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

Labour and birth

The optimal mode of birth following the death of an unborn baby or when a baby is expected to be born with a life-limiting condition is one that combines medical considerations and parent values, preferences and wishes. However, achieving an approach that balances parent-directed choice and professional care in the highly stressful, emotive, and time-pressured circumstances can be challenging.28 If the baby has died or if a life-limiting condition is known before labour has started, parents’ involvement in decision making around the timing, mode and place of birth can help to increase their sense of empowerment and control and will allow for practical, social, and emotional planning.

It is important to provide parents with options and information at all stages, including what might happen when giving birth to a baby who is going to be stillborn. Ensure that information is applicable to each parent’s situation.29 Information around labour and birth, including pain relief options, should be given in a range of formats bearing in mind that parents often report impaired clarity of thought in stressful and emotive situations. Parents should be given as much time as they need to make decisions about options offered.30

When a baby is not expected to survive for long after birth, a driving factor for mode of birth may be the parents’ wish to have time together with their baby while alive. This may also be an important consideration for religious or cultural ceremonies. There is wide agreement that, in such instances, caesarean birth should be provided as an option, together with appropriate discussion to ensure the parents are aware of the risks associated with this option.

“I think having choice helped us feel in control and helped us also to feel like parents, that we weren’t just suddenly the rejects if you like and having things done to us, we still had a say in how our daughter was born.”

Bereaved parent, Australia.29

Decisions about the length of time between diagnosis of the death of an unborn baby and the induction of labour and birth may need to be made. The timing of birth depends on a variety of factors and management should be individualised.31 Allowing sufficient time for discussion and decision making is important.10,32,33 Some parents may prefer that the birth occurs straight away and others may wish to go home before the birth to allow time to consider their birthing options, to share the news with family and to gather support.33

The mode of birth may be dependent on the baby’s gestational age and maternal clinical history and should be individualised with consideration for parents’ preferences. In Australia and elsewhere, guidelines for management of the birth of a baby who has died generally recommend vaginal birth, with caesarean birth reserved for special circumstances such as an increased risk of uterine rupture.34,35 In the USA, women whose baby has died usually give birth vaginally regardless of whether labour was spontaneous or induced or whether they had a prior caesarean birth. However, 15% of women underwent caesarean birth, often without a documented obstetric indication.36 The RCOG Guideline34 recommends vaginal birth for most women with intent to optimise future pregnancy outcomes, but caesarean birth will need to be considered for some. Vaginal birth carries the potential advantages of both quicker physical recovery and return to home, but with the risks of vaginal/perineal trauma and the need for forceps/ventouse or an emergency caesarean birth.31 Options for birth after diagnosis of late stillbirth include spontaneous vaginal birth, immediate induction, delayed induction, caesarean birth or expectant management. Methods of induction include misoprostol (with or without mifepristone), syntocinon infusion, and mechanical methods. Refer to RCOG Guideline34 for summary of induction of labour methods.

The full range of pharmacological and non-pharmacological pain relief options (including labour and birth in water) should be discussed with parents including advantages and disadvantages of each pain relief option.1,13 Parents should be advised of the potential for sedation to lead to later regrets about lost opportunities for interacting and spending time with the baby.37

Recognition of parenthood involves caring for parents in the same way as any other parents who are preparing for their baby’s birth. This includes providing reassurance that pain relief and physical and emotional support will be available during labour and birth.31 Parents want healthcare professionals to facilitate their choices, their sense of control, their autonomy, and their agency.30 Ensuring that all staff are aware of parents’ wishes and preferences  is vital to supporting parents’ experiences of labour, birth and  first moments with their baby.

Birth is your Bub’s first ceremony. You are still the parent of a beautiful Traditional Owner of the lands you are from.

Parent quote from the Jiba Pepeny (Star Baby) booklet.

Evidence-based recommendation 3.10

Evidence quality: moderate confidence

For labour and birth, parents should be given as much time as they need to make decisions about options offered.

  • Advise parents that labour and vaginal birth may provide physical and emotional benefit, compared to a caesarean birth without obstetric indication. However, parents’ values, preferences, and wishes need to be respected.
  • Ensure parents understand what usually happens when labouring with a baby who has died and what their baby may look and feel like following birth (for example physical appearance, size, tone, and temperature).
  • Advise parents that the full range of pharmacological and non-pharmacological pain relief options are available for them.
  • Offer strong pain relief/sedation with caution as this may interfere with opportunities for spending time with the baby.

Special considerations about maternal illness

Provisions should be made if the woman is unwell around the time of or following the birth. Careful consideration and sensitive discussion with parents to inform their decision about and preferences for care planning is required, as maternal medical complications associated with late stillbirth are high, including implications of caesarean birth for future pregnancies.38,39 When a woman is admitted to an intensive care unit or transferred to another hospital following birth, every effort must be made to ensure appropriate and timely communication so that she is kept informed and involved in decision making and care planning, particularly regarding memory making opportunities and considerations around perinatal death investigations.22 Opportunities for her to have access to her baby and to delay decisions where possible need to be considered and discussed with the woman, her partner and other family/whānau members as appropriate.

Care planning and decision making
Memory making and spending time with baby
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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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