1. Perinatal Loss, Bereavement, and Grief
Chapter 37
Perinatal Loss, Bereavement, and Grief
Copyright © 2016 by Elsevier Inc. All rights reserved.

2. Learning Objectives Define perinatal loss, bereavement, and grief.
Describe the causes of perinatal loss.
Describe the various responses parents and families may have to perinatal loss.
Analyze the personal and societal issues that can complicate responses to perinatal loss.
Formulate appropriate nursing diagnoses for people experiencing perinatal loss.

3. Learning Objectives (Cont.)
Identify specific nursing interventions to meet the special needs of bereaved women, their partners, and their families related to perinatal loss and grief.
Differentiate between helpful and hurtful responses in caring for women and their partners experiencing a perinatal loss.
Define complicated grief related to perinatal loss and how nurses can assess for it.

4. Loss, Bereavement, and Grief: Basic Concepts and Theories
Defining loss, bereavement, grief, and mourning
Useful grief theories in perinatal settings
Continuing bonds theory
Dual process model
Caring theory to guide nursing practice when pregnancy ends in loss
1. Knowing
2. Being with
3. Doing for
4. Enabling
5. Maintaining belief

5. Types of Losses Associated with Pregnancy
Defining perinatal loss
Miscarriage
Fetal death
Early
Late
Stillbirth
Death of live-born infant
Early neonatal death
Late neonatal death
Infant death

6. Types of Losses Associated with Pregnancy (Cont.)
Types of perinatal losses
Miscarriage
Serious fetal diagnosis
Pregnancy termination
TOPFA: termination of pregnancy for fetal anomalies
Selective reduction
Other losses
Perinatal care settings where nurses encounter loss
Perinatal palliative care

7. Miles’s Model of Parental Grief Responses
Three overlapping phases
Acute distress
Intense grief
Guilt, anger, resentment, bitterness, or irritability
Characterized by disorganization
Physical symptoms include fatigue, headaches, dizziness, or musculoskeletal aches and pains
Reorganization
Better able to function at home and work, experiences a return of self-esteem and confidence, can cope with new challenges, and has placed the loss in perspective
The term recovery is not appropriate because the grief related to perinatal loss, as with any loss, can continue for life.

8. Acute distress
Loss of a pregnancy or death of an infant is an acute and distressing experience for mothers and fathers who planned for and expected a normal healthy infant as the outcome
Parents generally are in a state of shock and numbness
Disbelief and denial can occur
Intense outbursts of emotion and crying are common

9. Intense Grief
Encompasses many difficult emotions, including loneliness, emptiness, yearning; guilt, anger, and fear; disorganization and depression; and physical symptoms
Deciding what to do about the nursery and baby clothes is particularly difficult during this period
Common response during this phase of grief is anger, resentment, bitterness, or irritability
Fear and anxiety can occur

10. Intense Grief
Difficulty in getting things done, and inability to concentrate, restlessness, confused thought processes, difficulty in solving problems, and poor decision making
Physical symptoms of grief include fatigue, headaches, dizziness, or backaches

11. Reorganization
Occurs when the parent is better able to function at home and work, experiences a return of self-esteem and confidence, can cope with new challenges, and has placed the loss in perspective
Begins to peak sometime after the first year as parents begin to achieve the task of moving on with their lives

12. Family Aspects of Grief
Grandparents
Complicated by emotional pain witnessing and feeling immense grief of their child
Siblings
Young children respond more to the reactions of parents.
School-aged siblings
Teenagers
Resolve through sharing resources

13. Family Aspect of Grief
Nurse caring for one of these patients needs to keep in mind that they have an entire family to minister to, including and especially grand parents and siblings
Grandparents are angry that they are alive and the grandchild is not

14. Perinatal Loss Care Management
When a loss is diagnosed: helping the woman and her family in the aftermath
Simple, unambiguous, and consistent language is crucial

15. Perinatal Loss Care Management (Cont.)
Helping parents with holding their fetus or infant
Research evidence supports the importance of parents’ seeing or holding their fetus or infant, but they should never be made to feel they “should” see or hold their baby.
Parents appreciate explanations about what to expect.
When bringing the baby’s body to the parents, it is important to treat the baby as one would a live baby.

16. Perinatal Loss Care Management (Cont.)
Helping parents with holding their fetus or infant (Cont.)

17. Case Study
You have just begun your shift and are receiving the patient report from the admitting nurse:
Mary is a 26-year-old G1 P0000 at 36 weeks of gestation. She presented to the prenatal clinic yesterday for her routine exam and the provider was unable to hear fetal heart tones. Intrauterine fetal demise was confirmed by ultrasound, and her labor began spontaneously soon afterward. Mary is here with her husband, Jeff, and both are crying.

18. Case Study (Cont.)
Envision and describe how you will introduce yourself to this couple and begin the shift.
Mary and Jeff are still in the first stage, latent phase of labor.
What are the most important initial questions to ask the couple regarding their labor and birth, ideally before the onset of the active phase of labor?

19. Case Study (Cont.)
Eighteen hours later, Mary delivers a baby girl with Jeff at her side.
After delivery, describe specific therapeutic nursing interventions.

20. Perinatal Loss Care Management (Cont.)
Helping parents with decisions regarding autopsies, organ donation, and disposition of the body
Autopsy
Personal, cultural, and religious views
Organ donation
Spiritual rituals
Respectful disposition of the body
Memorial or funeral service
Do not rush the family into making decisions.

21. Perinatal Loss Care Management (Cont.)
Help the Parents with Decision Making
Conducting and autopsy
Autopsy can be very important in answering the question “WHY”
Autopsies are not covered by insurance and are expensive
Organ donation
Donation of cornea can occur if the baby was born alive at 36 weeks of gestation or later
Decisions related tom spiritual rituals that may be helpful or important to parents

22. Perinatal Loss Care Management (Cont.)
Helping the bereaved parents acknowledge and express their feelings
Validate the experience and feelings of the parents.
Encourage them to tell their stories.
Listen with care.
Offer helpful versus unhelpful responses.
Allot enough time to engage with them without being rushed.

23. Perinatal Loss Care Management (Cont.)
Helping the bereaved family understand differing responses to loss
Reassure them that their responses are normal.
Prepare them for grief’s potentially lengthy process.
Educate about the grief process, including the physical, social, and emotional responses of individuals and families.
Recognize that there my be incongruent grieving in couples.

24. Perinatal Loss Care Management (Cont.)
Meeting the physical needs of the bereaved mother in the postpartum period
The mother should decide if she wants to remain on the maternity unit or to move to another unit.
Physical needs are the same as those of any woman who has given birth.
Lactation issues
Postpartum care instructions

25. Perinatal Loss Care Management (Cont.)
Assisting the bereaved parents in communicating and establishing support from family members

26. Perinatal Loss Care Management (Cont.)
Creating memorabilia for parents to take home

27. Perinatal Loss Care Management (Cont.)
Create Memories for Parents to Take Home
Nurse can provide information about the baby’s weight, height, and head circumference

28. Perinatal Loss Care Management (Cont.)
Addressing cultural and spiritual needs of parents
The nurse must be sensitive to the responses and needs of parents from various cultural backgrounds and religious groups.
The nurse needs to be aware of his or her own values and beliefs.
Culture and religious beliefs influence the customs following death.

29. Perinatal Loss Care Management (Cont.)
Providing sensitive discharge and follow-up care
Sensitivity about time and manner of discharge from hospital
Follow-up care
Finding a perinatal or parent grief support group
The focus of the group needs to match the parents’ needs.

30. Perinatal Loss Care Management (Cont.)
Providing postmortem care
Preparing the baby’s body and transporting to the morgue depend on the procedures and protocols developed by individual hospitals.

31. Perinatal Loss Care Management (Cont.)
Provide Postmortem Care
Preparation of the baby’s body and transport to the morgue depends on the procedures and protocols developed by individual hospitals
Sensitive and respectful approach for taking the fetus or infant to the morgue is the use of a “burial cradle”

32. Special Circumstances
Prenatal diagnosis with poor prognosis
Death of a fetus in a multiple gestation
Adolescent grief
Complicated grief
Also called complicated bereavement, prolonged grief, pathologic grief, or pathologic mourning
Differs from what is considered normal grief in its duration and the degree to which behavior and emotional state are affected
Posttraumatic stress disorder (PTSD)
Posttraumatic growth (PTG)

33. Special Circumstances
Posttraumatic growth
Women and their partners can experience personal growth in the aftermath of a perinatal loss
This phenomenon is characterized by development along one or more of five dimensions :
Personal strength
Appreciation for life
Spirituality
Relating to others
New possibilities

34. Special Circumstances
Loss of One in a Multiple Birth
Death of a twin or baby in a multifetal gestation during pregnancy, labor, birth or after requires parents to parent and grieve at the same time
Parents feel that they can do nothing right
Parents are at risk for altered parenting and complicated bereavement

35. Special Circumstances (cont)
Adolescent Grief
Adolescents grieve the loss of their babies through miscarriage, stillborn, or newborn death and need the emotional support from the nurses who care for them
Nurses and other health care professionals, as well as family members often believe that the adolescent ‘s loss of her baby was for the best
Adolescents girls, then, may not receive the support needed from staff and family
Adolescents do not have the support from the father of the baby

36. Special Circumstances (cont)
Complicated Bereavement
Parents have extremely intense grief reactions that last for a very long time
Evidence of complicated grief includes continued obsession with yearning and loneliness, intense and continued guilt or anger, relentless, depression or anxiety

37. Question
Which options for saying good-bye should the nurse discuss with a woman who is diagnosed as having a stillborn girl?
The nurse shouldn’t discuss any options at this time; there is plenty of time after the baby is born.
“Would you like a picture taken of your baby after birth?”
“When your baby is born, would you like to see and hold her?”
“What funeral home do you want notified after the baby is born?”

38. Key Points
Attachment to the idea of a baby can begin before pregnancy with many hopes and dreams for the future and can become more pronounced over the course of pregnancy.
Women can feel profound grief regardless of the length of gestation; however, women tend to have higher levels of grief with longer gestations.
When a fetus or a newborn dies, all members of a family are affected, but no two family members grieve in the same way.

39. Key Points (Cont.)
When birth and death coexist, sensitive care by a nurse is critical in assisting the woman and her family in their grief, regardless of the woman’s age or stage of gestation.
An understanding of the grief process is fundamental to care management of families experiencing fundamental perinatal loss.
Assessment of each family member’s perception and experience of the loss is important.

40. Key Points (Cont.)
Cultural and religious beliefs affect a family’s response to and method of coping with perinatal death.
Therapeutic communication and active listening can help women and their partners and families identify their feelings, feel comfortable expressing their grief, and understand their bereavement process.

41. Key Points (Cont.)
Follow-up after discharge is important in providing care to families who have experienced a loss because of the evolving nature of grief.
Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgmental environment of care and support for bereaved families.