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PAILS of Hope

How to Work With Your Obstetric Health Care Providers During Pregnancy After Loss and/or Infertility
by Deborah L. Davis, Ph.D.
If you are a bereaved mother:

Every midwife, doctor and nurse would like to say the right words and give the right touches. But many are uncomfortable. Uncomfortable with death, uncomfortable with tears, uncomfortable with the intensity of your feelings. This is natural. Your friends and family may feel uncomfortable too. In fact, at times, you may even feel uncomfortable with your grief. Most of us don't have much experience with death and grief. Many of us are taught that it's a morbid topic. Although you may wish your obstetric health care providers were above these biases, some are not. How many of us cringe when we remember the clueless words we offered to grieving parents before we had gone down this road ourselves?

When you visit your obstetric health care providers with a subsequent pregnancy, you may notice that your bereavement isn't top-of-the-list anymore. But for you, it still may be over-the-top. Even as you carry new life, you may long for your other baby, the "right" baby. Most health care providers will want to shift focus to the future and dim the past. Your nurses may cluck at your "good fortune" for getting another chance to "do it right." Your midwife may express concern that you are not bonding to the new baby. Your doctor may avoid the topic altogether. After all, your baby's death can rake up feelings of inadequacy in a professional who takes pride in healthy babies.

But it is still normal for you to dwell on the past. Holding onto your memories is how you say goodbye and gradually let go. Grieving is what frees you to enjoy and bond with the new baby. So how do you talk about your feelings without raising eyebrows? And how can you get what you need during this trying time?

If you have struggled with infertility:

You are finally pregnant. As your disbelief wears off, the immensity of your undertaking sinks in. What if this is your last or only chance to "do it right?" You may be highly invested in not only a healthy baby but also a full term pregnancy, a smooth labor, a normal delivery. Besides having an ideal scenario in mind, you may also have many fears lurking in the background. What if the morning sickness doesn't let your baby grow? What if you get worrisome test results? What if you go into preterm labor? What if you need an emergency Cesarean? WHAT IF SOMETHING GOES WRONG?

It is normal to be anxious. It is normal to want everything to be perfect. And yet, you may be worried about imposing on the nurses, doctors, midwives and genetic counselors with incessant calls, interrogations and requests. How can you ask all those questions and make all those demands without alienating everyone? How can you get what you need during this trying time?

The following are my TOP TEN TIPS for working with your doctor or midwife during pregnancy after loss or infertility:

  1. Don't apologize for how you feel. Whatever you are feeling, it's right for you. If you do have concerns about your emotional condition, ask for a referral to a counselor who is comfortable with parents like you. But you are entitled to your feelings and you needn't change them or deny them to please anyone.

  2. Surround yourself with emotional support. Get in touch with other moms going through a subsequent pregnancy. Some hospitals sponsor support groups. Empower yourself by finding information on pregnancy, prenatal care, delivery or any other topic that rakes up your anxiety. Accurate information is always an antidote to fear. Keep a journal. Not only will it help you deal with your worries and hopes, it's a lovely keepsake, whatever the outcome. If you've suffered losses, a journal can help you cope with the roller coaster of your grief and your investment in your new pregnancy. And continue to read books that help you deal with your mourning. All of these supportive measures also can alleviate your need to press your obstetric health care provider into being your therapist as well.

  3. Try to empathize with your doctor or midwife. Remember, your relationship may feel more complicated to her. If you are a bereaved mother, you are not just another patient. Most pregnant women are blissfully naive and excited. Not you. You may be fearful, demanding, depressed, angry, withdrawn and untrusting. Your doctor may feel bewildered and helpless. Grief education is not routinely included in medical training and death is not an anticipated feature of obstetric practice. A mutual sense of failure or anxiety can make you both feel awkward with each other. By keeping all this is mind, you can forge a more comfortable working relationship with your doctor or midwife.

    If you're pregnant after years of trying, you're not just another patient either. You may be anxious, hypervigilant and controlling. If you try to forge or extract a guarantee that everything will turn out fine, your doctor may feel overwhelmed by the demands or the pressure. It can be so helpful for both of you to step back and remember that you share the most important goal: a healthy baby. If you can talk about and focus together on this goal, you can form a cooperative partnership.

  4. Don't expect your health care providers to read your mind. Just because you are wearing a worried face doesn't mean they will draw you out. And don't take your cues from the doc or midwife who avoids your grief or your anxiety. Go ahead and say what's on your mind. Ask for what you need. Do you need reassurance? Do you need information? Do you have concerns and feelings you want to discuss? Do you need longer visits? More visits, more tests, fewer tests? (Some moms find testing reassuring--others find it unnecessary and mere mention is nerve-wracking.)

    Your health care providers can't read your body either. IF YOU ARE CONCERNED ABOUT ANY SYMPTOMS OR SENSATIONS, YOU MUST LET THEM KNOW THAT YOUR CONDITION FEELS WORRISOME TO YOU. REQUEST INFORMATION, FETAL MONITORING OR OTHER EXAMS TO GET ANSWERS OR REASSURANCE. Vigilance can avert tragedy (anxiety is good for something!) Practice good prenatal care and educate yourself about the signs and symptoms of problems which could pose a threat to your baby, e.g. preterm labor, placental bleeding, fever, infection, gestational diabetes, pre-eclampsia, sexually transmitted diseases, fetal distress. Not every disaster can be avoided but you can sure try!

  5. Have realistic expectations. We often idealize our doctors. They may seem so knowledgeable, successful and powerful. But they cannot guarantee a healthy baby. And they cannot erase your anxiety. You may feel disappointed in your doctor or midwife when you realize she or he isn't the life-giving, super-compassionate soul you wished for. No doctor or midwife is perfect. Work with one that is "good enough."

  6. Make appointments in the practice with those you find supportive. You don't have to "get to know" them all. And should you get the doc with the unpolished bedside manner during delivery, you'll be surrounded by other supportive advocates (see #8 below.) If you wish you had more time to talk, you can ask the receptionist to budget extra time for you or book an appointment during less hectic hours. And if you have concerns that maybe shouldn't wait until tomorrow, DON'T HESITATE TO CALL. They expect calls at all hours and would rather head off disaster than have to deal with it full-blown in the morning!

  7. Plan for your labor and delivery. How do you want labor managed? Do you want to be induced or left on your own as long as everything looks fine? Will you stay home as long as you can stand the thought of a car ride or will you check in at the first contraction? What kind of pain relief? (Even if you plan on none, choose what you'd like in case you deliver by cesarean.) How much monitoring of your progress or baby's heartbeat? Do you want to be kept fully informed about any interventions being considered or do you want to be spared the details and just informed of your options? Do you want the baby handed to you as soon as possible or do you want the essential health checks done first? While plans are not guarantees, they can help you feel in control.

  8. Make arrangements to have supportive advocates with you during labor and delivery so that you have assistance getting what you need and help with any decisions that must be made. Your partner may fit the bill, but consider additional people. Perhaps you have a friend or know another mother who would be assertive and persuasive on your behalf or maybe just a comfort to you. Hiring a doula (a trained caregiver who is there to support the couple during labor and delivery) is becoming more fashionable, and for you, may contribute significantly to your emotional well-being.

  9. Plan for your hospital stay. Particularly if your other baby died shortly before or after birth, you may have some strong feelings about the smallest details. It is normal to have flashbacks. You may be surprised by their intensity, and find them comforting or unsettling. Take into account that you might have some choices, whether you want things to be similar or very different. Do you want the same hospital but a different delivery room? Do you want your new baby wrapped in a special blanket or the standard-issue hospital duds? Do you want to be in a different section of the maternity floor? Private room or shared? Do you want to stay as long as possible or leave as soon as you can? It is normal to want to feel close to the baby you miss and yet distance yourself from the tragedy of untimely death. This can be tricky, but you will find the balance that is right for you. Whether you are bereaved or have struggled with infertility, there are things you also can do to make your hospital stay more special. First, consider rooming in and sleeping with the baby in your bed. It's amazing how well you and your little one will snooze, cozy and cuddly. Second, if you are invested in breastfeeding, it can be demoralizing when your baby is given glucose water or formula. If you feel strongly about this, you can turn down supplements without harm. During the few days in the hospital, a healthy baby, even one who's slow to latch on, doesn't need anything but what your breasts provide. It is normal to lose 10% of body weight. When your milk comes in, your baby will get just what she or he needs, right on time. If there is a concern about weight or hydration, nurse your baby at least every 3 hours a day when your milk comes in and that should get your baby back on track. Finally, pictures! Along with your own camera, consider bringing one of those disposable cameras with the built-in flash. They are easy to operate during the thrills of delivery and new parent jitters. Don't cover yourself or your baby in blankets. You'll want to capture your nurturing presence and every tiny feature of your little one. Babies grow so fast, even in the first week.

  10. If you decide to give your health care providers feedback, couch it in terms of what YOU need or needed. After all, you cannot speak for every parent who has suffered loss or infertility, but you can say what would help you. For example, "I needed this," rather than, "You should do this." Your health care providers will feel less defensive and more likely to take your suggestions to heart. As a result, you and other parents may get more of the support and understanding you need.

Deborah L. Davis, Ph.D. is a developmental psychologist who specializes in perinatal and neonatal crisis, medical ethics, parental bereavement and adjustment, parent education and child development. Dr. Davis is the author of four books for bereaved parents, Empty Cradle, Broken Heart (Fulcrum, 1991; 1996), Loving and Letting Go (Centering, 1993), Fly Away Home (Centering, 2000) and Stillbirth, Yet Still Born (PILC, 2000). With Mara Tesler Stein, Psy.D., she is the coauthor of The Emotional Journey of Parenting Your Premature Baby: A Book of Hope and Healing (NICU Ink, 2002).

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