Are you reading this because you have been told of your “Risk of Stillbirth”?
Firstly take a deep breath to lower your stress hormones and read on.
I recently did an online course with Sara Wickham: “Post-Term Pregnancy: Exploring Evidence, Inspiring Confidence”.
( EDIT 14/05/2018: I am aware that many women aren’t even getting to their due date, let alone getting to “post-term”, as induction is being recommended earlier and earlier for more and more reasons: gestational diabetes; IVF; “advanced maternal age”; too much fluid; too little fluid; big baby; small baby; etc; etc. If you want to make evidence-based decisions about any of these issues you need to get Sara Wickham’s book “Inducing Labour” )
I know the word “stillbirth” is very scary and quite hard to think rationally about. However, we do need to discuss it, and we need to find a way of talking about stillbirth without quickly spiralling into Fear.
I have written a lot on how fear impacts on pregnancy, labour, birth and beyond. But do you know how fear impacts on decision making?
There is a great article on fear and decision making which talks about the fact that when we are scared we activate the deep brain region called the amygdala. This is the part of our brain that triggers the Fight and Flight (Freeze and Appease) Response.
The Fight and Flight Response is a survival instinct that we have not evolved out of but we can moderate it with the Executive Thinking part of our brain, our Pre-Frontal Cortex.
However, if we are in extreme fear the amygdala wins and we simply can’t think straight.
“The mental paralysis induced by extreme fear may actually override the executive brain, making it impossible to think clearly”.
You can imagine the “Mental Paralysis” that occurs if you are being told that going past your “due date” means you have an increased risk of your baby being stillborn. So it is not surprising that you will defer to your Obstetrician’s ‘expertise’ because you really cannot think about this rationally anymore.
In my classes, I often talk about using the B.R.A.I.N (Benefits, Risk, Alternatives, Intuition, Nothing) Technique for decision making.
But the truth is you just can’t use your thinking brain in this state and you are at the mercy of your reactive brain (and your caregivers).
So what can you do when presented with your ‘Risk of Stillbirth’.
1. You need to find a way of tolerating and embracing uncertainty.
If you think about it there is uncertainty in everything, which means we take “risks” all the time.
It is worth thinking about who’s “risk” we are talking about?
Is it actually your care providers risk as dictated by their insurance company?
Who is it that is not prepared to tolerate and embrace uncertainty?
Are your birth choices being influenced by insurance companies and health and safety policies?
“There will always be those who claim birth is risky, no matter what the evidence says – because they benefit in some way.” ~ Sara Wickham, 2016
2. You need to understand the research.
But what about the ‘research’ and statistics your OB or hospital might be presenting you with?
You have probably been told that induction at 38/39/40/41 weeks will improve the outcomes for your baby.
Is this true?
In 2012 the latest Cochrane Review released.
This Cochrane Review included 22 trails (which includes a very old Chinese one) and concluded that:
“A policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections. Some infant morbidities such as meconium aspiration syndrome were also reduced with a policy of post-term labour induction although no significant differences in the rate of NICU admission were seen.
However, the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction).”
No one seems to mention the bit about that the absolute stillbirth risk being small and the need to appropriately counsel women so they can make an informed choice.
Do you feel that you are being told that the “absolute risk” is low and are you asking what your “relative risk” is?
Are you being appropriately counselled on this?
Are you being encouraged to make an informed (fear-free) decision?
The truth is that the stillbirth chance is lower than people believe.
Here are the Numbers according to a 1999 paper.
35 weeks 1 in 500
36 weeks 1 in 566
37 weeks 1 in 645
38 weeks 1 in 730 (very similar to 42 weeks)
39 weeks 1 in 840
40 weeks 1 in 926 (least likely)
41 weeks 1 in 826
42 weeks 1 in 769 (very similar to 38 weeks)
43 weeks 1 in 633
It is interesting to note that the chance of stillbirth is lowest at 40 weeks and that the rates are similar at 38 and 42 weeks.
WHO (2011) recommends induction for women who are KNOWN (read due dates on this) to have reached 41 weeks of pregnancy. However, they go on to state that the quality of evidence for this is low and the strength of the evidence is weak. Also remember that WHO must think “globally” so they have to consider women in developing countries too, in their statements.
It is also important to know that IOL and Caesarean section rates have doubled over the past decade yet we haven’t seen a proportional improvement in perinatal outcomes.
3. Ask your care provider to use the word “chance” not “risk”.
This was an “aha” moment for me when I first heard Sara talk about this at her “Recipes for Normal Birth” workshop.
I am a Hypnobirthing Australia™ practitioner so I understand the importance of language.
“Risk” and “Chance” mean the same thing. But “risk” is a fight and flight word and will activate the amygdala. Whereas “chance” opens up probability and possibility. It will lead to a much better discussion and decision-making process.
Of course, we can’t change the way other people behave. But we can change the way we react to their behaviour. So if your care provider continues to use the word “risk” make sure you tell yourself “chance”.
I want to loop back to my point about finding ways of embracing or tolerating uncertainty.
How can you do this for yourself? I really don’t think the medical profession has any imperative or desire to do this, so you need to concentrate on YOU and what YOU can do.
I hope thinking about whose risk we are talking about and doing your research helps.
But I know what I would do to manage my fear of stillbirth.
After over 20 years as a midwife and 13 years as a childbirth educator, I believe an independent childbirth education course is the best way to do this.
Not only will an independent childbirth education course help you learn to relax with uncertainty it will also give you tools to stay out of your “Fight and Flight Brain” so you can make clearer decisions. (Check out our classes HERE)
There is also this brilliant Ted Talk called “How to stay calm when you know you’ll be stressed” which explains why we don’t think well under stress, particularly when we have “medical’ decisions to make.
And finally, also watch this brilliant TED Talk and be Wonder Woman at your next appointment. Just watch it, you will understand 😉
- Cotzias CS, Paterson-Brown S, Fisk NM (1999). Prospective risk of unexplained stillbirth in singleton pregnancies at term: a population-based analysis. BMJ 319(7205): 287–288.
- Glantz JC, (2013). Obstetric variation, intervention, and outcomes: doing more but accomplishing less. Birth 39(4): 286-290.
- Gülmezoglu AM, Crowther CA, Middleton P et al. (2012) Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews Issue 6: CD004945