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Fetal demise

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by IamSecond IamSecond (New) New

About 2 months ago I started working as an OB nurse on an antepartum unit. We mainly care for moms experiencing a high risk pregnancy, a few postpartum moms and the occasional GYN patient. Recently though, we have had a few mothers whose babies were stillborn. These moms are almost always placed on our unit since it's emotionally easier for them to not be placed on the routine PP floor with the mothers and their healthy babies. I am having a hard time figuring out the best way to care for these mamas. I meet all of their physical needs but as far as knowing what to say and how to address their loss, I am finding myself struggling with the right words. Nothing seems appropriate and I almost feel when I do talk with them about it that it makes them more sad/upset. Does anyone have any advice on how to care for these mothers? Everything seems so insignificant in contrast with their colossal grief.

The first IUFD I had (just a few weeks ago), I had to go and get the baby's body out of the morgue because Mom and Dad wanted to spend some extra time with him. I will never forget that sweet little one's face as I wrapped his tiny body in a blanket, put a handmade hat on his head, set him in a basket and tried my best to fix him up to be presentable to his parents that he will never know in earth (it had been a day since delivery and death was really setting in). Tears streamed down my face as I prayed over him and told him I was sorry this happened to him. It was heartbreaking but I knew I had to pull it together before I walked in to hand him to Mom and Dad. I think I will keep that memory with me for a long time.

Please feel free to share your stories and advice for dealing with these situations. This is all new territory for me and I'm sure it will get easier as time goes on and I have more experience, but right now it is very difficult.

BecomingNursey

Specializes in Emergency Nursing.

I don't work L&D or anything like that. ER is my forte, but I had a patient not long ago that had been trying to have a baby for a long time and had started bleeding. After the doctor went into the room and told them that there wasn't a heart beat on the ultrasound and she was experiencing a miscarriage I went in to check on them. They were both crying on the stretcher, the husband holding his distraught wife. The were praying and the wife just kept asking God; "Why?" I came into the room and sat on the stretcher next to her and hugged her. I asked them if I could pray with/for them and with tears streaming down my face I prayed with them.

I don't think there is anything that we can say to make them feel better. Just like when my cousin died, no one could say anything to make me feel better.

The most that I feel that we can do in these circumstances is just to be there and let them know we are there if they need anything.

I work mother baby unit as a Tech, we were advised to not say anything unless the parents wanted to discuss it.

That is heartbreaking. Nurses witness so many highs and lows of human life it simply amazes me the depth of emotion we deal with daily in our jobs. I agree that there is absolutely nothing we can say to them to give them any relief from their pain. Of course I still feel compelled to want to acknowledge their loss in some way. I love that you prayed with your patients and I love that I work in a profession where many times that is a completely acceptable thing to do. That is definitely something I will consider doing with my grieving patients if they desire me to do so, It would be an honor.

Edited by IamSecond

My preceptor told me she thought the worst thing you could do is to not acknowledge their loss. Everyone is different, though if it were me, I think I would want the nurse to at least acknowledge my loss.

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

When in doubt, I ask.

In general I think it's fine to let the family see your tears. I think that honest empathy is generally a good thing. Just be careful of being distracted from your job as a nurse. That can be dangerous.

Long-term, learn as much as you can about healthy and unhealthy grieving. I've never researched it, but I would bet the survivors of a fetal demise run a higher risk of major depression, substance abuse, financial collapse and general badness. It never hurts to have referrals available. Plus, offering the referrals gives you an excuse to bring up the subject of grief in fairly neutral and respectful terms.

I have had a couple of these patients myself this past month. It was complicated by the fact that they didn't speak English. I didn't bring it up to one of them....she was much too quiet when her husband was around. The other I gave a book on infant loss. I don't think you absolutely have to bring it up. Not every patient is the same. I agree about never knowing what is the right thing to say. I really don't bring it up unless they ask or have questions just because I don't want to make them cry if they aren't already.

ktwlpn, LPN, RN

Specializes in Med Surg, Homecare, Hospice.

Sometimes saying nothing is the best approach.A hand on the shoulder, "how are you doing,can I do anything for you?"The healing process barely starts in the hospital.I will never forget the nurse who came in and gave me a back rub and a sleeper.We did not talk much...A week or so later she sent me a card with a lovely note.I cherish it......

Double Dunker

Specializes in Med Surg/PCU. Has 3 years experience.

I lost one of my babies a couple of hours after birth (we knew he wouldn't survive long). I agree the worst thing is to say nothing. I think the best thing is to find out the baby's name and call him/her by that name. "I'm so sorry you lost your precious Sarah Grace. What can I do for you?" Calling them by name acknowledges them in a way no other thing can. If the baby is still in the room with mom, acknowledge that, too. Stop and take a look in the bassinet, admire the fabulous head of hair just like you would a living baby. Offer to take pictures if that hasn't happened yet. It's the only thing we have.

sneaky_des

Specializes in Geriatrics. Has 1 years experience.

I lost my son 32 weeks in utero due to a cord incident. This was my first pregnancy so it was a very difficult thing to go through. The nurses acknowledgement of my baby's life is something that has and will continue to stay with me. The tender way they handled my baby is something I will always be grateful for. If you have the resources, please offer to take photos. Even if one of the parents doesn't want to, ask the other because sometimes in the moment you're in denial and don't want any reminder of the truth, but later they might regret not haven taken pictures. Those first photos fresh out the womb are the best, because once death starts settling in we do change. Also, I was given a Memory Box with info on how to cope with loss and some mementos, like the baby beanie that was placed on my baby's head when his pictures were taken. Give your condolences, and reassure mom you are there if she needs you.

EmRN14

Has 2 years experience.

I have been wondering the same as I am beginning a new career on the mother-infant unit in a large hospital. I already have a hard time finding the right things to say to patients that are sad so I cannot imagine finding what to say to parents that have lost their baby. I hope that I receive proper education on this topic and learn how to help families going through this. Just say what comes from the heart. And I know that in nursing school they say not to cry but I feel like crying shows empathy and caring. Be strong but show that you care.

ixchel

Specializes in critical care.

What you should say will change from family to family.

There are things you should never, ever say, though. Some of them -

1. This is part of God's plan

2. Really, avoid anything to do with religion

3. Also avoid any statement that alludes to this happening for a reason, or it having any purpose whatsoever

4. Never say it's okay because they can try again

5. Never make assumptions about parentage or method of conception. This may not have been her baby (or his), and they may have conceived the "old fashioned way", or, they may have put all of their life savings into reproductive endocrinologists to help make this baby

6. Don't say anything that will give the impression that the pain will go away. It will never go away.

7. Don't tell them about anyone else you know who went through the loss of an infant. This baby was their child - a unique soul they they loved and wanted.

Don't be offended if they hate talking to you personally about it. The "late term pregnancy loss club" is one that you can only be in through living it. It's one no one ever, ever wants to be in. These families will find the best companionship from others who understand this loss first-hand. I think it's very good of your hospital to recover these moms away from the recently postpartum moms who had live births.

When I talk to moms who have experienced this, I say to them with as much meaning I am capable of conveying...

"I am so, so sorry."

The next thing out of my mouth is based on what they say, but always begins with, "do you want to talk about it? We don't have to if you don't want to."

By the time they come to you, please forgive the graphic nature of this next part, it is very possible they have known they had their deceased child inside them for days, or even weeks, surrounded by people relishing in their "beautiful pregnancy glow," and constant questions about how they feel and how excited they are. They literally have to tell everyone close to them, their baby died. The next question is always, "what happened?!" It's hard enough livin through it actually happens, but to talk about it all the time? Absolute torture.

Forgive the deep level of doom and gloom here. I'm hoping to paint a bit of a picture as to why this is delicate and too difficult to say what you SHOULD say. I applaud your realization that finding the right words, and skipping the wrong ones, is important.

Best wishes going forward!

Hoosier_RN, MSN

Specializes in dialysis. Has 28 years experience.

I had a stillborn daughter in 1987. Still hurts to this day. There was nothing anyone could have said to make it better. As said previously, let the patient guide you.

OP, you have some really good advice above. As an L&D nurse, I deal with everything from miscarriage to fetal demise to neonatal death fairly often. The points below are a few things I have gleamed over time.

(Please note that as previously discussed, these measures should be gauged based on the response of the parents and/or their expressed wishes for how they want to be approached. With little exception, however, parents will appreciate it if you take the steps below).

1. Refer to baby by sex if possible. Use the appropriate pronouns (he/she) and try to avoid calling baby "it" as this dehumanizes baby and also reinforces that baby is deceased (most people would never call a live baby "it"!). If the sex is ambiguous or undetermined and you feel comfortable doing this, ask mom if she thinks baby was a boy or girl. Sometimes, mom and dad will already have been referring to baby as one sex or the other. See if you can get onboard with that trend.

2. Refer to the baby by name if possible. Some parents will choose not to name their baby, so keep this in mind if you inquire as to baby's name. Be ready to turn on your heel and validate the parents' decision not to name the baby if this is their choice.

3. If you are physically handling baby, treat baby like you would any other infant. Talk to baby, hold baby like you would any other, comment on baby's clothing, etc. One of my coworkers lost her baby at 36 weeks and still remembers that the nurse caring for her patted her baby's butt while holding her--a small but almost unconscious reaction to holding a baby. This not only models healthy bonding for the parents, but it reinforces that even though baby is no longer living, baby is still a baby.

4. If appropriate per the parents and you feel comfortable, I would argue that praying with the parents or making comments of a religious nature is completely acceptable. Again, take your cues from the parents. Let them initiate that kind of discussion or activity. But if they are looking for that kind of connection from you, that can make a huge impact not only in their care, but their overall experience. I still remember the people who were brave enough to look me straight in the eye in the midst of my grief and tell me, "I know this is horrible, but it's going to be OK. The Lord has your baby safe and sound." Those were some of the most powerful and positive experiences I had in the midst of my miscarriage.

5. Try to support mom and dad in their decisions, but also help them see through their fear and into what they might someday want. As an example for this rather ambiguous suggestion, if mom and dad don't want to see the baby after baby is born, try to gently offer options such as pictures, clothing, and other mementos that they may want in the future. Sometimes, fear of the unknown and grief can keep parents from really understanding what they're giving up by declining to see/hold/interact with baby. In presenting this discussion to parents who don't want to see baby, make sure you explain your motivation--you're trying to make sure that they as parents don't miss out on something they might regret later. Some patients (especially if they are really bonded to their nurse) will do whatever the nurse tells them to do, even if they don't want to. Make sure you clarify--even if you have to outright say it--that you're looking out for them and you have no dog in this fight. Be respectful of course, but also make sure you leave the door open to seeing baby later as it's fairly common for parents who initially don't want to see baby to change their minds (at least in my experience).

6. Springboarding off #5, if mom and dad are hesitant or nervous about seeing baby, be there with them to help them through. Understandably, some parents are really afraid of what they'll see, especially if baby isn't newly delivered. Help them to see baby as a little person. Point out those tiny hands, the little feet, the nose that looks like mom's, the eyes that look like dad's, etc. Sometimes, nursing plays a huge role in not only helping parents bond, but helping them to see their deceased child as one of their own.

7. Ditto, ditto, ditto the advice about what not to do: don't say it wasn't meant to be, it's ok because they can have another, etc. Acknowledge the uniqueness of both baby and the loss thereof. I think losing a child in pregnancy is such a personal thing that other people sometimes have difficulty understanding it as losing an actual human being. There is something about being born and being a known entity that frees you from this misconception. After all, you'd never console someone who had just lost their 4-year-old by saying, "It's OK--you can have another one!"

8. Make sure the parents know it isn't their fault. Many women will have serious identity questions to answer after a loss ("Who am I as a wife/girlfriend/woman if I can't have live children?"). It sounds a bit archaic in this feministic culture to ask those questions, but the bottom line is that the responsibilities of pregnancy and childbearing still belong solely to women, and even as much as we value our freedoms and our rights in this country and this era, the inability to perform what are considered basic functions of being female still has the great potential to cause a lot of confusion and distress.

9. Keep in mind that addressing mom' s emotional distress can help assuage her physical pain, too. I've seen on many occasions where physical pain (which there's plenty of in a miscarriage or fetal demise) is amplified and compounded by the emotional distress of loss.

10. Finally, if mom and dad are open to it, ask them if there is anything they want or don't want to have happen in their hospitalization. Ask if there's anything that hasn't been done that they want. Ask if there's anything that they don't want that they're concerned will happen anyway. As much as possible, just like in a live birth, tailor the experience to the desires and needs of the parents.

11. If you do say something that was taken incorrectly or insensitive, be the first to apologize. Those parents will probably remember you the rest of their lives, but they will really, really remember you if you say something thoughtless and either refuse to own up to it or choose to ignore it. To this day, my husband and I still talk about the ultrasound tech and the midwife who were with us when we found out our baby had died. The midwife was a sweetheart and very nurturing. She was adept at not only empathizing with us in our grief, but guiding us gently through the reality of losing our child. On the other hand, my husband still refers to the ultrasound tech, who was cold, correcting and rude as "the *****".

You have such an incredible opportunity to help these patients through something that, for many of them, will be one of the hardest experiences of their lives. All the best to you, OP. Thank you on a personal note for caring enough to ask for advice. You are already an asset to the patients who will come your way!

bagladyrn, RN

Specializes in OB.

Try to remember to be sensitive to the dad's loss as well. Many times I see not just medical personnel but family and friends concentrate so much on the mother's grief that the dad sort of gets lost in the background. He often needs the message that someone acknowledges the enormity of his loss as well and that he doesn't have to be "the strong one".

NurseNora, BSN, RN

Specializes in L&D. Has 52 years experience.

A lot can be addressed in your discharge teaching. When you're talking about dealing with breast engorgement, especially if she was planning to breast feed, an opportunity may arise. It will arise when talking about PP depression, you can warn her about reaching her due date, the first Mothers Day or whatever and how that may bring an unexpected grief. Resolve Through Sharing is an organization dedicated to helping families with the loss of an infant and has good in hospital resources. If yours isn't involved, check it out and perhaps you could bring it into your facility.

ixchel

Specializes in critical care.

A lot can be addressed in your discharge teaching. When you're talking about dealing with breast engorgement, especially if she was planning to breast feed, an opportunity may arise. It will arise when talking about PP depression, you can warn her about reaching her due date, the first Mothers Day or whatever and how that may bring an unexpected grief. Resolve Through Sharing is an organization dedicated to helping families with the loss of an infant and has good in hospital resources. If yours isn't involved, check it out and perhaps you could bring it into your facility.

Along these lines, some mothers of late term loss infants find healing in breast milk donation. Tread carefully when you consider mentioning this, as that may be something that offends them.

Future pregnancies will be terrifying to these moms. Every day will have some level of fear, second guessing. While pregnancy is so joyous to those who haven't experienced this loss, those who have experienced it live with constant hesitation to enjoy the pregnancy at all. Some find relief at learning the next pregnancy is with a baby of the opposite gender. Every milestone will be a reminder of what they lost the last time they were pregnant. And, they may feel this every single pregnancy thereafter.

Again, yes, yes, yes to all of the above. Make sure your hospital has a system for identifying moms in these rooms. In my workplace, we put a flower with a teardrop on the door so everyone from the housekeepers to the dietary folks to transporters know what kind of situation they're entering when they walk into that room, especially because it isn't your usual for our L&D/antepartum unit.

A small consideration but an important one--in the course of rendering non-emergent care, make sure none of the staff going in to that room are pregnant. We've had this issue lately on our day shift. We've had a high number of demises and every other nurse on days is about to pop. It's tough to make assignments and it can be tough to render non-emergent care that way (looking for a non-pregnant nurse to help with a repositioning, etc), but it can be so painful for that grieving couple to face head-on what they've lost, especially that early, though even after time has passed, sometimes that pain will rear its head when you least expect it.

Even a year after miscarrying, I still feel a twinge of anger and jealousy when I see my friends go through pregnancies that result in live babies. I don't wish any harm on them or anything like that; it's just painful and a hard reminder of my own loss when I see all that happiness that I didn't get. Like a previous poster said, make sure mom and dad are both aware that there will be things that they are sensitive to after their loss that probably wouldn't have bothered them before.

As another example, a few weeks after we lost our baby, my husband and I were at a social gathering where a man was telling the group about seeing his baby's heartbeat on the ultrasound for the first time at 10 weeks. At 10 weeks at our first ultrasound, we found out our baby had died a few weeks earlier. This man described his child and this incredible experience as a nothing more than a "blob on the monitor with a heartbeat". I was so offended. How dare he so casually discuss his living unborn child? How dare he take for granted what my husband and I didn't get? How dare he diminish the experience like that? Of course, that isn't how he meant it, but that's how I took it. I was so livid at his flippant description of his living child that I nearly came across the table at him. Thank goodness my husband has quick reflexes.

As much as you can, prepare your patients--let them know that they may experience the same moments of unexpected anger, grief, sadness, and loss. Other people's joy will be painful to them, sometimes even years later. Take steps to shield them from direct exposure while they're under your care and reassure them that it will get easier.

There are so many resources out there, too, and it's important for many people to be involved with other parents who have lost. No one understands you like someone who had a similar experience. It also helps ensure that if people are having difficulty grieving or are experiencing an unhealthy level of depression that someone is likely to notice and help that person or that couple get the help they need.