subsequent children [Archive] - Now I Lay Me Down to Sleep Discussion Forum

Deb Stoner

03-23-2006, 12:42 AM

At the end of this article is a sample of a birth plan. The article and birthplan both contain helpful info.
Hope this proves useful to someone out there!

GUEST CORNER
Pregnancy Following Pernatal Loss: An Interview Program for Parents

Joann O’Leary, MPH, MS

Over the last twenty years the importance of supporting families in pregnancy loss has been increasingly recognized. An abundance of resources has been written for families as well as for those caring for the families. Many hospitals have protocols for when families whose babies have died in utero present to their birthing units, and many communities have infant loss support groups for families when they go home.

While most observers think a new pregnancy is a sign of moving on, in reality a whole new set of issues surface as these families face the struggle and fears of a subsequent pregnancy. In addition to the loss of a child, families have lost all naivete. Many times, even when there has been a healthy baby born since the loss, any subsequent pregnancy brings back old fears. A prior loss is a significant factor in next pregnancies (Goldenberg et al., 1993). Families have taught us that, just as there are protocols to follow when a baby dies, so too should there be a protocol for a subsequent pregnancy. A protocol that incorporates issues related to medical care, birth education, and emotional support is needed because these pregnancies are so different.

The Pregnancy After Loss program at Abbott Northwestern Hospital was developed in 1988 out of a need expressed by parents for help in subsequent pregnancy. Losses may be the death of a baby due to stillbirth or early miscarriage, SIDS, loss due to termination by choice, loss within the first year of life or loss of the anticipated normal child when a baby is born with disabilities (including parents who make the painful decision to give a disabled child up for adoption). During the last two years families in a pregnancy of multiples who have had the loss of one or more babies while still carrying the surviving baby(ies) to term have participated in the program as well. These families want and need their pregnancies to still be acknowledged as a twin or triplet pregnancy. These families face similar issues — the struggle to grieve the loss of one child while continuing the pregnancy trying to be happy for the surviving baby(ies) — as do parents in a subsequent pregnancy. We have used what we have learned from families who have been brave enough and strong enough to deal with the pain of their loss as the foundation for our multifaceted program. [See sidebar, p. 7]

The first group in our program consisted of four women, all in their first or early second trimester of pregnancy. One had experienced two first trimester losses, one had a history of infertility with one previous loss at 6 weeks, one had a loss of a premature baby at 23 weeks gestation, and the fourth had a son who died 20 minutes after birth of a rare abnormality (which had a 50% chance of recurring and which was not diagnosable prenatally). Although each story was different, they all shared common feelings of fear, anxiety and disbelief that they would ever be parents to a live baby, all the while still focused on the baby who died. Coming from my background in early childhood, I was struck with the feeling that I was observing the prenatal equivalent of attachment disorders (Ainsworth et al., 1985). These mothers would seem to want this baby one week and the next week try to deny that they were even pregnant. Over the years I realized that this is one of the normal developmental processes in these pregnancies. Mothers and fathers struggle to attach to a pregnancy and to a new baby while still in grief over the loss of another baby. Their grieving of their previous baby does not go away just because they are pregnant again.

Families have taught us that, while wanting to be pregnant, it is normal to not feel ‘happy’ during the pregnancy. Anxiety, fear to attach, distrust of the medical community, and disbelief that their bodies can keep a baby safe are normative. They will be anxious, not trusting the aches and pains of ‘normal pregnancy.’ In fact, the next pregnancy is fraught with conflict because, no matter how long it has been since the previous loss, most families begin the pregnancy with grief as a part of the package. Health care providers need to be aware of these dynamics, giving more education and reassurance as pregnancy progresses.

Families are searching for others who understand that, although a child of theirs has died, they were parents once and, indeed, still are. As one parent said, "My baby died, but I am still a mom." The focus of our program is to validate the parenting experience they had and to help them find a place in their family for the baby who died (Theut et al., 1992). We guide them in learning to trust the behavior patterns of the baby they are carrying to give them the reassurance they need (O’Leary & Thorwick, 1993). As they learn to know this baby, they begin to attach and learn to trust their bodies again as they prepare for birth and parenting.

What you can do to help. Many parents want everything to be different in a next pregnancy, including clinic, doctor and hospital. They may need concrete evidence that this pregnancy is different, of how it will be managed differently and of what they can do differently. It may seem as if you are explaining the same things over and over, in different ways as the pregnancy progresses. That is normal. Families may need: •More frequent clinic visits; •Additional testing (early to rule out causes of the previous loss and later for safe keeping of the baby); •More ultrasounds to ‘see’ that they are really carrying a baby (in the first weeks, until movement is felt, and later to help them attach to a different baby) — these need not be detailed anomalies or level II scans; •Validation and reassurance that their fears and anxieties are normal.

An awareness that no amount of reassurance may ever be enough helps you in caring for them. Help them find ways to control what they have control over. Teach them how to learn about their bodies and their baby by feeling the difference between a contraction and fetal movement (particularly if the previous loss arose because they did not know that they were in pre-term labor). Give them hope without false reassurance. Acknowledge with them the reality they live with every day…that until their baby is born alive they cannot believe they will have a live baby. Be sure all that can be done to help them is being done. Even after the baby is born most still will be anxious.

How families may present to your unit. It is not unusual, and, in fact, very common, for families to seek help on anniversary dates. Read their chart: Is this pregnancy at the gestational age of their previous loss; is it the same month or day of their previous loss; are the presenting symptoms similar to what happened in the previous loss? Seek beyond their words, listen to what they may not be saying. They may describe: •decreased fetal movement; •fear of the baby being dead; •fear of ruptured membranes; •contractions; •anxiety attacks (and before you call for a psychological evaluation, look to see if this is an anniversary time); •vague feelings they cannot articulate.

Birth planning. If you have a program for these families or are able to work with them during the pregnancy, it is helpful to have them write a birth plan. A birth plan should reflect, in their own words, what they want the staff who will be caring for them to know about their family, and about this pregnancy and baby. An example of a birth plan can be found at the end of this article.

During labor. Just as Penny Simikin speaks to the special needs of women who have been sexually abused, so are families in a subsequent pregnancy experiencing post traumatic stress symptoms. Many families will not have gone to a birth class or toured the hospital since their last experience because they are afraid and don’t want to bring back memories. The memories may then come, causing flashbacks, when they are in active labor for the new baby. Things that might trigger a memory in the birthing area include: •the same room, or doctor or nurse as the last time; •the white walls; •ultrasonography (which may have been the way they found out that their previous baby was dead); •positions for pushing (since pushing means death — ask them what help they may need); •incidental loss of the tracing on the fetal monitor.

We have found, and the literature supports, that most families want you to acknowledge their previous loss. If they are comfortable, ask what that baby’s name was; ask if they have named this baby, and if they would like you to use the baby’s name during labor. Keep them in the present, reminding them that this is a different labor and a different baby.

Try to stay with them. Explain every procedure and give concrete reasons why you know the baby is safe. Get support from your coworkers so that assignments may be adjusted to avoid many different care providers.

The father is usually as afraid as is the mother. He needs just as much support, although his fear may come out as anger or questioning of the care you are giving. Keep in mind that anger is usually masking great fear.

Validate their right to feel anything they feel. Even if they have had support in working with their fears and anxieties, they will not act like a traditional laboring couple. Their last experience was tragic. They have a right to more care and closer monitoring.

The postpartum period. The postpartum period cannot always be anticipated by families as being difficult until they get there. This may be especially true for families whose loss was a few years ago. When this is the first live birth, sometimes it is not until the new baby comes that parents really realize what they missed with their other baby. One woman with repeated early losses became pregnant unexpectedly years after she stopped trying. She numbed herself throughout the pregnancy, afraid to believe it was even happening. She thought of herself as pregnant but never really having a baby. After her son was born she was still numb. Later she said that she wished she had had the nurse slow everything down, purposefully help her to hold her son, to look at all his parts and to really see that he was alive and well. She said she needed someone to help her feel the experience really happening.

Conclusion. Our program is designed to empower parents to understand their loss, to help them recognize and affirm that their fears and anxieties are normal and to support them in attaching to their baby, while continuing to love the baby who died. The program’s goal is to provide families with a sense of how the child who died and the new baby both belong in their lives. Parents find healing in seeing their grief and anxiety put into a normal developmental process.

Over the years the program has evolved to be more than about the medical care and emotional support of a subsequent pregnancy. It is about the child that follows the loss, about making sense of where his/her place is in the family, about helping that child become a unique and separate individual and about helping the siblings, along with the parents, greet this child while still remembering the baby who died. It is about helping parents honor their role as parents with all of the children who make up their family tree.

There is no one way. Everyone is different. Your challenge is to open yourselves to hear each family’s story and help them get the care they may need in their subsequent pregnancy.

References
Ainsworth MS, Belhar M, Waters E, Wall S (1978) Patterns of Attachment. Hillsdale, NJ: Lawrence Erlbaum.

Goldenberg RL, Mayberry SK, Cooper RL, Dubard MB, Hauth JC (1993) Pregnancy outcome following a second-trimester loss. Obstet Gynecol 81:444-446.

O’Leary JM, Thorwick C (1993) Parenting during pregnancy: The infant as the vehicle for intervention in high risk pregnancy. Int J Prenatal Perinatal Psych Med 5:303-310.

Theut S, Moss H, Zaslow MJ, Rabinovich BA, Levin L, Bartko J (1992) Perinatal loss and maternal attitudes toward the subsequent child. Infant Ment Health J 13:157-166.

***

An Example of a Birth Plan

PLEASE READ OUR BIRTH PLAN BEFORE YOU COME INTO OUR ROOM.

BACKGROUND INFORMATION
This is our fourth pregnancy. Our first daughter, Molly, was born after 14 hours of labor and minimal medication. She is now four years old. Our second pregnancy ended in a loss of a baby boy at 18 weeks gestation. He was delivered by a D/E so we were unable to see him or hold him. Our third daughter was born at 40 weeks, 2 days and was a stillbirth. They think it was a cord accident but we will never know for sure. This pregnancy has been very stressful and we have had weekly testing since 30 weeks gestation. It is hard for us to believe we will really have a live baby at the end. We know this is a girl and her name is Mary.

REQUEST FOR LABOR AND BIRTH
Both of us will need lots of support we will want continuous monitoring and reassurance all is well. We will need concrete examples of what is going well and want to be told immediately if anything changes. We will do better and work better with you if we know everything that is going on. I do not anticipate having a hard time with the pain of contractions but will be very emotional and need support. I am afraid of having flashbacks during pushing and so is my husband. Please help us remember this baby is alive and safe.

POSTPARTUM
We want the baby to stay with us at all times. We will need some time alone to grieve our other daughter as we welcome this baby into our family. Please expect us to be very emotional. Our four year old will be brought to be with us by her grandparents as soon as we call. I will be breastfeeding and may need help with this, although I breastfed my first daughter.

THANK YOU FOR YOUR HELP.

***

OTHER RESOURCES

O’Leary, J.M. and Clare Thorwick [Script writers]: After Loss: The Journey of the Next Pregnancy (Video 1995). Available for rental or purchase through Abbott Northwestern Parent Education Program, Minneapolis, MN. (612) 863-5964.

Pregnancy After Loss, 1993. Booklet written by parents for parents on the issues in a subsequent pregnancy. Abbott Northwestern Parent Education Program, Minneapolis, MN. (612) 863-5964.

Davis, Deborah L. (1996) Empty Cradle, Broken Heart: Surviving the Death of Your Baby. Second edition, Fulcrum Publishing, Golden, Colorado. Chapters 13 and 14 on the subsequent pregnancy and child.

PAILS of Hope (Pregnancy/Parenting After Infertility/Loss Support). A bimonthly newsletter for those contemplating pregnancy after infertility and/or loss, are pregnant or are parenting a child born subsequently to a loss and/or infertility; contact Pen-Parents, PO Box 8738, Reno, NV 89507-8738, FAX (702)826-7332.

Still to be born. (Video, 1987) Perinatal Loss, 2116 NE 18th Ave., Portland, OR 97212, (503)284-7426.

Schwibert, P. and Kirk, P. (1993). Still to be Born. Perinatal Loss, 2116 NE 18th Ave., Portland, OR 97212.

(All of these materials are available on loan from the WiSSP lending library)