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Perinatal loss 2012


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Perinatal loss 2012

  1. 1. Perinatal Loss March 29, 2012Sandy Warner RNC-OB, MSN
  2. 2. Grief is a process, not an event When your parent dies, you’ve lost your past. When your child dies, you’ve lost your future
  3. 3. Uniqueness of Perinatal GriefMother and her partner feel likeparents, but have no baby to parentTheir baby was not known to othersTaboo topic: sometimes hidden andnot discussedWe can never know another’s grief
  4. 4. Grief is experienced in relation to the significance of the attachment.
  5. 5. Frequency of Perinatal LossGreater than 1 million pregnancylosses yearly in USA25% of all conceptions end in 1sttrimesterLate losses occur 2-4% ofpregnanciesStillborn rate is 10.7% since 1990 African American stillborn rate is 20% » (AWHONN, 2009)
  6. 6. Diagnosis of Fetal DeathConfirmation of cardiacstandstill for 3 minutes in2D and color Dopplerusually by 2 providers:sonographer and MDTime to look foretiology, explain toparents why you continueto scan » (Dr. Donna Lambers, MFM TriHealth Maternal Fetal Medicine October 2011)
  7. 7. Estimates of maternal risk factors and risk of stillbirth EstimatedCondition Rate of StillbirthAll pregnancies 6.4 / 1000Pregnancy-induced HTN: Mild 9-51 / 1000Diabetes treated with diet 6-35 / 1000Thrombophilias 18-40 / 1000Smoking > 10 cigarettes/day 10-15 / 1000Previous stillbirth 9-20 / 1000Multiple gestation – twins 12 / 1000 triplets 34 / 1000Advanced Maternal Age 11-14 / 1000
  8. 8. Family HistoryRecurrent spontaneous abortionsVenous thromboembolism or pulmonaryembolismCongenital anomaly or abnormal karyotypeHereditary condition or syndromeDevelopmental delayConsanguinity ACOG Practice Bulletin, Number 102, March 2009
  9. 9. Maternal HistoryPrior venous thromboembolism orpulmonary embolismDiabetes mellitusChronic hypertensionThrombophiliaSystemic lupus erythematosus (Cont’d)
  10. 10. Maternal History (Cont’d)Autoimmune diseaseEpilepsySevere anemiaHeart diseaseTobacco, alcohol, drug or medicationabuse (Dr. Donna Lambers, MFM TriHealth Maternal Fetal Medicine, October 2011)
  11. 11. History of Perinatal Grief1944 – first published work on grief byLindeman (dealt with death from fire)1962 – “Reaction of RNs with mothers ofstillborns” Nursing Outlook1969 – Kubler Ross’s work published1976 – AJN and Contemporary OB Gynarticles published1984 – Davidson’s 4 phases of perinatalloss1985 – ACOG and NAACOG positionsstatements
  12. 12. Perinatal Loss DefinitionNon- voluntary end of pregnancy fromconception, during pregnancy and upto 28 days of the newborn’s life – (AWOHNN)Definitions vary from state to statewith weight, gestational age etc. – (AAP and ACOG)
  13. 13. Davidson’s Four Phases of BereavementShock and numbness Duration – first two weeks Characteristics: Short attention span Difficulty concentrating Impaired decision making Denial No concept of time “Feels like a bad dream”
  14. 14. Shock and Numbness con’t. Interventions: Allow for time Repeat, repeat, repeat Use simple terms Help them to think through decisions Discourage rapid decisions
  15. 15. Searching and YearningDuration: 2nd week – 4th monthCharacteristics: High energy Anger/guilt/dreams Weight loss or gain Sleep difficulties Aching arms, may hear baby crying Headache, blurred vision, palpitations Resentment
  16. 16. Searching and Yearning Con’t.Interventions: Encourage support groups Anticipatory guidance on normal process of characteristics
  17. 17. DisorientationDuration: 5th to 9th month Can last up to 24 months Can also last 3-5 years for multiple pregnancyCharacteristics: Low energy Thinks “I am going crazy” Social Withdrawal Disorganized Depression Likely to loose support
  18. 18. Disorientation Con’t.Interventions: Anticipatory guidance Assurance Support Group involvement
  19. 19. Reorganization/resolutionDuration: 19th- 24th monthCharacteristics: Some good days, some bad days Sense of relief Renewed energy Able to laugh and smile again Milestones are bittersweet
  20. 20. Reorganization/resolutionInterventions: Be available to listen Acknowledge baby’s presence Use baby’s name in conversation Remember important dates Meaningful remembrances: Tree, rose bush, flowering plant etc Donation to memorial fund
  21. 21. Men and Women Grieve differently Women: Body image issues Emotional swings Need to talk, cry Increased dependency needs Fear of intimacy, resuming sex Jealously
  22. 22. Differences in Gender Grief cont’Men: Increase sense of responsibility Withdrawal from partner/lack of communication Financial worries Physical symptoms Sense of failure Resentment of attention to partner Difficulty dealing with tears Need to “stay busy”
  23. 23. Tools for Men and WomenScheduling time to talk to each otherWrite a letter to each otherNo major life decisions for a yearAddressing returning to work
  24. 24. Cultural DiversityBaptism is important for Catholics andother Christian religionsMuslims: see death as natural stageof life. May not want to view baby.Loud crying is discouraged.Jewish: mourning rituals (familymember stays with baby but notgeneral viewing). Questionable ifbaby is named. No autopsy.
  25. 25. Cultural Diversity con’t.Native American: vary widely Focus on transition to afterlife Ceremonies with food, possessions at gravesite. May leave body exposed.Amish: Simplistic lifestyle with large number of children. Loss of child is profound but viewed as God’s will.
  26. 26. Cultural Diversity cont.Hispanic/Latino: females vocal withgrief and may even shake Males are stoic and can appear uncaring but are deeply affected. Mementoes and photos very important. Respect caregivers Usually family spokesperson – if caregiver establishes rapport, better outcome.
  27. 27. Cultural Diversity Cont.African American: Variety of religious denominations Strong spirituality and reliance on God Prayer is common at bedside Funeral delay until extended family present Vocal grief acceptable Importance of grandmother Appreciate inclusion of family minister
  28. 28. Cultural Changes in Mourning by Physicians“In 19th century America, the process of grieving was detailed and elaborate. The doctor’s letter of condolence was an accepted responsibility and an important part of the support offered to the bereaved.” NEJM, Vol. 344, No. 15, April 2001
  29. 29. Cultural Changes in Mourning by PhysiciansThe condolence letter: Begin with a direct expression of sorrow and personal memory if possible. Avoid revisiting the clinical details of the illness and death.Continued contact with family i.e., the parents per physician group. (Dr. Donna Lambers, MFM TriHealth Maternal Fetal Medicine, October 2011)
  30. 30. Physician Consolation Note(Dr. Donna Lambers, MFM TriHealth Maternal Fetal Medicine, October 2011)
  31. 31. Self reflection for care giverLoss is profound experience andinvokes own feelings of lossEmotionally draining, review of pastexperiencesNeed for staff supportEach nurse needs to examine theirfeelings as well, but not burdengrieving family.Tears are OK with grieving family
  32. 32. What to say:“I’m sorry.”“I’m sad for you.”“How are you doing with this?”“This must be hard for you.”What can I do for you?”“I’m here, I want to listen.”
  33. 33. What NOT to say:“You’re young, you can have others.”“You have an angel in Heaven.”“This happened for the best.”“Better for this to have happenednow, before you knew the baby.”“There was something wrong with thebaby.”Calling the baby “It” or “fetus”
  34. 34. Nursing CareProvide physical and psychological supportDescription of how the baby will look(before delivery)Include family members if appropriateRefer to chaplain, grief support etcPhotos, mementoesAllow parents and family opportunity tohold infant and say goodbye.Families see nurse as role model withbaby.
  35. 35. Anticipatory guidance for discharge home Prepare them for the reaction of others. Encourage offers of help from loved ones Suggest a plan on how to inform friends. Supply a few phrases: “We’re not pregnant any more”. “Our baby has died.
  36. 36. ReferralIdentify troubleKnow when to referReassure them they are not crazyRefer to Grief Support who has avariety of resourcesMaintain contact
  37. 37. Sibling and grandparent griefGrandparents often don’t want mom toview baby. (taboo)Siblings: Developmentally appropriate care May want to see baby Many books for children Fear they themselves or parents might die Relate to pet’s death sometimes easier than baby.
  38. 38. Subsequent PregnancyListen, talk and keep opencommunication.Allay fearsOffer guidance about potentialdifference in “bonding” to nextpregnancyTry to make this birth experience different from loss experience Know your patient’s history
  39. 39. Prepregnancy physician consult and the next pregnancy Detailed obstetrical history Ask if parents named baby and use the baby’s name throughout (versus the pregnancy in 2009) Ask to see any pictures they have Preface consult that you realize it will be difficult to talk about the day of birth but how important it is Have plenty of tissues – (Dr. Donna Lambers, MFM TriHealth Maternal Fetal Medicine, October 2011)
  40. 40.
  41. 41. ResourcesCompassionate Friends – IllinoisPregnancy and Loss Center – MNResolve through Sharing – WSSHARE – MissouriRichard Paul Evans – Angel Statueand memory walkLocal support groups
  42. 42. Welcome to the website of CLIMB, the Center forLoss in Multiple Birth, Inc. We are parentsthroughout the UnitedStates, Canada, Australia, New Zealand andbeyond who have experienced the death of one ormore, both or all of our twins or higher multiples atany time from conception through birth, infancyand childhood. We originated in 1987 when amother whose twin son died very suddenly at birthbelieved that she was truly the only one – thenbegan to search for "a few"
  43. 43. CHAPTERS INCLUDE:In The Beginning, Pregnancy Moments,Family Tree, Showers,The World Around You, Hello Little One,Your Illness, Hospital Stay, Taking Care of You,Every Day A Miracle, The Day You Died,Funeral Details, Final Resting Place, Hopes and Dreams,Holding You In My Heart, Websites and Support Groups
  44. 44. Online Grief