OB Clinical Rotation Presentation

1. PERINATAL LOSS AND GRIEF
Erin Kelly
Veronica Lopez

2. Tribute to my miscarriage
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3. EXPECTED INDIVIDUAL STUDENT LEARNING OUTCOMES
• Define perinatal loss
• Define the different types and frequency of
occurrence
• Identify risk factors for perinatal loss
• Identify signs and symptoms of perinatal loss
• Describe emotional responses
• Describe the process of grief and mourning
• Nursing diagnoses and interventions
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4. DEFINITION
per·i·na·tal loss
[per-uh-neyt-l] [laws, los]
–noun
The nonvoluntary end of a pregnancy from conception,
during pregnancy, and up to 28 days of the newborn’s
life. Also referred to as pregnancy loss.
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5. TYPES
• Ectopic Pregnancy
• Miscarriage
• Stillbirth
• Neonatal Death
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6. ECTOPIC PREGNANCY
• Implantation occurs outside of the uterus
• The baby (fetus) cannot survive
• Caused by a condition that blocks or slows the
movement of a fertilized egg through the
fallopian tube to the uterus (hormonal factors,
smoking)
• Signs: abdominal pain, GI symptoms, vaginal
bleeding, weakness, dizziness, fainting
• Diagnosis: pelvic exam, ultrasound,
measurement of hCG levels
• Risk Factors: multiple sex partners, Age >35, In
vitro fertilization
• Most common complication is rupture with
internal hemorrhage
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7. MISCARRIAGE
• Most common type of pregnancy loss often referred to as
“spontaneous abortion” or SAB
▫ 10-25% of clinically recognized pregnancies will end in miscarriage
• Occurs in ≤20 weeks gestation
• Most often the cause cannot be identified
▫ Chromosomal abnormalities, hormonal problems, lifestyle, maternal
age, maternal trauma
• Warning signs: mild to severe back pain, weight loss, white-pink
mucus, true contractions, brown or bright red vaginal bleeding,
tissue with clot like material passing through the vagina
• Types: Threatened, Incomplete, Complete, Missed, Recurrent
• Blighted Ovum
▫ Fertilized egg attaches to the uterine wall but the embryo DOES NOT
develop
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8. STILLBIRTH
• Late pregnancy loss
• Occurs >20 weeks gestation
• 1 in 160 pregnancies
• The majority take place before labor
• Causes: placental problems, birth
defects, growth restriction, infections
• Risk Factors: Age >35, malnutrition,
inadequate prenatal care, smoking,
drug and alcohol abuse
• Prevention: daily kick counts, avoid
certain substances, contact HCP if
notice vaginal bleeding
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9. NEONATAL DEATH
• Loss occurring from birth to 28 days of life
▫ The baby has demonstrated signs of life including
breathing, heart beating, pulsations of umbilical cord,
and movement of voluntary muscles
• Most common cause is premature birth (before 37
weeks gestation)
▫ RDS (Respiratory Distress Syndrome)
▫ Intraventricular Hemorrhage
▫ Infection
▫ Necrotizing Enterocolitis
• Other Causes: birth defects (heart, lung, brain,
spine), complications of pregnancy, complications
involving the placenta, infections, asphyxia
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10. FREQUENCY
• Perinatal Loss occurs in 1 million women every year
in the United States
▫ It is very common
• Early Losses(≤20 weeks): up to 25% of all
conceptions
• Late Losses (>20 weeks): 2%-4% of pregnancies
• Rates of pregnancy loss have remained the same,
but stillbirth rates have declined
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11. EMOTIONAL RESPONSES
• Research findings indicate that there are differences in grief
responses according to sex.
• Mothers often experience intense responses, including
extreme sadness; guilt; suicidal ideation; and feelings of
emptiness, isolation, irritability, and anger.
• Some mothers had difficulty being around pregnant women
and infants or in situations such as holiday celebrations that
reminded them of what might have been had their infant
survived.
• Fathers also experience a range of feelings, including
isolation, restlessness, anger, sadness, and powerlessness.
• Fathers are often concerned for their partner’s emotional
well-being.
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12. TREATMENT
• Hormone Therapy
▫ Progesterone
• If Maternal Autoimmune or clotting disorders are
known, Heparin or other drugs can be administered
• Emotional Treatment
• Prevention Measures: exercise, healthy eating,
manage stress, folic acid supplements, quit smoking
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13. GRIEF AND MOURNING
• When a baby dies, parents must work through profound
grief related to the loss of their child along with the loss
of their hopes and dreams for that child and their family.
• Grief is individual in nature.
• Stages of grief:
▫ Avoidance, disbelief, shock.
▫ Pain, physical discomforts, depression, difficulty
concentrating, anger at self or partner, guilt.
▫ Acceptance and adaptation. Grief persists, but a sense of
balance is achieved.
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14. NURSING DIAGNOSIS I
• Ineffective sexuality pattern r/t to self-esteem
disturbance resulting from pregnancy loss and
anxiety about future pregnancies.
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15. NURSING INTERVENTIONS
• After establishing a relationship with the patient, give
them permission to openly discuss issues dealing with
sexuality. Ask specific questions, starting with general
ones before getting personal.
• Use assessment questions and standardized instruments
to assess sexual problems.
• Encourage the patient to discuss concerns with their
partner.
• Assess psychological function such as anxiety,
depression, and low self-esteem.
• Discuss alternative sexual expressions for altered body
functioning or structure.
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16. NURSING DIAGNOSIS II
• Complicated grieving r/t to sudden loss of pregnancy,
fetus, or child.
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17. NURSING INTERVENTIONS
• Assess the patient’s state of grieving.
▫ Tools: Texas Revised Inventory of Grief (TRIG), Pathological Grief
Items (PGI), Hogan Grief Reaction Checklist (HGRC).
• Develop a trusting relationship with patient by using presence
and therapeutic techniques.
• Identify problems of eating and sleeping; ensure that basic
human needs are being met.
• Determine whether the patient is experiencing depression,
suicidal tendencies, or other emotional disorders.
• Educate the patient and their support systems on the grieving
process and how it is individual.
• Refer for appropriate support.
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18. OTHER IMPORTANT INTERVENTIONS
• Allow parents to express their feelings by being present and
listening.
• Express empathy and condolences. If the baby had been
named, refer to them by that name.
• AVOID clichés: “at least you are young, you can have another
baby.”
• Provide anticipatory guidance and educate about the process
of grieving and what to expect physically and emotionally.
• Refer parents to community services and support groups that
may assist in facilitating the grief process.
• Provide parents with memorabilia related to their baby, such
as pictures, blankets, a cap, lock of hair, ID bracelet and crib
card, foot/hand prints.
• It is important to keep in mind that grief is individual.
(culture, religion, personal experience, beliefs, etc..)
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19. NURSING JOURNAL ARTICLE
Supporting Parents After Stillbirth or Newborn Death. There is much
that nurses can do.
Karen Kavanaugh, PhD, RN, FAAN,
and Teresa Moro, AM, LSW
• Most widely known theory of grief: Kubler-Ross model
• Swanson’s middle-range theory of caring.
• Nonverbal support is communicated through eye contact, attentive listening,
and concerned facial expressions.
• Eliciting, listening to, and respecting parents’ needs and wishes must be
paramount.
• Parents, siblings (regardless of age), friends, and extended family members
should have unrestricted time with the infant before and after the death and
the opportunity to perform caregiving activities, such as bathing and dressing.
• Nurses themselves need to be informed and provide written information
about burial, autopsy, and organ donation options within their institution and
community.
• Follow-up visits are an important aspect of care, and phone calls should be
made within one week of a loss and again several weeks later.
• Nurses may also grieve. Working with many bereaved families in a short
period of time can lead to chronic, compounded grief, which may limit nurses’
ability to continue caring for these families.
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20. 20
Rights of Parents When an Infant Dies
• To be given the opportunity to see, hold, and touch their Rights of the Infant
infant at any time before and after death, within reason. • To be recognized as a person who was born and
• To have photographs taken of their infant, and made available has died.
to the parents or held in a secure place until the parents • To be named.
wish to see them. • To be seen, touched, and held by the family.
• To be given as many mementos as possible—for example, • To have the end of life acknowledged.
crib card, baby beads, ultrasound or other photos, lock of • To be put to rest with dignity.
hair, foot- and handprints, and measurement records.
• To name their child and bond with him or her.
• To observe cultural and religious practices.
• To be cared for by empathetic staff who will respect their feelings,
thoughts, beliefs, and individual requests.
• To be with each other throughout hospitalization as much as
possible.
• To be given time alone with their infant, allowing for individual
needs.
• To request an autopsy. In the case of miscarriage, to request
to have or not to have an autopsy or pathology examination
as determined by applicable law.
• To have information presented in understandable terminology
regarding their infant’s status and cause of death, including
autopsy and pathology reports and medical records.
• To plan a farewell ritual, burial, or cremation in compliance
with local and state regulations and according to their personal
beliefs or religious or cultural traditions.
• To be provided with information on resources that assist in the
healing process—for example, support groups, counseling,
reading material, and perinatal loss newsletters.

21. INTERVIEWS
• How many times have you experienced a perinatal loss?
• How far along were you?
• Was there a specific cause?
• How did you feel when you first found out you were
pregnant?
• How did you feel when you found out there was a loss?
• What is/was the hardest part?
• How has your life changed since it happened?
• What did you do to cope?
• What are you doing now?
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22. RESOURCES FOR THOSE SUFFERING
• http://angelbabymemorials.blogspot.com/
• Pregnancy Loss and Infant Death Alliance
▫ www.plida.org
• RTS Perinatal Bereavement Program
▫ www.bereavementprogram.com
• Associated for Death Education and Counseling
▫ www.adec.org
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23. What is the MAIN cause of perinatal loss?
A. Genetic Issues
B. Lifestyle Choices (ie: drugs and alcohol)
C. Hormone Levels
D. Chromosomal Abnormalities
E. All of the above, there is no main cause.
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24. TRUE OR FALSE
Grief is sequential.
Most common type of pregnancy loss is miscarriage.
Perinatal loss is uncommon.
Nurses also grieve for their patient.
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25. QUESTIONS?

26. SOURCES
Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: an
evidence-based guide to planning care. St. Louis, MO: Mosby Inc.
Chapman, L, & Durham, R. (2010). Maternal-newborn nursing: the
critical components of nursing care. Philadelphia, PA: F.A. Davis
Company.
Kavanaugh, K., & Moro, T. (2006). Supporting parents after stillbirth or
newborn death. American Journal of Nursing, 106(9), 74-79.
Loss and grief. (2008, October). Retrieved from
http://www.marchofdimes.com/baby/loss_miscarriage.html
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