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.