APPENDIX 1 .sx Medical Explanations .sx In the UK at present , 5 babies in every thousand are stillborn , and 5 more die within the first four weeks of life .sx So , 10 in every thousand babies , or one in every hundred , are stillborn or die shortly after birth .sx This figure does not include babies who are born dead or miscarry before twenty-eight weeks gestation , as these babies are not registered and do not enter the statistics .sx Every time a baby dies perhaps the most urgent immediate question is why ?sx What could have caused the death ?sx Could it have been prevented ?sx Sometimes a clear cause is found , but often parents find that there is no satisfactory medical explanation , because there is still so much that is not understood about pregnancy and about the different things that can affect the development of a baby .sx At the present time , no clear cause can be found even after a detailed post-mortem for about half of all stillbirths .sx And even when it is possible to say why a baby died during pregnancy or labour , it is often not possible to explain what started the chain of events that led to that death .sx In the case of a premature baby who has died after birth , the final cause of death is more often understood .sx But although doctors understand why some premature babies die , they still do not always understand why some labours begin too early .sx So , for a large number of parents , a full explanation of their baby's death is simply not possible at present and may never be .sx But all parents want and need to understand why , in medical terms , their baby died , or at least they want to know as much as it is possible to know .sx We hope that this chapter will confirm and clarify for many parents what they have already been told by the professionals caring for them and their baby .sx Other parents may wish to go back to their doctors or other professionals to ask further questions .sx We hope that this chapter will help them to do this .sx Medical knowledge and professional judgement .sx We have outlined what is known about why babies die before or shortly after birth under the headings listed below .sx In some cases the explanations are quite clear .sx In others they may seem frustratingly unclear .sx This is because , despite extensive and continuing research , there is still much that is not understood or is uncertain about how a baby develops in the womb and what affects this process .sx In these areas of uncertainty , doctors and midwives often have to rely on their own professional judgement and experience when caring for pregnant women and their babies .sx For this reason , there can be major differences between the approach of one consultant and another , even within the same hospital .sx There may also be differences in hospital practice because of variations in resources .sx Some hospitals are equipped with the latest high-tech equipment for diagnosis and treatment ; others are not .sx We have tried to give the current views and practices of the majority of obstetricians and paediatricians , but there will be some professionals who disagree , both with our understanding of the problem , and with our description of the treatments and preventive measures that may be used .sx Doctors and midwives sometimes find it very difficult to say when they are uncertain or simply do not know why something is going or has gone wrong , especially in the highly-charged situations of pregnancy , labour and neonatal care .sx Very often they feel they should know .sx For parents too , until they have experienced the loss of a baby , it can seem that medicine and science now have an answer to all obstetric problems and can control pregnancy and its outcome .sx More is heard about the successes of obstetric and neonatal medicine than about the failures and continuing uncertainties .sx Many tests can now be carried out during pregnancy to detect problems , but parents may not have realised that often , once a problem has been detected , little or nothing can be done to put it right .sx The message often put across in antenatal clinics is that if parents are obedient and careful they will be rewarded with a perfectly healthy baby .sx All parents naturally want and expect certainty , knowledge and a successful outcome , and it may be difficult to accept doubt and uncertainty in the professionals they encounter .sx But for bereaved parents , part of understanding the cause of their baby's death , may be understanding what is not known or what is uncertain or contentious .sx Medical Language .sx In this chapter , we have included some of the technical terms doctors and other professionals commonly use for their own convenience and for precision when discussing symptoms , causes and conditions .sx People who are not familiar with these terms can easily be put off and may even come to feel , wrongly , that they are not capable of understanding what is going on .sx This makes it difficult for parents to believe that they are the key participants in the situation , and that they are entitled to ask questions and to clarify confusions .sx However , in most cases there is nothing particularly mysterious or difficult about what is being described in medical terms .sx Medical language is just a set of alternative words describing ideas which we are usually familiar with and can understand quite well .sx For example , pyrexia simply means a raised temperature , pulmonary means to do with the lungs , hypoplasia means underdeveloped and haemorrhage means bleeding .sx In most cases it is not difficult for professionals to translate their message into plain English and to fill in any gaps in our understanding of the human body , but often doctors and others are no longer aware of what is and is not easy for a non-medical person to understand .sx Parents have every right to ask for an explanation in language they can understand .sx We hope that the medical terms we have used in this chapter will help increase their confidence and encourage them to ask - and to keep on asking - as many questions as they wish until they feel they understand .sx The problems of simplification .sx The human body consists of an extraordinarily complicated combination of systems which all affect and are affected by each other .sx In trying to outline different causes and effects , we have focused on what we understand to be the most important and direct chains of events and have left out many things that are going on at the same time .sx This has enabled us to be fairly brief and , we hope , clear .sx At the same time , it has inevitably involved judgements about what is and is not significant , and has meant omitting a lot of detail .sx Readers who would like to find out more about a particular subject may like to speak to their own GP or consultant , or to look at some of the books listed on page 243 .sx They may also like to contact one of the many voluntary groups offering information , advice and support for parents whose baby had died and/or who are considering another pregnancy after a bereavement .sx Some of these ( for example , the Miscarriage Association , the Stillbirth and Neonatal Death Society [SANDS] and Blisslink/Nippers Bereavement Support Group ) exist to provide general support for parents whose baby has died .sx Others ( such as the Sickle Cell Society and the Association for Spina Bifida and Hydrocephalus [ASBAH] ) provide support and information about specific conditions .sx Relevant voluntary organisations in the UK are referred to in the text and are listed on pages 245-51 .sx list .sx Problems to do with the placenta .sx The placenta , also called the afterbirth , connects the baby to the mother's body .sx It grows with the baby and is implanted in the lining of the mother's womb .sx The placenta acts as the baby's lungs , kidneys and bowel while the baby is in the womb .sx It allows oxygen , nutrients and antibodies ( which protect the baby from certain infections ) to pass from the mother to the baby , and the baby's waste products to pass back to the mother for disposal .sx The placenta also produces hormones which are needed to maintain the pregnancy .sx The baby has its own separate blood circulation system .sx Blood passes round the baby's body , along the umbilical cord to the placenta , and back again to the baby's body .sx The baby's circulation system is quite separate from the mother's .sx This is essential to ensure that the mother's immune system does not reject the baby in the same way as a kidney patient's immune system sometimes rejects a transplanted kidney .sx Although the mother's and the baby's circulation systems are quite separate , they run very closely alongside each other in the placenta , so that the baby's blood vessels are surrounded in the placenta by the mother's blood .sx This enables essential oxygen , nutrients and waste products to pass between the two circulation systems through the very thin walls of the blood vessels .sx The placenta is vital to the baby throughout pregnancy and during labour , up to the time when the baby is delivered and can begin to breathe for itself .sx Once the baby is born , the placenta comes away from the wall of the womb , and is delivered through the vagina .sx PLACENTAL INSUFFICIENCY AND PLACENTAL FAILURE .sx Placental insufficiency is sometimes called placental dysfunction .sx It occurs when the placenta is not working efficiently , has not developed properly , or does not keep growing with the baby .sx Placental insufficiency can also happen if the mother's circulatory system is not working properly because of high blood pressure or other chronic disease .sx As a result , the baby does not get enough oxygen or nourishment , becomes weak and does not grow properly .sx In severe cases the placenta is unable to provide the baby with enough oxygen and the baby dies in the womb .sx This is often known as placental failure .sx Placental failure is most likely to occur from twenty-eight weeks gestation onwards when the baby's growth usually accelerates rapidly .sx There may be little or no warning , and there may be no history of placental insufficiency .sx The baby may simply slow down and then stop moving .sx ( See also Placental failure , page 220 .sx ) .sx The causes of placental insufficiency and placental failure are not yet fully understood .sx Known causes include maternal blood pressure that remains high for some time ( see High blood pressure , page 197 , and Pregnancy-induced hypertension , page 188 ) and infections or blockages ( infarctions ) which affect the mother's blood supply to the placenta .sx It is not always possible to diagnose placental insufficiency but it may be suspected if the baby becomes less active or is not growing as expected ( also known as small for dates or intra-uterine growth retardation - that is , delayed growth within the womb) .sx If placental insufficiency is suspected , the baby's growth may be checked regularly by ultrasound scan .sx Wherever possible , the causes of placental insufficiency are treated so that the baby's growth improves , but often there is little or nothing that can be done to help the baby grow , even after placental insufficiency is confirmed .sx Babies who are born small for dates are at increased risk of infection and other problems such as low sugar or calcium levels .sx These risks increase further if a baby is also premature .sx Incidence :sx Placental insufficiency and placental failure linked with pregnancy-induced hypertension ( see page 188 ) are most common in first pregnancies .sx They are less likely to recur in further pregnancies with the same partner .sx Another pregnancy :sx If placental insufficiency is suspected doctors will usually carry out regular ultrasound scans to check the baby's growth rate .sx They may also carry out other checks on the baby's health such as heart rate traces or Doppler blood flow studies , which use reflected sound waves to examine the blood flow through the umbilical cord and the placenta and check how much oxygen is getting through .sx However , as mentioned above , it is not always possible to do anything to increase a baby's rate of growth .sx PLACENTAL DEGENERATION .sx The placenta usually reaches its peak of efficiency near the end of pregnancy .sx In some cases it begins to deteriorate too early or too fast causing placental insufficiency or placental failure ( see above) .sx