Perinatal loss 2010 review day 3


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  • Tears are normal. If this is too uncomfortable, please feel free to step out.
  • IE: teenager relieved, or grand multip relieved. Ambilence is normal in pregnancy, componded by grief now
  • Ectopic or tubal pregnancy, spontaneous abortion – ie miscarraige, late pregnancy loss, stillborn, vanishing twin, neonatal or newborn death
  • Other folks think they should be over this by now
  • Beginning to find meaning in life again Due date, delivery date, kindergarten, milestone of nieces, nephews close to their loss
  • If subsequent pregnancy when taking history, ask about other loss
  • Wants to make it “all better”, gets tired of listening
  • Autopsy viewed as desicration
  • Autopsy seen as desecration
  • Pregnancy is natural state – decreased PNC Even seizure like activity with grief – normal in their culture
  • Open ended questions, sometimes just your presence is enough Don’t be afraid of silence
  • If grandparent wasn’t allowed to grief prior loss, may want to spare child this pain
  • Perinatal loss 2010 review day 3

    1. 1. Perinatal Loss Sandy Warner RNC-OB, MSN Certified Perinatal Grief Counselor
    2. 2. Grief is a process, not an event <ul><li>When your parent dies, you’ve lost your past. </li></ul><ul><li>When your child dies, you’ve lost your future </li></ul>
    3. 3. Uniqueness of Perinatal Grief <ul><li>Mother and her partner feel like parents, but have no baby to parent </li></ul><ul><li>Their baby was not known to others </li></ul><ul><li>Taboo topic: sometimes hidden and not discussed </li></ul><ul><li>We can never know another’s grief </li></ul><ul><li>Caregivers need to know how bonded mom was to pregnancy </li></ul>
    4. 4. Frequency of Perinatal Loss <ul><li>Greater than 1 million pregnancy losses yearly in USA </li></ul><ul><li>25% of all conceptions end in 1 st trimester </li></ul><ul><li>Late losses occur 2-4% of pregnancies </li></ul><ul><li>Stillborn rate is 10.7% since 1990 </li></ul><ul><ul><li>African American stillborn rate is 20% </li></ul></ul><ul><ul><ul><ul><ul><li>(AWHONN, 2009) </li></ul></ul></ul></ul></ul>
    5. 5. History of Perinatal Grief <ul><li>1944 – first published work on grief by Lindeman (dealt with death from fire) </li></ul><ul><li>1962 – “Reaction of RNs with mothers of stillborns” Nursing Outlook </li></ul><ul><li>1969 – Kubler Ross’s work published </li></ul><ul><li>1976 – AJN and Contempory OB Gyn articles published </li></ul><ul><li>1984 – Davidson’s 4 phases of perinatal loss </li></ul><ul><li>1985 – ACOG and NAACOG positions statements </li></ul>
    6. 6. Perinatal Loss Definition <ul><li>Nonvoluntary end of pregnancy from conception, during pregnancy and up to 28 days of the newborn’s life </li></ul><ul><ul><ul><ul><li>(AWOHNN) </li></ul></ul></ul></ul><ul><li>Definitions vary from state to state with weight, gestational age etc. </li></ul><ul><ul><ul><ul><li>(AAP and ACOG) </li></ul></ul></ul></ul>
    7. 7. Davidson’s Four Phases of Bereavement <ul><li>Shock and numbness </li></ul><ul><ul><li>Duration – first two weeks </li></ul></ul><ul><ul><li>Characteristics: </li></ul></ul><ul><ul><ul><li>Short attention span </li></ul></ul></ul><ul><ul><ul><li>Difficulty concentrating </li></ul></ul></ul><ul><ul><ul><li>Impaired decision making </li></ul></ul></ul><ul><ul><ul><li>Denial </li></ul></ul></ul><ul><ul><ul><li>No concept of time </li></ul></ul></ul><ul><ul><ul><li>“Feels like a bad dream” </li></ul></ul></ul>
    8. 8. Shock and Numbness con’t. <ul><ul><li>Interventions: </li></ul></ul><ul><ul><ul><li>Allow for time </li></ul></ul></ul><ul><ul><ul><li>Repeat, repeat, repeat </li></ul></ul></ul><ul><ul><ul><li>Use simple terms </li></ul></ul></ul><ul><ul><ul><li>Help them to think through decisions </li></ul></ul></ul><ul><ul><ul><li>Discourage rapid decisions </li></ul></ul></ul>
    9. 9. Searching and Yearning <ul><li>Duration: 2 nd week – 4 th month </li></ul><ul><li>Characteristics: </li></ul><ul><ul><li>High energy </li></ul></ul><ul><ul><li>Anger/guilt/dreams </li></ul></ul><ul><ul><li>Weight loss or gain </li></ul></ul><ul><ul><li>Sleep difficulties </li></ul></ul><ul><ul><li>Aching arms, may hear baby crying </li></ul></ul><ul><ul><li>Headache, blurred vision, palpitations </li></ul></ul><ul><ul><li>Resentment </li></ul></ul>
    10. 10. Searching and Yearning Con’t. <ul><li>Interventions: </li></ul><ul><ul><li>Encourage support groups </li></ul></ul><ul><ul><li>Anticipatory guidance on normal process of characteristics </li></ul></ul>
    11. 11. Disorientation <ul><li>Duration: 5 th to 9 th month </li></ul><ul><li>Can last up to 24 months </li></ul><ul><li>Can also last 3-5 years for multiple pregnancy </li></ul><ul><li>Characteristics: </li></ul><ul><ul><li>Low energy </li></ul></ul><ul><ul><li>Thinks “I am going crazy” </li></ul></ul><ul><ul><li>Social Withdrawal </li></ul></ul><ul><ul><li>Disorganized </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Likely to loose support </li></ul></ul>
    12. 12. Disorientation Con’t. <ul><li>Interventions: </li></ul><ul><ul><li>Anticipatory guidance </li></ul></ul><ul><ul><li>Assurance </li></ul></ul><ul><ul><li>Support Group involvement </li></ul></ul>
    13. 13. Reorganization/resolution <ul><li>Duration: 19 th - 24 th month </li></ul><ul><li>Characteristics: </li></ul><ul><ul><li>Some good days, some bad days </li></ul></ul><ul><ul><li>Sense of relief </li></ul></ul><ul><ul><li>Renewed energy </li></ul></ul><ul><ul><li>Able to laugh and smile again </li></ul></ul><ul><ul><li>Milestones are bittersweet </li></ul></ul>
    14. 14. Reorganization/resolution <ul><li>Interventions: </li></ul><ul><ul><li>Be available to listen </li></ul></ul><ul><ul><li>Acknowledge baby’s presence </li></ul></ul><ul><ul><li>Use baby’s name in conversation </li></ul></ul><ul><ul><li>Remember important dates </li></ul></ul><ul><ul><li>Meaningful remembrances: </li></ul></ul><ul><ul><ul><li>Tree, rose bush, flowering plant etc </li></ul></ul></ul><ul><ul><ul><li>Donation to memorial fund </li></ul></ul></ul>
    15. 15. Men and Women Grieve differently <ul><li>Women: </li></ul><ul><ul><li>Body image issues </li></ul></ul><ul><ul><li>Emotional swings </li></ul></ul><ul><ul><li>Need to talk, cry </li></ul></ul><ul><ul><li>Increased dependency needs </li></ul></ul><ul><ul><li>Fear of intimacy, resuming sex </li></ul></ul><ul><ul><li>Jealously </li></ul></ul>
    16. 16. Differences in Gender Grief cont’ <ul><li>Men: </li></ul><ul><ul><li>Increase sense of responsibility </li></ul></ul><ul><ul><li>Withdrawal from partner/lack of communication </li></ul></ul><ul><ul><li>Financial worries </li></ul></ul><ul><ul><li>Physical symptoms </li></ul></ul><ul><ul><li>Sense of failure </li></ul></ul><ul><ul><li>Resentment of attention to partner </li></ul></ul><ul><ul><li>Difficulty dealing with tears </li></ul></ul><ul><ul><li>Need to “stay busy” </li></ul></ul>
    17. 17. Cultural Diversity <ul><li>Baptism is important for Catholics and other Christian religions </li></ul><ul><li>Muslims: see death as natural stage of life. May not want to view baby. Loud crying is discouraged. </li></ul><ul><li>Jewish: mourning rituals (family member stays with baby but not general viewing). Questionable if baby is named. No autopsy. </li></ul>
    18. 18. Cultural Diversity con’t. <ul><li>Native American: vary widely </li></ul><ul><ul><li>Focus on transition to afterlife </li></ul></ul><ul><ul><li>Ceremonies with food, possessions at gravesite. May leave body exposed. </li></ul></ul><ul><li>Amish: Simplistic lifestyle with large </li></ul><ul><ul><ul><ul><li>number of children. Loss of child is profound but viewed as God’s will . </li></ul></ul></ul></ul>
    19. 19. Cultural Diversity cont. <ul><li>Hispanic/Latino: females vocal with grief and may even shake </li></ul><ul><ul><li>Males are stoic and can appear uncaring but are deeply affected. </li></ul></ul><ul><ul><li>Mementoes and photos very important. </li></ul></ul><ul><ul><li>Respect caregivers </li></ul></ul><ul><ul><li>Usually family spokesperson – if caregiver establishes rapport, better outcome. </li></ul></ul>
    20. 20. Cultural Diversity Cont. <ul><li>African American: </li></ul><ul><ul><li>Variety of religious denominations </li></ul></ul><ul><ul><li>Strong spirituality and reliance on God </li></ul></ul><ul><ul><li>Prayer is common at bedside </li></ul></ul><ul><ul><li>Funeral delay until extended family present </li></ul></ul><ul><ul><li>Vocal grief acceptable </li></ul></ul><ul><ul><li>Importance of grandmother </li></ul></ul><ul><ul><li>Appreciate inclusion of family minister </li></ul></ul>
    21. 21. Self reflection for care giver <ul><li>Loss is profound experience and invokes own feelings of loss </li></ul><ul><li>Emotionally draining, review of past experiences </li></ul><ul><li>Need for staff support </li></ul><ul><li>Each nurse needs to examine their feelings as well, but not burden grieving family. </li></ul><ul><li>Tears are OK with grieving family </li></ul>
    22. 22. What to say: <ul><li>“I’m sorry.” </li></ul><ul><li>“I’m sad for you.” </li></ul><ul><li>“How are you doing with this?” </li></ul><ul><li>“This must be hard for you.” </li></ul><ul><li>What can I do for you?” </li></ul><ul><li>“I’m here, I want to listen.” </li></ul>
    23. 23. What NOT to say: <ul><li>“You’re young, you can have others.” </li></ul><ul><li>“You have an angel in Heaven.” </li></ul><ul><li>“This happened for the best.” </li></ul><ul><li>“Better for this to have happened now, before you knew the baby.” </li></ul><ul><li>“There was something wrong with the baby.” </li></ul><ul><li>Calling the baby “It” or “fetus” </li></ul>
    24. 24. Nursing Care <ul><li>Provide physical and psychological support </li></ul><ul><li>Refer to chaplain, grief support etc. </li></ul><ul><li>Include family members if appropriate </li></ul><ul><li>Photos, mementoes </li></ul><ul><li>Allow parents and family opportunity to hold infant and say goodbye. </li></ul><ul><li>Families see nurse as role model with baby. </li></ul>
    25. 25. Anticipatory guidance for discharge home <ul><li>Prepare them for the reaction of others. </li></ul><ul><li>Encourage offers of help from loved ones </li></ul><ul><li>Suggest a plan on how to inform friends. </li></ul><ul><li>Supply a few phrases: </li></ul><ul><ul><li>“ We’re not pregnant any more”. </li></ul></ul><ul><ul><li>“ Our baby has died. </li></ul></ul>
    26. 26. Sibling and grandparent grief <ul><li>Grandparents often don’t want mom to view baby. (taboo) </li></ul><ul><li>Siblings: </li></ul><ul><ul><li>Developmentally appropriate care </li></ul></ul><ul><ul><li>May want to see baby </li></ul></ul><ul><ul><li>Many books for children </li></ul></ul><ul><ul><li>Fear they themselves or parents might die </li></ul></ul><ul><ul><li>Relate to pet’s death sometimes easier </li></ul></ul><ul><ul><li>than baby. </li></ul></ul>
    27. 27. Subsequent Pregnancy <ul><li>Listen, talk and keep open communication. </li></ul><ul><li>Allay fears </li></ul><ul><li>Offer guidance about potential difference in “bonding” to next pregnancy </li></ul><ul><li>Try to make this birth experience </li></ul><ul><li> different from loss experience </li></ul><ul><ul><ul><li>Know your patient’s history </li></ul></ul></ul>
    28. 28. Resources <ul><li>Compassionate Friends – Illinois </li></ul><ul><li>Pregnancy and Loss Center – MN </li></ul><ul><li>Resolve through Sharing – WS </li></ul><ul><li>SHARE – Missouri </li></ul><ul><li>Richard Paul Evans – Angel Statue and memory walk </li></ul><ul><li>Local support groups </li></ul>