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Warning: this article is about stillbirth and its investigations, including autopsies and related procedures.

About six babies are stillborn in Australia every day – an incredibly difficult time for families.

Understandably, they want to know why their baby died. But for one in three stillbirths in Australia, we don’t have a reason, often because the death was not fully investigated.

I’m a perinatal pathologist, a specialist medical doctor and part of the team that investigates a stillbirth. Our role is to try to determine why a baby died, if the problem could recur in another pregnancy, and what might happen differently next time.

Here’s what I want you to know about these investigations, the options, and what happens afterwards.

The placenta is like a diary

The placenta is the diary of the pregnancy and is an essential part of investigating a stillbirth.

In Australia, a stillbirth is the death of a baby in the womb at 20 or more completed weeks’ gestation or a birthweight of 400 grams if the gestation is unknown.

Examining the placenta first involves a visual inspection, then weighing and measuring it. From that, we can see if the placenta is the correct size for the baby’s age and if there are any obvious abnormalities that may explain why the baby died, such as a big blood clot.

The visual inspection guides which small samples are taken to look at under the microscope. Other samples are sent to the lab to see if there is an infection or a genetic reason to explain the stillbirth.

We can return the placenta to you if you wish after the tests are done.

Examining the placenta is considered the most useful investigation, not only to explain a stillbirth but also to direct future pregnancy care. Abnormal changes in the placenta have been reported in 23–96% of stillbirths, depending on a variety of factors.

What’s an autopsy?

Perinatal pathologists, like myself, may perform an autopsy (also known as a postmortem) . This is a type of operation or medical procedure to investigate how your baby died. We take the same care as an operation on a living baby.

An autopsy helps identify a cause of death in 16–42% of stillbirths. Even if no cause of death is found, an autopsy still provides useful information about what did not cause the stillbirth.

The investigations performed during an autopsy will depend on the family’s wishes and can only go ahead with your consent – a legal, voluntary and informed process.

The next of kin (usually the mother) is given written information and spends time talking to her doctor and/or midwife so she can choose the extent of the investigations she feels comfortable allowing for her baby.

There are different types of autopsies and investigations.

Full autopsy

This is where the perinatal pathologist reviews all the clinical history and maternal investigations (such as blood tests) , and looks at the external and internal features of the baby, always treating the baby with utmost respect.

A surgical incision of the skin is made so organs such as the heart, lungs, liver, and kidneys can be examined in detail. Small samples of these organs may be taken and looked at under a microscope for any changes that may explain why the baby died.

The skin incision is stitched and covered with a dressing so it cannot be seen when the baby has clothes on.

If the family and clinical team think it is important to look at the baby’s brain, this is done by a surgical incision on the scalp.

Swabs are taken to look for infection and other samples may be taken to look for genetic or metabolic problems.

Other types of autopsies and investigations

A limited autopsy means one region of the baby is looked at (for example, just the brain or heart) . A minimally invasive autopsy means a sample of a specific organ (say the liver) may be taken with a small needle but with no surgical incisions of the skin.

An external examination involves measurements, external photographs, and close examination of the external features of the baby, but no examination of the internal organs. Radiology (X-rays or MRI) may be done as part of the external examination.

What happens next?

An autopsy report, prepared by the perinatal pathologist, usually takes six to 12 weeks to put together. This report is a synthesis of all the information gained from the autopsy and other investigations.

A multidisciplinary team reviews the findings. These findings then guide discussions with the parents, provides learning points for the care team, and helps inform any future planned pregnancies. Parents are given a copy of the report.

After an autopsy families can see, touch and hold their baby if they wish. The perinatal pathologists work with families to support their cultural needs and sensitivities related to examination of their baby and the placenta.

Perinatal pathologists, like myself, aim to uncover the truth and provide answers. There is warmth and kindness behind the work we do, even though sadly death is a constant.

If this article raises issues for you or someone you know, contact the Red Nose 24/7 Grief and Loss Support Line on 1300 308 307 or visit the Red Nose website for information and support.

Jane Dahlstrom is affiliated with the Centre of Research Excellence in Stillbirth and the Royal College of Pathologists of Australasia. She is an honorary Anatomical Pathologist at ACT Pathology, Canberra Health Services.