When suffering a traumatic event, a person’s ability to cope is greatly impacted by the experiences they have immediately following the incident. People who receive effective support in those critical hours are more likely to recover than to fall into despair. For parents who lose a baby during pregnancy or labor, the medical providers play the vital role of first responder. They must deliver the news of the baby’s death and accompany parents through medical procedures. One wonders who the first responders are for these medical providers when a perinatal loss occurs. What preparation have they received in their training to deal with the parents’ emotional shock and devastation? How does this experience affect them personally and professionally? What do they want parents to know about the impact the loss has on them? Where do they turn to for support? Lastly, how has Covid-19 complicated all of the above? An interview with a Nurse Midwife, Amelia, sheds some light on these topics.

Some Examples

Amelia:

“I remember one time when I couldn’t find the heartbeat. I kept trying to find the heartbeat, trying to find the heartbeat. It was awful. It’s always a panic.”
“At the beginning of Covid, we had to go to the operating room, and I was the one who brought the dead baby to the father. He was in the waiting room waiting to hear something. We don’t know why the baby died. The mother had felt movement that day, but when they came in, there was no heartbeat. That was tragic.”
“In those examples, the baby had already passed before the parents arrived. But, if it happens during labor, it can be a very confidence-shaking experience. I did have a baby that did not pass away, but was born in very bad condition and needed to get transferred to a higher level of care. They weren’t sure it was going to make it or not.”

Effect on the Medical Provider and Reactions

Bereaved parents may find it comforting to learn that medical providers are deeply affected by the loss of a baby, and that they remember each of those babies as well as their parents.

"It sticks with you"

Amelia:“These losses, they all stick with you. I’ve been to hundreds of births, and they all blend in together. But the losses, they’re not something you forget. I always cry. It feels unnatural not to cry - there’s a baby that has passed.”

Going the extra mile sometimes

Amelia:“After the stillbirth, there was confusion about where the remains of the baby were. So I called the funeral home to try to figure it out. I took that on because I knew the parents. One midwife said to me, ‘It looks like you like to do this’. I said, ‘I need to do this - it’s part of my job.”

Occasional follow-up

Amelia:“The mom reached out to me and asked if we could get together. I had taken care of her in her previous pregnancies. She said to me, ‘You’ve been with us for our greatest joys and our greatest loss.’ It’s strange because it is a very meaningful connection but I’m not in touch with her regularly.”

Reflections

Amelia:“I don’t think I was prepared at all for how to handle the loss of a baby - it’s not something you learn in school to tell someone their baby has died. At some point in our training I was told, ‘Just state the facts - I’m not finding a heartbeat. It doesn’t look as if the baby is alive anymore. And then, just be there.’ I almost think my goal is for them not to remember me. It’s not about me. I don’t want to say anything to them that will stick with them for the rest of their lives. I don’t want to say anything wrong, so I just try to have a quiet presence. We’re there for these very special moments. But then the way our scheduling works, I will be on my day off with my 7-year-old and my 3-year-old, and it’s hard to be present for my patients during those times.”

Need for a point person for bereaved mothers postpartum

Amelia:“We don’t have a set protocol for supporting parents after they lose a baby. What we have is a checklist for when it happens - there is a grief box, and we get clergy if they want it, a social worker, a photographer, little keepsakes like handprints and footprints. But, as far as our practice goes, we don’t have a point person for that woman postpartum. Because of our scheduling, they may see a different midwife postpartum, we need to change that.”

Personal Reactions

Dealing with the loss of a baby as a provider while being a mother

Amelia:“I am definitely very affected as a mom. I can imagine myself going through the pregnancy, and I can put myself in their shoes. I can empathize so much more after having had children myself.”

Dealing with the loss of a baby as a provider after experiencing a pregnancy loss

Amelia:“I had a pregnancy loss at nineteen weeks five years ago. I had an older child, and this was a baby between him and my daughter. That was very difficult as a mom. I knew how a baby turns into a 2-year-old...all the experiences I had already had. I think coping with pregnancy loss as a midwife when you’re already a mother is harder because you’re more intimately aware of what a pregnancy turns into. As a midwife, I couldn’t take on people’s anxiety for a while.”

Giving back

Amelia:“Usually I would shy away from a loss similar to mine, and ask someone else to take care of the patient. But I recently had a patient who went through what I went through, and I was able to say, ‘I know exactly what you’re going through.’ I think that was meaningful to her. This was one of the first times I felt I could now be helpful to someone else. You feel how isolating it is to lose a baby, and many people don’t know how to talk to other people about it.”

Who Supports the Midwives After a Loss?

Informal support

Amelia:“To process and unpack everything after a loss, I turn to my midwife friends. One midwife who had a series of bad outcomes arranged a drum circle and a cleansing of the floor by a shaman. It was kind of neat and powerful, a very special evening. We really support each other.”

Lack of formal support

Amelia:“There is no formal support after a loss. There’s a lot of burnout because there’s not a lot of support around this kind of work. We get wellness emails from up above, but it doesn’t feel as if our leadership is particularly looking out for our well-being. We need grief counselors to talk to about these really difficult outcomes.”

Helpful mentors

Amelia:“I would definitely recommend that new midwives find a mentor. Someone to talk to about all this is very helpful. It’s important to have people who understand the effect of the loss of a baby on a midwife to talk it through with. When that baby was born in a very bad condition, I kept replaying what I could have done differently and how I may have messed up. Early in my training, I was very lucky to have a great boss who said, ‘you’re going to course-correct for a while, and you’ll go back to finding your baseline. This is how you learn.“

Having to move on

Amelia:“We have to move on. I have another friend who had a baby pass on a shift, and then she had three more births, and she said, ’It was so good that I was so busy on that shift. I couldn’t have gone back to work otherwise, or gotten my head back in the game. It would have really wrecked me.’ But she kept on going.”

What Providers Would Like Parents to Know

Amelia:“It sits with us. It’s not as if we leave the room and that’s it. Even now I’m tearing up talking about it. We’re always thinking about these families, those babies. We replay it - all those scenes in our heads. We’re human, and we’re taking care of humans, and this is part of the humanity of midwifery. It’s not clinical, and it’s not all joy. It’s happy work, but it’s also being there during a lot of hardship. You are part of some really hard stories and a part of those lives. We want to tell parents, ‘If there is anything you need, reach out to us. We care about you.“

Covid-19 as an Exacerbator

Effect of Covid on a nurse midwife

Amelia:“Covid magnifies all the feelings - all the layers of Covid are so much more stressful. The stillbirth at the beginning of covid was such a tragic story. The hospital said they couldn’t have any support people in the hospital. So I had to go tell her husband that I wasn’t sure he was going to be allowed to stay in the hospital, after he lost his baby, and his wife was very sick and almost died. I had to say, ‘We’re working on allowing you to stay, but you might be asked to leave, and I don’t want to surprise you if you have to leave.’ It was just heartbreaking. But his response was, ‘I understand if this is what I need to do to keep people safe. We’re going to do what we need to do.’ And I think about how hard it must be for the mother - is she seeing her family, where does her family live…? There are so many more complications. With Covid, there is a lot of anxiety, and that has depleted me on top of everything. I remember when the shelter-in-place was issued in San Francisco and feeling so anxious. That baby’s death knocked me out for several weeks.”

Self-care during Covid

Amelia:“Seeing my friends is my recharge. And exercising and eating good food. In March and April it was hard because my friends and I couldn’t see each other. Now though we can get together in the park or outside, but it’s been hard. Also, my parents live far away - it’s been almost a year since I’ve seen my family, and I don’t have family in the Bay Area. So there’s a sadness there. We have to wait until there’s a vaccine. There’s also stress with the school and childcare situation. My 7-year-old is in second grade, and we’re struggling with teaching him and getting him to do his homework. We have to take it a day at a time. With Covid it’s similar to pregnancy - we have to get through the unknown without a clear outcome.”

Conclusion

This nurse midwife’s attitude toward her patients who lose babies is one of deep care, and the effect these losses have on her are long-lasting. For her, the memory of each bereaved couple and their babies is forever etched into her memory, and she wants the parents to know they can reach out to her. Being a mother allows her to empathize even more with other mothers who lose a baby. In addition, with the passage of time, her own experience of pregnancy loss is now enabling her to convey a deep understanding of these mothers’ pain and to support them with even more compassion. The experience of being a midwife after a perinatal loss is one of very meaningful connection with bereaved parents followed by having to move on, both because of the nature of the scheduling in the practice and also out of self-preservation. Amelia recommends that a point person be named to follow mothers postpartum and provide continuity of care after a loss. She also believes that new midwives would benefit from having a mentor to debrief with after negative outcomes. It appears that, for this nurse midwife and others in her practice, their first responders are their midwife colleagues. At the same time, in this midwife’s opinion, a more systematic protocol of support, possibly from social workers in the hospital or grief counselors, would help decrease the incidence of burnout. Lastly, Covid has magnified the challenges of being a nurse midwife after a perinatal loss, and has led to increased stress, anxiety, depletion, and isolation from family and friends. This has created a parallel experience with that of pregnancy for the couples this midwife works with unknown outcomes for everyone.

Pascale Vermont, PhD

Author of Surviving the Unimaginable: Stories of Coping with Pregnancy and Infancy Loss

A nurse midwife's experience of perinatal loss