Responsibility for permission for autopsy of stillbirths - Obstetric staff
(Paediatric staff are responsible for the investigation and permission for autopsy of neonatal deaths, unless the baby was previable or was induced for known lethal fetal abnormalities. In these cases the obstetric staff are responsible for obtaining autopsy permission).
Stillbirth is defined in Australia as the loss of a fetus who shows no signs of life at birth and is at least 20 weeks in gestation or 400 grams in birthweight if gestation unknown.
In Australia from 1992 – 2003 the stillbirth rate has declined from 6.4 to 5.1 per 1,000 births1. This has coincided with an overall decline in the perinatal mortality rate from 11 to 8 per 1,000 births1. Stillbirths, however, continue to account for two thirds of all perinatal deaths. In New South Wales, population based surveillance is performed by The Midwives Data Collection with a rate of 6.0 per 1,000 births reported in 20032. (NSW Mothers and Babies 2003)
The underlying aetiology for stillbirth is felt to be multifactorial with frequently cited risk factors including: maternal age, smoking, maternal weight, parity and socio-economic status. Many studies are retrospective reviews of established Mortality databases and there is a lack of more detailed prospectively collected information. Despite current knowledge regarding stillbirth there is much that is unknown and the area has been relatively understudied. In fact in 2002, 45% of stillbirths in Australia reported no specific cause1. Stillbirths nearer to term are more likely to be classified as unexplained than very preterm stillbirths2. Post mortem has an important role in documentation of causation for stillbirth with the percentage of unexplained fetal deaths decreasing if autopsy is performed. NSW currently has the lowest perinatal post mortem rate in Australia. In 2002, 30.3% of perinatal deaths in NSW had an autopsy with the percentage of unexplained stillbirths 39.2%. This rate of unexplained stillbirth is significantly higher than the South Australian unexplained stillbirth rate of 24.6% where post mortem was performed in 63.1% of perinatal deaths.2, 3
The classification of stillbirth in Australia and New Zealand was revised in 2002 with the aim of providing a uniform system for National use. Renamed the PSANZ-PDC (Perinatal Death Classification) in 2003 the system includes both obstetric and fetal factors as well as autopsy findings and placental pathology4. It has high interobserver reliability with a kappa statistic from 0.83– 0.954. The classification has been in use in NSW since 2002. A clinical practice guideline written by the Perinatal Mortality Special Interest Group incorporating the classification has recently been endorsed by the Royal Australian and New Zealand College of Obstetrics and Gynaecologists.5
The Perinatal Mortality Special Interest Group Clinical Practice Guideline for Perinatal Mortality Audit can be viewed at this website http://www.materrsc.org/page/psanz/pnmsig/pnmsig_guideline.html The establishment of the group was the culmination of collaborative efforts of members of the Perinatal Society of Australia and New Zealand (PSANZ) over many years. The objective of the guideline is to assist clinicians in the investigation and audit of perinatal deaths and to enable a systematic approach to this in Australia and New Zealand. It is designed to provide reliable, up to date information enabling integration of best practice into clinical care decisions.
INVESTIGATION CHECK LIST:
The following investigations are based on recommended best practice from the above guideline. A flowchart is attached as Appendix A. Although this is the ideal for thorough investigation we are aware that it may not be possible or feasible to perform every investigation in certain situations.
1. Paediatric Staff:
References:1. Australian Bureau of Statistics. Causes of Death Australia 2002. Cat No 3303.0 Canberra: ABS 2003
2. Centre for Epidemiology and Research, NSW Department of Health. New South Wales Mothers and Babies 2002. NSW Public Health Bulletin 2003; 14 (S-3)
3. Department of Human Services, South Australia. Maternal, Perinatal and Infant Mortality in South Australia 2002. 17th Report of the Maternal, Perinatal and Infant Mortality Committee. Department of Human Services, Adelaide 2003
4. A Chan, JF King, Flenady V, RH Haslam, DI Tudehope. Classification of perinatal deaths: Developmant of the Australian and New Zealand Classifications. Journal of Paediatrics and Child Health 2004; 40: 340-347