The loss of an infant through miscarriage, stillbirth, or neonatal death is perceived as a traumatic life experience. It is recognized as a tough life event, which can oftentimes cause complicated grief (CG) reactions that risk negatively influencing psychological and physical well-being. Generally, when a pregnancy ends in the death of a fetus or neonate, the loss is both unexpected and devastating for the mothers or the couple. They usually struggle with post-traumatic stress disorder (PTSD), anxiety, and depression, especially when not approached or managed properly.
The most likely causes of fetal death include chromosomal abnormalities, congenital malformations, infections such as hepatitis B, immunologic causes, and complications of maternal disease. If the death occurs before the time of quickening, the client will not be aware the fetus has died because she is not able to feel fetal movements. If a fetus dies in utero past the point of quickening, the client will be very aware that fetal movements are suddenly absent. On assessment, no fetal heartbeat can be heard. An ultrasound will confirm the absence of a fetal heartbeat.
Perinatal loss is a crisis within a crisis. Women and their partners undergoing pregnancy loss frequently talk of not getting on with their life goals, plans, and dreams. They appear stuck, off track, as if they are running in place as life passes them by. This care plan is directed at the emotional needs of the postpartum client who must cope with the death of a child.
The following are the nursing priorities for patients experiencing perinatal loss (miscarriage, stillbirth, neonatal death):
Assess for the following subjective and objective data:
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with perinatal loss (miscarriage, stillbirth, neonatal death) based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
Therapeutic interventions and nursing actions for patients experiencing perinatal loss (miscarriage, stillbirth, neonatal death) may include:
Grief is a deeply personal process that nevertheless follows a fairly predictable course. Although the parents have not built up a relationship with their infant, grief after pregnancy loss does not differ significantly in intensity from other loss scenarios. As has been found in bereavement involving first-degree relatives, grief symptoms usually decrease in intensity over the first 12 months. Perinatal losses have also been shown to have a substantial psychological impact on parents and families. Overall, high levels of complicated grieving are generally associated with a poorer state of mental health (Kersting & Wagner, 2022). One of the most difficult situations for nurses is caring for a client and her family when the pregnancy has spontaneously resulted in the baby’s death. Parents grieve in complex, individual, and powerful ways and require significant emotional support. Nurses must provide sensitive and supportive care for vulnerable families while coping with their emotional responses to the situation (Roehrs et al., 2008).
Assess the magnitude of the loss for both members of the couple. Regard how strongly the couple desired this pregnancy.
The magnitude or weight of the loss is a factor (e.g., whether the pregnancy was planned, whether the couple has lost other pregnancies, length of time associated with trying to conceive) in the extent and duration of the grief response. In addition, the parents may feel the loss throughout their lives, mourning for the child they will never know or watch grow up. Ambivalent attitudes toward the pregnancy were also found to be associated with more intense grief reactions, and the loss of unplanned pregnancy was often reacted to in the same way (Kersting & Wagner, 2022).
Assess the client’s/couple’s information and understanding of events surrounding the death of the fetus/infant. Provide more accurate information and correct misconceptions based on the couple’s readiness and ability to listen effectively.
Emotional reactions may prevent the couple’s ability to process information and interpret the significance of events. If the child has a congenital anomaly that led to the death, prepare them for this before bringing the child to them and explaining how the anomaly affected the child (Kersting & Wagner, 2022). Concrete thinking patterns (literal interpretation) may be the only available means of coping with information at this time.
Observe the client’s activity level, sleep pattern, appetite, and personal hygiene.
These areas may be neglected because of the process of grieving and associated depression. Sleep patterns may be disrupted, leading to fatigue and further failure to cope with distress. The client may require support in meeting physical needs and may need assurance that it is acceptable to resume usual activities. Be certain before the client is discharged from the healthcare facility that she has a support person she can rely on during the following week or month when the full impact of the fetal loss registers with her.
Consider religious beliefs, cultural processes, and ethnic background.
Perinatal loss is the only type of loss in Western society for which there are no culturally sanctioned rituals or traditions to help the bereaved to say goodbye. It is important to understand the cultural context in which these parents are forced to grieve in isolation and the psychological consequences of grieving a loss not recognized by society (Markin & Zilcha-Mano, 2018).
Assess the severity of depression.
The client/couple may detach themselves and have a problem making decisions. These early and late perinatal losses may have profound, negative effects on bereaved parents and have been associated with the development of severe anxiety, major depression, posttraumatic stress disorder (PTSD), increased suicidal ideation, and up to four times the rate of divorce. In subsequently healthy pregnancies after perinatal loss, increased health care use, anxiety, and depression were common, and increased postpartum depression was found after the birth of subsequent healthy infants (Hutti et al., 2018).
Observe the client’s/couple’s verbal cues often.
Recognize signs of developing or increasing somatic complaints, preoccupation with the death, loss of normal behavior patterns, overactivity with no apparent sense of loss, excessive hostility, or agitated depression. This may mean a sudden alteration in the client’s or couple’s way of coping with the situation. Guilt, failure, and depression may be more pronounced in couples with a history of child loss(es). Other signs may suggest dysfunctional grieving.
Allot a private room if the client wants it, with regular contact by care providers. Encourage feelings by unlimited visiting of family and friends.
A place where family and friends can open up and share their feelings without restriction promotes comfort. Based on stress theory, social support is thought to have a buffering effect, and poor social support from family and friends is associated with complicated grieving reactions (Kersting & Wagner, 2022).
Support free flow of emotional expression. Only restrict behavior that is dangerous to the well-being of the client/couple (e.g., pulling out IV, using fists to pound on the abdomen).
Expression of grief is influenced by cultural/religious beliefs and expectations, running the gamut from stoic silence to screaming and pounding one’s chest/throwing objects, etc. While expression of loss is cathartic, extended stoicism may impede the mourning process. Giving the client opportunities to express how she feels about this loss. “This must be a very difficult day for you” is the kind of statement that opens up the topic for discussion.
Include the partner in the planning of care. Grant opportunity for the partner to be seen individually. Reinforce discussion of concerns.
Partnership in planning and decision-making acknowledges that the partner has also lost a child and may need time to express feelings of loss and receive support without having to be supportive of the client and others. The loss of an infant during pregnancy can deeply distress a client and can put a strain on her relationship with the father, but it may also have a distinct psychological impact on the grieving father. Symptoms of grieving in men were found to be similar to those of women, except that men report less crying and feel the need to talk less about their loss (Kersting & Wagner, 2022).
Consider the individual nature of movement through the stages of grief; inform the client/couple that delays in the grief process or relapses of grief are normal.
The process of grieving is not usually a fluid progression through the stages to resolution; it is rather a fluctuation between stages and possibly involves skipping of stages. Knowing that grieving is individual helps the couple let each other grieve at his or her own pace. There are no set time limitations for resolving grief, and it is not unusual for the family to be actively dealing with the loss one to two years later.
Recognize the stage of grief being displayed, e.g., denial, anger, bargaining, depression, and acceptance. Use therapeutic communication skills (e.g., Active-listening, acknowledgment), respecting the client’s desire/request not to talk.
If the process of grieving is not completed, grief may become dysfunctional, resulting in behaviors that are disturbing to personal safety and the future of the family and marriage/relationship. The nurse can counsel the couple on the importance of sharing feelings, experiences, and needs in a non-threatening manner and encourage the partner to do the little things that show his partner that he cares for her and will not abandon her (Hutti, 2005).
Regarding communication patterns among the couple and support systems.
In various instances, parents display anger and blame toward one another. Anger may arise from fear of losing another child or a threat to self-esteem. Projections of guilt and blame, as well as angry feelings towards a partner and the loss of the vision of a future as a family, may put considerable stress on the relationship (Kersting & Wagner, 2022).
Reinforce the family’s expression of feelings and listen (remaining calm or commenting as appropriate). Observe body language. Promote a relaxed atmosphere.
Grieving families need repeated opportunities to verbalize their experiences. Verbal and nonverbal cues provide hints about the family’s degree of sadness, guilt, and fear. Active listening conveys caring, demonstrating an awareness of the unique significance of the loss to the client. Significant others should be encouraged to express how they feel about the baby’s death and the meaning this will have to the family and avoid minimizing the loss (Hutti, 2005).
Recognize what has happened as often as necessary, reinforcing the reality of the situation and encouraging discussion by the client.
Many families have no earlier struggle in coping with the death of a young person and have few role models to whom they can relate. The nurse can act as an educator and facilitator concerning ways to act and talk about the experience and explain and correct misconceptions. The couple may experience less stress in their relationship if each can accept how the other feels about the loss and the normality of those reactions (Hutti, 2005).
Take pictures of the child wrapped in newborn attire. Allow the couple to accompany or hold the child, if appropriate. Offer the couple footprints, hospital bracelets, or a lock of hair, if desired.
Pictures and touching or holding an infant can be effective and may begin acceptance of the reality of the loss. Ask if the parents wish to see the child after birth. Point out endearing features of the child as these can provide a focus for memories. However, some couples may not be able to cope with the loss. Remembrances of the infant, if not taken by the parents, should be filed with the chart so that they are prepared if the couple requests them at a later time.
Render physical care (e.g., bath, back rub, nourishment) as needed. Allow the client to engage at a level of ability.
Normal grief may include a period during which activities of daily living are impaired. Assisting in the client’s physical care displays caring and nurturing and helps the client conserve the energy required to meet the demands of the grieving process. Involvement in self-care maintains self-esteem and a sense of competence.
Talk about anticipated physical and emotional responses to loss. Evaluate coping skills.
This aids the couple in recognizing the normalcy of their initial and subsequent responses. Grieving is individual, and the extent and nature of the response are influenced by personality traits, past coping skills, religious beliefs, and ethnic background. Reactions to the loss of a significant person often include temporary impairment of day-to-day function, retreat from social activities, intrusive thoughts, and feelings of yearning and numbness, which can continue for varying periods (Kersting & Wagner, 2022).
Review role changes and plans to deal with loss. Note the presence of siblings.
Most families anticipate a healthy pregnancy and positive outcomes and are not prepared to focus on funeral arrangements, what to do with the nursery, how to carry on their lives, and how to plan for the care of the other children. Logsdon (2003) asserted that for social support to be perceived as helpful, it must match the needs and expectations of the recipient, the cost of returning the favor must not be excessive, and preferred support should come from an individual with whom one has a trusting and intimate relationship (Hutti, 2005).
Consider means for the parents to talk with siblings. Allow the parents to give simple, honest explanations, using correct words, at the level of the child’s understanding.
This provides the parents with an approach to handling challenging new experiences. Siblings’ sleeping patterns may be interrupted by their perception that they may also die. Siblings may feel guilt or responsibility for the death, especially if they had negative thoughts about the pregnancy or infant. If there are older children, it might help to explore how the client plans to explain the fetal death to them.
Refer to, or contact, clergy, according to the family’s wishes.
The family may want to meet with a minister or spiritual advisor to provide baptism, last rites, cultural rituals, and/or counseling. Note: Baptism is not acceptable in some religions (e.g., Jehovah’s Witness, Seventh Day Adventist). Religious communities are beneficial as another source of social support, as greater religious participation has been related to increased perception of social support contributing to less grief-related distress for parents (Kersting & Wagner, 2022).
Assist in obtaining requests and signatures for the performance of an autopsy if appropriate. Review the benefits and limitations of the autopsy.
Families may want or need an explanation of the cause of death, which may not be possible. Explain hospital procedures such as when the body will be released or what additional permission for an autopsy is needed.
Give information about the disposition of the infant’s body. Contact a mortician of the family’s choice if assistance is required.
Bodies of children, like those of adults, must be transferred from hospitals to mortuary facilities or other dispositions, usually within 24 hours of death. While burial may be delayed in most instances, Jewish tradition requires burial within 24 hours, which may further complicate the client’s grieving process if she cannot attend the ceremony. Israeli society is becoming more aware of the potential negative consequences of certain traditional attitudes around perinatal loss, and starting in 2014, parents of stillborn babies or fetuses that died toward the end of pregnancy are permitted to participate in funerals (Markin & Zilcha-Mano, 2018).
Refer to, or contact, social services, if necessary.
The family may need support in planning the cost of a funeral and other necessities. Effective social and professional support matches the needs and expectations of the recipient comes from a preferred individual, and does not have an excessive payback cost of returning the favor. Professional support interventions should be as close as possible to the parent’s standard of the desirable after the caring process of “knowing” has commenced (Hutti, 2005).
Plan follow-up meetings or phone calls, as appropriate. Refer to community resources/support groups (e.g., visiting nurse services, Compassionate Friends, etc.).
This provides the client or the couple with the opportunity to discuss and ask questions. This assists the client or couple at crucial moments in the grief process, providing role models and the opportunity to discuss the loss with others who share the same experience. Support is often viewed as most credible when it comes from someone who has previously experienced and successfully managed a similar crisis. Some parents will appreciate and use a referral to a support group for bereaved parents; others will not. However, this information should always be made available to them in case they change their minds (Hutti, 2005).
Refer for counseling or psychiatric therapy, if necessary.
Severe grief response may be noted in older women and those with longer-term pregnancies. In addition, carrying the fetus for one or more days after death increases the risk. In cases of pathological grief, ongoing counseling may be necessary to help the individual(s) identify possible causes of the abnormal reaction and resolve the grieving process. Note: The risk of a major depressive episode is highest during the first month following the loss, whereas women without other children or who have had a prior depressive episode remain at increased risk for six months.
Assess the present family situation and psychological status.
Members of the family may provide support for one another. But, disbelief, anger, and denial may momentarily weaken parenting skills, and other children may be neglected or handled differently from the way they had been handled before the death of the infant. Evaluate the meaning or significance of the loss for the family before intervening, or they may make assumptions in their care that will cause further pain (Hutti, 2005).
Review the family’s strengths, resources, and past coping skills.
Members of the family may be depressed, may feel entirely incompetent, and may need to review what has happened and what their goals in life may be. Adjustment after bereavement has been empirically shown to occur through a sequence of stages in a longitudinal study of bereaved individuals. This study revealed that in normal grieving, negative grief indicators such as disbelief, yearning, anger, and depression peak within approximately 6 months of loss (Kersting & Wagner, 2022).
Determine the understanding of the experience of loss.
The second step in intervening after a perinatal loss involves talking with the parents to evaluate the actual loss experience and compare it to the “standard of the desirable”, that is, how it ought to be, given that they must go through it. If the actual loss experience is widely divergent from their perceived standard, parents are likely to feel angry and victimized (Hutti, 2005).
Promote the exchange of feelings and listen for verbal cues indicating feelings of failure, guilt, or anger. Discuss normalcy of feelings.
Recognizing one’s feelings may trigger the realization of their causes and can be used to verify the acceptability of these feelings. Parents may be hesitant to describe negative feelings that they consider abnormal. The realization that feelings of grief, guilt, and anger are normal may help alleviate the parents’ sense of failure. Hutti found that conflict within the relationship was reduced if the partner accepted how each other felt and allowed each other to grieve in their way and at their rate (Hutti, 2005).
Discuss the situation regarding activities that need to be completed or continued and the available resources.
In some instances, grief causes immobilization, resulting in dysfunctional parental patterns to the point that normal household routines are disturbed, and outside assistance is required. In a study, approximately one-half of the mothers mentioned receiving practical assistance from family and friends. The assistance included helping with everyday life, such as child care and meals, and helping to make funeral arrangements. One mother advised that family and friends should anticipate the practical help the parents need because they may not know to ask for help (Kavanaugh et al., 2004).
Recognize expected role changes required by the loss.
Nurses can help the parents recognize that all of their support cannot come from their partners because both are experiencing a crisis that reduces their ability to support each other completely (Hutti, 2005). Foreseen changes include a period of disorientation or breakdown in normal patterns of conduct, succeeded by a period of reorganization in which energy is properly invested in new people and activities.
Provide information and assist parent(s) in dealing with the situation, balancing self-care, grief needs, and parenting responsibilities.
The death of a child requires unanticipated changes in parental roles. With the death of a first child, the only parental function that occurs is grief. If there are other children, however, parents may express concern about their parenting abilities. Feelings of failure or guilt may lead to a sense of ultimate inadequacy. Nurses may assist the couple in expressing their support needs by asking each parent how they wish to be supported (Hutti, 2005).
Give the client simple choices of activities, with the opportunity to do more as she progresses.
The client must convey that she is seen as a functional, competent person, even though she may not feel that way. Encouraging the client to clarify and express clearly their needs and expectations from their partner, their family members, and their healthcare provider is helpful (Hutti, 2005).
Identify ways in which the family may support the client after the loss.
Friends and family are often unsure how to provide support to bereaved parents. How families and friends support parents can have lasting effects. If parents perceive that they are not supported, they may feel isolated and misunderstood in their grief. Furthermore, a lack of social support has been linked to complicated or chronic grief. Often, many family members came to the hospital to be with the parents, and in many cases, parents explained that family bonds were strengthened after the loss because of their family’s presence (Kavanaugh et al., 2004).
Refer to resources such as social services, visiting nurse services, and other agencies.
This may be necessary to assist family members or to replace them when they are not available to help (because of distance and/or their lack of coping skills). This may foster the growth and individualization of family members. At times, caregivers may believe that one or both parents would benefit from professional bereavement counseling and follow-up, especially when grief appears to be unusually intense or “pathologic”. Pathologic grief differs from normal grief by its duration and the degree to which the parent’s emotional state and everyday behaviors are affected (Hutti, 2005).
Refer to parent support groups (e.g., Compassionate Friends, SHARE).
Others who have gone through the same process can reaffirm the normalcy of parents’ feelings and responses. A referral is best made when the client or couple is experiencing depression and shock. It is more complicated to refer the client or couple during the stages of denial and anger. Support is often viewed as most credible when it comes from someone who has previously experienced and successfully managed a similar crisis (Hutti, 2005).
Refer for psychiatric counseling or psychotherapy, if indicated.
Extra support in coping with grief may be necessary. Psychotherapy may be effective in cases of pathological grief or overprotectiveness, which can negatively affect normal parenting and the integration of loss into usual activities. A further recent study examining the efficacy of an Internet-based cognitive behavioral therapy for mothers after pregnancy loss showed positive treatment effects, with the intervention group showing significantly reduced symptoms of grief, PTSD, and depression after treatment relative to the waiting-list group, and these symptoms reduction was maintained at 3-month follow-up (Kersting & Wagner, 2022).
Self-esteem typically refers to feelings of self-worth or a global evaluation of the self, which has profound implications for individual well-being. For many women, motherhood is a role full of meaning and expectations. The loss of a baby or child represents the loss or shaking of that significant role. This may greatly affect the client’s concept of self (Hill et al., 2016). Birth and death are two of the most significant life events in their own right: in stillbirth, they fuse inseparably, with a devastating impact not just on the infant who has died but also on parents, families, healthcare professionals, communities, and the wider society. For all parents, the death of their baby caused them to reflect existentially on their life values and belief systems (Nuzum et al., 2017).
Assess the client’s perception of self.
One mechanism that may explain why the loss of a baby could have an intense impact on self-esteem relates to a women’s mother identity. Motherhood ranks high on the hierarchy of identity salience for clients with children- more so than marriage or career. In other words, a woman who highly ranks in her identity as a mother is more likely to form her centrality, psychological meaning, and commitment -consciously or unconsciously- around motherhood. The loss of this identity is a loss of the future status as a mother (Hill et al., 2016).
Identify the couple’s self-perceptions as parents.
Giving birth provides opportunities for giving love, being loved, building self-esteem, feeling proud and accomplished, establishing a reason for living, and creating a bridge to the future. Loss of the pregnancy and newborn is, therefore, frequently associated with feelings of inadequacy, powerlessness, and inferiority, directly affecting the sense of self and possibly shattering one’s self-esteem as a parent.
Assess the family’s response to loss, noting blame placed by family members.
Expression of anger or blame by other family members may further reduce self-esteem. The sense of loss/failure may be exacerbated in cases of repeated miscarriages or serial fetal/neonatal deaths. The quality and quantity of ties a person has with their social network are associated with improved health status. Unfortunately, family members often do not know how to respond appropriately to the bereaved couple, and lack of response or inappropriate response often results in a rupture in family communication (Hutti, 2005).
Review with parent(s) what has happened and assess how they perceive the death.
Another unique aspect of pregnancy loss is that women feel that their bodies have failed and that their femininity has been undermined. Negative life events, whether discrete or continuous, can lead to negative changes in the individual’s roles, which then wear away the protective elements of self-concept. (Hill et al., 2016) Additionally, anger among family members may be transferred to the client/couple, resulting in a distortion of actual events.
Explore destructive behaviors, differentiating the responses of others from self-elicited responses (e.g., expressions of blame and/or guilt).
Destructive behaviors may be obvious during the phases of anger, isolation, and depression. Denial may be used as protection against loss of self-esteem. Guilt may be verbalized, especially if the loss is related to a genetic problem, uterine trauma (e.g., car accident or fall), or teratogens from environmental exposure or drug ingestion. Self-blame may prolong the normal grieving process, especially if there was a feeling of ambivalence towards the pregnancy (Kersting & Wagner, 2022).
Present positive reinforcement for expressing needs and identifying concerns.
This helps in coping with the sadness of the situation. It aids the parents in accepting themselves as worthy human beings. Couples may experience less stress in their relationship if each can accept how the other feels about the loss and the normality of those reactions, as well as differences between men and women. Nurses can counsel couples on the importance of sharing feelings, experiences, and needs in a non-threatening manner and encourage men to do little things that show their partner that he cares for them and will not abandon them (Hutti, 2005).
Encourage the client to be assertive.
It is helpful when the client can be assertive and tell their family members, friends, or providers when their feelings have been hurt or when others have said or done something that made the client angry. This allows others to alter their behavior to better meet the support needs of the client. Instead of feeling victimized by the situation, the client is empowered. Unfortunately, some parents are usually in such a crisis that it is very difficult for them to act assertively and confront significant others in the immediate aftermath of a perinatal loss (Hutti, 2005).
Consider the parenting needs of other children as appropriate.
Continuing to care and to feel needed assists in preserving the client’s or couple’s identity as the worthwhile parent(s). Role stress and conflict may arise when a mother’s internal scripts and external social performances are interrupted. In one sense, the presence or absence of living children may not mitigate negative affective states: losing a child, one for whom a mother is charged to protect, may augment her internal social script for the motherhood role. However, having living children toward whom they can express those roles may be protective against the interruption of the external maternal role performance (Hill et al., 2016).
Provide an opportunity for verbalization, venting of emotions, and crying.
Sharing of loss provides an opportunity for needed acceptance, helps the parents sort through feelings, and validates the parents’ normal feelings of powerlessness and inadequacy. Give the client opportunities to express how she feels about this loss. “This must be a very difficult day for you” is the kind of statement that opens up the topic for discussion. Although this is a difficult time, encouraging them to express their grief can help make the fact the pregnancy has ended and allows the couple to begin rebuilding their life.
Encourage the client to list down their fears and anxieties and address them.
Nurses can encourage the parents to list their fears and anxieties and then use this list to explore and correct misconceptions. To deal with anxiety over the possibility of a subsequent pregnancy, parents should be encouraged to avoid emotion-focused coping strategies and instead use cognitive-behavioral and relaxation techniques to improve coping. Activities that may help them reduce anxiety include physical activity, positive self-talk, meditation, relaxation techniques, visualizing the birth of a healthy baby, and yoga (Hutti, 2005).
Help the couple recognize their needs and accept help from others.
Health care providers should encourage the couple to ask for and accept help from various sources, including family, friends, coworkers, health care providers, and support groups. Providers can also assist the couple in recognizing that strains in family communication often occur after a perinatal loss and encourage them to deal with it proactively (Hutti, 2005).
Consider referrals for counseling and assist with coordination of appointments (e.g., with social services or support groups).
The client’s or the couple’s ability to coordinate and perform tasks may be compromised. Referrals help provide support and assistance, which can facilitate the integration of loss into daily life and enhance self-esteem. Parents may not be ready to consider a support group until several weeks after the loss. This information should not be provided until after the birth (Hutti, 2005).
Assist the couple when they decide to “try again”.
When the time comes for parents to decide to become pregnant again after a perinatal loss, they want health care providers to explain the risks and benefits of becoming pregnant within a given period, and then they want the decision to be left up to them. In a subsequent pregnancy, couples with a history of losses need help from their health care providers regarding increased fear and anxiety, decreased self-esteem and sense of self, managing complex parenting issues, and increasing support and trust (Hutti, 2005).
Assess the client’s religious or cultural beliefs concerning pregnancy loss.
Examining the client’s reproductive story can serve as an assessment and intervention, wherein the nurse and the client use narratives to more deeply understand the client’s culture, worldview, and meaning-making for early pregnancy loss. For example, the nurse may use genograms, life maps, or ecomaps (Crockett et al., 2021).
Assess the impact of the client’s religious/spiritual beliefs on their coping.
Given the potential impact of religion/spirituality dimensions on the client’s experience of early pregnancy loss and their reproductive story, it may also be important to assess religion/spirituality factors. When assessing the client’s beliefs and their potential impact on coping, the nurse may find it helpful to adapt models such as the five functional tasks proposed by Butts and Gutierrez (2018). Applying a model like this helps the health care providers to better understand the client’s experiences as well as to inform goals “that are consistent with the client’s spiritual and/or religious perspectives” and preferences (Crockett et al., 2021).
Determine supportive connections and resources to use after discharge (e.g., extended family, friends, or religious affiliations).
The use of a support system is an effective means of coping with grief and maintaining perspective. Religious communities are beneficial as another source of social support, as greater religious participation has been related to increased perception of social support contributing to less grief-related distress for parents (Kersting & Wagner, 2022).
Develop a sense of self-awareness before exploring the client’s feelings.
In addition to understanding the client’s culture and worldview, the nurse must also actively cultivate self-awareness, including understanding their religion/spirituality “attitudes, beliefs, and values.” Self-reflection and the cultivation of self-awareness are ethical and professional duties for counselors. Understanding themselves and the limits of their understanding will help the nurse to use consultation and make referrals appropriately (Crockett et al., 2021).
Communicate with the client or couple therapeutically, giving importance to the client’s cultural and religious/spiritual beliefs.
Competent counselors use language and approaches that are consistent with the client’s culture and worldview, including their religion/spirituality perspectives. As the client processes their experiences of early pregnancy loss, the nurse must recognize and address therapeutically relevant religion/spirituality themes in client communication. The nurse should take care to use and explore the meaning of the client’s language concerning their experience of early pregnancy loss, as well as their culture and worldview, including religion/spirituality, gender, and affectional identities (Crockett et al., 2021).
Acknowledge and support the couple’s decision to perform religious ceremonies for the fetus/infant.
All parents in a study expressed how religious ceremonies helped them to attribute spiritual significance and value to their baby’s life. Participation in a ceremony helped the parents to express their grief and to confront the reality of physical separation by saying “goodbye.” Most parents had a ceremony of naming or blessing their baby after the baby was born; some had a baptism. Parents had a funeral or prayer service for their baby before burial or cremation (Nuzum et al., 2017).
Open up about the loss with the client or the couple.
Grieving and the attempt to make sense of the situation and to recover without the baby may cause the couple to doubt their religious beliefs and feel victimized or angry. Talking about the objective findings can benefit the client or couple to begin to cope properly with feelings of distress. Researchers have emphasized the need to break the culture of silence and help clients name their loss, examine how they make meaning of their loss, and explore how this meaning shapes their responses to the loss (Crockett et al., 2021).
Promote the discussion of the perception of unfairness. Recognize such perception as part of the grief process.
Families experiencing perinatal loss oftentimes doubt their religious beliefs and are focused on the purpose of life and death. The struggle of some parents with theodicy (the tension between three mutually incompatible axioms: divine goodness, divine omnipotence, and the existence of suffering) found expression in feelings of unfairness and injustice at why their baby died. All parents in a study experienced the death of their baby as challenging to their faith and belief (Nuzum et al., 2017).
Keep a nonjudgmental manner while giving a chance for the client or couple to express their anger.
Anger related to powerlessness may result in putting guilt and blame on oneself or someone else or on God for “selecting them to suffer.” The diagnosis of a life-limiting condition led some parents to express strong feelings of anger toward God yet simultaneously feel a sense of dependence on God to get them through the experience. This led to a confusing sense of dependent ambivalence (Nuzum et al., 2017). Nurses as counselors should be careful to avoid offering clichéd statements and making assumptions or judgments about the client’s experiences, goals, wants, or needs concerning the loss (Crockett et al., 2021).
Refer to a hospital priest, pastor, preacher, or appropriate spiritual advisor. Communicate with the mortician, as appropriate, in guiding the family with arrangements for a funeral.
Experts in spiritual beliefs and rituals may be needed to aid in making decisions related to burial and loss. Symbolism and ritual can provide comfort and connect family members with their spiritual beliefs. In a study, the role of spiritual care and chaplaincy is recognized as being of value in perinatal bereavement. It is in this painful wilderness that healthcare chaplains are best placed to provide sensitive and meaningful spiritual care (Nuzum et al., 2017).
Initiating Patient Education and Health Teachings
The postpartum period is usually a joyful time, but nurses occasionally care for grieving parents. With most of these parents, the nurse should simply listen to them and support them. Therapeutic communication techniques, such as open-ended questions or reflection of feelings, help the parents express their grief- an early step in resolving it. Resolution of grief takes a long time to process. However, acceptance of the current situation helps the parents to slowly process information and knowledge significant to their loss and their future. Contemplation of future pregnancy is a key issue of inter-conception care. The majority of women try to become pregnant again after a loss, but subsequent pregnancies are laden with worry, anxiety, and a sense of fragility. Ultimately, the decision to conceive again rests on the bereaved couples; however, nurses can help them assess their emotional and physical readiness for subsequent pregnancies (Moore et al., 2011).
Assess the family’s eagerness and ability to comprehend and retain information.
Emotional responses may conflict with the ability to hear and process information. The denial stage is not the right time for the individual to process information, and repetition of information may be necessary because of the individual’s ambiguity and lack of control of the situation. Simple reinforcement of reality may be all that family members are receptive to at the moment.
Recognize the client’s or the couple’s perceptions of events, and correct misunderstandings, as indicated.
Mistaken understandings need to be assessed regularly, and valid information reiterated. According to Swanson’s theory of Caring, knowing is “striving to understand “ and its meaning for the other. Additionally, providing caring-based support requires knowledge of the needs of the pregnant woman who has had a prior loss (Côté-Arsenault et al., 2014).
Determine family preference when providing information.
Families have varying needs for information, depending on the stage of family development and on whether the death was intrauterine or caused by external factors or genetic problems. The nurse should listen to the parents’ responses to determine the support needed, answer questions, and understand the grief behaviors individual to the family or culture.
Review flow of events and diagnostic tests performed, using pictures if possible and appropriate.
Through the unrelenting stress that follows the loss, the client or the couple understands and retains information more easily if it is performed in a detailed manner. Symbols such as footprints or pictures of the infant may be significant. Most nursing units make a memory packet containing items such as a lock of hair, footprints on a hospital birth certificate, an identification band, a photograph, and clothing or blankets.
Let the client open up the subject of another pregnancy.
Individuals learn their willingness to think about and talk about this possibility. The typical recommendation is to avoid considering pregnancy until grief has been resolved or until at least 6 mo after the loss. This helps prevent the new baby from becoming a “replacement baby” or someone to take the place of the dead infant rather than a unique individual in his or her own right.
Be aware of your language and the terms used during communicating with the parents.
To be therapeutic, the nurse’s language reflects cultural sensitivity and the appropriate education level of the clients. Importantly, medical terms such as failed conception, products of conception, missed abortion, reproductive wastage, and the dead fetus or stillbirth should be avoided because these common phrases in perinatal settings do not take into account the human experience of clients in the aftermath of the death of their expected baby (Moore et al., 2011).
Review factors that caused the miscarriage or fetal loss.
Several studies found that the knowledge of the cause of a late first-trimester miscarriage decreased the client’s level of anxiety and self-blame. Women were reassured when a miscarriage was related to a fetal abnormality and not attributed to maternal causes. Most women wanted to follow up to include medical information specific to their situation and that had the potential to explain the cause of the loss and its possible impact on subsequent pregnancies (Moore et al., 2011).
Consider parent’s readiness regarding reactions of friends and family; role-play responses.
Family members and friends usually do not recognize the severity of the parent’s grief. Role-playing can prepare the parents for different responses from friends and relatives, who may avoid conversation about the loss, wrongly assuming that avoiding the topic is therapeutic or less painful for the parent(s). Unfortunately, family members often do not know how to respond appropriately to the bereaved couple, and the lack of response or inappropriate response often results in a rupture in family communication (Hutti, 2005).
Provide knowledge regarding possible short and long-term physical and emotional effects of grief, including somatic symptoms, sleeplessness, nightmares, dreams of the infant or the pregnancy, emptiness, fatigue, altered sexual response, and loss of appetite.
Grief is a deeply personal process that nevertheless follows a fairly predictable course. Reactions to the loss of a significant person often include temporary impairment of day-to-day function, retreat from social activities, intrusive thoughts, and feelings of yearning and numbness, which can continue for varying periods. Although grief is a natural, nonpathological phenomenon, it can lead to complicated grief, where symptoms are more disruptive pervasive, or long-lasting than in a normal grief response (Hutti, 2005).
Review the appropriateness of genetic counseling as indicated.
Genetic counseling may be recommended if the parents are worried about the reoccurrence of the problem, even if the problem is not thought to be genetic. The terms “congenital,” “teratogenic,” and “trauma” should be defined and differentiated so that parents can comprehend risk factors. The couple may have had a prior evaluation with a reproductive endocrinologist, gynecologist, maternal-fetal medicine specialist, or other specialists, and testing may have been pursued to rule out other causes of recurrent miscarriages. A referral to a genetic specialist is warranted when the prior evaluations yielded normal results and when the pregnancy, medical, and family history evaluations suggest the possibility of a genetic cause for the miscarriages or fetal death (Laurino et al., 2005).
Educate the client regarding birth control methods with verbalizations of unreadiness for a new pregnancy.
A visit at six to eight weeks after the end of the previous pregnancy is recommended to discuss the couple’s relationship, contraceptive options, emotions, and coping strategies. Ultimately, the decision to conceive again rests on the bereaved couples; however, nurses can help them assess their emotional and physical readiness for subsequent pregnancies (Moore et al., 2011).
Refer to chaplain and community support groups.
Most parents do not believe in information until they have heard it from multiple sources. In some cases, religious values may affect not only the way that the client and her partner conceptualize and cope with a loss but also their views about medical options and the medical treatment that is available to them (Crockett et al., 2021).
Review information provided by referral agencies/groups.
Support groups provide information and assistance from people who have experienced the same and give reassurance of normalcy of physical and emotional responses. Support is often viewed as most credible when it comes from someone who has previously experienced and successfully managed an s similar crisis. Some parents will appreciate and use a referral to a support group for bereaved parents; others will not. However, this information should always be made available to them in case they change their minds (Hutti, 2005).
Arrange for a follow-up after the client’s discharge.
In the case of fetal or neonatal death, couples appreciate the opportunity to meet the provider involved with the birth and loss to discuss the probable cause of the loss. Meeting with those involved with the birth may provide some sense of closure and allows the couple to express gratitude to those who were present at this sensitive and painful event. It also provides the opportunity to discuss autopsy reports and address how to approach future pregnancies, and understand the risk of loss recurrence (Moore et al., 2011).
Determine the client or couple’s readiness for a subsequent pregnancy.
Nurses may use the list of questions developed by Wheeler to help the parents determine when they are ready to consider a subsequent pregnancy: (1) Does the loss still consume my every thought?; (2) Can I think about the loss without it tearing me apart?; (3) Am I able once again to find importance in other people and activities?; (4) Am I ready to welcome a new baby into my arms? (Hutti, 2005). Their answers can help couples and providers work through the complicated emotions that are involved in the planning of another pregnancy (Moore et al., 2011).
Evaluate the risks associated with a subsequent pregnancy.
The couple will need assistance in evaluating the risks associated with the subsequent pregnancy. They will need to consult with their primary care provider about this, depending on why the fetal death occurred and whether the birth was cesarean. Increased surveillance is warranted because these women are at increased risk for another perinatal loss and obstetric complications, including prematurity and congenital anomalies (Hutti, 2005).
Assess the client’s or couple’s emotional responses to a subsequent pregnancy.
Emotional responses to the death of a baby are unique to each parent and vary from feelings of self-blame and guilt, loneliness and emptiness, anger, fear, failure, and shame, to sadness and grief. In turn, the emotional response may not only influence but also shape, an understanding of the self and identity. These may impact decisions about becoming pregnant after loss (Dyer et al., 2019).
Assess for signs of possible mental health disorders.
A subsequent pregnancy after an early or late perinatal loss may not lessen a couple’s level of depressive symptoms, anxiety, and posttraumatic stress. Women, in particular, may experience more depressive symptoms and anxiety during the subsequent pregnancy. Stillbirth is a major stressor linked to a posttraumatic stress disorder, with 20% of the women experiencing posttraumatic stress disorder during their subsequent pregnancy (Moore et al., 2011).
Validate the client’s or couple’s grief work in the subsequent pregnancy.
It is extremely helpful if the nurse can recognize and validate the signs of grief work in the subsequent pregnancy. Terms such as the resolution of grief should be avoided. Many parents do not want to forget their dead babies, feel grief is a lifelong process, and resist the notion that they will someday feel as though the loss never happened. Instead, the nurse should use terms such as reintegration or reorganization. Parents can be assured that it is normal to feel more reserved in the subsequent pregnancy, especially related to announcing the pregnancy, planning the nursery, and participating in baby showers (Hutti, 2005).
Allow more time for the parents to process their decision for the next pregnancy.
During prenatal visits, the parents may need more time for dealing with their concerns and may need more frequent visits to hear the fetal heartbeat or for reassurance. Providers should recognize that these parents may use health care resources at a higher rate due to anxiety after a perinatal loss, and so they may need more frequent prenatal visits or extra time at their scheduled appointments to deal with their feelings during the subsequent pregnancy (Hutti, 2005).
Develop an individualized plan of care and birth plan with the couple.
Attending Lamaze or prenatal classes may be difficult for these couples, and one-on-one class instruction may be more appropriate. They may need to desensitize and do “dry runs” to the hospital before going into labor to prevent a posttraumatic stress episode. Parents can be encouraged to develop a birth plan so that their special needs and concerns are more likely to be met (Hutti, 2005).
Advise the couple to wait for at least six months before a subsequent pregnancy.
Many parents who have experienced fetal or perinatal loss will have further pregnancies. The WHO recommends couples wait at least six months before trying to conceive again, based on evidence that shorter interpregnancy intervals are associated with adverse pregnancy outcomes (Dyer et al., 2019).
Provide honest answers to the couple’s concerns and requests for information.
Couples often receive contradictory advice regarding the timing of a subsequent conception when they want only the facts that would enable them to make an informed decision. Parents may not want to hear advice from family or friends regarding the timing of future pregnancies and may disregard the advice of healthcare providers if it does not coincide with their desires. Healthcare providers should individualize their care and refrain from giving routine advice on the optimal timing of conception (Moore et al., 2011). Healthcare providers need to be mindful of the client’s individual preference for the amount and type of advice that they want or need (Dyer et al., 2019).
Provide unconditional support for the couple’s decisions.
Focus more on the desires of the couple and leave decisions pertaining to the timing of a subsequent pregnancy up to them. No matter when couples decide to conceive again, the nurse should be positioned to prepare them for the possibility of increased emotional distress that can accompany a new pregnancy (Moore et al., 2011).
Provide reliable resources of information for the couple’s concerns.
Parents should be empowered to access information at a time of their choosing when they feel ready. The nurse can direct the couples and their families to Internet sources that may protect them from poor-quality sites, with the goal of connecting them to evidence-based, up-to-date information specific to their loss. Internet sources can be personalized to meet religious, cultural, spiritual, psychological, and medical needs and can be diversified according to the needs of couples and families during the various stages of grief (Moore et al., 2011).
Administer analgesics and antipyretics as prescribed.
The child may need analgesics and antipyretics such as acetaminophen and decongestant nose drops to open the eustachian tubes and allow air to enter the middle ear. These are given for only 2 to 3 days because if they are given longer, a rebound effect can occur, causing edema and a subsequent increase in mucous membrane inflammation. Instruct the parents to administer acetaminophen every 4 hours or ibuprofen every 8 hours as prescribed.
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
Other care plans related to the care of the pregnant mother and her baby:
Recommended resources to further your reading about perinatal loss nursing care plans.
Gil Wayne ignites the minds of future nurses through his work as a part-time nurse instructor, writer, and contributor for Nurseslabs, striving to inspire the next generation to reach their full potential and elevate the nursing profession.
