S3 E2 The importance of clinical interactions when investigating perinatal loss

In the second episode of our mini-series on perinatal pathology, RCPA President Associate Professor,Trishe Leong, is joined by anatomical pathologist Dr Helen Harris and midwife, Serani Dodson, who how different professions work together to provide comprehensive care for families experiencing perinatal loss.

Transcript

00:00:00:00 - 00:00:11:10

Ms Serani Dodson

If I have an autopsy, will they 100% find out the reason why my baby died?

00:00:11:12 - 00:00:23:12

Dr Helen Harris

It's an absolute privilege to have the trust of parents to examine their baby and their baby's treated with utmost respect.

00:00:23:14 - 00:00:34:27

A/Prof Trishe Leong

I am Associate Professor Trishe Leong, president of the Royal College of Pathologists of Australasia.

00:00:35:00 - 00:01:03:12

A/Prof Trishe Leong

Hello and welcome back to this RCPA podcast series on perinatal pathology. I'm Associate Professor Trishe Leong, president of the Royal College of Pathologists of Australasia. And this is the second episode of our mini-series about perinatal pathology. In our first episode, we spoke to anatomical pathologist Professor Jane Dahlstrom OAM and specialist obstetrician and gynaecologist, Dr Farah Sethna about the importance of perinatal pathology and the implications of a lack of perinatal pathologists.

00:01:03:15 - 00:01:27:28

A/Prof Trishe Leong

In this episode, we're joined by anatomical pathologist, Dr Helen Harris, and midwife Ms Serani Dodson, who both work at the Royal Hobart Hospital in Tasmania. By speaking to Helen and Serani who are from two different professions, we aim to demonstrate the diversity of clinical interactions which are so vital when investigating a perinatal death. Hi Helen and Serani and thank you both for joining me today.

00:01:28:00 - 00:01:29:26

Dr Helen Harris

Thanks, Trishe, for this opportunity.

00:01:29:29 - 00:01:31:15

Ms Serani Dodson

Thanks, Trishe.

00:01:31:17 - 00:01:45:22

A/Prof Trishe Leong

So, Helen, you're first in the firing line. One thing we didn't touch on in our last episode is what training is required to be a perinatal pathologist. Could you explain the process around how you got to be where you are today?

00:01:45:24 - 00:02:11:12

Dr Helen Harris

Sure. A few steps are involved in the pathway. First step is to complete a medical degree to become a doctor. Medical students – I would strongly encourage them to try to get some exposure to pathology or autopsies. Whilst you're also a medical student, you can sit the Basic Pathological Sciences examination, which is a requirement for all Trainees that become pathologists to do.

00:02:11:14 - 00:02:50:09

Dr Helen Harris

Next step is to complete two years of clinical training. Once again, if the individuals can get some exposure to pathology and autopsies would be great. And then getting towards the end of the pathway is to commence anatomical pathology training with the Royal College of Pathologists of Australasia in an accredited institution. This is five years, full-time training, at the end of which you gain a Fellowship of the RCPA as an anatomical pathologist. During your training and probably be advisable to seek out rotations or training positions in institutions that provide perinatal pathology services.

00:02:50:11 - 00:02:58:17

Dr Helen Harris

And then the final step is to subspecialise in perinatal pathology and then to work in an institution with perinatal services.

00:02:58:19 - 00:03:17:01

A/Prof Trishe Leong

Yeah. So it's not a pathway that happens overnight, is it? So, given the shortage that we've got, it's important that we recognise that we've got that shortage now and get people who are interested into the training because it's some time before that can actually be spat out the other end and be contributing to the workforce.

00:03:17:04 - 00:03:28:12

Dr Helen Harris

Yeah, I think that undergraduate exposure is vital, and especially if you have some passionate mentors or teachers in this area. That is a key component of it as well.

00:03:28:14 - 00:03:35:19

A/Prof Trishe Leong

Yeah, it is a lot about you don't know, I mean, you don't know the opportunities or you don't know what you might be interested in if you don't get that exposure.

00:03:35:21 - 00:03:37:00

Dr Helen Harris

Exactly. Yes.

00:03:37:02 - 00:03:58:07

A/Prof Trishe Leong

So getting back to, I suppose the you know, the day to day life of a perinatal pathologist such as yourself, is there a clinical timeline which, you know, when is it still valuable to do perinatal autopsy after there's been a fetal death? Is there some sort of deadline you need to get it done by or other sort of constraint?

00:03:58:10 - 00:04:29:20

Dr Helen Harris

I would say a general answer to that question would be no. There's always a benefit from a postmortem examination of a baby and the placenta. Even in cases where there's been, for example, an intrauterine demise and a long interval between detection of that demise and the delivery of the baby. In some instances, some organs such as the brain are more susceptible to degradation, and examination is easier when there is a shorter interval between the delivery or death of the baby and the examination.

00:04:29:22 - 00:04:56:00

Dr Helen Harris

And, in these cases, with suspected brain pathology, imaging such as MRI is a great ancillary tool. Some specialised testing also requires tissue to be collected within a short window following demise to ensure good quality of the tissue required for that testing. Parents can have time with their baby before a postmortem examination, and it's usually no real urgency to start that examination.

00:04:56:03 - 00:05:02:22

Dr Helen Harris

And if they wish, they can also have time with their baby following the completion of the examination as well.

00:05:02:24 - 00:05:11:08

A/Prof Trishe Leong

Yeah, so it sounds like earlier might be better, but there's always something that you might be able to gain a value from doing the perinatal examination.

00:05:11:10 - 00:05:22:12

Dr Helen Harris

Absolutely. And I think examination of the baby in conjunction with the placenta, tying the two together can always give us some valuable information.

00:05:22:14 - 00:05:46:11

A/Prof Trishe Leong

So you mentioned the parents and time with the baby. I suppose whenever we're doing an autopsy, we always do have the family in our minds and, you know, the bereavement process and funerals or other things like that that might be planned. So I suppose with that in mind, how long does it usually take to perform perinatal autopsy and how quickly can you get the baby back to the parents?

00:05:46:13 - 00:06:22:20

Dr Helen Harris

This is a very frequently asked question. The timeline essentially depends on the examinations being undertaken. So with the examination, it can be a full postmortem, which is the gold standard, which involves an autopsy and ancillary testing. That ancillary testing includes imaging, genetic studies and microbiology. Or it could be a limited postmortem examination, which may be limited just to a cavity or organ of interest with ancillary testing again, or it could be an external only where it's just an external examination of the baby.

00:06:22:20 - 00:06:51:17

Dr Helen Harris

No incisions made with imaging as well. And usually the ancillary testing might be a little bit more limited, perhaps just to the placenta. The imaging is performed prior to the postmortem examination and that may occur the day before the postmortem and then follows on to the postmortem examination. And that timing is dependent on coordination and availability of radiology to some degree. Duration of the postmortem ranges from up to one hour.

00:06:51:17 - 00:07:18:03

Dr Helen Harris

If the examination is limited to external only, up to approximately three hours for a full postmortem examination. Ideally, the baby can be returned to the parents the same day or next day after being received for the examination. And always parents, individual wishes and plans are also accommodated. For example, if there's any cultural or religious funeral arrangements or requirements that need to be accounted for.

00:07:18:06 - 00:07:37:17

A/Prof Trishe Leong

We touched briefly earlier on about shortage of perinatal pathologists need to get more them into the workforce. And I suppose this same across the board for almost all areas of pathology. So with that in mind, do you have a backlog? Is there a wait period at the moment if you need to have a perinatal autopsy done in Tasmania.

00:07:37:19 - 00:08:08:10

Dr Helen Harris

In Tasmania, we’re obviously a smaller population base than our mainland states and territories and we have a centralised service within Tasmania with referral perinatal postmortems to the Royal Hobart Hospital. There are currently no significant delays in completion of the perinatal postmortem reports. We aim to have a preliminary report issued within 24 to 48 hours with the final report incorporated and/or the other investigation results issued usually within eight weeks.

00:08:08:12 - 00:08:27:25

Dr Helen Harris

We also have a good relationship with the obstetricians. If they know a lady is coming into clinic and her results aren't quite finalised, we can prioritise that case if there happens to be a bit of a backlog, if you like. But at this stage and historically we've actually been pretty good with our perinatal postmortems in Tasmania.

00:08:27:28 - 00:08:37:13

A/Prof Trishe Leong

So the people of Tasmania are fortunate. What about the lack of perinatal pathology in Australia in general though? What sort of concerns do you have about that?

00:08:37:15 - 00:09:03:27

Dr Helen Harris

Absolutely. Well, the main concern is the inability to continue to provide this high quality service. You know, to provide answers to families and specialists around perinatal death. A lack of perinatal pathologists limit the capacity of institutions to manage workload with subsequent delays in reporting. In smaller institution staff leave and absences may result in a temporary inability to deliver the service as well.

00:09:03:29 - 00:09:26:12

Dr Helen Harris

Some institutions may not be capable of providing a perinatal service at all, resulting in centralisation of services and associated transport costs and time as well. Similarly, the training of future perinatal pathologists will also be limited because you obviously need a pool of experts to be able to train the future generations.

00:09:26:14 - 00:09:52:27

A/Prof Trishe Leong

Thank you. It's a real concern for such an important area of pathology for families. So maybe over to you now, Serani, for the clinical perspective. You're patient facing. You know, you're the one who's really dealing a lot with the families. And the death of a baby, obviously, is a devastating event for both the families and the health professionals who have been looking after those families.

00:09:52:29 - 00:10:00:11

A/Prof Trishe Leong

So in your role as a midwife, how does your role cross over with the perinatal pathologist when it comes to fetal deaths?

00:10:00:14 - 00:10:33:02

Ms Serani Dodson

You know, that's a really interesting question, Trishe. It is absolutely heartbreaking for the families and it has a ripple effect across the maternity unit. But when it occurs, our focus is always going to be on providing care for those families in an informed evidence-based way and a core business of the midwife is just to be present and provide the family support and information while they're coming to the decision of whether they want to go ahead with an autopsy or not, or what investigations they want to have.

00:10:33:05 - 00:10:58:17

Ms Serani Dodson

So we don't often have a lot of direct contact with the pathologist, but we will often liaise with them, will ask our medical staff to liaise with them so parents can come to that decision. We are a very committed team so we try and make it as smooth as possible for the families, giving as much information as they require, and then we might liaise with the pathologists directly around issues that Helen mentioned about timing.

00:10:58:21 - 00:11:19:02

Ms Serani Dodson

There are some cultural aspects about when the baby would need to be cremated or people want other members of their family to come and see the baby before the baby goes to pathologist. And Helen was just mentioning earlier that on one occasion she has been asked to come to the maternity unit to have a discussion with the parents because they had some specific questions.

00:11:19:04 - 00:11:31:18

Ms Serani Dodson

So I guess the answer to that is we don't work face-to-face with the pathologists, but we're working or working alongside each other to sort of facilitate the decision that the families make.

00:11:31:20 - 00:11:59:11

A/Prof Trishe Leong

Yeah. I mean, you mentioned that families obviously have so many questions when there's been a stillbirth. And I understand that improving perinatal mortality review and outcomes via education workshops, which thank goodness has an acronym, although don't look at the acronym too closely because I think the letters don't quite line up, but improved workshops have been developed to address the educational needs of health professionals like yourself who are involved in caring for the families.

00:11:59:11 - 00:12:05:07

A/Prof Trishe Leong

After a stillbirth has happened. So can you tell us a little bit more about what the improved workshops are?

00:12:05:09 - 00:12:46:14

Ms Serani Dodson

So the improved workshops were developed to upskill and try and help professionals who are caring for families in these situations. The workshops are based on the Perinatal Society of Australia which is PSANZ and the New Zealand perinatal mortality guidelines. And the very core of this workshop is to take a structured approach to practice. So with this overarching aim to facilitate the implementation of a clinical practice guideline and that surrounds the care of stillbirth and neonatal death, and in the hope that this process and these improved workshops will contribute to finding answers to so many questions that arise when a baby dies.

00:12:46:21 - 00:13:14:22

Ms Serani Dodson

So it revolves around six stations. So there are small groups and it's very engaging, very interactive. Each group is facilitated by an experienced educator, so that might be the pathologist, a midwife, obstetrician, the social worker, medical staff, and small groups rotate around each station. So the stations are communicating with parents around autopsy. The second one is autopsy and placental exam.

00:13:14:22 - 00:13:33:25

Ms Serani Dodson

And that's a really interesting one. I thought, why would a midwife really need to go into the ins and outs of a placenta? But the last improved workshop that I went to, COVID had been around for a short while and they were talking about the spiral arteries in the placenta and how that might be affected by COVID and outcomes for babies.

00:13:33:25 - 00:14:05:29

Ms Serani Dodson

So each of these is really interesting to each different profession. So investigation of fetal death, examination of babies who die in the perinatal period, institutional and perinatal mortality audit and the last being respectful and supportive bereavement care. So the workshops are a really good overall look at what goes on when a baby dies. So each station is relevant to everyone in the health care team and just gives us information to pass on to parents.

00:14:06:01 - 00:14:13:11

A/Prof Trishe Leong

It sounds like you've found them helpful. You've been how to put your learnings into practice in your day-to-day interactions with families.

00:14:13:13 - 00:14:40:10

Ms Serani Dodson

Absolutely. So when I've spoken to other midwives that have gone to the improved workshops, they’ve stated it provides them with a wider scope of knowledge and our role in contributing to the clinical practice guideline and implementations are really small part of that really good documentation which might factor into the, you know, the audit at the end. And the participation in the workshops also is a way of preparing midwives for caring for these families.

00:14:40:17 - 00:15:11:09

Ms Serani Dodson

It demystifies and takes the fear out of the autopsy process, which makes it easier for us to discuss that with parents because it is an uncomfortable topic at times. And I think it reduces if we're all on the same page as midwives and we're all doing this consistent, we're all giving consistent care and information, I think it takes a lot of stress out for parents and just being able to answer patients’ questions and hopefully help them to find some answers.

00:15:11:11 - 00:15:41:05

Ms Serani Dodson

Questions that patients have asked or women have asked me. If I have an autopsy, will they 100% find out the reason why my baby died. So I can answer that a bit better now. And also, you know, will this make my next pregnancy less safer? And so I am able to answer those questions a bit better. And I just want to acknowledge that the generosity of some of our families who agreed to autopsy because they don't want any other families to ever have to experience the position that they are in.

00:15:41:08 - 00:15:45:12

Ms Serani Dodson

So that sometimes factors into their decision for autopsy.

00:15:45:14 - 00:16:07:19

A/Prof Trishe Leong

Yeah, it's the hope that the information that can be learned from their baby’s death might help another family. It's really important. It adds meaning to the process. Okay, so Serani, before this recording, you had the opportunity to ask your fellow midwives if they had any questions for Helen. So you're the interviewer now. Are there any questions that we haven't covered yet?

00:16:07:22 - 00:16:19:24

Ms Serani Dodson

I think that a lot of the families will ask how is the baby going to be treated at autopsy? So once we take baby down to the pathologist, what happens then? So Helen.

00:16:19:27 - 00:16:43:05

Dr Helen Harris

It's an absolute privilege to have the trust of parents to examine their baby and their baby is treated with utmost respect. Just like a newborn. And the examination itself is performed with precision and care, like a surgical operation. And at all stages there is respect, care and precision in everything that's undertaken.

00:16:43:12 - 00:16:59:21

Ms Serani Dodson

So, Helen, another question that some of the midwives were interested in is do pathologists suffer from trauma when performing autopsies on newborns? And is this more so than you sort of would with an adult.

00:16:59:24 - 00:17:26:08

Dr Helen Harris

As mentioned previously and known to us all, the loss of any baby is tragic and life changing for families. And with a baby versus an adult, one may think they didn't even get a chance. Personally, for babies, I feel sadness. However, we have to realise, you know, we've got this opportunity to help the families to find out why this pregnancy outcome occurred and to hopefully prevent it happening again.

00:17:26:10 - 00:17:43:20

Dr Helen Harris

I particularly find some of the personal items that are sent down with babies very beautiful and moving, whether it be the toys, pictures, drawings, writings. And so that's something that I find quite emotional at times.

00:17:43:23 - 00:17:52:18

A/Prof Trishe Leong

Okay. Well, thank you very much, Helen and Serani. Was there anything else you wanted to add about this very important area of medicine?

00:17:52:18 - 00:18:12:06

Dr Helen Harris

I might just say I really love my job and I find it so very interesting and rewarding. I would strongly recommend that medical students and junior doctors seek out some exposure to perinatal pathology and postmortems and certainly look at a career in this great field of pathology.

00:18:12:09 - 00:18:43:04

A/Prof Trishe Leong

I think that's a great point to finish up on. Thank you very much, both of you, Dr Helen Harris and Ms Serani Dodson. So, as we come to the end of this episode, I hope you've gained some valuable insights into the world of perinatal pathology from two different perspectives. I think together, Helen and Serani have demonstrated the collaborative nature of perinatal pathology, where different professions work together to provide comprehensive care for families who've experienced perinatal loss.

00:18:43:07 - 00:19:01:01

A/Prof Trishe Leong

And their insights underscore the importance of this field in improving outcomes and supporting families during these difficult times. Thanks very much, listeners, for joining us for this episode of our perinatal pathology series. And please stay tuned for more discussions on this important topic from the RCPA.