The attention of Fellows and Members is drawn to the following relevant documents:
- RCOG report Termination of pregnancy for fetal abnormality in England, Wales and Scotland (Jan 1996);
- Joint Report of the RCOG/RCPCH Guidelines for screening, diagnosis and management of fetal abnormalities (Dec 1997);
- Report of the RCOG Ethics Committee Late termination of pregnancy for fetal abnormality: A consideration of the law and ethics (Mar 1998);
- The British Association of Perinatal Medicine Memorandum, November 1999 - Fetuses and Newborn Infants at the Threshold of Viability: A Framework for Practice.
Late termination of pregnancy
Late abortion can be an extremely traumatic event, not only for the patient but also for the attendant, medical and nursing staff. There are serious clinical, ethical and legal issues and the patient should be managed according to the recommendations in the RCOG report Late termination of pregnancy for fetal abnormality in England, Wales and Scotland.
Parents must receive sympathetic and supportive counselling before and particularly after the procedure. For all terminations at gestational age of more than 21 weeks and 6 days, the method chosen should ensure that the fetus is born dead. This should be undertaken by an appropriately trained practitioner. Intracardiac potassium chloride is the recommended method and the dose chosen should ensure that fetal asystole has been achieved. It should be confirmed by observing the fetal heart by an ultrasound scan for five minutes. Additionally, it is mandatory to confirm asystole by an ultrasound scan 30-60 minutes after the procedure, and definitely before the patient leaves hospital. Consideration can be given to abolishing fetal movements by the instillation of anaesthetic and/or muscle relaxant agents immediately prior to potassium chloride administration.
It is essential to have an agreed multidisciplinary management plan prior to late termination, taking account of issues such as conscientious objection. The multidisciplinary team should include, where appropriate, obstetricians, neonatologists, midwives and nursing staff. Where the patient chooses not to have feticide in the presence of a lethal abnormality, discussion must take place within the appropriate team, and the patient’s wishes and agreement sought on the management of the fetus after birth.
Issues around fetal viability
The management of fetuses and newborn infants at the threshold of viability should be in accordance with the British Association of Perinatal Medicine’s Framework for Practice. It is professionally acceptable not to attempt to support life in fetuses below the threshold of viability. It is extremely important to distinguish between physiological movements and signs of life, as well as being aware that observed movements may be of a reflex nature and not necessarily signs of life or viability.
Where a fetus is born before the 24th week of gestation and did not breathe or show any signs of life, there is no provision for the event to be registered. However, the doctor or midwife who attended the delivery will need to issue a certificate or letter for the funeral director, cemetery or crematorium stating that the baby was born before the legal age of viability and showed no signs of life to allow a funeral to proceed, if that is the parents’ wish. Where a child is born after 24 weeks but did not breathe or show any sign of life, and is therefore classified as a stillbirth, these must be registered within three months and the Registrar will allow a funeral to proceed. In the event of a child being born which shows signs of life but subsequently dies, both the birth and death need to be registered, irrespective of the gestation period of the child, and the Registrar will then issue a form to allow the funeral to proceed. The Registrar General’s Office has confirmed that midwives are permitted to certify stillbirths only. In cases where there are any signs of life the baby must have been seen by a medical practitioner and that practitioner must sign the death certificate (otherwise it becomes a Coroner’s case).
In situations where parents feel they are unable to act as informants to effect a registration, alternative informants, such as “present at the stillbirth” or “present at the death”, are acceptable in order that registration can be achieved with as little distress to the family as possible.
(This advice was produced in collaboration with the Royal College of Midwives, the British Association of Perinatal Medicine and the Department of Health.)