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ABSTRACT Recent research suggests that maternity care-providers often avoid discussing the possibility of stillbirth with women in their care. For example, a study by Pullen and Nalos (2009), showed miscarriage is presented as a possibility by the care-provider only 48% of the time and stillbirth only 11%. The reluctance to discuss this kind of poor outcome often is from a wish to avoid “scaring the woman” however, not to do so is missing an opportunity to educate and alert the woman to adopt behaviours to help keep her baby safe. Maternity Care providers should provide women with sufficient and accurate information to enable them to be have freedom to be self-determinant and autonomous when making choices in relation to their care. This type of care ensures women are informed and given every opportunity to be advocates of their own experience with the knowledge and understanding to make informed decisions. However, raising and discussing sensitive topics such as stillbirth during antenatal care can be seen as controversial. Walking the fine line between informing the woman and scaring her with too much information is often a challenge. Rather than having a conversation on what can go wrong during pregnancy, more beneficial would be for care givers to have an ongoing dialogue that encourages parent’s sense of empowerment, awareness, and intuitive knowing of their unborn baby. Antenatal visits would then shift concentration from providers imparting knowledge; to parents sharing what they are learning about their baby with their provider at each visit. This paper will suggest an evidenced based [1] method for sensitively raising and discussing the possibility of stillbirth with pregnant women. In particular the suggestion will be made that if maternity care providers raise the topic of stillbirth as important and also give information to women about what they can activity do to minimise their risk of stillbirth then this information will empower and enable women to keep her baby safe. Reference Warland J Keeping baby SAFE in pregnancy: piloting the brochure. Midwifery e-publication ahead of print 10-NOV-2012 DOI 10.1016/j.midw.2011.11.008
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Discussing stillbirth with pregnant women
Dr Jane Warland
Overview
Raising public awareness of stillbirth
Talking to pregnant women about stillbirth
Why should we?
Why don’t we?
Using the SAFE message to talk to women
Comparing stillbirth to SIDS
What can we learn from the success of the reduction in SIDS ?
We still don’t know what causes SIDS
We have worked out how to protect the vulnerable baby by sleeping all babies on their back
Lessons from reduction in SIDS deaths
Key lessons:
Public Awareness
Simple do-able message
Public Awareness
The Public health promoter asks:
Why might the audience be motivated to do what you are asking them to do?
In order to persuade people to do something we must:
Keep it simple
Make it memorable
Evoke a response
Bugger Me! (Robyn Moore)
6 Australian babies die each and every day to Stillbirth
The annual rate of stillbirths in Australia exceeds the road toll by more than 40%
Simple Doable Message…SAFE
Sleep
Appointments
Feeling baby move
Early expert advice
The brochure is not meant as a recipe to prevent stillbirth
Sleep
aims to encourage women to be aware of their body and their baby even as they settle to sleep and if they wake during the night.
This section includes the suggestion to settle to sleep on the left and avoid sleeping on the back
Evidence base
Research:
increased risk of stillbirth if maternal sleep position in late pregnancy (night before stillbirth) was not the left position (OR=1.8 95% CI 1.1-2.8) (Stacey et al 2010)
Women who sleep on their backs in late pregnancy are 6 times increased risk of stillbirth (Gordon et al 2012)
Women who sleep supine are 8 times more likely to experience a stillbirth [O.R. 8.0, 95%CI 1.5-‐43.2] (Owusu, JT , et al (2013)
Practice (e.g. Thurlow & Kinsella 2002)
Physiology: (Kaupplia et al 1980)
Plausible (Warland 2013)
Always keep antenatal appointments
reminds them that it is okay to discuss their concerns and ask questions during antenatal visits
Evidence base Regular attendance assists in detection of problems
(Gilbert 2011)
Reduced antenatal attendance increases risk of perinatal mortality (Dowswell et al 2010)
Continuity of care provider facilitates women centered care, increases satisfaction and results in woman is more likely to discuss any concerns ( Fereday
et al 2009)
Feeling baby move
encourages the woman to being aware of who her baby is, how her baby is and immediately report if there is a change
Evidence base
Fetal movements do not normally decrease close to term. In fact decreased fetal movement at or near term places the pregnancy at substantial increased risk (Tviet et
al 2006, O’Sullivan et al 2009 )
42.6% women who experienced a late term stillbirth presented with DFMs at some time in their pregnancy compared to 9% of live born controls. (Stacey et al 2011)
Clinical practice guideline for the management of women who report decreased fetal movements. (Preston et al 2010)
Can awareness of fetal movements be protective against stillbirth?
Large multi-centred international RCT
68,000 participants
All risk groups i.e. entire clinics were recruited
‘Count to ten’ versus usual care
No Difference in stillbirth rate between groups BUT Stillbirth rate fell , across the cohort , from an expected 4:1000 to 2.8 :1000 ( Grant et al 1989)
Early expert advice
asks the woman to monitor her own pregnancy and promptly report any concerns
Evidence base
Identifying S&S for women to self monitor and immediately report i.e itchiness (cholestasis), headaches and visual disturbances (hypertension) should help . (Logic 101 )
Focus is maternal awareness 24/7
change the focus from what the maternity health care provider can do for the pregnant woman, to what the woman can do for herself in partnership with her provider.
Changing focus from providers assigning risk and maintaining control of information to recognising the woman knows her body and her baby best.
This is the very heart of woman centred care (Johnson et al 2003).
Raising awareness by discussing stillbirth with women
Why don’t we?
“Most doctors don’t talk about stillbirth, pregnancy is a joyous thing, but there are many things that can go wrong. If you sat down with a patient and told them everything that could go wrong you’d scare the hell out of them and no one would get pregnant. “ http://www.2theadvocate.com/features/53088387.html?showAll=y&c=y
Why didn’t you tell me this could happen to me?
The risks of meconium aspiration, postmaturity, uterine rupture, maternal mortality and stillbirth are real, and need to be discussed as openly as the benefits and risks of episiotomy, amniotomy and epidurals are. The feeling that pregnant mamas shouldn’t worry themselves that their babies could die, because it stresses them out unnecessarily, is misplaced. Mothers need to know that it can happen to them, because it does happen to mothers just like them every day, so that they can make informed decisions regarding their health care providers, their birthing facilities and their births.
http://www.thedestinymanifest.com/2-12/08/she-was-still-born/
Suggested use for the SAFE brochure
Give out and discuss at the beginning of the third trimester
Add to the discussion that you are ALREADY having from then on e.g.
S :How are you sleeping?
A :When you come next time we will …
F :Baby moving? Who, How, change?
E : Don’t forget to call me if you have any concerns
Talk to women about keeping SAFE rather than use the word “Stillbirth”
More information
Email: [email protected]
Follow links from my website
http://www.unisanet.unisa.edu.au/staff/homepage.asp?name=jane.warland
SAFE on facebook
http://www.facebook.com/safepregnancyAU
References
Dowswell T, Carroli G, Duley L, et al 2010. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD000934. DOI:10.1002/14651858.CD000934.pub2.
Fereday J, Collins C, Turnball D, et al (2009) An evaluation of midwifery group practice : Part 11: Womens’s satisfaction Women and Birth 22(1) 11-16
Gilbert E (2011) Manual of high risk pregnancy and delivery 5th Edition Mosby St Lois Gordon A et al Risk factors for late pregnancy stillbirth: The Sydney Stillbirth Study paper to ISA conference Baltimore 2012
abstract available at http://www.firstcandle.org/cms/wp-content/uploads/2012/10/IC-Program-2012-PROOF-1.pdf Grant A, et al 91989) Routine formal fetal movement counting and risk of antepartum late death in normally formed
singletons. Lancet. Aug 12;2(8659):345-9. Johnson M, Stewart H, Langdon R, et al (2003) Woman-centred care and caseload models of midwifery. Collegian 10 (1) 30-34 Kauppila A et al (1980) Decreased intervillous and unchanged myometrial blood flow in supine recumbency Obstetrics and
gynecology 55 (2) 203-205 O’Sullivan O, Stephen G, Martindale E, et al 2009 Predicting poor perinatal outcome in women who present with decreased
fetal movements 29: (8) 705-710 journal of obstetrics and Gynaecology Owusu, JT , et al (2013) Association Between Maternal Sleep Practices, Pre-eclampsia, Low Birth Weight, and Stillbirth in
Ghanaian Women International the International Journal of Gynecology & Obstetrics Jun;121(3):261-5 Preston S, Mahomed K, Chandha Y, et al. 2010 Clinical practice guideline for the management of women who report decreased
fetal movements. Brisbane, available online at http://www.stillbirthalliance.org.au/doc/FINAL%20DFM%20guideline%20Ed1V1%201_16Sept2010.pdf
Stacey T, Thompson JM, Mitchell EA, et al. (2011) Association between maternal sleep practices and risk of late stillbirth: a case-control study. BMJ ;342:d3403.
Thurlow J., Kinsella S 2002 Intrauterine resuscitation: active management of fetal distress International Journal of Obstetric Anesthesia (11) 2 105-116
Tviet JV, Saastad E, Bordahl P et al 2006 The epidemiology of decreased fetal movements. Annual conference of the Norwegian Perinatal Society. Oslo , Norway
Warland J, (2011) Pregnant women who experienced late stillbirth appear less likely to have slept on their left Commentary on: Stacey T, Thompson JM, Mitchell EA, et al. Association between maternal sleep practices and risk of late stillbirth: a case-control study. BMJ 2011;342:d3403. IN Evid Based Nurs 2011;Published Online First: 25 September 2011 doi:10.1136/ebn.2011.100175
Warland J (2013) Keeping baby SAFE in pregnancy: piloting the brochure. Midwifery 29 174-179
