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How to Counsel Pregnant Women after Previous Pregnancy Losses

How do you counsel women who are currently pregnant after experiencing a stillbirth, miscarriage or death of a child of any kind?

I lost twins at 26 weeks, due to my placenta abrupting spontaneously ( I took a dive down stairs ). I have also had three chemical pregnancies that my RE so rudely described as wasted pregnancies, but that is a totally different story. So if I am understanding you correctly, you are asking how to counsel them now that they are pregnant now but have miscarried or had a still birth, or experienced any loss in the past? That is loaded.

I am trying to conceive, and all I can say, is the therapy I have received has been sound. This happened to me 11 years ago, so I have had many years to deal with it, the chemical pregnancies all in the last year. My therapist basically told me that I would never ever get over losing my children, however that with time it would be easier, and she was correct.

My fear is that when I conceive again, and at 26 weeks, I will lose a baby again, so for me, I am going to make sure I stay away from stairs #1. Rationalize that what happened to me was an accident, and that it's not likely to happen again.

Women who miscarry, I find generally freak around the 10th week, when they hit magic week 13, and they have been in constant contact with their HCP, relax remarkably. Just talking to them and keeping tabs on them I think helps. I know with my chemical pregnancies, with my first one, my doc said, I don't want to see you till you are 9 weeks, and then when I spotted at 7 weeks, he was like, oh well can't do anything, if it's meant to be it's meant to be, and I think I would have felt better if he would have said, come in lets do a US and get some levels taken. Needless to say I switched OB's and this team I am with has 2 high risk OB's and 2 CNM's who are ALL incredible, and these last two CP's they were awesome, when I would make a new goal, they would really cheer me on.

I guess that and letting them talk about it would help. Or referring them to a Thanologist who deals with death would help if it's clear it's impairing their pregnancy.

I think it is best to establish with the client what her perception of the event is and what impact it had on her. Everyone experiences grief in a different way. You might want to also have her document her dreams. Dreams can be very revealing. Don't take the dreams as literal, look at them metaphorically or symbolically. You may notice a lot of water, ships or vessels of some sort or transportation device. She may also have others driving/flying/handling controls and if water is present it may be muddy or murky. Caves, tunnels or other things in that category may also be present.

If you see these symbols, she may be in some denial. She hasn't dealt with issues regarding her past situation. One very important thing is DON'T try to smooth things out for her, don't take away from her pain, don't try to empathize inappropriately. Allow her to freely express emotions, fears, false beliefs and anything else that comes up for her. Don't push anything as it could bring on a psychotic episode. (something that a non-professional should NEVER have to deal with)

My last "advice" is to remain objective enough to know when you are no longer qualified to assist this woman in her healing. It is always ok to refer to a professional experienced in dealing with grief/anxiety/stress counseling.

This is only my opinion based solely on my personal experience with grief and as a health professional dealing with situations like this quite often.

As a woman who has experienced the loss of twins at 22 wks, and as a Midwife who has had one client loose a baby prior to birth due to a knot in the cord, I can say that this is definitely difficult time. Being able to express your anger, sadness, etc. without fear of appearing too far over the edge is important. You too can cry and be sad. Loving and caring always helps. I attended the funeral for this infant with the parents. Being there for them is important. No one was there for me. Something else that I experienced with my own personal loss, and that other women have told me they experienced was that at the time the baby(s) was due, I found myself extremely emotional and sad. At first I could not understand why. Then, on reflection, I realized that it was around the time I should have been giving birth. Each baby is so precious. Loving and kind care will help ease the transition, but not trying to "rescue" her is not helpful.... just as trying to "rescue" women from the pain of childbirth has resulted in such a skewed method of birth.

Sit and listen, listen, listen. Be open to her pain and anger, even if it is directed at you. Be there for her.

Be aware that psychological problems may arise at the time of the original demise, and many women are anxious throughout their pregnancies. Women with first trimester miscarriages are often very anxious in first trimester, and women with stillbirths at term may be anxious at term and have labor dystocias.

Make sure you know the cause of the original demise, and whether there are things that can/can't/should/shouldn't be done differently in the current pregnancy. Bad things happen to good people. Sometimes there is nothing that can be done other than listen and support. Make sure you take a careful history to elicit possible causes of the demise (for instance, antiphospholipid antibody syndrome and habitual losses might require treatment during this pregnancy, stillbirth at term from cord accident would probably not alter your management, stillbirths due to maternal chronic disease such as hypertension and severe diabetes will require fetal surveillance in third trimester.

What I tell someone who has lost a baby through miscarriage, or stillbirth is that it is normal for many women not to feel as excited with this pregnancy as they were with the first pregnancy (or the pregnancies they had before)- many women find that they have ambiguous feelings in general, many feel very scared and/or nervous through out the entire pregnancy especially if they lost a near term or full term baby. Those who have been through more than one bad experience may find themselves feeling totally detached from the pregnancy in an effort not to be hurt so bad "this time".

What I say or how I approach the issue depends a great deal on the particular woman, and what the situation was with the previous child. I think it is a good idea to find out as many details (FACTS) as possible about what happened the previous time. In many instances, no "cause" can be ascertained so you can only reassure them and let them know what kind of feelings can be normal for them and to try and take each day at a time. If the other situation is something that can be explained or diagnosed or treated, tell her those things that she and you can work on to try and avoid the same situation. The bottom line is to reassure them, validate their feelings, and maybe expect a "needy" type of person at times

I had a miscarriage with my fourth pregnancy and was always extremely sensitive/unsure/ until I past that period in my subsequent pregnancies, and even a little farther in the pregnancy. Even though I had children both before and after, the extent of my feelings hasn't really changed, though it is not as acute as the time it happened. That is what many women experience though, have you heard ladies in their 60's-80's telling their stories??? They still well up with tears 40-50 years and many great grand children later.

I would just caution not treating the issue lightly and at least bring it up to see the woman’s response so you can glimpse a bit of how she might be reacting inside. Many women are very stoic on the outside and won't bring it up for fear there is something wrong with them or that the provider may think they have a mental problem of some sort

There is a great little book, actually two books. One is called When Hello Means Goodbye and the other is called Still To Be Born. They were both written/ complied by Pat Schweibert here in Oregon because of need and her work with women whose babies died and the second book for women who wished to have a baby after losing a baby. I am not sure where you can get them outside of OHSU (Oregon Health Sciences University). Anyway they are just great and really address the issues you or your client are facing.