Scared to care for IUFD and medical terminations

PinkDiamond6 · Mar 26, 2005

I'm still fairly new to L & D. I've been there almost a year and I didnt have to care for an IUFD until after I was off of orientation! So I was totally unprepared! So I just had to tell the charge nurse that it was my first time dealing with this situation and that I would need help. It was very difficult for me and I know it would be for you. But as harsh as it may seem you kinda have to seperate yourself or else you wont get through it. You care for the patient as much as you can and give all the sympathy that you can. You be there for them but you cant get torn up over it.

baby&mommynurse · Mar 26, 2005

I'm sorry for your loss Renee. Most IUFD patients just need space and time to adjust and grieve. They just need all the support you can give. Knowing that you have gone through the same thing might make it a bit easier for you to care for a patient with a fetal demise.

CA CoCoRN, RN · Mar 26, 2005

I am nearing the end of my L&D orientation and I haven't had to care for a pt with a fetal demise or one who has chosen medical termination. Honestly, I am very worried about how well I will keep it together. I lost a baby six years ago when I was 18 weeks pregnant and it was devastating!
I would greatly appreciate any thoughts, suggestions, comments, or experiences that will help.

You grieve with the pt in a composed manner. It's a hard thing to lose or be a part of the situation when a baby is lost.

Most IUFD situations I've cared for, I've shed tears with the parents. It allows me to "share" their pain...the same as I "share" their joy when a live baby is born.

Honestly, it does hurt my heart to know that their dreams for their little baby has been lost and, though other children may be had, cannot be replaced.

I've cared for moms with pre-viable losses and moms with full term demises: it still hurts.

While you shouldn't break down bawling with the pt, empathy with tears is a human expression.

I've had back to back IUFD pts before, and I've had to let my charge/supervisor know that I needed a break.

The hardest one I ever had was a pt who was coming in for a repeat cesarean, scheduled. When we put her on the monitor, baby was "gone". Surgery revealed a triple tight nuchal cord accidental asphyxiation. Nothing that could have been done. She'd just been checked in the office the day before. The baby came out perfect: he looked as if he were asleep. I can still see that baby in my minds eye.

talaxandra · Mar 26, 2005

I'm sure you would anyway, but please remember to explain tt eh mother what's going on.

A close friend delivered a baby at term who was dead (very fast labour - no time for fetal monitoring, so nobody knew he was dead until he was delivered). She's a nurse, and she says that while she has no doubts at all that they did everything possible to try to revive him, throughout the entire post-delivery resuscitation (of about half an hour) not a single person came and sat by her, explained what was going on, held her hand or anything.

I know some of that is because of the resus, but I suspect that some was also because it's so uncomfortable a situation for everyone. And as we all know, it's not about us...

talaxandra · Mar 26, 2005

it's so uncomfortable a situation for everyone. And as we all know, it's not about us...

Oops, just re-read that last part and realised it could sound like it was directed at the OP - not my intention at all; I just meant that it's easier to avoid that messy side than it is to be busy with a resus attempt or other work.

Of course it's going to be even more confronting for you than for people who haven't experienced this kind of loss themselves. I suspect, though, that you'll surprise yourself with how well you manage. I wish you luck.

BETSRN · Mar 26, 2005

I am nearing the end of my L&D orientation and I haven't had to care for a pt with a fetal demise or one who has chosen medical termination. Honestly, I am very worried about how well I will keep it together. I lost a baby six years ago when I was 18 weeks pregnant and it was devastating!
I would greatly appreciate any thoughts, suggestions, comments, or experiences that will help.

Your own loss will give you a special type of compassion that others cannot provide. I would suggest what is very important is that you show your comfort to the parents. Don't be afraid to cry with them, or to point out how perfect the baby is, or to point out the anomaly that might have been the cause of the death. Each time you do it, the scenario is different. Do footprints (and hand prints if you can) for the parents. If you use First Foto, they will develop the pictures free and send them to your nurse manager (in case the parents want them at a later date). Wrap the baby as gently as you can so it looks as "normal" as possible. let them dress the baby as they wish, ask them the baby's name, refer to the baby by name, help them begin to grieve. You get the picture.

We do not do medical terminations so I cannot help you with that. However, it is still a grieving process. Your presence can be powerful at that time as well.

Mermaid4 · Mar 27, 2005

It is always tough to take care of these patients for so many reasons. I still have a tough time with it all these years, but it is your personal experience which will make you the best nurse to know what or what not to do. I wrote this some time ago and it has been on the site before, but if it helps, please know that every experience is different because every patient and family has a different story. So does their nurse. Not long ago, I was happy to discover that one of my fetal demise patients was expecting. I didn't expect them to want me as their nurse because I would be a sad reminder of their loss. To my surprise and delight, they were worried that I wouldn't want them as my patients. Bottom line, we were all together for a VERY emotional and beautiful delivery of a healthy baby. You can be one of the most significant people in your patients life, just by how you handle their care. Sometimes it is in a touch or not saying anything at all. You will be ok, and tears are not a horrible thing. I am so sorry for your personal loss, but it is that which will help you empathize in a way many of us cannot....Take care....

George and Martha

One Nurses personal account of caring for a fetal demise family.

Night time briskness slapped me in the face as I climbed in to my car for the familiar trek to work. It was my third scheduled night shift but only the first I had felt half way healthy enough to attend. I had called ahead to prepare myself for the pace of the unit, and was already exhausted at the prospect of a wild night. The evening nurse had sounded breathless and added that she had not yet had one free moment to eat or go to the bathroom.

"That's just wonderful," I mused, as I negotiated the ten miles of rural darkness to the hospital. Busy nights on the maternity unit were not always the happy, baby rocking times that the general public and most other nurses believed them to be. They could be brutal and exhausting. Sometimes they could even be tragic and an inner voice nagged I should probably expect nothing less. As I drove into the parking lot past several ambulances in the emergency bay, I steadied myself for whatever chaos loomed ahead, keeping in mind that however short staffed the evening shift was, our shift would be even more compromised. Such is the stuff of the night nurse.

It took a concerted effort simply to walk up the hill and into the hospital. It hadn't escaped my notice that the Emergency room was packed or that there was a blazing harvest moon; two sure hints that my night was going to be busy. I chuckled at the thought that scientists had actually funded a study which determined there was no truth to the notion that a full moon impacted upon patient behavior or events. Obviously they weren't out in the trenches with us.

My husband had provided me with some soup so I wouldn't be hungry overnight. I just couldn't bear to tell him that if by some miracle I was able to arrive at a point that eating became likely, simply eyeballing the mixture sent my poor tummy into a tailspin. I attempted in vain to ignore the aroma.

I wasn't' surprised upon arrival. Full moons generally don't lie. At least one night nurse had been called in early to assist the evening staff, and looked as though she had put in a full shift. She seemed so pooped that I wondered how she would get through the remainder of the night. Not five minutes into report I was informed that because three night nurses had called in the night before, two evening staff had been mandated to stay, and were not there for the current shift. All eyes were focused directly on me. I was still ill enough that I didn't care, but didn't tell them that. Nurses are expected to be invincible and available whatever their condition. I apologized on behalf of everyone.

Perusing the patient board, it became readily apparent that it was not going to be the quiet night I had hoped for. Several people were in labor and there were patients in pre term labor as well. I prayed no one would have to be transferred to a specialty facility because there were no nurses to be spared for the ride.

Another nurse took me aside and whispered she had a patient she thought I should take. Apparently my "emotional support" skills were legendary and definitely required in this case, which was a twenty-two week fetal demise. The alternative was a drug seeking, needy, fresh c/section patient currently lobbying the staff to take her outside for a smoke. For the first time in quite awhile I wished for a labor to immerse myself.

That said, I informed the charge nurse I would do whatever she wanted. The expression of relief in her fatigued eyes made me glad I had given her the option. I took a deep breath, said a quick prayer, and prepared for battle.

Dragging myself out of the chair, I prepared to meet the unfortunate couple, who were in shock. They had gone to their regular office visit and discovered that there was no heart beat. There had been some spotting prior to their visit but the patient hadn't thought much about it because it was sporifice and had occurred with each of her other two pregnancies.

She didn't want to talk. That was ok by me. She had recently been medicated for the pain. Her husband was snoring on the couch and I noticed both she and I were annoyed by that.

I introduced myself and informed her I was to be her nurse for the night. She grunted something in reply and faced away from me. Her evening nurse had mentioned that this couple didn't want to deal with the staff. They were in a room at the end of the hall to minimize interaction with babies, but we could both hear the cries of the infant in the room next door, and she gave me a penetrating stare that signaled I close the door and get out. I did.

Ten minutes later I spied the husband walk down the hall to the kitchen. He breezed past me as though I didn't exist. I was not surprised or offended and quietly introduced myself adding that while I had every intention of respecting their privacy I would be looking in on them from time to time. He nodded, shook my hand and wordlessly, turned back toward their room.

The room light went on signaling a need for my presence. She wanted something else for pain because her cramps were becoming intense. I immediately called the doctor, an old fashioned elderly practitioner who just could not understand why I would bother him barely two hours after her last dose. He refused my suggestion of an epidural and was not impressed with my opinion that the patient should receive more pain medication. Even my argument that people in labor expecting a healthy baby generally receive multiple doses of analgesia at frequent intervals didn't faze him. Eventually he allowed me to offer the patient a sedative but emphatically insisted that she not be given more pain medication until four hours had elapsed from the first dose. No amount of cajoling would sway him, and I did not want to antagonize the doctor in the event I needed him later on. It was my belief that since we were not protecting a live baby and losing her child was already mind numbing, we should medicate the poor woman to the hilt. Every night I realize a moment when I become a patient advocate. This was it.

She wasn't happy with me. Anger blazed across her tear stained face. I told her it was perfectly acceptable to unleash her anger on me. I even encouraged it. Her features softened and she eyed me quizzically. I promised to bring the pain medication the moment it was due, giving her the option of accepting a heated body massage. I added in the event she chose the massage, I would not expect her to talk to me. To my great surprise and relief, she consented.

Ten minutes into the back massage her first words were directed to me in a strained vulnerable voice. "I just don't want to leave without my baby." Then, "this is the most horrible thing that could ever happen to anyone and I just never imagined it would happen to us." She continued to alternately talk and cry as I massaged her back, legs, feet and hands. As she relaxed her wall came down and the tears flowed. Mine joined them. I could see her husband was no longer sleeping, so made a point to mention that often fathers feel left out or helpless because they can't fix things. Sometimes it can seem that they don't care when that is simply not true. I noticed that he came over and sat by his wife's bedside as I spoke. I finished the massage and encouraged them to rest, noting that their embrace lingered and there were shared tears between them. I promised I would be close by and readily available, taking time to make sure that the call light was within reach.

Two am was the appointed time for pain medication and I gave it as promised. Not ten minutes later she rang for more and it crushed me not to be able to accommodate her. I sat with her while she cried, screamed and swore. I said nothing but stroked her cheek as she let out some of the pain we couldn't touch with any medicine, all the while thanking God for my four children.

She reached out and grabbed my hand as her poor husband sat helplessly by, pale and quietly suffering. I reached over and grasped his hand with mine and with a knowing glance that spoke louder than any words he might have uttered, he acknowledged his gratitude. We three sat there for some time like that, as one.

The older doctor had forbidden the patient to get out of bed and wanted her to use a bedpan. Something about dislodging the medication he had administered to promote cervical dilation and the eventual expulsion of the dead fetus. This was another tidbit left over from the dark ages I would have to figure out how to discuss with him.

When the patient begged to get up to use the bathroom, I told her I certainly wouldn't refuse but stayed close by due to my suspicion that delivery was imminent. I had been told she was five centimeters with bulging membranes just moments before she had received her pain medication. The fetus was small and it would not require much room to be passed. I asked if she felt lady partsl pressure and she angrily yelled that she wasn't sure. She refused to allow me to check her underwear. I think I knew what might happen so stationed myself just outside the bathroom door.

"OH MY GOD!"OH MY GOD!" "OH MY GOD!" I heard mere moments later. I helped her to bed and summoned the troops. I needn't have since, having heard her screams, they quickly assembled.

My heart sank as I peered into the toilet because I knew what I would find; what I would have to retrieve. Suddenly the soup that made my stomach jump seemed totally benign. I inhaled slowly and reached in to gently bring the baby back home, all the while trying to put the heart wrenching wails of grief coming from the bed, out of my mind.

The fetus was intact, enclosed in the amniotic sac with an intact placenta. He was perfectly formed and seemingly suspended in space within the sac. I wrapped him in a towel, and called the doctor to tell him we had a delivery. He didn't want me to rupture membranes so I motioned him aside and told him as a mom I would want to hold my baby and looking at him through amniotic fluid would not be the way I would want to remember things. Crusty and old fashioned with a reputation for eating nurses for lunch, he softened and asked simply that I note the fetus was intact and I was the one to break the water. He walked down the hall a few feet, turned and gestured that I approach. "You are a good nurse and this lady is lucky to have you." Momentarily floored, I no longer felt so poorly.

She didn't want to see the baby at first so I quietly suggested she hold him while I stood behind the curtain close by in case she couldn't do it. After several minutes she agreed and as all moms will do, unfolded the blanket and checked to see if he had all his fingers and toes. Behind the drape, my tears flowed as she said to her husband, "Look at his long fingers." I wondered if she would take my suggestion that he be named but she refused.

As I was preparing to leave that morning she was already dressed. I gave her a memory box with the tiny footprints I had taken, along with a poem I had composed just for her. Silently she undid the ribbon and more tears flowed between us. No words were needed. She reached up and gave me a long hug. "Thank you for being my nurse." In all the years I have been in nursing these are the words that keep me going back.

I learned early on that palliative care is really all one can do in tragic times, and often it surpasses the importance that clinical intervention provides. Really, it is a marriage of the two that provides optimal support for the patient. In the case of a fetal demise a good OB nurse will learn that while the bond between him or her and a patient is understandably strong, the patient customarily wants to get as far away from the situation as is humanly possible. One of the reminders of her loss is the nurse who cared for her. An OB nurse has to come to understand and not take it personally if the patient does not want her to attend subsequent labors. Taking cues from the patient and family will always lead the nurse into providing the best of physical, psychological and emotional care. I learned a lesson from a patient early in my career who said simply, "you can't save everyone." Well, at least I can try.

My patient walked by the desk and stood there without speaking until I noticed, and looked up.

"George Alexander," she whispered with a hint of a smile, "after my father."

"That will be his name." "Do you think they will find each other in Heaven?"

"It's a strong name," I countered, meeting her sad flecked hazel eyes. "I am absolutely certain they are already side by side." I asked her to wait while I made a card with his name, and watched as she placed it in the memory box, along with some pictures I had taken of George.

She was gone before my final paperwork was done. Next week I may not even remember her name. Next year I hope if she remembers me it will be because she is back in labor on or near her due date listening to a healthy heart beat on the monitor. If I am lucky, she will request me for her nurse but I will fully understand if she does not.

Until then, she now has an angel in Heaven and however sad I am, I am also grateful and graced that I was appointed to share this experience with them. As I exit the unit, I have to smile as I note that "George" and "Martha" will be irrevocably entwined, always.

Written by: Martha J. Crowninshield O'Brien R.N.

camay1221_RN · Mar 27, 2005

Thank you all for your help and advice! Mermaid, the story you posted was beautiful! Thank you so much for that!

I am confident when the time comes, I will be able to handle it, but right now, it is just a daunting thought. I want to care for my pts the way my nurses, cared for me when I lost my baby. It is comforting to hear others have shed a tear or two with their pts. Though I don't think I will fall apart sobbing, I know I will have tears. And from what all of you have told me, that it's okay to have tears with my pts.

Many thanks again!