26.4: Newborn Loss

Learning Objectives

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

• Describe the causes of neonatal deaths
• Identify ways to debrief with fellow coworkers and providers after a neonatal death
• Identify the nurse’s role in supporting a family grieving after a neonatal death

A neonatal death is when a baby dies within the first 28 days of life. The occurrence in the United States is about 4 in 1,000 babies (less than 1 percent) (National Center for Health Statistics, 2023). Death of a newborn at any time is a traumatic event and requires specialized interdisciplinary care for families. In this section, the causes of neonatal deaths and the nurse’s role in supporting the grieving family will be reviewed.

Causes of Neonatal Mortality

According to the World Health Organization ([WHO], 2022), in 2020, rates of neonatal death varied widely depending on where the infant was born; for example, the area of sub-Saharan Africa represented 43 percent of all neonatal deaths, and Central and Southern Asia represented 36 percent (WHO, 2022). In the United States, neonatal mortality rates were higher in Black (non-Hispanic), American Indian, Alaskan Native, and Pacific Islander persons, and in the states of Mississippi, Louisiana, North Carolina, South Carolina, and Arkansas (United Health Foundation, n.d.). Most neonatal deaths occur within the first 24 hours of birth or the first week of life.

The most common causes of neonatal loss are prematurity, low birth weight, and congenital anomalies (CDC, 2023b). A pregnancy, labor, or birth with complications also increases the risk for neonatal loss, especially that due to asphyxia and infection. Refer to Chapter 25 Care of the Newborn at Risk for more information on causes of neonatal loss.

Preterm Birth

Preterm birth, birth occurring prior to 37 weeks’ gestation, is a significant cause of neonatal mortality. Preterm newborns are usually of low birth weight and have more health problems than term babies. In the United States in 2022, 1 in 10 infants was born preterm (Martin et al., 2022). These infants’ brain, liver, and lungs lack the intrauterine development that occurs in the last few weeks and months of pregnancy and, therefore, have developmental delays, respiratory problems, feeding difficulties, and higher mortality (CDC, 2023c).

Newborns born prior to 34 weeks (Figure 26.2) will most likely suffer from respiratory distress syndrome due to lack of surfactant, which allows the lungs to inflate and deflate easily (March of Dimes, 2017). Intraventricular hemorrhage, or bleeding in the brain, is seen in preterm babies and is a common cause of mortality (March of Dimes, 2017). Preterm babies can also suffer from necrotizing enterocolitis (tissue death in the intestines); this causes diarrhea, feeding problems, and an edematous abdomen. This is a serious complication that can lead to death (March of Dimes, 2017). Some maternal complications can cause preterm birth, such as preeclampsia, placental abruption, and premature rupture of membranes.

Figure 26.2 Preterm Newborn Preterm infants often need assistance with breathing and are at risk for respiratory distress due to lack of surfactant. (credit: “Lyra” by Chris Sternal-Johnson/Flickr, CC BY 2.0)

Childbirth Complications

Research suggests that timely treatment of preterm birth, intrapartum complications, and infection could result in fewer neonatal deaths (Lawn et al., 2023). Delay in decision making during labor, delay in presenting to the hospital, and delay in adequate prenatal care all contribute to neonatal mortality (Lawn et al., 2023). Common intrapartum complications resulting in neonatal mortality include birth trauma, such as intracranial hemorrhage and skull fracture; placental problems, such as placental abruption, cord avulsion, vasa previa, and cord accidents; and maternal complications, such as uterine rupture, preeclampsia/eclampsia, injury, and substance use (Tesfay et al., 2022).

Infections

Chorioamnionitis is the infection of the bag of water affecting the uterus and the fetus. Group B streptococcus (GBS) is the cause of most neonatal invasive infections and is associated with a high morbidity and mortality rate. Most GBS infections occur within the first week of life and are acquired during birth but can occur weeks later. Between 20 and 30 percent of pregnant persons are colonized with GBS, but only 1 to 2 percent of neonates will develop the infection (Mynarek et al., 2021). GBS can be a cause of preterm birth, leading to neonatal mortality (Mynarek et al., 2021).

Neonatal sepsis can be caused by a maternal infection. During pregnancy, an infection can cross the placenta; during labor, it can ascend the vaginal canal to the uterus and fetus (Figure 26.3), and after birth, an infection can be acquired from breast-feeding (Pace & Yanowitz, 2022). Neonatal sepsis can be caused by a bacterium, virus, or fungus with a presentation of fever, tachypnea, lethargy, hypothermia, and poor feeding (Pace & Yanowitz, 2022). The age of the neonate can drastically change the chance of survival, with a fatality rate of 20 percent in preterm neonates and 2 percent in term neonates (Pace & Yanowitz, 2022).

Figure 26.3 Intrapartum Infection Bacteria, viruses, or fungi can ascend from the vagina into the uterus, causing an infection. (CC BY 4.0; Rice University & OpenStax)

Herpes simplex virus (HSV) infection occurs in 10 per 100,000 live births (Mahant et al., 2019). HSV can infect the neonate during pregnancy or delivery and has a mortality rate of 4.1 to 7.3 percent (Mahant et al., 2019). Symptoms of neurologic infection, usually occurring after 2 weeks of life, include seizures, poor feeding, lethargy, bulging fontanelles, temperature irregularities, and skin lesions; disseminated disease occurs after 10 days of life, with symptoms of respiratory failure, encephalitis, multiorgan failure, and death (Mahant et al., 2019). Another organism causing neonatal mortality is E. coli. E. coli can cause pneumonia, sepsis, and meningitis and is transmitted mostly as a nosocomial infection (Lai et al., 2021). Neonates with fever or temperature instability can be readmitted for possible sepsis.

Birth Defects

Birth defects can be responsible for neonatal deaths. Cardiac defects can be treated with surgery; however, more complex defects may not be treatable and can cause neonatal death (March of Dimes, 2017). Lung defects can occur because of underdevelopment, which can be caused by prematurity or oligohydramnios, as lungs cannot expand and develop with low amniotic fluid. Neurologic defects such as anencephaly, that is, lack of development of the brain and skull, are many times the cause of stillbirth; however, some anencephalic infants are born but die shortly after birth (March of Dimes, 2017).

Caring for the Caregiver

Many parents or caregivers blame themselves and experience extreme guilt in cases of newborn death, especially in the case of inheritable genetic diseases. Grief has been described as a loss of an attachment, and the attachment between a parent and child is one of the strongest of all human attachments (Duncan, 2018). Coping after the loss of an infant can be influenced by culture, religion, family dynamics, and social support. The nurse should assess these influences in order to provide referrals and arrange for additional support.

Nurses who care for these families need support themselves. Debriefing with other nurses, managers, and social workers is important for self-care. Nurses can suffer from grief and depression. When they recognize these symptoms, they must reach out for help in order to care for themselves. Being supported by peers allows nurses to work through their feelings and ideally prevent grief from turning into depression.

Cultural Considerations

The process of grieving can be influenced by a family’s culture, such as their values, beliefs, and religion (Arslan & Buldukoğlu, 2019). Grief rituals can range from wearing black clothing for a certain period to avoiding weddings or other celebrations while grieving to isolating from others (Arslan & Buldukoğlu, 2019). Culture can influence the desire for a burial or cremation. Beliefs can also determine if the body will be viewed in an open casket. The nurse can assess for cultural beliefs to provide culturally competent care. The nurse can contact the patient’s church or religious group to help plan for burial or cremation.

Cultural Context

Death Rituals Practiced in Certain Religions

In Judaism, the body is not embalmed, nor will the service include an open casket (Lowey, 2015). In Catholicism, a priest performs a funeral mass at the church followed by internment (Lowey, 2015). In Protestant denominations, cremation or burial is acceptable, and funerals may be held at a funeral home or church. For followers of Islam, burial occurs as soon as possible, and the body of the deceased is buried facing Mecca (Lowey, 2015). The nurse can assess for cultural beliefs and provide culturally competent care.

Referrals for Help

Validated depression screening should be done. Depending on the health-care facility, nurses can refer families to bereavement resources or consult the hospital’s social worker or bereavement committee to obtain referrals for families. Cognitive behavior therapy (CBT) and counseling can be helpful to those families experiencing a newborn death. Grief counseling is another therapy that can be helpful. Support groups are available to provide professional and social support to families experiencing similar grief. Medications such as antidepressants and anxiolytics can be used to assist with coping.

Link to Learning

Mommies Enduring Neonatal Death (MEND) is a support group providing resources and support to families who have lost a child to miscarriage, stillbirth, and infant loss.

Helping Families Understand the Grief Process

Parents dealing with the loss of a newborn can experience a lack of desire for life and daily activities. They may feel anger, sorrow, and shock. Physical symptoms, such as chest pain, fatigue, stomachache, and digestive issues, can result from grief (Arslan & Buldukoğlu, 2019). Table 26.4 lists more symptoms of grief. Families should be provided reassurance that these feelings and symptoms are part of the normal grief process. Nurses should explain that there is no timeline on grieving, and everyone grieves in their own way. Suggestions for dealing with the grief process include the following:

1. Acknowledge the loss and pain.
2. Understand that grief can trigger many unexpected emotions.
3. Know that grief is unique to the person.
4. Find people who care and support you.
5. Take care of yourself mentally and physically.
6. Recognize signs of depression.

(Smith et al., 2023)

Type	Symptoms
Emotional	Shock Disbelief Sadness Guilt Fear Anger
Physical	Fatigue Nausea Compromised immunity Weight changes Aches/pains Insomnia

Table 26.4 Symptoms of Grief (Smith et al., 2023)

The nurse will explain that grief is different from depression. Depression is despair and extreme sadness that interferes with daily activities, with frequent thoughts of death, worthlessness, or suicide, and does not lessen with time (Schimelpfening & Gans, 2023). Grief can decrease with support and time but can also recur during special situations such as the birthday or anniversary of a loved one; depression does not change depending on the circumstances (Schimelpfening & Gans, 2023).

Helping Siblings

Helping a sibling understand the death of a newborn is difficult. Children’s understanding of death depends on their age, development, their ability to think abstractly, their other experiences with loss, and their cognitive development (Arslan & Buldukoğlu, 2019). Young siblings who experience loss can exhibit anxiety and have behavior issues; older children can show signs of depression (Arslan & Buldukoğlu, 2019).

Supporting a sibling through a newborn death requires honesty and openness. Parents should acknowledge the sibling’s grief, be honest about their own grief, and help the sibling keep the memory of the newborn alive (Support for Siblings after a Neonatal Death, n.d.). Give the sibling permission to cry and grieve, explain that the death was not anyone’s fault, and reassure them their parents are okay, as children many times fear other loved ones dying (Support for Siblings after a Neonatal Death, n.d.). Counseling specifically for siblings and children is available and referrals can be provided by the nurse.