Why Not Stillbirth Prevention? It is Time for Us to Try to Prevent Our Saddest Fetal Outcome

June 28, 2021
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This presentation will discuss the lack of fetal movement education standardization and stillbirth prevention protocols in the US and how I incorporated the UK/Austrialia protocols and fetal movement education in my practice.

Dr. Heather Florescue is an OBGYN at in private practice at Women’s Gynecology and Childbirth Associates in Rochester, N.Y. She delivers babies at Highland Hospital in Rochester, NY.  Her passion is doing grief counseling and support for patients who have experienced loss – this lead to a passion for spreading awareness, education for providers and taking up the cause of prevention.   

She received her medical degree at the University of Rochester School of Medicine & Dentistry, completed her internship and residency in obstetrics & gynecology at the University of Rochester Medical Center.  She is certified by the American Congress of Obstetrics & Gynecology.  She and her husband are parents to a set of triplets.  Dr. Florescue is passionate about the prevention of pregnancy and infant loss and the care for families who suffer these terrible tragedies.   

Dr. Florescue has disclosed that she does not have any real or perceived conflicts of interest in making this presentation.

La’Zette Smith: Hello, my name is La’Zette Smith and I’m the father of LaSaaun Jerrell Tyiska Smith. I’m here to introduce one of our presenters for our summit. Dr. Heather Florescue is a practicing OB-GYN at Women’s Gynecology and Childbirth Associates. She received her BA and MD degrees from the University of Rochester. Her passion is grief counseling and support for patients who have experienced loss. Dr. Florescue’s work with grieving families and an experience with the UK’s Saving Babies’ Lives Care Bundle led to a passion for spreading awareness, educating providers, and taking up the cause of prevention. Her presentation is titled, Why Not Stillbirth Prevention: It is Time for Us to Try to Prevent Our Saddest Fetal Outcome. Now, Dr. Heather Florescue.

Dr. Heather Florescue: Hi. I am Dr. Heather Florescue, and I am honored today to talk to you about what I’ve been doing these past two years since I attended the 2019 Star Legacy Summit. I will be talking to you; my title today is It’s Time to Solve the Puzzle of the Stagnant Stillbirth Rate in the United States. I give this talk in honor of many wonderful families that I have come to get to know well over the course of my entire career, but three really special babies and their moms who have been my cheerleaders for the last two years and even longer than that. I dedicate this talk in honor of Will who’s on the top holding his brother Asher’s hand, and then Cooper is on the bottom left, and Vincent is on the bottom right.

What are the facts? In 2017, nearly 23,000 babies were born still, approximately 1 in 166. The US represents nearly one fourth of all stillbirths in the world’s highest income nations. A school bus full every day. Between 2000 and 2015, the United States had the second to lowest annual reduction rate for stillbirth out of 49 high-resource nations. Two thirds of unexplained stillbirths occur after 35 weeks.

We are warned about many dangers in our children’s lives, but we really do very little to warn people about stillbirth, despite the fact that it is far more common than the things that we talk a lot about in terms of drowning, and gun safety, and fire safety, and especially, we’ll talk more about listeria and how well we educate moms about the hazards of unpasteurized milks and cheese.

The WHO and the CDC say that 2.6 million babies are born still worldwide. Stillbirth is a neglected tragedy. Since 1940s, dramatic improvements in maternity care resulted in a reduction in the occurrence of stillbirth. However, more recently that decline has slowed or halted. The CDC commits to engaging healthcare providers to raise awareness and provide education for families on the importance of stillbirth valuation.

Something that’s important to stillbirth. Something that’s a neglected tragedy. ACOG, surely, has given us some guidelines on how to prevent this from happening. There is nothing from ACOG to guide us on the management of decreased fetal movement or stillbirth prevention. No committee opinions, no practice bulletins, no practice advisories, no obstetrics consensus series, no task force reports.

Do providers educate patients about listeria and toxoplasmosis? I think we would all agree that we do a good job of that. Listeria. 675 cases of listeriosis were reported in the United States in 2014, 15% were associated with pregnancy, and a quarter of those resulted in loss. That led to 25 lost pregnancies that year. 25 versus 24,000.

Did ACOG help us with that? Yes, they did. Here’s the ACOG Committee Opinion #614. This shows us what to do if somebody is presumptively diagnosed with listeria. It also has an excellent summary of the foods that we should be educating patients about not to avoid eating. Pregnancy loss due to stillbirth is 1000 times more common than listeria. But remember, we have nothing from ACOG to prevent this.

I’m going to drive home this point. What about toxoplasmosis? I can gather that there is not a single pregnant woman in this country who doesn’t know that they shouldn’t change their cats litter box. We have educated our patients very well about this. 1 in 10,000 babies is born with severe congenital toxoplasmosis every year. There’s an estimated 400 to 4,000, but there is an ACOG practice bulletin #151 to address toxoplasmosis. The stillbirth rate is 60 times higher than that is of congenital toxoplasmosis.

One more time driving this home, what about Zika virus? This is what came out during the time of the Zika virus concern and look at all that ACOG gave us. There is more information that you could possibly gather to be able to say, “What do I do if a patient thinks she’s been exposed?” In 2017, CDC reported that 57 babies were born with anomalies from the Zika virus. In 2017, approximately 23,000 babies were born still.

There are good guidelines about the management of patients with listeria, toxoplasmosis, and Zika, and we could also add COVID to this, to prevent fetal morbidity and mortality. Why should stillbirth be handled so differently?

Room for improvement. Here’s where we are. This is from what I alluded to earlier that we are dead last in our annual rate of reduction from The Lancet series. I can’t gather that we’re ever going to be as good as Iceland or the Netherland or Denmark with their wonderful standardized medical care, but we can certainly do a little bit better. My hope and goal is that we can at least approach Australia and UK with use of this protocol.

This is from 2019 Star Legacy Summit. I’m actually in the back row there with blonde hair in the black sweater sitting next to the woman who’s standing with a drink in her hand. When I went to this conference, I really don’t know what I thought my goals were, but I thought I was going to meet a lot of people who were physicians, who had the same passion as I did for caring for women, who’ve lost a baby.

I went to the conference and started shaking hands of people. I was like, “Hi, nice to meet you. I’m Dr. Florescue. Everybody who shook my hand said that they were a lost mom, or they were a nurse, or they were a social worker. Around, probably, the first day of the conference, I went to look at the CME table and I was shocked at how few people were actually there getting continuing medical education. It really just made me be like, “I got to take in what’s happening.”

Then on the second day of the conference, Dr. Catherine Calderwood spoke, and I learned that what I had believed was completely not true. There’s a myth that if we don’t prevent the stillbirth, it was inevitable. Our prenatal care is so phenomenal that if any stillbirth happens, there’s nothing we can do. I learned that was completely untrue.

I got on the plane and I started fiercely writing notes. I was like, “You know what? I’m going to go, and I’m going to talk to everybody. Everybody’s going to be like, “Oh my God, I had no idea,” and the world was going to be a better place.” I can’t say it exactly ended the way I hoped, but I want to talk to you about how I think I made the practice that I work with a better place, and I hope it will go further from there.

What is the UK protocol? It’s based on the Scotland protocol that has led to a 30% reduction in the stillbirth rate. The protocol was implemented through the UK in 2010, and from 2010 to 2017, the stillbirth rate in the UK fell by 18%. What are the steps? The first step is to reduce maternal smoking including carbon monoxide monitoring. The second is to educate mothers about the importance of fetal movement. The third is to identify all fetal growth restricted babies. The fourth is a formal plan for maternal reported decreased fetal movement.

My practice is Women’s Gynecology and Childbirth Associates, WGCA, and for step one, to reduce maternal smoking, we identified all mothers who smoke at the beginning of the pregnancy. We ensured their smoking status is assessed regularly during prenatal care. Our local favorite high-risk OB Dr. Dan Grace worked on a plan for monitoring carbon monoxide management. And we ensured that women in the third trimester did receive a growth scan since smoking does increase the risk of stillbirth and fetal growth restriction.

Step two, by far the most important I think along with step four, in terms of making big changes from our current standard of care, is the education of that fetal movement. Known risk factors account for only 19% of stillborn babies at the time of diagnosis. Decreased fetal movement is thought to be a clinical manifest of the fetus reacting to nutrient and oxygen deprivation secondary to placental insufficiency.

What is the data? Fetal movement. 72% of women report some change in fetal movement in the days prior to their stillbirth diagnosis. 16% will also report an increase in fetal movement in the days prior to their baby’s death. In the UK, 57% of parents felt that their concerns regarding fetal movement were not listened to by their care providers. In the United States, 70% of families felt this way.

40% of women will be concerned about fetal movement at least once. 4 to 15% will contact providers because of a persistent decreased fetal movement in the third trimester. Interestingly, even if a mother presents and the fetus is still alive and she’s delivered, the mortality rate after birth is 8.2 per a thousand versus 2.9 per a thousand. Decreased fetal movement is associated with an odd ratio for stillbirth of 4.51. That is significantly higher than pre-eclampsia, gestational hypertension, and insulin dependent diabetes. 22% of cases of decreased fetal movement are associated with adverse outcomes, impaired growth, preterm delivery, neonatal depression, and emergency delivery.

What have we done in our practice? First thing is that we always make sure to use the stillbirth word. One of the things that is very clear is that women don’t even know stillbirth still happens. Therefore, they are surprised to learn that when they didn’t call about decreased fetal movement, that may have even been a risk factor because this didn’t happen anymore, so we use the word.

When I talk to women about this, I’m very clear that there’s evidence that we can probably prevent out 40% of term stillbirth, but never going to get to a hundred percent because I don’t want women to feel that if this protocol doesn’t work for them, it is their fault. We place signs in all of our bathrooms talking about fetal movements and kick counts. The kick count signs we use are the Count the Kick ones because that app is by far the most evidence based, and I think user friendly.

At 20 to 24 weeks and our third trim master talk as well, our nurses and providers are handing out cards about fetal movement, and we’re not just handing them and saying, “Here this is.” We’re handing it to them. We’re having them look at it. We’re talking about it. One of the big things I’m showing them about it is the myths that aren’t on there. Juice, crackers, even doing a kick count reduced fetal movement, because we just want them to call. That babies slow down closer to term. That they sleep for a long period of time.

We discuss that a concerning increase or no fetal movement are all risk factors for stillbirth. Most importantly, we tell them to trust their instincts and give us a call. We tell them don’t drink juice and crackers and lie down. Again, “Don’t do the kick count. You’re worried about your baby. We just want to hear from you.” Very standardized.

This is the standard prenatal flow sheet that we have. I just want to illustrate, again, the point that if you look at every part of this, from the weight to the blood pressure, to the urine, to what the RH status is, or the hemoglobin status, we know exactly what to do if those things aren’t right. We know exactly how to manage those. There’s nothing about how we manage the fetal movement education, or what we do when the complaint of decreased fetal movement occurs.

These are the cards that we’re handing out created by Star Legacy. They’re really very simple, hit all education levels. The other thing that you’ll see included in here is the Australian protocol has a fifth step, which is encouraging to go to sleep on the side. That is in there. I find this very similar to toxoplasmosis and listeria though. Again, all moms seem to be well informed that sleeping on their side is the. Actually, I like this because women will panic when they wake up in their back. I really like that this encourages patients that the side that you fall asleep on, about 70% of the time, you’ll spend your night there. You don’t have to worry if you wake up on your back. We have this translated into many different languages as well. In order to get these cards, you just go onto the online store, they are free, and they’re phenomenal.

What is step three? Is identifying all fetal growth restricted babies. A provider is assigned to review the charts of all the patients in the third trimester talk which we do around 32 weeks in our practice and order an ultrasound if indicated. Just a simple chart review. Per the UK protocol, we obtain an ultrasound for BMI greater than 35, and those with large myomas due to the inaccurate fundal height. We also are performing ultrasounds on our COVID exposed patients.

This is just a non-inclusive probably list of all the things that you might want to get an ultrasound on and reviewing those every time we do it, including as I said, COVID and pregnancy.

Step four. Again, I think this is the very oceanic change compared to standard prenatal care. When a woman calls her provider and says, “I’m worried about my baby’s movement,” she can get any of these responses. She can get, “I don’t know why you called me. That’s not anything to worry about, babies slow down at the end.” She can get the response of, “Drink some juice or crackers. Call me back if it’s not better.” She can get the response of, “Drink some juice and crackers, and I’ll call you back.” She can get the, “Do a kick count.”

It leaves the mother not knowing if one, she did the right thing, or two, giving her miss that then can lead to tragedy. When a patient calls our practice, we do the same thing every time. She calls, we start the flowsheet, an NST is automatically performed if appropriate gestational age. If there are risk factors for stillbirth, an ultrasound for fluid and growth is done within 24 hours even if there’s a reactive NST. If it’s non-reactive, then we have the plan. We do the BPP and react accordingly.

If the NST is reactive, we ask if the mom is reassured. If not, an ultrasound is performed in absence of risk factors, and we call the next day and continue to assess. If decreased or no fetal movement is recurrent or persistent, an induction after 39 weeks can be offered as well as frequent testing until that 39-week mark. We’ve actually had two patients who are so worried that we got MFM approval for 38 to 39 weeks.

This is what it looks like in our chart. This is directly the UK protocol and you’ll see that it says, ask, assess, act, advise, and follow up. It has all the check marks just to guide right through. Also the risk factors for growth restriction, but these are though the risk factors for stillbirth. Again, you’ll see multiple complaints of reduced stillbirth as well to catch anybody who didn’t initially fall into this.

Then this is what it looks like on our face sheet for our electronic record. You’ll see that you can see the antepartum record and then you can see that this patient presented three times for reduced fetal movement concerns. It’s just really nice because if I see this patient at 39 weeks, I can say, “I see you come in three times for this concern. Would you like to talk about maybe setting up an induction?”

I’d like to talk about how this would look before and after implementation. EM presented to our office at 37 and 4 days with her first baby. The baby is felt to be breech on exam. The ultrasound that day showed that 60% of EFW, AFI of 12 centimeters, and a normal urine R/M doppler. You’re probably asking, “Why was this performed?” It certainly wasn’t indicated, but the RIT student we had was there that’s a local ultrasound kind of education area. She wanted to play around and practice. She did this and it was normal. That was a Friday.

On Saturday, the patient had her baby shower and reports that she felt little to no movement, but she thought it was because she was running around, very busy, not paying much attention. On Sunday, she felt no movement as well, but she thought that because she had heard the baby sleep at the end, the baby was crowded and out of room and the baby was breeched that that was why she wasn’t feeling fetal movement. Then unfortunately she called us on Monday morning with her 48 hours of no fetal movement and fetal demise was diagnosed. Baby Sarah was born the following day and the cause of death was placental insufficiency due to maternal floor infarction.

I think the thing that everyone’s seeing, there’s two big takes on points from this. One, if this mother had been educated about fetal movement, the outcome very well could have been the same. The other thing is, the testing was very reassuring on that Friday. There was nothing to indicate that this baby was near to being stillborn.

This is post-protocol, and I think you’ll all see how much different this looks. SM reported to the office at 37 weeks and 1 day for a growth scan due to marginal cord insertion. The EFW was 45th percentile, AFI was 12. This baby was breech as well. Breech is not a risk factor for stillbirth. It just happens to be for both these scenarios, what we found.

The patient called at 37 weeks and 2 days with a complaint of decreased fetal movement. The protocol, she had an NST, which was reactive and because she had an ultrasound within 24 hours no further ultrasound was indicated at that point, and the patient said she was reassured. She called two days later at 37 weeks and 4 days with a complaint of pink discharge and no fetal movement. A speculum exam was performed showing no blood or evidence of rupture and there was a reactive NST. The patient stated, however, that she was not reassured this time that something was very wrong.

Based on this protocol, it had now been more than 24 hours from her last ultrasound, so a repeat fluid was done and 3.8 centimeters was found. So oligohydramnios. No two by two pocket was seen. A C-section was performed in the breech presentation for a healthy baby named Jane. The placenta showed a marginally increased twist index, basal chronic villitis, and an intervillous thrombi.

Why does this happen? Why do babies look okay a few days prior to when they either are impending stillbirth or impending oligohydramnios? I think Dr. Kleinman was the one who came up with an analogy. I apologize if it was somebody else, but I love it, so I’m going to use it. It was the low gas tank analogy. When we’re driving down the road and our car is very low on gas, we will still be driving 55 miles per hour. Our car drives exactly the same until it runs out of gas and then we stop.

I believe that is exactly what happened in these two scenarios. Even though the patient in the first scenario had a normal doppler, normal ultrasound three days before, and probably even maybe less, she passed that test, but something was wrong and the baby passed away. It was still going 55 miles per hour. It still passed a doppler, a fluid, and a growth check, but clearly the low gas warning was going off and the mother didn’t know it that weekend because she wasn’t educated.

Versus the second patient who received education and was encouraged to advocate for herself who knew that low gas warning was coming on, but she, instead of the first patient, was able to advocate for herself based on her education. Based on the protocol, we were able to discover the new onset oligohydramnios and have a healthy outcome.

Because it all comes down to this as well. What does a tracing look like before stillbirth occurs? Do we know? I think we’d all like to assume that it is the horrible tracing on the lower left or maybe the deep variables on the lower right. That when those moms come in with decreased fetal movement, of course, we’re going to deliver them right away. Maybe it’s just a minimal variability strip like on the top right. But what happens if it can look just like the one on the top left. A reactive tracing. We don’t know, because remember this may be very similar to the ultrasound that while that gas tank still has a little bit in it, the baby can still pass this test.

The goals we set up locally in Rochester and my practice were to make induction of labor for no or decreased fetal movement or persistent decrease movement non-elective after 39 weeks. We ensured communication between the attending provider at the time of the non-stress test to identify a patient presenting with a recurrent complaint of decreased fetal movement, inpatient or out, and make a plan for follow up. Give the chief complaint of change in fetal movement the same consideration that we give for headache, rupture membrane, preterm labor, and increased blood pressure, and ask and document if the patient feels reassured. If they don’t, we act on this.

The goal in Rochester and obviously now the whole country, my goal is to implement this UK plan in all outpatient places that provide prenatal care. Advocation efforts with ACOG to develop a practice bulletin for stillbirth prevention and decreased field movement evaluation and management to ultimately save baby lives.

I hope you’re left with the same feeling I got two years ago about why are we not making an effort in stillbirth prevention? Why are we not making effort? Why don’t we make an effort to tell every woman to make sure that her husband changes that litter box and that she doesn’t eat too much cold cuts or eat cheese with unpasteurized milk. I will conclude with that and thank you very much for having me talk today.

This presentation was part of the Stillbirth Summit 2021.   This individual lecture will be awarded .5 hours of continuing education credit to include viewing the lecture and completing evaluation and post-test.  Once received a certificate will be emailed to the address you provide in the post-test.  If you did not register for the Summit WITH Continuing Education, you can purchase the continuing education by clicking here.  This purchase will provide you access to all Stillbirth Summit 2021 lectures including continuing education credit. There is no charge for viewing the presentation.

To receive continuing education credit for this lecture, the participant must complete the evaluation and post-test.

Please feel free to ask questions of the presenter.  We will obtain their answers/comments and provide them here as received.  

6 Responses

  1. Annie Kearns
    have you noticed an increase in NSTs and/or ultrasounds done on the L&D floor because of this new flowsheet? How do your L&D colleagues respond to this increased volume of patients?

    1. Dr. Florescue’s reply:
      I think that the protocol does lead to increased testing, but delivery is only done with strong indicators so unindicated inductions before 39 weeks have not happened. We do all the daytime NSTs. L and D has been fine with the workups. I have worked hard to get them there with our chair’s support

  2. Jim Nicholson
    Based on the ARRIVE Trial and other recent research, why is IOL at 39 weeks classified as “elective” – several recent editorials in OB journals have stated that IOL at 39 weeks should be considered “preventive” of both C/S, PIH ……and would be prevent some stillbirths that would occur after 39 weeks. Comments?

    1. Dr. Florescue’s reply:
      I completely agree that delivery between 39-40 weeks is ideal and totally support that this is not elective, but resources to induce all women are a challenge. Many more RNs are needed to make this happen.

  3. Eilene Browne
    Would you please share a copy of your standardized fetal movement record that mom uses and the education she receives regarding fetal movement?

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