CHPT 37- Perinatal Loss, Bereavement, and Grief
When a loss is diagnosed:
-helping the woman and her family in the aftermath is key LANGUAGE IS VERY IMPORTANT **Simple, unambiguous, and consistent language is crucial**
MAINTAINING BELIEF:
-involves encouraging the woman and her family to believe in their ability to survive their loss. -By spending time with the family, the nurse becomes familiar with their strengths and coping abilities and helps them draw on these resources to grow from the loss. -outlining their strengths & allowing them to accept their grief -we allow them to embrace whatever emotions they are feeling in the moment.
protocols for death of a live born infant:
-weigh the baby in grams -hospital protcols -state protocols -if baby is under a certain weight or over -many different things - if baby is under a certain weight we still have to call TN donor services -dont think we need to know this!
Dual Process Model
1. Developed by Strebe & Shut (1999) puts the focus on the strategies that people use to manage grief and bereavement rather than using the Stages of Grief 2. They move their focus back in forth from grief to their future -EX: if we were taking care of mom & they were crying one moment & the next they weren't 3. Don't misinterpret this for Denial—They may carry on with their ADL's etc but this is their grieving process this is the way they cope!!! some may be focused on grief process & others can be more like this where they flip flop
Fetal Death EARLY:
1. Early: Most of the time is early in the pregnancy 1. Preterm delivery (super early) 2. Non-viable gestational age—under developed -could be multiple system abnormalities - under developed body systems
Bonds of Attachment:
1. Klass, Silverman & Nickman (1996) says: -the Bonds of attachment forged in life continues into the survivor's future (what life will be like in the future for the survivors of the loss) 1. Resolution of grief is not about detachment from that person, but incorporating them into their lives still. (in death- time w a newborn to build memories is shortened so we can do a few things to help to take on memories in their future.- ex: using the last thing a baby touched itself) 2. Sometimes with a newborn death, or miscarriage or stillbirth, the time to build memories for the parents is shortened, but there are other things we can do. (ie. Precious prints, memory books, pictures, etc. )
Caring theory to guide nursing practice when pregnancy ends in loss:
1. Knowing 2. Being with 3. Doing for 4. Enabling 5. Maintaining belief
1. Acute Distress
1. Loss of identity as a parent/anticipated parent 2. Sometimes there is a lack of emotions: crying (refer back to Dual Process Model—their grief is what it is) 3. They may develop depression/anxiety (nurses must recognize it, educate on it and know what to do about it- DOES IT NEED TO BE CLINICALLY LOOKED AT?) 4. Men may respond differently-men are fixers- A&B A. They may see themselves as the support person and hide their emotions B. Nurses....be intentional with them, engage and include them: they need to be supported as well. nurse needs to gauge them in the involvement of the grief process. 5.Lots of decisions here regarding plans, funeral homes, after death care etc. SOME THINGS WE MAY SEE IN THIS ACUTE STAGE **go through shock, numbness, loss of reality, powerlessness, disbelief, foggy reacting, profound sadness, emotional outburts
Margaret Miles Model of Parental Grief Responses MORE INFO
1. She worked for years with expectant parents in grief situations- DECIDED TO LOOK @ THEIR RESPONSES DURING THIS TIME 2. Referred to them as mothers and fathers 3. Worked to understand the grief cycles and how parents responded to these situations. 4. Developed a model to help us and parents work through their grief
Family Aspects of Grief:
*Grandparents: -Complicated by emotional pain witnessing and feeling immense grief of their child. *Siblings: -Young children respond more to the reactions of parents.- so depending on the age they may not be at the hospital. -School-aged siblings- need support & be inclusive w them -Teenagers: same as above. -Resolve through sharing resources: support groups for the FAMILY & MOM
FETAL DEATH STILLBORN:
- A lot of the time it's from unknown causes 1. Nucal cord 2. Realized that she hasn't felt the baby move and comes in. 3. Sometimes it's a total surprise -many times will send placenta for pathology to maybe figure out why.
organ donation protocol
- baby would have to be born alive & remains on life support till organ can be donated -has to make sure baby doesn't have congenital abnormalities, infection, or genetic issues.
if parents don't have the funds to do funeral
- communities of people that have burial options for these babies, certain funeral homes & cemeteries for free.
things we may do as nurses for out pts who experience loss-
- will put signs of a leaf or heart on door to let others know this pt is dealing w loss -may move floors so they don't have to witness other moms or babies.
Useful grief theories in perinatal settings
-Continuing bonds theory -Dual process model
nurses need to-
-Creating memorabilia for parents to take home -Assisting the bereaved parents in communicating and establishing support from family members
Loss, Bereavement, and Grief: Basic Concepts and Theories:
-Defining loss, bereavement, grief, and mourning
You have just begun your shift and are receiving the patient report from the admitting nurse: Mary is a 26-year-old G1 P0000 at 36 weeks of gestation. She presented to the prenatal clinic yesterday for her routine exam and the provider was unable to hear fetal heart tones. Intrauterine fetal demise was confirmed by ultrasound, and her labor began spontaneously soon afterward. Mary is here with her husband, Jeff, and both are crying.
-Each individual nurse will have her or his own approach to this situation, but it should be based on the following foundations. From Chapter 37: Women, their partners, and extended families look to the nursing staff for support and understanding during the time of loss. Caring theory provides a model for practice by which nurses can be particularly helpful to grieving persons. Swanson developed her caring theory from her research with women and their partners experiencing a perinatal loss, specifically miscarriage (Swanson, Chen, Graham, Wojnar, & Petras, 2009). Knowing Being With Doing For Enabling Maintaining Belief
Providing postmortem care
-Preparing the baby's body and transporting to the morgue depend on the procedures and protocols developed by individual hospitals. state & hospital protocol for this
Helping the bereaved family understand differing responses to loss
-Reassure them that their responses are normal. -Prepare them for grief's potentially lengthy process. -Educate about the grief process, including the physical, social, and emotional responses of individuals and families. -Recognize that there my be incongruent grieving in couples.- can be damaging during time for the couple so counseling is a good idea.
Helping parents with holding their fetus or infant:
-Research evidence supports the importance of parents' seeing or holding their fetus or infant, but they should never be made to feel they "should" see or hold their baby. ***Parents appreciate explanations about what to expect.- SO IMPORTANT! (if pre me telling them what their skin may look like, etc) -ALWAYS TREAT THE BABY AS IT WERE A LIVE BABY. - when going to morgue we don't hold baby like a baby- they will be completely wrapped up -When bringing the baby's body to the parents, it is important to treat the baby as one would a live baby.
Perinatal palliative Care Centers:
-Special facilities like hospitals that are geered to provide this service. Like a hospice for babies. -whole place is set up for babies going through these struggles.
Meeting the physical needs of the bereaved mother in the postpartum period
-The mother should decide if she wants to remain on the maternity unit or to move to another unit. -Physical needs are the same as those of any woman who has given birth. -Lactation issues: we need to tell them to wear a tight sports bra, don't turn in shower to hot water bc it can make it worse, s/s of engorgement & mastitis. -Postpartum care instructions
Addressing cultural and spiritual needs of parents
-The nurse must be sensitive to the responses and needs of parents from various cultural backgrounds and religious groups. -The nurse needs to be aware of his or her own values and beliefs. -Culture and religious beliefs influence the customs following death.
Death of a live born infant
-There are many protocols for live births that end up passing away! 1. Some are congenital 2. Some are not 3. Many causes or it could be unknown.
Pregnancy Termination: SELECTIVE REDUCTION
-This reduces the number of developing embryos to a safer number to carry. -Occurs mostly in the IVF world. -placed fertilized embryo into moms uterus for it to attach to lining - hoping it will implant & can put in more than one! - if all attached then provider may ask if they want a selective reduction where they will abort a certain amount developed embryos out of uterus
Helping the bereaved parents acknowledge and express their feelings
-Validate -Encourage -Listen -Offer helpful versus unhelpful responses. -Allot time 37.1 pg 817 - lists of what to say & what not to say
BEING WITH:
Being with denotes the caring presence of the nurse, who as a function of professional caring conveys acceptance of the various feelings and perceptions of each family member. -CARING PRESENCE -ACCEPTANCE OF FEELINGS
1.Bereavement:
Being without someone you love because of their death. W OUT A VALUED ONE!
Types of Losses Associated with Pregnancy
Defining perinatal loss: -Miscarriage -Fetal death: •Early •Late •Stillbirth Death of live-born infant: •Early neonatal death •Late neonatal death •Infant death
DOING FOR:
Doing for refers to those activities and interventions that the nurse performs on behalf of the woman and her family that provide physical care, comfort, and safety. -PHYSICAL ASSESSMENTS -CARE -COMFORT -PT SAFETY IN PHYSICAL & MENTAL
Other Losses:
EAB's or elective abortions because of unwanted pregnancy or if there's a medical reason the mother should terminate
Types of Losses Associated with Pregnancy (Cont.)
Types of perinatal losses: -Miscarriage -Serious fetal diagnosis -Pregnancy termination: •TOPFA: termination of pregnancy for fetal anomalies •Selective reduction -Other losses Perinatal care settings where nurses encounter loss: •Perinatal palliative care
ENABLING:
Enabling occurs when the nurse offers the woman and her family options for care. -Providing information, -giving guidance, -articulating choices for decision making, and -giving support help the family feel more in control of a situation in which they can feel out of control. •Enabling allows them to feel more comfortable in asking for what they need such as creating memories, spending time with their infant or with the infant's body, or garnering support from other sources such as friends and clergy. •Women and their families then have more autonomy in working through their grief within the family's own traditions and needs. -CAN MAKE THEM FEEL MORE OPEN TO ASKING QUESTIONS THEY MAY FEEL UNCOMFORTABLE ASKING
Serious fetal diagnosis
US @ 18-20 weeks usually detects most issues if there are any. **This is sometimes past the time of an elective abortion in some states- sometimes it is not & they need to decide if they want to keep the pregnancy or not. - if they do there's a risk of intrauterine loss & live birth loss **At the time of the discovery, they may be making those decisions or choose to keep it or place the baby for adoption **they do continue with the pregnancy, there is a chance of intrauterine loss or loss after delivery (depending on the issues
KNOWING
Knowing means that the nurse must assess the woman, her partner, and family (as applicable and appropriate) in order to understand how they perceive the loss and what the loss means to them. nurse assesses to see how they are dealing w loss & what that loss means to them! (assessment)
FETAL DEATH LATE:
Late: Most are from genetic anomalies or malformations and developmental issues 1. Could be genetic/environmental causes -environmental is associated w intrauterine life: when the baby is developing in the uterus. 2. Mostly intrauterine deaths
Eighteen hours later, Mary delivers a baby girl with Jeff at her side. After delivery, describe specific therapeutic nursing interventions.
See Chapter 37: Help the Bereaved Family Understand Differing Responses to Loss; Meet the Physical Needs of the Bereaved Mother in the Postpartum Period; Assist the Bereaved Parents in Communicating and Establishing Support from Family; Create Memorabilia for Parents to Take Home; Address Cultural and Spiritual Needs of Parents; Provide Sensitive Care At and After Discharge; Provide Postmortem Care -End-of-life care in perinatal settings brings together death—one of the most difficult of human experiences—and birth, what is usually one of life's most joyful occasions. When death and birth coexist, nurses face great challenges. Intervening effectively for these women and families in this situation takes great skill, which can be cultivated by a thorough understanding of the implications of types of pregnancy losses.
-Envision and describe how you will introduce yourself to this couple and begin the shift. -Mary and Jeff are still in the first stage, latent phase of labor. -What are the most important initial questions to ask the couple regarding their labor and birth, ideally before the onset of the active phase of labor?
See Chapter 37: Decisions: Autopsies, Organ Donation and Disposition of the Body; Help the Bereaved Parents Acknowledge and Express Their Feelings; Help the Bereaved Family Understand Differing Responses to Loss; Address Cultural and Spiritual Needs of Parents WHAT TO SAY AND WHAT NOT TO SAY TO BEREAVED PARENTS What to Say: "I'm sad for you." "How are you doing with all of this?" "This must be hard for you." "What can I do for you?" "I'm sorry." "I'm here, and I want to listen." -What Not to Say "God had a purpose for her." "Be thankful you have another child." "The living must go on." "I know how you feel." "It's God's will." "You have to keep on going for her sake." "You're young; you can have others." "We'll see you back here next year, and you'll be happier." "Now you have an angel in heaven." "This happened for the best." "Better for this to happen now, before you knew the baby." "There was som
Miles's Model of Parental Grief Responses:
THREE OVERLAPPING PHASES -ACUTE DISTRESS -INTENSE GRIEF -REORGANIZATION
Pregnancy Termination: TOPFA
Termination of Pregnancy for fetal anomalies
how to give support-
Try to establish or determine where their support system is. Give them information on groups in their area and most of the time they include groups for all of the family members together or individually
Words and Euphemisms can be MISUNDERSTOOD
Use words specific to the circumstance especially with those from different cultures (Use Death, Dead, Died, not passed away, or lost) -BEING CLEAR LEAVES LITTLE ROOM FOR MISCOMMUNICATION -Miscarriage should be used consistently with early pregnancy loss -Use Has Died or "there is no longer a heartbeat" for neonatal deaths or fetal demises. Using "passed or gone" is too ambiguous- NO AMBIGUITY OR SLANG
HOW PEOPLE MOURN IS
VERY PERSONAL & CULTURAL! -we need to find out their traditions as a nurse so we can all be on the same page- ask what their expectations are for you.
Helping parents with decisions regarding autopsies, organ donation, and disposition of the body
a lot of this is protocol based & hospital based -Autopsy: •Personal, cultural, and religious views -Organ donation -Spiritual rituals: knowing what their culture is & what the family needs from you. -Respectful disposition of the body. -Memorial or funeral service -Do not rush the family into making decisions. -mom & dad can keep baby as long as they want.
picture of leaf on slide 7
indicates their has been a loss in that room
2. Grief:
all the emotional feelings that come after a loss.
3. Mourning:
another word associated with "Loss" but this term may have certain cultural, or traditional elements to it. People mourn in different ways
memorabilia
we may wrap them in a special blanket, hats, booties to put on baby to give to parents in a packet form. -pictures on newborn babies can be apart of this too.
unknown reasons for birth deaths:
will send placenta to pathology & sometimes may send fetal remains as well. -more pathology rather than autopsies.
3. Reorganization
•Better able to function at home and work, experiences a return of self-esteem and confidence, can cope with new challenges, and has placed the loss in perspective. •The term recovery is not appropriate because the grief related to perinatal loss, as with any loss, can continue for life.
2. INTENSE GRIEF:
•Guilt, anger, resentment, bitterness, or irritability all of these are ok feelings to be feelings. •Characterized by disorganization •Physical symptoms include fatigue, headaches, dizziness, or musculoskeletal aches and pains HURTING FROM INSIDE OUT! BM will still come in, lochia, etc that will remind them so we need to do HOLISTIC CARE HERE!!!
