Antenatal diagnosis of a life-limiting condition — structured SAQ (15 marks)

(a) Diagnosis and prognosis conversation (3 marks)

One mark per element. ^[4][5]

• Setting and structure: private room, the most senior clinician available, the partner or chosen support person present, sit down at their eye level, a warning shot ('I'm afraid I have difficult news'), plain words, and then silence — silence is an intervention.
• Frame the prognosis as life-limiting. "Your baby has a condition called bilateral renal agenesis. The kidneys have not formed, and there has been very little amniotic fluid. The lungs cannot develop normally, and the prognosis is that the baby will not survive for long after birth." Use the baby's name when known.
• Avoid the language pitfalls: never use 'incompatible with life' as an opener, never say 'there is nothing more we can do' (what changes is the goal — from cure to comfort), never use 'at least', never compare to another loss, never say 'you're young, you can have another'. State that both continuing the pregnancy and termination are supported choices and neither will be steered.^[4][5]

(b) The perinatal palliative care birth plan (4 marks)

One mark per element. ^[6]

• Continuing the pregnancy is a supported choice, and termination is also genuinely offered; the decision is revisitable as the picture evolves.
• The monitoring-coherence principle: if the plan is not to intervene for fetal compromise (because the baby will not survive), continuous CTG in labour commits the team to a caesarean it has already decided against. Intermittent or no monitoring may be the coherent choice. The monitoring decision must match the intervention decision and be recorded.
• Mode and place of birth: vaginal birth is usually preferred; caesarean is reserved for maternal indications. The position and place of birth are recorded.
• The birth-room plan: who is present, who receives the baby, whether resuscitation is attempted and to what ceiling, what happens in the first hour (warmth, swaddling, skin-to-skin unless declined, anticipatory symptom relief prescribed in advance), and out-of-hours contingency — what happens if she presents to a different hospital or shift that has not seen the plan.^[6]

(c) Investigation bundle and the Kleihauer decay (3 marks)

One mark per element. ^[1][2]

• Placental histopathology every time — the single highest-yield investigation and the most often omitted. Send it with a clear request: maternal vascular malperfusion, fetal vascular malperfusion, villitis, chorioamnionitis. Consent for placenta is separate from autopsy consent and less confronting.
• The Kleihauer (or flow cytometry for fetal haemoglobin) taken early — the proportion of fetal cells in the maternal circulation decays over hours to days after birth; a Kleihauer taken late may be falsely low and miss a significant fetomaternal haemorrhage. Take it within hours of birth.
• The rest of the bundle: autopsy offered but not first, with limited and imaging-only alternatives; cytogenetics or microarray on an appropriate sample taken promptly; maternal bloods (FBC, HbA1c, TFTs, antiphospholipid antibodies where indicated); bacteriology and virology; clinical photography and skeletal survey where structural anomaly is suspected.^[1][2]

(d) PSANZ two-axis classification with worked example (2 marks)

One mark per axis. ^[1]

• PSANZ-PDC (Perinatal Death Classification) is applied to EVERY perinatal death and classifies the single most important maternal or fetal antecedent factor. PSANZ-NDC (Neonatal Death Classification) is applied ADDITIONALLY to neonatal deaths and classifies the neonatal condition causing death.
• Worked example: a 25-week birth after spontaneous preterm labour, the baby dies of necrotising enterocolitis on day 18. The PSANZ-PDC is spontaneous preterm birth; the PSANZ-NDC is necrotising enterocolitis. The two axes tell different parts of the story.^[1]

(e) Follow-up structure and aftercare (3 marks)

One mark per element. ^[4][1]

• A named follow-up appointment with a date before the family leave hospital, with a named clinician who will explain the autopsy, placental histopathology and other results as they return — closes the loop on the investigation bundle.
• Screen both parents for depression, anxiety and post-traumatic stress, and refer to bereavement support. The psychosocial impact of stillbirth is measurable for years.
• Counsel proactively about practical aftercare: lactation suppression (the most-often-forgotten bodily consequence), birth and death registration, funeral or cremation, financial help, bereavement leave. Stop the system harming them: cancel antenatal appointments, notify community providers, flag the record.^[4][1]