Learning Objectives
By the end of this section, you will be able to:
- Define the causes of intrapartum fetal deaths
- Identify ways to debrief with fellow coworkers and providers after an intrapartum fetal death
- Identify the nurse’s role in supporting a family with grief after an intrapartum fetal death
An antepartum fetal death is a death that occurs before the onset of labor. An intrapartum fetal death (IPFD) occurs after 20 weeks of gestation and after the onset of labor but before birth (Centers for Disease Control and Prevention [CDC], 2022; McNamara, Meaney, & O’Donoghue, 2018). Globally, 1.3 million IPFDs occur each year (McNamara, O’Donoghue, & Green, 2018). When an intrapartum fetal death occurs, all health-care providers, nurses, and staff are affected. In this section the causes and treatment of IPFD, support of families, and debriefing for nurses and providers during this stressful life event will be reviewed.
Causes of Intrapartum Fetal Deaths
Risk factors associated with IPFD include prior cesarean birth, multiparity, lack of obstetric ultrasound and prenatal care, delay in decision making for escalation in care, birth weight of less than 2,500 g, advanced maternal age, chronic medical diseases (hypertension, diabetes), congenital anomalies, and obstetric complications (preeclampsia, gestational diabetes) (Komboigo et al., 2023; Shanker et al., 2020). IPFD occurred most often between 33 and 37 weeks’ gestation (Shanker et al., 2020). Causes of IPFD can be congenital malformations, cord prolapse, diabetes, infections, antepartum hemorrhage, and preeclampsia (Shanker et al., 2020). Table 26.2 shows a percentage breakdown of different causes. Chapter 12 Pregnancy at Risk and Chapter 19 Complications of Labor and Birth provide more information on the causes of IPFD.
| Causes of IPFD | Percentage of Total (%) |
|---|---|
| Unknown | 53.27 |
| Infection | 20.95 |
| Hypertensive disorder | 15.77 |
| Placental abruption | 10.19 |
| Cord accident | 5.56 |
| Fetal growth restriction | 5.57 |
| Congenital anomalies | 4.04 |
Reduction in IPFD can be seen with routine use of nonstress tests, early and timely interventions during the intrapartum period, and increased antenatal visits (Shanker et al., 2020). Intermittent auscultation (IA) during labor is appropriate for low-risk pregnant persons; however, continuous electronic fetal monitoring (CEFM) is required for high-risk pregnant patients and can reduce the incidence of IPFD. Nurses and health-care providers must be proficient in reading EFM strips, and most hospitals require nurses to become certified in EFM. An article by Chiweza et al. (2022) noted that approximately 40 percent of IPFD could be prevented by careful, quality antepartum and intrapartum monitoring with subsequent rapid operative birth.
Obstetric nurses should also be trained in intrauterine resuscitation and emergency protocols for intrapartum events such as shoulder dystocia and prolapsed cord. All staff should participate in emergency drills to understand the equipment available to them and be familiar with recognizing and responding to emergencies. (See 25.3 Newborn Resuscitation for more information.)
Debriefing for Nurses and Providers
Emotions felt by health-care providers and nurses during an intrapartum loss are similar to emotions described by parents of a stillborn infant: guilt, shock, anger, sadness, and fear (McNamara, Meaney, & O’Donoghue, 2018). Nurses can experience posttraumatic stress disorder, and health-care providers can sometimes leave obstetrics because of the emotional trauma and self-blame. In McNamara, Meaney, & O’Donoghue’s 2018 study of physicians after an intrapartum loss, only four of 10 providers were given emotional or collegial support. They noted a “blame culture,” in which some providers openly blamed another provider. This study found that debriefing with all involved was important for everyone’s emotional health and healing.
Nurses must remain emotionally strong and professional while caring for a couple dealing with perinatal loss. However, nurses can feel ill equipped and inadequate in these situations. Some nurses will complain of headache, insomnia, and physical tension after caring for bereaved patients (Willis, 2019). When surveyed, nurses dealing with patients experiencing perinatal loss stated support from their colleagues was most helpful, but found they needed more managerial support (Willis, 2019). Debriefing after a perinatal loss allows nurses to express their emotions and feelings while accepting support and understanding from their coworkers (Willis, 2019).
Clinical Safety and Procedures (QSEN)
Debriefing after a Perinatal Loss
Nurses and health-care providers must practice self-care to provide safe, appropriate care to their patients. The following are steps for debriefing after the perinatal loss of an intrapartum death:
- Introduction: The person leading the debriefing introduces the rules of the debriefing and the importance of confidentiality. “We are here to discuss and debrief the care of Ms. Smith. We must maintain confidentiality regarding the patient and the information our colleagues share.”
- Fact gathering: Each nurse describes the event.
- Reflection: The person leading the debriefing facilitates the discussion of their feelings regarding the event in a nonjudgmental manner.
- Support: The person leading the debriefing discusses what happened, the positives and negatives of the care and activities surrounding the event; points out the opportunities to learn from the event; and helps nurses feel closure surrounding the event.
- Follow-up: The person leading the debriefing assesses those who might need additional counseling or support and refers them for help.
Supporting the Birthing Person, Their Partner, Support Persons, and Family
Grieving birthing persons, their partners, support persons, and family members need time to talk about their feelings without hearing advice or platitudes. Nurses can encourage friends and family to surround the birthing person and their partner with support. Nurses can educate the family that people can grieve in different ways, and the birthing person and their partner should be supported in the way that is best for them. The nurse should determine if a person of faith is desired to perform any rituals for the newborn and family. The nurse can directly contact the chaplain or the social worker or bereavement committee (per facility policy) to help arrange for a chaplain or spiritual leader to provide for the spiritual needs of the family.
Most birthing persons and their partner want to see and hold their infant. Allow them time to be with the infant, take pictures, and honor the infant’s life. Prepare the birthing person and their partners for how the infant will look; some infants will have peeling skin or deformities. Allow other support persons and family members to see and hold the infant as indicated.
When supporting the birthing person, their partner, and other family, AVOID saying the following:
- referring to the baby as “it”
- pretending the stillbirth did not happen
- suggesting the parents can get pregnant again
- discussing faith or “God’s will”
- suggesting the parents be thankful for the children they already have
(How to support family or friends after a stillbirth, n.d.)
Link to Learning
Friends and family desire to support their loved ones after a pregnancy loss; however, most people are at a loss for words. This video provides the voices of parents who have experienced loss and their suggestions on how to discuss the loss.
Cooling Cots
Many birthing persons and their partner desire to spend as much time as they can with their newborn; however, as deterioration of the body begins, the newborn must be taken to the morgue to cool and preserve the body. This limits the time the birthing person, their partner, and their family are able to spend with the newborn. Cooling cots are mats placed in the crib that keep the infant cool, preserving the body for 2 to 3 days and allowing the newborn to remain at the bedside. This gives the birthing person and their partner time to plan a religious ceremony or funeral. It also provides time for extended family to travel from out of town. Allowing the family time to make memories with the newborn is important for the grieving process.
Link to Learning
The body of a stillborn infant can be at the bedside for only a short time until it begins to break down. Cooling cots keep the body cool to give families more time with their infant. This article and video tell the story of one family and their experience using the cooling cot after the loss of their child.
Infant Memory Boxes
Creating memories of the infant is an important part of the grieving process. Nurses can help by creating a memory box and inserting footprints and handprints, a lock of hair, pictures, the baby’s measurements, an outfit, and a blanket. These mementos are a tangible way for the birthing person and their partner to remember their child. If the birthing person and their partner are not ready to see these items or take them home, many hospitals will store the box until they feel ready to accept it.
Newborn Photographs
Another way to create memories for the birthing person, their partner, and the family is by taking newborn and family photographs. The nurse can assist with this by contacting organizations that provide this service. Organizations such as Now I Lay Me Down to Sleep provide photographers trained in handling stillborn infants who volunteer their time to create memories for grieving families. Again, if the birthing person and their partner are not ready to accept these pictures, the nurse can place them in the memory box until the birthing person and their partner are ready.
Arranging for Transport to a Funeral Home
If the birthing person and their partner have decided to have a funeral and burial and they are ready to transport the newborn to the funeral home, the nurse or social worker will contact the funeral home chosen by the parents. Many labor and delivery units have a list of funeral homes experienced in dealing with stillborn infants. Some funeral homes provide free burial or cremation for the baby. The hospital chaplain, social worker, or bereavement committee (when available) can help the family make choices for a ceremony or celebration of the infant.
Trauma Possible at the Next Birth
After a perinatal loss, the birthing person and their partner can experience grief, depression, anxiety, and PTSD during a subsequent pregnancy. Studies have shown that birthing persons and their partners can feel uncertainty, guilt, continued grief, and fear of recurrent loss; these feelings can lead to an inability to bond with and attach to the new infant (Donegan et al., 2023). Pregnant persons with a previous perinatal loss fear that anxiety would negatively affect the pregnancy. This study also noted that persons with a previous perinatal loss desired more frequent fetal monitoring and individualized care. Persons with a perinatal loss can possibly need specialized support and care that emphasizes emotional recovery, peer support, and reassurance during subsequent pregnancies (Donegan et al., 2023).
Antenatal care for subsequent pregnancies usually includes more frequent prenatal visits and ultrasound exams (Wojcieszek et al., 2019). Pregnant patients with a previous intrapartum fetal loss may also be offered labor induction or elective cesarean birth (Wojcieszek et al., 2019). Health-care providers should use shared decision making regarding the timing and route of birth for subsequent pregnancies after a loss. Anticipatory guidance should be provided regarding possible trauma if birthing in the same facility.
Lactation after Infant Death
Nurses should provide anticipatory guidance regarding lactation after a loss. Most patients are not prepared to lactate after a stillbirth; however, lactation can occur 2 to 3 days after birth. A handout and online information for those who will experience lactation after an infant death (LAID) have been researched and found to be helpful for patients (Table 26.3). This information allows for anticipatory guidance on lactation after loss, acknowledges the complex emotions surrounding lactation, helps decrease physical side effects of poorly managed lactation, and provides shared decision making regarding all options for managing milk, such as donation or prevention of further lactation (Carroll et al., 2020).
| Goal | Interventions |
|---|---|
| Acknowledgment of milk and lactation after stillbirth or infant death | Acknowledge that lactation can occur; that strong emotions can be related to lactation; and that frozen milk can be donated, kept as a memento, or discarded. |
| Breast changes associated with lactation | Explain breast engorgement and milk leakage. |
| Advice on alleviation of symptoms of engorgement, infection, pain, or leakage | Discuss nonpharmacologic and pharmacologic ways to relieve symptoms. Explain signs of infection/mastitis. |
| Description of all lactation suppression options | Advise techniques for milk suppression. Explain that some parents have found that lactation suppression is helpful after a loss. Provide options for what to do with saved milk (donate, keep as memento, or discard). Use pharmacologic suppression only with the guidance of a health-care provider. |
| Description of sustained lactation options | Advise on techniques for milk expression, with the option of donating or not donating milk. Explain that some parents find solace in expressing milk. |
| Description of milk donation options | Explain the process of milk donation, how milk banks use milk, and the screening process for donation. Provide resources for local milk banks. Discuss the hazards of informal sharing of milk. Explain that the process of donation helps some parents with grieving. |
| Recognition that additional bereavement and lactation support may be needed | Provide resources, websites, and support groups, along with health-care professionals who can advise the parents. |
Link to Learning
Milk banks collect donated breast milk to be used for infants in need, especially premature infants. Milk banks screen the breast milk, pasteurize it, and test it for any infections that could be passed along to another infant. Milk banks can accept donated milk from a person after a fetal death. The Human Milk Bank Association of North America provides information on donation after fetal death.
Postpartum Depression and Anxiety
Patients experiencing a stillbirth have higher incidences of postpartum depression (PPD), anxiety, PTSD, and obsessive-compulsive disorder (OCD) (Lewkowitz et al., 2022; Westby et al., 2022). Research has noted that patients experience more PPD when their partner will not discuss the loss of the infant (Lewkowitz et al., 2022). After a stillbirth, unmarried patients experienced more PPD than married patients (Westby et al., 2022). Research also notes an increased risk for PPD in patients who felt a lack of emotional support during the birth and those who did not feel that they were able to spend enough time with the infant after the birth (Westby et al., 2022).