Stillbirth and perinatal bereavement

• Stillbirth is the death of a baby in the uterus before birth: after 24 completed weeks in the UK, 20 weeks in the US, and counted from 28 weeks in many global comparisons. ^{[1][2][4] [9]}
• About 2.6 million babies are stillborn each year worldwide, and the number has not fallen as fast as maternal or under-5 deaths. ^[4][6]
• More than 40% of stillbirths occur during labour and birth; good intrapartum care could prevent an estimated 1.3 million of them. ^[3][4]
• A cause can be suggested in up to three-quarters of late stillbirths when investigation is thorough: placental failure, maternal disease, infection, fetal abnormality, cord compromise or labour complications. ^[1]
• Induction with a single 200 mg dose of mifepristone followed by misoprostol by gestation is first-line, and vaginal birth is recommended for most women. ^[1]
• Bereavement care, clear communication and memory making shape grief for years afterwards; many parents regret not being offered these choices.
• The next pregnancy needs psychological and medical care together, with continuity of caregiver and clear discussion of what is known and unknown from the previous loss.

By the end of this page you should be able to:

1. Define stillbirth and the gestational cut-offs used in the UK, the US and global reporting.
2. Explain the main causes and risk factors, distinguishing antepartum from intrapartum deaths.
3. Plan the investigation of a stillbirth, stating what each test can and cannot answer.
4. Induce labour after stillbirth safely, choosing misoprostol doses by gestation and discussing mode of birth.
5. Communicate the diagnosis, support memory making, and plan follow-up and the next pregnancy.
6. Recognise regional, cultural and low-resource differences in stillbirth and bereavement care.

An earlier spontaneous death between viability and these cut-offs is usually called a miscarriage or mid-trimester loss. The World Health Organization and UNICEF count stillbirths from 28 weeks for international comparison, which is why a global figure of about 2.6 million stillbirths is so much larger than a high-income count would be.

Stillbirth is not a single diagnosis. It is the final common pathway of several processes: placental failure, maternal disease, infection, congenital abnormality, cord compromise and events during labour. ^[4]

A stillbirth is classified by timing:

• Antepartum: the baby died before labour started. Most stillbirths fall in this group.
• Intrapartum: the baby died during labour. More than 40% of all global stillbirths occur during labour and birth, and these are the deaths most preventable by high-quality intrapartum care. ^[3][4]

Stillbirth rates vary more than almost any other perinatal outcome, between and within countries. Burden and colleagues report rates from 2.0 per 1000 total births in Finland to ^[7] 4.6 per 1000 in the United Kingdom and more than 40 per 1000 in Nigeria, Ethiopia and ^[7] Pakistan. ^[7]

Globally, about 2.6 million third-trimester stillbirths occurred in 2015, essentially ^[4] unchanged since 2011, while maternal and under-5 mortality fell. ^[4][6] WHO and UNICEF estimate about 2 million stillborn babies per year using the 28-week ^[3] definition, one every 16 seconds. ^[3] Ninety-eight percent of stillbirths are in low- and middle-income countries and about two-thirds occur in rural families. ^[7] Three-quarters of all global stillbirths occur in sub-Saharan Africa and Southern Asia. ^[3]

High-income countries carry a far smaller share but have not eliminated the problem. Flenady and colleagues calculate that if every high-income country matched the rate of the best performers, 19 439 late-gestation (28 weeks or more) stillbirths would have been ^[5] avoided in 2015. Substandard care contributes to 20-30% of all stillbirths there, and the ^[5] share is even higher for late-gestation intrapartum stillbirths. ^[5]

Within countries, inequity matters. In high-income countries a woman living under adverse socioeconomic circumstances has twice the risk of a stillborn baby compared with more advantaged women. ^[5] Improved care at birth could prevent an estimated 1.3 million intrapartum stillbirths per year. ^[4]

No single cause applies to most stillbirths. The overall figures hide many overlapping pathways. In rural and disadvantaged settings, infection and poor access to care dominate; in urban high-income settings, maternal age, obesity, diabetes and assisted reproduction feature more prominently.

• Maternal disease: pre-existing or gestational diabetes, chronic hypertension, pre-eclampsia, systemic lupus erythematosus and antiphospholipid syndrome, renal disease, thyroid disease.
• Infection: malaria (population attributable fraction 8.0%), syphilis (7.7%), ^[4] parvovirus B19, cytomegalovirus, listeria, group B streptococcus and other TORCH infections are all potentially modifiable causes. ^[4]
• Age: maternal age above 35 years contributes about 6.7% of stillbirths; outcomes are ^[4] worse at the extremes of reproductive age. ^[4]
• Nutrition and lifestyle: under- and over-nutrition, micronutrient deficiency, smoking, alcohol and substance use (each contributes roughly 10%). ^[4]
• Obesity, previous adverse pregnancy history, nulliparity, assisted reproduction, multiple pregnancy, and unmarried status are consistently reported risk factors. ^[2]
• Prolonged pregnancy (post-dates) contributes an estimated 14.0% of stillbirths. ^{[4] [4]}
• Social deprivation: adverse circumstances double the risk in high-income settings. ^{[5] [5]}

• Placental failure and fetal growth restriction (FGR): Lawn and colleagues describe impaired placental function, often together with FGR or preterm labour, as a central pathway in stillbirth. ^[4]
• Placental abruption and placenta praevia are acute placental events.
• Congenital abnormalities: in 18 countries with reliable data, anomalies account for a ^[4] median of only 7.4% of stillbirths. Many are lethal chromosomal or structural abnormalities; a few are treatable. ^[4]
• Infection of the fetus (congenital infection, chorioamnionitis) causes both preterm and term stillbirths.
• Cord events: true knot, nuchal cord with obstruction, cord prolapse, vasa praevia, velamentous insertion.
• Isoimmunisation (rhesus disease) is now uncommon where anti-D is given.
• Multiple pregnancy carries higher stillbirth rates at all gestations.

• About two-thirds of all stillbirths in high-income data sets are antepartum; the remainder occur in labour.
• Intrapartum stillbirths cluster where access to emergency obstetric care is poor, and the risk is highest for the baby who is already small. ^[4][5]

The mechanism is almost always hypoxia, preceded by a period of chronic compromise in antepartum deaths and an acute event in intrapartum ones.

1. Chronic placental insufficiency (FGR, hypertensive disease, smoking, maternal diabetes with vascular disease) reduces utero-placental perfusion. The fetus adapts with redistribution of blood flow, rising umbilical resistance and falling amniotic fluid; if stress continues, cardiac decompensation and death follow.
2. Acute placental or cord events (abruption, cord prolapse, vasa praevia) cut oxygen delivery within minutes.
3. Infection and inflammation (chorioamnionitis, congenital infection) cause fetal inflammatory response and multi-organ injury.
4. Maternal medical disease (severe pre-eclampsia, diabetic ketoacidosis, arrhythmia) can precipitate sudden fetal compromise.
5. Congenital abnormality or severe anaemia (parvovirus, isoimmunisation) may kill without any placental failure at all.

These mechanisms explain the clinical picture: reduced fetal movements as the fetus becomes acidotic and quiet; a growth-restricted baby that stops growing; a single acute catastrophe in a previously well, large baby.

Stillbirth is usually detected by absence of fetal movements, suspected before the hospital visit. Many women have a premonition that something is wrong; reduced or absent fetal movements, a feeling of heaviness and a loss of normal pregnancy symptoms are common. ^[8]

Some stillbirths are found at routine antenatal appointments, in women who felt well and reported normal movements until shortly before the diagnosis. A few present in labour with an abnormal or absent fetal heart rate.

Diagnosis is confirmed by real-time ultrasound: no fetal cardiac activity, no movement, and corroborating findings (absent Doppler in the umbilical artery, skull signs of maceration). Cardiotocography alone should never be the only test in a woman reporting absent movements, because fetal sleep can mimic a trace.

Once IUFD is confirmed, look immediately for conditions that change management:

• Pre-eclampsia or eclampsia
• Sepsis or chorioamnionitis
• Placental abruption with bleeding and coagulopathy
• Diabetic ketoacidosis
• Prolonged retention (more than the supporting sources specify), where coagulation may become disturbed

RCOG focuses clinical and laboratory assessment on maternal wellbeing, including coagulopathy, and on determining the cause of death, the chance of recurrence, and how future complications might be avoided. ^[1]

The way the diagnosis is communicated is not an afterthought. Ellis and colleagues found that staff behaviours have a memorable impact on parents in 53% of included studies, and ^[8] that clear, structured information given sensitively helps parents through the experience.

Practical points supported by their review:

• Name the finding directly and in simple words; silence while scans are interpreted is frightening to parents. ^[8]
• Give time, space and options rather than one instruction. ^[8]
• Stay in the room for a while after giving the diagnosis; leaving immediately was reported as abandonment, while staying and acknowledging the loss was valued. ^[8]
• Use eye contact, plain language and non-verbal acknowledgement; parents noticed when staff avoided them. ^[8]
• Acknowledge both parents as parents, especially fathers, whose fatherhood was often not recognised. ^[8]
• Do not say "you can have another" or "at least you have other children"; parents found these comments the most hurtful. ^[8]
• Acknowledge uncertainty honestly and commit to follow up. ^[8]

The confirmatory question is not "what else could this be" but "is the baby truly dead?". Technical and observer errors do occur, especially with maternal obesity and anterior placenta. Always confirm with a second experienced operator if there is doubt, and repeat the scan if the picture is unclear.

When a woman presents with reduced fetal movements, the possible explanations include benign fetal sleep, maternal inattention, polyhydramnios, a placental problem, an anomaly or, rarely, an at-risk fetus. Reduced fetal movement itself is a marker that must be taken seriously, and women reporting it should never be sent home reassured without assessment: many women in Ellis's review "suspected something was wrong" before diagnosis and felt disregarded. ^[8]

Maternal symptoms that accompany or explain the loss include collapse from haemorrhage, seizure from eclampsia, fever from chorioamnionitis, and hyperglycaemia or ketoacidosis.

The goals are three: to confirm the death and the mother's condition; to determine the cause and chance of recurrence; and to provide parents with answers, even when the answer is that none was found.

• Real-time ultrasound with Doppler for fetal cardiac activity, movement and liquor.
• Maternal vital signs, blood pressure and urine (pre-eclampsia).
• Full blood count, group and antibody screen, coagulation screen (Consumption coagulopathy is a real risk and is specifically mentioned in the RCOG guidance). ^[1]
• Infection screen (temperature, maternal symptoms, midstream or high vaginal swab, toxoplasma/CMV/parvovirus serology where available, syphilis and malaria tests in endemic areas). ^[4]

• Placental examination: macroscopic and histological examination of the placenta, cord and membranes. Essential in almost every case; a large share of answers lie here. ^[2]
• Fetal postmortem (autopsy): the most informative single test when parents consent. ACOG lists fetal autopsy as part of evaluation; RCOG states that postmortem can provide information sometimes crucial to managing the next pregnancy. ^[1][2]
• Cytogenetic testing of the baby, performed after written consent, covers chromosomal abnormalities. ^[1]
• Genetic evaluation more broadly, including microarray or targeted testing, where a structural abnormality or a family history suggests it. ^[2]
• Maternal tests: oral glucose tolerance test or HbA1c for diabetes, renal and thyroid function, and autoimmune and thrombophilia panels where the clinical picture points to them. Many of these are guided by local protocols rather than by a single global standard.

Parents should be told that full investigation (including postmortem and placental histology) finds a possible or probable cause in up to three-quarters of late IUFDs. ^[1] Even so, a significant proportion of stillbirths remains unexplained. Both statements are true and need to be held together. ^[2]

Ellis's review lists tailored post-mortem discussions, post-natal information and giving options and time as recurring themes. ^[8] Parents who were not offered an autopsy expressed regret; parents who had one expressed none. ^[8] Parents should be given written information as well as spoken discussion, and enough time to decide, including the option of a limited or targeted examination if a full post-mortem is declined.

• Some parents will refuse a full postmortem. Offer a limited, external or imaging examination, and palpation or photography if that is all they can accept. The aim is to obtain the maximum information consistent with their wishes.
• Explain turn-around times for results honestly, because delayed and inconclusive results are a documented source of distress. ^[8]
• Decisions about disposal, burial, cremation and funeral should be offered with clear information on local law and costs. ^[8]

There is no scoring system for stillbirth itself, but uniform classification matters: reporting a death as "unexplained" hides avoidable causes. The Stillbirth Collaborative Research Network, CODAC, ReCoDe and the WHO application of ICD-10 to perinatal deaths (ICD-PM) are the commonly used frameworks; WHO provides a standard classification for perinatal deaths through ICD-PM. ^[3] In practice, the bedside task is to determine whether the death was antepartum or intrapartum and to record the best estimate of cause; both guide prevention next time.

Maternal wellbeing comes first. Then the baby. The RCOG guidance expects that the environment provides adequate safety according to clinical circumstance while meeting the parents' needs to grieve and feel supported. ^[1]

Immediate steps:

1. Confirm death on ultrasound with a second observer if possible.
2. Assess the mother for bleeding, hypertension, sepsis, pre-eclampsia, diabetes and coagulopathy.
3. Start an intravenous line, cross-match if bleeding is heavy, and give anti-D if she is rhesus-negative.
4. Break the news using the communication principles above, and do not rush to a plan before parents have had time to absorb it.
5. Move her to a quiet private room away from the newborn area. ^[8]

Vaginal birth is recommended for most women, but caesarean birth will need to be considered for some. A detailed informed discussion should cover both the physical and the psychological aspects of vaginal birth versus caesarean birth. ^[1]

The RCOG guideline gives first-line pharmacological induction:

• A single 200 mg oral dose of mifepristone (a progesterone-receptor antagonist that ^[1] softens the cervix) followed by misoprostol, with the misoprostol dose by gestation:
  • 24+0 to 24+6 weeks: 400 micrograms buccal, sublingual, vaginal or oral every 3 hours
  • 25+0 to 27+6 weeks: 200 micrograms by the same routes every 4 hours
  • from 28+0 weeks: 25-50 micrograms vaginal every 4 hours, or 50-100 micrograms ^[1] oral every 2 hours ^[1]

There is insufficient evidence for a specific misoprostol regimen above 28+0 weeks in ^[1] women with a previous caesarean or transmural uterine scar. Women with more than two lower segment caesarean births or atypical scars should be advised that the safety of induction is unknown. ^[1]

Other management points supported by the guidance:

• Delivery timing: RCOG leaves method and timing to shared decision-making, taking account of gestational age, previous intrapartum history and the safety of induction. ^[1]
• Expectant management is reasonable for some parents after a recent stillbirth, especially with a previous caesarean, but induction avoids prolonged retention and the anxiety that accompanies waiting.
• Prevention of haemorrhage: induction after fetal death can be associated with atonic postpartum haemorrhage; active third stage and uterotonics should be used.
• Infection: if chorioamnionitis is present, give antibiotics and expedite birth.
• Disposition of the baby: parents must be given choices about seeing, holding, washing, dressing, naming and taking the baby home, with skilled support. ^[8]

Communication is clinical care. The same behaviour that hurts on the delivery suite also makes news of the cause bearable months later.

Key principles drawn from the Ellis review:

• Explain what is happening and what happens next, because uncertainty about duration and next steps was a repeated source of distress. ^[8]
• Use plain words; technical terms during the scan frightened and excluded parents. ^[8]
• Offer presence, not just privacy: parents who reported negative care described staff leaving the room immediately after the diagnosis; those reporting positive care described staff staying for a while. ^[8]
• Recognise both parents as parents, including fathers. ^[8]
• Avoid hurtful reassurance. ^[8]
• Ask parents what they already suspect and what they most fear; many feared the baby would be deformed or monstrous and had not voiced this aloud. ^[8]
• Give structured information at appropriate times rather than all at once. ^[8]

Memory making is the part most parents value most, and the one most often done late or not at all. In Ellis's review, supporting memory making was a theme in 53% of included ^[8] studies, the highest frequency for a single care theme. ^[8]

Memory making means helping parents meet and remember their baby as a person, not as a clinical specimen. It is parent-led, and all consents should be explicit. Items offered (where available) include:

• Seeing and holding the baby, with unhurried time and help covering any deformity
• Photographs (including professional bereavement photography where available)
• Hand and foot prints, foot casts, locks of hair
• A blanket, hat, certificate, candle or star, and a memory box
• Naming, baptism, blessings or other religious or cultural rituals according to parental wishes
• Inviting family members or siblings if parents want this
• Bathing and dressing the baby, and taking the baby home for a time

Several points from the literature:

• Offer these choices more than once, gently and without pressure; some parents need time to be ready. ^[8]
• Many parents who initially declined to see their baby later regretted it, because no one had told them it was permissible or what the baby would look like. ^[8]
• Seeing and holding the baby, and finding family traits, brought some parents a sense of pride and helped them cope. ^[7]
• In low- and middle-income settings, stigma, beliefs in evil spirits or maternal sin, and fear of disapproval can prevent parents from seeing, naming or mourning their baby; care must therefore be culturally and religiously adapted and stigma actively reduced. ^[7]
• Sensitive, assumption-free practice matters: some parents only want to see parts of their baby, and consent is needed before taking any memento. ^[9] (Frontiers review of 16 bereavement guidelines identified memory making as the most frequently ^[9] cited intervention across stillbirth guidelines.)

Memory making is not just a ritual. Burden and colleagues found that the opportunity to say goodbye, make memories and, where agreed, have a post-mortem examination contributed a sense of finality that aided healing. ^[7]

• Coagulopathy: a retained dead fetus can disturb clotting. Check coagulation in every case before and after delivery and treat early. ^[1]
• Haemorrhage: atonic postpartum haemorrhage is a recognised risk after induction in this setting; active management of the third stage is essential.
• Infection: sepsis and chorioamnionitis worsen outcomes and make induction urgent.
• Psychological morbidity: up to 5-19% of women develop a clinically diagnosed ^[9] depressive disorder after miscarriage or stillbirth, and symptoms of grief and distress ^[8] are considerably more common and may last from months to years (Burden 2016; Frontiers review). ^[7][9] Single studies report prolonged grief in up to 25% years later in some cohorts. ^[8]
• Grief suppression: fathers in particular often feel obliged to be the strong one; suppressed grief raises the risk of chronic psychological problems. ^[7]
• Substance use, employment and financial problems: more commonly reported in fathers and in low-resource settings. ^[7]
• Relationship strain: incongruent grieving styles between partners are documented; some couples become closer, others experience breakdown. ^[7]
• Disenfranchised grief: when society, families or clinicians do not acknowledge the stillbirth as a real death, distress is greater. ^[7]
• Subsequent pregnancy complications: anxiety, reduced bonding, and increased use or avoidance of healthcare services are common. ^[7][8]

Whether parents get answers depends on investigation. In up to three-quarters of late IUFDs a possible or probable cause can be found when investigation is full. ^[1] In many more, the death remains unexplained even after a thorough evaluation, which is not the same as "no cause existed" and should be discussed honestly. ^[2]

For the next pregnancy:

• Most women (a large majority) who lose a baby to stillbirth go on to have a live birth.
• The recurrence risk is individual. Flenady notes that socioeconomic adversity doubles risk in high-income settings, which implies that modifiable factors (smoking, pre-eclampsia, FGR, diabetes control, access to care) matter. ^[5]
• Anxiety and depression in subsequent pregnancy are common and may need treatment. ^[7]
• Tailored antenatal care with continuity, usually with more frequent visits and monitoring agreed locally, reduces anxiety and improves engagement. ^[8]

Most stillbirth prevention is good-quality maternity care delivered consistently.

• Intrapartum care is the highest-yield step globally: improved care at birth prevents an estimated 1.3 million intrapartum stillbirths a year. ^[4]
• Antenatal care with enough contacts for screening and counselling, including iron and folate, infection screening and management of maternal disease.
• Modifiable maternal conditions: malaria and syphilis treatment, glucose control, blood pressure management, weight and smoking advice, and treatment of anaemia. ^{[2] [4]}
• Fetal growth surveillance: since FGR is the commonest identifiable pathway, combining symphysis-fundal height, risk factors and serial ultrasound improves detection; planned early delivery of the growth-restricted term baby is the logical next step.
• Post-dates management: prolonged pregnancy contributes about 14.0% of stillbirths; induction by the agreed due date policy is prevention. ^[4]
• Decreased fetal movement awareness: women should be told to report it and taken seriously; staff in experienced practice miss or dismiss it, and many mothers later say they knew something was wrong. ^[8]
• Audit and learning: local and national perinatal mortality audit, better classification, truthful registration of all stillbirths, and inter-professional review. ^[5]
• Address stigma and taboos, particularly in low- and middle-income settings, so deaths are registered and parents seek care. ^[3][7]

• Low- and middle-income settings: 98% of stillbirths occur there; malaria, syphilis, ^[4] malnutrition, unattended birth and transport delays dominate. Prevention is intrapartum care, antenatal contact and infection control. ^[3][4]
• Multiple pregnancy with a surviving co-twin: the RCOG Green-top Guideline No. 55 explicitly excludes this; management is specialist and differs.
• Previous caesarean: RCOG warns there is insufficient evidence for misoprostol regimens above 28 weeks after caesarean or transmural scar; women with more than two lower segment caesareans or atypical scars should be told induction safety is unknown. ^{[1] [1]}
• Parents with mental health difficulties: depression and anxiety are common after stillbirth and in subsequent pregnancy; referral to bereavement counsellors, support groups and mental health professionals is advisable, and pharmacotherapy may be needed. ^{[2] [9]}
• Fathers and partners: they grieve, often differently, and are at risk of suppression, substance use and employment problems; remember to ask. ^[7]
• Siblings and subsequent children: attachment and anxiety can be affected long-term; postnatal and childhood support helps. ^[7]
• Advanced maternal age: increases risk and is not modifiable; counsel, do not blame.

Where tests and drugs are scarce, the priorities are the ones that save lives:

• Detect and act on reduced fetal movements; encourage women to come early and take them seriously when they do. ^[8]
• Birth with a skilled attendant and a partograph or equivalent intrapartum monitoring. ^[4]
• Antenatal infection control where malaria and syphilis are endemic. ^[4]
• Register every birth and every stillbirth; fewer than 5% of neonatal deaths, and ^[4] even fewer stillbirths, are registered in some settings. ^[4]
• Consent-based postmortem is often impossible; clinical and placental examination carried out with care, and photography, can still provide answers.
• Bereavement care must be culturally adapted: family, faith leaders and community stakeholders help reduce stigma. Memory making can be simple, respectful and low-cost. ^[7]
• Mental health and follow-up often depend on peer support organisations; connect families to them.

• Stillbirth is death in utero before birth, cut off at 24 weeks in the UK, 20 in the US and 28 in global comparisons. ^[1][2][4]
• About 2.6 million babies are stillborn each year and the figure has stalled while other maternal and child outcomes improve. ^[4][6]
• Ninety-eight percent occur in low- and middle-income countries and three-quarters in sub-Saharan Africa and Southern Asia. ^[4][7]
• More than 40% occur during labour; good intrapartum care prevents roughly 1.3 million per year. ^[3][4]
• Causes are heterogeneous: placental failure, maternal disease, infection, fetal abnormality (median 7.4% in well-documented settings), cord accidents and labour complications. ^[2][4]
• Modifiable contributors include malaria (8.0%), syphilis (7.7%), nutrition and lifestyle (about 10%) and prolonged pregnancy (14.0%). ^[4]
• Confirm fetal death on ultrasound and check maternal coagulation, infection and blood pressure before anything else. ^[1]
• First-line induction is mifepristone 200 mg orally once plus gestation-specific ^[1] misoprostol; vaginal birth is recommended for most women. ^[1]
• Caesarean is reserved for standard obstetric indications, previous scar and informed parental request after discussion. ^[1]
• Full investigation finds a possible or probable cause in up to three-quarters of late ^[1] IUFDs, so consented postmortem and placental histology should be offered. ^[1]
• Memory making and bereavement care have the largest and most durable impact on parents; offer photos, prints, hair, time with the baby and choices about naming and ritual, more than once. ^[7][8]
• Communication is clinical: presence, plain words, no hurtful reassurance, and honesty about uncertainty. ^[8]
• The next pregnancy needs early engagement, continuity of caregiver, risk-factor control and psychological support, without implying that the grief will simply be replaced. ^{[5] [7] [8]}
• Local and national perinatal mortality audit, better classification and de-stigmatisation are part of prevention. ^[3][5][7]

Stillbirth risk factors overlap with fetal growth restriction, hypertensive disorders of pregnancy including pre-eclampsia, gestational diabetes, antepartum haemorrhage, preterm labour, chorioamnionitis, vasa praevia, rhesus isoimmunisation, and maternal mental health after childbirth. Preconception care, bereavement care and neonatal death are closely related reading.

Across settings, a single clinician who listens, names the baby, stays in the room and explains is the intervention with the largest effect size in the bereavement literature; it costs nothing but training and culture. ^[8]