- Email: [email protected]
Good Grief: Coming to Terms with the Childbirth Experience
principles and practice Good Grief: Coming to Terms with the Childbirth Experience J E A N N E T . G R A C E , R N , BS The practical application of what is known about the grieving process is discussed in connection not only with obvious grief-laden situations, but also with situations in which thegrief content is more subtle. It is proposed that learning to identify the less traumotic situations in which an expression of grief can help obstetric patients and their families cope with the childbirth experience is also a part of optimum nursing care.
A baby is not the only product of conception. During pregnancy, parents also develop a fantasy image of the perfect infant and a set of expectations of themselves as childbearers and childrearers. Parents' reactions to stillbirth-death of a real child they have never actually known -indicate the investment of hopes and dreams they have made in their fantasy child. Similarly, parents may have a great emotional stake in the maternity experience itself. Discrepancies between reality and the perfect experience, as differences between real and fantasy babies, can engender a sense of loss. Loss is a common and universal experience. At a very basic level, any childbirth experience involves some degree of loss. The mother gives up her special pregnant status and usually ceases to command the weekly attentiveness of her physician when her baby is born. Both parents and siblings as well give up some of the ways the family has satisfied their needs to meet the demands of the new child. Postpartum depression and sibling rivalry are, in part, reactions to this change. The degree to which loss disrupts a person relates to the importance of the lost object to his life, his usual patterns of coping and attitudes toward loss, and any special resources or disabilities
18
for coping he possesses at the time of the loss.' Peretz distinguishes four categories of loss: developmental, e.g., losing the gratifications of nursing through weaning, loss of external objects, loss of an aspect of self, and, most profound, loss of a significant valued person.' Many of the losses of childbearing can be understood as losses of "self" aspects: feelings of attractiveness, special capabilities and worth, a sense of health, or selfdefinitions of social role.' The mother who screams when she hoped to be calm disrupts her inner sense of control. The man who wishes to attend his child's birth but cannot loses part of his image of himself as a father. There is an emotional reaction to loss, whether the lost object is a mitten, a mother, or the ideal of a painless labor and delivery. The intensity of feeling, of course, varies with the nature of the loss. When a person loses something on which he depends for gratification in life, he experiences an overwhelming sense of helplessness and threat to his survival. His feelings may be so intense that they may seem threatening in themselves. He may experience anger and find it unacceptable. The person who suffers serious loss may respond to the threat to his psy-
chic well-being in many ways. He may become depressed. He may repress the situation or displace his feelings about it. He may deny the loss by walling off all the affected areas of his life. He may Aee physically or mentally, through travel, use of alcohol, or use of drugs. Or, he may grieve. Grief is the most common response to loss. It is the mechanism through which feelings of loss are acknowledged; the ways in which the lost object provided gratification are examined, and new patterns of gratification develop. Grief is painful, but it is also positive. In comparison to the defensive responses described above, grief gradually frees one's psychic energy from preoccupation with that which is gone to the life that remains. The defensive responses to loss-repression, denial, displacement-are maintained only through enormous continuing expenditures of psychic energy. Typically, grief progresses much like labor in reverse. After the initial shock and numbness, the bereaved experiences recurrent spasms of overwhelming sensations and all interest is withdrawn from others to deal with inner events. Gradually, the grief episodes become less frequent, of less duration, and less powerful; and interest in the outside January/February 1978 JOCN Nursing
world is reestablished. Lindemann provides the classic description of the sensations:
. . . somatic distress occurring in waves lasting from 20 minutes to an hour at a time, a feeling of tightness in the throat, choking with shortness of breath, need for sighing, and an empty feeling in the abdomen, lack of muscular power, and intense subjective distress described as tension or mental pain. . . . There is commonly a slight sense of unreality, a feeling of increased emotional distance from other people . . . and there is intense preoccupation with the image of the deceased. . . . Another strong preoccupation is with feelings of guilt. , , . In addition, there is often disconcerting loss of warmth in relationship to other people, a tendency to respond with irritability and anger, a wish not to be bothered by others. . . .* The preoccupation with what is lost is the starting point for restitution, or grief work. In this process, all aspects of the relationship with what is lost are called to mind and reexamined, until the bereaved can make real inside himself what has already happened externally. Such reviews are initially apt to trigger episodes of acute grief, but grief work successfully concluded allows the bereaved to face both his future life and his memories without disabling psychic pain. The work of grief can be interrupted or suppressed by other demands, such as the new or continuing responsibility for small children. Since many people in our society are uncomfortable when strong feelings are expressed, family members may urge the grieving parent to “pull yourself together” or “look on the bright side of things.” If grief work is incomplete, grief may resurface at a later time-frequently during a subsequent pregnancy. Thus, workers may encounter actively grieving individuals during any part of the maternity cycle. How can we recognize and help them? First, we must consider the possiJanuary/February 1978 JOGN Nursing
bility that loss has occurred. Many parents expect more from childbirth than simply a safe outcome, important as that may be. A fair number of couples, for example, hope to participate together in a spontaneous vaginal delivery of their child. Many expect to greet the infant with love at first sight. Other expectations may be very individual and subtle. We can help couples explore the disparity between real and ideal, and the significance they attach to it, by asking, Was your childbirth experience what you expected?” “Does your baby look like you thought he would?” It is all too easy to assume that any negative feelings parents have about their maternity experience are somehow cancelled by the joy of the arrival of a healthy baby. Most of us, parents and professionals alike, have received a cultural message that new parents should be elated, grateful, and proud. Yet there is ambivalence even in the happiest situation. The parent who discovers strong inner feelings of dismay, regret, fear, or anger when (s)he “ought” to be happy may find those emotions personally unacceptable. The parent’s dilemma increases if the assisting people around convey the message that such feelings are unacceptable to them, as well. (S)he cannot resolve feelings because (s)he cannot admit they exist. (S)he does not have room to grieve. Ms. R’s second pregnancy resulted, quite unexpectedly, in twins. Faced with the demands of three children under age two, she was frustrated and angered by cheery comments about her “double blessing.” She says she began to enjoy the twins only after her pediatrician listened to her feelings and said, “well, it’s a love-hate relationship.”
We enable parents to admit and express their feelings by creating an environment where it is safe to do so: safe people, safe places, safe situations.
Childbearing is a biological partnership that is frequently a sustaining emotional partnership as well. Parents can be “safe people” to each other when loss threatens or occurs. One way to facilitate this sharing is by providing information to both parents, preferably at the same time. Another is to allow couples to remain together as much as they wish during labor, delivery, and the postpartum period. Should complications arise, the parents who learn about them together have each other for immediate support. In any circumstance, we can encourage parents to discuss their feelings honestly with each other and with close friends and family. If it is explained that the reactions of grief are a normal response that honor the importance of the loss, we may increase the parents’ comfort in accepting their own and each other’s behavior and feelings. One parent-often the fathermay feel compelled to suspend his own grief in order to comfort his spouse. If he is encouraged to acknowledge his own loss, a positive contribution is made to his ability to support his wife, as well. The K’s son was born with a lethal birth defect. When Mr. K called his prenatal class instructor to report the tragedy, she expressed concern for Ms. K. and the baby. But she also listened to Mr. K’s own feelings and talked about his special pain in being the one to inform relatives and accompany the baby to another hospital alone. Later Mr. K told friends how important it had been for him to be able to “call my class instructor and cry.”
Another group of “safe people’’ are parents who have had similar experiences of loss. The mother who has just brought her ABO incompatible infant home, for example, can offer not only empathy but information and hope to another mother whose jaundiced baby remains hospitalized. Some childbirth education organizations sponsor local or national parent-to-parent groups orga19
nized around specific childbirth experiences. C-SEC, composed of parents whose children were delivered by cesarean section, is one example. of course, members of the helping professions can be “safe people,” too. They may lack a special family bond or mutual experience with the grieving parent, but can express their caring through creative listening. We indicate our willingness to hear out another’s feelings when we comment on the emotional content of conversation or nonverbal behavior. (“You sound angry.” “You seem upset.” “You look absolutely numb.”) Reassurance or anticipatory guidance can be offered by suggesting some of the common emotions associated with loss, e.g., “Many parents who find themselves in this situation are angry, as well as sad.” Most important is to accept those feelings, no matter how different they are from the ones we might expect of ourselves in a similar situation. Anger experienced as a result of loss or helplessness is often projected onto the nearest person perceived as having power. Counter-productive defensive reactions must be avoided when we are so confronted. If a person discovers that he does not drive away those who care for him by expression of even his strongest, most inconsistent feelings, he acquires a bit more courage to examine and resolve them. Just as safe people aid the parent in expressing potentially overwhelming feelings, so does a safe place. Many Americans weep only in private and may resist acknowledging grief unless a quiet room or its equivalent is available. The need has two aspects: The bereaved require a space apart so they feel free to grieve, and they need to be protected so that their grief does not arouse anger or impatience in uninvolved people around them. For many families, no place is safer than home. Resources for physical care should be organized so that parents who seek the emotional security of familiar surroundings can do so with medical safety. “Safe situations” are those that offer worthwhile activity without taxing the bereaved’s limited ability to
20
cope. Involving parents in their care and the decisions made about it can facilitate these situations. Offer a choice of concrete alternatives, for example: Would the mother of a jaundiced baby prefer to have the baby and phototherapy unit moved to her room? Does she wish to help prepare her baby for phototherapy? Would she prefer to come to the nursery to feed her infant? Does she wish to be awakened at night to do so? Does she wish to extend her hospital stay to remain during her baby’s treatment? Would she prefer to take her child home and return as necessary for further tests? When we consult and respect parents’ preferences, we communicate how important those feelings are, and we also diminish, if only by a little, the overwhelming sense of helplessness that accompanies loss. A “safe situation” may also mean the presence of a caring person at a particularly difficult time. The woman in labor sent to x-ray for determination of pelvic adequacy. is better able to cope if her husband, coach, or nurse accompanies her. The new mother who cannot have contact with her baby may appreciate someone who will sit with her when other infants are brought to their parents. The mother going home without her child could use some company as she packs to leave. The threat of an anguish-producing situation is reduced because someone cares enough to recognize and share it. The grief-stricken person can release his feelings more freely when he knows someone is available to help him regain his control afterward. The person who is left alone in his loss experiences a further isolation as a result. Just as we either facilitate or discourage the expression of feeling by our actions, so we can encourage or impede grief work. The job to be accomplished, making the inner sense correspond to the external reality, requires clear and accurate information about that external reality. Parents, however, may be in no position to collect it for themselves. The woman, for example, who is experiencing strong contractions every 3 minutes has little time and energy for reality-testing her environment.
If she uses prepared childbirth techniques or receives pain medication, her selective or general inattention increases. Afterward, she relies on others to fill the gaps in her objective perceptions. If she acquires conflicting data about the external aspects of her experience, she is handicapped in making sense of her subjective responses. Ms. G. was admitted in active labor and found to be severely preeclamptic. Following emergency treatment and medication, she delivered safely. Postpartum, one physician minimized her condition and attributed her problem to “being high-strung.” Another declared her disease probably justified even more aggressive management. A nurse blamed Ms. G.’s hypertension on Methergine, a drug she had not received. Ms. G. became preoccupied with her fragmentary memories of labor and consulted medical texts to ”get the number of the truck that hit me.”
At the very least, those who offer their versions of reality to parents should base their opinions on a thorough review of the available data. When a coherent, clear, and accurate picture is presented of what has happened or will happen, it helps the parents assess the nature and significance of any loss involved. When we are confronted with parents who have suffered serious loss, we, too, react with shock and denial. In our own discomfort and desire to avoid causing pain in the form of grief spasms, we find ourselves making excuses to avoid acknowledging the loss. When we act on our denial, however, we cannot help parents face their reality. Whose needs are being met when we deny grieving parents the chance to hold their stillborn child? How can grief work proceed when we whisk the deformed child off to the nursery and leave parents with their untested “monster” fantasies? And what have we told these parents about the acceptability of grief when we behave this way? The mother of a child born with a cleft lip and palate told a maternity care conference, “The first sin is not telling the parents right away. And the second, once you have, is going on as though nothing happened. ” January/February 1978 JOGN Nursing
Persons under stress do not easily grasp information about the reality situation, even when clearly and honestly presented. When I ask a parent what she’s been told about her situation, I frequently hear “ I was too upset to listen.” The simple explanations appropriate during an emergency or period of emotional stress should be repeated, with additional details, when the parent is better able to hear them. Once is rarely enough, since more questions arise as the parent works through the emotions engendered by the initial information. A mother who suffers unexpected complications during pregnancy or childbirth may not be ready to hear explanations clearly before the end of her hospital stay. She should be provided with, or encouraged to obtain, a written account of what is understood about her situation, and she should be encouraged to contact one of her caretakers at a later date, when further questions come to mind. It is not easy for her to ask these questions, since they may be interpreted as showing a lack of confidence in, or satisfaction with, her care. We can ease communication by telling the departing patient something like, “You will have more questions when you’ve been home a while. Please call me 3 weeks from today to talk again.” One can help the patient who literally does not know what questions to ask by discussing those issues other parents report resolving as they work to accept a similar loss. What are the consequences for the child? For future children? For subsequent pregnancies? And, most basic, in what ways did the parents’ actions contribute to the loss? The sense of guilt pervades grieving as things done or undone are reviewed, and parents may believe any ambivalent feelings they experienced influenced the external course of events, as well. These beliefs may be exposed for reality testing by commenting “You probably worry about being to blame for your condition.” While it is hard for a mother to accept the fact that her body is out of her control, or that the causes of her loss are simply not understood, it is far harder for her to live with responsibility for harm to JanuaryIFebruary 1978 JOGN Nursing
herself o r her child. Parents who are blameless in the development of their loss need to hear that reassurance. In certain maternity situations, the potential for loss is apparent before the actual loss occurs. Pelvic measurements early in pregnancy may indicate the impossibility of vaginal delivery. Low estriol levels and lack of uterine growth may cast grave doubts on the infant’s ability to survive birth. When such information is shared openly with parents, they may experience anticipatory grief. They begin to resolve their expected loss even as the pregnancy continues. Some professionals argue that people should not worry parents with the possibility their expectations will not be fulfilled. This attitude poses some practical problems if parents are expected to cooperate with a treatment regimen made necessary by the complication. Delayed disclosure is also apt to shift the burden of grief to a time of other physical or emotional demands, e.g., recovery from surgery or responsibility for newborn care. Moreover, it also blocks communication and destroys trust between parent and professional, once parents begin to suspect the truth. Ms. T. had her heart set on delivering naturally. “But when my doctor came to my husband and me in labor and explained that a c-section might be necessary-after a while I could see that [vaginal delivery] would hurt me and the baby. He prepared me before I went to xray, and I could accept the section. “After Eric was born I kept noticing band-aids on him but when I asked the nurse she said it was routine tests. Then the house doctor came in, and he was very abrupt and told me I couldn’t have my baby or feed him because he had an infection and jaundice. “ I could accept the c-section because I was prepared for it, but when I heard about the jaundice I became a hysterical female. I felt I had no control over the destiny of my child. I thought someone was trying to take him away from me. The affair has colored my faith in hospital doctors.”
Grief may not be diminished by advance preparation, but the ability to cope with loss appears to be improved. Glick, et ala studied young
widows and discovered that those women who had an opportunity for anticipatory grief before their husbands’ deaths were more apt to remarry. Our surmise is that where the husband’s death was anticipated and could confidently be ascribed to a disease process, then it was cancer or emphysema that was thereafter feared. But where the death was unanticipated, . . . where a marriage that had seemed entirely reliable had suddenly and inexplicably ended, then danger might seem everywhere once one was in marriage, and marriage itself was feared.’
Is it not possible that a similar dynamic exists for loss in childbearing? Grief can be facilitated as a response following loss or in anticipation of an expected loss. Is there any way to help parents prepare for an unexpected experience? This is an issue of particular importance in prenatal education, since parents attend these classes specifically to acquire a knowledge of what to expect. Some childbirth educators provide factual information on grief, much as they discuss transition or signs of labor.‘ I do not always find this appropriate or comfortable. I do feel compelled to remind my students of the variety of childbirth experience possible and to present the factors they cannot control, as well as those they can. I encourage them to examine their hopes and desires in view of evaluating their possibility for fulfillment. I also encourage parents, where possible, to work to help their dreams come true. They can be provided with knowledge and self-help skills, but they require the cooperation of those who care for them, as well. The essence of family-centered maternity care is consideration of what is satisfying to parents, as well as safe. When parents and professionals plan together, when facilities are flexible enough to serve many different “perfect experiences”, perhaps there will be less occasion for grief.
References 1. Peretz, D.: “Development, ObjectRelationships, and Loss,” in Schoenber, B., A. Carr, D. Peretz, and A.
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Kutscher (eds): Loss and Grief: Psychological Management in Medical Practice. New York, Columbia University Press, 1970, p p 3-20 2. Lindeman, E. : “Symptomatology and Management of Acute Grief.” A m J Psychiatry 101:141-148, Sept. 1944 3. Glick, I., R. Weiss, C. Parkes: The First Year of Bereavement. New York, John Wiley and Sons, 1974, p 259 4. Hallet, E.: “Birth and Grief.” Birth E‘am J 1:18-22, Fall 1974
Hazel], L. D. : Commonsense Childbirth, rev. ed. New York, Berkley Publishing Co., 1976 Rozdilsky, M. L., B. Banet: What Now?! A Handbook for New Parents. New York, Charles Scribner’s Sons, 1975 Seitz, P., L. Warrick: “Perinatal Death: The Grieving Mother.” A m J Nurs 74 :2028-2033, NOV.1974 Zahoureck R., J . Jensen: “Grieving and Loss of the Newborn.” A m J Nurs 73:836-839, May 1973
Supplemental Bibliography Engel, G.: “Grief and Grieving.” A m J Nurs 64:93-98, Sept. 1964 Gyulay, J. : “The Forgotten Grievers.” A m J Nurs 75:1476-1479, Sept. 1975
Address reprint requests to Ms. Jeanne T. Grace, RN, 24 Crescent Road, Fairport, N Y 14450
Jeanne Grace is a graduate of the University of Rochester School of Nursing i n New York and teaches childbirth classes for CEA of Rochester. She has also helped develop and teach prenatal classes at the Rochester Adolescent Maternity Project and was instructor of prenatal classes in the high-risk obstetric clinic at Rochester Regional Perinatal Center, Strong Memorial Hospital at the time this article was written.
Perlnahl Rogtam A unique ladder-designed program is being offered to prepare clinicians, practitioners, and clinical specialists in high-risk perinatal nursing. The program Is offered by Houston Baptist Unlversity and Jefferson Davis Hospital, in conjunction with Baylor College of Medicine. It is funded by HEW and The National Foundatlon-March of Dimes. The curriculum plan of the program is as follows: Maternal-Fetal Clinician, 1 quarter; Neonatal Clinician, 1 quarter; Perinatal Practitioner, 3 quarters (BS requlred); Perinatal Clinical Specialist, 3 quarters plus additlong1 graduate currlculum at Houston Baptist University. Admission date for the program is March 3, 1978. For further information contact College of Nursing, Houston BapHst Universlty, 7502 Fondren, Houston, TX 77074 (713)774-7661.
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January/February 1978 JOGN Nursing
PERINATOLOGY
The Mount Sinai Hospital of New York announces a 2-day continuing education program entitled "New Directions in Perinatoiogy: Caring for the High-Risk Mother and Infant"-April 10, 11, 1978. The focus on the 10th will be the mother-amniocentesis, sonography, estriol level, and fetal monitoring. On the 11th it will be the high-risk newborn-pulmonary and ctrculatory changes at blrth, respiratory problems and management, thermoregulation, and nutritional support. For information contact Rosemary Murray, RN, MA, The Mount Sinai Hospital, School of Continuing Education in Nursing, 1 Gustave Levy Place, New York, NY 10029, or call (212)650-5704/5.
PSYCHOPROPHYLAXIS IN OBSTETRICS
The American Society for Psychoprophylaxis in Obstetrics will sponsor a continuing education workshop at Boston Hospital for Women, Lying-In Division, on Saturday, April 15, 1978. Elisabeth Blng, author of works on prepared childbirth, and most recently, Making Love During Pregnancy, will speak on "Sex and Pregnancy." Other topics Include cesarean birth, crisis prediction (fetal monitoring), the modern midwife, and grief management. Application has been made for CEU's for nurses. For further informatlon, contact Conference Manager, ASPO, 1411 K Street, N.W., Suite 200, Washington, D.C. 20005. or call (202)783-7050.
HEALTH PROFESSIONS JOURNAL A new, interprofessional Journal,Evaluation and the Health Professions, will commence publication In the Spring of 1978. The editors are R. Barker Bausell, PhD, and Carolyn F. Waltz, PhD, of the Center for Research and Evaluation, University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201. This new journal is being initiated "in response to the intensifying need for providing a forum for the widespread Sharing of inlormatlon concerning program development and evaluation in all of the health fields." Brochures describing the journal in more detail, subscription Information, or information about submitting manuscripts are avellable from the editors. The journal will be published by Empirical Publications of Baltimore, Maryland.
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JanuaryIFebruary 1978 JOCN Nursing
A baby is not the only product of conception. During pregnancy, parents also develop a fantasy image of the perfect infant and a set of expectations of themselves as childbearers and childrearers. Parents' reactions to stillbirth-death of a real child they have never actually known -indicate the investment of hopes and dreams they have made in their fantasy child. Similarly, parents may have a great emotional stake in the maternity experience itself. Discrepancies between reality and the perfect experience, as differences between real and fantasy babies, can engender a sense of loss. Loss is a common and universal experience. At a very basic level, any childbirth experience involves some degree of loss. The mother gives up her special pregnant status and usually ceases to command the weekly attentiveness of her physician when her baby is born. Both parents and siblings as well give up some of the ways the family has satisfied their needs to meet the demands of the new child. Postpartum depression and sibling rivalry are, in part, reactions to this change. The degree to which loss disrupts a person relates to the importance of the lost object to his life, his usual patterns of coping and attitudes toward loss, and any special resources or disabilities
18
for coping he possesses at the time of the loss.' Peretz distinguishes four categories of loss: developmental, e.g., losing the gratifications of nursing through weaning, loss of external objects, loss of an aspect of self, and, most profound, loss of a significant valued person.' Many of the losses of childbearing can be understood as losses of "self" aspects: feelings of attractiveness, special capabilities and worth, a sense of health, or selfdefinitions of social role.' The mother who screams when she hoped to be calm disrupts her inner sense of control. The man who wishes to attend his child's birth but cannot loses part of his image of himself as a father. There is an emotional reaction to loss, whether the lost object is a mitten, a mother, or the ideal of a painless labor and delivery. The intensity of feeling, of course, varies with the nature of the loss. When a person loses something on which he depends for gratification in life, he experiences an overwhelming sense of helplessness and threat to his survival. His feelings may be so intense that they may seem threatening in themselves. He may experience anger and find it unacceptable. The person who suffers serious loss may respond to the threat to his psy-
chic well-being in many ways. He may become depressed. He may repress the situation or displace his feelings about it. He may deny the loss by walling off all the affected areas of his life. He may Aee physically or mentally, through travel, use of alcohol, or use of drugs. Or, he may grieve. Grief is the most common response to loss. It is the mechanism through which feelings of loss are acknowledged; the ways in which the lost object provided gratification are examined, and new patterns of gratification develop. Grief is painful, but it is also positive. In comparison to the defensive responses described above, grief gradually frees one's psychic energy from preoccupation with that which is gone to the life that remains. The defensive responses to loss-repression, denial, displacement-are maintained only through enormous continuing expenditures of psychic energy. Typically, grief progresses much like labor in reverse. After the initial shock and numbness, the bereaved experiences recurrent spasms of overwhelming sensations and all interest is withdrawn from others to deal with inner events. Gradually, the grief episodes become less frequent, of less duration, and less powerful; and interest in the outside January/February 1978 JOCN Nursing
world is reestablished. Lindemann provides the classic description of the sensations:
. . . somatic distress occurring in waves lasting from 20 minutes to an hour at a time, a feeling of tightness in the throat, choking with shortness of breath, need for sighing, and an empty feeling in the abdomen, lack of muscular power, and intense subjective distress described as tension or mental pain. . . . There is commonly a slight sense of unreality, a feeling of increased emotional distance from other people . . . and there is intense preoccupation with the image of the deceased. . . . Another strong preoccupation is with feelings of guilt. , , . In addition, there is often disconcerting loss of warmth in relationship to other people, a tendency to respond with irritability and anger, a wish not to be bothered by others. . . .* The preoccupation with what is lost is the starting point for restitution, or grief work. In this process, all aspects of the relationship with what is lost are called to mind and reexamined, until the bereaved can make real inside himself what has already happened externally. Such reviews are initially apt to trigger episodes of acute grief, but grief work successfully concluded allows the bereaved to face both his future life and his memories without disabling psychic pain. The work of grief can be interrupted or suppressed by other demands, such as the new or continuing responsibility for small children. Since many people in our society are uncomfortable when strong feelings are expressed, family members may urge the grieving parent to “pull yourself together” or “look on the bright side of things.” If grief work is incomplete, grief may resurface at a later time-frequently during a subsequent pregnancy. Thus, workers may encounter actively grieving individuals during any part of the maternity cycle. How can we recognize and help them? First, we must consider the possiJanuary/February 1978 JOGN Nursing
bility that loss has occurred. Many parents expect more from childbirth than simply a safe outcome, important as that may be. A fair number of couples, for example, hope to participate together in a spontaneous vaginal delivery of their child. Many expect to greet the infant with love at first sight. Other expectations may be very individual and subtle. We can help couples explore the disparity between real and ideal, and the significance they attach to it, by asking, Was your childbirth experience what you expected?” “Does your baby look like you thought he would?” It is all too easy to assume that any negative feelings parents have about their maternity experience are somehow cancelled by the joy of the arrival of a healthy baby. Most of us, parents and professionals alike, have received a cultural message that new parents should be elated, grateful, and proud. Yet there is ambivalence even in the happiest situation. The parent who discovers strong inner feelings of dismay, regret, fear, or anger when (s)he “ought” to be happy may find those emotions personally unacceptable. The parent’s dilemma increases if the assisting people around convey the message that such feelings are unacceptable to them, as well. (S)he cannot resolve feelings because (s)he cannot admit they exist. (S)he does not have room to grieve. Ms. R’s second pregnancy resulted, quite unexpectedly, in twins. Faced with the demands of three children under age two, she was frustrated and angered by cheery comments about her “double blessing.” She says she began to enjoy the twins only after her pediatrician listened to her feelings and said, “well, it’s a love-hate relationship.”
We enable parents to admit and express their feelings by creating an environment where it is safe to do so: safe people, safe places, safe situations.
Childbearing is a biological partnership that is frequently a sustaining emotional partnership as well. Parents can be “safe people” to each other when loss threatens or occurs. One way to facilitate this sharing is by providing information to both parents, preferably at the same time. Another is to allow couples to remain together as much as they wish during labor, delivery, and the postpartum period. Should complications arise, the parents who learn about them together have each other for immediate support. In any circumstance, we can encourage parents to discuss their feelings honestly with each other and with close friends and family. If it is explained that the reactions of grief are a normal response that honor the importance of the loss, we may increase the parents’ comfort in accepting their own and each other’s behavior and feelings. One parent-often the fathermay feel compelled to suspend his own grief in order to comfort his spouse. If he is encouraged to acknowledge his own loss, a positive contribution is made to his ability to support his wife, as well. The K’s son was born with a lethal birth defect. When Mr. K called his prenatal class instructor to report the tragedy, she expressed concern for Ms. K. and the baby. But she also listened to Mr. K’s own feelings and talked about his special pain in being the one to inform relatives and accompany the baby to another hospital alone. Later Mr. K told friends how important it had been for him to be able to “call my class instructor and cry.”
Another group of “safe people’’ are parents who have had similar experiences of loss. The mother who has just brought her ABO incompatible infant home, for example, can offer not only empathy but information and hope to another mother whose jaundiced baby remains hospitalized. Some childbirth education organizations sponsor local or national parent-to-parent groups orga19
nized around specific childbirth experiences. C-SEC, composed of parents whose children were delivered by cesarean section, is one example. of course, members of the helping professions can be “safe people,” too. They may lack a special family bond or mutual experience with the grieving parent, but can express their caring through creative listening. We indicate our willingness to hear out another’s feelings when we comment on the emotional content of conversation or nonverbal behavior. (“You sound angry.” “You seem upset.” “You look absolutely numb.”) Reassurance or anticipatory guidance can be offered by suggesting some of the common emotions associated with loss, e.g., “Many parents who find themselves in this situation are angry, as well as sad.” Most important is to accept those feelings, no matter how different they are from the ones we might expect of ourselves in a similar situation. Anger experienced as a result of loss or helplessness is often projected onto the nearest person perceived as having power. Counter-productive defensive reactions must be avoided when we are so confronted. If a person discovers that he does not drive away those who care for him by expression of even his strongest, most inconsistent feelings, he acquires a bit more courage to examine and resolve them. Just as safe people aid the parent in expressing potentially overwhelming feelings, so does a safe place. Many Americans weep only in private and may resist acknowledging grief unless a quiet room or its equivalent is available. The need has two aspects: The bereaved require a space apart so they feel free to grieve, and they need to be protected so that their grief does not arouse anger or impatience in uninvolved people around them. For many families, no place is safer than home. Resources for physical care should be organized so that parents who seek the emotional security of familiar surroundings can do so with medical safety. “Safe situations” are those that offer worthwhile activity without taxing the bereaved’s limited ability to
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cope. Involving parents in their care and the decisions made about it can facilitate these situations. Offer a choice of concrete alternatives, for example: Would the mother of a jaundiced baby prefer to have the baby and phototherapy unit moved to her room? Does she wish to help prepare her baby for phototherapy? Would she prefer to come to the nursery to feed her infant? Does she wish to be awakened at night to do so? Does she wish to extend her hospital stay to remain during her baby’s treatment? Would she prefer to take her child home and return as necessary for further tests? When we consult and respect parents’ preferences, we communicate how important those feelings are, and we also diminish, if only by a little, the overwhelming sense of helplessness that accompanies loss. A “safe situation” may also mean the presence of a caring person at a particularly difficult time. The woman in labor sent to x-ray for determination of pelvic adequacy. is better able to cope if her husband, coach, or nurse accompanies her. The new mother who cannot have contact with her baby may appreciate someone who will sit with her when other infants are brought to their parents. The mother going home without her child could use some company as she packs to leave. The threat of an anguish-producing situation is reduced because someone cares enough to recognize and share it. The grief-stricken person can release his feelings more freely when he knows someone is available to help him regain his control afterward. The person who is left alone in his loss experiences a further isolation as a result. Just as we either facilitate or discourage the expression of feeling by our actions, so we can encourage or impede grief work. The job to be accomplished, making the inner sense correspond to the external reality, requires clear and accurate information about that external reality. Parents, however, may be in no position to collect it for themselves. The woman, for example, who is experiencing strong contractions every 3 minutes has little time and energy for reality-testing her environment.
If she uses prepared childbirth techniques or receives pain medication, her selective or general inattention increases. Afterward, she relies on others to fill the gaps in her objective perceptions. If she acquires conflicting data about the external aspects of her experience, she is handicapped in making sense of her subjective responses. Ms. G. was admitted in active labor and found to be severely preeclamptic. Following emergency treatment and medication, she delivered safely. Postpartum, one physician minimized her condition and attributed her problem to “being high-strung.” Another declared her disease probably justified even more aggressive management. A nurse blamed Ms. G.’s hypertension on Methergine, a drug she had not received. Ms. G. became preoccupied with her fragmentary memories of labor and consulted medical texts to ”get the number of the truck that hit me.”
At the very least, those who offer their versions of reality to parents should base their opinions on a thorough review of the available data. When a coherent, clear, and accurate picture is presented of what has happened or will happen, it helps the parents assess the nature and significance of any loss involved. When we are confronted with parents who have suffered serious loss, we, too, react with shock and denial. In our own discomfort and desire to avoid causing pain in the form of grief spasms, we find ourselves making excuses to avoid acknowledging the loss. When we act on our denial, however, we cannot help parents face their reality. Whose needs are being met when we deny grieving parents the chance to hold their stillborn child? How can grief work proceed when we whisk the deformed child off to the nursery and leave parents with their untested “monster” fantasies? And what have we told these parents about the acceptability of grief when we behave this way? The mother of a child born with a cleft lip and palate told a maternity care conference, “The first sin is not telling the parents right away. And the second, once you have, is going on as though nothing happened. ” January/February 1978 JOGN Nursing
Persons under stress do not easily grasp information about the reality situation, even when clearly and honestly presented. When I ask a parent what she’s been told about her situation, I frequently hear “ I was too upset to listen.” The simple explanations appropriate during an emergency or period of emotional stress should be repeated, with additional details, when the parent is better able to hear them. Once is rarely enough, since more questions arise as the parent works through the emotions engendered by the initial information. A mother who suffers unexpected complications during pregnancy or childbirth may not be ready to hear explanations clearly before the end of her hospital stay. She should be provided with, or encouraged to obtain, a written account of what is understood about her situation, and she should be encouraged to contact one of her caretakers at a later date, when further questions come to mind. It is not easy for her to ask these questions, since they may be interpreted as showing a lack of confidence in, or satisfaction with, her care. We can ease communication by telling the departing patient something like, “You will have more questions when you’ve been home a while. Please call me 3 weeks from today to talk again.” One can help the patient who literally does not know what questions to ask by discussing those issues other parents report resolving as they work to accept a similar loss. What are the consequences for the child? For future children? For subsequent pregnancies? And, most basic, in what ways did the parents’ actions contribute to the loss? The sense of guilt pervades grieving as things done or undone are reviewed, and parents may believe any ambivalent feelings they experienced influenced the external course of events, as well. These beliefs may be exposed for reality testing by commenting “You probably worry about being to blame for your condition.” While it is hard for a mother to accept the fact that her body is out of her control, or that the causes of her loss are simply not understood, it is far harder for her to live with responsibility for harm to JanuaryIFebruary 1978 JOGN Nursing
herself o r her child. Parents who are blameless in the development of their loss need to hear that reassurance. In certain maternity situations, the potential for loss is apparent before the actual loss occurs. Pelvic measurements early in pregnancy may indicate the impossibility of vaginal delivery. Low estriol levels and lack of uterine growth may cast grave doubts on the infant’s ability to survive birth. When such information is shared openly with parents, they may experience anticipatory grief. They begin to resolve their expected loss even as the pregnancy continues. Some professionals argue that people should not worry parents with the possibility their expectations will not be fulfilled. This attitude poses some practical problems if parents are expected to cooperate with a treatment regimen made necessary by the complication. Delayed disclosure is also apt to shift the burden of grief to a time of other physical or emotional demands, e.g., recovery from surgery or responsibility for newborn care. Moreover, it also blocks communication and destroys trust between parent and professional, once parents begin to suspect the truth. Ms. T. had her heart set on delivering naturally. “But when my doctor came to my husband and me in labor and explained that a c-section might be necessary-after a while I could see that [vaginal delivery] would hurt me and the baby. He prepared me before I went to xray, and I could accept the section. “After Eric was born I kept noticing band-aids on him but when I asked the nurse she said it was routine tests. Then the house doctor came in, and he was very abrupt and told me I couldn’t have my baby or feed him because he had an infection and jaundice. “ I could accept the c-section because I was prepared for it, but when I heard about the jaundice I became a hysterical female. I felt I had no control over the destiny of my child. I thought someone was trying to take him away from me. The affair has colored my faith in hospital doctors.”
Grief may not be diminished by advance preparation, but the ability to cope with loss appears to be improved. Glick, et ala studied young
widows and discovered that those women who had an opportunity for anticipatory grief before their husbands’ deaths were more apt to remarry. Our surmise is that where the husband’s death was anticipated and could confidently be ascribed to a disease process, then it was cancer or emphysema that was thereafter feared. But where the death was unanticipated, . . . where a marriage that had seemed entirely reliable had suddenly and inexplicably ended, then danger might seem everywhere once one was in marriage, and marriage itself was feared.’
Is it not possible that a similar dynamic exists for loss in childbearing? Grief can be facilitated as a response following loss or in anticipation of an expected loss. Is there any way to help parents prepare for an unexpected experience? This is an issue of particular importance in prenatal education, since parents attend these classes specifically to acquire a knowledge of what to expect. Some childbirth educators provide factual information on grief, much as they discuss transition or signs of labor.‘ I do not always find this appropriate or comfortable. I do feel compelled to remind my students of the variety of childbirth experience possible and to present the factors they cannot control, as well as those they can. I encourage them to examine their hopes and desires in view of evaluating their possibility for fulfillment. I also encourage parents, where possible, to work to help their dreams come true. They can be provided with knowledge and self-help skills, but they require the cooperation of those who care for them, as well. The essence of family-centered maternity care is consideration of what is satisfying to parents, as well as safe. When parents and professionals plan together, when facilities are flexible enough to serve many different “perfect experiences”, perhaps there will be less occasion for grief.
References 1. Peretz, D.: “Development, ObjectRelationships, and Loss,” in Schoenber, B., A. Carr, D. Peretz, and A.
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Kutscher (eds): Loss and Grief: Psychological Management in Medical Practice. New York, Columbia University Press, 1970, p p 3-20 2. Lindeman, E. : “Symptomatology and Management of Acute Grief.” A m J Psychiatry 101:141-148, Sept. 1944 3. Glick, I., R. Weiss, C. Parkes: The First Year of Bereavement. New York, John Wiley and Sons, 1974, p 259 4. Hallet, E.: “Birth and Grief.” Birth E‘am J 1:18-22, Fall 1974
Hazel], L. D. : Commonsense Childbirth, rev. ed. New York, Berkley Publishing Co., 1976 Rozdilsky, M. L., B. Banet: What Now?! A Handbook for New Parents. New York, Charles Scribner’s Sons, 1975 Seitz, P., L. Warrick: “Perinatal Death: The Grieving Mother.” A m J Nurs 74 :2028-2033, NOV.1974 Zahoureck R., J . Jensen: “Grieving and Loss of the Newborn.” A m J Nurs 73:836-839, May 1973
Supplemental Bibliography Engel, G.: “Grief and Grieving.” A m J Nurs 64:93-98, Sept. 1964 Gyulay, J. : “The Forgotten Grievers.” A m J Nurs 75:1476-1479, Sept. 1975
Address reprint requests to Ms. Jeanne T. Grace, RN, 24 Crescent Road, Fairport, N Y 14450
Jeanne Grace is a graduate of the University of Rochester School of Nursing i n New York and teaches childbirth classes for CEA of Rochester. She has also helped develop and teach prenatal classes at the Rochester Adolescent Maternity Project and was instructor of prenatal classes in the high-risk obstetric clinic at Rochester Regional Perinatal Center, Strong Memorial Hospital at the time this article was written.
Perlnahl Rogtam A unique ladder-designed program is being offered to prepare clinicians, practitioners, and clinical specialists in high-risk perinatal nursing. The program Is offered by Houston Baptist Unlversity and Jefferson Davis Hospital, in conjunction with Baylor College of Medicine. It is funded by HEW and The National Foundatlon-March of Dimes. The curriculum plan of the program is as follows: Maternal-Fetal Clinician, 1 quarter; Neonatal Clinician, 1 quarter; Perinatal Practitioner, 3 quarters (BS requlred); Perinatal Clinical Specialist, 3 quarters plus additlong1 graduate currlculum at Houston Baptist University. Admission date for the program is March 3, 1978. For further information contact College of Nursing, Houston BapHst Universlty, 7502 Fondren, Houston, TX 77074 (713)774-7661.
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January/February 1978 JOGN Nursing
PERINATOLOGY
The Mount Sinai Hospital of New York announces a 2-day continuing education program entitled "New Directions in Perinatoiogy: Caring for the High-Risk Mother and Infant"-April 10, 11, 1978. The focus on the 10th will be the mother-amniocentesis, sonography, estriol level, and fetal monitoring. On the 11th it will be the high-risk newborn-pulmonary and ctrculatory changes at blrth, respiratory problems and management, thermoregulation, and nutritional support. For information contact Rosemary Murray, RN, MA, The Mount Sinai Hospital, School of Continuing Education in Nursing, 1 Gustave Levy Place, New York, NY 10029, or call (212)650-5704/5.
PSYCHOPROPHYLAXIS IN OBSTETRICS
The American Society for Psychoprophylaxis in Obstetrics will sponsor a continuing education workshop at Boston Hospital for Women, Lying-In Division, on Saturday, April 15, 1978. Elisabeth Blng, author of works on prepared childbirth, and most recently, Making Love During Pregnancy, will speak on "Sex and Pregnancy." Other topics Include cesarean birth, crisis prediction (fetal monitoring), the modern midwife, and grief management. Application has been made for CEU's for nurses. For further informatlon, contact Conference Manager, ASPO, 1411 K Street, N.W., Suite 200, Washington, D.C. 20005. or call (202)783-7050.
HEALTH PROFESSIONS JOURNAL A new, interprofessional Journal,Evaluation and the Health Professions, will commence publication In the Spring of 1978. The editors are R. Barker Bausell, PhD, and Carolyn F. Waltz, PhD, of the Center for Research and Evaluation, University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201. This new journal is being initiated "in response to the intensifying need for providing a forum for the widespread Sharing of inlormatlon concerning program development and evaluation in all of the health fields." Brochures describing the journal in more detail, subscription Information, or information about submitting manuscripts are avellable from the editors. The journal will be published by Empirical Publications of Baltimore, Maryland.
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JanuaryIFebruary 1978 JOCN Nursing