Emotional Care of a Perinatal Loss and its impact on the Labor and Delivery Nurse

by
Brenda Whiting Beard, R.N., B.S.N.
Louise Ward, R.N., M.S.N.
Senior Nursing Staff, Labor and Delivery Suite

Reprinted with permission

"Oh, you're a labor and delivery nurse? ... That must be so much fun!" is the usual comment gushed with great enthusiasm when people find out what kind of nursing I do. They might be envisioning loving Madonna's with their angelic babes all pink and healthy with the nurse present for surrogate mothering when the mum's needed to rest. What a great job that would be.

The reality is that nursing at a level 3, tertiary care center is a mixture of emergency nursing, operating room nursing, an Intensive Care Unit, some basic maternity and a large portion of teaching. My college education prepared me for that and much more. What the best education in the world cannot prepare one for is a perinatal loss- a stillborn infant, or a premature delivery where all efforts fail to save the neonate's little life. I have been enabled through education and empowered by experience, to manage the clinical aspects of caring for a family facing a perinatal loss, but what do I do with my own sense of grief ? No one ever told me that as a nurse I would grieve so deeply and sometimes so often with families that were until recently strangers to me. As a professional, my head knows to stay focused so I can help start the family on the right path for grieving. A complex and perhaps never-ending process at a time that should be filled with great joy. Also as a parent, my heart tells me many other things.

This is what a dear friend (and coincidentally, my minister) calls stirring up the 'pot of loss'. When faced with a loss situation, all previous losses are stimulated. They will rise to the surface much like stirring up a soup or stew made of every ingredient one Is kitchen might have. By stirring, this concoction, left so long on the back burner, is seasoned, tasted again and a new seasoning - a new loss - added and put back to simmer. A family experiencing a perinatal loss will have their 'pot of loss' uncovered and all previous losses will surface. They may remember a family member's death, the loss of a friend, loss of a pet or loss of a dream. How they dealt with these events will impact on how they deal with this perinatal loss. Likewise, it is my 'pot of loss' that impacts on how I deal with them as their nurse. It is a very well seasoned pot that provides the sustenance needed to continue in a healthy way. I taste from it briefly, am strengthened and go forward to do the work at hand.

The first thing I do when admitting a family with a loss to Labor & Delivery is to initiate a Perinatal Loss Checklist (PLC). The PLC is documentation of the events that transpire and the support team involved. It is a concise list that helps the nurse stay focused while providing care. It also insures that all team members are notified that their services may be required. The team includes the doctors (obstetrician and pediatrician), the nurses, social worker, religious ministry and frequently the genetics department. We work as a team, one service complimenting and adding to the others contributions. The end goal to be facilitating the family to grieve. Depending on circumstances, the family may not see all members of the team while on Labor & Delivery, so the PLC also acts a guide to the team. What is not documented at delivery will be attended to at another time prior to discharge. A copy of this form is forwarded to the attending physician's office so that the repetition of painful questions can be decreased and accurate communication of helpful information will be increased.

The PLC's most important function is to stimulate the collection of memorabilia for the families, The time spent on the labor and delivery floor after birth is often the only time the family may have with this child. Whether the loss is a stillborn, a severely premature infant or a baby born with anomalies that are incompatible to life, it is important to emphasize the act of making memories. I will often make suggestions to the family to help them plan for the delivery of their baby in order to make the most of this encounter. In the best of circumstances, I take the time to discuss with the families their desires for after the baby is born. They may not have any concrete plans beyond deciding whether to see their baby or not. This issue alone can be of great importance. Those who are sure they would like to see their baby, make my job that much easier. The ones who are unsure, I will advise to see the baby, offering to hold the infant for them while they look on, if that might make it easier for them. My most difficult task is working with a family that chooses not to see the baby at all. I respect their decision, (albeit with a heavy heart that I keep to myself), and inform them that some families feel this way often as a result of fear. I can only assure them that reality is very often less frightening than imagination. I usually take this opportunity to share some of my previous experiences. First of all, I state that their decision is not irrevocable, leaving the door open for them to change their minds. Until they are discharged or the baby is picked up by the designated funeral home, there is always an opportunity to retrieve the baby and see it in our morgue's family area. While I know that the most optimal time is soon after birth due to the baby's condition, all attempts are made to make the viewing as easy as possible. I also give them the benefit of my previous experiences with families that have contacted me expressing regret over having not seen their baby. I feel comfortable that I am doing this in a very non-judgmental way. When a family opts not to see their baby, I take extra time holding this baby in private. This is one of the ways I help myself to heal after caring for a loss.

I take opportunities to inquire about their faith and their desires for a chance to meet with a member of our clergy staff. Some families have strong desires while others may not have even thought of having the baby blessed or a prayer said. This is just one more of the ways in which I as the nurse can help to guide the family through an event in which they have no prior experience. During the delivery, I try to keep the room a safe, quiet place while providing physical comfort and facilitating the birth process. I will have informed the physician or midwife of the wishes of the family during the labor so that all of us are aware and sensitive to their needs. I position myself on one side of the bed and encourage the father (or significant other) to be at the other side. If the father has expressed fear of watching the birth, I suggest that he look into his partner' s eyes towards the top of the bed. I often see them glancing at the delivery. I usually am ready with a blanket to take the baby from the midwife and place it gently in the prepared crib. I preheat the crib and have baby blankets and towels lining it as I would do for any infant. I cover the baby completely or partially as to the predetermined plan. I often note that if a grandparent is in the room at this time, they venture over for a closer look in the crib. once the physical aspects of the delivery are completed, such as the delivery of the placenta, repair of the perineum and mother's vital signs are stable, I am then able to turn my attentions to the baby.

I will wipe the baby dry taking care not to damage the skin which may be very fragile. I do the baby care in the room of the patient as often as possible. By having the families watch this process, they are able to see how I handle their baby with gentle and respectful touches. I think it also helps them to see that it is acceptable to touch these babies. I am tearful at the deliveries that I attend. I cannot help but be saddened by the loss of potential life and love that this family is experiencing. I believe that my tears help to validate that this is a life worth grieving for.

I encourage the family in the room to touch the baby as I prepare the baby for presentation to the mother. Sometimes I will hear them comment about features that resemble family members. Even in babies with anomalies, there is often a trait they notice to be familiar. When I hand the baby to the mother, I will introduce the baby as "your son or daughter". I make every attempt to place this baby into the family. When the families discuss naming, I suggest that they can either go with the name that they had originally chosen or they may wish to save that name for another child and chose something different. The point is to encourage naming this baby to help give him or her an identity within the family. Protocol requires taking pictures of the baby both clothed and unclothed. The parents are informed that this will be done and that they may choose to take the pictures home with them. If they opt not to take them home, they are kept on file with the social worker. There has been an incident of a family returning to claim them seven years after delivery. Most likely these may be the only pictures of this child as many families are not prepared to bring cameras with them.

I try to take pictures that I would want of my own family. The Polaroid camera at work allows me to take multiple shots to achieve the best pictures possible within the limitations of the camera. In recent years, I have begun to photograph the actual deliveries, the blessings and the family members with the baby. These are unopposed pictures and I am careful to be as unobtrusive as possible. I also take pictures of the baby alone using a background frame that I developed to eliminate the hospital equipment from the scene. By using stuffed animals donated from the labor and delivery staff, I can add a nursery atmosphere as well as use the animals to prop and pose the baby. These pictures have been very well received. The rest of the memorabilia packet contains foot and hand prints, locks of hair, the hospital identification bands, the actual blanket, tee shirt and hat that the baby wore during the pictures and while being held by the family. I also enclose a copy of When Hello Means Goodbye and a baby memory booklet filled in with the time and date of delivery, weight, length and the persons who have been involved with the patient's care.

In the future, our perinatal loss care will include but not be limited to: follow up phone calls - at 2 weeks, 6 months, 1 year; an invitation to an annual memorial service; encouraging involvement with community support groups; providing in-services for our co-workers; and continued evaluation and improvements to our memory package based on input from families, co-workers and professional journals.

The care of these special families is rewarding and extremely satisfying work. I choose to care for them as often as I can or to precept a less experienced nurse to allow her to grow in a nursing skill that is not always covered in a text book. I am very fortunate to work alongside a very compassionate team who are dedicated to making this tragic road somewhat easier to travel.