Perinatal and infant postmortem examination

Difficult to ask for but potentially valuable

The relatively large concentration of deaths in the perinatal period and infancy and the need to provide explanations for parents might suggest that clinicians frequently turn to pathologists for information from postmortem examinations. Yet Cartlidge and colleagues in this week's BMJ draw attention to the fact that the rate of postmortem examination for perinatal and infant deaths in Wales is only 58% (p 155).1Their results are probably typical of the rest of Britain. For example, the confidential inquiry into stillbirths and deaths in infancy in the North Western region found a similarly low rate of only 53% in 1993 (A J Barson and J A Sands, personal communication).

The value of the perinatal postmortem examination extends beyond its ascertainment of factors that contributed to death. It may provide the basis for informed genetic counselling; it may challenge or verify diagnoses made by new techniques before death; it serves to monitor possible adverse effects of new treatments; it is a basis for research and education; and, finally, it can be a source of information in epidemiological surveys.2All this assumes a high quality postmortem examination, but the evidence suggests that this is far from guaranteed. In the Welsh survey a postmortem examination was not requested in 17% of all deaths and not permitted in 25%. Clinicians are urged to take a more positive attitude towards postmortem examination, and others have suggested the same with respect to deaths in children.345Yet there is a difficult problem here, partly because of changing attitudes towards perinatal death. Whereas previously the idea of a funeral service for a stillborn infant would have been looked at incredulously, it is now quite common.6Obstetricians are faced with the uncomfortable prospect of letting parents nurse and bond with their stillborn infant, perhaps for some hours, and then asking for consent for a postmortem examination.

Similarly, there has also been a change in the circumstances surrounding neonatal death. Deaths now commonly occur after prolonged intensive neonatal care, particularly in extremely immature babies. Life support may be withdrawn after distressing discussions with parents, who often express a wish to nurse and perhaps bath and dress their dead baby. In these circumstances an understandable reason for parents declining consent for a postmortem examination is that their baby has “already suffered enough.”

There is no euphemism to describe a postmortem examination. On the one hand, parents desire their last memory of their baby to be one that is disentangled from technology; on the other hand, there is the perception of their loved one's body being desecrated.

How can we work towards resolving this problem? Firstly, seeking parental consent for postmortem examination requires communication skills and experience. It is best done by the person who has already established rapport and understanding with the parents. In most cases this will be a consultant clinician, but often a midwife, nurse, junior doctor, family doctor, or religious minister may have established a close relationship with the parents and this aids communication.

Secondly, many parents erroneously consider the postmortem examination to be solely for research and linked with the notion of “donating the body for science.” Informed discussion is needed about how an examination might be helpful. In truth, a fine line sometimes exists between the true benefits for the parents and the broader and indirect benefit to other babies. If this is the case then it must be acknowledged. Confusing the issue is a recipe for creating guilt on both sides, whereas a scrupulously honest approach is often rewarded by a genuine desire of parents to see their baby's death as in some way helping others.

Thirdly, those seeking consent must be prepared to answer questions about how the body will appear after the postmortem examination has been completed. The notion of “suffering” may in fact be based on an erroneous perception that the body will be damaged beyond recognition before the burial or cremation.

Fourthly, if this fear cannot be alleviated by discussion it is often possible to obtain permission for a “limited” postmortem examination and the advice of the pathologist should be sought. The idea of damage to the head may underlie refusal to give consent, and one might negotiate consent to an examination that specifically excludes examination of the intracranial contents. This is useful when, for example, there are specific pointers towards congenital heart disease or liver or kidney disorders. Information can also be obtained from needle biopsy of organs. If there is a suspicion of dysmorphism then examination of the body by a clinical geneticist is important, and this can be supplemented by blood sampling or skin biopsy for chromosome analysis and a radiological skeletal survey. Valuable bacteriological, biochemical, and toxicological information can be obtained by examination of appropriate body fluids. Finally, the placenta should not be neglected as an important source of information.