4.5 Intrauterine Fetal Demise, Stillbirth & Bereavement Care
Key Takeaways
- Stillbirth is defined as fetal death at 20 0/7 weeks or later or a birth weight of 350 g or more, and the US rate is approximately 5.5 per 1,000 births.
- Diagnosis requires real-time ultrasound showing absence of fetal cardiac activity, because a handheld Doppler can mistake the maternal uterine souffle for fetal heart tones.
- Vaginal birth is the preferred route, and retention beyond about 4 weeks risks consumptive coagulopathy, so platelet count and fibrinogen are monitored weekly if birth is delayed.
- Fetal autopsy and placental pathology are the two highest-yield diagnostic tests, and chromosomal microarray is preferred over karyotype because it does not require dividing cells.
- In a subsequent pregnancy, antenatal testing typically begins at 32 weeks or one to two weeks before the gestational age of the prior loss, with delivery usually planned by 39 weeks.
Definitions and Epidemiology
Stillbirth (intrauterine fetal demise, IUFD) is fetal death at 20 0/7 weeks or later, or a birth weight of ≥350 g when gestational age is unknown. Losses before 20 0/7 weeks are classified as spontaneous abortion. Stillbirth is subdivided as early (20 0/7–27 6/7 weeks), late (28 0/7–36 6/7 weeks), and term (≥37 0/7 weeks).
- The US stillbirth rate is approximately 5.5 per 1,000 births — close to the number of deaths during the entire first year of life.
- Non-Hispanic Black patients experience roughly twice the stillbirth rate of non-Hispanic White patients, a disparity that persists after adjustment for income and education and that the midwife should be able to name as a structural rather than biologic inequity.
- Leading identified causes: placental pathology, obstetric complications (abruption, preterm prelabor rupture of membranes, cord accident), fetal genetic and structural anomalies, infection, hypertensive disorders, and maternal medical disease. No cause is identified in roughly one quarter of cases even after complete evaluation.
Recognition and Confirmation
Presentation. The most common presenting complaint is absent or markedly decreased fetal movement. Others include absent fetal heart tones at a routine visit, a fundal height that has stopped increasing, or vaginal bleeding.
Confirmation is sonographic. The diagnosis is made by real-time ultrasound demonstrating absence of fetal cardiac activity, ideally verified by a second clinician. Never diagnose or exclude demise with a handheld Doppler: the maternal uterine souffle can be mistaken for fetal heart tones, and failure to obtain tones by Doppler is not by itself diagnostic of death at any gestational age.
Delivering the news. Tell the patient immediately, in the room, using the words died or death. Euphemisms such as "I can't find a heartbeat" leave patients uncertain for hours. Sit down, allow silence, offer to call a support person, and do not speculate about cause before the evaluation is complete.
Management of Birth
In the absence of infection, abruption, or coagulopathy there is no emergency, and the patient can be given time before decisions are made.
| Option | Considerations |
|---|---|
| Expectant management | Roughly 80–90% labor spontaneously within 2 weeks. Requires a patient who can tolerate waiting and reliable coagulation surveillance. |
| Induction of labor | Chosen by most patients. Vaginal birth is the route of choice, including for most patients with a prior low transverse cesarean. Regimens are gestational-age dependent: higher-dose misoprostol protocols in the second trimester, standard cervical ripening and oxytocin at later gestations. |
| Dilation and evacuation (D&E) | An option before roughly 24 weeks where a skilled provider is available. It precludes an intact fetal autopsy but still permits placental and cytogenetic testing. |
[!CAUTION] Consumptive coagulopathy. Thromboplastin released from a retained dead fetus can precipitate disseminated intravascular coagulation, classically after about 4 weeks of retention. Obtain a baseline platelet count and fibrinogen, and repeat weekly if birth is delayed. A falling fibrinogen is the earliest laboratory warning.
Additional intrapartum care: offer full analgesia including neuraxial anesthesia; administer RhD immune globulin to unsensitized Rh-negative patients; reserve antibiotics for a clinical indication.
Evaluation for Cause
Evaluation changes management of the next pregnancy and helps parents make meaning of the loss. Consent for each component separately.
- Fetal autopsy — the single highest-yield test. If a full autopsy is declined, offer a limited or external examination, photographs, radiographs, or postmortem MRI.
- Placental, cord, and membrane pathology — the second highest-yield test and one that is rarely declined. Send the placenta fresh and unfixed.
- Cytogenetic analysis — chromosomal microarray on amniotic fluid, placental tissue, or fetal tissue. Microarray outperforms karyotype after fetal death because it does not require dividing cells.
- Kleihauer-Betke or flow cytometry for fetomaternal hemorrhage, drawn before birth when feasible.
- Maternal laboratory workup — CBC, antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti-β2-glycoprotein I), HbA1c or glucose, TSH, toxicology, and syphilis serology; parvovirus and other serologies when hydrops or infection is suspected.
- Indirect Coombs antibody screen if not recently performed.
Routine inherited-thrombophilia panels and TORCH titers are not recommended in the absence of specific findings.
Bereavement Care and Follow-Up
Bereavement care is a clinical skill with measurable effects on long-term maternal mental health.
- Follow the parents' lead. Offer, but never impose, seeing and holding the baby. Describe in advance what they will see, including skin changes, so there is no shock.
- Memory making: photographs (including volunteer professional photography), hand and foot prints or molds, a lock of hair, the blanket and hat, an identification bracelet, a memory box. Store items indefinitely if declined at the time — many families return for them months later.
- Naming and rites: ask the baby's name, use it, and facilitate cultural and religious practices such as blessing, baptism, ritual washing, or burial timing.
- Language: avoid "at least" statements, reassurance about future children, and causal speculation. "I am so sorry. Tell me about her." is enough.
- Lactation: secretory activation will occur. Discuss suppression (supportive bra, cold compresses, avoiding stimulation, analgesia) versus milk donation, which some bereaved parents find meaningful.
- Documentation: a fetal death certificate is required at 20 weeks or greater in most states; assist with disposition and funeral decisions.
- Referral: bereavement programs using models such as Resolve Through Sharing, peer organizations (Share Pregnancy & Infant Loss Support, Star Legacy Foundation), and perinatal mental health providers. Screen for depression, anxiety, and post-traumatic stress at the postpartum visit and again at 3–6 months.
- Contact early. A phone call within a few days, a follow-up visit at 2 weeks rather than 6, and a named clinician who will deliver the autopsy results prevent families from feeling abandoned.
Counseling About a Future Pregnancy
- Recurrence risk depends on the identified cause; overall, prior stillbirth carries roughly a 2- to 10-fold increased risk in a subsequent pregnancy.
- Optimize modifiable factors preconceptionally: glycemic control, blood pressure, weight, smoking cessation, and treatment of any identified antiphospholipid syndrome.
- Subsequent pregnancy typically includes low-dose aspirin when indicated, early dating, a detailed anatomy survey, serial growth ultrasounds, and antenatal testing beginning at 32 weeks or one to two weeks before the gestational age of the prior loss, with delivery usually planned by 39 weeks.
- Anticipate and normalize heightened anxiety: offer more frequent contact, extra auscultation visits, and mental health support throughout the next pregnancy.
A patient at 36 weeks reports no fetal movement for a day. The midwife cannot obtain fetal heart tones with a handheld Doppler after several minutes. What is the correct next action?
A patient with an intrauterine fetal demise at 22 weeks elects expectant management and has not labored after three weeks. Which surveillance is most important during this interval?