"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!