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  Chapter 28 Perinatal loss 

Disclaimer | Medical Termination of Pregnancy (TOP) Guide for C | Screening and diagnosis | Termination of pregnancy  | Fetal demise | Care of the woman experiencing perinatal loss | Care of mother and baby after delivery | Placenta | Mementos | Autopsy | South Australian Perinatal Autopsy Service | Culturally sensitive care | Certificate of death | Burial options | Taking baby home | Discharge planning | References | Last reviewed
 
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Document title:                     Perinatal loss

First developed:                   04 August 2004

Subsequent updates:          23 March 2009; 19 May 2009; 17 May 2010

Last reviewed:                      12 April 2011

ISBN number:                       

Replaces document:            New guideline

Author:                                   South Australian Perinatal Practice Guidelines

                                                Workgroup

Audience:                               Medical, midwifery and allied health staff in South Australia public and private maternity services

Endorsed by:                         South Australian Perinatal Practice Guidelines Workgroup

Contact:                                 South Australian Perinatal Practice Guidelines workgroup at: cywhs.perinatalprotocol@health.sa.gov.au

Disclaimer

The South Australian Perinatal Practice Guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach.

Information in this guideline is current at the time of publication and use of information and data contained within this guideline is at your sole risk.

SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not sponsor, approve or endorse materials on such links.

SA Health does not accept liability to any person for loss or damage incurred as a result of reliance upon the material contained in this guideline.

Although the clinical material offered in this guideline provides a minimum standard it does not replace or remove clinical judgement or the professional care and duty necessary for each specific patient case. Where care deviates from that indicated in the guideline contemporaneous documentation with explanation should be provided.

This guideline does not address all the elements of guideline practice and assumes that the individual clinicians are responsible to:

>  Discuss care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. This includes the use of interpreter services where necessary

>  Advise consumers of their choice and ensure informed consent is obtained

>  Provide care within scope of practice, meet all legislative requirements and maintain standards of professional conduct

>  Document all care in accordance with mandatory and local requirements

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    Download Medical Termination of Pregnancy Guide for Clinicians Regarding Legality flow chart  here

Screening and diagnosis

>  Screening procedures and diagnostic tests to detect structural and fetal anomalies may be carried out in the first and second trimesters

>  Specific testing for genetic disorders may be available in some clinical situations. Consultation with a Clinical Geneticist is essential as early as possible, preferably before conception

>  Parental decisions about screening and diagnostic testing must be made on the basis of clear information about the nature and risks of the available interventions. Offer written information and time to consider choices

First trimester screening and diagnostic tests   

>  South Australian Maternal Serum Antenatal Screening (SAMSAS) Programme first trimester screen (link to pretest information)

>  5-10 mL clotted blood between 10+0 and 13+6 weeks

>  Ultrasound for crown-rump length and nuchal translucency from 11+0 to 13+6 weeks

>  Chorionic villus sampling (between 10+0 and 13+6 weeks) for chromosome analysis or specific genetic or biochemical testing

Second trimester screening and diagnostic tests

>  South Australian Maternal Serum Antenatal Screening (SAMSAS) Programme second trimester screen for trisomy 13 and 21 and neural tube defects

>   5-10 mL clotted blood between 14+0 and 20+6 weeks, but preferably at 15 – 16 weeks)

>  Amniocentesis (after 15+ weeks) for chromosome analysis or specific genetic or biochemical testing

>  Morphological ultrasound (18 – 20 weeks)

Ethical considerations

>  The medical practitioner counselling the pregnant woman who has a fetus with structural and / or other anomalies should explain:                                 

>  The full nature of the fetal abnormality

>  The possibility that the abnormality will be lethal

>  The probability of impaired cognitive function

>  The known degree or likelihood of physical impairment

>  Counselling from a clinical geneticist, paediatrician or paediatric surgeon may be helpful in specific cases

>  Parents faced with antenatally diagnosed fetal anomalies may need additional support whether they proceed with the pregnancy or decide to request a termination of pregnancy. Parents should be offered non medical counselling at the time that a diagnosis or suspected diagnosis is made e.g. referral to a social worker or genetic counsellor

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Termination of pregnancy    

>  In South Australia, termination of pregnancy may be performed in a prescribed class of hospital for this purpose, where two legally qualified medical practitioners have medically examined the woman and agree:

>  that the continuance of the pregnancy would pose greater risk to the life of the pregnant woman, including her physical or mental health, than if the pregnancy were terminated

>  that there is a substantial risk that the child if born would suffer from such physical or mental abnormalities as to be seriously handicapped provided that the woman has not reached twenty eight weeks or more gestation

   (Criminal Law Consolidation Act 1935 Section 82A)

>  The green C.O.R. 19 form ‘Certificate to be completed when an abortion is performed under Section 82A of the Act’ for an extract of the ‘Criminal Law consolidation Act 1935’ (Section 82A medical termination of pregnancy) must be completed before the procedure is performed.

>  Refer to flow chart on Medical Termination of pregnancy - Guide for clinicians regarding legality for further information

>  The Commonwealth Government recognises all births over 20 weeks.  Therefore, women / families are entitled to a bereavement payment under the Australian Government Family Assistance Scheme (Centrelink), including for GTOP.  The woman should be issued with a Centrelink Bereavement Payment Form

>  Staff have a legally protected right to refuse to be involved in termination of pregnancy

Method of termination

Second trimester pregnancies are usually terminated by one of the following two methods: 

1.    Medical abortion (induction of labour) with mifepristone and the prostaglandin analogue misoprostol  (link to chapter 97a Medical induction for second trimester terminations of pregnancy and miscarriages

Other prostaglandin analogues may occasionally be used and include gemprost (Cervagem®) vaginal pessaries and extra or intra amniotic prostaglandin PGF2 alpha

2.       Surgical abortion (dilatation and evacuation procedure).  Prostaglandin analogues, mifepristone, laminaria tents or a cervical balloon catheter may be used for cervical priming preoperatively. In South Australia,  dilatation and evacuation (D & E) is offered at the Women’s and Children’s Hospital up to 16 weeks size and at the Pregnancy Advisory Centre up to 22 weeks

Care considerations

The medical officer should consider the following in relation to the procedure of choice:

>  Does the woman wish to see and hold her baby?

>  Is the experience of labour important to the woman?

>  Time factor involved for different methods of termination

>  Is the woman aware that a D & E usually precludes viewing and handling of the fetus and may lead to some limitations with pathological examination?

>  In those cases where the fetus has been diagnosed with single or multiple malformations, has the issue of further investigations such as an autopsy been discussed? 

>  If the woman proceeds with D & E are further investigations required? This may include amniocentesis, fetal tissue being sent for chromosome analysis and /or DNA storage.  If the fetus is intact an autopsy could be requested.

>  The woman’s views in relation to mementos e.g. photographs, foot or hand prints, memory box

>  Consider any specific circumstances (e.g. reduced liquor) that may influence choice (Report on late terminations of pregnancy 1998)

Care at delivery and documentation (GTOP)

>  If no overt signs of life at birth, there is no requirement to assign an Apgar score or to register the birth regardless of the gestation

>  If there are obvious signs of life, regardless of gestation, an Apgar score is assigned and a time of birth and then a time of death must be recorded

>  If an Apgar score is assigned:

>  A Birth Registration Form must subsequently be issued

>  A Perinatal Death Certificate must subsequently be issued

>  The birth is to be recorded in the Delivery Suite birth register.  (An electronic transfer of information is made to the Department of Births, Deaths and Marriages)

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Fetal demise

>  Fetal demise (whether early or late) requires confirmation from a formal ultrasound

>  According to the Births, Deaths and Marriages Registration Act 1996, a still-born baby is at least 20 week’s gestation or, if it cannot be reliably established whether the period of gestation is more or less than 20 weeks, with a body mass of at least 400 grams at birth, that exhibits no sign of respiration or heartbeat, or other sign of life, after birth but does not include the product of a procedure for the termination of a pregnancy

>  The birth of a still-born baby should be registered

>  In the event that a fetus is born with signs of respiration or heartbeat before 20 weeks gestation, the birth should be registered and a Perinatal death certificate completed as this is classified as a neonatal death

>  Vaginal delivery (spontaneous or elective induction of labour) is suitable for late pregnancy loss

Multiple pregnancy

>  When one baby in a multiple pregnancy dies before 20 weeks gestation but is not born until over 20 weeks, it is considered a missed abortion and, therefore, not required to be registered

>  If selective feticide results in the death of one or more fetuses a Medical Termination of Pregnancy Form (green C.O.R. 19 form ‘Certificate to be completed when an abortion is performed under Section 82A of the Act’ for an extract of the ‘Criminal Law consolidation Act 1935’) needs to be completed

>  However, if gestation at death is uncertain and the weight of the dead twin is 400 grams or greater, the birth of that twin must be registered:

>  A Birth Registration Form must subsequently be issued

>  A Perinatal Death Certificate must subsequently be issued

>  If the twin was known to be alive at 20 weeks or more, it must be registered irrespective of it’s weight

Medical induction

> Follow link to medical induction for second trimester termination of pregnancy and stillbirths

Surgical dilatation and evacuation

> Management is the same as for surgical management of miscarriage.  Follow link to Miscarriage/surgical management

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Care of the woman experiencing perinatal loss

>  Explanation and support for the woman and her family should begin immediately following confirmation of fetal death or decision for medical termination

>  Parents should be offered non medical counselling at the time that a diagnosis or suspected diagnosis is made e.g. referral to a social worker or genetic counsellor

>  The emotional and psychological preparation related to the timing of the induction / termination procedure after diagnosis should be discussed with the woman

>  Aim for continuity of caregivers 

>  Provide a detailed explanation to ensure that the woman is fully informed before starting any procedure

>  Obtain intravenous access and take bloods as indicated (follow link to chapter 26 Investigation of stillbirths)

>  Group and save

>  Complete blood picture

>  Coagulation profile (if at risk of coagulopathy or > 24 hours after IUFD)

>  Discuss the woman and her family’s option to see, touch and hold the baby after delivery, receive mementos (discussed below), and take photographs. Parents may be unsure about seeing and holding their baby after death.  It is important that staff gently explore any parental concerns and respect their choice to do what is right for them

>  Offer stillbirth and neonatal death support group information (such as SANDS) and brochures to the woman and her family

>  In the case of a termination of pregnancy for a fetal abnormality offer information about the Support After Fetal Diagnosis of Abnormality (SAFDA ) support group

>  Arrange early anaesthetic review.  If regional block required, obtain results from complete blood picture and coagulation profile before insertion

>  Social work support

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Care of mother and baby after delivery

Care of mother

>  It is important that the wishes of the woman and her family in relation to seeing, touching and holding their baby are respected at this time

>  The parents should be encouraged to name their baby and begin to develop memories of their baby          

>  The gender of the baby should not be identified if any doubt exists.  Indeterminate sex should be documented in the notes and pathological examination to determine gender should be requested as soon as possible. The gender can be determined within 24 hours by the South Australian Perinatal Autopsy Service at the Women’s and Children’s Hospital

>  Observations as indicated and allow parents some time alone as appropriate

>  If the placenta is retained, arrangements should be made for evacuation of the uterus in theatre. The urgency of performing this procedure should be determined by the amount of ongoing vaginal blood loss

>  As appropriate, parents may include siblings and other family members in photographs to aid the development of memories following their baby’s death

Care of baby

>  If parents wish to see and hold their baby, ensure baby is wrapped and    presented in a way that is sensitive to their individual needs

>  There should be someone close at hand to remove the baby when appropriate

>  Document weight and length, date and time of birth, gender and name of baby in case notes and on memento card for parents

>  Medical / midwifery staff should be aware and advise women and their family as appropriate, that refrigeration (at 4˚ Celsius) of the baby is advised at least within the first 24 hours. If the woman wishes to keep her baby with her, staff should encourage regular periods of refrigeration (e.g. overnight if possible)

Blessing baby

>  Women and their family may choose to have a blessing of their baby (may be arranged privately or midwifery staff can notify the hospital chaplain or other appropriate denomination if available)

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Placenta

>  Histological examination of the placenta provides additional information about perinatal deaths

>  Where possible, all placentas of stillborn infants, early neonatal deaths and mid-trimester miscarriages / genetic terminations should be sent for examination

>  The placenta should also be sent to histopathology if a chromosomal abnormality is suspected or neonatal fetal death is probable

>  Twin placentas must be adequately labelled as Twin I and Twin II.

>  Document description and weight of placenta in case notes

Autopsy

>  The placenta is sent with the fetus to the South Australian Perinatal Autopsy Service at the Women’s and Children’s Hospital (WCH mortuary)

No autopsy 

>  The placenta may be sent to the hospital’s histopathology department 

>  The placenta should be sent as soon as possible (i.e. within 12 hours) fresh, without any preservative solutions or refrigerated if there is any delay

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Mementos

>  All babies who have post mortem examination by the South Australian Perinatal Autopsy Service will have a memento package including:

>  High quality colour digital photographs (disc with photos available on request)

>  Foot and hand prints       

>  Name band and hair (if possible)

>  Individual hospitals may also create memento packages for all second trimester fetal loss, stillbirths and neonatal deaths

>  Mementos may include some or all of the following:

>  Identification bracelets, cards and tape measures used to measure baby (as appropriate), naming certificate, clothing, e.g. gown, bonnet, quilt, memento box

>  Parents who do not wish to receive these mementos may change their minds at a later date (several weeks, months or years after their baby’s death), and wish to collect their baby’s items

>  Provisions for indefinite storage of mementos should be made at individual hospitals

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Autopsy

>  Consent to autopsy is legally required for any fetus over 20 weeks, weighing over 400 grams or live born

>  However, the South Australian Perinatal Autopsy Service recommends obtaining consent to autopsy or pathological examination at any gestation (tissue retention act)

>  The South Australian Perinatal Autopsy Service (at the Adelaide Women’s and Children’s Hospital) provides a perinatal autopsy service for all public and private hospitals in South Australia, as well as Alice Springs Hospital, Broken Hill and Mildura

>  A plain language autopsy report can be requested from the South Australian Perinatal Autopsy Service (ph: 81617333) at any time. If it is anticipated that a plain language autopsy report will be required, this may be requested on the original autopsy consent form at the time of autopsy consent

Benefits of obtaining perinatal autopsy

>  May confirm or help determine cause of death

>  May establish a diagnosis

>  Important for establishing iatrogenic disease

>  Important for research and teaching

>  The information obtained from autopsy may be useful for counselling in relation to the index pregnancy for parents as well as for siblings and future pregnancies

>  A Wales review of perinatal autopsy has found that:       

>  13 % of clinic pathological classifications were altered

>  18 % of autopsies provided a main cause of death

>  8 % of autopsies provided new information (Khong, 1996)

>  A recent retrospective study reported that autopsy added information that led to a refinement of the risk of recurrence in 27 % of cases examined (Boyd et al. 2004)

Before obtaining consent

>  The booklet ‘when a person dies: The Hospital Autopsy Process – information for family and friends’ should be given to the parents to read before any request for autopsy consent from the medical officer (link to booklet)

>  It is the responsibility of the medical officer to answer any queries that the woman and her partner may have related to autopsy consent before obtaining their consent for autopsy

>  The autopsy request and authority form (a) MR82F should be completed by the medical officer

>  The ‘autopsy request and authority form (b) MR82F’ should be completed by the senior available next of kin and signed by a witness (also interpreter if required)

>  A copy of the autopsy report may be sent to the woman’s general practitioner according to the woman’s wishes (documented on form (b) MR82F) 

>  Parents can choose not to have an autopsy performed

>  Initial information from autopsy is usually available after two weeks, but final results may not be available for some time

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South Australian Perinatal Autopsy Service

>  The following forms should be completed and sent to the South Australian Perinatal Autopsy Service with the fetus / baby for autopsy:

>  Autopsy request and Authority forms MR82F (Parts a & b), for all non-coronial autopsy examinations (link to forms)

>  Burial Authority and Information required by Undertaker Form

>  Disposal arrangements form (for stillbirths < 20 weeks as no death certificate required)

>  Confidential Report on Perinatal Death (Maternal, Perinatal and Infant mortality Committee) (may be sent directly as indicated on the form)

Transport of the fetus / baby for autopsy

>  The doctor at the transferring hospital should telephone (08) 8161 6101 to inform staff at the South Australian Perinatal Autopsy Service to expect a baby

>  The referring hospital should arrange transport of the baby with SA Pathology  on phone number (08) 8222 3000 or via Funeral director of choice

>  Transport may be by road or air as appropriate

>  The baby should be refrigerated at 4˚ Celsius until transfer

 

Follow these guidelines for any fetus / baby being transported to the South Australian Perinatal Autopsy Service:

>  The baby / bucket should be clearly labelled         

>  The baby should be wrapped in a shroud (sheet), then plastic

>  A small fetus < 20 weeks may be transported dry in a bucket

>  Transport without fixative or other fluids

>  Include fresh placenta dry in sealed bag

>  Use a plastic esky with ice bricks (e.g. small containers of frozen water) carefully positioned around but separate from baby (or bucket) for cold storage transport

>  It is important that baby is transported dry and undistorted

>  Include clinical information – obstetric history of the mother

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Culturally sensitive care

>  Women often have different values, perceptions and behaviours that differ not only across cultural backgrounds but also within their own culture

>  It is important for health professionals to acquire a general working knowledge of those practices that may be considered offensive in some cultures

>  Health professionals should be aware that families from other cultural backgrounds may have very different belief systems and practices around death and important rituals that need to be performed 

>  A detailed account of various multicultural practices around death is beyond the scope of this guideline.  A brief description of issues that may be relevant for Aboriginal and Muslim women is included

 

* Refer to section 4 of ‘SANDS – Appropriate Care for women and their partners when their baby dies’ for a detailed account of culturally sensitive care

Aboriginal women

>  It may be important for Aboriginal women to include their extended family who may or may not include blood relatives when grieving perinatal loss

>  Utilise Aboriginal liaison services where available as support until the arrival of relatives

>  It is important to understand that eye contact and questioning may be offensive to the woman

>  Care for the woman at a pace suitable to her individual needs 

>  Ensure the woman is aware of any aboriginal services as well other available services (including funeral options) so that choices most appropriate to the woman’s cultural needs can be made

Muslim women         

>  Usually make own burial arrangements for stillborn baby with the funeral director.

>  Ensure the woman is aware of available services at the hospital

>  According to Islam, for forty days following delivery, the mother of a stillborn baby is unclean and may not touch a dead body

>  The stillborn baby may be washed by a relative of the same sex

>  Early discharge may be requested for early burial of the stillborn baby

>  The stillborn baby should be interred (usually in a shroud) within 24 hours after death (may be without a coffin).  If required, autopsy should be expedited for the parents

>  These arrangements may affect the hospital’s ability to create mementos

>  The funeral service is usually held in a Mosque, but may also take place in a funeral parlour or cemetery

>  Cremation is not usual

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Certificate of death

>  Following a stillbirth, a doctor’s certificate on the form approved by the Births Deaths and Marriages Registrar, certifying the cause of fetal death should be given to:

a.       The Births Deaths and Marriages Registrar

b.       The funeral director or other person who will be arranging for the disposal of the human remains (Births, Deaths and Marriages Registration Act, p. 12, 1996)

Post-mortem

>  The death certificate is signed by the doctor carrying out the post-mortem

No Post-mortem

>  The death certificate should be signed by the doctor caring for the woman and her stillborn baby (any legally qualified practitioner can sign)

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Burial options

Greater than 20 weeks gestation

All intrauterine fetal deaths or neonatal deaths ≥ 20 weeks receive a birth certificate and a death certificate (excluding those babies that are a result of a termination of pregnancy unless liveborn).  Funeral arrangements are made privately and the woman is responsible for all costs

>  Coronial enquiry – stillborn babies do not require investigation by the coroner.  Investigation is at the Coroner’s discretion

>  The above funeral services apply to all babies who die in the perinatal period (i.e. from birth to 28 days after delivery) as well as second and third trimester fetal losses 

>  Discuss burial or cremation options after delivery.  Organise social work support in accordance with individual hospital or medical arrangements

Genetic termination

>  It is not compulsory for a funeral if a birth is not registered.  The hospital mortuary may provide a death certificate for all genetic terminations over 20 weeks gestation, for the funeral director, so a cremation can occur (legal requirement)

Available options for the woman and her partner are:

>  A private funeral (Burial or Cremation) and the parents are responsible for all costs OR

>  Surgical disposal of fetus          

NB: Parents' grieving process is often assisted by involvement in a physical parting. Burial may be an option at any gestation

Less than 20 weeks gestation / genetic termination

>  The woman organises a private funeral, and is responsible for all costs OR

>  Hospital arranged cremation through funeral consultants and the cremation will be with other babies (not available at all hospitals)OR

>  Surgical disposal of fetus

>  The mortuary will provide the required paperwork

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Taking baby home

Greater than 20 weeks                   

>  Usually, the undertaker from the chosen funeral parlour will collect baby from the hospital before burial, however, this is not a legal requirement

>  Occasionally women may wish to take their baby home in preparation for the ceremony or before transporting baby to the funeral parlour

>  Arrangements for the above should be made on a case by case basis

>  Parents who take their baby home and then to the funeral parlour should also take the death certificate, (including both portions for the undertaker and registrar) to hand to the undertaker with the baby

>  In the above circumstances, it is important to explain to the parents:                  

>  Cold storage requirements for the transport and care of their baby

>  Their responsibility to take the baby to the funeral parlour within 24 hours 

>  It is advisable for staff caring for the woman to obtain contact details of the receiving funeral parlour and telephone the funeral parlour the following day to ensure they have received the baby

>  Baby may be dressed and dry wrapped and transported home in an esky (may be foam if no plastic esky available) with ice bricks (e.g. small containers of frozen water) carefully positioned around but separate from baby for cold storage transport

Less than 20 weeks gestation / genetic termination

>  A fetus at less than 20 weeks gestation is not considered human remains

>  On request, in cases where there are no infection contraindications, women may take the remains of their baby home for burial

>  In these circumstances, it is preferred that staff offer the available cremation service whereupon the ashes may then be taken home to be kept / scattered as appropriate

>  If cremation has not been undertaken, the fetus should be wrapped in a waterproof shroud for transport and placed in a sealed ice box (e.g. esky containing ice bricks carefully positioned around but separate from the fetus) for cold storage

>  The parents should be advised to contact their local council to ensure that burial is carried out in accordance with their local council regulations

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Discharge planning

>  Contraception advice as appropriate

>  Lactation suppression advice

>  Follow up medical appointment after two weeks (according to individual hospital arrangements).  At this appointment the woman receives a physical check and the results of any investigations / autopsy in a plain language report (may take 4-6 weeks to complete).  A formal report is sent to the referring general practitioner

>  Offer the woman follow-up counselling by the service provider or another appropriate agency / counsellor

>  Arrange domiciliary follow up as indicated

>  Medical discharge letter

>  If the woman has transferred from the country, a discharge phone call and letter to the woman’s general practitioner (with the woman’s consent) should be attended by the medical officer caring for the woman

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References

 

  1. Skene L.  Prenatal diagnosis and late termination:  A legal perspective. Aust NZ J Obstet Gynaecol 1995; 1:3-6.
  2. Criminal Law Consolidation Act 1935 – Section 82A.  Medical termination of pregnancy [Act] (online).  Available:  http://www.austlii.edu.au/au/legis/sa/consol_act/clca1935262/s82a.html
  3. Births, Deaths and Marriages Registration Act 1996 [Act] (online) Available: http://www.parliament.sa.gov.au/
  4. Department of Histopathology. Perinatal loss and how to access the state perinatal autopsy service. Adelaide South Australia: Women’s and Children’s Hospital; 2003
  5. Department of Human Services. When a person dies, the hospital autopsy process – information for family and friends, Government of South Australia Adelaide: Hyde Park Press; 2002. p.1-16.
  6. Khong T. The contribution of the pathologist after a perinatal loss – what should we be telling the parents. Aust NZ Obstet Gynaecol 1996; 36:15-17.
  7. Boyd PA, Tondi F, Hicks R, Chamberlain PF.  Autopsy after termination of pregnancy for fetal anomaly:  retrospective cohort study. BMJ 2004; 328:137 - 139.
  8. National Collaborating Centre for Women’s and Children’s Health. Antenatal care, routine care for the healthy pregnant woman. Commissioned by National Institute for Clinical Excellence.  London: RCOG Press; 2003. p. 47-48.
  9. Report on late term terminations of pregnancy.  Medical Practitioners Board of Victoria, Acute Health Division, Department of Human Services; 1998
  10. South Australian protocol for Investigation of Stillbirths. In: Maternal, perinatal and infant mortality in South Australia 2006. Adelaide: Department of Health; 2007. p. 56 – 59.
  11. Waterson P, Richardson R, editors. Stillbirth and neonatal death support (SANDS). Appropriate care for women and their partners when their baby dies, second edition, NSW: 1998.
  12. Stillbirth and Neonatal Death Support (SANDS).  My empty arms information kit, SANDS (SA) Inc, South Australia: 2003.

Useful websites

South Australian Perinatal Autopsy Service

http://www.wch.sa.gov.au/services/az/divisions/labs/sapas/index.html

 

South Australian Maternal Serum Antenatal Screening (SAMSAS) Program

http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html

 

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First developed: 04 August 2004    Subsequent updates: 23 March 2009; 19 May 2009; 17 May 2010 

Last reviewed: 12 April 2011

South Australian Perinatal Practice Guidelines. Please read our disclaimer.

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