Clinical Concerns In The Rainbow Pregnancy

May 28, 2014
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By Lindsey J. Wimmer, RN, MSN, CPNP
Executive Director, Star Legacy Foundation

As I mentioned in my last blog, coping with a pregnancy after a loss are among the most commonly asked questions we get from stillbirth families.  Primarily, the questions we get are how to work with the physicians and midwives to manage the subsequent pregnancies.  My last blog focused on the anxiety and emotions that come with pregnancies after loss.  This time, I will try to address the medical management.  This is a difficult topic because every pregnancy is very different, and it all comes back to the individual provider’s approach.

  • My first suggestion is to talk to your OB either before becoming pregnant or as early in the pregnancy as possible to discuss what you all expect and plan to do through the next pregnancy.  It is important that the family and the provider clearly understand the needs of each other and can all feel comfortable with the plan.  If this isn’t possible, it may be an indicator that the family should find another provider to care for the next pregnancy.
  • Next, do what is possible to control, manage, or eliminate any medical concerns for the mother.  This, obviously, isn’t always feasible, but it is preferable whenever possible.  Many parents choose to have genetic testing and counseling done at this time as well – particularly if a chromosomal issue was known or suspected to have played a role in the loss.
  • Be sure you are healthy!  All women considering a pregnancy are encouraged to begin taking folic acid and eating a healthy, balanced diet.  If you are overweight, it is advisable to achieve a good weight before your pregnancy – your provider can provide you advice on the best approach for you. Smoking, alcohol, or drug use should be stopped and programs may be available to assist with this process – again, just ask your provider.  Give your baby every opportunity to thrive before he/she is born!
  • Once pregnant, this pregnancy should be considered ‘high-risk’ based on the previous loss.  A visit with the OB early allows for more detailed discussions about the plan, confirmation of the pregnancy, and ultrasound for dating the pregnancy.  If the mother’s history indicated, additional tests may be done at this time.  Also during the first trimester, the PAPP-A blood test can provide information about risks of chromosomal or anatomical concerns, and it is also an indicator of placental function – a benefit that is not always discussed but vitally important.
  • During the second trimester, the usual ultrasound at 18-20 weeks will be done to assess the baby’s anatomy.  I encourage providers to also assess the baby’s growth, placental characteristics, cord insertion, and blood flow through the umbilical cord.  Ask your doctor about growth charting based on ultrasound measurements rather than the tape measure approach so that a change in growth for your baby can be easily identified.
  • The Quad screen provides more information about placental function and risks of concerns about the baby’s health. Diabetes screening and follow-up testing will be completed as is routine for all pregnancies.
  • In the third trimester, all pregnant women should be aware of their baby’s movements, personality, and tendencies.  Any changes to this baby’s norm should be reported and investigated immediately. Each baby is different – so don’t try to compare this baby with your previous ones or your friends. You can learn more about this process in our See Me, Feel Me materials.
  • Monitoring for signs of infection or Group B Strep status will be conducted as usual.  Providers are encouraged to begin weekly ultrasounds to monitor and track the baby’s growth, the amniotic fluid index, and placenta and cord characteristics. These often begin at 28 weeks gestation.  Some providers will include in this evaluation a biophysical profile (ultrasound with specific criteria regarding baby’s behaviors) and non-stress testing with kick counting.  Other providers will wait until 32 weeks to begin these additional tests.  Again, discuss these plans with your provider early on.
  • Any concerns or declines in the health of the mother, baby, or pregnancy should prompt a discussion between the family and the health providers about options and pros/cons or risks/benefits of any decisions.  This conversation may mean early delivery of the baby if the intrauterine risks of continuing the pregnancy are too great.  This is especially true at later gestations and as the pregnancy approaches full term.  If all goes well and as expected, early delivery (by induction or c-section as appropriate) should be scheduled by 39 weeks, or earlier if desired by the family and the baby’s lung maturity has been confirmed by amnioscentesis.

This is a VERY general guide, but can be a place to start the discussion with your healthcare provider.  Some OBs will also include a perinatologist or maternal-fetal medicine specialist in your care.  There are MANY variations to protocol, but the most important thing is that you and your provider are in agreement about how things are going, what should be done, and the coming plan.

As the pregnancy progresses or issues arise, continue to have open discussions to make adjustments as needed.  If you ever feel uncomfortable or have persistent worries, DO NOT hesitate to immediately mention this to your provider and insist your concerns be thoroughly investigated. There is no question or concern that you have that should be dismissed or avoided by you or your healthcare team.  

2014 Stillbirth_Summit logo

Uma Reddy

Dr. Uma Reddy from the Eunice Kennedy Shriver National Institute of Child Health and Development (NICHD) has done a significant amount of work in this area.  She will be one of the speakers at the Stillbirth Summit in June 2014 – you won’t want to miss the chance to hear this nationally-recognized stillbirth researcher!

Tracey MillsIn addition, Dr. Tracey Mills from the University of Manchester is involved with a clinic in the UK dedicated to caring for families during a rainbow pregnancy!  She will also be at the Stillbirth Summit and will be sharing her protocols, experiences, recommendations, and more!  This will be a must see presentation for all providers who care for women during a subsequent pregnancy and all families anticipating or hoping for a rainbow baby.

Ruth Fretts

Dr. Ruth Fretts has written several opinion pieces for the American Congress of Obstetricians and Gynecologists (ACOG).  She will be talking about the Stillbirth Scandal that often comes into play with subsequent pregnancies as well.


Some of my favorite medical articles about caring for subsequent pregnancies are below.  Feel free to share them with your provider and use them as a place to start your rainbow conversation.

Antepartum Testing for Women with Previous Stillbirth

Prediction and Prevention of Recurrent Stillbirth

ACOG Practice Guidelines — Management of Stillbirth

For more information or to have See Me Feel Me materials mailed to you, email me at [email protected].




Melina Ceballos

Hello Im Melina, wanted to mentioned I recently had a still birth. My first pregnancy was a miscarriage at 10 weeks my sec one was a still birth at 27 weeks. My ? Was will I ever be able to have a live healthy baby, or from my history..will I not be able to carry a baby full term?

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