As birth and death coincide - Miscarriage,Stillbirth & Neo-natal death - Part One

These three topics have  been seprarated from the more general protocol  as they have special considerations in addition to those ‘normally’ associated with the acutely dying child.

And they are being dealt with as a single topic because they share some common features, common ‘helping protocols’, and also simply to keep the book as user –friendly as possible.

This does not in any way however suggest any particular emotional ranking or loading,-or lack of it,-to any or all of these particular situations.

For the purposes of this book the term ‘miscarriage’ refers to any ‘foetus’ which would be unlikely to survive in an extra-uteruo environment including a neo-natal intensive care unit at an academic hospital; which may have been spontaneously aborted; or where the mother may have received a therapeutic dilatation-and-curettage.

Medically speaking, miscarriage is considered to be the loss of a known pregnancy within the first 20 weeks of conception.Miscarriages may also occur before the woman knows she is pregnant.

The term ‘stillbirth’ refers to the death-in-uteruo of a foetus that is sufficiently developed and mature to have statistically survived in an extra-uteruo environment, even if that meant a neo-natal unit. There is an assumption that the death was caused by an overwhelming or precipitous obstetrical emergency event.

Medically, it is defined as a baby born dead, after 24 weeks of pregnancy.

The four weeks between miscarrigae  (20/40 weeks) and stillbirth (24/40 weeks)  may  be called ‘late foetal loss’.

Although the term ‘foetus’ is used in this chapter, it is from a purely medical and legal viewpoint.
For a lot of (potential) parents, the foetus is in fact their baby psychologically and emotionally and spiritually, a view that I share.
 It goes without saying that the parents always lose a ‘baby’, or ‘a child’, and not 'a foetus'.

The term ‘neo-natal’ death refers to the death of any baby within 28 days  of a live birth, but in particular it is concerned with children born with irreparable, non-life-sustaining physical conditions, including congenital abnormalities or deformities.

These distinctions are not merely an academic exercise but rather a brief attempt to provide some working definitions for pre-hospital EMS staff in particular, in a field of medicine that is dynamic and constantly changing. At the time of writing in 1987, and within South Africa, it is considered ethically and practically acceptably acceptable to attempt to resuscitate a 27-week-old “baby”.

At the time of editing , a baby  of  24 or 25 weeks gestation , who weighs more than 500 grams may be considered for resuscitation. 

New attitudes in Obstetrics and neo-natalogy; new drugs and techniques, new modes of ventilation are all changing the parameters of pre-, and post-, natal care.

But its generally accepted that babies who are both extremely premature and extremely small, weighing less than 500grams,have a very low chance of surviving without severe disability.

And this book is no the place to discuss those issues.

Further, it is certainly a valid and realistic expectation of parents for their miscarried or aborted baby to be given a religious burial service.

A general note is that as far as is possible, the parents must always be offered or given a medical reason  or epidemiological explanation for the cause of the miscarriage, stillbirth or neo-natal death.

Sometimes , and  particularly in miscarriage its just not possible to offer a reason. 
I write this with caution, but it may be useful and helpful to put a particular miscarriage into context, by discussing the international statistics about  miscarriage with the parents, as part of the debriefing, if it is appropriate.

The statistics are presented simply as background information, but provides an opportunity to dispel some of the common myths ,which include issues like “I have weak eggs/my husband has weak sperm”.

So the interaction is not done from the viewpoint of “look how many other people there are in the same boat”. 
Rather its done from the viewpoint of “these are the number of women who have had  miscarriages and for which medical science is unable to provide an explanation. 
This does not mean that (a) there is something wrong with you or (b) that you won’t ever have a successful pregnancy. ”

Miscarriage is generally assumed to occur in some 15 – 20 % of pregnancies.And this number hasn’t really changed in the last 30 years.

It is no less painful to the parents than the death of an older baby or child. In fact, it often (subjectively and anecdotally) appears worse.

One father recalled, “We did everything right: good prenatal care, prepared childbirth with no drugs and we had a beautiful baby who died. 
No one ever told us that this could happen. 
It’s been over a year and I still don’t feel that the world is safe”.

Apart  from the psychological belief that ‘bonding’ can occur from the moment of “realization of conception”, there are as well actual physical events which cause the foetus to be internalised by the parents as a ‘baby’ and for them to start to view themselves as proto-parents, particularly in a first pregnancy.

The most obvious of these is the sonar or scan , that “allows the parents to see (and hear) their baby’s heartbeat as early as eight weeks and (as) a recognisable immature baby” a few weeks later. 
This “profoundly affects the couple’s awareness of the foetus in the first tri-mester, making subsequent miscarriage harder to deal with”.

And of course the parents are usually given a ‘hard copy’ photo of the sonar to take home and show their families and frequently put into their photo album.

As the foetus develops, there are of course the normal physiological changes that occur in pregnancy; the parents can feel the baby move; there are various social expectations from family and friends and so there develops a situation where the baby is very real and very alive and very much part of the proto-family

For the mother/parents/family who miscarries, there are numerous psychodynamic issues to consider and be aware of not least  (invalid) feelings  of guilt and inadequacy.

(Clearly these feelings exist with the death of older children as well, but they do seem particularly magnified in miscarriage and stillbirth.)

The mother for example who miscarries and is a single parent and who perhaps, however fleetingly once wished that she was not-pregnant, faces intense guilt and feelings that “her wish came true” coupled with the  'normal'  grief.

Parents often report that they feel as if they are being punished.

They are often unsure of what should warrant such punishment but will link it to some action from their past that they will think was “evil” or deserving of retribution by god.

Both the mother and father may feel unable to discuss their grief-firstly because they might believe that they contributed to the miscarriage in some way, for example by having sexual intercourse in the first tri-mester. Secondly they might  think that the “value” of their loss is not sufficient to warrant consideration and counselling.

When the counselling starts  it is always wise to check for a ‘larger than normal’ component of guilt in their grief, particularly manifesting as anger, particularly between each other.

Generally the counsellor would strive to ensure that any interaction between the parents and the various health professionals would be non-judgemental and non-blaming.

Acknowledge all of the parent’s feelings both spoken and hinted at; and give them time to raise any questions.

Acknowledge in an open manner that they might be experiencing guilt by starting the interaction with a phrase such as, “There are a lot of things we could talk about today. For example some mothers think that the miscarriage was their fault or wonder of they will ever be able to carry a baby to term”.

If there is an expression of guilt it is vital that both parents are counselled,  possibly separately and together, even if only one of them verbalises the feelings.

Remember that it is a couple that has suffered and that they have to interact and live together as a couple. 
Their relationship must be buttressed against the ravages of the death of their baby.

Stick to the simple biological facts when discussing the death. Consider working with as large and multi-disciplinary a group of carers  as possible including inter alia, their minister of religion;trusted family memebers or friends;self help organizations.

And ensure this particularly if they believe that they are being punished for some past indiscretion.

And of course, as always, give of your time and share your concern. 
Hold their hands, say a prayer with them if they ask, or simply be with them.

The truth is that they will do most of the grief work in their own time and space and frankly in their own heads and so you should use this as an opportunity to impart information to them to think about rather than as an opportunity for you to “cure” them.

Of course, as well as feelings of grief and guilt there may also be exaggerated feelings of inadequacy – ‘my body couldn’t support my child’. 
Or in the case of a physically deformed child, there is sometimes a sense that the parents have ‘bad genes”.

Again these feelings must be identified and dealt with so that mourning can be adequately begun.

Show the parents their baby, for they are indeed parents, and their baby, however deformed, is still their baby.

If he is markedly deformed cover the deformation with a blanket or nappy.

When showing the baby to the family, concentrate initially on those features that are normal.

Novak makes the point that “making parents aware  of the normal characteristics of their baby helps them lessen their guilt (over having produced an “imperfect” baby who then dies).

By seeing that they are capable of producing a virtually perfect infant, they don’t view themselves as failures a s child bearers”.

In addition, Kaplan “emphasis the importance of helping the (parents) face reality,” and insists that “even the painful experience of seeing their children is less painful to the parents than the fantasies (they) would continue to have without the benefit of a real experience.”

Cathcart too makes this point when she says that the      “available evidence suggests that most relatives do not regret seeing the body. 
It could be helpful if the Nurse asks first what the person expects to see. The fantasy can be confirmed or corrected.”

The issue is not that parents who do not want to see their child will be forced to do so; it is that parents who want to see the baby will be denied the opportunity, as sometimes happens , as “well-meaning” staff who think that they know better, simply bundle up the baby.

Again all the interactions must be non-judgemental and open-ended to allow the parents to communicate their fears and concerns so that they may be dealt with.

As a brief digression here, some thought needs to be given to deaths within a multiple-birth situation.

Simply, is the death of one child, one twin, one triplet easier to cope with because there is another child left over?

The short answer is “no”.

It is in fact often more difficult.

Ton-Johansen makes the point that “the dead twin may seem like a fantasy, while the mother is supposed to be grateful for the survivor. Every effort should be made to ensure that the parents have some experience of their dead baby. The dead and live babies can be photographed together, and the photos kept for the parents at a later stage. 
This helps to confirm the reality of the situation, facilitating the grieving process.”

Practically, the couple that go into hospital pregnant with twins expect to take two babies home. They prepare for two children, for example buying two cots and   a double pram.

And socially,twins and other multiple birth combinations, have a higher interest value, so more people will have been told about the pregnancy.

And of course,obviously, the surviving child is a constant daily reminder of the child who died. 
Some parents find this difficult to deal with and occasionally have been known to “blame” the surviving child, -at an unconscious level-, for the death of the other baby.

They attribute to the dead baby all the wonderful characteristics they perceive to be lacking in the survivor. The parents sometimes reject the survivor emotionally which may result in problems later in the relationship.

Whilst this happens only rarely, it is prudent to advise the parents that mixed feelings of grief and happiness, anger and joy are normal and natural. 
And that it is neither their fault nor the survivor’s fault that a baby died.