Fundamentals of Midwifery: A Textbook for Students (159 page)

Privacy – most Maternity Units have a Family Room for caring for bereaved families, but where this is not available there must be privacy and no interruptions.

Avoid assumptions – allow the woman and her family to take control as much as possible inrelation to the amount, pace and language of the information provided.

Provide choices where possible.

Allow time and do not be uncomfortable with silence whilst the woman and her family areabsorbing information or dealing with their emotions.

Be honest and truthful.

Co-ordinate information giving so that women and their families are not overwhelmed.

Recognise when someone does not wish to talk.378
Box 17.3 Issues to consider in relation to cultural and religious preferences

Etiquette in respect of talking about death – the use of appropriate language about death and the deceased.

Cultural/religious rituals – in relation to handling the body (who is allowed, how the body shouldbe prepared and dressed) and whether burial or cremation is required.

What ceremonies or rituals are required during the period of mourning.

How grief is expressed – is public wailing/crying expected or is grief expressed quietly and inprivate.

Gender roles in mourning.most essential element of meeting cultural and religious need, therefore, is to communicate effectively and not be afraid to ask what the woman and her family want. It is also important to recognise that the theories discussed earlier in this chapter are all Western, and do not there- fore necessarily apply to everyone (Walter 2010). As Mander (2006) suggests, stereotype-based assumptions about preferences of bereaved parents have to be avoided. Box 17.3 offers some guidance as to issues that midwives may wish to gently ask about to determine cultural or religious preferences. It may be difficult to ask questions about preferences and rituals when women and their families are distressed, however, it is better to ask than to cause further distress and offence by making assumptions.
Care around the time of death
Privacy may be required for prayer and some families may want a religious leader or chaplainto be present. Christians may want their baby to be baptised.Some cultures have customs that require the extended family to gather at the bedside and wherever possible this should be accommodated.
Figure 17.2
A private comfortable environment on a labour ward for parents who have experienced loss. Source: Women and Children’s Hospital Hull and East Yorkshire NHS Trust, reproduced with permission of Janet Cairns, Head of Midwifery.The provision of privacy should not leave parents and families feel unsupported; they need to know how to contact a midwife when they need to so the call bell system should be fully explained to ensure they do not feel isolated and fearful (SANDS 1995). Labour wards may have rooms specifically for the care of women and families following loss as shown in Figure 17.2.
Care following loss
It is important to remember that this is a situation where what is generally accepted as goodpractice does not meet everyone’s needs. This may be for cultural or religious reasons, but it may just be that it is not how the individual wants to be cared for. It is also important to remem- ber that the woman and her family may not know what they want or what their culture or religion expects of them in respect of the loss of their baby, so they will need time to make decisions and to consult with others.Some parents may not wish to see or hold their baby after death at all, whilst others may want the baby to be washed before they hold her/him as their cultural beliefs are that the fluids associated with birth are unclean. There may be rituals associated with the preparation of the body and who performs these. Where staff are asked to prepare the body it is important to ask about clothing and positioning. Some Orthodox religions (e.g. Orthodox Jews, some Muslims and Hindus) may require healthcare staff to wear gloves when handling the body. Care should be taken in relation to jewellery and the placing of flowers with the body may not be acceptable to some parents.Naming the baby may be important for some parents regardless of how early in the preg- nancy the loss occurs, whilst for others it may not be appropriate. When names are given it is good practice to use them in discussions with parents.Photographs of the baby are generally welcomed by parents; however some may have strong objections to this practice. It is important to sensitively ascertain why parents do not want photographs as some do regret not having them later. Offering to take photographs and
379380‌keeping them with the notes may be appropriate for those who are unsure, but not for those who have an objection to it.Some religions and cultures do not permit post mortem examination, so this is a subject that should be approached with extreme sensitivity and honesty about the answers such an exami- nation may provide. It is the need for answers that create a tension between beliefs and wishes for parents at times, so understanding this can enhance communication. Where there is a legal requirement for a post mortem this can cause considerable distress for parents who did not want this to happen. It is important for communication between professionals to minimise the impact on both the parents and the body of the baby where possible.Some religions require cremation whilst others require burial, though these rulings may differ between adults and children. For example for Hindu and Sikh adults are cremated, but children are buried. Funerals and ceremonies relating to death vary between both cultures and religions. There may be rules relating to women that are difficult to understand for Western midwives, as women generally may worship separately within the religion and in some cultures women are seen as unclean following birth.
Midwifery care
Whilst there are some general principles to be applied to all situations of grief and loss within
maternity care as discussed above, there are also some aspects of care that present particular challenges or need specific considerations. The following section will consider these challenges and specific needs.
Stillbirth
A stillbirth is legally defined as a baby born after the 24th week of pregnancy that has not breathed or shown any sign of life (Stillbirth Definition Act 1992). Stillbirths can occur at any stage during the last 16 weeks of pregnancy and there is not always any warning that there is anything wrong with the fetus or the woman. Sometimes however women identify that they are aware that the baby is not moving as much or at all and then it is vital that they are admit- ted for fetal monitoring and if a heartbeat is not detected an ultrasound scan should be done to confirm the diagnosis of stillbirth. Sensitive and empathetic care is absolutely vital during both the monitoring and scan and following the diagnosis. There may be a temptation to be overly reassuring whilst seeking the fetal heart but this can damage the trust between midwife and woman and can cause confusion when the diagnosis is finally confirmed. A professional approach keeps the woman informed of what is happening and why, whilst demonstrating an understanding of the anxiety and even panic she will be experiencing. Reassurance that every- thing is being done for her by calm, competent staff is what she needs at this very difficult time. Whilst it is necessary to get the baby delivered before the complications set in, the woman and her family require time to absorb the bad news and understand what will happen next. Women will want to know why their baby died and whether they could have done anything to prevent it. They are often overwhelmed with guilt even though they will have done nothing wrong. It can be difficult to address their concerns because even following the post mortem results it is not always possible to say why the baby died. Even when there is evidence of a cause, the full results of the post mortem and any other tests such as microbiology take time. A follow-up appointment will be necessary at around 6 weeks following the birth to discuss find-ings and answer any questions.Emotional support and honest professional information giving is crucial for the woman and her family. Holding the baby and the taking of mementoes such as hand and foot prints will allbe helpful. The midwife who delivered the baby can sign and issue the stillbirth certificate which will be necessary for the registration of the death. Funeral arrangements can be made by the hospital or can be done privately by the family. Families may want to dress the baby in a special outfit or wish to have a cuddly toy to go in the coffin which is no problem at all where the baby will be buried, but some materials are not always suitable for cremation and advice should be sought about this.‌
Neonatal death
A neonatal death is defined as one that occurs within a month of birth and can be due to pre- maturity, congenital abnormality, infection or asphyxia associated with labour and delivery. Care is necessarily split between the paediatric team with responsibility for the baby and the midwives looking after the woman. It is essential, therefore, that communication is inclusive and co-ordinated between the teams. Whilst the practicalities of mementoes (see Box 17.4) and funeral arrangements may be managed by the neonatal staff, midwives still have a role in pro- viding support and information giving in much the same way as they have when a stillbirth occurs. The neonatal team may only have limited involvement if death occurred as a result of a failed resuscitation at birth, and where there may be confusion as to who is responsible for what, it is vital that midwives ensure this is addressed to make sure nothing is missed or replicated unnecessarily.
Miscarriage
Traditionally women suffering early pregnancy loss requiring hospital care were admitted to gynaecology wards. However realisation that this was not a satisfactory situation for either the woman or the nursing staff on such wards has meant that increasingly cases are cared for by midwives in Early Pregnancy Units or where these are not available on Maternity Units. A miscar- riage is defined as a spontaneous loss of a pregnancy before 20 weeks; however most occur before 14 weeks. Miscarriage is sometimes known as a spontaneous abortion in medical circles which can cause great distress to women as the term abortion is more commonly associated with planned termination of pregnancy and not with the unplanned and distressing loss of a wanted baby. However, early a miscarriage occurs for many women and their families, it is the loss of a baby not a pregnancy and this is an important issue when caring for them. It can be easy to dismiss the loss as less important because it occurs before the baby starts to move or even before a scan picture is available, but with pregnancy testing being readily available many women have known since the first month that they are pregnant and have made plans for their baby.
381