Stillbirth prevention — structured SAQ (15 marks)

(a) The five Safer Baby Bundle elements and the universal principle (5 marks)

One mark per element, one mark for the principle. Marks are lost for a generic "risk assessment" with no specifics. ^[1][2]

• Supporting women to stop smoking — brief intervention at every visit, opt-out quit referral, behavioural support, NRT where indicated.^[1]
• Improving detection and management of fetal growth restriction — risk-stratify, serial customised growth charts, umbilical artery Doppler for increased-risk.^[1][3]
• Raising awareness and improving care for decreased fetal movements — advise on normal patterns, prompt reporting, CTG and ultrasound as indicated.^[1][4]
• Improving awareness of safe going-to-sleep position from 28 weeks — settle to sleep on either side, not supine.^[1][5]
• Improving decision making about timing of birth for increased-risk women.^[1][3]
• Principle: the bundle is delivered universally to every woman because most stillbirths occur in women with no identified risk factor; risk stratification intensifies care rather than exempting the standard-risk woman.^[1][2]

(b) Evidence for the sleep position element (3 marks)

One mark for the study design/size, one for the key finding, one for the PAR. ^[5]

• The CRIBSS individual participant data meta-analysis pooled five case-control studies (851 stillbirths, 2257 controls).^[5]
• Supine going-to-sleep position more than doubled the odds of late stillbirth — adjusted odds ratio 2.63 (95% CI 1.72–4.04) compared with left side; right and left side were equally safe.^[5]
• Population attributable risk was 5.8% — the proportion of late stillbirths attributable to supine sleep, which could be eliminated if every woman settled to sleep on her side from 28 weeks.^[5]

(c) Antenatal surveillance plan (4 marks)

One mark per component. Marks are lost for omitting aspirin or for not specifying serial growth scans with Doppler. ^[3][6]

• Low-dose aspirin 150 mg daily from 12–16 weeks — high risk of placental dysfunction given previous stillbirth with FGR, high BMI, and smoking.^[3]
• Serial growth ultrasound with umbilical artery Doppler every 2–4 weeks from 26–28 weeks, given the previous growth-restricted stillbirth.^[3][6]
• Smoking cessation — structured brief intervention, opt-out quit referral, NRT; this is a modifiable risk factor with a PAR of 4–7%.^[6]
• An agreed, documented plan for timing of birth — individualised, balancing the stillbirth risk of her history against iatrogenic prematurity; planned birth at 39 weeks is a common decision point for the uncomplicated increased-risk pregnancy.^[1][3]
• All five bundle elements delivered, including sleep position and movement counselling from 28 weeks.^[1]

(d) Reduced fetal movements at 36 weeks — immediate assessment and management (3 marks)

One mark per action. The killer error is reassurance without a CTG. ^[1][4]

• Assess immediately — do not reassure on history alone; the woman attends now.^[1][4]
• Cardiotocograph (CTG) now to detect acute fetal compromise.^[4]
• Focused ultrasound for growth and liquor volume given her risk profile and recurrent presentation; if there is evidence of compromise or growth restriction with abnormal Doppler, plan timely delivery — the AFFIRM trial showed a movements care package did not reduce stillbirth but increased intervention, so the decision is evidence-informed and balanced against iatrogenic prematurity.^[4]