CME: Finding the right words after a pregnancy loss

March 1, 2009

Pregnancy loss bereavement counseling wasn't taught in medical school, leaving many ob/gyns struggling to find the right words in these tragic circumstances. An expert shares his 'algorithm' of skills and techniques to help patient's heal emotionally.

Chances are you've been down this road more than once:

A first-time mother with a normal antepartum course, with no risk factors, comes in at 37 weeks for her routine visit and you find no audible fetal heart tones or see no viability on ultrasound. How do you deliver the devastating news that her baby has died?

When a patient's pregnancy ends in miscarriage, stillbirth, or infant death, we struggle to find the right way to break the news, provide the appropriate medical or surgical treatment, and help her recover physically and emotionally. Unfortunately, most of us haven't been taught to provide such bereavement care. We quickly learn that there are hospital nurses, social workers, bereavement counselors, support groups, and clergy to whom we can refer our patients. So all too often, we do the D&C and we attend and assist in the birth of the baby who has died prior to delivery, but then, we refer.

My goal here is to share my own approach to bereavement care as we revisit our opening scenario and suggest words, gestures, and methods that can help comfort patients during these difficult times. Although the stillborn baby who might have been born viable is surely the greatest emotional and management challenge, we must recognize any loss in pregnancy as a life-altering event for our patients. That loss is poignantly expressed in the following unattributed lines:

"...The woman conceives. As a mother she is another person than the women without child. She carries the fruit of the night..in her body. Something grows. Something grows into her life that never again departs from it. She is a mother. She is and remains a mother even though her child dies, though all her children die. For at one time she carried the child under her heart. And it does not go out of her heart ever again. Not even when it is dead..." Anonymous

The ob/gyn as the link between the stillborn child and the grieving family

When I was a fellow in maternal and fetal medicine in 1976, one of the great challenges for perinatal obstetricians was to save the baby of an Rh-sensitized mother. The standard therapy-intra-uterine exchange transfusion-was quite dangerous. Observing babies die in these circumstances greatly affected the direction I subsequently took as a practicing obstetrician. I discovered that if I was proactive and involved in the bereavement that followed my patients' pregnancy losses, I didn't feel as nervous, awkward, or uncertain about talking to them about their losses. By immersing myself in their lives, in their losses, I learned to be part of their experiences, and that not only helped them recover emotionally; it helped me heal as I shared in their pain and grief.

Perinatal bereavement and pregnancy loss awareness movements began to spring up in the late 1970s. Organizations such as SHARE Pregnancy & Infant Loss Support, Inc. were founded on the realization that the birth and death of a stillborn baby evokes very powerful feelings. These organizations also realized that mourning, memorializing, ritualizing, and above all dignifying such a birth is a vital part of the healing process. Older physicians might recall how parents were sheltered from seeing their stillborn babies, who not only were seldom memorialized, but usually disposed of en masse in unmarked graves. Fortunately, this no longer occurs.

Obstetricians-particularly those in training programs-must understand how important our influence and presence is to our patients when they lose their babies. Yet we've been the last to embrace the idea of incorporating bereavement care into our curriculum and practice. The care of the patient experiencing a pregnancy loss is a paradigm for what we do as physicians. It tests not only our clinical skills and judgment; it stretches the fibers of the human aspect of caring very thin.

Although we might ask, "How can we heal when our patients' children are incurable, when they are suffering or when they die?" or "What do we do when the advanced technology that has become a part of our black bag fails," we must understand that we can heal by providing comfort, empathy, and hope. As bad as this experience is for our patients, we can make it better. If we remain aware that we are the link between the stillborn baby and the bereaved family, that we were the first to touch and hold their child, albeit their stillborn child, then we can share this with them, remember this with them, and from this point forward, heal with them. The bond we form becomes the unbreakable fiber that strengthens and indeed cements our role in the doctor-patient relationship.