Interpretation
Defining the cause of death helps bereaved parents in their grieving process,10, 11 estimated the recurrence risk in future pregnancies, serves mortality statistics and future public health interventions to reduce the number of perinatal loss.12 Elucidating the cause and underlying risk factors through thorough and concise post-mortem investigations may therefore prevent future stillbirths.
Clinical Practice Guidelines are “statements that include recommendations intended to optimize patient care”.13 Whilst their aim is to enhance the medical practice of doctors and guide them along with evidence-based knowledge towards better patients’ care,14 studies have likewise revealed poor adherence in cases where guidelines are not based upon good evidence,15lead to over-treatment rather than “effective” treatment of a patient,16 or when conflicts of interests of authors create a bias in clinical recommendations.17, 18 Evidence-based clinical practice guidelines on maternal and fetal post-mortem examinations therefore ought to be implemented in every hospital in order to optimize, standardize and harmonize their practice according to national guidelines such a supported by the RCOG, PSANZ or ACOG with the aim of finding the cause of fetal death and improve maternal care in subsequent pregnancies. Ideally, sensitivity of post-mortem examinations should be high with a low inter-rater variability in result interpretation in order to determine the underlying aetiology with high accuracy.2, 19 Placental histopathology fetal autopsy and fetal genetic testing are considered the gold standards following stillbirth.20Known barriers to post-mortem examinations, however, are considered the parents’ dislike of invasiveness, inefficient communication and lack of understanding of the purpose.21 Contrarily, parents’ desire for more information acts as a facilitator and it therefore lies within the responsibility of the caring obstetrician to propose the optimal post-mortem workup after stillbirth in a respectful way to bereaved parents. Obstetricians most commonly consent bereaved parents for perinatal autopsy, yet about 12.4% claim to lack training in counselling, after all.22
Although the annual stillbirth rate in Austria has held stable at around 3.1 stillbirths per 1000 live births beyond 24 gestational weeks for the last 12 years, 23 a reduction of 10-15% by 2025 is desirable. In the UK, the annual stillbirth rate of 4.7 per 1000 live births ranks among the highest in Europe, which led the UK Department of Health and Social Care support the National Health Service to reduce the stillbirth rates by 50% by 2025. In 2015, the national prevention programme “Saving Babies’ Lives Care Bundle” has been introduced, comprising four measures: (a) reduction of smoking in pregnancy, (b) assessment of risk and surveillance in growth restricted fetuses, (c) raising awareness of reduced fetal movements and (d) effective monitoring during labour.24 Subsequently, UK hospitals had to implement local maternity guidelines in order to follow these steps towards better maternal and fetal care and prevention of stillbirth. A recent study evaluated the local practice guidelines from 75 participating UK hospitals and found that whilst only the minority of 5.6% of evaluated guidelines were recommended for clinical use and 75% needed some modifications, 16.7% were not recommended at all.25 Assessment of staff opinions on the use of their clinical guidelines revealed that over half considered the guidelines to offer higher quality care to women, yet 30% of staff claimed not to be able to follow their guidelines due to time issues, while 24% were not able to implement their recommendations at all. These limitations clearly indicate that the quality, content and perceived utility of guidelines need to be addressed internationally.