Introduction
Pregnancy loss can be defined as the loss of the fetus and it may happen as a result of various reasons which may not relate to the actions of the mother or any other party. Pregnancy loss has four major faces which include; miscarriage, stillbirth, birth loss and medical termination. Miscarriage happens within the first 20 weeks of pregnancy with more happening in the first trimester. It results from genetic problems of the fetus which may inhibit the development of the fetus. However, miscarriage may result from ectopic pregnancy where conception takes place outside the uterus and the embryo starts to develop outside the uterus causing medical risks and thus calling for a medical termination.
In stillbirth, the pregnancy is lost during the last 20 weeks of the gestation period and the baby is born dead. Its cause depends on many reasons which may range from problems with the placenta to genetic conditions of the fetus. Birth loss refers to a situation where the baby is born alive but premature due to a medical problem with the mother. However, doctors have developed techniques to increase the rates of survival of the baby. In medical termination, the pregnancy is terminated for medical reasons, for instance, if the mother’s life is threatened by the continuation of the pregnancy and when the fetus has a genetic problem and the mother opt to terminate the pregnancy rather than having the baby (Cuisiner et al, 1996).
Despite the reason for the loss of the pregnancy, both the mother and the father and all those who were involved in the pregnancy suffer emotionally, physically and sometimes they may develop psychological problems; thus psychological and emotional support should be given to the parents.
Perinatal Grief
Grief can be termed as the emotional reaction of a loss shown by a person’s feelings through shock, numbness, anger, guilt, sadness or anxiety (Hughes & Riches, 2003). Mourning, grieving and bereavement can be used interchangeably where mourning means a process through which a person uses to deal with emotions and bereavement refers to a period during which a person overcomes the emotions. When a pregnancy is lost, both the mother and the father of the unborn child will experience grief and will whereby they will slowly accept and let go of the psychological ties with the baby.
The grief process or mourning process may be complex and may depend on previous pregnancy loss, previous childbirth occurrences, a span of gestation, maternal age among others; each person will have a different and unique way of dealing with the grief. Moreover, the cultural environment, for instance, avoiding talks related to the loss, avoiding morning publicly, avoiding participating in loss-related activities among others may impede loss adaptation (Leon, 1995). Perinatal grief has been associated with sadness, anxiety, eating disorders, obsessions with the lost baby, guilt shame among others to both parents (though women are regarded to morn more despite the stage of the loss).
The span and power of grief will highly depend on the time of development of the fetus and the emotional connection between the mother and the developing fetus. As the saying goes “time heals every word”, grief will cease as time passes by and greatly decline within the first year. Even though both parents grief for the loss of the pregnancy, the mother and the father will show different signs of grief; where the mother will show emotional and somatic agony and the father will show difficulty in working, drunkard ness, social abandonment and anxiety. Grieving for a lost baby differs from grieving for an older person in that, grieving for an older person involves a display of real memories shared with him or her while grieving for a lost baby or pregnancy involves the display of the attachment built on hopes and imagination of future together with the unborn child. Moreover, the loss of pregnancy is hasty, unseen and elusive; without a socially expressible entity (funeral, ritual) (Hughes et al, 2001).
The lack of social recognition may bring out the feeling of shame and guilt to the parents. In order to reduce the grief, many parents have opted to have another pregnancy that should be accompanied by successful birth which fills the gap that had been left by the lost pregnancy. However, there will be a relationship problem between the child born and the mother; thus it is advisable for the woman to take time to ensure emotional and physical healing prior to becoming pregnant again (Buckman, 1996).
Risk Factor for Complicated Grief
After the loss of the child, the parents may experience intense grieving which may go beyond one year and may affect the long-term performance of an individual. The possibility of having complicated grief can be detected from the poor psychological function of the parent prior to the loss. If a woman is suffering from mental illness, postpartum stress and disturbed personality, she is likely to suffer from complicated grief after the loss of her pregnancy. Moreover, lack of social support, problems in marriage, poor physical health, the feeling of uncertainty towards the pregnancy and barrenness may cause complicated grief in case of loss of a pregnancy.
To add to this, medical history such as hypertension, cancer, blood disorder; interventions to attain and maintain pregnancy such as extended bed rest as well as the age of the mother, for instance, old women who may be approaching menopause and young women who do not have resources and support, may make grieving far much difficult (Turton & Hughes, 2002). Other outside problems such as monetary crises, unemployment, and the death of another family member may also affect the grieving process. Thus a physician who helps pregnant women should make sure that he or she has the patient’s mental functioning and psychiatric history which will help him in treating the complicated grief in case of the loss of the pregnancy.
Interventions
After the perinatal loss, the nurses and physicians guide the patient through the grieving news; however, the help may affect the emotional and physical recovery of the patient either positively or negatively. When helping a patient with perinatal loss the initial focus is on the medical and physical well-being of the woman but as time passes emotional needs of both parents are looked at. Interventions usually begin when a setback has been identified and runs through to ensure that the news has been delivered and the patient is starting to recover. Baile et all (2000) developed a six steps approach to delivering bad news to the patient called SPIKES. These steps include:
Setting; in the setting, the physician should ensure that there is seclusion when talking to the patient. The physician should choose a room or a place where he or she can talk to the patient in privacy. When a physician identifies a setback while examining the patient, he or she should ensure that the patient gets dressed first before telling her the news. For instance, when a physician sees bleeding during pregnancy and thus a possibility of miscarriage, he should first let the patient get dressed.
Perception; the physician should try and get information about how many details the patient knows on the issue. He or she should also try and get information on how much the patient understands the problem, how complex the problem is and the emotional state of the patient.
Invitation; the physician should also try to know how much the patient may want to hear on the identified problem. This is because some patients prefer having an overview of the entire problem while others may want to have the problem broken down into o various parts and they be explained in detail.
Knowledge; the physician should warn the patient that he is about to deliver bad news and this he should do in bits to allow the patient to synthesize and ask questions concerning the problem.
Empathy; the physician should try and respond to the patient’s feelings and try to make them appear to be ordinary. For instance, he can ask the patient how she feels about the problem (medical termination of pregnancy).
Strategy/ Summary; after delivering the news to the patient, the physician should provide a plan on the way forward and ensure the patient that he/she will support her through the plan. The physician should also provide an outline on how follow-ups will be done, how the patient can contact him or her or any other person who can provide the required care to the patient.
When communicating the problem or the information to the patient, simple words should be used and the physician should avoid medical or gynecological words that may have a negative effect on the patient. The main objective of the intervention is to help the patient have positive grief. This can be achieved by following the COPE protocol which involves;
Communication
When a patient loss her pregnancy effective communication should be done to help the patient recover, however, it may become difficult for the physician and the caregiver as they may show emotional reactions to the situation. The physician or the caregiver may feel helpless, guilt, incompetent and sadness which may impede the ability of the caregiver to assist the patient. The caregiver therefore should avoid idealizing and recalling about loss and try to internalize and rationalize their actions which will help them overcome the misery they may be feeling. This will assist them in helping the patient and count themselves as more competent.
The caregivers’ words during the grieving period are important and portray authority; furthermore, they are recalled by the patient throughout the grieving period. Medical malpractices during the perinatal loss may result from inadequate and insensitive communication with the grieving couple. However, warm and soothing words from the medical practitioner may lead to fast healing of the patient, for instance, crying may help form a bond between the patient and the caregiver and this bond assists in legitimizing the patients’ grief.
In some cases the patient may turn to the caregiver and blame them for the loss of pregnancy; this may happen if the patient is feeling helpless and without strength. The caregiver, therefore, should not stop the patient or try to defend him or herself but should understand that the blame has been attributed to the feeling of vulnerability and anguish (Hughes et al, 2001).
Options
When a physician is working on the patient, he should ensure that patients have various choices of decisions and interventions thus promoting a connection and increasing the patients’ sense of control. In presenting the options, the physician should allow for guidance and time to consider each decision. The physician should provide the patient with encouraging real interventions that allow one to accept the loss and mourn in a healthy manner. The options may include; choices on induction, delivery, whether to wait for the loss or to medically terminate the pregnancy, having a support person instantly, taking photos of the fetus among others (Buckman, 1992). The physician should also provide information on the various options provided so that the patient can know what to expect from each option.
Physical Support and Emotional Support
Physicians should ensure that they are physically present to the patient after a perinatal loss as this helps the patient heal and recover fast. When the patient is in the hospital, the physician should ensure that the needs of the patient are met, for instance, allowing her visitor to extend during visiting hours, allowing the father to visit more often among others. Moreover, the staff tending to the deceased baby’s body should do it with concern and respect.
During discharge, the patient should be provided with dates for follow-up and the contact of the physician. However, in some cases, a call by the physician or follow-up visit to the physician may awake the emotion again resulting in the woman grieving all over again. Patients who have lost their pregnancy may lose interest in self-care and thus the physician should recommend regular exercise and good diet, socialization, sexual intimacy among others so the patient is relieved from the pressure and grief (Leon, 1995).
Emotional support should be provided prior to, through and after perinatal loss. Even though it is the woman who has lost the pregnancy, both parents should be given emotional support. However, the fathers are many times left out and thus they should be included in every conversation concerning the care, follow up and grief tutorial. The physicians should ensure that they tell the parent the cause of the perinatal loss in a sensible manner and in simple terms.
All grief tutorials should be given orally and in written material; this information should be given piecemeal and should be reintroduced at every follow-up meeting. The parents may also be advised to attend perinatal loss groups that will help in emotional support. Parents who show mental problems should be referred to mental hospitals soon to avoid any complications.
Conclusion
Losing a child during pregnancy or soon after delivery is a tough moment for both the parent and the physicians. Both the physician and the parents suffer from grief but the physician should ensure that he comes out of the grief soon so he or she can help the parents. Grieving may be complicated and maybe portrayed in different ways to both the father and the mother of the baby. Any intervention during the time of grief affects the span and the intensity of grief to both parents. When helping the patients COPE with grief, the physician should ensure effective communication and provide options for decisions (Balle, et al 2000). The physician should also ensure that the parents get physical and emotional support from the medical staff, perinatal loss groups and grief tutorials.
References
Hughes, P., Turton, p., Hopper, E., McGauley, G. & Fonagy, P. (2001), Disorganised Attachment Behavior among Infants Born Subsequent Stillbirth. Journal in Child Psychology Psychiatry. Vol 42; 791-801.
Leon, I. G. (1995). Helping families cope with Perinatal loss. Lippincott.
Balle, W.R., Buckman R., Lenzi, R, et al (2000), SPIKES: A six- Step Protocol for Delivering Bad News- application to the Patients with Cancer. Oncologist.
Buckman, R. (1992), A Guide for Health Care Profession. Baltimore: John Hopkins.
Turton, P. & Hughes, P. (2002), Post-Traumatic Stress Disorder and Management of Stillbirth. British Journal of Psychiatry. Vol 42: 180-279.
Cuisiner, M., Jenssen, H., Baker, S et al (1996), Pregnancy following Miscarriage: Cause of Grief and Determining Factor.
Hughes, P & Riches, S. (2003), Psychologies Aspect of Perinatal Loss. Journal on Obstetrics Gynecology. Vol 23.