Childbirth Education for Parents Experiencing Pregnancy after Perinatal Loss

Abstract

Expectant parents who have experienced previous perinatal loss have special concerns, which can be partially addressed by modifying prepared childbirth education courses. This article presents a review of current literature, highlighting the unique needs of expectant parents who have experienced previous pregnancy loss. Modifications to traditional childbirth education courses are suggested, which include addressing parents' grief, managing anxiety, and facilitating communication with health-care providers and others.

The National Vital Statistics System (2001) reported that, for all races, the perinatal mortality rate was 6.9 per 1,000 live births in 2001. The agency's number may reflect an under-reporting of the actual number of miscarriages in the U.S. because data are gathered only for those losses occurring after 20 weeks of gestation. A growing body of literature addresses the incidence of pregnancy loss and pregnancy after that loss (Armstrong, 2002; Caelli, Downie, & Letendre, 2002; Cote-Arsenault & Dombeck, 2001; Van & Meleis, 2003).

A number of authors and researchers have discussed the unique needs of parents experiencing perinatal loss and have suggested helpful interventions (Caelli et al., 2002; Chan, M. E., Chan, S. H., & Day, 2003; Cote-Arsenault & Freije, 2004; Herkes, 2002; Van & Meleis, 2003; Wallerstedt, Lilley, & Baldwin, 2003). However, none addressed the possibility of tailoring traditional childbirth education classes for parents experiencing pregnancy after a pregnancy loss. This paper presents a proposed teaching plan, based on published literature and the author's experience, for such parents.

LITERATURE REVIEW

Women who have experienced pregnancy after perinatal loss have reported a number of unique concerns, including grief and depression (Armstrong, 2002; Caelli et al., 2002; Hughes, Turton, & Evans, 1999). Grief is commonly experienced following the loss, but the perceptions of grief vary among parents (Hutti, 1992). In a descriptive study of six married couples who had experienced miscarriage within the previous 18 months, Hutti (1992) found that grief was most intense among parents who accepted the pregnancy and baby as real. In another study, while some women did not report experiencing grief after miscarriage, others reported an intense sense of loss (Hutti, dePacheco, & Smith, 1998). Additional studies found some women were so affected by miscarriage that they chose not to become pregnant again and, instead, chose to become foster parents or to adopt (Hutti, 1992; Van & Meleis, 2003).

Women who have experienced pregnancy after perinatal loss have reported a number of unique concerns, including grief and depression.

Parents who choose to become pregnant following perinatal loss often report initial feelings of happiness that are short-lived (Caelli et al., 2002) and overshadowed by worry. Many studies support the notion that parents experiencing pregnancy after perinatal loss feel more anxious toward the pregnancy than parents who are pregnant for the first time (Armstrong, 2002; Cote-Arsenault & Dombeck, 2001; Cote-Arsenault & Freije, 2004; Hughes et al., 1999; Van & Meleis, 2003). Armstrong (2002) found that such parents approached pregnancy with fear and hesitated to expect a positive outcome. The anxiety experienced by mothers during pregnancy after perinatal loss is best conveyed in their own words. One participant in a phenomenological study said, “You can never enjoy a pregnancy again, never!” (Caelli et. al, 2002, p. 132). This notion is echoed in the words of a participant in another study, who stated, “There was never a point where I relaxed. Never” (Van & Meleis, 2003, p.34). Some studies' findings indicated that the amount of anxiety toward the current pregnancy was related to the degree of attachment to the baby who died (Hutti, 1992; Hutti et al., 1998). Many studies' findings suggested that feelings of anxiety delay attachment during the subsequent pregnancy (Cote-Arsenault & Dombeck, 2001; Rillstone & Hutchinson, 2001; Van & Meleis, 2003; Wallerstedt et al., 2003). However, a study by Armstrong (2002) found that, contrary to other findings, attachment to the current pregnancy was not affected by previous perinatal loss.

Some literature points out that parents who encounter perinatal loss frequently feel their experiences are misunderstood and minimized by friends, family members, and even health-care providers (Caelli et al., 2002; Cote-Arsenault & Freije, 2004; deMontigny, Beaudet, & Dumas, 1999; Van & Meleis, 2003; Wallerstedt et al., 2003). Caelli and colleagues (2002) reported that such parents perceived health-care providers frequently dismissed their fears. Some women have reported separating themselves from those who did not seem to understand their experience (deMontigny et al., 1999). Others reported using specific means of coping with unsupportive responses of others, such as ignoring them, forgiving them, or attributing them to a lack of understanding (Van & Meleis, 2003). Both social and professional relationships can be permanently affected by unsupportive responses (deMontigny et al., 1999; Wallerstedt et al., 2003). For example, parents who felt unsupported during perinatal loss often changed providers during a subsequent pregnancy (Wallerstedt et al., 2003).

Parents who encounter perinatal loss frequently feel their experiences are misunderstood and minimized by friends, family members, and even health-care providers.

Although parents who have experienced perinatal loss may be initially hesitant to develop a trusting relationship with a new provider, they tend to seek care and advice more frequently out of fear and anxiety that something could go wrong (Armstrong, 2002; Caelli et al., 2002; Rillstone & Hutchinson, 2001; Van & Meleis, 2003; Wallerstedt et al., 2003). Furthermore, such parents tend to form attachments to their health-care providers (Rillstone & Hutchinson, 2001). Caelli and colleagues (2002) asserted that the development of a trusting relationship during this crucial time could be fostered through a focused prenatal program. Such a program has the potential to facilitate a trusting relationship with health-care providers by validating the special circumstances of parents experiencing a pregnancy after perinatal loss. A specially targeted course enables the childbirth educator to incorporate the unique needs of bereaved parents into a modified traditional format.

CHILDBIRTH EDUCATION FOR PARENTS EXPERIENCING PREGNANCY AFTER PERINATAL LOSS

Traditional childbirth education classes were designed to help women and their partners prepare for the experience of labor and birth. Typically, information such as common discomforts of pregnancy, care of the newborn, and recovery are addressed. However, current literature indicates that parents experiencing pregnancy after perinatal loss have needs and views of the pregnancy that differ from those of parents experiencing first pregnancies (Van & Meleis, 2003). Women experiencing pregnancy after perinatal loss have been shown to benefit from targeted interventions during pregnancy (Caelli et al., 2002; Cote-Arsenault & Freije, 2004). The desire to meet others who are also encountering pregnancy after perinatal loss was expressed by such parents (Caelli et al., 2002; Cote-Arsenault & Freije, 2004; Rillstone & Hutchinson, 2001; Van & Meleis, 2003). One study participant found that meeting others who had the same experience offered a “whole different level of support” (Rillstone & Hutchinson, 2001, p. 297). Also, participants who have experienced a similar loss understand each other's pain and can form caring relationships with one another (Cote-Arsenault & Freije, 2004). An asset of a pregnancy-after-perinatal-loss program is connecting parents who share the same profound experience. They can share unique aspects, such as the need to cope with grief, manage anxiety, and maintain positive supportive relationships with others.

Coping with Grief

Many women who have experienced pregnancy after perinatal loss report a strong need to talk about their experiences in a supportive and nonjudgmental atmosphere (Caelli et al., 2002; Cote-Arsenault & Dombeck, 2001; Cote-Arsenault & Freije, 2004; Van & Meleis, 2003). Those who participated in support groups or a special-delivery service provided by midwives believed facilitators of these groups required a unique ability to show support and understanding (Caelli et al., 2002; Cote-Arsenault & Freije, 2004). African-American women noted the “importance of having someone to listen to them without judgment or criticism” (Van & Meleis, 2003, p. 32), and parents who participated in a special-delivery service cited the willingness of the midwife to listen to them as a strength of the program (Caelli et al., 2002). One woman, speaking about the facilitator of a pregnancy-after-loss support group, stated, “She had so much excellent information… but also she went at it from the perspective of what were your issues during the birthing process… your concerns, your fears…. I don't think just anybody can come in and facilitate this kind of group” (Cote-Arsenault & Freije, 2004, p. 663).

To create a welcoming atmosphere, the facilitator for the pregnancy after perinatal loss course could arrange the chairs in a circle or around a small table. The facilitator might also plan to allow the participants to seek answers to their questions and discuss their needs, rather than deliver a prefabricated lesson on coping with grief. This approach will validate the experiences of the participants and target their unique needs. The facilitator must be prepared to acknowledge the participants' past experience with openness, support, and warmth. Therapeutic communication skills, such as eye contact, use of touch, and attentive listening, are essential. The use of these skills will convey a willingness to provide not only information about pregnancy but also support and understanding of the unique needs of the group.

After receiving a brief introduction to the facilitator and the course, participants can be encouraged to meet each other and discuss why they chose to participate in the specialized class. The discussion creates the opportunity for parents to explore collectively their experiences with miscarriage. It is also important for the facilitator to determine the parents' level of attachment to the previous pregnancy because this status was found to be an indicator of anxiety during the current pregnancy (Hutti, 1992; Hutti et al., 1998). The facilitator may accomplish this by steering the discussion toward the baby who was lost. The discussion may lead to the participants' expression of grief (see Table). Childbirth educators are expected to be competent in “the grief and mourning process that follows loss and/or unexpected outcomes” (International Childbirth Education Association, 1999, p. 35). Thus, a childbirth educator who intends to facilitate a course for parents experiencing pregnancy after perinatal loss should not only meet the requirements of a childbirth educator but also possess skills in counseling. Redman (2003) pointed out that counseling skills are learned and help the practitioner move beyond basic communication. Counseling requires special training that prepares the practitioner to help parents explore painful issues (Redman, 2003). Furthermore, childbirth educators who choose to facilitate a pregnancy-after-perinatal-loss course are encouraged to be prepared to provide referrals for participants who appear to be experiencing profound grief.

Table.

Outline of Childbirth Education Course for Parents Experiencing Pregnancy after Perinatal Loss

Week 1

• Introductions to the facilitator and the course

• Ice breaker focusing on what brought the participants to the specialized course

• Discussion of what the participants would like to learn and of any concerns, fears, or questions they have

• Recognizing and coping with grief

• Acceptance of the pregnancy and discussion about how it might differ from previous pregnancy or pregnancies

• Normal growth and development of the infant, including tips for health promotion during pregnancy

• Relaxation-for-pregnancy exercise (guided imagery, focusing on the baby within to foster attachment)

Week 2

• Common symptoms of pregnancy, including when and when not to worry

• Dealing with fears of loss: Harnessing hopefulness (visualize the desired outcome)

• Signs of preterm labor

• Signs of labor: Timing of contractions, when to call the health-care provider

• Early and active labor: What it is, how it feels, and what to do (comfort positions and interventions, such as showering, rocking, breathing, and choosing medications)

• The role of the labor-support partner, including discussion of concerns of the labor-support partner

• Relaxation and deep breathing during early and active labor

Week 3

• Role play: How to respond to others when asked, for example, “Is this your first baby?”

• Discussion of and ways to establish a trusting relationship with the health-care team

• Medical interventions during labor (episiotomies, pitocin)

• Transition: Comfort measures, managing pain and anxiety

• Unexpected outcomes: Cesarean section, use of vacuum or forceps

• The role of the labor-support person during transition

• Video presentation of normal vaginal birth and birth via cesarean section

• Discussion of fears surrounding labor and birth

• Relaxation and breathing exercises for transition

Week 4

• Postpartum care: Self-care

• Postpartum blues/depression, including the re-emergence of grief and when and where to seek help

• Guest speaker: One who has encountered pregnancy after perinatal loss, to discuss her postpartum experience

• Presentation: The normal newborn

Week 5

• Care of the newborn, including feeding, bathing, and CPR

• Parenting: Sleep habits, managing stress, developing a support network

• Discussion: Fears about parenting (Do you think your parenting experience will be different because of your loss? If so, how?)

• Integrating the loss, avoiding idealizing parenthood

• Tips on parenting the newborn, presentation of parenting styles (e.g., see Sears, W., & Sears, M., 1993)

• Infant safety, including home safety, safe baby furniture and toys, and car-seat safety

Childbirth educators are expected to be competent in “the grief and mourning process that follows loss and/or unexpected outcomes.”

It is also essential to counsel participants that grief over the previous loss may resurface at different times in their life (Van & Meleis, 2003), especially during labor and birth (Wallerstedt et al., 2003). Therefore, participants will benefit from information on how to support their partners if grief re-emerges during labor and birth. Armstrong (2002) noted that some fathers may be hypervigilant toward the current pregnancy or may perceive that they had failed to protect their family; therefore, fathers will benefit from receiving information on their special role in supporting their partner. Another helpful suggestion may be to encourage the development of a birth plan. Considering birth options, such as whether epidural medication or natural birth is desired, can help parents feel more in control of the birth. The childbirth educator may also suggest that parents consider the services of a doula (Wallerstedt et al., 2003) who will provide one-on-one labor support and advocate for the parents' wishes during labor and birth.

The childbirth educator is encouraged to conclude the first class of a pregnancy-after-perinatal-loss course with a relaxation exercise that includes slow, deep breathing and creative visualization. Because some studies' findings indicated that attachment to the current pregnancy may be delayed following a previous loss (Cote-Arsenault & Dombeck, 2001; Rillstone & Hutchinson, 2001; Van & Meleis, 2003; Wallerstedt et al., 2003), a visualization exercise that fosters attachment to the baby would be most useful. Many CDs of visualization exercises are currently available for use during classes. Childbirth educators may also develop their own set of visualization exercises.

Managing Anxiety

With the groundwork for a therapeutic relationship in place, the second class of the course can focus on recognizing and managing anxiety. As documented above, several studies support the notion that parents experience increased anxiety during pregnancy after perinatal loss; therefore, course content addressing stress management and relaxation would be helpful. Furthermore, common discomforts of pregnancy, which are typically included in traditional childbirth classes, can be discussed in detail. Greater knowledge of what is and is not normal during pregnancy can help alleviate fears. A gaming exercise in which participants identify symptoms as either “normal” or “a sign of trouble” may also be useful to reinforce content.

As in traditional childbirth education classes, Class 2 of this special course can include information on recognizing when labor has begun, managing the discomforts of early and active labor, and employing deep-breathing and relaxation techniques. However, for those participants who are less than 37 weeks pregnant, signs of preterm labor are especially important because these parents, experiencing pregnancy after perinatal loss, are likely to be more anxious than other parents about the possibility of preterm labor. A handout detailing when to seek medical attention can be given to the parents. Additionally, the class facilitator may encourage discussion regarding any anxieties or concerns the participants have about their current pregnancy.

The second class may end with a relaxation exercise aimed solely at relaxation of the parents, rather than attachment with the baby. The exercise can utilize slow, deep breathing and progressive muscle relaxation. The parents should also be aware that the breathing practiced during the exercise will be useful when labor begins. Acceptable methods of stress relief (e.g., gentle massage, walking, warm packs to the neck, and use of soothing scents such as lavender) may also be discussed.

Maintaining Relationships with Others

As previously noted, many recent studies reveal that parents who had encountered miscarriage believed others did not understand their experiences. Therefore, Class 3 can begin with an exercise aimed at helping parents deal with the comments of others. Couples can be asked to participate in a role-play exercise using scenarios developed by the facilitator. For example, the couples can switch partners, one asking an assigned question (e.g., “Is this your first baby?”) and one answering. The facilitator must be actively present with participants in order to offer support to parents who become upset during the exercise. It is important to remind parents that well-meaning friends and colleagues may ask these types of questions. Thus, encouraging participants to consider coping strategies in advance may be useful.

Because many parents experiencing pregnancy after perinatal loss perceived that health-care providers were quick to dismiss their fears and anxieties (Caelli et al., 2002), it is important to assist parents to develop trusting relationships with current health-care providers. This specialized course may allow parents a forum in which to discuss their unique needs and fears related to developing a trusting relationship with their health-care provider. Also, such parents are likely to seek advice more frequently than other expectant parents (Armstrong, 2002; Caelli et al., 2002; Rillstone & Hutchinson, 2001; Van & Meleis, 2003; Wallerstedt et al., 2003). In part, this specialized program can meet this need because it will allow access to a childbirth educator for direction and support. If parents perceive health-care providers are not adequately addressing their needs and concerns, the class facilitator can review the use of assertive communication skills. For example, parents can be taught to use I statements followed by a request, such as, “I am anxious about this pregnancy and I would like reassurance that my pregnancy is progressing normally.” The statement conveys the exact feeling the parent has toward the pregnancy and gives the health-care provider specific direction in planning care.

Parents can be taught to use I statements followed by a request, such as, “I am anxious about this pregnancy and I would like reassurance that my pregnancy is progressing normally.”

During Class 3, the facilitator might also discuss the possibility of choosing medical interventions during active labor, ways to manage complications and transition, and the role of the labor-support partner. Of particular importance is offering information on how to establish a trusting relationship with providers and how to manage anxiety if an unexpected outcome occurs, such as the need for a cesarean section. Again, it might also be helpful to remind parents that grief may re-emerge unexpectedly during labor and, should this occur, partners must be prepared to communicate the mother's needs to the health-care staff.

Classes 4 and 5 can include the content of traditional childbirth classes, with minor modifications. For example, Class 4 may include postpartum care, as well as a discussion about postpartum blues and depression. Participants can be given information on when to seek help. Partners, in particular, will benefit from receiving information on how to recognize signs of postpartum depression and where to seek help. Class 5 may include content on parenting, with special attention to the unique parenting needs of the group. Wallerstedt and colleagues (2003) asserted that parents encountering pregnancy after perinatal loss have special parenting needs and may tend to idealize the experience of parenting. Parents might be encouraged to discuss any fears or concerns they may have about parenting. The class facilitator can distribute a list of community resources, Web sites, books, and other literature about parenting after loss.

IMPLICATIONS FOR PRACTICE

Healthy People 2010 (2004) set childbirth education as a goal for all pregnant women. A childbirth education course specifically targeted to parents experiencing pregnancy after perinatal loss has the potential to create a supportive and healing environment for parents, while offering the information needed to manage late pregnancy, labor, and birth. Such a course may improve markedly the birth experience for this group. Research is needed to determine whether an education program targeted specifically to parents experiencing pregnancy after perinatal loss increases attendance at childbirth classes, meets their special needs, and optimizes the birth outcomes for both infants and parents.