IMR Press / CEOG / Volume 49 / Issue 10 / DOI: 10.31083/j.ceog4910221
Open Access Commentary
Mode of Delivery after the Diagnosis of Antepartum Stillbirth: Support and Care for Shared Decision Making
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1 Egeria Medical Center, 20122 Milano, Italy
2 Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
*Correspondence: laura.avagliano@unimi.it (Laura Avagliano)
Academic Editor: Michael H. Dahan
Clin. Exp. Obstet. Gynecol. 2022, 49(10), 221; https://doi.org/10.31083/j.ceog4910221
Submitted: 29 June 2022 | Revised: 14 July 2022 | Accepted: 22 July 2022 | Published: 21 September 2022
(This article belongs to the Special Issue Stillbirth: Improving Knowledge, Understanding, and Patient Care)
Copyright: © 2022 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license.

Upon diagnosis of antepartum stillbirth, most women desire prompt delivery. Unless clinically contraindicated, vaginal birth is the recommended mode of delivery [1]. However, occasionally women with a fetal demise are not prepared emotionally for a vaginal birth and often they assume that their baby will be delivered quickly and easily by a cesarean section [2, 3]. They may therefore request a cesarean section firmly and resolutely [4]. Sometimes, women with a stillbirth may perceive vaginal birth as an insensitive imposition inflicted upon them by their caregivers [1, 4]. It is important to highlight that the need for repeat cesarean section or increased risks of cesarean section in a subsequent delivery is a risk of the cesarean section that must be discussed with bereaved mothers requesting a cesarean section.

Monari F. et al. [5], in the paper titled “Mode of delivery in women with stillbirth: results of an area-based Italian prospective cohort study” and published in the present special issue “Stillbirth: Improving Knowledge, Understanding, and Patient Care” evaluated the different mode of delivery in an Italian prospective cohort of stillborn cases. They observed that the mode of delivery was vaginal birth in most of the cases (84.3%) and by cesarean section in the minority of cases (15.7%) most of which related with clinical emergency.

When are not absolute clinical indication, how should caregivers support women in the choice on the mode of delivery? Although guidelines highlight the importance of informing women on the benefit of vaginal delivery, to reduce potential risk factors for the future pregnancies [1], caregivers should be mindful that bereaved women do not appreciate the automatic projection to the future pregnancies [4]; they still wait for the baby that they still feel in their womb; sometimes they think that cesarean section is less traumatic for their stillborn baby [4]. Caregivers should provide supportive, sensitive, clear information about the choice around mode of delivery, with an effective counseling that address any fear and concern, understanding the reasons for requiring a caesarean birth rather than a vaginal birth. A sensitive communication can improve the chance of a shared decision making [6], aimed at containing both emotional and physical morbidity.

Frequently women are scared and wish to avoid labor pains, hence they ask a cesarean section. However, labor pain can be (must be!) avoided. Caregivers should warrant pain relief and should discuss and offer the variety of options. Monari F. et al. [5] showed that almost 80% of their cases received epidural analgesia. No information is available about the other 20% of women. Usually, the vast majority of women received epidural analgesia during labor and delivery of a stillborn baby, but sometimes women also received sedation.

Caregivers should be mindful that sedation should not be the first choice because it can lead to later regrets about lost opportunities for meeting and interacting with the baby [1].

“…. The contractions are intense, she asks for an epidural analgesia. The Anaesthetist offers her an intravenous sedation: “It’s better, Madam, you won’t remember anything”. She refuses. She doesn’t want to have a smoky and distant memory of this day, she wants to remember her child, she wants to live this farewell, even just for the few moments she can spend with him. The Doctor doesn’t understand: he doesn’t understand this suffering, doesn’t understand that a mother needs to see, parents need memories, they need to be supported; she does not want to feel herself just like a body doing its job, with a disconnected mind; she does not want to wake up with an empty womb and nothing in the arms…. Some hours later the stillborn baby is born; the mother and her partner are able to spend the precious time with him. I was honoured to have had the opportunity to support them in the way of their unforgettable journey as parents”. (From the memories of a senior midwife).

Author Contributions

LA have the idea; LA and RF wrote the manuscript. All authors read and approved the final manuscript.

Ethics Approval and Consent to Participate

Not applicable.

Acknowledgment

The authors are grateful to parents and clinicians for their support and inspiration.

Funding

This research received no external funding.

Conflict of Interest

The authors declare no conflict of interest. LA is serving as one of the Editorial Board members and Guest editors of this journal. We declare that LA had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to MHD.

Publisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References
[1]
Flenady V, Oats J, Gardener G, Masson Vicki, McCowan Lesley, Kent A, et al. Clinical Practice Guideline for Care Around Stillbirth and Neonatal Death. 2020. Available at: https://starlegacyfoundation.org/wp-content/uploads/Flenady-2020-PSANZ-Clinical-Practice-Guideline-for-Stillbirth-and-Neonatal-Death.pdf (Accessed: 29 June 2022).
[2]
Ellis A, Chebsey C, Storey C, Bradley S, Jackson S, Flenady V, et al. Systematic review to understand and improve care after stillbirth: a review of parents’ and healthcare professionals’ experiences. BMC Pregnancy and Childbirth. 2016; 16: 16.
[3]
Lisy K, Peters MDJ, Riitano D, Jordan Z, Aromataris E. Provision of Meaningful Care at Diagnosis, Birth, and after Stillbirth: a Qualitative Synthesis of Parents’ Experiences. Birth. 2016; 43: 6–19.
[4]
Siassakos D, Jackson S, Gleeson K, Chebsey C, Ellis A, Storey C. All bereaved parents are entitled to good care after stillbirth: a mixed-methods multicentre study (INSIGHT). BJOG: an International Journal of Obstetrics & Gynaecology. 2018; 125: 160–170.
[5]
Monari F, Menichini D, Salerno C, Donno V, Melis B, Neri I, et al. Mode of Delivery in Women with Stillbirth: Results of an Area-Based Italian Prospective Cohort Study. Clinical and Experimental Obstetrics & Gynecology. 2022; 49: 151.
[6]
Bakhbakhi D, Burden C, Storey C, Siassakos D. Care following stillbirth in high-resource settings: Latest evidence, guidelines, and best practice points. Seminars in Fetal & Neonatal Medicine. 2017; 22: 161–166.
Publisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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