As Midwives, we are often in a privileged position to care for and support women who return to our maternity settings for a subsequent pregnancy. But as practitioners, are we taking the time to consider what has gone before and are we curious about this next pregnancy and what it means for the woman and her partner in light of a previous loss(es)? 
To effectively care for women who have experienced a previous loss, it is important to understand the emotional impact of that loss on the next pregnancy.

​For a woman and her partner who have previously experienced miscarriage, stillbirth, or the death of a baby, conceiving another child can be fraught with mixed emotions. For some, a subsequent pregnancy can be overwhelming and there is often fear that this baby will die too. Sometimes relief may be achieved when nearing the gestation of the previous loss, however the anxiety does not necessarily disappear, and parents can be left with uncertainty and fear around the health of this next baby. Sometimes the anxiety can be crippling.

It is important to understand what the previous loss meant and what (if any) attachments were made to the baby who died. The woman and partner may have felt strong attachments early in the previous pregnancy and profound grief is therefore possible (Black, Wright and Limbo, 2016). We need to understand the individual’s loss story and not make assumptions based on the gestation of the previous loss or on the number of living children a mother has. We also need to be cognisant of the potential emotional and/or physical struggle to get pregnant again and the number of cumulative losses which can impact on the emotional state in this subsequent pregnancy. Many women do not believe they will get to take a live baby home with them, and it can be a long and anxious pregnancy for them. 

What does the research say? 
These parents often need extra support however there is little clear evidence to guide clinicians in the provision of psychosocial support in a subsequent pregnancy to help us provide the best care to these parents (Wojcieszek et al., 2016). Wojcieszek suggests that parents need better emotional support in these pregnancies, and more opportunities to participate actively in decisions about their care. 

Another study included women who had experienced a previous stillbirth, and the results point to these women facing a significantly greater risk of anxiety (22.5%) and depression (19.7%) in the subsequent pregnancy compared with women with a previous live birth and previously nulliparous women. In this study, it was also noted that anxiety and depression decreased 6 to 18 months after the birth of a live-born baby, but increased again 36 months postpartum (Gravensteen et al., 2018). 

Trying again
For some the decision to not have another baby is made. Some will decide that for them, the right decision is not to try for another baby and reasons for this may include overwhelming anxiety; physical barriers to another pregnancy; family relationship/dynamic changes; financial burden or that it is simply not the right time. 

It is vital that as Midwives, we provide adequate and effective support to any family who we encounter, who may be grappling with the decision to start trying again for another baby following a previous loss. Sometimes it is appropriate to refer on to a Grief Counsellor or Perinatal Psychologist for specialised and targeted support. 

Implications for practice 
As Midwives we must provide thoughtful, empathic, and collaborative care in all pregnancies following perinatal loss which includes the following additional measures: 

• Ensuring the mother is part of all decision-making processes
• Providing extra emotional support
• Offering referral for counselling (to a Grief Counsellor or Perinatal Psychologist)
• Assessing all risk factors (there is an increased risk of stillbirth occurring again) 
  • Educating woman to side sleep after 28 weeks; immediate reporting of change in fetal movements; smoking cessation; attending antenatal appointments 
• Consider increased antenatal visits
• Consider increased ultrasound/fetal surveillance
• +/- Induction of labour
• Flagging medical history (previous loss(es))
• Normalising thoughts/feelings/reactions (grief may resurface even after birth)
• Offer specific education and training for health professionals 

Education and Training 
To effectively care for women who have experienced a previous loss, it is important to understand the emotional impact of that loss on the next pregnancy. Good bereavement care principles include care in a subsequent pregnancy and with specific perinatal loss education and training you will feel more confident to care for and support women in a subsequent pregnancy. 

For information on perinatal loss training, please go to course “Perinatal Loss in Practice: What Hospital Staff Need to Know” at: 
www.cope.org.au/training and/or
www.theperinatallosscentre.com.au/training

Resources for those in your care 
The Centre of Perinatal Excellence (COPE) is a one-stop-shop for hopeful, expectant, and new parents, and contains valuable information surrounding coping with perinatal loss (and specifically coping after a miscarriage and stillbirth). 
Visit 
www.cope.org.au/planning-a-family/pregnancy-loss/
www.theperinatallosscentre.com.au

Finding support for perinatal loss
COPE has a dedicated perinatal mental health directory, which includes the range of specialist services focussing on perinatal loss. To find a treatment or support service simply go to the ‘Find help’ section of the COPE website (cope.org.au), specify your search and a list of individual practitioners and specialist services will be presented. Listings include both face-to-face, online/phone treatment and support services for perinatal loss (and other perinatal emotional and mental health conditions). 
Visit www.cope.org.au/e-cope-directory/ search/ 
​www.cope.org.au/e-cope-directory/ search/

The Perinatal Loss Centre THERAPIST REGISTER
Currently under construction, The Perinatal Loss Centre's Therapist Register lists therapists around Australia who have completed the COPE training course "Perinatal Loss in Practice: What Therapists Need to Know" by Dr Renée Miller (Perinatal Clinical Psychologist)
www.theperinatallosscentre.com.au/therapist-register.html

Community Support services
Other comnunity support services can be found here.

References
Gravensteen, I., Jacobsen, E., Sandset, P., Helgadottir, L., Rådestad, I., Sandvik, L., & Ekeberg, Ø. (2018). Anxiety, depression and relationship satisfaction in the pregnancy following stillbirth and after the birth of a live-born baby: a prospective study. BMC Pregnancy and Childbirth, 18(1). doi: 10.1186/s12884-018-1666-8
Wojcieszek, A., Boyle, F., Belizán, J., Cassidy, J., Cassidy, P., & Erwich, J. et al. (2016). Care in subsequent pregnancies following stillbirth: an international survey of parents. BJOG: An International Journal Of Obstetrics & Gynaecology, 125(2), 193-201. doi: 10.1111/1471-0528.14424

Published in Australian Midwifery News • Winter Issue 2021 A publication of Australian College of Midwives 
 

The Coronavirus pandemic has understandably increased the anxiety levels of expectant couples. Additionally, COVID restrictions have brought about some limitations to the support pregnant and birthing women have been able to receive.

Sadly, for families who experience a stillbirth during the pandemic, hospital restrictions have resulted in some additional challenges. Along with the shock and devastation of losing their much-wanted babies, bereaved parents have felt more alone and isolated in their grief due to the Coronavirus restrictions.
 
Bereaved parents have had to grieve without the support of family and friends being able to visit them in hospital and at home.

Professional photographers such as Heartfelt, have at times been unable to visit and take professional photos of babies who have died.

There have been limitations around the number of family and friends able to attend the baby’s funeral.

In hospital settings, Midwives and Obstetricians supporting women and their partners whose babies have died, are working hard to make up for the limitations imposed by the Coronavirus pandemic. 

What is being done?
Bereavement Midwife Eliza Strauss highlights what healthcare professionals can do to care for bereaved families during these extremely difficult times, and to help bereaved parents mourn and honour their baby’s short lives.

Many bereavement care practices that were in place prior to the pandemic can continue, so that bereaved mothers and fathers are still able to gather memories and parent their babies who have died.

Typical bereavement practices:

• The use of a cuddle cot to ensure the baby is not separated from the parents
• Unrushed time for the parents to spend with the baby
• Creation of a memory folder including collection of tangible memories such as foot & handprints, measurements, weight and birth details
• Dressing and bathing the baby
• The offer to take baby home if this is the parents’ wish
• The taking & printing of photos, using a donated camera or the parents’ phone (with their permission)
• Early referral to an appropriate funeral company 
• Early referral for counselling and support 

Additional bereavement practices during the pandemic:

• Extra input from Midwives or other health professionals to present alternative options so bereaved parents are informed of what is and is not possible due to the restrictions
• Suggesting that parents FaceTime their families if they want them to meet the baby
• Offering to film the parents on their phones with a message to their older children, introducing their sibling who has died (if the parents would have otherwise brought the children in to the hospital)
• Encouragement to ask the funeral company whether they have live streaming options for friends and family who cannot attend the funeral due to Coronavirus restrictions

The Coronavirus pandemic has catapulted the world into a collective grief. Restrictions and limitations imposed by the virus need not impede the care and support health professionals can give to their grieving patients.

It is important that bereaved families know that the people looking after them are working within the coronavirus restrictions to honour their babies in ways that will help them through their ongoing grief and mourning.

Resources

The Perinatal Loss Centre: www.theperinatallosscentre.com.au/information.html
Red Nose: www.rednose.org.au
Sands Australia (miscarriage, stillbirth and newborn death support): www.sands.org.au
Pink Elephants Support Network: www.miscarriagesupport.org.au
Bears of Hope: https://www.bearsofhope.org.au/

Article by Eliza Strauss, Co-founder of The Perinatal Loss Centre, Bereavement Midwife, Melbourne, Australia.

Eliza Strauss conducts online perinatal loss training for health professionals, in association with the Centre of Perinatal Excellence.
​Read more here.