Health and Social Care Committee

HSC(4)-11-12 paper 11

 

Inquiry into stillbirths in Wales - Suggested Terms of Reference

 

 

 


 

Introduction

The Committee agreed at its meeting on 2 February 2012 to launch an inquiry into stillbirths in Wales that focuses specifically on poor fetal growth and reduced fetal movements. 

The purpose of this paper is to present the Committee with some background information, suggested terms of reference and suggested witnesses.

 

 

 

 

 

 

This briefing has been produced by the Research Service for use by the Health and Social Care Committee.

For further information contact Victoria Paris in the Research Service
Telephone ext. 8678
Email:
victoria.paris@wales.gov.uk

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Background information

Terminology

Depending on when a foetus/baby is lost:

¡  Miscarriage (or spontaneous abortion) - during first six months of pregnancy;

¡  Stillbirth – born after 24 or more weeks but did not, at any time, breathe or show signs of life;

¡  Early neonatal – the baby dies within seven days of birth;

¡  Perinatal – includes stillbirths and early neonatal deaths;

¡  Neonatal – baby dies within 28 days of birth;

¡  Post-neonatal – baby dies between 28 days and 1 year.

 

Prevalence of stillbirth

There are around 4,000 stillbirths every year in the UK and one in every 200 births ends in a stillbirth.  Eleven babies are stillborn every day in the UK, making stillbirth 10 times more common than cot death.[1]

 

Causes of stillbirth

The cause of many stillbirths is unexplainable and although the below list of conditions and factors can contribute to the baby’s death they are not necessarily the direct cause.  These include:

¡  The mother haemorrhaging either before or during labour;

¡  The baby has a congenital abnormality;

¡  Problems with the placenta: which can separate from the womb before the baby is born (placental abruption), or the placenta can fail to provide the baby with enough oxygen and nutrients which means that the baby does not grow properly (intra-uterine growth restriction (IUGR) is associated with one-third of all stillbirths);

¡  Problem with the umbilical cord: which can slip down through the entrance of the womb before the baby is born (known as cord prolapse and it occurs in about 1 in 200 births), or it can wrap around the baby’s neck;

¡  Pre-eclampsia: a condition that can cause high blood pressure in the mother; mild pre-eclampsia can affect up to 10 per cent of first time pregnancies and more severe pre-eclampsia can affect 1-2 per cent of pregnancies;

¡  An infection in the mother that also affects the baby.[2]

 

There are also factors which increase the risk of stillbirth.  Stillbirths occur more frequently among the following women:

¡  twin or multiple pregnancies;

¡  older mothers, i.e. over the age of 35;

¡  teenage mothers;

¡  women with specific medical conditions, especially diabetes, hypertension and thrombophilia;

¡  women with a past obstetric history of complications (liver disorder);

¡  women who smoke;

¡  women who are obese;

¡  women living in areas of social deprivation;

¡  women from ethnic minority groups.[3]

 

Prevention

There are many things which can be done during pregnancy to help improve the mother’s health and reduce the risk of a stillbirth.  These include stopping smoking (if applicable), avoid drinking alcohol, eating healthily, attending antenatal appointments etc.  It is important that mother and baby are monitored during pregnancy so that pregnancies that are at high-risk of complications and stillbirth are identified and the appropriate care is given.  However, the majority of unexplained stillbirths occur in pregnancies where no risk has been identified, this could be due to lack of knowledge about certain pregnancies or inadequate monitoring of the mother and baby.

Sands (the Stillbirth and Neonatal Death Society) believe more effective methods of monitoring pregnancies need to be developed.  These include:

¡  Fetal growth – there is an association between babies who do not reach their growth potential and stillbirth.  However, currently only 30 per cent of growth restricted babies are identified during antenatal appointments.

¡  Fetal movements – babies that are stillborn often change their movement patterns before death.[4]

 

Small for gestational age (SGA) foetus

Small for gestational age (SGA) foetus is a term used to describe a foetus which has not achieved an estimated weight threshold by a specific gestational age.  SGA foetuses are at a greater risk of stillbirth.  There are a variety of methods used to detect SGA foetuses including abdominal palpation, measurement of symphyseal fundal height[5] and ultrasound.  However it is important that these tests are not done in isolation and that other factors such as foetus growth trend and maternal characteristics are taken into account.

 

Reduced fetal movements (RFM)

Fetal movements are first perceived between 18 and 20 weeks of gestation and rapidly conform to an observable pattern.  Fetal movements consist of any discrete kick, flutter, swish or roll.  A significant reduction or sudden alteration in fetal movement could be seen as an important clinical sign and reduced or absent fetal movements could be a warning sign of impending death.

 

Guidance

In November 2002 the Royal College of Obstetricians and Gynaecologists (RCOG) produced a guideline and made recommendations on the Investigation and management of small for gestational age fetuses.

In March 2008 the National Institute for Clinical Excellence (NICE) published clinical guidance on Antenatal care: routine care for the healthy pregnant woman which provides information on best practice for baseline clinical and antenatal care of all pregnancies and provides evidence-based information on appropriate treatment in specific circumstances.    

In February 2011 the RCOG published new advice for clinicians on the management of women with Reduced Fetal Movements (RFM) during pregnancy, providing recommendations as to how women presenting RFM in both the community and hospital settings should be managed. 

In September 2011 the Welsh Government published A Strategic Vision for Maternity Services in Wales which sets out the Government’s expectations of NHS Wales in delivering safe, sustainable and high quality maternity services. 

 


 

Suggested Terms of Reference

 

The purpose of this session is:

¡  To examine the awareness, implementation and effectiveness of current guidance and recommendations across the different sectors with regard to stillbirth prevention, especially in relation to poor fetal growth and reduced fetal movements, and where potential improvements can be made. 


 

Witnesses

 

It is suggested that the Committee takes evidence from the following:

¡  Public sector bodies e.g. Welsh NHS Confederation; Public Health Wales;

¡  Professional bodies e.g. Royal College of Nursing Wales, Royal College of Obstetricians and Gynaecologists; Royal College of Midwives; British Medical Association;

¡  Third sector organisations e.g. Sands; National Childbirth Trust; International Stillbirth Alliance.

Members might also wish to seek written evidence from interested parties in addition to the general call for evidence.

At the end of the meeting a private session will be scheduled for Members to consider the evidence received and agree what action to take. 

 



[1] Sands, Research, Statistics [accessed 12 March 2012]

[2] NHS Choices, Stillbirth – Causes [accessed 12 March 2012]

[3] Sands, Research, Causes and risk factors for stillbirth [accessed 12 March 2012]

[4] Sands, Research, Identifying pregnancies at risk of stillbirth [accessed 12 March 2012]

[5] A measurement is taken from the pubic bone (symphysis pubis) to the top of the uterus or fundus, giving a fundal height in centimetres.  The measurement in centimetres should closely match the foetus gestational age in weeks, within 1 or 2 cm, e.g., a pregnant woman's uterus at 22 weeks should measure 20 to 24 cm.