In the past, bereaved parents were often mistreated. They were usually segregated on a medical floor, ignored by hospital personnel who didn't know what to say, and discharged without any discussion of what went wrong or what to expect in the future. Medical or emotional follow-up was rarely offered to them, and they were often avoided by medical professionals affected by their own grief, guilt, or fear of lawsuit.
Ten to 15 years ago, this began to change. Elizabeth Kübler-Ross' seminal work on death and dying was applied to perinatal loss, and the topic of bereavement counseling became a part of obstetric care. We now help parents to anticipate the stages of the grieving process and to know what feelings and behaviors are a normal part of their grief reactions. We help them to integrate the medical facts of what happened and to assuage any guilt they may feel about their own actions. We tell them how others have handled this process, and we provide support groups as well.
What we have not yet done is to focus on helping the medical professionals deal with their reactions to their patients' losses. Although we have recognized that physicians, nurses, and nurse-midwives all find it difficult to face bereaved parents, we must now develop strategies for teaching our students and new graduates to help each other to deal with feelings in a way that leads to personal and professional growth and also improves the care our patients receive. The following case is illustrative.
Janice was a 32-year-old high school teacher who was very excited about her second pregnancy. Her new husband was so involved, and her eight-year-old daughter was thrilled. At about 35 weeks, she was referred to a perinatologist for external version because her baby was breech. The version attempt was not successful, and the physician noted that the estimated fetal weight was less than the fifth percentile, indicative of intrauterine growth retardation (IUGR). After weeks of reactive nonstress tests (NSTs) and good biophysical profiles, the same physician determined that there was no longer any indication of IUGR. The baby was vertex and was estimated to weigh nearly 7 pounds. We ail relaxed and decided that a nice normal labor and birth could be expected. The parents could hardly wait for this delivery.
On general principles, weekly NSTs were continued. Then came the call. At 41 weeks, just three days after a reactive NST, Janice called me to say that she had not felt the baby move since the previous morning, and she requested an NST. This had happened once before, and everything had been fine, yet I felt my worried “sinking stomach” feeling. The nurses at the hospital could not find a fetal heartbeat—would I come? As I drove, I tried to control my shock and disbelief. I tried to think of what I could do. What if I found a fetal heart rate of 60 or 80? Whom should I call? How to tell her that the baby might be damaged? I tried to remember her last NST. Did I misinterpret it? Could I have predicted this? Should I have noticed something or done another biophysical profile? Maybe the nurses would have found the fetal heartbeat by the time I arrived. I hoped and hoped.
When I arrived at the patient's side, I found no fetal heartbeat, and I had to tell this favorite patient that her baby was dead, that all of our NSTs were not able to warn us of her child's problem. Her loud sobs were heartrending, and I cried too. How could this happen? I looked again at her recent NST—there was no question it was reactive. I felt angry. I had believed in the science that told me that nothing would go wrong if we had good NSTs. Was this baby growth retarded after all? What else should I have done? How could I have let this happen when she trusted me to make sure that her child would be all right?
Three days later, Janice delivered her healthy-looking, 7-pound daughter, with a tight true knot in the cord. This was one of those rare instances where some explanation could be offered for the stillbirth.
This scenario is probably familiar to all experienced midwives. How we handle these difficult situations is important to each of us as professionals, and to our future patients as well. Should we always be so ready to blame ourselves, to shoulder all of the responsibility for the outcome of someone's pregnancy? Are we also conditioned by the popular belief that pregnancy should always turn out well, that bad things only happen when someone is negligent? When I was a student, we talked about bereavement counseling, but no one mentioned the midwife's feelings. This made my first experiences with poor outcomes more difficult, as I thought perhaps I was the only one who felt as I did.
Many fears and doubts surface after a poor outcome such as this one. Another experienced midwife told me that, after her first loss, she questioned whether she should even be a midwife. This is a normal feeling. We, just like patients, need to know what are the normal feelings and emotional states to expect following a loss. We go through stages too: shock, grief, self-doubt, anger, fear of the future, and a variable time of reviewing the experience over and over again. In the normal situation, with good support, we eventually put the emotional reactions aside. We may have decided how to better handle a similar situation in the future, whether it is managing another shoulder dystocia or facing another patient with a loss. This is an appropriate resolution—learning. And the midwife should recover with self-esteem and decision-making abilities intact.
This recovery will be facilitated by preparation and by supportive colleagues. Students should have an opportunity to discuss crises and patients' losses in terms of their own probable reactions, and they should feel able to discuss their reactions with other, more experienced mid-wives. This is no more than we do for our patients who experience loss. We tell them about the stages of grief; we tell them what has helped others in similar distress, and we offer them an opportunity to express their feelings.
Faculty and senior staff need to be more open about discussing emotional reactions to patients' losses, letting junior staff know that these feelings are acceptable. Cases with poor outcomes should be reviewed with the midwife involved in a sensitive fashion so that learning can be facilitated and/or management validated. Colleagues must offer support when another experiences such a difficult case. For the midwife involved, silence is not the best way to get over the traumatic experience.
Fear of the patient's reaction often becomes a barrier to a continued relationship, but it is important for both the patient and the midwife that the unique caring relationship developed during the pregnancy be continued. Another midwife may assume the role of primary bereavement counselor for this patient, but the midwife involved must face the patient without being defensive or projecting her own anger about the situation onto the patient.
The case described earlier was easier than many. There is no damaged baby to remind me of my self-doubts; I have little fear of lawsuit in the future because there was an obvious cause to blame. The patient herself, although grieving, knows that her child was healthy and does not feel inadequate as a mother. She also feels that she received tremendous support from all of the medical professionals involved in her care. Unfortunately, this is not always the situation.
Despite the best of medical care, some patients will experience the loss of a baby, and, more often than not, no reasonable explanation will be found. Medical professionals must be prepared to deal with perinatal loss, must be able to anticipate their own reactions, and be able to find a source of support where they can ventilate their emotions. Ideally, peers will review the case and share their insights in a nonjudgmental environment. This will allow learning to occur and, ultimately, patient care will benefit.
Author identity withheld to protect the confidentiality of the patient.