"Born still and yet still born" Care of women and partners following diagnosis of late intrauterine fetal death - chapter 1

The first chapter of my dissertation in brief:

Time between diagnosis and induction of labour 

- Women delaying induction of labour from time of diagnosis more than 24 hours are at significant risk of suffering anxiety related symptoms in the future, this should not necessarily mean that women should be made to start induction immediately. The time inbetween diagnosis and induction can be used effectively to begin to come to terms with the loss and start healthy grieving processes

- Women in several studies have expressed that staff left them alone following breaking bad news to them, most of these women did not wish to be left alone during this time - this made them feel abandoned and out of control of the situation. Contrarily, fathers would rather be left alone in peace to adjust and calm down, this in combination with the amount of things they needed to deal with at the time led to fathers feeling conflicted. In accordance with NMC (nursing and midwifery council) code of conduct and SANDS guidelines best practice in this situation is to clarify with the family whether they would rather be left alone to come to terms with things or whether they want you to stay with them to begin to answer questions.

- Waiting for induction has been described by women as worse than the delivery itself, however there were ways they found to make the time useful and meaningful. For example sharing grief with others, family members, seeing other children and grieving together as well as meeting with priests and counsellors helped to clarify the situation and keep women focused on the task. Taking this into consideration it is reasonable to consider delaying induction for a short time in order to accomodate these interactions.

- The department of health and the NMC make it clear that women and partners need time and information in a way they can understand in order to begin to make choices. In the situation of intrauterine death the best way to communicate is likely to be slow-drip of information, repeated as necessary, a small study found that at times women were given more information than they could digest and needed some time to recover before moving on to the next step. Another study discovered that during this 'waiting' period women were not just waiting for delivery of the baby but also for information, sometimes that information never came. This lack of information could contribute to women and partners feeling frightened and wanting to delivery the baby as soon as possible, as the whole situation felt abnormal. Providing information and choices could help alleviate some of this fear before delivery.

- Conclusions from this chapter were that hospital policy does not include advice for midwives caring for women in terms of their psychological health and grieving - they are mainly focussed on the medical aspects of induction, therefore more psychological and grief research as well as womens views need to be included in policy. Further research into the effectiveness of interventions such as counselling in the period between diagnosis of intrauterine death and induction of labour is needed to determine whether they cause more good than harm. With this information an improvement in policy could contribute to better well-being of families in the future and possibly during prospective childbearing continuums.

References I have used for this chapter are below incase anybody would like to do some further reading.

Onto the next chapter - choices in labour following diagnosis of late intrauterine death.

References

Centre for Maternal and Child Enquiries (CMACE) (2011) ‘Perinatal Mortality 2009: United Kingdom’. CMACE. London.

Department of Health (2004) Maternity Standard, national service framework for children, young people and maternity services.

Erlandsson, K., Lundgren, H., Malm, MC., Davidsson-Bremborg, A., Radestad I. (2011) ‘Mothers experience of the time after the diagnosis of an intrauterine death until the induction of the delivery: A qualitative internet-based study’ J. Obstet. Gynaecol. Res. 37 (11) pp. 1677-684

Geerinck-Vercammen, CR (1999) ‘With a positive feeling’ The grief process after stillbirth in relation to the role of the professional caregivers. European Journal of Obstetrics and Gynecology and Reproductive Biology 87 pp. 119-121

Hibbert, G (2011) ‘The Other Side’ The Practising Midwife 14(7) pp. 16-17

Local Trust Guidelines (2007) ‘Guidelines for the care of women with an intra-uterine death’

Malm, MC., Radestad, I., Erlandsson, K., Lundgren, H (2011) Waiting in no-mans land – mothers experiences before the induction of labour after their baby has died in utero. Sexual and Reproductive Healthcare 2 pp. 51-55

NICE (2008) Induction of labour – CG70. National Institute for Health and Clinical Excellence. London.

NMC (2008) The Code: standards of conduct, performance and ethics for nurses and midwives. Nursing and Midwifery Council. London.

Radestad, I (2001) ‘Stillbirth: care and long term psychological effects’ British Journal of Midwifery 9 (8)

Radestad, I., Steineck, G., Nordin, C., Sjogren, B (1996) ‘Psychological complications after stillbirth – influence of memories and immediate management: population based study’ BMJ 312 (1505)

RCOG (2010) Late intrauterine fetal death and stillbirth – Green-top guideline No. 55. Royal College of Obstetricians and Gynaecologists.

Saflund, K., Sjogren, B., Wredling, R (2004) The role of caregivers after a stillbirth: views and experiences of parents. Birth 31 (2)

Samuelsson, M., Radestad, I., Segesten, K (2001) A waste of life: fathers experience of losing a child before birth. Birth 28 (2)

SANDS (2012) available at: http://www.uk-sands.org/ (accessed 28/02/12)

Schott, J,. Henley, A,. Kohner, N (2007) Pregnancy Loss and the Death of a Baby: Guidelines for professionals. 3^rd edition. SANDS.

Scott, J (2011) ‘Stillbirths: breaking the silence of a hidden grief’ The Lancet 377 (1353)

The Lancet (2011) ‘Stillbirths’ Available at: http://www.lancet.com/series/stillbirth (accessed 10/02/2012)

Trulsson, O., Radestad, I. (2004) The Silent Child - mothers experiences before, during and after stillbirth. Birth 31 (3)

Neonatal Unit Experience

Well, I just finished 2 weeks experience on the neonatal unit. Not much experience for a student midwife I thought when I first started the course - I wanted a full 6 week placement and expected to find it really interesting! I think part of me expected at some point to want to work in a neonatal unit (if I managed to find out who accepted midwives as staff that is).

I have learnt loads, much of it I can apply to my midwifery practise - the main points of keeping a baby out of the neonatal unit - keep it warm, get it fed! Invaluable advice, that although simple, may just help a smaller baby along in life.
But something has been nagging at me. I've been bored. How awful that statement sounds! Let me clarify, not bored in the sense that I wasn't interested in what was going on, but I couldn't do anything! I trained to build relationships with women, support them through labour, monitor their well-being and when the time comes facilitate their meeting with their baby. I felt as though my 3 years of training had come to nothing when I was in there, its a whole different kettle of fish, like starting from below scratch.

However, something more has been ticking away at the back of my mind. Something I'm bothered by. Everyone says to me "oh how awful, you must be so sad when you work in the neonatal unit. How horrible to see those poor babies". Except I'm not sad. I don't find it awful. I've tried, and I've stood by the incubators, and the heated cots and contemplated how things like this shouldn't happen. But at the end of the day, whats nagging in the back of my mind is this: These babies on the neonatal unit are the ones who survived. The lucky babies that, though born early, are still alive, with their parents and getting help. I couldn't help but feel that where I belonged, and where I could be of use was back on the delivery suite, helping those families who never got to meet their babies. And that reminds me why I do what I do: I love the bonds I make with the women, and I want to make a difference there. I'm glad of my time on neonatal to remind me of this and I seriously can't wait to get back to caring for women next week!

Stillbirth at home?

So, in researching for my dissertation I have so far found several things of interest that I will be including:

- That awful time following the discovery that your baby has died in the womb but before you are induced at the hospital - it seems to me this time needs to not be of a set length but discussed with the parents, parents should not be left alone to digest this unless they request so and most importantly the time should be structured to give parents answers and information they need, at a rate which does not cause them distress.
- Making memories with the baby and gaining remembrance items can be essential to aiding grieving processes, however parents should not be forced into seeing and holding a baby who is born sleeping if they do not want to. With gentle encouragement and support from midwives holding and photographing the baby can reduce symptoms of anxiety further along your journey.

Something which has struck me, and I have not yet found any information on at all is the possibility of giving birth at home. The hospital environment could make a vulnerable couple feel more exposed at their time of need. The maternity ward is full of newborn babies. Could giving birth at home be a viable option? More comfort, never having to leave your baby before the funeral (provided some kind of cold cot could be provided), having whoever over whenever you like to meet and make memories with your baby? The risks could be great - inducing a mother and then sending her home is unlikely to be something an obstetrician would consider and not being induced could lead to anxious feelings about the child still inside - but could it become a reality if support was offered in the right way?

I have been unable to find any research or experiences of this - have you had a stillbirth at home? Do you know of somone who has who would be willing to share? I would be appreciative of any help in possibly making this a reality.

Gem

Welcome to the blog - week in the life of a student!

Hello!

I've been threatening to start a blog for ages but never actually done it so here it is finally! I figured I'll kick off with a week in the life of a 3rd year student midwife - I wrote it at the start of my 3rd year community placement and hope you enjoy!

Monday

I struggle to get up this morning, have been awake about 5 times in the night to check my phone in a panic. I’m on call for a caseload lady who is 10 days overdue. My mentor is giving a talk at a study day this morning so I don’t need to be in until 10am, this gives me chance to actually make some lunch (a very rare occurrence!). I have a ‘day 5’ postnatal visit today, here I will check mum is ok, weigh baby for the first time since birth and carry out the heel prick test. I have a look at the rota and find there is a pool car available for me to use (this helps keep my petrol costs down!) which is quite exciting as often there isn’t one going! I grab a quick cup of tea and spend some time checking appointments for my caseload women, and checking some scans for ladies who are newly pregnant. Once in the car I get out my map and check where I’m going, it looks like a complex one way system so I cross my fingers and head off. I finally find the house (after only 2 U turns!) and grab my postnatal stuff and head inside.It’s a difficult visit with the baby having lost more weight than anticipated, I spend a lot of time giving advice and reassuring the parents before doing the heelprick test which thankfully goes well – I do not like repeating those!
At this rate I’m going to miss clinic! I start to wish I had accepted that coffee I was offered on the way in! I leave after giving contact information for the breast feeding support team, promising to be back in 2 days to re-weigh baby and see how they are getting on, and rush straight to clinic – looks like no break to eat that lunch I made after all! Clinic is full and we have one extra on the end, many of our women today do not speak English and one of them speaks no English and is a new appointment, crammed into a 15 min slot so it’s a difficult one! I’m starting to feel better about clinic as my mentor takes a step back and lets me do everything, and answer questions – she only steps in now if she feels she can add something. I also see my caseload lady she is due induction soon so we cross our fingers and hope it won’t be needed.
Back to the unit with all the paper work from the clinic, it takes me another hour to do this and I take a couple of visits and write them down to give to a different mentor tomorrow and finally I can go home!

Tuesday

I really struggle to get up and into work, I’m so tired. Still no call from my caseload lady, I’m getting really twitched, will they ring me when she labours?!
Once in I spot some referrals left on the desk for my attention and ring up a couple of the women to book them in for their home booking appointment that day, print off some ID stickers for them and label up the booking pack while waiting for my mentor. We head off together to our first visit – a BP check for a lady with creeping up BP and a general unwell feeling, its fine (after 3 checks!) so we agree to see her again tomorrow to check again. I head off from here in the pool car to my first booking, realising on the way there that the pool car has no petrol and I have no idea how to fill it up! I head back to the unit to find out and one of the community support workers gives me a credit card for the car and lets me in on the secret – I feel quite important! That is until I get to the petrol station and realise I don’t know whether its unleaded or diesel or whether indeed they will let me buy the petrol, thankfully all goes well and I’m on my way again!
I arrive at my booking only half an hour later than I said I would be (oops! Guess being organised isn’t so easy after all). I carry out the booking and it doesn’t take as long as usual, didn’t seem to get a rapport with the lady, she already had a child and seemed to know a lot of what I was telling her, and I didn’t manage to take her bloods! I leave feeling I could have done a better job, am quite upset by this. I go straight back to the unit and manage to get some lunch and a coffee today yay! A couple of the other students are there and we have a bit of a chat and arrange to meet later that night to do some work on our group poster/presentation. At 1.15 its time to go to clinic at the children’s centre, I’m told there is an hour gap between women so save all my booking paper work for then, only when we get there the clinic is full! I have met all the women who attend today already which is lovely; on occasion I have seen some of the women more than my mentor. We see 2 women who have lost babies recently, the next pregnancy is a real struggle for them and I really feel for them both. The centre manager also comes to speak to the midwife about a girl who wants to apply to midwifery and getting experience, I give her my email address just in case she wants any questions answered. At 3.30 the clinic ends and I phone my booking lady and ask her to make an appointment with the phlebotomist at the surgery to have her bloods done, this is much easier for her. I head off and battle through the traffic and post the blood forms to her then go to my next booking, by now it’s getting dark! I arrive at the same time as the woman is getting in from work. They are a lovely couple with a cute kid and I enjoy doing the booking, it feels like this woman has a lot more questions and is much more interested in the booking apt. than the last one. I am able to get some blood from this lady thankfully and answer all her questions no problems. Back to the unit for me and I pod all my bloods to the lab before getting together with the other girls to do this poster.

Wednesday

This morning I finish off the booking paper work and look up the guidelines I need, it turns out one of my women needs a consultant appointment so I arrange this. There are a few phone calls from worried women, most of whom I manage to reassure and one who I promise to phone back once I have spoken to my midwife. Once the midwife gets in we arrange who we are each seeing today and she answers my query regarding the woman on the phone, after I have phoned the lady back I take a phone call regarding domestic violence, my mentor and I deal with this as a team which is nice. I’m heading back to visit the lady I saw on Monday and re-weigh the baby, I look up the guidelines as to what to do just in case the babe hasn’t put on any weight and set off. Lucky I did as the baby weighs exactly the same as on Monday (takes a while to get the reading as the baby is screaming and the scales swing massively!) I ring children’s day assessment for advice and they tell me they had better see the baby, mum is very upset and feels like a failure. I am so upset, I feel like it’s my fault! I give her a hug and try to reassure her about her breastfeeding – it’s not her fault sometimes things just happen. I leave and promise to ring back later and find out how everything is going. Clinic this afternoon is ok, one of my caseload women is on it and it’s nice to see her and find out how everything is going. There are 2 new women on the end of the clinic so we end up finishing a bit late. I feel like a lot of responsibility has been given to me this week and I am simultaneously grateful and overwhelmed.

Thursday

Today is my day off! Woohoo! I have a little lie in and then drag myself downstairs at about 8am for a cuppa and the news. Once I’m awake I do my piece for our group poster and then get ready to go out. My caseload lady is being induced today so I’m on my way to say hi and see how she feels about this. The ward is very busy and nothing has been done with her yet, I speak to the midwife in charge and she says it will be a big help if I could admit her and do a CTG tracing. This is great I think! Only she has gone for a little walk when I get to her bay. I fill out all the notes as best I can without the information from her and wait for her to get back. We have a little chat when she arrives, closely followed by her husband. I do the obs and CTG and we chat some more about the induction and her preferences. I grab a quick cuppa on the ward while waiting for the CTG then take it off in time for her to have some lunch. I wish them luck and head home to await my phone call (after writing it everywhere and begging the midwives to remember to call me … I may have gone over the top!). get some lunch and do some washing up but don’t feel like doing uni work or house work, this is my only day off though and I don’t get a chance otherwise.

Thursday Night

11pm I get a phone call from the maternity ward, my lady is not in labour but going down to delivery suite to start off the induction process. They promise to ring me back when they know if I can go in. I don’t hear anything else and by midnight I’m starting to worry so I phone them, I get hold of the co-ordinator who tells me that a band 5 is caring for her, students can’t work with band 5s, but, by the time they have started off the induction etc. and got her into labour it will be morning so best not to come in yet, she tells me they will phone when she is in labour. I spend most of the night awake waiting for them to ring and worrying they won’t.

Friday

Nothing. No phone call! When I phone them before handover at 7.20 they tell me she hasn’t delivered, it’s been a busy night and she’s just getting into labour. The midwife looking after her will ring me back. By 10am I’m really worrying and starting to give up a bit – I know the unit is busy so can’t complain that I haven’t heard anything. I ring at 10.30 and the co-ordinator says “well aren’t you coming in?!” … cue mad dash to the car and into the unit. 12 hours later I leave having delivered a beautiful baby to a wonderful couple, completed all my notes and got her sorted for the ward. I’m really grateful to the midwives for letting me come in despite it being my community placement. I was complimented on my delivery by both midwives present and this makes me quite proud. Phew what a day! I’m so tired but there is one more thing left to do today … glass of wine before bed!!