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 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.
Nursing Care Plans
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 is passing them by. This plan of care is directed on the emotional needs of the postpartal patient who must cope with the death of a child.
May be related to
- Death of fetus/infant
Possibly evidenced by
- Verbal expression of distress, anger, loss, guilt
- Alteration in eating habits or sleep pattern
- Patient participates in self-care activities of daily living (ADLs), as able.
- Patient recognizes impact/effect of the grieving process (e.g., physical problems of eating, sleeping) and inquires proper help.
- Patient identifies and expresses feelings (e.g., sadness, guilt, fear) freely.
- Patient looks toward/plan for future, one day at a time.
|Label patient’s chart, room door, and/or head of bed, as indicated.||Alerts hospital staff and volunteers so they are informed about the patient’s loss.|
|Allot a private room if patient wants it, with regular contact by care providers. Encourage of feelings unlimited visiting by family and friends.||A place where family and friends can open up and share their feelings without restriction promotes comfort.|
|Support free flow of emotional expression. Only restrict behavior that is dangerous to well-being of patient/couple (e.g., pulling out IV, using fists to pound on 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 mourning process.|
|Include partner in planning care. Grant opportunity for partner to be seen individually. Reinforce discussion of concerns.||Partnership in planning and decision making acknowledges that partner has also lost a child and may need time to express feelings of loss and receive support without having to be supportive of patient and others.|
|Discover the magnitude of the loss for both members of the couple. Regard how strongly couple desired this pregnancy.||The magnitude or weight of the loss is a factor (e.g., whether pregnancy was planned, whether couple has lost other pregnancies, length of time associated with trying to conceive) in the extent and duration of the grief response. In addition, parents may feel the loss throughout their lives, mourning for the child they will never know or watch grow up.|
|Consider the individual nature of movement through the stages of grief; tell patient/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. Note: There is no set time limitations for resolution of grief and it is not unusual for the family to be actively dealing with the loss 1-2 yr later.|
|Assess patient’s/couple’s information and understanding of events surrounding the death of the fetus/infant. Provide more accurate information and correct misconceptions based on 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. Concrete thinking patterns (literal interpretation) may be the only available means of coping with information at this time.|
|Recognize stage of grief being displayed, e.g., denial, anger, bargaining, depression, acceptance. Use therapeutic communication skills (e.g., Active-listening, acknowledgment), respecting patient’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 to the future of the family and marriage/relationship.|
|Regard communication patterns among members of 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 threat to self-esteem.|
|Reinforce family’s expression of feelings and listen (remaining calm or commenting as appropriate). Observe body language. Promote relaxed atmosphere.||Grieving families need repeated opportunities to verbalize their experience. Verbal and nonverbal cues provide hints about family’s degree of sadness, guilt, and fear. Active-listening conveys caring, which demonstrates an awareness of the unique significance of the loss to the patient.|
|Recognize what has happened as often as necessary, reinforcing the reality of the situation and encouraging discussion by the patient.||Many families have no earlier struggle of 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 can explain and correct misconceptions.|
|Take pictures of the child wrapped in newborn attire. Allow couple to accompany or hold the child, if appropriate. Offer the couple footprints, hospital bracelets, or lock of hair, if desired.||Pictures and touching or holding infant can be effective and may begin acceptance of the reality of the loss. Note: Couple 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 couple requests them at a later time.|
|Observe patient’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. Patient may require support in meeting physical needs and may need assurance that it is acceptable to resume with usual activities.|
|Render physical care (e.g., bath, back rub, nourishment) as needed. Allow patient to engage at level of ability.||Displays caring and nurturing and helps patient conserve energy required to meet the demands of the grieving process. Involvement in self-care maintains self-esteem and sense of competence.|
|Talk about anticipated physical and emotional responses to loss. Evaluate coping skills. Consider religious beliefs and ethnic background.||Aids the couple in recognizing normalcy of their initial and subsequent responses. Grieving is individual, and the extent and nature of the response is influenced by personality traits, past coping skills, religious beliefs, and ethnic background.|
|Review role changes and plans to deal with loss. Note presence of siblings.||Most families anticipate a healthy pregnancy and positive outcome 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.|
|Consider means for parents to talk with siblings. Emphasize importance of words that are used, such as when the word “sleep” is replaced with “death.” Allow parents to give simple, honest explanations, using correct words, at the level of the child’s understanding.||Provides parents with approach for handling challenging new experience. 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.|
|Assess severity of depression.||Patient/couple may detach themselves and have problem making decisions.|
|Observe the patient’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.||May mean sudden alteration in patient’s/couple’s way of coping with the situation. Guilt, failure, and depression may be more pronounced in couples who have had previous child loss(es). Other signs may suggest dysfunctional grieving.|
|Refer to, or contact, clergy, according to 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).|
|Help in obtaining requests and signatures for performance of autopsy if appropriate. Review benefits and limitations of autopsy.||Families may want or need explanation of cause of death, which may not be possible.|
|Give information about disposition of infant’s body. Contact mortician of family’s choice if assistance is required.||Bodies of children, like those of adults, must be transferred from hospitals to mortuary facilities or other disposition, usually within 24 hr of death. While burial may be delayed in most instances, Jewish tradition requires burial within 24 hr, which may further complicate patient’s grieving process if
she is not able to attend ceremony.
|Refer to, or contact, social services, if necessary.||Family may need support in planning for cost of funeral and other necessities.|
|Plan follow-up meetings or phone calls, as appropriate. Refer to community resources/support groups (e.g., visiting nurse services, Compassionate Friends, etc.).||Provides patient/couple with opportunity for discussion and asking questions. Assists patient/couple at crucial moments in the grief process, providing role models and opportunity to discuss loss with others who share the same experience.|
|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 1 or more days after death increases risk. In cases of pathological grief, ongoing counseling may be necessary to help individual(s) identify possible causes of the abnormal reaction and to achieve resolution of the grieving process. Note: Risk of major depression episode is highest during the 1st month following the loss, whereas women without other children or who have had a prior depressive episode remain at increased risk for 6 months.|
Risk for Altered Family Processes/Role Performance
- Risk for Altered Family Processes/Role Performance
Risk factors may include
- Situational crisis (death of child)
Possibly evidenced by
- Not applicable; presence of signs/symptoms establishes an actual diagnosis]
- Patient verbalizes understanding of role expectations/obligations.
- Patient identifies needs and resources to nurture roles/family ties.
- Patient expresses feelings freely and appropriately.
- Patient demonstrates individual involvement in problem-solving process directed at resolution of crisis.
|Assess 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.|
|Review 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 goal in life may be.|
|Promote 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 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. Realization that feelings of grief, guilt, and anger are normal may help alleviate the parents’ sense of failure.|
|Discuss situation in terms of 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.|
|Recognize expected role changes required by the loss.||Foreseen changes include 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||Death of a child requires unanticipated changes in parental roles. With 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.|
|Give patient simple choices of activities, with the opportunity to do more as she progresses.||The patient needs to get the message that she is seen as a functional, competent person, even though she may not feel that way.|
|Refer to resources such as social services, visiting nurse services, and other agencies.||May be necessary to assist family members or to replace them when they are not available to help (because of distance and/or their own lack of coping skills). Fosters growth and individuation of family members.|
|Give medications judiciously, as needed (e.g., sedatives, antianxiety agents/antidepressants).||May help patient get some sleep/rest (e.g., following difficult or exhausting delivery or cesarean birth). Note: Improper use of medications can cloud emotional responses and inhibit the grieving process.|
|Refer to parent support groups (e.g., Compassionate Friends, SHARE).||Others who have gone through the same process can reaffirm normalcy of parents’ feelings and responses. Note: Referral is best made when the patient/couple is experiencing depression and shock. It is more complicated to refer the patient/couple during the stages of denial and anger.|
|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 integration of loss into usual activities.|
Situational Low Self-Esteem
- Situational Low Self-Esteem
May be related to
- Perceived failure at a life event
Possibly evidenced by
- Verbalization of negative feelings about the self
- Negative self-appraisal in response to life event in a
person with a previous positive self-evaluation
- Difficulty making decisions
- Patient demonstrates adaptation to death of infant and integration of loss into daily life by planning for the future.
- Patient identifies strengths and resources available.
- Patient expresses positive self-appraisal.
|Identify couple’s self-perceptions as individuals and parents. Assess family’s response to loss, noting blame placed by family members.||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 sense of self and possibly shattering one’s self-esteem as a parent. Expression of anger or blame by other family members may further reduce self-esteem. Note: Sense of loss/failure may be exacerbated in cases of repeated miscarriages or serial fetal/neonatal deaths.|
|Review with parent(s) what has happened and discover how they perceive the death.||Anger among family members may be transferred to patient/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.|
|Present positive reinforcement for expressing needs and identifying concerns.||Helps in coping with sadness of situation. Aids parents accept themselves as worthy human beings.|
|Consider parenting needs of other children, as appropriate.||Continuing to care and to feel needed assists in preserving patient’s/couple’s identify as worthwhile parent(s).|
|Provide opportunity for verbalization, venting of emotions, and crying.||Sharing of loss provides opportunity for needed acceptance, helps parents sort through feelings, and validates parents’ normal feelings of powerlessness and inadequacy.|
|Consider referrals for counseling and assist with coordination of appointments (e.g., with social services or support groups)||Patient’s/couple’s ability to coordinate and perform tasks may be compromised. Referrals help provide support and assistance, which can facilitate integration of loss into daily life and enhance self-esteem.|
Risk for Spiritual Distress
- Risk for Spiritual Distress
Risk factors may include
- Need to adhere to personal religious beliefs/practices; blame for loss directed at self or God
Possibly evidenced by
- [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
- Patient verbalizes acceptance of situation and hope for the future.
- Patient demonstrates strength to help self and/or participate in usual activities.
- Patient discusses beliefs/values about spiritual issues.
|Open up about the loss with patient/couple.||Grieving and attempt to make sense out of the situation and to recover without the baby may cause the couple to doubt their religious beliefs and to feel victimized or angry. Talking about the objective findings can benefit the patient/couple begin to cope properly with feelings of distress.|
|Promote discussion of perception of unfairness. Recognize such perception as part of grief process. Keep a nonjudgmental manner while giving chance for patient/couple to express anger.||Families experiencing perinatal loss oftentimes doubt their religious beliefs and are focused about the purpose of life and death. Anger related to powerlessness may result in putting guilt and blame on oneself or someone else, or at God for “selecting them to suffer.”|
|Determine supportive connections and resources to use after discharge (e.g., extended family, friends, or religious affiliations).||Use of a support system is an effective means of coping with grief and maintaining perspective.|
|Refer to hospital priest, pastor, preacher, or appropriate spiritual advisor. Communicate with mortician, as appropriate, in guiding family with arrangement for funeral.||Experts in spiritual beliefs and ritual 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.|
- Deficient Knowledge
May be related to
- Lack of exposure to, or unfamiliarity with, information resources
- Misinterpretation of information
Possibly evidenced by
- Request for information
- Statement of misconception
- Patient verbalizes understanding of reasons for loss, when known.
- Patient differentiates causes of death that are controllable and those that are uncontrollable.
- Patient discusses possible short and long-term effects of the loss.
|Assess family’s eagerness and ability to comprehend and retain information.||Emotional responses may conflict with the ability to hear and process information. The stage of denial 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 patient’s/couple’s perceptions of events, and correct misunderstandings, as indicated.||Mistaken understandings need to be assessed on a regular basis and valid information reiterated.|
|Determine family’s preference when providing information.||Families have varying needs for information, depending on the stage of family development and on whether death was intrauterine or caused by external factors or genetic problems.|
|Review flow of events and diagnostic tests performed, using pictures if possible and appropriate.||Through the unrelenting stress that follows the loss, the patient/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.|
|Let patient open up the subject of another pregnancy.||Individuals learn their own 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.|
|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 parents’ grief. Role playing can ready parents for different responses from friends and relatives, who may avoid conversation about the loss, wrongly assuming that avoiding the topic is therapeutic/less painful for parent(s).|
|Provide knowledge regarding possible short and long-term physical and emotional effects of grief, comprising of somatic symptoms, sleeplessness, nightmares, dreams of the infant or the pregnancy, emptiness, fatigue, altered sexual response, and loss of appetite.||In several cases, parents do not know why their child died and may have a fear of later pregnancies. Causes of intrauterine death, stillbirth, or perinatal death are sometimes uncertain even after autopsy, and families may feel guilty about the cause of death. Providing knowledge about these factors can be effective in settling the grief of these individuals. Helps prepare couple for normal changes and difficulties associated with usual activities of daily living, and helps couple recognize extent of loss.|
|Review appropriateness of genetic counseling as indicated.||Genetic counseling may be recommended if the parents are worried of 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.|
|Refer to chaplain and community support groups.||Most parents do not believe in information until they have heard it from multiple sources.|
|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.|
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Maternal and Newborn Care Plans
Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Care Plans
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 4 Care Plans
- Prenatal Hemorrhage | 7 Care Plans
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Pregnancy Induced Hypertension | 6 Care Plans
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Care Plans