Looking for our parents page?
See stillbirthcre.org.au/parents
Parents with a history of stillbirth are at an increased risk of stillbirth and other complications in subsequent pregnancies, including pre-eclampsia, SGA, fetal growth restriction (FGR), placental abruption, fetal distress, chorioamnionitis, preterm birth, and neonatal morbidity and death.10,11 Strategies for reducing the risk of adverse outcomes in a subsequent pregnancy include addressing modifiable risk factors, monitoring the pregnancy (for example using ultrasound), and considering timing/mode of birth for the current pregnancy.
Getting the results of postmortem investigations was of paramount importance for couples whose babies had a genetic or congenital anomaly.
“…having a reason of course is huge. It was a 4% chance of it happening again.”
Bereaved parents, daughter stillborn.5
Modifiable risk factors for stillbirth include overweight (body mass index 25 to 29.9 kg/m2) and obesity (body mass index ≥30 kg/m2), smoking, FGR, hypertension, and diabetes.7,11,30 Risk mitigation strategies should begin from the postpartum/preconception counselling visit and continue through subsequent pregnancies.
Evidence-based recommendation 5.6
Evidence quality: Moderate confidence
Review maternal risk factors and results of investigations from the previous pregnancy, with detailed clinical history and information from parents, to identify risks and opportunities to improve outcomes.
Evidence-based recommendation 5.7
Evidence quality: High confidence
At the initial antenatal care visit, explore parents’ expectations, concerns, and support needs including:
Consensus-based recommendation 5.8
Consider early screening for gestational diabetes mellitus (GDM) in addition to routine screening at 26–28 weeks for women with a previous unexplained stillbirth.
Fetal monitoring frequency and schedules should be based on obstetric history, screening findings, and parental preferences.2,11 Women with a history of stillbirth with or without SGA/FGR may be at risk for FGR in the subsequent pregnancy and may benefit from serial growth ultrasound. Recommended monitoring and management of these pregnancies includes consideration of fetal growth ultrasound every 4 weeks from 24 weeks gestation, with additional ultrasounds as clinically indicated and standardised serial symphyseal fundal height (SFH) measurements at each antenatal visit from 24 weeks gestation. Serial fetal biometry measurements are recommended for detecting SGA/FGR.31,32 Additional ultrasound investigations such as uterine artery Doppler, middle cerebral artery Doppler, cerebroplacental ratio and ductus venosus Doppler may be used to assist in the investigation and management of established FGR.7
Parents may benefit from additional support or scans at significant milestones in the pregnancy (such as at the gestational age at which their previous baby died). However, some parents may prefer not to have a scan unless it is clinically indicated9,31,33 because increased monitoring and scans may provide only temporary reassurance and increase anxiety and fear.2,11,31
Maternal perception of decreased fetal movement often precedes stillbirth.34-36 All pregnant women should be routinely provided with verbal and written information about fetal movement, including what is considered normal, and what to do if fetal movements stop, decrease11,37-39 or change. All women who report a concern about fetal movements to their healthcare professionals should be invited to the health service for assessment without delay.37,40,41 The benefit of remote home monitoring is yet to be established in high-risk pregnancy populations and for women in pregnancies following loss.42
Consensus-based recommendation 5.9
Determine fetal monitoring frequency based on obstetric history, the circumstances surrounding the index stillbirth or neonatal death, screening findings, and parental preferences.
It is recognised that low-dose aspirin (LDA) is frequently used in clinical practice and there is no strong evidence of harm associated with its use. While LDA to prevent preterm pre-eclampsia is well established,32,43,44 its routine use is not indicated for women with a history of stillbirth without other risk factors for preterm pre-eclampsia. There is no high-level evidence to support the use of LDA to prevent FGR and therefore there is practice variation.45 In NZ, the Small for Gestational Age and Fetal Growth Restriction Clinical Practice Guideline46 does recommend LDA to reduce the risk of developing FGR.
Consensus-based recommendation 5.10
Consider the use of low dose aspirin (LDA) prophylaxis in a pregnancy following loss if preterm pre-eclampsia, or other forms of placental dysfunction, was evident.
Low-molecular-weight heparin (LMWH) may be prescribed with the primary aim of preventing fetal complications among women with a history of stillbirth, although currently there is no high-level evidence for this use.47 However, LMWH should be considered for women at high risk of maternal venous-thromboembolism due to antiphospholipid syndrome.47 Further, unfractionated heparin (UFH) or LMWH given in combination with aspirin during pregnancy may increase live birth rates among women who have persistent antiphospholipid antibodies. However, this finding is from one study and the comparator was aspirin treatment alone.45
Consensus-based recommendation 5.11
It is not recommended to routinely offer women low-molecular-weight heparin (LMWH) in pregnancies following stillbirth, unless there are other medical considerations or thrombophilia is present.
Healthcare professionals and parents should engage in open discussions and parent-centred decision making about the timing and mode of birth in subsequent pregnancies.11 Currently, giving birth at 39 weeks’ gestation or beyond is recommended unless earlier birth is medically indicated.15 Emotional support is crucial for parents who have previously experienced stillbirth, and early birth may be required. For some parents, early term birth may be an opportunity for reducing risk of stillbirth, but this must be balanced with the risks of adverse outcomes for the newborn.11,15
It is important for parents to receive care from consistent caregivers familiar with their prior experiences, plans, and birthing decisions to reduce distress and improve feelings of security.24
There is no evidence about the role of caesarean birth for non-medical reasons in reducing perinatal death or morbidity for women with a history of stillbirth.1 The option of a planned caesarean birth should form part of the parent-centred decision-making process.31 Women who have experienced a previous intrapartum stillbirth may be more likely to choose a planned caesarean birth.1
Evidence-based recommendation 5.12
Evidence quality: Moderate confidence
To support parent-centred decision making, discuss timing and mode of birth and consider the circumstances of the previous stillbirth or neonatal death, current pregnancy, and emotional state of parents:
Evidence indicates that specialist antenatal classes for bereaved parents are rarely provided, despite the benefits of group-based/peer antenatal support and education programmes for parents who have experienced loss.9
Evidence-based recommendation 5.13
Evidence quality: Moderate confidence
Offer parents individualised preparation for birth including:
Level 3, Aubigny Place
Mater Research Institute
Raymond Terrace,
South Brisbane QLD 4101
The University of Queensland Faculty of Medicine
