Stillbirth: Causes, Probability and Medicolegal Importance
Every year a lot of infants are found dead all around the world. There are various situations of the death of an infant and stillbirth is one such example. Stillbirth refers to the condition in which the child is born after 28 weeks of gestation period and does not show any signs of life, at any time after being completely born.
According to the World Health Organization (WHO) there are 2 million stillbirths every year with 40 percent of stillbirths occurring during labor. In 2014, the World Health Assembly endorsed the Every Newborn Action Plan (ENAP) which includes a global target of 12 or fewer per 1000 total births in every country by 2030.
They are most frequently shown in illegitimate and immature male infants in primipara. The incidence of stillbirths is 6 percent of all the births and in primipara it is about 9 percent.
Stages of Stillbirth
Stillbirth can be categorised into three stages:
- Early Stillbirth- Fetal death occurring between 20-27 weeks of pregnancy
- Late Stillbirth- Fetal death occurring between 28 to 36 weeks of pregnancy
- Term Stillbirth- Fetal death occurring at 37 or more weeks
Sometimes a stillborn child and dead-born child sound synonymous but they are not. In stillbirths the infant is alive in the uterus but dies during the delivery process whereas a dead-born child dies in the uterus and may show signs of rigor mortis, maceration or mummification.
Causes of Stillbirth
It can be due to a number of reasons which may include:
- Prematurity
- Various types of anoxia
- Erythroblastosis foetalis
- Congenital defects
- Birth traumas like intracranial haemorrhage due to excessive moulding
- Toxaemia of pregnancy
- Bacterial infections
- Umbilical cord accidents
- Placental abruption, etc.
The most common cause is prolonged labor which leads to scalp oedema, Cephalohematoma or severe molding of the head.
Changes Observed in Autopsy
- Chest is flat, circumference is less than that of abdomen, presence of narrow intercoastal spaces.
- Diaphragm is present at the level of fourth or fifth rib.
- The lungs lie at the back of thoracic cavity behind the heart and thymus gland with covering pleura which is loose and wrinkled.
- The lungs have small volume and sharp edges.
- Lungs appear non-marbled and smooth with dark-blue red in color.
- They are firm, dense, liver-like and non-crepitant.
- Expanded air sacs are not seen on surface.
- The blood in the lungs is half as compared to circulation in live-born infants.
- Signs of struggle to breath are observed which are developed in the following sequence.
- Dark fluid blood, haemoconcentration, pseudo-clots
- Cyanosed and expanded lungs due to- Obstruction emphysema, Inhaled liquor amnii or vernix.
- Tardieu’s spots on pericardium, pleura and thymus
- Swollen liver due to congestion
- Distension of large bowel with meconium
- Ascites
- Retroperitoneal oedema
Probability of Stillbirth
Presence of following conditions are probable to stillbirth:
- Desquamation of bronchial epithelium
- Maceration of infant
- Distention of large bowel with meconium indicating the struggle to breathe
- Flooding of lungs with liquor amnii
- Evidence of phagocytosis of meconium by the cells lining the air sacs.
Medicolegal Importance
Whenever a dead body of an infant is found in suspicious conditions then a lot of questions arise regarding his/her birth and death. Stillbirth is one such important question, which needs to be determined.
Careful external examination and autopsy can elucidate that the child was a stillborn or dead-born or live-born and then died or murdered. Gross examination and microscopic evaluation are helpful in determining the cause of death. Then accordingly the investigation will proceed.
Conclusion
Stillbirth is one of the factors of the mortality of infants. There are various reasons for the stillbirths including prolonged labour, health conditions of the mother, congenital defects, etc. All the factors need to be diagnosed and treated as early as possible to prevent stillbirths.
It is the responsibility of the forensic pathologist to carefully examine and estimate the cause of death in infants. Strict measures need to be adopted by the international agencies to prevent stillbirths.
