1. Perinatal Loss
March 29, 2012
Sandy Warner RNC-OB, MSN

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. Uniqueness of Perinatal Grief
Mother and her partner feel like
parents, but have no baby to parent
Their baby was not known to others
Taboo topic: sometimes hidden and
not discussed
We can never know another’s grief

4. Grief is experienced in relation to the
significance of the attachment.

5. Frequency of Perinatal Loss
Greater than 1 million pregnancy
losses yearly in USA
25% of all conceptions end in 1st
trimester
Late losses occur 2-4% of
pregnancies
Stillborn rate is 10.7% since 1990
African American stillborn rate is 20%
» (AWHONN, 2009)

6. Diagnosis of Fetal Death
Confirmation of cardiac
standstill for 3 minutes in
2D and color Doppler
usually by 2 providers:
sonographer and MD
Time to look for
etiology, explain to
parents why you continue
to scan
» (Dr. Donna
Lambers, MFM
TriHealth
Maternal Fetal
Medicine
October 2011)

7. Estimates of maternal risk factors and
risk of stillbirth
Estimated
Condition Rate of Stillbirth
All pregnancies 6.4 / 1000
Pregnancy-induced HTN: Mild 9-51 / 1000
Diabetes treated with diet 6-35 / 1000
Thrombophilias 18-40 / 1000
Smoking > 10 cigarettes/day 10-15 / 1000
Previous stillbirth 9-20 / 1000
Multiple gestation – twins 12 / 1000
triplets 34 / 1000
Advanced Maternal Age 11-14 / 1000

8. Family History
Recurrent spontaneous abortions
Venous thromboembolism or pulmonary
embolism
Congenital anomaly or abnormal karyotype
Hereditary condition or syndrome
Developmental delay
Consanguinity
ACOG Practice Bulletin, Number 102, March 2009

9. Maternal History
Prior venous thromboembolism or
pulmonary embolism
Diabetes mellitus
Chronic hypertension
Thrombophilia
Systemic lupus erythematosus
(Cont’d)

10. Maternal History (Cont’d)
Autoimmune disease
Epilepsy
Severe anemia
Heart disease
Tobacco, alcohol, drug or medication
abuse
(Dr. Donna Lambers, MFM TriHealth Maternal Fetal Medicine, October 2011)

11. History of Perinatal Grief
1944 – first published work on grief by
Lindeman (dealt with death from fire)
1962 – “Reaction of RNs with mothers of
stillborns” Nursing Outlook
1969 – Kubler Ross’s work published
1976 – AJN and Contemporary OB Gyn
articles published
1984 – Davidson’s 4 phases of perinatal
loss
1985 – ACOG and NAACOG positions
statements

12. Perinatal Loss Definition
Non- voluntary end of pregnancy from
conception, during pregnancy and up
to 28 days of the newborn’s life
– (AWOHNN)
Definitions vary from state to state
with weight, gestational age etc.
– (AAP and ACOG)

13. Davidson’s Four Phases of
Bereavement
Shock 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. 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. Searching and Yearning
Duration: 2nd week – 4th month
Characteristics:
High energy
Anger/guilt/dreams
Weight loss or gain
Sleep difficulties
Aching arms, may hear baby crying
Headache, blurred vision, palpitations
Resentment

16. Searching and Yearning Con’t.
Interventions:
Encourage support groups
Anticipatory guidance on normal process
of characteristics

17. Disorientation
Duration: 5th to 9th month
Can last up to 24 months
Can also last 3-5 years for multiple pregnancy
Characteristics:
Low energy
Thinks “I am going crazy”
Social Withdrawal
Disorganized
Depression
Likely to loose support

18. Disorientation Con’t.
Interventions:
Anticipatory guidance
Assurance
Support Group involvement

19. Reorganization/resolution
Duration: 19th- 24th month
Characteristics:
Some good days, some bad days
Sense of relief
Renewed energy
Able to laugh and smile again
Milestones are bittersweet

20. Reorganization/resolution
Interventions:
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. 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. 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. Tools for Men and Women
Scheduling time to talk to each other
Write a letter to each other
No major life decisions for a year
Addressing returning to work

24. Cultural Diversity
Baptism is important for Catholics and
other Christian religions
Muslims: see death as natural stage
of life. May not want to view baby.
Loud crying is discouraged.
Jewish: mourning rituals (family
member stays with baby but not
general viewing). Questionable if
baby is named. No autopsy.

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. Cultural Diversity cont.
Hispanic/Latino: females vocal with
grief 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. 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. 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. Cultural Changes in Mourning
by Physicians
The 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. Physician Consolation Note
(Dr. Donna Lambers, MFM TriHealth Maternal Fetal Medicine,
October 2011)

31. Self reflection
for care giver
Loss is profound experience and
invokes own feelings of loss
Emotionally draining, review of past
experiences
Need for staff support
Each nurse needs to examine their
feelings as well, but not burden
grieving family.
Tears are OK with grieving family

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. 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 happened
now, before you knew the baby.”
“There was something wrong with the
baby.”
Calling the baby “It” or “fetus”

34. Nursing Care
Provide physical and psychological support
Description of how the baby will look
(before delivery)
Include family members if appropriate
Refer to chaplain, grief support etc
Photos, mementoes
Allow parents and family opportunity to
hold infant and say goodbye.
Families see nurse as role model with
baby.

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. Referral
Identify trouble
Know when to refer
Reassure them they are not crazy
Refer to Grief Support who has a
variety of resources
Maintain contact

37. Sibling and grandparent grief
Grandparents often don’t want mom to
view 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. Subsequent Pregnancy
Listen, talk and keep open
communication.
Allay fears
Offer guidance about potential
difference in “bonding” to next
pregnancy
Try to make this birth experience
different from loss experience
Know your patient’s history

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. med.umich.edu

41. Resources
Compassionate Friends – Illinois
Pregnancy and Loss Center – MN
Resolve through Sharing – WS
SHARE – Missouri
Richard Paul Evans – Angel Statue
and memory walk
Local support groups

42. Welcome to the website of CLIMB, the Center for
Loss in Multiple Birth, Inc. We are parents
throughout the United
States, Canada, Australia, New Zealand and
beyond who have experienced the death of one or
more, both or all of our twins or higher multiples at
any time from conception through birth, infancy
and childhood. We originated in 1987 when a
mother whose twin son died very suddenly at birth
believed that she was truly the only one – then
began to search for "a few" others.
www.climb-support.com

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
www.centering.org

45. Online Support
www.silentgrief.com
www.babycenter.com
Grief section
www.marchofdimes.com