Stillbirth

STILLBIRTH, death of a viable fetus that occurred during pregnancy or during childbirth from causes dependent on both the fetus and the mother. Statistics of S. It is difficult to determine the exact number of cases of S. Fetuses falling under this category must first have all signs of viability. Objective indicators of viability are not always sufficient for an indisputable assessment of the case. Then, to confirm S., it is necessary that the death of the fetus occurred before the beginning of extrauterine life. The differential diagnosis between cases of S. and cases of death of the fetus in the first minutes of life is of great practical interest, especially in a forensic-medical respect, since the latter category should also include cases of violent death of newborns—infanticide (see). To establish S. of viable fetuses, pathological-anatomical examination is necessary. In most cases of S., examinations are not performed, and S. is confirmed on the basis of either medical opinions alone or testimony from other medical personnel, service staff, or even the parents themselves. The imperfection of accounting for S. cases also depends on the accounting system itself, which varies in different countries (civil, church, and medical registration), and on the different interpretations of the concept of S. by statistical institutions of different countries. Thus, for example, in some cases, prematurely born viable fetuses are included here, while in others, those who died in the first hours or days of life before the expiration of the mandatory birth registration period (France). The need to establish a uniform definition of the concept of S. for all countries for the purpose of ordering statistical accounting has been repeatedly discussed and was confirmed by the International Statistical Congress (1913). Relationship between S., early childhood mortality, and birth rate. Comparison of data on S., births of live fetuses, and early childhood mortality apparently indicates 1) the absence of a connection between stillbirth and normal birth rate, and 2) the presence of a certain parallelism between stillbirth and mortality in the first days and weeks of life. S. among boys and girls. It is a well-known fact that there is a higher rate of S. among boys compared to girls. With average figures for S. of 3.5-4.5%, in the group of boys it is 0.6-0.8% higher than the corresponding figures for girls, i.e., one case of S. occurs per 29 births of boys or 35 births of girls. The increased S. in boys was by older authors largely attributed to the conditions of the birth act, which contains more dangers for male fetuses due to their slightly greater weight, larger head volume, and longer duration of labor (see below). Along with this explanation, in recent years the question of the excess of S. among boys compared to girls has been intensively studied by geneticists from the point of view of explaining the phenomenon of unequal S. of boys and girls based on data from the theory of lethal, sex-linked genes (Lenz).—Based on all available statistical material from bourgeois countries, it should be considered an established fact that there is a higher rate of S. among children born out of wedlock. Thus, according to Berlin statistics for 1892-1902, out of 257,368 births, there were 39,341 stillbirths; of these, in the marital group—3.2%, in the non-marital group—5.1%. In Hamburg for the 25-year period 1872-96, out of 478,535 births there were 16,681 stillbirths; of these, in the marital group—3.25%, in the non-marital group—5.44%. Table 1. Rate of S. in various countries (in % of total births). Countries 1927 1928 1929 | Germany ..... Denmark....... Finland .... France...... Iceland ..... Italy...... Latvia....... Luxembourg .... Holland ..... Austria...... Portugal .... Romania ..... Switzerland .... Spain...... Czechoslovakia . . Hungary...... Japan ...... Dutch India Egypt....... Chile........ Uruguay...... Canada....... New Zealand . Belgium...... Danzig ...... 2.7 1.7 1.8 2.5 3.8 8.1 3.1 3 3.1 2.3 2.5 3.8 2.3 3.8 8.5 2.5 3.0 3.9 1.9 2.3 2.2 2.8 3.8 3.1 ! 3.7 I - 1 3,* I У \ 4.1 2.1 2.8 I Dan. 1 г 1.6 stoch. 2.8 3.1 Table 2. Rate of S. in Germany depending on sex (per 1,000 births). Years Boys Girls so 1S28........ 192 i........ Table 3. Stillbirth rate in Leningrad (per 1,000 births). Years In marital group In non-marital group 1881 S5 ...... 1886-90...... 1891-95...... 1896 1900..... 1901-05...... 1906-09...... 40.0 41.5 38.8 37.5 36.3 35.4 19.0 51.2 j 47.9 f 42.0 i 42.7 S 52.3 ( 69.0 As can be seen from this table, S. in the non-marital group, after a temporary decrease in the decade 1886-96, then increases. In particular, the following factors may influence the increase in S. among children born out of wedlock: 1) more frequently occurring unfavorable conditions of labor, lack of specialized assistance; -2) a higher percentage of primiparas among this category of parturients, in whom the duration of labor is longer. The numerical data presented speak to the necessity of separate accounting of births from registered and unregistered marriages. S. and age of mother. The rate of S. shows significant fluctuations depending on the age of the mother, as can be seen from table 4. Table 4. Stillbirth rate in Leningrad for 1923-26 in connection with mother's age. Mother's age Rate of S. per 1,000 births Mother's age Rate of S. per 1,000 births Under 19 yrs. . . 20-24 yrs. . . 25-29 yrs. . . 30-34 » . . 14.4 14.8 17.1 19.7 35-39 yrs. . . 40-44 » . . 45-49 » . . 23.1 31.0 28.0 With increasing age of the mother, S. also increases, and the coefficient of growth, being almost the same throughout all five-year periods of life, Table 5. Stillbirth rate in Leningrad for 1924-26 in connection with the ordinal number of births in the mother. Ordinal .№ births Coeff. S. per 1,000 births Ordinal № births Coeff. S. per 1,000 births 1st 2nd 3rd 4th 5th 6th 17.8 12.5 17.0 18.2 17.4 17.0 20.0 8th .... 9th .. . . 10th .... 11th .... 12-14th . . 15th and above 18.3 18.3 23.0 25.2 28.4 48.0 Table 5a. Stillbirth rate in Leningrad for 1924-26 in connection with the ordinal number of births in the mother (by groups). Ordinal number of births Rate of S. per 1,000 births 10-14th births....... 15th and above births .... 16.1 18.0 20.0 25.0 48.0 gives a special increase for the group of women aged 40-44. Some decrease in S. for the group of women aged 45 and above must be considered accidental in view of the small amount of material in this group. According to some foreign statistics, as well as old Russian ones, a somewhat lower S. was found at age 20-24. This circumstance does not find confirmation in the latest research, which is explained mainly by the change in the 'structural' composition of parturients, an increase in the percentage of primiparas, which particularly affected the group exactly in the age range of 20-24 years. The dependence of the rate of S. on the number of previous births is not as close as on the age of the mother (table 5). As can be seen from table 5, S. sharply decreases with second births, increases again with third births, and remains at this level with minor fluctuations almost until the ninth birth, after which it begins to show more marked increases. Since the age of the mother and the ordinal number of births usually increase in parallel, there is reason to attribute the main cause of the increase in S. with subsequent births not so much to the number of previous births as to the simultaneously increasing age of the mother. The change in age among primiparas has an even greater effect on S. In the group of primiparas aged 40-44, the coefficient of S. is 4 times higher than the rate of S. in the same group of primiparas under 19 years, while in the general group of mothers, the analogous coefficient is only 2.1. The birth act and S. The birth act in a full-term fetus contains many moments that can adversely affect the condition of the fetus, and sometimes cost it its life. In ²/3 of all stillbirths, the cause is to some extent the birth act.—The duration of the birth act directly affects the rate of S. Of course, to establish such a dependence, one must be guided only by material from which all other complications of the birth act (e.g., abnormal fetal presentation, etc.) will be excluded, which themselves affect the rate of S. and are therefore able to obscure the picture. Analysis of the percentage ratio of individual groups of births by the duration of their first two periods undoubtedly indicates the close connection here between S. and the duration of the birth act (table 6). This table, compiled on the basis of materials from the Leningrad State Obstetric-Gynecological Institute, illustrates the distribution of births by their duration in the general group and in the S. group. The lowest S. is found in the group with a duration of the birth act from 11 to 24 hours, i.e., exactly the group with the average duration of a normal birth act in primiparas. A somewhat increased S. is found in the group with a relatively short duration of the birth act (up to 10 hours).

In the group with a duration of the first two stages of labor from 1 to 2 days, stillbirth is 2^nd/g times higher, and in the group with a duration of over two days, it is 3V₂ times higher than stillbirth in cases with an average duration of labor. It is interesting that the optimum outcome of labor for the fetus by no means coincides with the minimum of its duration, i.e., cases with the shortest duration of labor are by no means the most favorable for the fetus. Obviously, not only the time during which the fetus is subjected to the expulsive forces of the mother is important, but also the character of these forces and the possibility of functional adaptation of the fetus's individual systems and organs. In cases of rapid delivery, one has to observe contractions and labor pains of special strength and intensity; the rapid alternation of these with brief pauses does not give the vascular and skeletal system of the fetus the opportunity to adapt, which often leads to intracranial hemorrhages, which are one of the main causes of fetal death during and in the first hours and days after birth. The influence of the duration of labor on the rate of stillbirth is found to the same extent in the material of multiparous women. The largest number of cases of stillbirth during labor is observed after the rupture of membranes (92% of all cases not complicated by operative interventions), and the danger to the fetus arises regardless of the stage of labor. Especially in elderly primiparas, excessive elongation of the dilatation stage with early rupture of the bag presents a substantial danger to the fetus. Excessive pressure on the bones of its skull and the insufficient adaptability of its vascular system to the changed conditions of circulation and external pressure constitute a complex of conditions that in many ways resemble those in a prolonged expulsive stage. But along with elements of similarity, there are also differences in the mechanics of the forces acting to cause fetal death: in the latter case (expulsive stage), the fainting of the fetus is apparently due to active excessive expulsive forces of the mother, while in a prolonged dilatation stage due to rigidity and density of the uterine os, the main cause of fetal fainting lies in the passive resistance offered by it to unyielding and non-stretching tissues of the os. The dependence of stillbirth on the duration of labor cannot be explained solely by the presence of a discrepancy between the capacity of the mother's pelvis and the size of the fetus, since the weight of the fetus and the size of the presenting part do not always run parallel with the duration of labor. This can be established both by analyzing the duration of labor in cephalic and breech presentations (the average duration of full-term labor according to the institute's materials for 1904-07 in primiparas with breech presentations was 20 hours 35 minutes, with cephalic presentations 18 hours 37 minutes) and by analyzing its duration in uncomplicated cephalic presentations. The danger to the fetus from excessively prolonged labor does not result exclusively from the discrepancy between the mother's pelvis and the size of the fetus, resp. the presenting part: it arises mainly due to disharmony and anomalies of expulsive forces; along with the size of the fetus, other difficult to account for factors also acquire significant importance. Stillbirth and weight of the fetus. In the chain of conditions and causes that may influence fetal stillbirth, the latter's weight plays a minor role, slightly increasing the stillbirth rate only in cases where the fetus weighs over 4,000 g. As for fetuses with a weight below average, which serve as a transitional stage from premature to full-term fetuses, the stillbirth rate in this group increases faster than in groups with higher weight. The stillbirth rate in the group born with a weight of 2,500-3,000 g is higher than in the group born with a weight over 5,000 g. This circumstance again confirms the assumption of the greater importance of the physico-chemical and biological properties of fetal tissues than its absolute weight. The tissues of fetuses with low weight have a reduced ability to resist the violence experienced by them during labor. This circumstance is confirmed by autopsy protocols of both full-term and premature fetuses. Among the causes of stillbirth in the full-term group (where there was no operative intervention), birth trauma and associated intracranial hemorrhages account for approximately ¹/₃ of all cases, with the majority of these occurring in fetuses with relatively low weight. In the premature group, birth trauma should be attributed to over 50% of all stillbirth cases. The exaggerated view of the importance of fetal weight as a factor in stillbirth served as the reason for attempts to explain the difference in stillbirth rates between boys and girls by the difference in their average weight, i.e., higher in boys and lower in girls. The works of Gasper and Feit (Gasper, Feit) have shown the unequal stillbirth rates in boys and girls even in groups with the same weight. And in this case, it remains higher in boys and lower in girls. Obviously, this circumstance could also find explanation in the character of the physico-chemical and biological properties of fetal tissues, the limit of their elasticity and rupturability, which are very possibly different in male and female organisms, just as many other biological properties of tissues and systems of male and female individuals are different. Type of delivery operations and stillbirth. Operative intervention in childbirth constitutes one of the main (if not the main) causes of death of full-term fetuses. More than half of stillbirths in Baden and too many stillbirths in Hamburg for 1920-23 are attributable solely to these operative interventions. Different types of operations give different stillbirth rates. The most favorable of the delivery operations for the fetus, not counting abdominal cesarean section, which occupies a special place in this regard, is the operation of applying obstetric forceps, giving an average stillbirth rate of 6-8% of cases. This stillbirth figure is significantly reduced in cases of typical forceps and, conversely, increases in cases of difficult forceps with atypical or high standing of the head (high forceps), where the stillbirth rate reaches 25% and higher. Operations of version with extraction give on average 23-25% stillbirth and 10-12% for full-term fetuses, the operation of extraction by the foot of the fetus-12% stillbirth. It is necessary to take into account that on the stillbirth rate in version and extraction, some influence is exerted by 1) the composition of the parturients themselves, i.e., the predominance among them of cases with premature fetuses, and 2) the high percentage of labors with foot or breech presentation. Even uncomplicated by operative intervention (except for necessary assistance) labors with breech presentation give 8-10% stillbirth for primiparas. Prevention of stillbirth. The movement of the stillbirth rate over the last quarter century according to Leningrad materials shows a systematic and steady decrease. The following table illustrates the movement of stillbirth and early mortality for 1923-25 compared with the pre-war period. Compared with the pre-war period of 6 years, where stillbirth and early infant mortality were taken as 100, we have a decrease in stillbirth in 1925 by 19%; stillbirth in 1926 is lower than that of 1925. Similar data are provided by the health-preventive institutions of the Moscow Health Department: 1924-26-3.83-3.39% stillbirth in relation to the total number of births, 1926-28-2.41%. This decrease, while significantly lagging behind the decrease in early infant mortality, nevertheless represents exceptional interest, and precisely because German statisticians (data of Fahlbusch and Schwarz) do not detect any improvement in the stillbirth figures, and Fahlbusch even states a substantial increase in both stillbirth and early (in the first 4 days of life) infant mortality both in the pre-war and (which is especially significant) in the post-war years. Particularly strongly according to the last author, the increase in stillbirth in cities and industrial centers. Schangot (large Vienna statistics) gives the following stillbirth rates in relation to the total number of births: 1901-02-2.98-3.14%, 1903-04-3.15-3.37%. The differences in the data of the USSR on the one hand, and German and Austrian on the other, must find their explanation in the new improved conditions of Soviet obstetric care, in the better organization of the entire matter of protection of motherhood and infancy. The stillbirth figures in cases where labor ended with any vaginal delivery operation, according to the data of M. Hirsch (M. Hirsch), covering the material of Baden and Hamburg, and the data of Feigel, have remained almost stable.

The general increase in the frequency of obstetric operations, judging by Feigel's material, has also not led to any significant reduction in infant mortality; on the contrary, as analysis of data from the obstetric-gynecological institute (Leningrad) shows, the increase in the percentage of delivery operations has resulted in a certain increase in stillbirths, which forces one to look for the cause of the decrease rather in other social factors. Modern obstetric material with its increase in the total number of primiparas and especially elderly women should presumably increase the frequency of various complications during childbirth, and thereby increase the frequency of stillbirths. However, in reality a decrease in stillbirths is observed. Analysis of materials from stationary institutions for separate periods of time can give the key to understanding the causes and factors influencing the reduction in stillbirths. Table 8, Full-term (based on material from the State Gynecological Institute). Years Total stillbirths Stillbirths in which heartbeat ceased before admission to the delivery room. Admitted macerated and with malformations 1808-18 ... 1914-23 . . . 1924-27 (first half) Ы (35.0%) 09 (42.8%) 29 (23.7%) 51 (19,65%) S5 (21.7%) 19 (15.5%) The percentage of cases that arrived at the maternity department with the fetus already deceased has particularly significantly decreased. This category decreased by almost 40% (while cases of macerated fetuses and fetuses with incompatible with life malformations remained almost stable). These facts speak to the importance of providing stationary obstetric care to all parturient women in large centers and their timely admission to these institutions. This is achieved by organizing systematic medical observation of pregnant women in prenatal consultations (in cases of both normal and complicated pregnancy) and by organizing transport for the timely transportation of parturient women to maternity institutions. The decrease in stillbirths of full-term fetuses is obviously mainly due to a certain decrease in those cases where the death of the fetus occurs due to untimely provision of obstetric care for various sudden complications dangerous to it (prolapse of the umbilical cord, etc.). However, the number of cases where the death of the fetus occurs before the parturient woman is admitted to the maternity ward is still quite large (about 25% of all cases of stillbirths in full-term infants).--Stillbirths and premature births. The ratio between term and premature births is also of great importance, since among different causes of stillbirths, premature births of course play the main role. Thus, according to literary data, the percentage of stillbirths among premature infants is approximately 32-35. In particular, based on materials from the obstetric-gynecological institute for 1908-27, the number of stillbirths in premature births amounts to 57% of the total number of stillbirths. The fact of the decrease in the number of premature births requires careful study in order to identify the causes contributing to the premature birth of an underdeveloped fetus and the conditions eliminating these causes. The firmly established for some time and still not abandoned opinion about the exceptional significance of maternal syphilis as a cause of premature births does not find confirmation in later, more refined research, according to which definitely established cases of syphilis among stillborn premature infants constitute only 12-20% of the total number of stillbirths. [The percentage may be higher, since stillborn children of syphilitic mothers are sometimes born without visible manifestations of syphilis (lues latens)]. Among other causes of premature births, toxicoses of pregnancy play a major role, then acute infectious diseases (influenza, typhus, etc.), sometimes poisoning of the mother (arsenic, CO), much less frequently repeated injections of salvarsan made for therapeutic purposes, occupational hazards, etc. These data clearly indicate the path that must be taken to reduce stillbirths from premature births. In the fight against toxicoses and the like, the prenatal consultation is of very great importance, where prevention of these diseases is possible. The number of premature births, as well as stillbirths, according to many authors, shows fluctuations depending on the social-living conditions of the mother; therefore, legislative measures to improve the labor and living conditions of pregnant women are an important factor contributing to the reduction in the number of premature births and stillbirths (Pismenny, Feigel). A woman's right to be exempt from work in the last months of pregnancy, the organization of systematic observation in the consultation of her health and the course of pregnancy, the possibility of timely detection there of the slightest deviations in the course of the latter and in particular changes in the condition of individual organs, timely placement in the maternity ward, appointment of an appropriate regime to eliminate various harmful factors—all these are very important measures for the organization of antenatal protection of infancy.

I. Feagel. Pathoanatomical diagnosis of S. Since S. has significant medico-legal importance, its diagnosis should be made not only on the basis of autopsy data, but necessarily taking into account also the clinical data from childbirth in a clinical institution and preliminary information when it comes to medico-legal autopsies of newborns. The absence of marbling of the lungs, the absence of air-containing parts in the lungs, established by the lung test, the absence of air in the stomach, and the presence of ecchymoses on the epicardium and on the pleura speak in favor of S., but these signs are by no means absolute, since in medico-legal practice there are known cases of infanticide in the period of apnea before the onset of pulmonary respiration. Due to artificial respiration, significant parts of the lungs, especially their anterior edges and to some extent the upper lobes, become air-filled. During artificial respiration, air can penetrate into the stomach. Air can get into the lungs and even into the stomach during the passage of the infant through the birth canal due to premature respiratory movements. Therefore, the mere presence of air in the lungs and in the stomach does not always indicate that the infant was born alive. Attention must be paid to this aspect, since in ordinary prosector's practice one often has to deal with the clinical diagnosis 'born in deep asphyxia, not revived'; at the same time, the autopsy shows the presence of air-filled areas in the lungs and often air in the stomach. And in medico-legal examination of a newborn, one should not hasten with a diagnosis of live birth based solely on the presence of only small air-filled areas in the lungs and air in the stomach. Although in medico-legal practice one does not encounter artificial respiration, it should still be remembered that air swallowing can occur even during the passage of the child through the birth canal. Only consideration of all clinical data, circumstances of the case, and autopsy data clarifies the diagnosis. S. in connection with the act of childbirth. The dominant cause of S. is trauma associated with the act of childbirth. The anatomical characteristic of birth trauma is various changes in different organs and tissues. This includes, first of all, a sharply expressed birth tumor of the head (caput succedaneum), cephalohematoma. Damage to the cranial bones is also often encountered, both in the form of indentations and bends, and in the form of actual violations of their integrity. Indentations have the appearance of grooved or so-called spoon-shaped indentations, located mostly on one of the parietal or frontal bones. In the deepest part of the indentation, as well as at the edges of the bone, one can sometimes see a crack or an actual fracture of the latter. These marks on the bones occur from strong pressure of the head against the promontory or symphysis of the mother's pelvis. Cracks in the cranial bones are more common; they are found almost exclusively on the parietal bones, more often in one of them, more rarely in both. Usually only one crack is found, as an exception - two or more. These cracks have a typical direction, run parallel to the rays of ossification, and most often begin from the edge of the sagittal suture of the parietal bone. Such injuries are observed mainly during prolonged or difficult labor. Compression of the head is accompanied by a strong load on the plates of the cerebellar tentorium and the falx cerebri. With excessive tension of them, rupture of veins and hemorrhage between the layers of the falx cerebri and cerebellar tentorium occur. These hemorrhages themselves are not fatal, but they indicate strong compression of the skull. From strong displacement of the cranial bones, ruptures of vessels of the soft meninges flowing into the sinuses can occur. Less often there is an avulsion of v. magnae Galeni at its point of entry into the straight sinus; cases of sinus rupture are quite rare. Ruptures of the cerebellar tentorium are often observed; most often they are located on the upper plate of the edge of the tentorium. Hemorrhages into the cranial cavity, associated with rupture of vessels or (which rarely happens) sinuses, are divided into subdural, subarachnoid, ventricular, and into the brain substance. In connection with birth trauma, ischemic necroses are also described in the brain tissue. Their origin Beneke associates with reflex ischemia. Foci of softening can be complicated by subsequent hemorrhage. According to Kruska, foci of hemorrhage are found in 2.5% of cases. Sometimes in the medulla oblongata in the region of the olives, punctate hemorrhages can be encountered, but they are more likely to depend on asphyxia. In most cases, with histological examination, no changes are found in the brain tissue. In the cervical part of the spinal cord, ruptures of ligaments and hemorrhage into the membranes of the spinal cord are sometimes encountered. The spilled blood can reach the medulla oblongata and the posterior cranial fossa. Birth trauma as a cause of death is also manifested in damage to other organs. Sometimes hemorrhages in the area of the sternocleidomastoid muscle are encountered. These hemorrhages, in the presence of abrasions, acquire medico-legal interest in connection with suspicion of compression of the neck. Only analysis of the case reveals the essence of the matter. Hemorrhages into the liver with its tears, into the abdominal cavity, into the spleen and kidneys can also be the result of birth trauma. Hemorrhages into the adrenal glands, contrary to the opinion of some authors, occur relatively rarely. Ruptures of the large intestine have been observed repeatedly: Paltauf associates them with excessive filling with meconium. A certain percentage of S. falls on disorders of placental blood circulation: prolapse of the umbilical cord, twisting of it, shortness of the umbilical cord, sometimes reaching 4 cm. To this category of causes should be attributed premature separation of the placenta, placenta praevia, anomalies of fetal position, breech position, transverse position, etc. (even in clinical institutions, the number of stillbirths in breech positions is much greater than in cephalic). According to the data of Kleinwachter, in breech positions, the numbers of live-born and still-born children relate as 84.37% : 15.63%. This must be taken into account especially in medico-legal cases, in secret births, where the dangers for the child are much greater. In such cases, the autopsy gives the usual picture of asphyxia. Careful examination of the contents of the respiratory tract and lungs clarifies the cause of death. This examination should not be omitted in any case, especially in medico-legal cases, when information about the conditions in which the childbirth took place is often extremely scarce. Due to premature respiratory movements caused by irritation of the respiratory center, aspiration of amniotic fluid, meconium, blood, and mucus from the vaginal pathways often occurs. Sometimes macroscopically it is already visible that in the respiratory tract there is meconium, pieces of vernix caseosa, mucus, and blood; on the surface of the lungs, areas with aspiration of this material appear as yellowish spots from vernix caseosa and greenish spots from meconium. However, more often one has to resort to microscopic examination of smears, which should be taken not only from the respiratory tract, from the branching of the bronchi, but also from the peripheral parts of the lungs. With significant aspiration of meconium, the smear from the surface of the lungs may have a yellowish-green tint. Microscopic examination in such cases reveals droplets of fat of various sizes, cells of flat epithelium without nuclei (epidermis of the infant), hairs without medulla, individual crystals of cholesterol from amniotic fluid, cells of alveolar epithelium, cylindrical cells with cilia from the mucous membrane of the bronchial tree, red blood cells, nucleated cells of flat epithelium from the vagina, and mucus. In the presence of meconium, light-green bodies of meconium are visible. If there is no other cause of death, then the finding in the lungs of components of amniotic fluid, mucus, meconium even in the expanded state of the lungs indicates that the death of the infant can be associated with the act of childbirth. S. in connection with the act of childbirth often also depends on obstetric operations (see above). For some time it was believed that uric acid infarcts are undoubtedly a sign of the live birth of the infant, but at the present time it should be considered proven that they can also occur in stillborn infants. Diseases of the mother (syphilis, intoxication, etc.) and of the fetus can lead to the death of the fetus. In terms of frequency, syphilis should be mentioned first. In the anamnesis of macerated fetuses, it is often possible to establish influenza or other infectious disease suffered by the mother before childbirth. Toxicoses of pregnancy, eclampsia, uremic conditions of the mother are often accompanied by intrauterine death of the fetus. Poisonings, in particular with arsenic, carbon monoxide, repeated injections of salvarsan, are often accompanied by stillbirth. In poisoning with carbon monoxide, hemorrhages into the area of the striatum of the brain were sometimes found in the fetus. Diseases of the placenta and of the fetus itself are often accompanied by S. Diseases of the lungs, in the form of intrauterine pneumonia, fetal peritonitis, encephalitis, significant hydrocephalus, etc. can have as a consequence S. This category of causes also includes malformations. However, in this respect a certain caution should be observed. Malformation should be considered as a cause of S. only when it makes extrauterine life absolutely impossible.

When assessing the damages found in stillborn infants, one must consider damages 1) from self-aid by parturient women (abrasions on the face, etc.); 2) as a result of various methods used to revive the fetus. Incompetent removal of aspirated mucus from the oral cavity and pharynx can lead to injuries to the mucous membrane of the pharynx and mouth in the form of abrasions (ecchymoses) and even tears of soft tissues. Rhythmic pulling on the tip of the tongue (Laborde's method) is often accompanied by swelling of the tongue, erosions on the surface of its tip, and hemorrhages in the tongue, pharynx, and the tissue around the esophagus. With artificial resuscitation according to the Schulze method, there can be hemorrhages in the soft tissues of the chest, especially around the nipples, as well as hemorrhages in the liver, kidneys, lungs, epicardium, and the membranes of the spinal cord. These are difficult to distinguish from hemorrhages associated with asphyxia and birth trauma, but hemorrhages in the membranes of the spinal cord, especially in the lumbar region, should rather be associated with the resuscitation method (Kpar). These injuries are not only of clinical interest, but as practice shows, they can become the subject of a forensic medical examination. The causes of stillbirth are complex, and it is not always possible to find a satisfactory explanation for stillbirth at the autopsy table. All the more reason is it necessary to perform an autopsy on every stillborn infant and to account for all clinical data and circumstances of the case. The fact that a certain percentage of newborns are stillborn from so-called natural causes, i.e., causes related to the act of birth, and from diseases of the mother and fetus, has great forensic medical significance. When the body of a newborn infant is found, the question of violent death first arises. Unfortunately, this view is not only widespread among the general public but is also held by some representatives of investigative bodies and even physicians. On the basis of the above facts, in a forensic medical examination of the body of a newborn infant, one should therefore also consider the possibility of death from so-called 'natural' causes.

3. Morgenstern. Lsh.; Vladýkin A., Newborns (4 years of clinical life, ed. by D. Ott, vol. I, part 2, p. 363, SPB, 1911); Vyklýukov A., Stillbirth in SNB, diss., SPB, 1902 (lit.); Feýgel I., Stillbirth, M.-L., 1929 (lit.); Feigel I., Das Geburts-trauma und seineBedeutung in der Geburtshilfe, Monatscnr. f. Geb. u. Gynakol., B. LXXXIT, 1929; Schultze B., Tod des Kindes wahrend der Geburt (Handbuch d. Geburtshilfe, herausgegeben v. Winckel, B. und, vol. 3, Wiesbaden, 1905, lit.).