Paediatrics: Perinatal death

Perinatal death

Causes

•   Extreme prematurity (40%).

•   Congenital abnormalities (30%).

•   RDS.

•   Sepsis.

•   Perinatal asphyxia.

•   Pulmonary hypoplasia.

•   Miscellaneous.

After death

•   Take photographs and mementos, e.g. footprints, according to parents’ wishes.

•   Inform all relevant professionals, (e.g. GP, obstetrician).

•   Refer to coroner (Procurator Fiscal in Scotland) if required. UK criteria are:

o cause of death unknown;

o no medical practitioner attended illness leading to death;

o intraoperative death or prior to recovering from anaesthetic;

o suspicious circumstances.

•   Explain and offer post-mortem to parents. Possible benefits include:

o determines cause of death;

o identifies unknown comorbidities;

o determines degree of normality;

o audits clinical care;

o research;

o medical education.

•   Unexpected/unexplained death. As soon as possible consider (with consent!):

o blood for culture—save serum for possible later testing (iem);

o throat, eye, ear surface swabs for bacterial and viral culture;

o suprapubic aspiration (spa) of urine to be saved (iem);

o axilla skin biopsy for fibroblast culture (send in sterile saline).

•   Currently, no neonatal organ or tissue is harvested for transplantation in UK.

•   If able, issue completed death certificate to parent/guardian who is then responsible for registering the death. In the UK there is a specific certificate required for a neonatal death (i.e. <28 days old).

•   Offer follow-up appointment with senior doctor at 4–6wks to discuss issues surrounding death, post-mortem findings, bereavement.

Withholding or withdrawal of life support

Up to 70% of deaths on UK neonatal units follow withholding or elec-tive withdrawal of life-sustaining treatment. In UK the Royal College of Paediatrics and Child Health states that there are 5 situations when with-holding or withdrawal of life sustaining treatment may be appropriate. Three are relevant to newborns and are summarized here:

• No chance’: life-sustaining treatment simply delays death without significant alleviation of suffering, e.g. spinal muscular atrophy type 1.

• ‘No purpose’: although the baby may be able to survive with treatment, the degree of physical or mental impairment will be so great that there is no quality of life, e.g. severe permanent brain injury after perinatal hypoxia.

• ‘An unbearable situation’: treatment is more than can be borne by the baby and/or family when the illness is progressive and irreversible, e.g. recurrent cardiopulmonary resuscitation in an infant with irreversible and progressive cor pulmonale.

• The other two situations relating to ‘brain death’ and ‘permanent vegetative state’ cannot currently be diagnosed in the newborn.

Withholding or withdrawing life-sustaining treatment must be first dis-cussed with the parents. Almost always a joint decision can be made in the child’s best interests. Time, rather than court proceedings, is usually the best approach, the latter being best reserved for extreme situations.

Procedure for withdrawal of life-supporting treatment

Remember, withdrawal of life-sustaining treatment does not equal with-drawing care:

• If possible, allow parents and family to say their good-byes, spend time alone with baby, have appropriate religious services conducted.

• Parents may wish to be present at the time of withdrawal. Offer options of being present or holding the child in a private quiet room during withdrawal or afterwards.

• Stop all non-palliative infusions and remove all peripheral vascular lines and gastric tubes. Clamp central lines and chest drains.

• Switch off all alarms/monitors.

• If ventilated, disconnect and remove ETT.

• Dress or swaddle infant and then allow parents to cuddle infant.

• Give parents/family space and privacy.

• After death undertake relevant tasks as outlined in b ‘After death’, above.