stillbirth

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Classification according to ICD-10
P95 Fetal death of unspecified cause

stillbirth

036.4 Care of the mother in the event of intrauterine fetal death
ICD-10 online (WHO version 2019)

A stillbirth is present if no recognizable sign of life can be detected after the birth of a child and certain minimum dimensions (usually 500–1000 g body weight, 25–35 cm body length, 21–28 weeks gestation period ) are met, otherwise one speaks of a miscarriage . The minimum dimensions and signs of life differ depending on the country, institution and time. The diagnosis is intrauterine fetal death (IUFT) or infans mortuus . Perinatal mortality includes stillbirths and children who die up to one week after birth. Infant mortality is about deaths in the first year after birth .

Definition of the minimum dimensions and signs of life

According to the German Civil Status Ordinance, a stillbirth has occurred (since April 1, 1994) if, after the birth of a child weighing at least 500 grams, no recognizable sign of life can be detected, i.e. neither the heart beat, the umbilical cord pulsates or natural lung breathing has started ( § 31 PStV until October 31, 2019). The length of pregnancy and body length were insignificant to date. Since November 1, 2018, stillbirth has been considered if the weight of the child is less than 500 grams, but the 24th week of pregnancy has been reached (Section 31 PStV Paragraph 2 No. 2). According to the statistics of the natural population movement of the Federal Statistical Office, only children with a birth weight of at least 500 g count as stillborns since April 1, 1994, previously 1000 g from July 1, 1979, previously at least 35 cm in length. A body length of 35 cm and a weight of 1000 g correspond to each other if the child develops normally.

From 1938 to 1957/1958, natural lung breathing was the focus in Germany. The current definition of live births was introduced in the former federal territory in 1958 on the recommendation of the World Health Organization (WHO) and was also applied in the new federal states from 1990 onwards. In the GDR from 1957 to 1990 two characteristics (heartbeat and lung breathing) were required for classification as a live birth.

In addition to the criteria established in Germany, the Austrian Midwives Act (HEBG) assesses the child's voluntary muscle movement as a further sign of life ( Section 8 (1) 1 HEBG). The last change took place here in 1995 when the minimum body length of 35 cm was changed to a minimum weight of 500 g.

In Switzerland, a stillbirth is given if the child weighs 500 grams or if the pregnancy lasted at least 22 weeks.

Further definitions and definition changes can be found in the Frequency section.

Legal consequences

Germany

In Germany, a stillbirth is notifiable . The parents receive a birth certificate with a death note for their stillborn child . You have the right to name the child; Whether it is the family name of the mother or the child's father is irrelevant. A stillborn child is subject to compulsory burial in all German federal states . The mother is entitled to statutory midwifery , in addition to pregnancy and childbirth accompanied the care in the postpartum period covers. In addition, she has the right to maternity protection under Section 3 of the Maternity Protection Act . Accordingly, the woman who has recently given birth may not be employed eight or twelve weeks after the birth of the dead child. An exception is only possible at the express request of the mother and with a medical certificate. In this case, the employment ban is at least two weeks. The mother is free to revoke her declaration at any time ( Section 3 (4) MuSchG).

Switzerland

In Switzerland, in the case of stillbirths, the maternity clinic or the parents are required to notify the civil registry office of the place of birth within three days, which records the stillborn child as a stillbirth in the civil registry. The child is entered with the family name and, at the request of the parents, with the first name. Married parents receive a family card with the child's entry. From an inheritance law perspective, the stillborn child is the testator and the parents are the legal heirs. In practice, the inheritance is directly concluded by determining the lack of property without any further procedure.

frequency

In Germany between 1841 and 1875, around 4% of children were stillborn every year. Since 1875 the rate has always remained below 4%, since 1931 below 3%, since 1938 only children over 35 cm in length have been taken into account, since 1955 the stillborn rate has been below 2%, since 1970 below 1%. The probability of being stillborn with a birth weight of over 1000 g since July 1979 or over 500 g since April 1994 is between 0.3% and 0.5%.

In Baden-Württemberg, 0.56% of children over 35 cm long were stillborn in 1978, 0.48% in 1980 and 0.3% of children over 1000 g in 1993, and since 1995 less than 0.41% of children over 500 g were dead born. The change in the minimum dimensions has a clearly statistically significant influence (1979 decrease by 15%, 1994 increase by 30%), which can be clearly distinguished from the usual annual fluctuations.

Being stillborn in or after the 28th  week of pregnancy is least common in Singapore and Finland with a rate of 0.2%. Germany is 0.24%, France 0.39%. Nigeria has the highest rates with 4.2% and Pakistan with 4.7%.

In Switzerland, being stillborn with more than 500 grams or after the 22nd week of pregnancy has had a rate of between 0.6% and 0.3% since 1980.

In France, until 1993, the question of stillbirth / live birth was solely based on the criterion of life at registration at the registry office. Thus part of the mortality in the first week after birth was counted as stillbirth in France, while in other countries this is counted only under perinatal mortality. Furthermore, no minimum criterion had to be met, so that births counted as miscarriages in other countries were also included as stillbirths and in perinatal mortality. From 1993 to 2001, pregnancies lasting only 180 days were counted. The lowering of this criterion in November 2001 to at least 22 weeks of pregnancy or at least 500 g weight increased the rate from 0.48% to 0.82%. If the additional criterion was completely abandoned at the beginning of 2008, the rate rose by 0.13% from 2007 to 2008, as well as from 2008 to 2009; other influences obviously also play a major role here. Accordingly, there have been no more miscarriages in France since 2008.

causes

Child causes

An intrauterine death can be attributed to various causes, including abnormalities of vital organs, chromosome features such as trisomy 13 or trisomy 18 , severe fetal diseases such as haemolytic disease fetalis , lack of oxygen supply by an inadequate function of the placenta or its premature detachment and by umbilical cord complications, such as umbilical cord nodes , umbilical cord incident and tight umbilical cord wrapping . New studies indicate that a genetically caused long QT syndrome could lead to fatal cardiac arrhythmias even in the womb , which could be responsible for up to 5% of stillbirths.

Maternal causes

Other possible causes of infant death in the womb include infections such as listeriosis , toxoplasmosis and cytomegaly , diseases such as eclampsia , HELLP syndrome and diabetes mellitus , substance abuse, malformations of the uterus, rare complications such as ruptured uterus and amniotic fluid embolism , and psychosocial stress such as him can be triggered by war, flight or displacement. A caesarean section in a previous pregnancy doubles the risk of stillbirth in a later pregnancy.

Deliberate induction

Fetocide , in which the death of a viable child is artificially brought about as part of a late abortion , for example by injecting potassium chloride into the fetal heart or tying the umbilical cord, must be distinguished from the causes mentioned above .

Symptoms and diagnosis

The affected mother first notices a lack of child movements, the level of the uterine fundus and the body size decrease. Due to the leaching of the child's blood pigment, flesh-colored to brown amniotic fluid is released when the bladder ruptures.

If intrauterine fetal death is suspected, the CTG is used to first attempt to detect a child's heart activity. However, the final diagnosis is made through an ultrasound scan, during which the cardiac arrest and the stopped blood flow in the umbilical cord are verified. In addition, depending on the time of death, an abnormal curvature or kinking of the child's spine and so-called skull signs such as the formation of steps in the parietal bones appear .

The fear of poisoning the mother is unfounded if the amniotic sac is intact. If the child dies in the womb, aseptic self-dissolution begins , which causes the tissue to soften and break down and is known as maceration . The maceration is divided into three grades, but does not allow any reliable conclusions to be drawn about the exact time of death, as it occurs at different rates. It is not to be confused with bacterial putrefaction .

Complications

If intrauterine fetal death is diagnosed late and autolysis substances have entered the maternal bloodstream during advanced maceration, the risk of fibrinogen consumption increases around four to five weeks after death . This fibrinogen deficiency can lead to an increased bleeding tendency with the resulting life-threatening consumption coagulopathy . Such a coagulation disorder caused by fetal death is also known as dead fetus syndrome and occurs only in rare cases.

Clinical approach

Once the diagnosis of intrauterine infant death has been confirmed, the birth is usually induced artificially and regional pain is eliminated with the help of epidural anesthesia . After the “birth”, the mother is weaned with medication . It is possible to autopsy the child and have the placenta examined histologically .

Psychosocial care

Basket for miscarriage and stillborn children

While it was routine until the 1980s to sedate the mother in the event of an expected stillbirth and to remove the child from the delivery room without showing it to her, it became increasingly well known through the commitment of those affected, midwives and psychologists at the end of the 1980s that the mourning process after a stillbirth does not depend largely on the care before, during and after the delivery and on how the child is dealt with. Based on the recommendations of the author Hannah Lothrop , who in 1991 with the publication of the book Gute Hoffnung - abrupt end opened a new chapter in the accompaniment of parents with stillbirths, a paradigm shift took place in many obstetric institutions .

Grave field at the main cemetery in Karlsruhe

Today's concepts therefore include, among other things, the support of the midwife and the gynecologist based on the individual wishes of those affected, as well as support from psychologists or pastors , the renouncement of the routine administration of sedatives and the possibility offered to the parents to treat the child after birth to see, to touch and to dress. In addition to data on the child's birth and information on the child's name, height and weight, footprints and handprints, a lock of hair, a name ribbon and souvenir pictures are recorded on a card provided for this purpose. Since the spring of 2009, the Frauenworte eV association has been supplying the German maternity clinics with so-called clinic boxes with its sub- project Clinic Campaign Butterfly Children. These include, among other things, clothing made by volunteers for the children, coffin gifts, farewell candles, mosquito baskets and information materials for parents and nursing staff that provide help for the difficult loss situation and show how you can say goodbye to the child with dignity.
After the German Hospital Society demanded the dignified burial of deceased embryos and fetuses in 1999, numerous clinics are now offering the option of collective burial, which is usually associated with a memorial service for the parents concerned.

Nationally active associations such as the Rainbow “Glücklose Pregnancy” initiative and the Federal Association of Verwaister Eltern eV also offer support through self-help groups .
Stillborn children are euphemistically referred to as star , angel, butterfly or cloud children by these self-help groups and affected parents .

The modern language expression Stillgeburt is based on the English term stillbirth ; he summarizes miscarriages and stillbirths.

See also

literature

Web links

Wiktionary: stillbirth  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ↑ a b c Federal Ministry for the Environment, Nature Conservation, Building and Nuclear Safety - Announcement of a statement with scientific justification by the Radiation Protection Commission (factors influencing the sex ratio of newborns with special consideration of the effects of ionizing radiation - from July 17, 2014) BAnz AT April 17, 2015 B2
  2. ↑ None (France), one (Germany: 500 g), some (Switzerland: 500 g or 22 weeks) or several of these minimum dimensions are currently to be met in various European countries
  3. ↑ Article 9 Civil Status Ordinance ZStV , SR.211.112.2
  4. ^ Federal Institute for Population Research
  5. ^ State Office for Statistics Baden-Württemberg
  6. ↑ Worldwide study: 7,000 stillbirths - every day. In: Süddeutsche.de . April 14, 2011, accessed April 14, 2011 .
  7. ^ Federal Statistical Office
  8. ↑ L. Crotti, DJ Tester, WM White, DC Bartos, R. Insolia, A. Besana, JD Kunic, ML Will, EJ Velasco, JJ Bair, A. Ghidoni, I. Cetin, DL Van Dyke, MJ Wick, B Brost, BP Delisle, F. Facchinetti, AL George, PJ Schwartz, MJ Ackerman: Long QT syndrome-associated mutations in intrauterine fetal death. In: JAMA: the journal of the American Medical Association. Vol. 309, No. 14, April 2013, pp. 1,473-1,482; ISSN  1538-3598 . doi: 10.1001 / jama.2013.3219 . PMID 23571586 .
  9. ↑ British study: Caesarean section doubles the risk of stillbirth. Spiegel Online, 2003.
  10. ↑ Meeting point ethics: dealing with miscarriages and stillbirths, see PDF file ( Memento from October 25, 2007 in the Internet Archive )
  11. ↑ website of the clinic action Schmetterlingskinder ( Memento from 1 May 2011 at the Internet Archive )
  12. ↑ Colorful clothes for “star children” Chiemgau-Zeitung, OVB online, April 2, 2010
  13. ↑ Warmly dressed in fond memories ( Memento from December 28, 2011 in the Internet Archive ) Südhessen Morgen, April 15, 2010
  14. ↑ Butterfly children clinic campaign ( Memento from May 1, 2011 in the Internet Archive )
  15. ↑ This is how clinics bury. Medical Tribune, Issue 21, May 27, 2005.
  16. ↑ www.veid.de
  17. ↑ see also English Wikipedia: 'stillbirth'