On very rare occasions the baby dies in the uterus. If this occurs before the 28th week of pregnancy it will inevitably lead to mis-carriage. If it occurs after the 28th week it will inevitably result in delivery occurring fairly soon. Most women at some stage of their pregnancy feel certain that their baby has died. It must be remembered, however, that babies frequently stop moving, or apparently stop, for several hours and occasionally for as long as a day, and a woman should have no concern unless she fails to feel movement of her baby for longer than 24 hours, and even then everything may still be quite satisfactory.
The causes of intrauterine death during late pregnancy are not properly understood. The majority of such deaths are caused by placental insufficiency where the placenta has either grown in-adequately or become diseased so that it is unable to maintain an adequate oxygen and food supply to the baby. Other causes are premature separation of the placenta (abruptio placentae), congenital abnormalities of the foetus, Rhesus disease and accidents to the umbilical cord.
As soon as the baby dies the formation of progesterone and oestrogen is dramatically reduced with resulting diminution of the physical signs normally present during pregnancy. The sensation of being pregnant disappears quite quickly. The breasts decrease in size and the marks made by the veins under the skin of the breasts go quite rapidly. Any swelling of the fingers or ankles disappears and the uterus (together with the abdomen) gradually decreases in size. This shrinking of the uterus is due to the absorption of the amniotic fluid from around the foetus. Amongst the most dramatic of these signs is loss of weight previously gained.
The death of the baby in the uterus does not have any adverse effects on the mother’s health, except in very rare instances when it may change her blood clotting mechanism. It is usual, therefore, when such a woman goes into labour, or has labour induced, for her blood clotting mechanism to be checked at the onset or immediately before the onset of labour. Any abnormality is corrected. The effect of an intrauterine death upon the mental state of a woman, however, is usually considerable.
The diagnosis of intrauterine death can sometimes be difficult. Loss of weight, diminution of breast changes, reduction of venous engorgement on the breasts and the reduction of swelling of the ankles are all factors which suggest but do not confirm it. A diminution in the size of the uterus itself is very suggestive that the baby has died. The doctor will listen to the baby’s heart with a stethoscope, but even the absence of a foetal heart beat is not definitive because babies occasionally get themselves into positions where it is almost impossible to hear the heart. Ultrasonic detectors are extremely accurate and if they fail to detect a foetal heart then it is extremely likely that the baby is dead. Finally, the changes which occur in the foetus after its death can be detected by X-ray examination but not until the baby has been dead for 3, or perhaps 4, days.
When the diagnosis of intrauterine death has been made, the doctor or midwife must decide how to tell the woman, if she is unaware of it, and how to treat her. The majority of doctors and midwives are reluctant to inform her in an ordinary antenatal clinic that her baby is dead or is even suspected of being dead and she is generally asked to return with her husband or a responsible relative before discussing the problem.
When the woman and her husband have been told their natural reaction is to ask for the dead baby to be removed as soon as possible. Until recently it was always considered best that labour should commence spontaneously and without interference. Justice, however, must be tempered with mercy, and the majority of obstetricians today agree that labour should be induced as soon as possible, providing the woman’s health will be in no way endangered.
There should be no difference between the labour involving a live or a dead baby. The psychological impact on the woman, however, is different. The certain knowledge that the baby is dead frequently creates an adverse reaction to the labour, with the result that it is more painful and uncomfortable. Labour usually begins shortly after the death of the foetus, frequently within 2 or 3 days, but in rare instances the onset of labour may be delayed and it is in these circumstances that the doctor is expected to induce labour.