Perinatal Loss: Standards of Care

1
Perinatal Loss Standards of Care

• Controversies in Childbirth Conference
• Dallas, Texas
• presented by
• Dorotha Graham-Cicchinelli, MMM LCCE
• dorothacicch_at_yahoo.com
• March 29, 2009

2

• The babies were frail and almost as soon as they
  came they sickened and died. Penny had buried
  them one by one with little wooden tombstones.
  Some had names, others only legends
• From The Yearling

3

• She never saw the light of day

4
What Well Cover Today

• A little history
• Stats and definitions
• Standards of care
• What you can do in practice
• Your thoughts

5
1500-1900Midwives to Doctors

• Folk medicines magic religion
• Unlicensed doctors
• Decline in midwives
• Dr.s of Midwifery emerge
• Delivery instrument fashionable
• Rise in childbed fever hemorrhage
• Mortality rates high

6
1900-1930 High Mortality Rates Recognized

• Womans League of Boston responds
• Federal Childrens Bureau in 1912
• A study shows U.S. ranks unfavorably
• Nursing Assoc. provide prenatal care training to
  women
• Sheppard-Towner Act passed

7
1930-1960 Medical Field Responds

• Increase in medications and mechanized birth
• American Academy of OB/Gyn created standards of
  OB care emerge
• Births and deaths recorded (20 weeks)
• Decline in maternal child deaths
• Williams Obstetrics publishes on pregnancy

8
1960-1990Child Birth Support Emerges

• Prepared child birth movement begins
• Importance of maternal-infant bonding noted
• Attention to stillbirth and infant death
  increases
• Prenatal death protocols for hospitals
• When Pregnancy Fails published in 1980

9
1990-presentRise and Fall of Loss Services

• Stages of perinatal loss gestation established
• Early formation of standards of care for loss
  patients
• Grief support groups in hospitals rise and fall
• Focus on acute care in hospitals

10
Did You Know

• 4.5 million pregnancies
• 4.3 million births (2007)
• 974,000 miscarriages (2004)
• 1 in 3-5 pregnancies miscarry
• 25,600 stillbirths (2004)
• 19,000 neonatal deaths (2002)
• 6.2 in 1,000 pregnancies over 20 weeks end in
  death

11
Pregnancy Loss Gestations

• Ectopic 0-8 weeks
• Miscarriage 0-13 weeks
• Early Stillbirth 14-19 weeks
• Stillbirth 20-40 weeks
• Neonatal Death newborn-28 days
• Newborn Dearth 29 days to 12 weeks

12
Pregnancy Loss Grief Sequence

• 3-4 weeks shock, denial
• 2-5 months sadness, guilt, anger
• 5-6 months thinking about another pregnancy
• 8-12 months in subsequent pregnancy

13
Standards of Carewhen there is a loss

• No nationally accepted standards
• Little research study
• Based on accepted practice and professional
  wisdom
• Locally developed by organizations and hospitals
• Address office, hospital , at-home care

14
(No Transcript)
15
In the Office or Clinicfor the doctor

• Confirm diagnosis
• Manage under 12 weeks in office or ER
• Refer 12-14 weeks loss refer to ambulatory
  surgery
• Refer 15 weeks loss to labor and delivery
• Refer premature labor to antepartum

16
Upon Admissionfor the staff

• Explain the procedure ordered
• Provide and discuss the grief packet
• Determine cultural religious needs
• Encourage parent to invite family
• Notify chaplain and bereavement counselor if
  desired
• Explain and order autopsy

17
In the Hospitalfor the staff

• Encourage parents to see, hold, and name their
  baby
• Place baby in warmer in room
• Parent may parent their baby
• Provide mementos
• Counsel on mortuary arrangements
• Explain forms and order autopsy
• Give postpartum discharge instruction

18
In the Hospitalfor the doctor

• Visit the patient after the delivery
• Answer patient family questions
• Set a one week check up
• Encourage patient to obtain proper support
• Set follow-up schedule of appointments at 3 and 6
  weeks, and 3 and 6 months
• Plan to review autopsy report when available

19
Follow-up Carefor the counselor

• Call 7-10 days after discharge or at agreed upon
  date
• Conduct telephone assessment of patient and
  family coping level
• Evaluate support systems
• Set appointment for group or individual
  counseling as appropriate

20
Why Use a Protocol

• Address physical needs
• Minimize depression thoughts of suicide
• Mitigate against substance and spouse abuse
• Avert sibling abuse neglect
• Reduce isolation
• Create supportive environment for subsequent
  pregnancy

21
Are We There Yet
Probably Not
22
A Few Hurdles To Overcome

• The changing focus of hospitals
• to acute care
• Few support services under
• managed care
• Shrinking budgets
• Need for pre- in-service training
• Perceived limitations of HIPAA laws
• Limited use of community care

23
Whats Next

• Questions
• Comments
• Discussion

24
Perinatal Loss Standards of Care

• Contact
• Dorotha Graham-Cicchinelli, MMM LCCE
• at
• dorothacicch_at_yahoo.com