When my own daughter was pregnant recently, no one mentioned stillbirth – until she was more than a week overdue and resisting any suggestion from hospital staff to have the baby induced. After all, the message from her antenatal natural childbirth course had been loud and clear: even if the baby is overdue try to avoid an induction because it can lead to more intervention during the birth.
Then a midwife from the maternity unit dropped the ‘S’ word, saying that another overdue mother who’d recently resisted an induction had had a stillbirth.
“The placenta gets past its use by date,” the midwife said.
My daughter had an induction – and a healthy son. But we were left wondering why her ante-natal class emphasised avoiding induction – without also explaining the increased risk of stillbirth when women are overdue.
It’s partly because no one, including health professionals, likes using the word stillbirth – but also because we need a clearer message about which women have a higher stillbirth risk when babies are overdue, says Professor Mike Beckmann, medical director at Brisbane’s Mater Mother’s Hospital.
“The risk of stillbirth is small – in Australia one in a thousand babies are stillborn at term. But we need to have a conversation about the increased risk of stillbirth for some groups of women whose pregnancies are overdue – women over 35, women who are very overweight and women who smoke,” he says, explaining that maternal age, overweight and smoking can all adversely affect the quality of the placenta.
“We talk to women about their risk of Down syndrome, for example, but we don’t apply this to the risk of stillbirth. Even though the absolute risk is low, a woman over 35 has twice the likelihood of stillbirth as a woman of 25. In women over 40 the risk is three fold. Many clinicians don’t mention the risk of stillbirth amongst older mums at all – and we certainly aren’t tailoring that information to a woman’s specific age or whether she’s very overweight or smokes.
“Induction is about helping a baby to be born safely and with women in these age groups it should be discussed to reduce the risk of stillbirth. Studies also tell us that caesareans are no more common in women who are induced.”
“With women who are very overweight it may be that midwives and doctors can’t reliably detect if a baby is too small – and this is the factor that increases stillbirth risk,” Beckmann adds.
Another issue is when exactly is a baby overdue? A baby’s due date is calculated at 40 weeks from the first day of a woman’s last period – although the baby is considered at term at 37 weeks. Inducing labour should be considered from 41 weeks, according to the National Institute of Clinical Excellence, Beckmann says.
Still, giving women good information about risks in pregnancy without terrifying them can be a balancing act, says Caroline Homer, Professor of Midwifery at the University of Technology Sydney.
She also points out that while rates of induction in Australia have risen, the numbers of stillbirths haven’t dropped in the last 10 to 15 years – instead they’ve remained the same.
“A lot of women over 35 have babies and they’re not all stillborn,” Homer says. “But there are good reasons to go into pregnancy at a healthy weight. When women are overweight it’s harder to monitor the baby’s growth, caesarean sections are more common – and more difficult – and it may also be more difficult to feel the baby’s movement.”
Being in touch with the baby’s movements, especially in the third trimester of pregnancy, is now recognised as a way of reducing preventable stillbirths, she says.
Norwegian research has found that mothers monitoring their baby’s movements daily from 28 weeks resulted in a 30 per cent reduction in stillbirth, adds Meleseini Tai-Roche of Still Aware http://stillaware.org/ which raises awareness of stillbirth and how to prevent it.
“Every baby is different – it’s about getting to know what your baby’s normal pattern of movement is – and acting promptly if there’s a change in that pattern,” says Tai-Roche, a midwife whose first son was stillborn.
This message is replacing the standard advice given to women whose baby’s movements slow down or stop – ‘sit down, have a cold drink or something to eat and see if the baby starts moving’.
“Now we encourage women to come into hospital promptly rather than procrastinate,” she says.
Continuity of care also matters. This means that instead of seeing many different health professionals through pregnancy, you see the same midwife or team of midwives consistently.
“With midwifery continuity of care women are 16 per cent less likely to lose a baby at any stage of pregnancy,” says Homer.
We’d also be better off tailoring advice to women as individuals rather than relying on one-size-fits-all guidelines, adds Tai-Roche.
“If a baby hasn’t arrived by 40 weeks plus 10 days, that’s when induction is recommended and for most women waiting until then is fine. But there will be some women for whom an induction at 38 weeks would be more appropriate,” she says.
“That’s why it’s important for women to have continuity of care from a clinician who’s got to know them through their pregnancy and provides individualised care.”
by Paula Goodyear
Source: Brisbane Times, Jan. 29, 2017