The family physician's role following a neonatal death

Journal of Family Practice, Nov, 1989 by Linnie Newman, Janice Willms

As the findings of researchers suggest, and the words of the parents themselves confirm, keeping a stiff upper lip " is a destructive waste of time. The object is not to forget, but to remember ... and go on.

-Nancy Berezin'

Neonatal death provides the family physician with a unique opportunity to help grieving families. The cause of the death, be it perinatal or intrauterine, is irrelevant to this article. The concern here is with the characteristics that are specific to this loss. Fathers, mothers, and siblings react differently to a neonatal death. This article offers suggestions that may be useful to the family physician regardless of the level of involvement in the pregnancy and delivery.

Substantial differences distinguish the impact of a neonatal death from that of the death of an older child or adult. First, there are few memories associated with a baby who is either born dead or dies shortly after its birth. Often, no one other than the parents has seen, held, or known the infant who dies so early. No bonding has developed between this child and the relatives and friends who will make up the mourners. In contrast, the persons grieving for the death of an older child or adult grieve for a known and beloved person for whom these relatives and friends have shared memories. In neonatal death often only the mother and the father have known their child as an individual being; therefore, they have no one with whom to share this loss.

Second, parents and siblings have been awaiting the arrival of the new family member from the moment the pregnancy was confirmed. After months of growing anticipation and preparation, emptiness is the only outcome.2 Friends and family have not developed this same sense of anticipation.

The mother of the neonate has specific issues with which she must deal. Her breasts are engorged and prepared to feed an infant. She is postpartum. Her abdominal muscles are soft. She may have a painful perineum. These circumstances usually would not trouble the new mother of a healthy child. With infant death, however, the mother has to deal with the constant reminder that after months of physical change, she has nothing to bring home but an altered and not altogether friendly body.

A third set of problems arises when friends and relatives try to deal with the neonatal death. Frequently the parents will hear various unsatisfactory cliches. Examples of such inadequate attempts at comfort are, "This is God's will," "You're very young, you can have another," or "You already have a healthy child, you should be grateful for that." Least useful is, "Why do you feel so bad? You didn't even know this baby."(3)

There is no predictable "normal" time at which the grief should have worked itself through. People mistakenly tend to believe the grieving process should be completed by 6 months, after which it is not uncommon for the parents to At the Time a Problem is Recognized Be Candid, Be Honest. If an unfortunate outcome of pregnancy is anticipated, meet with the parents together, if at all possible, when informing them. Telling either parent without the other about the impending death of the newborn places an enormous burden upon that individual. If the death occurs unexpectedly during delivery, inform both parents immediately and simultaneously.1 Discuss Decisions Together. Any decisions about interventions should be made together and they should be made without moral judgments. The physician's role is to provide the information, to clarify the options, if any, and to help guide the parents in making a wise decision for their own future and that of the child in question. Suggest Parents Hold the Baby. If the neonate is living and is expected to die soon, suggest that the parents hold and love the infant while it is still alive. The physician should use discretion in encouraging the parents to see or hold a deformed baby, keeping in mind that the grossest of physical deformities can usually be covered with blankets. If there is no hope that this child can be saved, give the parents the option of having the baby stay with them around the clock. Photographs taken now will prove helpful later in the grieving process. Point Out importance of Naming the infant. Encourage the parents to name the baby if they have not already done so. A name provides the baby with an even clearer identity to which the parents may attach the grieving process.1 include Siblings and Grandparents. Siblings, grandparents, and close friends should be urged to visit if at all possible during this time. They should also be encouraged to see and touch the baby. By doing so, these individuals will be helped to accept that there has been a living, breathing, human being. It will aid them in their own grief and will make them more effective in helping the parents through the succeeding grief period.

Urge Vaginal Delivery, if Possible. If the infant is known to have died in utero, explain carefully to the parents why it is important that the woman have a vaginal delivery rather than a cesarean section. To put a woman through the distress of labor knowing she will have a nonviable child may seem unusually cruel; however the mother will benefit by seeing her baby and then leaving the hospital relatively promptly. During the course of the labor she should have as much pain control as is necessary, but she should not be so sedated that she does not experience the birth or have the opportunity to hold her baby. Following vaginal delivery, she should be feeling well enough to participate in planning for and to attend her infant's funeral. Keep the Family Together. If the critically ill neonate must be transferred to another institution for care, the mother should be discharged with the baby. In this way the entire family, mother, father, and endangered infant, may stay together. If the parents are separated, an undue burden rests on the father to be the emissary bringing news, both good and poor, to his partner. He also becomes responsible for making decisions on the infant's behalf. At the Time of the Death Let Parents See and Hold Baby. If the parents have not been able to handle the child before its death, provide the opportunity for them to hold and see their baby for as long as they feel the need.