Perinatal palliative care — structured oral station (12 minutes)

Opening prompt — "The parents are in front of you. Begin."

Model response — demonstrate the script out loud: ^[4][5]

• Sit down at their eye level. Confirm the partner or support person is present, and that they would like them to stay.
• "I'm afraid I have difficult news. The scan today has shown that your baby's kidneys have not formed properly — bilateral renal agenesis — and there has been very little amniotic fluid around the baby. Because of this, the lungs cannot develop normally, and the prognosis is that the baby will not survive for long after birth."
• Then stop talking. Sit with them. Silence is an intervention.
• Acknowledge the questions that come — do not deflect with 'why'. Use the baby's name if they have chosen one.^[4][5]

Probe 1 — "What are their options?"

• "There are two genuine options, and I will support either. The first is to continue the pregnancy with a focus on comfort for the baby at birth — what we call perinatal palliative care. The second is to terminate the pregnancy. Both are supported choices; I will not steer either way."
• "Whatever you decide, I will plan the care with you. There is no time pressure to decide today."^[6]

Probe 2 — "They decide to continue. Build the plan."

Scored treatment/management domain. ^[6]

• "I would confirm the diagnosis with a second-opinion scan and a senior maternal-fetal medicine review. I would name a coordinator — usually me or the consultant — and assemble the team: obstetrics, neonatology, midwifery, social work, spiritual care if they wish, bereavement support."
• "The plan would cover: the choice to continue, the monitoring-coherence decision (if we are not going to intervene for fetal compromise, we should not be doing continuous CTG in labour), the mode and place of birth (vaginal usually preferred; caesarean only for maternal indications), the analgesia policy (unrestricted, offered early), the birth-room plan (who is present, the resuscitation ceiling, comfort care from the first moment), and the out-of-hours contingency (what happens if she presents elsewhere)."
• "I would write the plan into the notes and give them a copy to carry."^[6]

Probe 3 — "What investigations will you send after the birth?"

• "Placental histopathology every time — it is the highest-yield specimen and the most often omitted; I send it with a clear request. The Kleihauer or flow cytometry for fetal haemoglobin taken early, because the result decays with time. Cytogenetics or microarray on an appropriate sample. Maternal bloods — FBC, HbA1c, TFTs, antiphospholipid antibodies where indicated. Bacteriology and virology. Clinical photography and skeletal survey where indicated."
• "Autopsy is offered, but not first. I explain what it can and cannot answer and offer limited, targeted and imaging-only alternatives — post-mortem MRI is an acceptable alternative where full autopsy is declined."^[1][2]

Probe 4 — "How will you classify the death for the perinatal mortality audit?"

• "The PSANZ Clinical Practice Guideline applies two axes. PSANZ-PDC classifies the single most important maternal or fetal antecedent factor — for a baby who dies of pulmonary hypoplasia after renal agenesis, the PDC is congenital anomaly. PSANZ-NDC is applied additionally to neonatal deaths and classifies the neonatal condition causing death."
• "The audit cycle is: investigate, classify with PDC and NDC, record associated conditions, identify contributing factors, generate recommendations, feed back, re-audit. The audit must not be disciplinary — I attend, present honestly, bring the intrapartum record."^[1]

Probe 5 — "How will you follow them up?"

Scored communication and rapport domain. ^[4][1]

• "Before they leave, I give them a named follow-up appointment with a date, with me as the named clinician who will read the autopsy report, interpret it for them, and bring it to the perinatal mortality review. I close the loop on every investigation."
• "I screen both parents for depression, anxiety and post-traumatic stress — not waiting for a request — and refer to bereavement support. I counsel proactively about lactation suppression, birth and death registration, funeral or cremation, financial help, and bereavement leave. I cancel antenatal appointments, notify community providers, and flag the record so the system does not keep harming them."^[4][1]