Management of Patient for Emotional Trauma of Perinatal Death, in <b>Collected Letters</b> of The International Correspondence Society of Obstetricans and Gynecologists, Kellner, KR(ED), Contributing Authors: Emanuel Lewis, MD, Elizabeth Kirkley Best PhD, Glen Davidson, PhD,Catherine LaRoche, MD, John M. Astrachan, MD, and Rev. Thomas Van Eerden.

FROM: JOHN M. ASTRACHAN, MD, New York, NY ( Associate Clinical Professor of Psychiatry in Obstetrics/Gynecology , New York Hospital-Cornell Medical Center)

There are three essential things a physician encountering this important clinical situation must do:

1. establish a strong physician/patient relationship before the perinatal death;

2. facilitate the expression of normal grief (what is felt or experienced) and mourning ( the processes involved) in the patient; and

3. Identify and manage abnormal mourning in the patient if it should occur. A strong physician/patient relationship is the cornerstone of all good medical care, and all physicians have individual ways to effectively work with patients. In preparing for these tragic events, the wise physician will additionally help himself assess the coping capacity of the patient by making tactful inquiry into her physical and psychological health, her feelings about this pregnancy, about this time in her life, and her past management of losses. A perinatal death is an enormous stress for patient and physician. For the patient, it has intense pathogenic potential in terms of the high frequency of subsequent abnormal mourning reactions. There are few more difficult tasks for the physician. More often than not his strong feelings when around these situations will militate for his withdrawal from his patients when he is most needed. If the physician can keep this in mind and try to overcome it as best he can, and is familiar with the characteristics of normal grief and mourning, he will be in the position to help facilitate normal grief and mourning in his patients. The following suggestions have been found useful:

1. When breaking the sad news, the physician should clearly and compassionately announce the facts of the death without the use of clichés. If possible, give the news where the patient and persons close to her can express their feelings openly. Authentic feelings on the part of the physician may also be expressed.

2. The physician should make himself readily available for answering questions about the death, and should be prepared for strong feelings being expressed by the patient and her family: anger, disappointment, shock, and great sadness. Other children in the patient's family should not be left alone in this situation and the parents should be encouraged by the physician to discuss this situation with them.

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3. The physician should tactfully encourage the patient to see, name and help in the planning for the funeral of the child. A further opportunity for discussion and cousneing presents itself if there is an autopsy, and should be used by the physician with an eye toward mitigation of any guilt in the family. He may also sympathetically convery what the parents might expect in terms of symptoms of grief and insure that any physical discomfort on their part is properly managed.

4. An appointment should be made for an office visit in two to three months, six months, and one year, so discussions and counseling may continue and the physician can maintain his observation of his patient. If the issue of another pregnancy is discussed, the physician should suggest that mourning be completed before beginning another pregnancy. During these regular visits with patient in the period of her mourning, physician should note any evidence of psychotic behavior, significant depression, the appearance of psychosomatic complaints, radical alterations in interpersonal relationships, i.e. marital conflict, evidence of drug abuse or other self-destructive behaviors, or the reappearance of past psychiatric symptoms. The management of these evidences of abnormal mourning may be conducted by the practitioner, depending on his familiarity with such conditions. In most of the above instances psychiatric consultation is indicated. If there is any question as to the advisability of referral, discussion between the primary physician and his consultant will help resolve the issue.

FROM: ELIZABETH KIRKLEY-BEST, PhD, Gainesville, FL (Adjunct Assistant Professor, Department of Psychology, University of Florida) When discussing the emotional trauma of perinatal death, it is necessary to realize the trauma spoken of is grief ---and nothing less. Several studies and reviews of the psychology of perinatal bereavement have noted the strking sameness of grief at perinatal loss and grief at the death of any loved person. 1-5 While the concept of prenatal maternal attachment has received little attention outside of psychoanalytic interpretations, it appears through recent work that a very deep emotional bond between mother and child forms during pregnancy and that any disruption of that earliest of relationships can have devastating consequences for mothers and their families. It has been recently found that while all loss in pregnancy produces---or can produce---a lasting grief, the intensity of grief steadily increases across time in pregnancy , based on blindly -rated interviews of mothrs experiencing perinatal death when interviewed at one month, postpartum. 6

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Once we recognize the nature and intensity of perinatal bereavement, we proceed to aid parents by supporting them in their struggle with a difficult grief. Grief is perhaps the most frustrating of interpersonal situations. The grieving parent experiences too much emotional pain to reach out for support. The caretaker, friend, or relative wants very much to alleviate the suffering felt by a parent, and yet there is nothing that can be said or done to allay the pain. Grief presents the epitome of helplessness and hopelessness for both bereaved parents and those who seek to comfort them. For this reason the most effective interventions for parents experiencing perinatal death involve active listing, a legitimizing of the grief parents experience over the death of their son or daughter, an assurance of the normal nature of their grief, and the representation and facilitation of choices that parents must make surrounding the baby's death. We know from past research that seeing and holding the baby, receiving and keeping mementos of the infant, receiving autopsy information and participating in ceremony surrounding perinatal death, are extremely important. We have evidence now that the most critical factor in adjustment, however, may be that the parents have no regrets about their decisions. 7 The possibility of wise choices should be discussed with parents and their wishes should be respected and supported, even when they are different from what we as professional thing are best. In creased communication an support will allow parents to keep open vital lines of emotional support and work through the profound grief that perinatal death incurs.

References:
1. Kennell JL, Slyter H. Klaus M: The mourning response of parents ot the death of a newborn infant. New Engl J Med 283:344, 1970.
2. Peppers L., Knapp R: Motherhood and Mourning. New York, Praeger, 1980.
3. Borg S, Lasker, J: When Pregnancy Fails: Families Coping with Miscarriage. Stillbirth and Neonatal Death. Boston, Beacon Press, 1981.
4. Berezin N: After a Loss in Pregnancy. New York, Simon and Schuster, 1982.
5. Kirkley-Best E. Kellner KR: The forgotten grief: A review of the psychology of stillbirth. Am J of Orthopsychiat 1982 (in press). *See note
6. Kirkley-Best E. Grief at prenatal loss: An argument for the earliest maternal attachment. Dissertation Abstracts International, University of Florida, 1981 (in press.) *See note
7. Kirkley-Best E: Cremation, burial and memorial services: Choices of mothers experiencing prenatal death II: Implications for caretakers. Presented to the Fourth Annual Conference of the National Forum for Death Education and Counseling, Cambridge, MA 1981.

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FROM: EMANUEL LEWIS, MD London, England ( Consultant Psychotherapist, Charing Cross Hospital and Tavistock Clinic) A stillbirth is a nonevent in which there is intense anxiety, guilt and shame, yet with no tangible person to mourn. It is an empty tragedy that takes place at a bewildering interface of life and death. There is a painful emptiness that is difficult to talk or think about. Mourning involves thinking and feeling about the death baby and as a death without a body seems unreal an experience of the body of the stillborn baby helps the process of mourning. To facilitate morning I recommend that a stillbirth be managed by making the most of what is available to be remembered. The aim is to make memories that can be though about and shared with others. The bereaved parents should be encouraged to look at and hold their dead baby at delivery. They may wish to repeat this looking and holding later. Naming the baby helps give it an identity within the family. A photograph of the dead baby is a vital aid to fading memories. It is also easier to show a photograph of the stillbirth to siblings rather than the actual dead baby. A postmortem examination an d X-ray will assist with genetic counseling and also serves as a focus to help physicians talk with the parents about their grief. Avoiding a conspiracy of silence by talking to the mother about her stillborn helps overcome the anxiety, guilt and shame that impede mourning. The family should attend the funeral and the baby should have a marked space or grave. Pamphlets and books are available to assist the bereaved parents. It can be helpful to put the parents in touch with a local stillbirth group. The will also benefit form expert counseling. The bereaved should be advised against a quick replacement pregnancy. Mourning takes time and pregnancy tends to impede the mourning process. The bereaved mother and her physician need to be aware that the mothering of a subsequent live baby can be fraught with memories. The mother needs help in understanding her bewilderment when her delight at the new live baby is marred by painful and distressing memories about her stillborn. A mother's ideas and feelings about her live and dead babies can get muddled: she will need help in separating them out. FROM: REV. THOMAS VAN EERDEN, Grand Haven, MI, (Pastor-Counselor, Calvin Christian Reformed Church, Muskegon, MI) If fetal and neonatal development is considered as part of a continuum that begins at conception (as I believe it does) then it follows that abortion (medical or self-induced) is the killing of a human life. With the above as my own premise, it might be well for me to give a brief resume how I, as a pastor, dealt with a "stillborn" child. This was a full-term pregnancy. Both parents were terribly shocked when told of the little girl's death. She was the third child born to this 35-year-old couple. They had two older---five and eight-year-old sons. The father called me immediately after hearing the news and I rushed to the hospital. I entered the room of this grief-stricken, weeping couple. At the mother's request, the little body was placed in the mother's arms.

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I prayed with them at this time and afterwards the nurse carried the baby to the waiting mortician. Because of the mother's difficult delivery she was unable to leave the hospital for several days. It was decided therefore, to have a graveside service the later part of the a\same afternoon. Upon our arrival at the cemetery a most touching thing happened. The mortician opened the door of the car and the father said, "This is our baby, would you mind if I carried it to the grave?" With tears in the eyes of both the mortician and myself, we watched the father carrying the casket to the grave. At the graveside we had a brief committal service consisting of a few verses from Mark 10:13-14---a few words expressing God's love for little children, and His concern for the mourning parents. The three of us then left the graveside in silence. After the graveside service, I returned to the hospital and explained in detail the entire service. Mother and I prayed together for comfort and guidance from our Heavenly Father. The mother---although her eyes were filled with tears---seemed extremely comforted. When the mother was released from the hospital, I visited her several times in her home until I though the mourning processes were well under control.

FROM: CATHERINE LaROCHE, MD, Montreal, Quebec, Canada (Department of Psychiatry, Allan Memorial Institute)

To help offset the high incidence of pathological emotional sequalae to perinatal death it is important to recognize the impact of such a loss-not only for the mother and her immediate family, but also for the professional-treatment staff. Like parents who want and lose a child, the staff must also cope with feelings of sadness, emptiness, a sense of failure, anger, and guilt. An increasing number of centers recognize the importance of a multi-disciplinary team-approach in sensitizing and promoting staff-support systems and in teaching effective techniques for working with bereaved families. These teams can provide crisis-intervention interviews with parents that facilitate the grief process, encourage communication between husband and wife, parents and medical staff. The parents should be offered unlimited visiting privileges and a choice of remaining on the obstetrical unit. They should also be given as much time as possible to decide: (1) whether to see and touch the baby, (2) the method of disposal of the body, (3) the choice of funeral service, and (4) autopsy. Bereaved parents may also be helped by literature and self-help groups. Photographs and footprints of the infant are often highly valued. Follow-up interviews are useful in monitoring grieving and in discussing autopsy findings. Studies have reported some of the parents who are at highest risk of developing pathological grief reactions. These include

(1) mothers with a surviving twin or subsequent pregnancy less than five months after the baby's death,
(2) mothers who strongly desired to have a baby,
(3) patients with a previous psychiatric history who fail to see their infants, And
(4) those who have communication problems with the baby's father.

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REFERENCE: La Roche C. Lalinec M, Fuller N, et al." Grief reaction to perinatal death: An exploratory study. Psychosomatics 23:510, 1982.

FROM: GLEN W. DAVIDSON, PhD Springfield, IL (Chairman, Department of Medical Humanities, Professor of Psychiatry, Chief of Thanatology, Southern Illinois University School of Medicine)

The clinical goal for helping a patient face perinatal death is to foster adaptation skills. The women who seem to adapt best to perinatal loss are those: (1) who receive repeated show of concern for their well-being from the physician and nurses (many newly bereaved mothers report that they feel abandoned by their obstetrician); (2) who were involved with decision-making as early, and as completely, as possible following their loss; (3) who were given the opportunity to perceptually confirm the birth of their baby either through viewing or holding the body; (4) who have some artifacts to refer to during their bereavement, i.e. pictures of the body, a lock of hair , the blanket used to first wrap the body; (5) who have a supportive, not oppressive, spouse,; and (6) who have a continuing strong group-relationship based on trust and open discussion. Clinical assessment is basic and needs to be repeated frequently during the first days following loss, and again during the fourth month after the loss. Expressions of emotional trauma take many forms---from stoic silence to histrionic behavior. No specific expression is very reliable on which to base an assessment. Major error in clinical judgment is common if interventions are based on momentary exposure to a patient's emotional reactions. Five factors seem to be appropriate for prognostic assessment:

1. Is the patient a regular participant in a group (family, close friends, secular or religious organizations) that allows the couple to talk about their experience rather than trying to distract them from their loss?
2. Are the mourners careful about nutritional balance---or during the pregnancy did the patient have difficulty complying with weight-control advice?
3. Do the mourners have adequate fluid intake (exclusive of caffeine or alcohol-cased liquids)?
4. Are both of the couple physically active as opposed to being primarily sedentary?
5. Do the mourners get adequate rest or do they tend to over-extend themselves?

Mourners who have difficulty with these five factors (particularly the first three) prior to their loss are the most likely candidates for

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pathological reactions, both physically and emotionally, after the loss. Crying or not crying, anorexia or hearty eating, being busy or depressed, are not reliable prognastic indicators for adpatation.

The first assessment factor----involvement in a supportive group---seems to be the most important. In order to overcome the disorientation of the loss it seems necessary for most mourners to have ready access to sympathetic and reorienting friends. If either of the couple does not relate well to others, referral to a self-help group like SHARE or AMEND is most approrate. Prescribing a tranquilizer or an anti depressant, or use of alcohol, failure in the mourner. If sleep disturbance becomes chronic however and if there is no history of mental illness, a mild tranquilizer may be helpful if used only near bedtime and over a short period of time. It is important for the physician to remember that bereavement --the overt symptoms of adaptation--will take approximately two years. No means have yet been found that shorten the period. The most vulnerable perods tend to be the first week, months five though sever, and anniversary dates. Least helpful to mourners are: (1) use of alcohol; (2) long-term use of tranquilizing drugs;(3) cliches about being pregnant again (contraindicated for most women until after the characteristics of mourning clear, usually by the 14th to the 18th month); and (4)encouragement to change jobs, residence, or locale that only add to a couple's disorientation.

EDITORIAL COMMENT

The management of fetal death in utero has been imporved tremendously by the development of ultrasound for definitve diagnosis and prostaglandin suppositories for safer termination.

At the same time, the importance of the emotional aspects of this tragedy are being appreciated. Although the team approach to counseling has many advantages with a lager diversified service, it should still be the responsibility of the private obstetrican who already has a working relationship with the family.¹ He is in a unique position to show continued support and compassion for the family at this difficult time. most practitioners are poorly trained to handle this problem and tend to avoid the patient, which is exactly the opposite of what is needed. Fortunately, thliterature as that cited by our respondents is now available and it behooves the practitioner to become familiar with it. His patient needs him now more than ever...E.

REFERENCE

1. Kellner KR, eta all: Perinatal Mortality counseling PRogram for Familes who expereince a stillbirth. Death Education 5:29, 1981.

This issue edited by:
Kenneth R. Kellner, MD, PhD
Assistant Professor
Division of Maternal /Fetal Medicine
Director, Perinatal Mortality Counseling Program
Department of Obstetrics/Gynecology
University of Florida College of Medicine
Gainesville, Florida