Care Around Stillbirth and Neonatal Death (CASaND) Clinical Practice Guideline

Approach to care  

Informed, sensitive, and specialised care benefits parents and optimises their short-term and longer-term health and social and emotional wellbeing.4,11 Care should start with a postpartum/preconception consultation following the death of a baby to discuss future pregnancy planning.8 This includes addressing modifiable risk factors (for example, smoking, obesity, and diabetes).11,13-15 Review of parents’ health and obstetric history allows healthcare professionals to anticipate and provide necessary care such as targeted support, referrals (such as to genetic counsellors)11 and further investigation into cause of death, if required or appropriate. Parents should be assured that their expectations and concerns can be revisited at future appointments, as these may change over the course of the pregnancy. Healthcare professionals and parents can work together to develop and follow an appropriate flexible plan that considers individual risk, parent preferences, and available resources.

Addressing management of future pregnancies is an important component of postpartum care following a stillbirth or newborn death.

It is important to acknowledge and consider the specific care and support needs of parents who are planning a pregnancy following termination of a wanted pregnancy for medical reasons. In these circumstances, parents often experience disenfranchised grief, societal stigma, and feelings of shame and guilt, which extend into subsequent pregnancies. Subsequent pregnancies may be characterised by high levels of anxiety and depression, particularly in the first trimester.16 It is crucial that all parents receive compassionate, trauma-informed care and nonjudgmental support that considers their previous loss, history of positive screening test results, and risk of recurrence of fetal anomaly and termination.16,17 Expressing understanding, and normalising and validating parents’ fears, concerns and worries is critical.18

Evidence-based recommendation 5.1

Evidence quality: Moderate confidence

Offer bereaved parents postpartum/preconception consultation(s) to discuss future pregnancy planning.

  • Provide information about the types of specialised care and support available that may benefit parents in a subsequent pregnancy.

The optimal interpregnancy interval for a pregnancy following stillbirth or neonatal death is unclear. Interpregnancy interval is defined as the time between the end of a pregnancy and the conception of a subsequent pregnancy.19-21 In a large international cohort study, parents who conceived within 12 months did not have increased risk of adverse outcomes (for example subsequent stillbirth, preterm birth, or small-for-gestational-age [SGA] birth) compared with parents who conceived within two to five years.19 Interpregnancy interval and subsequent birth outcome appear to be unrelated to gestational length of the previous pregnancy resulting in stillbirth.19 However, in an earlier systematic review an interpregnancy interval of less than 12 months was associated with increased risk of stillbirth, early neonatal death, preterm birth, and low birthweight,20 and a 2006 meta-analysis found interpregnancy intervals shorter than 18 months and longer than 59 months were associated with increased risk of preterm birth, low birth weight, and SGA.21

Parents often face challenges in planning and deciding on pregnancy after loss, including their desire for parenthood, fear and readiness6 and impact on the partner relationship. Understanding, through postmortem investigations, why their baby died is crucial for many parents and may inform the timing of a subsequent pregnancy.6

Evidence-based recommendation 5.2

Evidence quality: Moderate confidence

Support parents to plan the timing of a subsequent pregnancy, taking into consideration physical and emotional recovery and the circumstances of the previous birth.

Parents value acknowledgement of the unique challenges of pregnancy and  parenting after previous loss.10

Multidisciplinary models of continuity of care are associated with improved clinical outcomes for parents in a pregnancy following loss, particularly a reduction in risk of preterm birth and improved experience for the woman.7 Several specialist clinics dedicated to pregnancy after loss have been established in Australia and internationally to provide care from specialist obstetricians and midwives. For example, the Rainbow Clinic in the United Kingdom (UK) ensures each woman has a structured care plan to meet their clinical and counselling needs, and partners and extended family can also receive support.22 In 2018, a social return on investment analysis was conducted on the Rainbow Clinic to evaluate the effectiveness of this model of care in terms of social impact and health, wellbeing and social changes. For every pound invested in the Rainbow Clinic, £6.1 of value was derived for parents and staff.23

In Australia, the Pregnancy After Loss Clinic (PALC) at the Mater Mothers’ Hospital in Brisbane24 and the STAR (Stillbirth and Reproductive Loss) Clinic at the Mercy Hospital in Melbourne25 are examples of specialised clinics providing care to parents and families/whānau experiencing pregnancy following stillbirth or neonatal death. These clinics provide emotional and clinical care to parents and families within a multidisciplinary continuity of care model involving midwives, registrar, sonographer, counsellor, and consultant obstetricians. Care includes pre-pregnancy advice, investigation, and extra support through obstetric care, midwifery care, point-of-care ultrasound, and perinatal care. Individualised care plans include the availability of increased and flexible appointments, opportunity to contact healthcare professionals between appointments (for example telephone contact), individualised preparation for birth, and education and postnatal support that can benefit parents in a pregnancy following perinatal loss.11

Cultural considerations

Parents and families/whānau need to feel safe to express their cultural needs, traditions, and rituals. Culturally responsive care for parents and families/whānau in a pregnancy following loss can be achieved by:

  • avoiding cultural stereotypes and culture‐based assumptions
  • asking all parents whether they have any cultural, religious, or spiritual needs and related preferences for care (for example ethnicity or gender of interpreters)
  • offering to contact appropriate cultural support services on behalf of the parent
  • using language that is in line with health literacy and language needs
  • being aware that vulnerable groups may have a history of trauma and loss.26

Ask parents how you can better meet their cultural and spiritual needs and offer resources to enable these needs to be met.26

Parents living in rural and remote regions of Australia and Aotearoa New Zealand face unique barriers to accessing care and support during pregnancy. Telehealth is widely used for pregnancy care, although evidence of its effectiveness is limited. Preliminary evidence for use of telehealth applications in high-risk pregnancies indicates similar maternal and neonatal outcomes between telehealth and routine care.27 

Pregnancy after a stillbirth or neonatal loss may be a time of intense anxiety for parents and families/whānau.12 Healthcare professionals can assist discussions about the needs and expectations of parents and their family/whānau so that cultural respect for a deceased baby can be maintained in a subsequent pregnancy.

Multidisciplinary specialist care and cultural, religious, and spiritual care for parents and family/whānau should be discussed with the parents/family/whānau and previous pregnancies reviewed.1,5,28 For some populations within Australia and Aotearoa New Zealand, consanguineous unions are common,29 and cultural respect regarding this should be maintained.28

Evidence-based recommendation 5.3

Evidence quality: Moderate confidence

Provide care in a subsequent pregnancy within a continuity of care and carer model with a multidisciplinary focus and appropriate to cultural, religious, and spiritual needs of each family/whānau.

Evidence-based recommendation 5.4

Evidence quality: Moderate confidence

Acknowledge parents’ previous loss, including if and how they would like healthcare professionals to refer to their previous baby (for example by name).

Evidence-based recommendation 5.5

Evidence quality: Moderate confidence

Ensure effective referral pathways and appropriate handover and documentation processes are in place, with previous loss identifiable in medical records.

Care in subsequent pregnancies
Management of a subsequent pregnancy
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Western Pacific Regional Office of the International Stillbirth Alliance
Coordinating Centre, Stillbirth and Neonatal Death Alliance, Perinatal Society of Australia and New Zealand

Level 3, Aubigny Place
Mater Research Institute
Raymond Terrace,
South Brisbane QLD 4101
The University of Queensland Faculty of Medicine

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