. Ideally, a senior clinician involved in the patient's care, and possibly a pathologist, initiate this discussion [65,66].

Reasons parents give for declining postmortem examination include concerns about disfigurement, a wish to have the child left in peace, a belief that an autopsy is unnecessary because they have no unanswered questions [67], and cultural and religious beliefs [68]. These concerns should be addressed with patience, sensitivity, accurate information, and respect for the mother's/parent's choice. A systematic review found no adequate randomized trials of support for parents making decisions about autopsy or other postmortem examinations, and concluded that clinicians must rely on the ad hoc knowledge and experience of those involved at the time [69].

Although parents should be given sufficient information about the postmortem examination to ensure that their perception of the procedure matches the procedure performed, the specific information that needs to be provided is controversial [70-73]. For example, there is disagreement about the appropriate level of detail on retention of whole organs and histologic slides, use of histologic slides for educational or research purposes, and ultimate disposal of any organs or tissues retained as part of the autopsy.

The clinical value of autopsy and placental examination, components of the examination, and potential findings are reviewed in detail separately. (See "Stillbirth: Maternal and fetal evaluation".)

Disposition of the newborn — We suggest that hospitals have clear policies regarding disposition of the stillborn from the labor and delivery unit, which may include developing a checklist and assigning a provider to be responsible for adherence to the checklist and knowledge of the location of the baby's remains. Stillbirths may be sent to either the morgue or the pathology department. Historically, there are anecdotal reports of miscommunications, such as pathology departments who have not received the request or a consent for autopsy and babies being "lost," left in morgues, not undergoing a requested autopsy, sent to locations other than those originally planned for, or picked up incorrectly by funeral homes.

Many hospitals have specially trained bereavement counselors and individualized algorithms, which can help parents through the decision process for disposition of the newborn. Some parents may elect to have a full burial, while others may choose to dispose of the newborn's body through the hospital's usual mechanisms. In the United States, state law governs the process of burial and disposition, which varies from state to state.

Death certificate — Many parents in the United States are upset that a fetal death certificate is issued instead of a birth certificate in cases of stillbirth. The requirements for fetal death reporting are governed individually by each state, with states defining a stillbirth based on fetal weights as low as 350 grams and gestations of 20 weeks or more. For this reason, some states issue a "Certificate of Birth Resulting in Stillbirth" to parents of stillborn children, rather than a Certificate of Fetal Death.

Postpartum accommodations — Some patients who deliver a stillborn may not want to be around patients with healthy newborns on the postpartum unit. Accommodations should be made to accede to their wishes to be admitted after birth to a unit where there are no live born infants. These issues should be discussed with the patient before transfer off of the labor and delivery unit.

Many obstetric units identify the room of a patient who has had a stillbirth (eg, with a special sticker on the door) to ensure that all hospital personnel entering the room are aware of the death and do not inadvertently assume that the birth was a live newborn.

Breast engorgement after stillbirth — Breast engorgement and physiologic milk secretion after perinatal loss potentially adds to maternal discomfort. It is therefore essential that the mother be informed about the likelihood of postpartum milk leakage and breast engorgement. Mothers who do not receive this information are more likely to develop anger and other signs of emotional distress. While some mothers will want to stop lactation after a stillbirth as quickly as possible, others may take comfort in pumping and donating breast milk. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Breast engorgement'.)


Overview — The weeks after hospital discharge are usually very difficult for the parents. They have just experienced a major traumatic event; they need to accept the fact that they do not have a live baby; they need to inform others of their loss; they may have to dismantle preparations they may have made in expectation of bringing the baby home; and they need to cope with their grief in relation to the people in their surroundings (eg, home, office, community) [74]. In addition, if there are other children, discussions about the stillbirth need to be initiated with them. A study exploring this issue concluded that parents could support their children by recognizing and acknowledging the child's grief, including the child in family rituals, and keeping the baby alive in the family memory [75]. (See "Preparing children and adolescents for the loss of a parent or guardian".)

We suggest that the clinician contact patients regularly after birth and schedule an early first postpartum visit. Talking regularly with patients during this time, and especially at the first postpartum visit, helps the provider discern their emotional status, whether signs of depression are present, and whether professional referral is indicated. The evaluation of postpartum patients for depression is discussed in detail elsewhere. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)

Stillbirth may be an independent risk factor for subsequent long-term maternal cardiovascular disease, especially if the stillbirth was related to fetal growth restriction, placental abruption, or pregnancy-related hypertensive disease [76]. Such patients may benefit from information about this risk, encouragement to adopt lifestyle interventions for risk reduction (eg, healthy diet, weight loss, exercise), and advice to follow-up with their primary care provider.

Grief and bereavement — The patient's caregivers need to be cognizant of the nature of grief and bereavement [3]. Bereavement may precipitate or exacerbate suicidality and mental disorders such as complicated grief, major depression, anxiety disorders, and posttraumatic stress disorder. Complicated or traumatic grief describes a syndrome in which the individual does not return to the level of function and wellbeing at which they lived before the loss. It involves the persistence of reactions (eg, difficulty accepting the death, denial of the death, absence of grief, searching, preoccupation with thoughts of the deceased, avoidance of reminders of the deceased, auditory and visual hallucinations of the person who has died, symptoms of identification with the deceased) that are normal in the immediate period after a loss. Complicated grief can lead to prolonged dysfunction; these patients should be referred to a psychiatrist for evaluation. (See "Prolonged grief disorder in adults: Epidemiology, clinical features, assessment, and diagnosis", section on 'Clinical features'.)

Emotional support — Emotional support helps individuals identify and express their feelings, which may involve anger, guilt, blame, fear, anxiety, sorrow, grief, and failure. Grieving parents have expressed wanting staff to appreciate the severity of their loss, offer understanding and support, and allow them to talk about the death. An appropriate approach consists of empathetic, honest communication between parents and hospital staff that acknowledges the specific needs and cultural practices of individual mothers/couples [77] and the differing needs of each parent [78,79].

The grief process often does not occur in a linear fashion, is cyclical, and manifests in many different ways. No two people grieve or express their grief in the same way or for the same time period.

Patients who deliver a multiple gestation with both healthy and stillborn infants require different types of support. These parents experience both joy and grief and may experience difficulty with attachment [80].

Support groups — Support groups may be helpful for some parents [81]. In one study, participants in such groups stated that the group helped members recognize their commonalities, remember their earlier babies who died, develop caring relationships, and learn new coping skills [82]. Support groups for parents who have lost a fetus or child exist in many hospitals and communities. Three organizations supporting families after pregnancy loss include:

Discussion of test and autopsy results — A "wrap-up" meeting is scheduled when all results of testing and the autopsy are available, which may take up to several months. However, parents should be informed as progress is made along the way.

Some parents prefer to meet with their clinician alone, while others prefer to bring along some family members or friends. At the wrap-up meeting, information about the events leading up to the fetal demise and stillbirth, as well as the laboratory results, placental pathology, and the autopsy report (if an autopsy was performed), should be reviewed, with ample opportunity for the parents to ask questions. The cause or possible causes of the stillbirth, risk for recurrence, and, if desired, a plan for the next pregnancy are discussed. This information should be provided in clear and understandable nonmedical language and may need to be repeated. Clinicians should diligently prepare for these meetings so they can answer the complex questions likely to arise and should try to give the mother/couple hope.

RECURRENCE RISK — Patients who experience a stillbirth are almost five times more likely to experience a stillbirth in their next pregnancy than those who had a live birth (odds ratio 4.77, 95% CI 3.70-6.15) [83]. However, an individual patient's recurrence risk of stillbirth is affected by multiple factors, including maternal risks, gestational age, and characteristics of the stillbirth [84-86]. For example, a patient with a small for gestational age stillbirth at term in a first pregnancy has a risk of stillbirth of 4.7 of 1000 in the second pregnancy versus 2.1 of 1000 in a patient with a prior live birth.

Etiology not determined – There are wide variations in the reported proportion of unexplained stillbirth (eg, 10 to 70 percent), and despite all evaluative efforts, the cause of fetal death often cannot be determined [63]. In such cases, the adjusted risk of recurrence was increased three- to fourfold in two studies but was not increased in a third study [87-89]. Even in the absence of determining an etiology, the subsequent pregnancy appears to be at increased risk for abruption, preterm birth, and low birth weight [90].

Etiology known or suspected – If a specific cause for the fetal demise or stillbirth is identified (eg, abruption, infection), then the recurrence risk can be estimated, based upon review of the literature. The recurrence risk of specific disorders and risk-reduction interventions are discussed separately in individual topic reviews on each disorder.

The finding of a congenital anomaly in a stillborn is important because of the risk of recurrence in future pregnancies. In a population-based study of patients whose first infant had a congenital anomaly, the risk of the same anomaly in the second infant was increased 7.6-fold and the risk of a different anomaly in the second infant was increased 1.5-fold compared with those whose first infant was structurally normal [91].

When counseling patients with a stillbirth associated with uteroplacental insufficiency, the impact of this finding on future pregnancy should be discussed. It has been hypothesized that placental abruption, intrauterine growth restriction, preeclampsia, and stillbirth are different manifestations of ischemic placental disease, and all predispose to preterm birth. These disorders often coexist in a pregnancy, or one may occur in one pregnancy while another occurs in a subsequent pregnancy. For example, the birth of a SGA live born infant in a first pregnancy has been associated with stillbirth in a subsequent pregnancy, especially if the SGA birth was preterm (table 3) [87,92]. Thus, patients with these pregnancy complications comprise a high-risk group in their subsequent pregnancies [93,94]. (Refer to individual topic reviews on abruption, fetal growth restriction, preeclampsia, and stillbirth.)

PLANNING FUTURE PREGNANCIES — (See "Stillbirth: Incidence, risk factors, etiology, and prevention", section on 'Strategies for prevention of recurrent stillbirth'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stillbirth".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Stillbirth (The Basics)")


Conveying the diagnosis: After confirmation of the fetal death, the couple should be informed expeditiously, in an empathetic and straightforward manner, in surroundings where the parents can react privately. (See 'Conveying the diagnosis of stillbirth' above.)

Delivery timing: Parents should not be rushed into deciding the timing of delivery in the absence of serious maternal medical concerns. Spontaneous labor begins within one to two weeks of fetal death in the majority of cases. However, waiting for spontaneous labor increases the risk of developing coagulation abnormalities, particularly if the dead fetus is retained for several weeks. (See 'Timing' above.)

Dilation and evacuation and induction

Before 24 weeks of gestation, we suggest dilation and evacuation rather than misoprostol induction if a clinician with appropriate technical expertise is available (Grade 2C). If technical expertise is not available, misoprostol is used for induction. (See 'Fetal death before 24 weeks' above.)

After 24 weeks of gestation, in patients with favorable cervix (Bishop score ≥6), we suggest induction of labor with oxytocin in standard doses rather than misoprostol (Grade 2C). In patients with an unfavorable cervix, we administer misoprostol vaginally before oxytocin (not concurrently). Various effective regimens have been described. (See 'Fetal death after 24 weeks' above and 'Alternative approaches' above.)

Another reasonable regimen for pregnancies at 24 to 28 weeks is mifepristone-misoprostol. (See 'Alternative approaches' above.)

Patients with a prior cesarean birth: We encourage patients with antepartum fetal demise and previous low-segment cesarean birth to attempt vaginal birth. However, we perform a repeat cesarean birth if the patient chooses this type of birth after counseling about the risks and benefits of both approaches. If the cervix is unfavorable in the third trimester, our preference is to use a mechanical method of cervical ripening followed by oxytocin induction. For a second-trimester fetal death in women with a single previous low transverse hysterotomy incision, misoprostol is an acceptable alternative to mechanical methods of cervical ripening because the risk of rupture, although increased over baseline, is low. (See 'Previous cesarean birth' above.)

Delivery room care:

Parents should be offered choices about viewing and holding their baby. Developing a physical or visual connection with the baby makes the death real and helps prevent emotional withdrawal from the loss. (See 'Helping parents connect with and separate from their child' above.)

Emotional support involves empathetic, honest communication between parents and hospital staff that acknowledges the specific needs and cultural practices of individual couples and the differing needs of each parent. People grieve in different ways and over varying time periods. (See 'Emotional support' above.)

Postdelivery care:

The patient should be informed about the likelihood of postpartum milk leakage and breast engorgement and offered the choice of postpartum care on a maternity floor or elsewhere in the hospital. (See 'Breast engorgement after stillbirth' above and 'Postpartum accommodations' above.)

After the birth of a stillborn child, parents have described six "qualities" that they want from their caregivers: support in meeting with and separating from the baby, support in chaos, support in bereavement, explanation of the stillbirth, organization of their care, and understanding the nature of grief. (See 'General principles' above.)

Hospitals should have clear policies regarding disposition of the stillborn from the labor and delivery unit. Developing a checklist for each step is helpful. (See 'Disposition of the newborn' above.)

Bereavement counselors can help parents through the decision process for disposition of remains and for obtaining a certificate of birth resulting in fetal death. (See 'Disposition of the newborn' above and 'Death certificate' above.)

Regular communication with patients after discharge can help in assessing their emotional status, whether there are signs of depression, and whether professional referral is indicated. Bereavement may precipitate or exacerbate suicidality and mental disorders such as complicated grief, major depression, anxiety disorders, and posttraumatic stress disorder. (See 'Care after hospital discharge' above and 'Grief and bereavement' above.)

Autopsy: Autopsy is suggested because the cause of stillbirth and, in turn, the risk of recurrence may be impossible to determine without fetal and placental pathologic examination. (See 'Discussing autopsy' above.)

Risk of recurrence: For low-risk patients with unexplained stillbirth, the risk of recurrence is approximately 8 to 11 per 1000 births, and most of these deaths occur preterm; recurrence occurs at term in 1.8 per 1000 births. The subsequent pregnancy is at risk for abruption, preterm birth, and birth of a small for gestational age (SGA) infant. (See 'Recurrence risk' above.)

Planning a future pregnancy: The pregnancy after stillbirth should be delayed until parents feel they have achieved psychological closure of the previous pregnancy loss. This typically takes 6 to 12 months. A preconception visit is helpful to review findings associated with the prior stillbirth and to plan care and management of future pregnancies. (See 'Planning future pregnancies' above.)

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