• To enable a high quality systematic approach to the provision of care around the time of a perinatal death including investigation, audit and bereavement care.

Livebirth: A livebirth is the complete expulsion or extraction from its mother of a fetus, irrespective of the term of gestation, which after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered liveborn.

Neonatal death: is defined as death of a liveborn baby within 28 days of life.

Stillbirth (fetal death): Death prior to the complete expulsion or extraction from its mother of a fetus of 20 or more completed weeks of gestation or of 400 gms or more birth weight. The death is indicated by the fact that after such separation 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.

Registered Birth: A birth that meets the criteria for a live birth or stillbirth.

Unregistered Birth: Any baby born before 20 weeks gestation or if the gestation is unknown, weighs less than 400gm, who did not, at any time after being born, breathe or show any other sign of life. 

FDIU: Fetal Death In Utero

It is the responsibility of the an obstetrician/registrar to complete the Perinatal Audit medical record package and prepare the case for presentation at the Obstetric Morbidity and Mortality Meeting and the Regional Morbidity and Mortality Meeting

Equipment

The Maternity Unit keeps a stock of relevant literature, documentation packs and memorabilia items to assist in the care of parents that experience perinatal loss. The Emergency Department and 3 North should use the documentation packs and other resources outlined/provided by the Maternity Unit.

Procedure

Consider the following:

• Women with a confirmed FDIU (Refer to Appendix 1 Non Detection of Fetal Heart Sounds) who require an induction of labour should be admitted to the maternity unit, regardless of gestation.
• Women with a confirmed FDIU who require surgical termination of pregnancy should be admitted to 3 North.
• Women with threatened abortion greater than or equal to 14 weeks gestation should be admitted to the maternity unit.
• Bereaved parents should be provided with a private room, away from the busiest part of the ward and a symbol (Orange Butterfly Sticker) placed on door to alert all staff to the situation.
• Continuity of care is recommended, 1 to 1 care is required while in labour
• Referral to a social worker should be offered and if accepted to provide support, counselling and information pertaining to support groups and funeral options.
• Notify contracted hospital Photographer, Record consent for photo's in the progress notes and on the careplan.
• Medical Clinicians should discuss the value of an autopsy with the parents in all cases of a perinatal death and offer the option of the procedure.
• Notification of the death to the General Practitioner and other relevant care providers should be undertaken as soon as possible after the death. This should be followed by a comprehensive clinical summary promptly after review of the death.
• Provisions should be made in the event that the mother is unwell following the birth (e.g. septicemia, admission to Intensive Care Unit, located in another hospital), to provide an opportunity for access to the baby during and/or after maternal recovery.
• Using the Cuddle Cot in the room, simpe instructions are with the cot, the second cuddle cot can be loaned out to parents so the they can take the baby home with them until the funeral director collects them. Domcare will then pick up the cot and bring it back to the hospital

Management

Core Investigations for all stillbirths refer to References PSANZ Clinical Practice Guideline for Care Around Stillbirth and Neonatal Death (2018) Investigations for Stillbirth Chapter 5 and PSANZ Stillbirth Investigations Flowchart Placental, membrane and cord histopathology

Following a stillbirth; neonatal death or birth of an infant that required extensive resuscitation, the placenta, membrane and cord should be sent fresh and unfixed for macroscopic and histological examination by the pathologist regardless of whether consent for an autopsy has been gained. Where a postmortem is required, the placenta is to be sent to the mortuary fresh for holding until the baby is in the mortuary. (Refer to the CPP0235 Placenta-Indications and Procedures for Pathological Examination)

Transfer of Baby to the Mortuary

Complete MR forms:

MR/076.0 Transfer to Mortuary - Registered Birth

MR/076.1 Transfer to Mortuary - Unregistered Birth

Baby to be transferred to the Morturay by the yardman/security

Perinatal post-mortem examination

Refer to References PSANZ Clinical Practice Guideline for Care Around Stillbirth and Neonatal Death (2018) Perinatal Autopsy Including Placental Assessment Chapter 4 and PSANZ Autopsy Consent Brochure for Parents

Communication and consent for post-mortem examination

All hospital perinatal autopsy examinations require written consent from the parent following informed discussion. The extent of the examination including retention of organs needs to be clearly explained and documented in the consent form. Options for a full, limited or stepwise autopsy should be explained. Consent from parents is required for peri-mortem investigations such as, tissue and blood sampling. Written consent is not required for histopathological examination of the placenta. If a postmortem is declined the parents should be informed that this is a part of the routine investigation which may provide valuable information.

PLEASE NOTE: Clinicians should discuss the value of an autopsy with all parents in all cases of stillbirth and neonatal death and offer the option of the procedure.

Autopsy consent

• Where possible, a senior clinician who has established a rapport and understanding with the parents should discuss the value of a post-mortem examination and offer the option of the procedure.
• The clinician approaching for autopsy consent should discuss the options for a full, limited or stepwise post-mortem examination; the issue of retained tissues; the value of the autopsy and the possibility that the information gained may not benefit them but may be of benefit to others. Parents should be given written information explaining the post-mortem examination.(refer to link in refernce list 'Information for Parents About Autopsy')
• Consent for the autopsy which clearly outlines the extent of the investigation should be recorded on an approved consent form and a copy made for the hospital patient record and a copy to accompany the baby to the venue of the autopsy (MR/056.3 Consent for Post Mortem Examination.)
• Where parents decline an autopsy a consent declining the autopsy should be attended and placed into the patient record. (MR/056.3 Consent for Post Mortem Examination.)

Alternative investigations where permission for autopsy is not obtained

• If permission for an autopsy is not obtained or declined, other less invasive testing may assist in establishing whether any important abnormalities have been missed. These alternatives permit detailed investigation of the fetus or infant while still respecting the wishes of the parents. Consent for the following procedures/investigations should be gained:
  • External examination by a perinatal/paediatric pathologist, clinical geneticists or paediatrician. (Refer to link reference list 'Clinical Examination of a Baby Checklist')
  • Babygram,Parents who decline an autopsy should be asked for consent to undertake a full body X-ray (Babygram). A Babygram may detect abnormalities (mainly skeletal) which may not be detected on an external examination.
  • Magnetic Resonance Imaging MRI (if available) may be offered to parents who decline an autopsy investigation. The investigation should be undertaken as soon as possible after a stillbirth.

Quality and minimum standards for postmortem

A perinatal/paediatric pathologist should perform or supervise all perinatal post-mortems.

Transport of the baby with appropriate expertise should be arranged to ensure that all perinatal post-mortem examinations are of sufficient quality. Transport should be arranged with a registered undertaker.

A comprehensive maternal history should accompany the baby for a post-mortem examination including:

• clinical/obstetric history including relevant previous obstetric history
• copy of the death certificate;
• copies of all antenatal ultrasound reports; and
• copy of amniocentesis report if applicable.

Other Documents required

• The RWH Protocol for External Hospital Referring Registered or unregistered Postmortems form is to be used to gain consent. The original form must accompany the baby to postmortem.
• Where the postmortem is performed at the RWH, an External Referral to the RWH for Postmortem intention of arrangement form is to be completed and accompany baby to the postmortem.
• Pathology slip requesting autopsy.

Psychological and Social Aspects of Perinatal Bereavement Refer to Reference PSANZ Clinical Practice Guideline for Care Around Stillbirth and Neonatal Death (2018) Chapter 3 Psychological and Social aspects of Perinatal Bereavement

• Birth options-ascertain an appropriate time to discuss birth options following determination of a fetal death in utero or abnormalities. The timing, the mode of delivery, analgesia options and benefits of birthing options information should be given and discussed.
• Delivery of information should be clear, honest, parent friendly language and sensitive. Repeat important information. Ensure both parents are present if possible. The mode of information may include fact sheet/written information given for frequent reference for the parents. Allow time for discussion.
• Timing of information should allow plenty of time to discuss issues at the most appropriate time.
• Parents are given time to make decisions
• The deceased baby to be treated with same respect as live baby
• The parents need to feel supported and in control; death validated
• Cultural/religious practices: different approaches to death and rituals must be respected

Hospital stay

• Environment: parents are cared for in a private room in surgical or maternity ward.
• A symbol of a small orange butterfly sticker is placed outside the room to alert all staff of perinatal loss.
• Placing the baby in the cuddle cot
• There is a second cuddle cot that is used for loan purposes,parents who would like an early discharge can then take their baby home until the funeral director collects them from there residence
• Domcare will then pick up the cot and bring it back to the hospital

(ii) Creating memories

• It is important that parents are prepared for the appearance of the baby, particularly when the baby is extremely premature or has a congenital abnormality
• Validating the death of the baby assists in facilitating a healthy grieving process and is enhanced by the encouragement of the creation of memories. Providing suitable clothing, blankets, cots and baskets and seeing, holding and naming their baby assists the parents in creating memories, which may aid in the grief process.
• As a minimum, items included should be:
  • hand and footprints
  • ID bracelet
  • measuring tape
  • cot card
  • digital photographs
  • lock of hair (where possible and only after permission of the parents has been given)
• Parents may take days, months or years to decide that they would like these mementos; therefore no time provision should be made regarding storage. Some families may choose to never receive these items.
• Baptism/Blessing for the baby can be arranged through the appropriate hospital chaplain. Some families may choose to baptise or name their baby themselves, or have a relative or friend do this for them.
• Where possible parents, should be given unrestricted time and access to their baby. Parents should be informed that they can hold, undress and bath baby as desired.

(iii)Documentation Requirements

Registered Birth

• A Perinatal Death Certificate and birth registration are required by the Australian Bureau of Statistics (ABS) for all Registered stillbirths, Neonatal deaths and resuscitated stillbirths.
• Birth Deaths and Marriage https://www.bdm.vic.gov.au/service-partners/medical-practitioners
• A centrelink form is also required for the parents of registered births, this is also online
• A completed Delivery summary on BOS.

(iv)Funeral arrangements

• Parents should be informed of their options in relation to funeral arrangements. It is a legislative requirement to arrange a funeral for a baby whose gestation is 20 weeks or greater. Parents should be informed of this, as they may not be aware of this requirement. (Also refer to Appendix 2 Disposal of Recognisable Human Tissue Fetus for fetus < 20 weeks gestation)
• It is useful to provide the parents with written information regarding funeral directors and to include several options. Parents should be given choice of funeral directors.

(v) Aftercare

• Maternal changes: advice on milk production and methods to manage suppression of lactation. Expected vaginal discharge in the postpartum period.
• Support services for parents and children: written information given regarding available support services for parents and children
• Referral to the Domicilliary service for women who were 20 weeks or of greater gestation.
• Grief: inform parents of expectations of grief journey, also offer written information.
• Follow up/Appropriate referral: expectations for 6 week check up with GP
• Continued access to baby if desired

(vi) Health care professionals

• Education: specific training in support skills given to relevant staff
• Access to support: debriefing/support services available to staff working with perinatal death

• All perinatal deaths should be reviewed in a timely manner, by the Mortality and Morbidity committee, including deaths of infant born within the service but who died elsewhere.
• Parents and families involved in perinatal loss should be provided with enough support to enable them to reach their own decisions regarding their care and the care of their baby. The provision of care needs to be responsive to their individual needs.
• If the fetal or neonatal death is a Coroner’s case the requirements for the care of the baby may alter.