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Induction and more monitoring needed to reduce stillbirth

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Reducing the risk of stillbirth requires better monitoring of women during pregnancy to help find those whose babies’ lives could be saved by early delivery, according to UK academics.

They suggested women should be induced when they reached term, especially if their infant was considered to be “small for gestational age”, to reduce the risk of stillbirth.

“Better ways of screening for small for gestational age are urgently required”

Gordon Smith

The “most promising” approach to screening for stillbirth risk may be to improve identification of small for gestational age infants, they said in the journal The Obstetrician & Gynaecologist.

The reviewers noted that in the UK the absolute risk of stillbirth is low – affecting approximately four in 1,000 babies, according to the recent Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRACE).

For most cases the exact cause of death was unclear, said the study authors, but they highlighted that stillbirth was associated with complications during childbirth, maternal infections during pregnancy, maternal health conditions, foetal growth restriction, and congenital abnormalities.

In particular, they noted that half of all stillbirths occurred in small for gestational age babies.

“Stillbirth rates are low in the UK but they could and should be even lower”

Louise Silverton

Review author Professor Gordon Smith, from Cambridge University, said: “While women should be encouraged to address risk factors such as smoking and obesity, the only way to prevent antepartum stillbirth in an otherwise apparently healthy infant is to induce delivery.

“Of course this requires identifying women at high risk and needs to be balanced against the risks inherent in early delivery and preterm birth,” he said.

“We know that careful and timely monitoring of small for gestational age babies using ultrasound measurements of placental blood flow helps reduce the risk of death,” said Professor Smith.

“However, routine care currently identifies less than a quarter of small for gestational age babies prior to delivery, so better ways of screening for small for gestational age are urgently required,” he added.  

Louise Silverton, director for midwifery at the Royal College of Midwives, said there was a “clear need for further research” on the subject.

“Stillbirth rates are low in the UK but they could and should be even lower,” she said.

“When the recent MBRACE report was published we stressed that there are clearly large numbers of women who should have additional surveillance throughout pregnancy,” said Ms Silverton.

“This includes those under 20 and over 40, women who are non-white whether UK born or not and those from socially disadvantaged groups,” she said. “More has got to be done for these women.

“There is also a pressing need to for maternity services to be reaching out to those women who are only engaging with maternity services late into their pregnancy or are poor attenders at appointments,” she said.

“Many units around the UK have no access at all to computerised monitoring”

Janet Scott

But she warned that midwives must also “have the time to do a thorough initial assessment of a woman”.

“We are concerned that the amount of time midwives have to do these assessments is being squeezed more and more,” she said. “Moving forward we must also ensure women have ongoing risk assessments during pregnancy.”

Janet Scott, research and prevention lead at the charity Sands, said the review’s focus on improving detection and timely delivery of these babies was “extremely important”.

She said the charity supported the call for a “more open approach to induction of labour at term”.

“Induction after 39 weeks gestation brings no increased harm to mother or baby, and significantly reduces perinatal mortality, so it is hard to see why this option is not made more frequently available to pregnant women,” she said.

Ms Scott also called for all maternity units to use computerised CTG (cardiotocography) for assessing babies’ wellbeing.

“Non-computerised CTG has significantly poorer outcomes, yet many units around the UK have no access at all to computerised monitoring,” she added.

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Readers' comments (2)

  • Customised growth charts are one way to drastically reduce still births

    Food for thought though - NICE guidance for low risk women does not recommend CTG monitoring - it is thought to cause harm and increase C section rates

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  • It would be a shame if all women had induced labour at 39 weeks gestation. Surely it would be better to offer all women closer monitoring from 38 weeks onwards to identify those pregnancies that have a higher risk of stillbirth or problematic births. Women who have experienced a normal spontaneous labour and also an induced labour will tell you that the induced labour is more stressful and more painful. It is more likely to require powerful pain relief or an epidural, therefore removing the 'normal' from the equation.

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