Placental Abruption

The placenta usually separates from the uterus after the birth of the baby. Placental abruption is a condition where the placenta separates from the uterine wall during the pregnancy. Placental abruption is a serious condition and can put the baby at risk. This is a medical emergency. Hypertension can sometimes lead to placental abruption. Women who have blood-clotting disorders may experience placental abruption. Women suffering from diabetes or abusing drugs are also at higher risk for placental abruption. Those women who have had multiple pregnancies are also at higher risk for placental abruption.

A pregnant woman suffering from placental abruption is likely to have abdominal and back pain. There might be rapid uterine contractions. There is tenderness in the abdomen. Uterine bleeding is often noticed. Placental abruption can occur anytime after the 20th week of pregnancy.

An ultrasound can help in locating any possible blood clot behind the placenta. It can also help in checking for any signs of fetal distress. Fetal monitoring is essential since the placenta supplies nutrients to the growing fetus. There may be decreased fetal movements. The extent of placental abruption decides the course of treatment to be followed. Partial placental abruption needs adequate bed rest and close monitoring. In cases of total placental abruption, delivery of the infant is undertaken. This is either with vaginal delivery or cesarian section. But there is a risk of premature birth and fetal death. The newborn baby could suffer brain damage due to low levels of oxygen in the blood.

Fetal Distress

When the fetus is not coping well during labor, it indicates fetal distress. Fetal distress is rare and may not occur if the mother and the fetus have been progressing well through pregnancy. The term fetal distress is normally used when the baby's oxygen supply is compromised in the uterus.

During fetal distress, the heart rate of the fetus is monitored continuously using an electronic heartbeat monitor. Symptoms of fetal distress include:

• Mother feels decreased fetal movement
  
• Meconium in the amniotic fluid
  
• Increased/decreased heart beat in fetus particularly after contractions

Causes for fetal distress

• Oxygen supply through the umbilical cord has reduced
  
• Delivery is happening beyond the expected date of delivery
  
• Abnormal presentation or position of fetus
  
• Prolonged labor
  
• Contractions are happening very fast for the mother
  
• Baby size is smaller than average
  
• Prolapse of the umbilical cord
  
• Placental abruption, wherein during delivery fetus separates from placenta too early
  
• Diabetic mother
  
• Uterine rupture
  
• Mother has low blood pressure in mother during delivery
  
• Multiple deliveries
  
• Mother is over 35 years of age while delivering the baby.

The doctor attending to the mother experiencing fetal distress may follow any of the following:
Cesarean section
Episiotomy
Inducing labor with medication.
Vacuum extraction delivery - using a suction cup to pull the baby down the birth canal by placing the suction cup on the baby's head.
Making the mother lie down on her left side so as to ease the pressure off the blood vessels and thus the uterus.
Mother may be put on intravenous to improve fluid levels.
Mother may be put on additional oxygen to improve supply of oxygen to the fetus.

Stillbirth

A baby who is born without any signs of life at or after 24 weeks of pregnancy is defined as still birth. It could have been during late pregnancy, called intrauterine death or could have died during labor or birth, called intrapartum death. Though stillbirth is uncommon, it cannot be said as rare.

Possible Causes

Genetic factors or

How the placenta works or

Age and lifestyle of the parent and

Infection.

Out of these, problem with the placenta or placental insufficiency is probably the most common cause of a baby dying in the womb. Though the exact reason for placenta not functioning properly is not understood, the blood vessels that connect a mother to her baby could become constricted. This may result in a drop in nutrients and oxygen to the baby, causing growth problems and hence death.

Reduced blood flow to the baby via the placenta could be due to pregnancy illness called Preeclampsia.

About 10 % of the babies are still born due to genetic or chromosomal defects. This happens when the placenta separates from the womb causing placental abruption.

Sometimes health condition of the mother such as diabetes, and rare infections such as flu, group B streptococcus, listeriosis or toxoplasmosis can cause the loss of baby in the womb.

The risk of stillbirth is more in older women. This risk appears to be highest at around 41 weeks. That is why in some hospitals, an older mother-to-be is sometimes recommended to have labor induced few weeks before due date. It is very rare that a baby may be stillborn at the very end of pregnancy. This could be due to problems with the placenta wearing out. If you are several weeks past the due date, the placenta may not work as well as it did earlier. Hence, induced labor is recommended by about 41 weeks. Lifestyle factors such as obesity, heavy drinking and smoking in pregnancy increase the risk of a baby being stillborn. Smoking again, can restrict a baby's growth as it reduces the supply of oxygen to the baby via the placenta.

Stillborn during labor or birth

It is quite rare for a baby to die unexpectedly during labor or birth. Most of the times, stillborn babies are lost when they are still in the womb. If the baby is large, in rare instances, his/her shoulders may get stuck as he/she leaves the birth canal, severely reducing the flow of oxygen to the baby. While most babies recover well, sometimes the shoulder dystocia can result in a baby being stillborn. Another cause is problems in the umbilical cord which could result in loss of oxygen to the baby. Either the cord can slip through the cervix or becomes wrapped around a baby's neck.

Diagnosis

Fetal behavior and changes in fetal movements or sleep-wake cycles can indicate if there is any fetal distress. Decreased or cessation of fetal activity is an indication of fetal distress or even death. Medical examination including a non-stress test is recommended. Obstetricians recommend the use of a kick chart to assist in detecting any changes. Fetoscopy/doptone, ultrasound or electronic fetal monitoring aid in confirming fetal distress or death. In case the fetus is alive but inactive, extra attention is given to the placenta, and umbilical cord during ultrasound examination to ensure that there is no dearth of oxygen supply and nutrients to the baby.

What happens if the baby dies in the womb ?

The sad reality is that even after the baby dies, the mother has to go through with the birth, as it is better for her health and physical recovery. It is rare for a stillborn baby to be born by cesarean section. In most cases, the labor will have to be started artificially induced. While some parents would want to have the induction as soon as possible, some others would prefer to wait a day to two to see what happens if the labor starts by itself. In case the mother is infected, they will advise the labor induced straightway.

Whether induced or natural labor, the midwife or doctor will administer effective morphine-based pain relief. In case of twins or more, and the death of one baby occurs, the doctor normally advises not to have an induction of labor. Other issues such as whether or not the babies share a placenta, and at what stage the loss occurred should be viewed. The doctor would give the best shot for the live baby or babies to develop and mature a bit longer in the womb. The babies can then be born at the same time, when it is best for the mother's health.

A post mortem examination is done to:

1. Identify a cause or causes for death

2. Provide information about the baby's development

3. Information about health problems to combat future pregnancy.

4. Officially confirm the baby's gender.

Not all parents agree to get a post mortem done and it is only carried out with prior written consent of the parents. Post mortem could also be refused for personal, religious or cultural reasons or for any other personal reasons which the parents may not want to disclose.

Implications for next pregnancy

The decision to try for another baby can be difficult for some mothers, whereas, there is an overwhelming urge to get pregnant again as soon as possible in some others. Depending upon the cause of the stillbirth, the doctor should be able to work together to reduce the risk of it happening again.