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Grief support in hospital after prenatal and perinatal loss event

1. Grief: definition of the term

Grief refers to the affective, psychological, and physiological reactions to the loss of an emotionally important figure and typically includes severe and prolonged distress. People in grief are depressed, despairing, dejected, angry, and hostile. Behaviourally, they tend to act agitated and fatigued, cry spontaneously, and are socially withdrawn. Cognitively, they are preoccupied, with thoughts of the deceased, have negative self-judgments, feel hopeless and helpless, have a sense of unreality, and experience memory and concentration problems.
    According to attachment theory, grief is a natural product of an individual’s continuing attempt to foster proximity with the object of attachment and minimize separation from him or her. Initially, there are energetic reactions to the absence of proximity after a loss composed of searching and protest and, subsequently, passive responses suggesting the beginning of process of disengagement from the attachment figure. There are initial stage of numbness and disbelief, followed by a stage of separation distress during which yearning for the deceased is primary, then a period of sadness and despair, and a concluding phase of recovery and reorganization. (Brier Norman, 2008)

2. Stages of grief

Also known as the 'grief cycle', it is important to bear in mind that Kubler-Ross (5) did not intend this to be a rigid series of sequential or uniformly timed steps. It's not a process as such it's a model or a framework. People do not always experience all of the five 'grief cycle' stages. Some stages might be revisited. Some stages might not be experienced at all.

    Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. It's a defense mechanism and perfectly natural. Some people can become locked in this stage when dealing with a traumatic change that can be ignored. Death of course is not particularly easy to avoid or evade indefinitely. When person is in denial, he (she) may respond at first by being paralyzed with shock or blanketed with numbness. It is still not denial of the actual death, even though someone may be saying, “I can not believe”. They are saying this first of all because it is too much for their psyche. Denial helps to unconsciously manage their feelings. This first stage of grieving helps them to cope and make survival possibility. These felling are important; they are psyche’s protective mechanism. To fully believe at this stage would be too much. The denial often comes in the form of questioning reality: Is it true? Did it really happen? Asdenial fades, it is slowly replaced with the reality of the loss. (Kubler-Ross, E, Kessler D, 2005)

    Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. Knowing this helps keep detached and non-judgmental when experiencing the anger of someone who is very upset. This stage present itself in many ways: anger at who person lost, anger at person did not take better care of whom has lost or anger at the doctor or nurse who could be able to be more attentive or kind, may be angry that bad things could happen to someone who meant so much to the person. Anger is a necessary stage of the healing process. More the person truly feels anger, the more it will begin to dissipate and he (she) more will be heals. Anger is pain, grieving person’s pain. It is natural to feel deserted and abandoned, but we are live in society that fears anger. Some people may feel grieving person’s anger is harsh or too much. But grieving person’s job is firs of all to allowing themselves to be angry even scream if they needs. Anger can be an anchor, giving temporary structure to the nothingness of loss. Anger means the grieving person are progressing and should not be criticized by anyone. (Kubler-Ross, E, Kessler D, 2005) There are some situation when anger are getting endless, then person should think how to deal with “permanent anger”.

    Traditionally the bargaining stage for people facing death can involve attempting to bargain with whatever God the person believes in. People facing less serious trauma can bargain or seek to negotiate a compromise. For example "Can we still be friends?.." when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it's a matter of life or death. “I will never hate my morning sickness again if my pregnancy, my baby will just back to me”. Guilt is often bargaining’s companion. The “if only” cause the person to find fault with him(her)self and what he (she) could has done differently. Bargaining can help grieving person’s mind move from one stage of loss to another; fills the gaps that strong emotions generally dominate, with often keep suffering at a distance. (Kubler-Ross, E, Kessler D, 2005) 

    Also referred to as a preparatory grieving. In a way it's the dress rehearsal or the practice run for the 'aftermath' although this stage means different things depending on whom it involves. It's a sort of acceptance with emotional attachment. It's natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality. This depression is not a sign of mental illness, it is the appropriate response to a great loss. In grief, depression is a way for nature to keep the person protected by shutting down the nervous system so that he (she) can adapt to something they feel they cannot handle. (Kubler-Ross, E, Kessler D, 2005)

    Again this stage definitely varies according to the person's situation, although broadly it is an indication that there is some emotional detachment and objectivity. People dying can enter this stage a long time before the people they leave behind, who must necessarily pass through their own individual stages of dealing with the grief. Acceptance is not of being all right or okay with what has happened. This stage is about accepting the reality that the person’s loved one is physically gone and recognizing that new reality is the permanent reality. Finding acceptance may be just having more good days than bad. As the grieving person is begun to live again and enjoy the life, he (she) often feel that is betraying their loved one. The person who lost can never replace what has been lost, but can make a new connection, new meaningful relationships. (Kubler-Ross, E, Kessler D, 2005). See more.

Another classification is knows as "The 7 Stages of Grief": Shock and denial, Pain and guilt, Anger and bargaining, Depression, reflection loneliness, The upward turn, Reconstruction and working through Acceptance and hope.
There are some features of grieving after a pregnancy loss.

3. Baby loss grief: what is particular?

What is a pregnancy loss?

    Pregnancy loss is all-inclusive. It is early first trimester miscarriages, ectopic pregnancies, second trimester genetic termination and natural losses, the demise of one baby in a multiple gestation, a full-term stillborn, the death of baby soon after it is born (Michael R. Berman, 2001). Also ”perinatal death” is used to refer to fetal death in the second and third trimesters as well as “neonatal deaths” occurring in the first 28 days after birth. (Gold Katherine, Dalton Vanessa, Schwenk Thomas, 2007)

    Initially, a sense of shock and unreality is described, following by feeling of confusion over the sudden disappearance of a maternal role, and disappointment over the loss of anticipated future. The intensity of grief is described as similar to the intensity of grief individuals experience after other types of significant losses, such as that of family member. Also described are symptoms of stress, sadness, depression, guilt, and self-blame. (Brier Norman, 2008)

How long does grief endure following a miscarriage?

    For the major of women after early miscarriage is 6 - 7 month (PGS), 6 - 12 months (MGS), 3 - 6 month (PGIS). Grief levels in women who became pregnant following a miscarriage are significantly lower than grief levels of women who had not become pregnant. (Brier Norman, 2008)

Term of grieving usually depends on a stage of gestation, age of woman and her previous pregnancy history. Grief after miscarriage on early stage of gestation about 7 weeks (the time of heartbeat registration by ultrasonic examination) takes 3 - 4 months in average. Miscarriage on 12 - 21 weeks of gestation persists about 6 - 12 months. Following miscarriage grieving can be over 2 - 3 years long if the woman is over 40 years old or (and) had experience of pregnancy loss before or a long term of infertility treatment. Such factors as being under psychological pressure by family if pregnancy does not occur expected soon after marriage also leads woman to stay in high level of grief for years.

4. Social aspects of pregnancy lost

In Japanese medical language a stillborn infant named 死産(しざん, shizan) what literally means: “a delivery of dead baby”. Then social active group of parents who lost their infant have created a new word: 誕生死(たんじょうし, tanjoushi), what could be translate as “a birth of baby who dead”, what sound softly and less psychologically traumatic. This approach is realiy helps to parents to cope with their loss.

5. Advises for a caregivers

During our practice gradually we have learnd to care on stillborn infant the same way as it was a newborn alive baby. We use to make an effort to organize for the mother and the family condition to meet their stillborn baby what should consolidate the family even they are parents of stillborn child. We expected that the meeting of mother and her stillborn baby will help her to remove out of mind the scary image how ugly her dead baby could be. We were hoped this is a benefit of the meeting of mother and her stillborn infant, but in reality consequences were different from our expectations.

However this approach could not change the mother’s inner feeling. In most of cases the mother obtains more traumatic impression from this meeting. Furthermore most of mothers rejected of possibility to see her stillborn baby when doctor  was offering this. The reason of such situation straightly connected to the way of when and how to delivery the bad news.

Breaking bad news
    Breaking bad news is difficult and stressful. Parent had only bad memories if the information was given badly, if the person giving it seemed not to understand the significance of what he or she was saying or was not supportive. Bad news given insensitively can affect parent’s long-term well-being. Phrases such as: "I am afraid it is bad news…”, “I am sorry to say that the result are not what we expected… , “I am afraid this is not the news you wanted…” may be helpful. (Alix Henley, Judith Schott, 2008)

Pregnant woman naturally has a beautiful image of the baby what she is carrying inside. She began to think about how he or she looks like from early stage of pregnancy and sudden dramatic news turns this “picture of an angel” to image of “an ugly ghost”. Rejection of meeting the stillborn baby is nothing but desire to keep her own mental image about how baby suppose to looks and a fear to crush on scary reality.

The best way to delivery the breaking news is to do it gradually. The mother needs a time to accept the fact of loss. There is should be an intermediate stage © to turn mother’s felling from “I am going to be happy mother” to “I have lost my baby” via “I am carrying My baby regardless alive or dead”. Then she will be ready to see her baby and naturally pass her loss over. 

Otherwise the mother who did not accepted the bad outcome of her pregnancy will be shocked and reject a chance to meet stillborn baby or will accept the offer to see and will suffer more as result of unexpectedly new image of her baby. Finally her grief will be much longer with, probably strong anger reaction and deep depression stage.

Unfortunately in standard practice, physicians rush to terminate this process. There are several reasons: first of all, the cause of rapid termination of unfortunate pregnancy is they do not want to take a risk to aggravate the situation with mother’s health condition such as DIC syndrome and similar consequences of carrying in the dead fetus. Even thiese rare occur in a medical practice, most of hospitals keep this traditional approach. 

Another reason is no one in the hospital wants to deal with family’s aggressive reaction as response on sudden bad news. So , they want to finish this process as soon as it is possible before the patient’s relatives will start to handle of the event.

Creating memories
    If the baby miscarried or was stillborn, the parents have never seen their baby alive, and in early pregnancy loss there may no body. Many parents are too shocked and distressed to think about creating mementoes at the time of the loss, especially if it is sudden and unexpected. Most are very grateful afterwards to staff who suggested that they might want to create or collect mementoes of their baby and who have helped them. (Alix Henley, Judith Schott, 2008)

Grief is natural and expectable reaction on a loss. The extend of grieving and duration of each stage of grief depends on many factors such as age of mother, her life history and family relations, national traditionals and faiths, there are given and could not be change, but must to be taken notice. Also there is one factor what strongly depends on a medical staff professional approach: a proper care on family who lost their infant and also their big hope to be a parents in the nearest future. 

The unexpected tragic event keeps family members in numbness condition for a while. Then, naturally, arises an active stage of grieve: anger. This is not logical, but high emotional stage of grief and as a most expectable target of the anger would be, first of all, the medical team what provided of care on the mother who lost her baby.

Crucially for medical staffs at this time is to deal with grieving parents in an appropriate way for avoiding the causeless lawsuit between the parents who lost their infant and innocent medical staff who have done everything what due to be done in the situation of unexpected pregnancy result. 

There are several rules that should be followed during care on parents. 

First of all, at the time when obstetrical pathology has been diagnosed a rapidly medical termination of pregnancy should not be insisted. Usually that suggestion makes the parents to feel there were some mistakes made by medical staffs and now they in hurry to cover its by pregnancy termination procedure .

Doctor has to explain than died baby inside of her does not make any effect on mother health condition and give her time to accept the tragic fact. 

In stillbirth case a dead infant should be treated in the same way as alive newborn baby what support mother and father become the parents as they expected during all pregnancy term until obtain the disaster news. Otherwise they have feeling sort of cheating on them by the medical staff.

The parents should know the truth but they ready to listen not right soon after the loss event. Following shock and numbness arise high emotional anger stage when no any logical explanation and important information able to rich of parents emotionally unclean consciousness. Medical staffs need to be tolerant and let the patients to spill out of their anger, show up their sad feeling; even it is naturally undesirable for the doctors and nurses. Then after the emotional stage gone, a readiness to accept of the logical explanation will come. At that time the parents and medical staff can communicate effectively what leads to avoid a lawsuit at all and furthermore to mutual support in the grief. Important: do not try to explain anything before the emotional stage past away.

Undoubtedly to provide that professional care takes a lot off emotional but necessary as a self-protection way counter to a major medical staff fears: “Maybe I have done wrong?” and ”What will start from now with parent’s reactions and actions?”; and guilty “I could be more confidence and diagnosed it earlier”. There are some ways how medical staffs cope with their feeling after the loss event.

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