Chapter 37: Perinatal Loss, Bereavement, and Grief

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You know, usually when we talk about a medical diagnosis, there's this expectation of precision.

Right, like it's totally binary.

Exactly.

It's like engineering.

You break your arm, the x -ray shows that jagged white line, and the doctor just points at it and says, you know, there it is.

Broken or not broken, the treatment path is incredibly clear from there.

And there's comfort in that clarity, right?

We like things to be visible, to be categorized.

But then you step into the maternity ward specifically, into the incredibly delicate, often devastating space of perinatal loss, and suddenly that x -ray machine is just broken.

Dope, completely.

It really is the absolute definition of diagnostic muddy waters.

You are standing right at this intense intersection of birth and death.

Which is why we are here.

Welcome to a very focused edition of our Deep Dive.

If you are a college nursing student listening right now, consider this your ultimate clinical preceptor session.

Yes, grab your notebooks.

We are taking the really dense pages of chapter 37 from Maternity and Women's Health Care, the 13th edition, which covers perinatal loss, bereavement, and grief.

And we are translating that text into the reality of the hospital room.

Because as a nurse in this setting, you're not just memorizing facts.

You are managing two monumental tasks simultaneously.

You have to provide the standard physiological postpartum care to a patient who has just given birth, while at the exact same time providing intense psychological care to a family whose entire future just vanished.

It's so heavy.

So to start making sense of this, I think we really need to get our vocabulary straight.

People tend to use words like loss, bereavement, and grief interchangeably.

But clinically, I mean, they mean very different things.

They do.

And understanding the nuances actually changes how you care for the patient.

So loss is the baseline.

It's simply the absence of a valued person or object.

Bereavement is the state of being.

It's the condition of living without that valued other.

Grief, however, is the emotional process itself.

It is dynamic, it's pervasive, and it's enduring.

It is the work of making meaning out of the loss.

And then mourning is different from grief.

Yeah, mourning involves the culturally mandated rituals surrounding that grief.

So like wearing black or holding a memorial service.

Got it.

Now, when the word grief comes up, my mind immediately jumps to, you know, Elizabeth Kubler -Ross, the famous five stages, denial, anger, bargaining, depression, and acceptance.

Right.

And her work was completely groundbreaking back in 1969.

But modern clinical practice has really shifted.

How so?

Well, we now view these stages as entirely nonlinear.

Grieving people don't just march through them in a neat, predictable sequence, you know.

It is a highly individualized process.

So they might bounce from anger to acceptance back to denial.

Exactly.

And the danger for a nurse is that when we expect people to grieve in a specific sequence, we risk labeling their perfectly normal, chaotic responses as abnormal.

Which is so unfair to the patient.

That actually brings up a concept from the text that I found incredibly profound, disenfranchised grief.

This is essentially unacknowledged loss.

Yes.

That's a huge concept in this chapter.

I kept picturing it like a movie where the main character is screaming at the top of their lungs in a crowded room, but the audio is muted for everyone else.

Society just doesn't recognize their pain, so they are trapped in total isolation.

That is a stunning way to visualize it.

And that isolation is incredibly common in perinatal settings, which often involves what we call ambiguous loss.

Right, because there's no social script for it.

Exactly.

Think about it.

A mother might be grieving a fetus she never physically held, a baby that no one else in her community ever even met.

The outside world doesn't know what to do with that, so they often say nothing at all.

Leaving the parents totally alone.

Modern grief theory also pushes back on the old idea of, you know, moving on.

The continuing bonds theory argues that the goal is not to detach from the baby, but to figure out how to incorporate the deceased child into the family's future.

Like finding a new way to carry them with you.

Right.

There's also the dual process model, which explains how parents oscillate.

They swing back and forth between focusing heavily on the loss and then focusing on restoring their daily life.

Okay, wait.

So if a mother who just lost a baby suddenly stops crying, asks for a turkey sandwich, and turns on a sitcom, she hasn't suddenly entered the denial stage?

No, not at all.

She is just oscillating to a restorative state because the human brain can literally only handle so much overwhelming pain at once.

It needs a break.

That makes so much sense.

But how does a nurse actually operationalize all these theories?

The textbook introduces Swanson's caring theory as the clinical framework for this.

Right.

Swanson gives nurses five actionable concepts.

First is knowing this means you don't make assumptions.

You actively assess how this specific family perceives their loss.

Okay, so treating them as unique individuals, what's the second one?

Second is being with.

Sometimes this just means giving them your quiet, caring presence without trying to fix it because you can't fix it.

And the third?

Third is doing for providing the physical care and comfort they cannot do for themselves right now.

Fourth is enabling, offering them options and guidance so they feel a tiny sliver of control in an uncontrollable situation.

Like giving them choices about their care.

Exactly.

And finally,

maintaining belief, which is the nurse encouraging the family's intrinsic ability to somehow survive this trauma.

Okay, so that's the theoretical framework for how we care.

But the clinical reality of what we are caring for changes drastically depending on the timeline of the pregnancy.

Absolutely.

The timeline dictates everything.

The text breaks down the specific categories of loss.

And I can see why a nursing student would need to know these intimately, not just for an exam, but because the timeline dictates the entirely different environment the patient is in.

Let's look at miscarriages, or spontaneous abortions, which happen before 20 weeks.

Because they happen so early, the mother is often suffering at home, perhaps bleeding in her own bathroom.

Totally isolated.

Right, because she might not have told anyone she was pregnant yet.

Contrast that with what happens around the 18 to 20 week mark.

That's when parents usually go in for the routine anatomy ultrasound.

And they go in expecting to find out if they are having a boy or a girl, and instead they are diagnosed with a severe fetal anomaly.

A fetal death or stillbirth is categorized as early, if it happens between 20 to 27 weeks, right?

Right.

And late, if it's 28 weeks or beyond.

Finding out at the anatomy scan forces parents into agonizing traumatic decisions.

Sometimes this leads to a pregnancy termination due to a fetal anomaly.

Or if it's a multiple gestation, they might have to do a multi -fetal pregnancy reduction to try and save the remaining healthy fetuses.

Yes.

And if the baby is born alive but doesn't survive, we are looking at an early neonatal death if it's under 7 days old, a late neonatal death between 7 to 27 days, and an infant death any time within that first year.

Those usually happen in the agonizing environment of the Neonatal Intensive Care Unit, the NICU.

And that brings up a vital evidence -based practice box in the text regarding neonatal palliative care, or NPC.

What's the shift there?

For babies with terminal conditions, nurses shift from curative care to palliative care.

The priority becomes absolute pain relief for the dying infant and involving the parents early so they can be the ones to parent their child in those final hours.

But the text highlights a huge challenge here.

Nurses must manage their own moral distress.

It's so true.

Because it's human nature to want to run away from something that sad, avoidance is a very common coping strategy for stressed healthcare workers.

Just finding a reason to stay at the nurse's station instead of going into the room.

Exactly.

But as a nurse, you have to lean in.

You cannot abandon the family emotionally just because the medical outcome is grim.

We also have to acknowledge that grief isn't always tied to death.

The text covers non -death losses, too.

Oh, absolutely.

Like grieving the sudden trauma of an unexpected preterm birth, or a mother mourning the loss of the unmedicated birth she desperately wanted because she had to be rushed in for an emergency cesarean.

The grief there is incredibly real.

It is real, and it is valid.

And once you identify what the family is grieving, you can anticipate how they will react using the Miles model of parental grief responses.

The textbook outlines three phases for this.

Phase one is acute distress.

I imagine this is just pure shock, numbness, a feeling of total unreality.

Yes, and their only task in this phase is just accepting that the reality of the loss has actually happened.

That's it.

Then phase two is intense grief.

And the text gets very specific about the physical symptoms here.

We aren't just talking about emotional guilt or cognitive disorganization.

No, the physical symptoms are brutal.

Women might suffer severe fatigue, intense headaches.

And this is where the physical reality of postpartum hits the emotional reality of loss.

Women might physically ache to hold a baby, like their arms literally hurt.

It's profoundly visceral.

They might even hear a phantom cry in the room because their brain and body are still hardwired to expect a newborn.

That is heartbreaking.

It is.

And eventually they move into phase three, which is reorganization.

Notice the text is very explicit here.

Recovery is the wrong word to use.

Right, because you don't just, you know, recover from losing a child and go back to who you were before.

Exactly.

You reorganize your life around the loss and figure out how to move on.

This phase deals with the profound anxiety of resuming a normal life.

The ambivalence about resuming sexual activity.

Or the terrifying decision of whether to try and become pregnant again.

Yes, the anxiety with a subsequent pregnancy is immense.

I do want to push back on something I noticed in the chapter, though.

It spends a significant amount of time detailing the non -birthing partner's grief.

But, I mean, isn't the physical and emotional toll on the mother the ultimate priority in the maternity ward?

She's the one who just went through labor.

It's a very natural assumption to make that the mother needs all the focus.

But the reason the text emphasizes the partner is because partners often deliberately hide their feelings to be the rock for the birthing mother.

Ah, I see.

They push their own devastation down.

This leads to completely unrecognized grief, which is incredibly dangerous for their mental health and for their relationship.

So their grief becomes disenfranchised, even within their own family.

Precisely.

And we also have to consider LGBTQIA couples.

In those families, the non -biological mother might also experience profound perinatal depression.

If a nurse only focuses on the gestational parent, they are completely failing the family unit as a whole.

And the parents aren't the only ones in the room.

The nurse is constantly assessing the entire family dynamic, including grandparents and Grandparents are uniquely vulnerable here because they experience a complex double grief.

Double grief?

Yeah.

They are mourning the loss of their grandchild, all those hopes and dreams, while simultaneously enduring the sheer agony of watching their own child suffer.

And the text mentions that's often compounded by a heavy layer of survivor's guilt.

Like, why am I still here when this baby isn't?

Exactly.

And for siblings, I mean, their understanding of the death is entirely dependent on their developmental age.

Because young children don't fully grasp the permanence of death.

Right.

Completely.

They might show their grief through clinging behaviors or sudden regressions in eating and sleeping.

Teenagers, on the other hand, might pull away from the family and rely entirely on their peers to process the grief.

So what's the nurse's role with siblings?

The nurse should encourage the parents to include siblings in the morning rituals, like coming in to see the baby, but only based entirely on what the family feels comfortable with.

There's no one -size -fits -all approach.

Okay, so let's walk through how this actually looks in practice.

I'm imagining walking into a room where a loss has just been diagnosed.

What do I even say?

My instinct would be to soften the blow.

Use gentle euphemisms, maybe say something like, I'm so sorry, but the baby passed.

That instinct comes from a place of depth compassion, it really does.

But clinically, it's exactly what you shouldn't do.

Wait, really?

Yes.

Under immense psychological stress, the human brain literally cannot process euphemisms.

Think about it, if you tell a mother who is bleeding heavily that her baby has passed, she might think you mean she has passed the baby through the birth canal, or passed a blood clot.

Oh wow, she might think the baby's alive somewhere else.

Exactly.

The textbook stresses that you must be gentle, but absolutely unambiguous you must use clear words like has died.

That is such a vital distinction.

Let's apply this to the textbook's next -gen NCLX unfolding case study.

This features a patient named Sarah.

Right, Sarah.

So Sarah is a 27 -year -old.

She is pregnant with her first child at 35 weeks gestation.

She comes into triage, reporting decreased fetal movement.

And tragically, an ultrasound confirms fetal demise.

So as her nurse, you immediately deploy Swanson's Caring Theory.

When you assess her unique individual response without assuming how she feels, you are practicing knowing.

And when you offer her choices about her care, you are enabling.

Yes.

And when you bring her warm blankets and provide physical comfort, you are doing for her.

In the care management phase, the text highlights that you must treat Sarah's loss as entirely unique.

You advocate for her social support, and you offer a clergy visit, but only if you've assessed that this matches her spiritual needs.

Right, no assumptions.

But here is where my instincts as a non -nurse might be wrong again.

When Sarah actually delivers her skill -born infant, my instinct would be to protect her by whisking the baby away so she doesn't have to look at the trauma.

And again, clinical evidence tells us the exact opposite.

Seeing the baby actually facilitates the grief process.

It confirms the reality of the loss and allows them to actually say goodbye.

But as the nurse, you have a crucial job before you hand that baby to the parents.

Yes.

You must prepare them for the baby's appearance.

The text mentions preparing them for maceration.

What does that look like?

Maceration occurs when a fetus dies in utero and remains in the amniotic fluid for a time.

It causes the skin to peel.

And it can make the baby's licks look unusually brightly red.

That sounds incredibly startling if you aren't ready for it.

Exactly.

Imagine handing a parent their child, and the skin is incredibly fragile and peeling.

If they aren't prepared for that, that image becomes a lasting trauma.

But by gently explaining the physical changes beforehand, you allow the parents to look past the maceration and just see their beautiful baby.

The book actually includes photographs.

Figures 37 .1 and 37 .2 showing a family holding their baby, Laura, after a loss.

It's absolutely heartbreaking to look at, but it illustrates just how vital that physical connection is.

It really does.

And right after that, figure 37 .3, it shows a picture of a door card.

It has a picture of a leaf or a teardrop on it.

What's the protocol with that?

That door card is an essential communication tool for the entire hospital.

It warns every staff member before they walk into that room that a loss has occurred.

So it prevents a well -meaning dietary worker from strolling in and cheerfully asking, you know, how's the new mom doing today?

Precisely.

Which would just devastate the family all over again.

Now, I have to ask you about something else mentioned in the text.

The cuddle cop.

Ah, yes.

It's a cooling device used to keep the deceased infant in the hospital room with the parents for an extended period.

I have to be honest, isn't keeping a deceased baby in the room for days kind of morbid?

It can absolutely feel that way to someone outside the situation who isn't trained in bereavement.

But remember that ambiguous loss we talked about earlier?

Right.

The cuddle cot is a direct intervention for that.

That cooling device slows the physical deterioration of the infant.

It buys the family time.

Time they wouldn't normally have.

For these parents, this is the only time they will ever have on this earth to parent this child.

It allows them to read a book to their baby, to sing a song, to memorize their face.

It allows them to form memories that will have to sustain them for the rest of their lives.

Okay, when you frame it like that, it's not morbid at all.

It's a profound act of care.

It truly is.

As the nurse, you're also deeply involved in the decision -making process after the birth.

You have to explain the option of an autopsy, which means keeping in mind the family's religious considerations and the difficult reality that autopsies are expensive.

You also have to navigate organ donation.

The Organ Procurement Organization, or OPO, dictates the protocols.

But nurses should know that even in neonatal loss, if the baby was born alive after 36 weeks, corneas can often be donated.

Wow, I didn't know that.

Yeah, and that can bring a lot of comfort to a grieving family.

You also have to explain the respectful disposition of the bido, guiding them through the overwhelming choices between cremation or burial.

And through all of these impossible conversations, the nurse has to be incredibly careful about their own words.

Box 37 .1 in the text and the second NCLEX case study, which features a 37 -year -old suffering a loss at 20 weeks,

explicitly cover what to say and what not to say.

It is always indicated and appropriate to simply validate the pain.

Saying I am sad for you or I hear you saying this is so hard is powerful.

But the text lists phrases that are strictly contraindicated.

Things like God has a plan, or be thankful you have other healthy children, or you're young, you can always have another one.

Oh, those are so damaging.

But I hear people say these things all the time in everyday life.

Why are they so harmful in the clinical setting?

Because they completely invalidate the specific loss of this child.

They are attempts to fix the unfixable.

When you tell a mother she can have another baby, you are implying that this baby was replaceable.

Yeah, it shuts down the patient's grief instead of making safe space for it.

Exactly.

Well, once that emotional groundwork is laid, the nurse still has to attend to the mother's physical postpartum needs and prepare the family for discharge.

We cannot forget that this mother's body thinks she has a baby to feed.

That is one of the cruelest aspects of perinatal loss.

She is going to have painful afterbirth cramping, and crucially, a few days later, her breast milk is going to come in.

That has to be agonizing.

Your body is physically making food for a baby that isn't there.

It is a profound, painful physical reminder of the loss.

The nurse must actively help her suppress lactation using ice packs and supportive garments.

Or they can offer her the option of human milk donation if she wishes to pump.

Right.

Crucially, yes.

For some mothers, donating their milk to an NICU gives them a sense of purpose and honors their baby.

Memory making is also a huge nursing priority before discharge.

Figure 37 .4 shows a memory kit.

This is where the nurse takes footprints.

And there's a great clinical tip here from the techs.

Use a little alcohol wipe on the baby's feet first to help the ink adhere because the skin is so fragile.

That's a great tip, especially if maceration is present.

You can also cut a small lock of hair from the nape of the neck, always asking permission first, of course.

You save the tape measure you used for their length, the little crib card.

What about photos?

Taking sensitive photographs is highly encouraged, but the nurse must gently warn the family about the risks of posting those photos on social media.

They need to be emotionally prepared for the public's reaction before they share something so intimate.

That makes a lot of sense.

Assessing their individual cultural and spiritual needs is also vital before discharge, asking if there are emergency lay baptisms or specific rituals that need to take place.

And when it is finally time to leave the hospital, the text emphasizes discharge sensitivity.

Right.

You absolutely do not wheel a bereaved mother out to her car at the exact same time as a mother happily holding a live newborn.

No.

You coordinate with other staff to ensure the hallways are clear.

The text also covers post -mortem care.

Figure 37 .5 shows the burial cradle.

Instead of using a clinical, impersonal transport bag, right?

Exactly.

The infant is placed in a small cradle made of styrofoam or wood to be transported to the morgue with the utmost dignity.

We've talked so much about emotional preparation, but is there any physiological preparation for the nurse?

Like, what happens in that room that a textbook can't fully prepare you for?

There is a critical nursing alert in this chapter, and if you are a nursing student, pay very close attention to this.

Dying neonates can have reflexive twitches, or what we call agonal respirations, for hours after they have been pronounced dead.

Wait, hours?

Yes.

It is a physiological reflex and electrical firing in the nervous system.

It is absolutely not a sign of life, but if you are standing in a quiet room and the baby you just pronounced dead suddenly gasps, it is incredibly startling.

I can't even imagine.

As the nurse, you must be prepared for this reality.

You must maintain your absolute composure to keep the family from panicking, calmly explain what is happening, and quietly call a physician to reconfirm the death.

That requires an incredible amount of emotional fortitude.

Before we wrap up, we need to touch on the special circumstances the chapter outlines.

Situations that require adapted care, like a prenatal diagnosis of a lethal anomaly where the parents have to carry a pregnancy knowing the baby won't survive.

Or the loss of a multiple gestation.

Imagine the agonizing emotional whiplash of losing a twin.

These parents have to simultaneously grieve a death while celebrating a live birth.

They might be planning a funeral in the morning and sitting by an NICU incubator celebrating a weight gain milestone in the afternoon.

The text says they often feel guilty for being sad when they have a healthy baby and guilty for being happy when they just lost one.

It's a completely paradoxical grief.

What about adolescent grief?

I feel like society has this terrible stereotype that losing a teen pregnancy is somehow a blessing in disguise because they were too young anyway.

That assumption is incredibly harmful and completely false.

Adolescents grieve just as deeply, but because their brains are still developing cognitively, they process the trauma differently.

So how should a nurse approach them?

They desperately need a trusting relationship with their nurse, one devoid of any judgment, and they rely heavily on peer support groups to cope.

The chapter ends by contrasting complicated grief with post -traumatic growth.

Complicated grief is when the mourning becomes prolonged, resulting in an inability to function or severe PTSD symptoms that absolutely require a professional mental health referral.

But on the other side of that spectrum is post -traumatic growth.

What does that look like?

This is a phenomenon where parents eventually report increased personal strength, deeper relationships with their partner, and a profound new appreciation for life.

It doesn't mean they aren't sad anymore.

It means they grew from the trauma.

And when a nurse sees that growth beginning, they should absolutely validate it.

So what does this all mean for you, the student preparing to step into this role?

We spend so much time studying how the family grows from this trauma, but I want to leave you with a final thought to mull over.

How does walking a family through their darkest, most intimate moment permanently change the nurse doing the walking?

It absolutely changes you.

Consider how providing this post -mortem care, standing in the murky diagnostic waters and being the quiet, steady anchor,

might spur your own post -traumatic growth as a health care professional.

You quickly realize that while you couldn't fix the medical outcome, the profound empathy and clinical excellence you provided dictated how that family will remember their child forever.

Back to that x -ray machine.

It might be broken and perinatal loss, the landscape is murky, but your presence, your clinical reasoning, and your empathy that becomes the clarity they need.

Thank you for listening, and best of luck on your exams from all of us here at the Last Minute Lecture Team.