Revealed: How doctors have unlocked the secret to HALVING stillbirths
... by using a very old-fashioned technique to help reverse the UK’s appallingly high record
AT 42 weeks pregnant Samm Micklethwaite was happy to be induced. Eight hours later, she was in labour, but after two hours’ pushing, and two failed attempts at delivering her baby with forceps, she had to undergo an emergency caesarean, 26 hours after her induction.
Not long after her son Roman was safely delivered, Samm, 33, a supermarket duty manager from Wakefield, West Yorkshire, developed a fever and started vomiting. ‘I felt certain something wasn’t right,’ she recalls. Six hours later, Samm developed a pain she describes as ‘ten times worse than labour’ in her abdomen, and begged for a doctor to examine her, only to be told by midwives that her discomfort was to be expected after her surgery.
Three days later, Samm’s heart rate suddenly dangerously spiked to 215 beats a minute — three times the normal resting rate — and she couldn’t pass urine. A CT scan and X-ray revealed she had an abdominal infection, which had sent her body into septic shock.
‘I was in hospital for ten days, and barely remember any moments with my son,’ says Samm. ‘Now, 14 months on, I am still suffering severe pain.’
Samm and husband Wayne, who have started legal proceedings for medical negligence, are convinced that had she been induced earlier, she would have avoided both the emergency caesarean and the lifethreatening infection.
The risk of a woman developing an infection after her waters have broken rises from 0.16 per cent after 37 weeks to 6.15 per cent at over 42 weeks, according to a study published in the American Journal of Obstetrics and Gynaecology in 2003.
A prolonged pregnancy also raises the risks of placental abruption — where the placenta separates from the womb, depriving the baby of oxygen and nutrients, and causing lifethreatening bleeding: the risk is highest (0.44 per cent) at 42 weeks, according to a study in the same journal a year later.
But could inducing women before they reach 40 weeks reduce such complications? And, perhaps more importantly, could it also cut the number of babies being stillborn?
LAST
year, 696,271 babies were born safely in England and Wales — but the stillbirth figures remain largely unchanged from the early Nineties and the UK is ranked 24th out of 49 high-income countries for stillbirths (where the baby dies after 24 weeks of pregnancy).
Last week, the health secretary Jeremy Hunt pledged to halve the rates of stillbirths, maternal and newborn deaths by 2025.
He announced that all deaths will be referred to a new NHS safety investigator and, within a week of the cause of death being established, the findings will be shared with NHS trusts across the country to avoid a repeat of the same mistake.
But could there be a simpler, more radical way to reduce stillbirths by inducing women before 40 weeks? Under current NHS guidelines, pregnant women are offered induction at between 41 and 42 weeks’ gestation.
Contrast this with Denmark, which has one of the lowest stillbirth rates in the world. This has been ascribed to the fact that a quarter of women pregnant beyond 37 weeks are now induced. Very few Danish women go to 42 weeks, following a national effort to prevent prolonged pregnancy, according to a study published in 2014 in the journal BMJ Open.
These findings were controversial, with commentators pointing out there were other factors involved.
But now a major UK study, involving 77,327 low-risk first-time mothers, has found inducing women at 40 weeks could reduce the number of stillbirths or deaths of babies within seven days of birth by a massive 66 per cent — from 26 per 10,000 pregnancies to just eight.
The groundbreaking study, which looked at mothers over the age of 35, ‘ represents the strongest evidence yet that moving the offer of induction to 40 weeks might reduce the risk of stillbirth in this specific age group, which we know faces a greater risk of stillbirth and neonatal death’, said Hannah Knight, of the National Maternity and Perinatal Audit at the Royal College of Obstetricians and Gynaecologists, who led the study conducted jointly with the University of Cambridge and published in the journal PLOS Medicine.
In fact there are even suggestions that all women should be induced earlier, not just those aged 35 and older. An ongoing study in the U.S. is looking at inducing labour at 39 weeks as standard to see if it can improve birth outcome statistics.
The study, funded by the U.S. National Institute of Health, has recruited 6,000 pregnant women, randomly allocating them either an induction at 39 weeks or waiting for spontaneous labour.
The researchers hope to present their findings in February at the annual Society for Maternal-Fetal Medicine conference. Professor Mark Johnson, an obstetrician at Chelsea and Westminster Hospital, says better birth outcomes in other EU countries are due to factors including better monitoring of foetal movement and fundal height (a measurement of the bump which can indicate if the baby is not growing properly and if there may be a risk of stillbirth or placental problems). But he suggests early induction is also key. ‘My view is that all pregnant women should be told that if they stay pregnant once at full term — 37 weeks — their risk of stillbirth increases week by week,’ says Professor Johnson. ‘The only way to avoid that risk is to be induced earlier.’
He told Good Health he thinks women should ideally be induced between 39 and 40 weeks.
But why is 39 weeks the focus, when the risks of stillbirth and infection increase after 37 weeks?
Professor Johnson explains that although 37 weeks has the lowest chance of stillbirth, there’s an increased risk of the baby having breathing problems, as at this point the lungs are not mature enough and have more fluid inside them.
As the weeks pass this decreases, lowering the chance of the baby needing help breathing after birth. ‘Roughly, the stats on breathing problems in relation to gestation decrease in this fashion — one in 400 have breathing problems if delivered at 37 weeks, one in 800 at 38 weeks, then one in 1,500 at 39 weeks,’ says Professor Johnson.
Currently one in five labours in the UK is induced. Typically, prostaglandins (hormones that cause increased blood flow to an area) are administered using vaginal pessaries to soften and dilate the cervix; the next stage may be a drip containing oxytocin, to lead to contractions).
Still, the case for earlier inductions is not black and white. As Hannah Knight pointed out following the new UK study, there are potential downsides to inducing women earlier, not least the greater demand on NHS resources.
‘Further studies are needed to
examine the impact of such a change in policy on NHS costs and women’s satisfaction,’ she said following her report.
And although there may be good medical reasons for induction, ‘it can lead to a more painful labour and is associated with higher risk of having a forceps or Ventouse delivery — often with an episiotomy — and these things can be traumatic’, warns Kim Thomas, a spokesman for the Birth Trauma Association and author of Birth Trauma. Also, it can be highly distressing for a woman to be suddenly plunged into the later stages of labour.
‘While induction is safe and studies have shown no shortterm adverse impact on mother or baby, induction of labour represents an intervention, is associated with costs to the service, and can be a more prolonged process than spontaneous labour,’ Professor Lesley Regan, president of the Royal College of Obstetricians and Gynaecologists, told Good Health.
‘We welcome any new research which may help to reduce stillbirth and neonatal death rates.
‘The implications of such a change in policy would be enormous for both the health service and women themselves, so further research to determine the impact of such a change in practice is needed.’
Dr Clea Harmer, chief executive of the stillbirth and neonatal death charity Sands, says: ‘The decision whether to deliver or not requires good, reliable evidence about both the benefits and risks.’
‘At Sands we hear from too many older bereaved mothers whose babies died after 40 weeks but who had no idea they were at a higher risk — in retrospect they deeply regret that their baby was not induced in time.’
She adds that the important thing is for mothers to be able to make genuinely fully-informed decisions about their maternity care.
RACHAeL
Seddon is tortured by the thought that had her daughter Hope been delivered just a few days earlier, she would not have been stillborn.
The 28-year- old, who lives in Bolton, Lancashire, with her husband Joshua, 30 and their son Otis, two, was 39 weeks pregnant when she went to her local maternity assessment unit in November 2013 complaining of reduced movements and a feeling that something was wrong.
After a brief examination, where the baby’s heartbeat was heard, she was sent home.
Three days later, Rachael could no longer feel her baby moving so she returned to hospital, but it was too late. An ultrasound scan confirmed Hope’s heart had stopped beating — Rachael had to be induced.
Afterwards, a doctor told Rachael the placenta had been smaller than it should have been, which might have been to blame for Hope’s reduced movements and death.
The post-mortem also found meconium — a baby’s first stool — in her lungs which can be an indicator of foetal distress. Ultimately, however, the exact cause of her death is unknown.
Rachael ‘ absolutely believes’ women should be induced earlier than full-term if they have concerns. ‘The day after the delivery, I was told Hope had died no more than 24 hours earlier and that haunts me,’ says Rachael.
‘Perhaps if I had been induced at 39 weeks when I told them I was worried about her moving less, they could have saved my baby.’
ViSiT sands.org.uk for bereavement support for anyone who has been affected by the death of a baby before, during or shortly after birth. information for pregnant women can be found at saferpregnancy.org.uk