26.2: Pregnancy Loss

Learning Objectives

By the end of this section, you will be able to:

• Define the difference between early and late pregnancy loss
• Identify ways to help a person, their partner, support persons, and family cope with pregnancy loss
• Identify the nurse’s role when caring for a person experiencing a pregnancy loss

Several terms describe the nature and timing of a loss. A perinatal loss is the involuntary end of a pregnancy after implantation or death of a newborn within 28 days after birth (Qian et al., 2021). Perinatal loss occurs within the obstetric period. An early pregnancy loss occurs after implantation and before 20 weeks’ gestation and is most often the result of spontaneous abortion (American College of Obstetricians and Gynecologists [ACOG], 2018). A late pregnancy loss occurs after 20 weeks’ gestation and is commonly defined as intrauterine fetal demise. A neonatal loss is when a newborn dies before 28 days of life.

The experience of perinatal persons, their partners, support persons, and family members during and after a perinatal loss is called perinatal bereavement (Zhuang et al., 2022). It is a devastating event with substantial physical, psychologic, emotional, social, and economic consequences. Nurses can refer parents, partners, support persons, and family to social services for perinatal bereavement care to help cope and manage the impact of this traumatic event (Metz et al., 2020).

Causes of Pregnancy Loss

Early pregnancy loss is the most common complication in the first trimester of pregnancy. Approximately 15 percent of pregnancies end in spontaneous abortion and 2 percent end in ectopic pregnancy (Galeotti et al., 2023). The risk of first trimester spontaneous abortion increases with the age of the pregnant person. Cervical insufficiency is another cause of early pregnancy loss and is diagnosed in the second trimester of pregnancy. See Chapter 12 Pregnancy at Risk for more information on causes and treatment of early pregnancy loss.

Pregnancy loss after 20 weeks’ gestation is commonly called an intrauterine fetal demise (IUFD) and is also known as a stillbirth. In the United States, late pregnancy loss occurs in 1 out of 160 pregnancies (McLaren et al., 2022). The most common risk factors are non-Hispanic Black race, advanced maternal age, and pregnancy resulting from assisted reproductive technology. The most common modifiable risk factors include obesity, chronic hypertension, diabetes, and alcohol and tobacco use (McLaren et al., 2022). Women of non-Hispanic Black race experience a rate of late pregnancy loss twice that of other groups. Pregnancies with more than one fetus are also at a higher risk. Refer to Chapter 12 Pregnancy at Risk for more information on causes and treatment of late pregnancy loss.

Cultural Context

Pregnancy Loss and Cultural Experiences

Different cultures and religions deal with pregnancy loss in different ways. A study of ultraorthodox Jewish people in Israel discovered that the loss of a pregnancy offered a way for parents and families to experience their belief in God and to experience God’s love. These people stated their faith provided them with calmness, stronger faith, and confidence in their God. The study hypothesized that, by attaching meaning to their loss, parents were able to process their grief and move on.

(Hamama-Raz et al., 2014)

Termination of pregnancy is also considered a perinatal loss, especially when performed due to fetal anomalies and increased risk for the life of the pregnant person. Even though counseling occurs before the decision for termination, bereavement is experienced by the pregnant person, their partner, and all support persons after the procedure. Nurses can encourage use of support groups and counseling to help with feelings of loss. Please refer to Chapter 12 Pregnancy at Risk for more information on termination of pregnancy.

Studies show that health-care workers caring for this population experience demanding working conditions related to the lack of access to these services and moral ethical dilemmas surrounding fetal viability (McLean et al., 2023). Facilities that do offer such services many times provide support systems and education on self-care.

Cultural Context

How Culture Can Affect Data Collection on Stillbirths

A study performed in Afghanistan found that gathering reliable statistics on stillbirth was problematic in low- and middle-income communities. One cause was a difference in terminology and determination of stillbirth among communities. Most births occur outside a hospital. Many birth attendants did not allow the parents to see or hold their baby, making their recollection of the event difficult. Unintentional misclassification of the birth occurred with some birth attendants. The authors noted that birth attendants and families felt social pressure when reporting a stillbirth.

The study found that data were collected more accurately when families were shown their baby, allowing for better recollection of life at the time of delivery or stillbirth at delivery. Families who recognized stillbirth and were open to discussion provided better data and were less likely to underreport stillbirth.

Families were more likely to demand an investigation of the cause of stillbirth when the child was male as opposed to female. The authors note that at times, female infants were not allowed lifesaving measures. Stillborn infants with congenital abnormalities were many times left at the hospital when the parents secretly left the hospital due to shame. These incidents do not allow for the collection of data for these stillbirths.

(Christou et al., 2019)

Bereavement Care

Perinatal bereavement consists of building a relationship with the family and loved ones. The nurse establishes trust, then encourages the persons to speak honestly and openly about their emotions and feelings. The nurse expresses understanding, respect, and support. Anticipatory guidance for grief allows the family to understand the normal grieving process.

Perinatal bereavement care is provided in, but not limited to, antepartum settings, emergency departments, perioperative areas, high-risk pregnancy units, labor and birth suites, mother-baby units, and neonatal intensive care units (NICUs). The care can start after the loss has occurred (spontaneous abortion), while the loss is in progress (intrauterine fetal demise), or when the loss is inevitable (lethal congenital anomaly). In addition to nurses and other health-care providers, chaplains, grief counselors, funeral directors, social workers, child life specialists, and support groups are part of bereavement services (Wool & Catlin, 2019).

Bereavement care is provided within a culture of collaboration, support, and respect within the health-care system. Table 26.1 summarizes the actions nurses and health-care systems can take based on the expectations for bereavement care.

Expectations	Nursing and Institutional Actions
Individualized care	Care should recognize personal, cultural, or religious needs.
Good communication	Communication should be clear and honest. The terms fetus, embryo, or spontaneous abortion should not be used. The nurse can ask the parents how to address the fetus.
Shared decision making	Patients should be provided all information to make important decisions and given adequate time to make those decisions.
Recognition of parenthood	Recognition of parenthood and memory making is important. Lack of memories of the baby is a reported regret of parents.
Acknowledging partner’s and family’s grief	Recognition of the partner and family’s grief is important. Families and partners need support and resources.
Burials, cremation, and funerals	Options for the baby should be provided prior to the birth, if possible, to give time for the family to consider their options.
Testing	Testing should be offered to the person experiencing loss to increase the possibility of diagnosing the cause and preventing future perinatal loss. The most useful tests include genetic testing (when possible), autopsy of the fetus (cost not usually covered by insurance), and pathology of the placenta.
Health-care providers’ and nurses’ bereavement training	All health-care professionals caring for bereaved patients should have bereavement training.
Health-care providers’ and nurses’ access to self-care	All staff caring for bereaved patients should have access to information about effective self-care.

Table 26.1 Bereavement Care

Nursing Care after Pregnancy Loss

Physical recovery after pregnancy loss is similar to postabortion or postpartum recovery. The nurse educates the patient that bleeding can last 4 to 6 weeks after the birth and to avoid tampons, douching, or intercourse until bleeding has stopped. The nurse also informs the patient that menses can return at approximately 4 to 6 weeks as well. Contraception should be discussed and a follow-up appointment with the health-care provider scheduled.

Patients who have a late pregnancy loss can experience lactation. The nurse educates the patient to wear a supportive bra and hand express a small amount of milk to relieve engorgement but not stimulate milk production. Patients can use a cold compress or cabbage leaves to relieve pain and decrease milk supply. The nurse can also suggest natural remedies to stop milk production, such as sage, peppermint, and parsley. Some patients would like to donate breast milk and can be referred to a lactation consultant regarding the donation process. See 26.2 Intrapartum Fetal Death for more information on breast milk donation.

Emotional recovery is a long process. Pregnancy loss can cause depression and posttraumatic stress disorder (PTSD), leading to feelings of failure, sadness, and despair; however, nurses can help provide a positive birth experience (Galeotti et al., 2023). Nurses give emotional and physical support, reminding the patient that this outcome is not their fault. Many hospitals provide training for nurses and health-care providers that teaches the essentials of bereavement care. This care should be individualized, considering the patient’s cultural and religious beliefs. Referrals should be provided for counselors and mental health specialists. Nurses can also provide support to parents and families experiencing perinatal loss. The following are Internet links to several support groups:

• Share Pregnancy & Infant Loss Support
• International Stillbirth Alliance
• SANDS
• The Compassionate Friends
• HAND