Stillborn Investigation Protocol

The following procedures are recommended for a complete investigation of a stillborn:

Placenta and Cord

Placenta tissue, following delivery, collect a sample of fresh placenta tissue as per Appendix A for:

  • Cytogenetics
  • Cultures

Placenta and Cord Histopathology

In all cases send the placenta to the lab with complete documentation for histopathology or if an autopsy consent has been obtained send the placenta with the body to the morgue.

Stillborn Examination

Perform a detailed physical examination with measurements as per Appendix B.

  • Use the Stillborn Examination and Investigation Record (Form #HS001-128) to document your findings. The stillborn examination should be performed by a clinician skilled in examination of the newborn. The stillborn examination is most crucial if a consent for autopsy has not been obtained from the parents.

Autopsy

Request permission for a complete autopsy in all cases, even if the cause of death seems evident.

If consent for complete autopsy is refused, request permission for the following examinations as separate components of a limited autopsy:

  • External examination by pathologist/clinical geneticist
  • Photography
  • Radiological Examinations (especially with multiple malformations or suspected skeletal dysplasia)
  • Internal examination limited to brain and/or spinal cord; chest organs, or abdominal organs as appropriate
  • Removal of small skin or organ samples by needle biopsy (for DNA analysis, cytogenetics studies and cultures).

Document permitted examinations on an autopsy consent form. Make arrangements for these studies personally or in cooperation with pathology laboratory (See Appendixes C and D).

Maternal Investigations

Maternal investigations can be completed prior to discharge.

In all cases:

  • CBC, platelet count
  • Blood group, Rh type and antibody screen Kleihauer-Betke (screen for feto-maternal hemorrhage) Note: must be done prior to delivery by cesarean section
  • Serology for syphilis; IgM and IgG for parvovirus; CMV; rubella and toxoplasmosis
  • Maternal blood culture
  • Hgb AIC

Consider as clinically indicated: Autoimmune serology (anti-DNA, ANA, lupus anticoagulant and anticardiolipin antibodies), especially if history of recurrent pregnancy losses

  • Thyroid studies
  • Hgb electrophoresis
  • HIV serology
  • TB skin test

Maternal and Family History

Ensure complete documentation of relevant history is included on the mother's hospital chart including:

  • History of present pregnancy specifically in regard to:
    • Gestational age
    • Fetal growth
    • History of bleeding
    • Recent illness/exposure (fever or flu-like illness during this pregnancy)
    • Systemic disorders (including diabetes, hypertension, collagen disease, seizures and severe anemia)
    • Substance use
    • Oligo/polyhydramnios
    • Maternal trauma
    • Medications used during pregnancy
  • Previous obstetrical history including miscarriages, stillbirths, neonatal deaths and congenital anomalies
  • Maternal/paternal family history including history of miscarriages, stillbirths, neonatal deaths, hereditary disease and congenital anomalies
  • Labour and delivery events
  • Provide supporting documents to pathologist – Alberta Prenatal Record, Labour and Delivery Record, Notice of Birth or stillbirths, stillborn Examination and Investigation Record, ultrasound reports, non-stress tests (NSTs), biophysical profile(s), fetal monitoring strips, laboratory results, amniocentesis/CVS and prenatal maternal serum screening

Grief Management and Follow-up

Referral to community support services is recommended. The follow-up for parents is most important in resolving issues surrounding the birth of a stillborn baby and in planning future pregnancies. They should be provided with the results of all investigations, counseling, genetic referral (if indicated) and an opportunity to discuss the investigation results in relation to future pregnancies. An appointment should be made for review of the outcome of investigations. (Appendix E)

Costs

The costs of the stillbirth investigation, including transport of the body to an autopsy facility and return for burial should be the responsibility of the originating regional health authority.

Fatality Inquiries Act

Stillborns are not included within the definition of a person as currently determined by the Supreme Court of Canada. For this reason stillborns are generally not reportable to the Medical Examiner. However, in the event that a woman presents to hospital having already delivered a "stillborn" the Medical Examiner's Office should be contacted if there is any question, whatsoever, that the infant may have, in fact, been born alive. The reason for involvement of the Medical Examiner is that the possibility of infanticide needs to be considered in the differential diagnosis as to the cause of death.

Contacts

If you have any questions about a investigation of a stillborn you may wish to contact the following:

Edmonton and North Zone

  • Laurie Russell, MD, FRCPC
    Laboratory Medicine and Pathology
    Misericordia Hospital
    Edmonton, AB
    Phone: 780-735-2076
    Pager: 780-445-6781
    University Autopsy Pager: 780-445-5374
    Royal Alexandra Hospital Autopsy Pager: 780-445-5281

Central Zone

  • Clarissa Fauth, MD, FRCPC
    Anatomic/Pediatric Pathologist
    Red Deer Regional Hospital
    Red Deer, AB
    Phone: 403-358-4373
    or Autopsy Coordinator Phone: 403-314-6098

Calgary and South Zone

  • Marie-Anne Brundler, MD, FRCPC
    Pediatric Pathologist
    Alberta Children's Hospital
    Phone: 403-955-7211
    On-call Pediatric Pathologists ACH switchboard: 403-955-7211

Microbiology:

  • Provincial Laboratory
    Contact virologist on call
    Calgary: 403-944-1200
    Edmonton: 780-407-7121

Cytogenetics:

  • Calgary: 403-955-7375
    Edmonton: 780-407-1542

In addition to investigating the medical aspects of a stillbirth, it is important to consider the psychological effects on the family. The Alberta Perinatal Grief Management Form (#HS001-129) lists several measures to facilitate the grief process. The birth of a stillborn is a devastating experience for parents and families.