Bereavement Support and Delivery of a Nonviable Fetus (Maternal-Newborn) - CE
ALERT
Discuss the loss of a fetus or newborn with the patient and family, and use words such as “miscarriage” or “death” in place of the word “loss.”
OVERVIEW
There are many reasons, both predictable and unpredictable, for the loss of a pregnancy. Regardless of the cause, the family experiences varying degrees of grief that health care personnel must address. Pregnancy loss is often overlooked. Hearing friends or coworkers share their stories of a lost loved one, such as a parent, is common, but hearing those who have lost a pregnancy or newborn sharing stories in the same way is not. Because others may feel uncomfortable discussing the miscarriage, stillbirth, or death of a newborn, the family experiencing the loss may grieve with the grief alone or may feel isolated from society when experiencing such grief.undefined#ref1">1
In many cases, when a perinatal death occurs, the nurse is responsible for both the patient's clinical care and the patient's and her family's emotional support. Depending upon the setting, the nurse may also be responsible for caring for the dead fetus or newborn. The family should be offered the opportunity to hold the newborn for as long as desired. Some patients and families may initially decline to hold a stillborn; however, the nurse should always offer the opportunity. If the patient and family initially decline, the nurse should inform them that the baby will be kept in a private area of the nursery, and that they may change their mind at any time. If the patient and family desire, the newborn may be taken to the nursery intermittently and then brought back for periods of holding. For some, this process may be brief, but the nurse should be prepared for families who desire an extended period of time with their newborn.
As a member of the health care team who spends a significant length of time with the patient, the nurse should provide reassurance and comfort to the patient and her family during their time of grief (Box 1)![Box 1]()
. This can be an emotional and exhausting experience for the nurse, but it is also a privilege and an opportunity to provide support during an extremely vulnerable period in the life of the patient and her family.1
The obstetric nurse should be well educated in the signs and symptoms of parental grief and in how to provide bereavement care to the family experiencing perinatal loss. Even in settings where social workers or chaplains are available, the nurse needs to feel comfortable dealing with the grief process. Many factors to consider when providing bereavement care include the circumstances surrounding the loss, the patient's age and cultural and religious beliefs, and the support system in place for the family. The nurse also need to ensure that the family has resources for grief support after the patient is discharged from the clinical setting.1
PATIENT AND FAMILY EDUCATION
Delivery after fetal death
- Introduce yourself to the patient and family and acknowledge their loss.
- Advise the patient and support person about what to expect during the labor and delivery process.
- Instruct the patient and support person about effective relaxation techniques.
- Advise the patient and family about what to expect depending upon the underlying cause of pregnancy loss.
- Fetal anomalies
- Maternal complications
- Instruct the patient about pain-management options (epidural, IV, or intramuscular opioids, as well as hydrotherapy, birth ball, others).
- Instruct the patient and support person about necessary interventions.
- IV catheter placement
- Administration of IV fluid or blood replacement
- Blood pressure monitoring
- Collection of laboratory specimens
- Interventions specific to maternal complications or disease processes that may be a precipitating factor in pregnancy loss (i.e., severe preeclampsia, abruption placentae)
- Labor monitoring, such as contraction determination and surveillance
- Advise the family about what to expect regarding the newborn's appearance depending upon gestational age.
- Size of fetus
- Appearance of fetus
- Potential presence of anomalies
- Encourage the patient and family to express their wishes in preserving memories, whether by actions (bathing and dressing the newborn) or by mementos (pictures, alone or with siblings or plaster casts of the hands or feet) that may help them through their grief.
- Encourage questions and answer them as they arise.
General education
- Instruct the patient and support person about the interventions being initiated if stillbirth is unexpected or if neonatal resuscitation is needed and attempted after delivery.
- Use realistic terms such as "miscarriage" or "death" to describe the loss of a fetus or newborn to the family.
- Instruct the patient and family on the symptoms of parental grief.1
- Acute distress: Symptoms of shock, crying, and depression
- Intense grief: Feelings of loneliness, guilt, resentment, anger, fear, anxiety, sadness, and depression, as well as possible physical symptoms
- Reorganization: Potential start of a reduction in stress, of searching for meaning in the loss, of reentering normal life activities more easily, and of making future plans, to include another pregnancy
- Instruct the patient and family on what interventions may be provided to preserve their memories of their fetus or newborn.
- Weight and length measurements
- Photograph(s) (following bath)
- Lock of hair (with family permission and if possible)
- Footprints and handprints
- Identification (ID) bracelets
- Hat, blankets, or clothing used
- Instruct the patient and family about bereavement team (if available), follow-up contacts, and support groups available to assist with the grieving process following discharge.
- Encourage questions and answer them as they arise.
ASSESSMENT AND PREPARATION
Assessment
- Perform hand hygiene before patient contact.
- Introduce yourself to the patient.
- Verify the correct patient using two identifiers.
- Complete the initial assessment for a high-risk obstetric patient.
- Assess the patient's and family's knowledge and ability to absorb education.
- Assess the patient's and family's grief.
- Assess the patient and family for any specific cultural or religious beliefs they would like incorporated into their care and the care of their baby.
- Assess the patient's and family's need for spiritual support before, during, and after the procedure.
- Assess the patient's and family's request for additional support persons to be present during labor and birth, and after delivery.
Preparation
- Gather delivery supplies as needed.
- Gather supplies to be used for memento or keepsake collection.
- Notify any additional family and friends, chaplain, or social work support as desired by the patient and family and as required.
- Be aware of one's own reaction to loss and grief and how it may affect care of the patient and family.
- Review state reporting requirements for fetal and neonatal deaths.
Rationale: Fetal and neonatal death reporting varies by state.
PROCEDURE
- Perform hand hygiene.
- Introduce yourself to the patient.
- Verify the correct patient using two identifiers.
- Acknowledge the patient's and family's loss.
- Ensure patient privacy.
- Place a card or symbol on the patient's door and medical record indicating pregnancy loss if known on admission.
Rationale: All hospital employees should be aware of the pregnancy loss before interacting with the patient or family to avoid inappropriate comments or questions that may unnecessarily upset them.
- Provide ongoing support to the patient and family. When pregnancy loss is known before delivery, provide necessary psychosocial support throughout the labor and delivery process.
Rationale: The patient and family should feel as if they are receiving the same attention as other patients who are delivering live newborns. In addition, the family may have many questions regarding how their baby will be handled following delivery.
- Perform hand hygiene and don gloves.
- Prepare the patient for induction of labor as needed.
- Obtain laboratory specimens as ordered.
- Obtain large-bore IV access.
- Initiate IV infusion as ordered.
- Discard supplies, remove gloves, perform hand hygiene, and don appropriate personal protective equipment (PPE), based on the delivery method.
- Assist with delivery.
- Record time of delivery.
- Administer oxytocin or other medications according to the practitioner's orders and assist with fundal massage.
- Promote skin-to-skin contact with the mother, and offer the family an opportunity to hold the newborn for as long as desired. If the patient and family initially decline, inform them that the baby will be kept in a private area of the nursery, and that they may change their mind at any time.
Rationale: Some patients and families may initially decline to hold a stillborn; however, the nurse should always offer the opportunity.
If the family declines to hold the newborn, do not pressure them to do so. Offer the opportunity to each family member separately and allow him or her time to consider the choice.
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- Dry, weigh, and measure the newborn.
- Complete matching ID bracelets for the patient and the newborn.
Rationale: ID bracelets serve as mementos for the family.
- Clean, diaper, and apply a hat to the newborn and wrap him or her in a warm blanket.
Rationale: To assist the family's healing process, it is extremely important to clean and diaper the newborn as if he or she were born alive. The memory of the delivery is just as significant to them as it is to the family of a live newborn. The family should have the opportunity to remember their newborn as clean and swaddled.
- Remove gloves, perform hand hygiene, and don clean gloves.
- Label the placenta and send it to the pathology laboratory per the practitioner's orders with attention to genetic studies requested, if indicated.
- Assist the practitioner with repair of episiotomy or lacerations.
- Supply requested suture for repair.
- Supply other requested instruments.
- Cleanse perineum after repair.
- Remove PPE, perform hand hygiene, and don clean gloves.
- Transport the newborn in the crib or basket to the nursery or other holding area, or keep the newborn in the patient's room if requested.
- Offer the patient and family the opportunity to bathe and dress the newborn. If the patient and family do not desire to do so, bathe the newborn and dress him or her in clothes provided by the patient or the organization.
Rationale: Before photographs are taken, the newborn should be dressed in clothing just as a live newborn would be. The patient and family should be given the opportunity to bathe the newborn if they desire. They may want to perform expected parenting activities, such as dressing the newborn and combing the hair.
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- Obtain mementos of the newborn for the family to take home per organizations practice.
- Photographs (following bath)
- Lock of hair (with family permission and if possible)
- Footprints and handprints
- ID bracelets
- Newborn hat, blankets, or clothing worn
Rationale: Most patients and families will want physical keepsakes. Initially, some patients may decline these; however, they should be obtained and offered to the patient before discharge. In some instances, patients will return weeks or months later and request photographs. Photographs of congenital anomalies should also be obtained.
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- Offer the patient and family an additional opportunity to hold the newborn following the bath. Offer the patient and family private time with the newborn, informing them when you will return and offering to return promptly when requested.
Rationale: The patient and family should be offered the opportunity to hold the newborn as often and for as long as desired. They should also be offered private time together; the nurse should always tell them how long they will be left alone and offer to return promptly if requested, as feelings of anxiety and intense distress may be present during the early period of parental grief.
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- Prepare the newborn for subsequent time with the family.
- After the family spends initial time with the newborn, undress the newborn and wrap him or her in plastic wrap to protect the skin. Place the newborn in a cooled environment.
- If the family chooses to see the newborn again, remove the plastic wrap, dress the newborn again, and place him or her in warm blankets.
- Discard supplies, remove gloves, and perform hand hygiene.
- Encourage the patient and family to have other family members or support persons visit or hold the newborn if they desire.
Rationale: Just as someone giving birth to a live newborn would, patients and families may want their family and friends to see their child. They should be encouraged to invite family and friends as they desire.
- Offer social services or chaplain support to discuss funeral or other arrangements.
Rationale: Spiritual or religious beliefs may influence what rituals the family desires, and should be offered.
- Discuss the available options and assist the family in making those decisions.
- Autopsy
- Organ donation
- Genetic studies
- Complete the required documentation, depending upon gestational age, for fetal death or newborn death.
- Contact the funeral director as needed.
- Perform hand hygiene.
- Document the procedure in the patient's record.
MONITORING AND CARE
- Perform recovery care.
- Assess, treat, and reassess pain.
- Monitor the patient's and family's response to loss. Provide ongoing support and comfort to them by encouraging expression of feelings.
- Provide resources for grief support and follow-up after discharge.
- Provide written materials about grief and mourning.
EXPECTED OUTCOMES
- Delivery without complications
- Collection and provision of newborn mementos and keepsakes to the patient and family
- Actualization of the loss
- Family expressions of mourning and grief
UNEXPECTED OUTCOMES
- Delivery with complications
- Inability to collect newborn mementos and keepsakes to provide to the family
- Family denial of loss with no expression of grief
DOCUMENTATION
- Maternal assessment findings
- Nursing interventions and patient's response to them
- Adverse responses
- Status of newborn at delivery and details of any resuscitation interventions
- Time of delivery
- Time of placenta delivery
- Recovery care provided to patient
- Patient and family education
- Support provided to patient and family
- Disposition of patient and family
- Patient's and family members' signs and symptoms of grief and level of coping
- Care provided to newborn and details of mementos and keepsakes obtained
- State-mandated reporting forms
- Unexpected outcomes and related nursing interventions
- Black, B.P. (2016). Chapter 37: Perinatal loss, bereavement, and grief. In D.L. Lowdermilk and others, Maternity & women’s health care (11th ed., pp. 909-930). St. Louis: Elsevier.
ADDITIONAL READINGS
American College of Obstetricians and Gynecologists (ACOG). (2009, Reaffirmed 2016). ACOG practice bulletin no. 102: Management of stillbirth. Obstetrics & Gynecology, 113(3), 748-761. doi:10.1097/AOG.0b013e31819e9ee2
Elsevier Skills Levels of Evidence
- Level I - Systematic review of all relevant randomized controlled trials
- Level II - At least one well-designed randomized controlled trial
- Level III - Well-designed controlled trials without randomization
- Level IV - Well-designed case-controlled or cohort studies
- Level V - Descriptive or qualitative studies
- Level VI - Single descriptive or qualitative study
- Level VII - Authority opinion or expert committee reports
