{{infobox disease | name	Stillbirth | Image Baby in ultrasound.jpg | Caption Ultrasonography is often used to diagnose stillbirth. | DiseasesDB | ICD10 | ICD9 | ICDO | OMIM | MedlinePlus 002304 | eMedicineSubj search | eMedicineTopic Stillbirth | MeshID D050497 }}

A stillbirth occurs when a fetus has died in the uterus. A wide variety of definitions exist. The Australian definition specifies that fetal death is termed a stillbirth after 20 weeks gestation or the fetus weighs more than . Once the fetus has died, the mother may or may not have contractions and undergo childbirth. The term is often used in distinction to live birth or miscarriage and the word miscarriage is oftentimes used incorrectly to describe stillbirths. Most stillbirths occur in full-term pregnancies.

Human stillbirth

Causes

The causes of a large percentage of human stillbirths remain unknown, even in cases where extensive testing and autopsy have been performed. A rarely used term to describe these is sudden antenatal death syndrome or SADS, a phrase coined by Cacciatore & Collins in 2000.

In cases where the cause is known, some possibilities of the cause of death are:

bacterial infection

birth defects, especially pulmonary hypoplasia

chromosomal aberrations

growth retardation

intrahepatic cholestasis of pregnancy

maternal diabetes

high blood pressure, including preeclampsia

maternal consumption of recreational drugs (such as alcohol, nicotine, etc.) or pharmaceutical drugs contraindicated in pregnancy

postdate pregnancy

placental abruptions

physical trauma

radiation poisoning

Rh disease

Female Genital Mutilation umbilical cord accidents

*"Prolapsed umbilical cord" - Prolapse of the umbilical cord happens when the fetus is not in a correct position in the pelvis. Membranes rupture and the cord is pushed out through the cervix. When the fetus pushes on the cervix, the cord is compressed and blocks blood and oxygen flow to the fetus. The mother has approximately 10 minutes to get to a doctor before there is any harm done to the fetus.

*"Monoamniotic twins" - These twins share the same placenta and the same amniotic sac and therefore can interfere with each other's umbilical cords. When entanglement of the cords is detected, it is highly recommended to deliver the fetuses as early as 31 weeks.

*Umbilical cord length - A short umbilical cord (<30 cm) can affect the fetus in that fetal movements can cause cord compression, constriction and ruptures. A long umbilical cord (>72 cm) can affect the fetus depending on the way the fetus interacts with the cord. Some fetuses grasp the umbilical cord but it is yet unknown as to whether a fetus is strong enough to compress and stop blood flow through the cord. Also, an active fetus, one that frequently repositions itself in the uterus can cause entanglement with the cord. A hyperactive fetus should be evaluated with ultrasound to rule out cord entanglement.

*Cord entanglement - The umbilical cord can wrap around an extremity, the body or the neck of the fetus. When the cord is wrapped around the neck of the fetus it is called a nuchal cord. Again, these entanglements can cause constriction of blood flow. These entanglements can be visualized with ultrasound.

*Torsion - This term refers to the twisting of the umbilical around itself. Torsion of the umbilical cord is very common ( especially in equine stillbirths) but it is not a natural state of the umbilical cord.The umbilical cord can be untwisted at delivery. The average cord has 3 twists.

Sometimes a pregnancy is terminated deliberately during a late phase, for example for congenital anomaly. UK law requires these procedures to be registered as "stillbirths".

Prenatal diagnosis

It is unknown how much time is needed for a fetus to die. Fetal behavior is consistent and a change in the fetus' movements or sleep-wake cycles can indicate fetal distress. A decrease or cessation in sensations of fetal activity may be an indication of fetal distress or death, though it is not entirely uncommon for a healthy fetus to exhibit such changes, particularly near the end of a pregnancy when there is considerably little space in the uterus for the fetus to move about. Still, medical examination, including a nonstress test, is recommended in the event of any type of any change in the strength or frequency of fetal movement, especially a complete cease; most midwives and obstetricians recommend the use of a kick chart to assist in detecting any changes. Fetal distress or death can be confirmed or ruled out via fetoscopy/doptone, ultrasound, and/or electronic fetal monitoring. If the fetus is alive but inactive, extra attention will be given to the placenta and umbilical cord during ultrasound examination to ensure that there is no compromise of oxygen and nutrient delivery.

Constricted umbilical cord

When the umbilical cord is constricted (q.v. "accidents" above), the fetus experiences periods of hypoxia, and may respond by unusually high periods of kicking or struggling, to free the umbilical cord. These are sporadic if constriction is due to a change in the fetus' or mother's position, and may become worse or more frequent as the fetus grows. Extra attention should be given if mothers experience large increases in kicking from previous childbirths, especially when increases correspond to position changes.

Prevention

As many of the causes are unknown or untreatable, prevention is difficult. Symptoms of bacterial infection, such as from a dental abscess, in pregnant women may also include unusual periods of incoherence and symptoms of shock, and should be treated by a physician immediately. High blood pressure, diabetes and drug use should be regulated with physician's advice. Umbilical cord constriction may be identified and observed by ultrasound, if requested.

Research published in the Journal of the American Medical Association in 2011 found a number of maternal factors associated with stillbirth. Among them: being age 40 or older, having diabetes, having a history of addiction to illegal drugs, being overweight or obese, and smoking cigarettes in the three months before getting pregnant.

Prenatal maternal treatment

An in utero stillbirth does not usually present an immediate health risk to the woman and labour will usually begin spontaneously after two weeks, so the woman may choose to wait and birth the fetal remains vaginally. After two weeks, the woman is at risk of developing blood clotting problems, and labor induction is recommended at this point. In many cases, the woman will find the idea of carrying the dead fetus emotionally traumatizing and will elect to be induced. Caesarean birth is not recommended unless complications develop during vaginal birth.

Prevalence

The mean stillbirth rate in the United States is approximately 1 in 115 births, which is roughly 26,000 stillbirths each year, or on an average one every 20 minutes. In Australia, England, Wales, and Northern Ireland, the rate is approximately 1 in every 200 births, in Scotland 1 in 167. (From The National Statistical Office and other sources.) Many stillbirths occur at fullterm to apparently healthy mothers, and a postmortem evaluation reveals a cause of death in only about 40% of autopsied cases.

In developing countries, where medical care can be of low quality or unavailable, the stillbirth rate is much higher.

Legal definitions of stillbirth

Australia

In Australia any stillborn weighing more than 400 grams, or more than 20 weeks in gestation, must have its birth registered.

Austria

In Austria a stillbirth is defined as birth of a child of at least 500 g weight without vital signs, i.e. blood circulation, breath or muscle movements.

Canada

Beginning in 1959, "the definition of a stillbirth was revised to conform, in substance, to the definition of fetal death recommended by the World Health Organization." The definition of "fetal death" promulgated by the World Health Organization in 1950 is as follows: :''"Fetal death" means death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps.''

Germany

In Germany a stillbirth is defined as birth of a child of at least 500g weight without blood circulation or breath. Details for burial vary amongst the federal states.

Ireland

Since 1 Jan 1995 stillbirths occurring in the Republic of Ireland must be registered; stillbirths which occurred before that date can also be registered but evidence is required. For the purposes of civil registration, s.1 of the Stillbirths Registration Act 1994 refers to :-

''"...a child weighing at least 500 grammes, or having reached a gestational age of at least 24 weeks who shows no signs of life."''

United Kingdom

The registration of still-births has been required in England and Wales from 1927, in Scotland from 1939 but is not required in Northern Ireland .

England and Wales

For the purposes of the Births and Deaths Registration Act 1926 (as amended), section 12 contains the definition that :-

''“still-born” and “still-birth” shall apply to any child which has issued forth from its mother after the twenty fourth week of pregnancy and which did not at any time after being completely expelled from its mother, breathe or show any other signs of life.''

A similar definition is applied within the Births and Deaths Registration Act 1953 (as amended), contained in s.41.

The above definitions apply within those Acts thus other legislation will not necessarily be in identical terms.

s.2 of the 1953 Act requires that registration of a birth takes place within 42 days of the birth except where an inquest takes place or the child has been "found exposed" in which latter case the time limit runs from the time of finding.

Extracts from the register of still-births are restricted to those who have obtained consent from the Registrar General for England and Wales.

Scotland

Section 56(1) of the Registration of Births, Deaths and Marriages (Scotland) Act 1965 (as amended) contains the definition that :-

''“still-born child” means a child which has issued forth from its mother after the twenty-fourth week of pregnancy and which did not at any time after being completely expelled from its mother breathe or show any other signs of life, and the expression “still-birth” shall be construed accordingly''

s.21(1) of the same Act requires that :-

''Except so far as otherwise provided by this section or as may be prescribed, the provisions of this Part of this Act shall, so far as applicable, apply to still-births in like manner as they apply to births of children born alive.''

In the general case, s.14 of the Act requires that a birth has to be registered within 21 days of the birth or of the child being found.

Unlike the registers for births, marriages, civil partnerships and deaths, the register of still-births is not open to public access and issue of extracts requires the permission of the Registrar General for Scotland.

Northern Ireland

In Northern Ireland the Births and Deaths Registration (Northern Ireland) Order 1976, as amended contains the definition :-

'' “still-birth” means the complete expulsion or extraction from its mother after the twenty-fourth week of pregnancy of a child which did not at any time after being completely expelled or extracted breathe or show any other evidence of life.''

Registration of still-births can be made by a relative or certain other persons involved with the still-birth but it is not compulsory to do so. Registration takes place with the District Registrar for the Registration District where the still-birth occurred or for the District in which the mother is resident. A still-birth certificate will be issued to the registrant with further copies only available to those obtaining official consent for their issue. Registration may be made within three months of the still-birth

United States

In the United States, there is no standard definition of the term 'stillbirth'. The Centers for Disease Control and Prevention collects statistical information on "live births, fetal deaths, and induced termination of pregnancy" from 57 reporting areas in the United States. Each reporting area has different guidelines and definitions for what is being reported; many do not use the term "stillbirth" at all. The federal guidelines suggests (at page 1) that fetal death and stillbirth can be interchangeable terms. The CDC definition of "fetal death" is based on the definition promulgated by the World Health Organization in 1950 (see section above on Canada). Researchers are learning more about the long term psychiatric sequelae of traumatic birth and believe the effects may be intergenerational

The federal guidelines recommend reporting those fetal deaths whose birth weight is over 12.5 oz (350g), or those more than 20 weeks gestation. Forty-one areas use a definition very similar to the federal definition, thirteen areas use a shortened definition of fetal death, and three areas have no formal definition of fetal death. Only 11 areas specifically use the term 'stillbirth', often synonymously with late fetal death, however they are split between whether stillbirths are "irrespective of the duration of pregnancy", or whether some age or weight constraint is applied. A movement in the U.S. has changed the way that stillbirths are documented through vital records. Previously, only the deaths were reported. However 27 states have enacted legislation that offers some variation of a birth certificate as an option for parents who choose to pay for one MAB Legislative Page [MAB legislative page]

See also

Childbirth

Coffin birth

Live birth

Perinatal death

*Intrapartum death

*Neonatal death

**Sudden infant death syndrome

Abortion

*Elective abortion

**Anomalous pregnancy

***Ectopic pregnancy

***Molar pregnancy

*Spontaneous abortion

Maternal death

Stillbirth and Neonatal Death Society

References

Further reading

G. J. Barker-Benfield, "Stillbirth and Sensibility The Case of Abigail and John Adams," ''Early American Studies, An Interdisciplinary Journal,'' Spring 2012, Vol. 10 Issue 1, pp 2–29.

External links

Unspoken Grief.com Support for parents grieving due to perinatal loss (miscarriage, stillbirth, neonatal death).A safe place to share your story.

Share Pregnancy & Infant Loss Support Support for parents who have experienced the death of a baby through early pregnancy loss, stillbirth or infant death.

The Wisconsin Stillbirth Service Program (WiSSP), a branch of the University of Wisconsin-Madison's Clinical Genetics Center. One of the foremost authorities on the causes of stillbirth and responsible for many stillbirth evaluation protocols, including the widespread use of the Kleihauer-Betke test in deciding whether Rh disease is to blame for a stillbirth. This program is now directed by Dr. Elispeth McPherson at the Marshfield Clinic in Marshfield, WI.

Pregnancy Institute founded by Dr. Jason H. Collins, OB/GYN specializes in umbilical cord research

Investigating perinatal death: a review of the options when autopsy consent is refused.

UK Stillbirth and Neonatal Death Society

Category:Pathology of pregnancy, childbirth and the puerperium Category:Fertility Category:Demography Category:Death

ar:إملاص da:Dødfødsel de:Totgeburt es:muerte fetal fr:Mortinatalité ja:死産 pl:Wewnątrzmaciczne obumarcie płodu pt:Natimorto simple:Stillbirth fi:Kohtukuolema ta:செத்துப் பிறப்பு th:ทารกตายคลอด zh-yue:胎死腹中 zh:死產

developer	Darkworks(2008–2010)Ubisoft Shanghai(2010–2011)
publisher	Ubisoft
engine	LEAD
released	PlayStation NetworkXbox Live Arcade
genre	Survival horror
modes	Single-player
ratings	|ACBMA 15+|PEGI18}}

| platforms = PlayStation 3, Xbox 360 | media = Download }} ''I Am Alive'' is a survival horror video game developed by Ubisoft Shanghai and published by Ubisoft. The game focuses on facing the permanent insecurity of a now decaying and hazardous world, and humanity's darkest inclinations. Originally under development by Darkworks from 2008 until 2010, Ubisoft Shanghai completed the title. It was released for Xbox Live Arcade on March 7, 2012 and was released on the PlayStation Network on April 3, 2012 in North America and April 4, 2012 in Europe.

Plot

The game takes place after America has gone through a massive earthquake that destroys most cities and areas. Due to the damage of the aftermath, many people are forced to go without resources. The government tries to help citizens, but their attempts are small and useless since they are not able to complete much as hazardous dust clouds have paralyzed the city. Supplies become low and this causes citizens to become agitated, violent and bitter and turn them to savage hunters.

A male survivor named Adam travels to his old home of the fictional city Haventon, to rescue his wife Julie and daughter Mary. When he gets to his old apartment though, he finds they have left to get to safety and meanwhile video tapes his apology for not being there and says that he will do everything to find them. As he is leaving, Adam sees a small girl who he mistakes for his daughter and saves her from three hostile men. The girl, Mei, is missing her mother and gives Adam a walkie-talkie in which he talks to Henry, a friend of Mei. Henry asks Adam to bring Mei to him and he agrees. Adam and Mei travel out to Henry's apartment but soon stop in a dilapidated mall to rest during a dust storm and Adam notices that Mei is having a fever. He goes to find a supply drop that the government landed for survivors and is able to recover medicine for Mei. The two leave the next day and arrive at Henry's place and sees that Henry is a cripple who is unable to walk. Adam is then tasked of finding a radio for Henry and traverses through the deadly dust clouds and makes it to an old boat. After searching the boat and finding the radio, Adam makes it off and travels back to Henry.

Adam makes it back and Henry thanks him and finally trusts Adam as a friend. Henry also suspects that Mei's mother might be in a local hotel and pressures Adam into finding her for Mei. Adam gets to the hotel and fights through a large number of killers who have kidnapped and attacked women into doing embarrassing sexual acts for them. Adam finds Mei's mother, Linda, and rescues her from the men. They both get back to Henry's place and Mei reunites with her mother. Linda is able to use the radio to get messages from a boat coming to Haventon to pick up survivors. This seems as their way out but they soon learn that the boat is not coming to shore because of the dust. Henry makes the plan of creating a beacon to bring in the boat by using fireworks. Adam is able to discover some fireworks and successfully makes a beacon for the boat. Just after they set it up though, hunters attack and Adam is forced to fight them off but Henry is nowhere to be found after. Finally, the beacon attracts the boat and it arrives at the dock just in time.

In the end, Mei and Linda go aboard the boat but Adam decides to stay, hoping to find Henry and his family. Mei and Linda bid Adam farewell and he records his last tape and says that he will find Julie and Mary and try to rescue Henry, before it is shown that Julie has been watching all his videos and currently has all his gear as well. She cries after the video ends and it is left on a cliffhanger whether or not Adam and Henry survived.

Gameplay

The player controls the main character from a third person perspective during navigation, the camera switches to first-person when aiming and shooting. During encounters with hostile survivors, the player can use various tactics to stay alive, including sneaking to surprise enemies with a machete quick kill, performing stealth kills with a bow, or using bluff and intimidation e.g. pointing an empty gun at hostile non-playable characters.

The game has an emphasis on climbing and exploration. The player will scale wrecked buildings and navigate hazardous areas. Every effort has a cost and, when engaging in physically demanding activities, such as climbing or jumping, it is critical to manage the main character's stamina for him to survive. By managing stamina skillfully players are rewarded by accessing hidden paths, resources and other survivors.

Gameplay also involves collecting hidden resources and supplies scattered throughout the city: water, food, gas, medicine, cigarettes, tools, climbing gear, weapons, and ammunition. Anything that the player can salvage from the destroyed city can be used to keep the main characters strong and healthy, or prove helpful in his quest by allowing him to rescue survivors. Retries can be collected throughout the game by helping or rescuing people, with optional side quests to complete.

Development

The game was first rumored to be in development in July 2008, when it was known that ''Assassin's Creed'' producer Jade Raymond was working on a new game, which was announced at E3 2008, along with a trailer. It was later revealed that Raymond was not working on the game. Development experienced various delays. The original developers, Darkworks, announced that it would not be working on it any longer due to a "mutual decision" and that the studio had other obligations, and that the game would be finished at Ubisoft Shanghai's studio. On August 2009, various screenshots of an old build of the game were leaked onto the Internet. An announcement from Ubisoft indicated a release window between Q2 April 2010– Q2 March 2011. These dates passed with no new information, until June 2011 when a notification was published at the Australian classification website which indicated a possible release in the late summer of 2011.

Ubisoft CEO Yves Guillemot said at the start of 2010 that the studio was "totally re-engineering the product." Elias Toufexis is reported to have a major role in the game, playing a character known as Henry. In May 2011, Ubisoft cancelled a number of games, but it was revealed that ''I Am Alive'' and another Ubisoft title ''Beyond Good & Evil 2'' were not among them, with Ubisoft stating that the cancelled games were unannounced games. On September 29, 2011, a new announcement trailer was released for the game with a release date of "this winter" at the end. On January 23, 2012, the developers announced on Facebook that the game would be available for Xbox 360 on March 7, 2012.

Reception

At Metacritic, which assigns a normalized rating out of 100 to reviews from mainstream critics, the game received an average score of 72, based on 45 reviews, indicating "mixed to average reviews". At GameRankings, the game received an aggregated score of 73.81%, based on 26 reviews.

GameSpot gave it an 8, complaining that "The few unrealistic elements are a stark contrast to the engrossing world and only lessen the experience." Eurogamer gave it an 8, commenting "What I Am Alive lacks in originality, though, it makes up for in execution.", praising the tone and gameplay. Several reviews praised the survival aspects of the game, commenting on the scarcity of resources and oppressive atmosphere. IGN gave a negative review, giving it a 4.5, citing outdated graphics and poor gameplay elements.

References

External links

Category:Cancelled Wii games Category:Cancelled Windows games Category:PlayStation 3 games Category:PlayStation Network games Category:Post-apocalyptic video games Category:Survival video games Category:Ubisoft Entertainment games Category:Unreal Engine games Category:2012 video games Category:Video games developed in the People's Republic of China Category:Xbox 360 games Category:Xbox 360 Live Arcade games Category:Horror video games

ca:I Am Alive es:I Am Alive fr:I Am Alive is:Alive (tölvuleikur) it:I Am Alive lv:I Am Alive pl:I Am Alive pt:I Am Alive ru:I Am Alive fi:I Am Alive uk:I Am Alive zh:我依然存在