Stillbirth & Termination

Experiencing the loss of a pregnancy or the death of a baby is often devastating, but not uncommon. In 2009, the rate of stillbirth in Canada was 7.13 per 1000 total births and 2.4% of terminations of pregnancy are > 20 weeks gestation (Quebec excluded). Midwives providing care to a client who is terminating a pregnancy or whose baby is stillborn need to prepare for this physically and emotionally taxing role.

Providing support

Clients respond differently to the experience of stillbirth or termination and have varying expectations of support from their midwives.  Following the client’s lead is always best, especially when it comes to knowing what words to use (for example: “fetus” vs. “baby”; “termination procedure” vs. “giving birth”, etc.) and what kind of emotional support to offer.

Scope of practice

In the case of prenatal detection of fetal anomalies that may require immediate postpartum management or in the case of intrauterine fetal demise, midwives consult with a physician pursuant to college standards.

Where misoprostol is used to induce labour in cases of stillbirth or termination of pregnancy, midwives consult with a physician for the misoprostol order. Midwives can then administer misoprostol under physician’s order and manage the labour.

Not all hospitals perform terminations. Midwives may be supporting clients in a hospital where they do not have privileges. In these cases, midwives should be proactive with hospital staff in communicating their role clearly and only providing clinical care in an emergency. To avoid confusion and to make it clear that midwives are there to provide supportive care and not clinical care, midwives should avoid wearing their hospital ID or scrubs or gowns (except those provided to support people) ID. 

Clinical considerations and preparation

Labour and birth may be different in the case of stillbirth or termination of pregnancy. With stillbirth, fluid can have stronger odor or colour; there is a higher chance of shoulder dystocia; and the third stage of labour can often be longer. Midwives may need to ensure that a backup is available to provide sleep relief as labours can be long.

Parents may request fetal remains or the placenta to be released to them. In cases where hospital staff are unclear about allowing this, HIROC has a risk note that midwives may find useful when advocating for clients.

Documentation

In the case of stillbirth, OHIP forms must still be filled out and include the infant’s sex, date of birth, birth parent’s last name and be clearly marked “STILLBIRTH”. Parent’s signature is not required. The tear-off strip with pre-printed number should not be detached. According to the Vital Statistics Act, midwives can sign the Notice of Live or Still Birth but a physician or coroner is required to sign the Medical Certificate of Stillbirth or the Medical Certificate of Death. Midwives can fill out autopsy requests, should parents want one.

Bereavement support resources to share with clients

In 2015, Ontario passed the Pregnancy and Infant Loss Awareness, Research, and Care Act(Bill 141), which aims to increase resources and support for families, as well as research on loss. There are a number of supportive resources that can be shared with clients, the community hospital may also be able to provide local resources.

• Pregnancy and Infant Loss Network (PAIL) Network
• Grief Support Centres and Resources
• Bereaved Families of Ontario
• Now I Lay Me Down to Sleep

These situations can also be emotionally difficult for midwives. Mental health and wellness resources and support are available through the member assistance programs offered through the AOMBT for midwives and their families. Best Start has a resource on vicarious trauma for prenatal and early childhood services providers.

Members who are unsure of their role in a stillbirth or termination situation are encouraged to call AOM On Call, a 24-7, confidential assistance program.