Perinatal Grief: Phases And Support Protocol

Dealing with the loss of a loved one is always complicated. However, what happens when this loss takes place during the process of pregnancy? In this article, we are interested in perinatal bereavement. It seems important to us to deal with a subject which has caused much ink to flow but around which there is a great deal of misinformation.

The World Health Organization (WHO), in the tenth revision of the International Classification of Diseases (ICE-10), defines loss during pregnancy according to the following criteria:

• Early fetal death: this refers to fetuses less than 22 weeks pregnant and / or weighing less than 500 grams. We also speak of “miscarriage”
• Intermediate fetal death  : it includes fetuses between 22 and 28 weeks of pregnancy and / or a weight between 500 and 999 grams

• Late fetal death : includes fetal deaths from 1000 grams and / or fetuses over 28 full weeks of pregnancy

Authors such as Lopez (2011) extend the concept of mourning. This includes:

• Cases of abortion (voluntary or involuntary)
• The voluntary termination of pregnancy for problems related to the fetus or the health of the mother endangered
• Selective reduction in the case of multiple pregnancies
• Intrauterine death or during childbirth
• Loss in multiple pregnancies and newborns

The loss during childbirth has not always been of equal importance. Today, thanks to better information and more sensitivity on the subject, we are now able to help parents during the grieving process.

Protocol for dealing with loss and perinatal bereavement

The protocol’s recommendations are to  provide care that reflects parents’ natural desire to see and hug their child after birth. The protocol also provides the appropriate tools for the professionals involved in taking charge of the process.

We can distinguish different stages:

After announcing the news

• Establish a relationship with parents based on sensitivity
• Understand  the impact of the news for parents
• Make sure parents are supported throughout the process
• Provide clear information about the different options they have. Indeed, when we discover that the baby has no pulse, there are two possibilities:
  • Staying in expectation: this consists of waiting for the body itself to cause the elimination of the remains. This process is very similar to childbirth
  • Perform curettage: this option is necessary when the mother does not give birth spontaneously

During childbirth and birth

If the parents have expressed no concerns about contact with their child, the most natural and respectful attitude possible can be adopted as one would with any parent the newborn would like to see.

After birth

• Provide tactful and individual guidance to parents as they get to know their child
• Normalize professional contact with the deceased child to show parents the path to follow
• Offer the possibility of keeping a memory of the baby
• Respect and fully support the wishes of parents who do not wish to see or spend time with their child. Respect their decision that the support is provided by someone else

Confrontation and phrases of perinatal mourning

Faced with the loss of a loved one, and more so in this case,  we must respect the freedom and decisions of parents. You have to understand, listen and ensure that they maintain as much control as possible over the course of events.

The phases that parents go through in this type of case are (López, 2011; cited by Vicente, 2014):

• They first experience  shock and numbness, confusion and functional difficulty. All of this comes with feelings of regret
• Then come  the disorientation and disorganization of everyday life. It goes hand in hand with the feeling of emptiness and distress
• Finally, parents manage to reorganize their lives  and regain the ability to enjoy, but without forgetting

To face or overcome the death of the baby, there are several remedies and measures to support parents (Vicente, 2014):

In the health sector

• Derivation and information on resources upon discharge from hospital: provide couples and family members with information on bibliographic resources, online resources, associations, support groups, etc.

• Facilitate the expression of emotions  without any judgment
• Offer support during the hospitalization process, using listening as a therapeutic tool. Inform and guide to facilitate independent decision-making on the part of parents
• Train healthcare staff in certain skills and provide them with tools and techniques that will improve the management of perinatal loss and bereavement in the early stages

Outside the health sector

• Creation and development of  information and social awareness campaigns
• Creation and stimulation of  mutual aid groups intended for parents, brothers and sisters, grandparents, etc.
• Support and accompaniment in the grieving process
• Guidance for administrative procedures
• Bereavement counseling and therapy at the couple, family or individual level

Ultimately, it is necessary to train professionals so that they can take charge, accompany and support both parents and family, without forgetting that  it is the parents who must set the pace of the process.

Our thoughts

The most important postpartum change is the one that is not visible, the one that the mother feels inside.