Fetal Demise

During my sojourn at Ft Bliss/William Beaumont, I had the opportunity to see how an intrauterine fetal demise is managed-from US to second opinion, to induction (On several different patients, not the same one). It was interesting watching different providers interact with the different moms/partners as well as seeing different parts of the process.

The first case was that of a 32 y/o AA mom, G2P1, at 15wks GA. Informing mom of a likely demise on US was handled tactfully, with another provider consulted and a second opinion offered. The mom in this case was upset, but not shocked--she was in office that day because she was worried about her baby--"something isn't right".
I saw her again with the provider offering a second look--confirming still no fetal movement/cardiac activity, no signs of life. The second provider offered options. Both parents were present. It took them some time to digest the information given regarding the 3 options--watchful waiting, induction, or D&E. The provider gave them a lot to think about, then advised them they had time to talk it over before deciding. They left the room with the information they needed to consider and verbalized what they needed to do to complete the process. Both were calm, all questions they had at the time answered.

The next couple illustrated what an induction would be like. This involved a 35 y/o G3P2 at about 28 wks. They were admitted to L&D at around 0800. A plan was in place--mom was to be induced using 600 mg cytotec and infant delivered. Mom did not want any pain meds delivered as she wanted to be lucid and not "drugged up". Her statement was that this was the only time she was going to have with her baby girl, and she "wanted to make the most of it."
She actually delivered around 5 hours later. We had been worried that little one was presenting breech and that this was going to be a difficult passage. Luckily it worked out well. Little one was was tiny and fragile--650 some grams. Dad had a much harder time of it than mom afterwards. It was interesting to observe the family dynamics. Both sons, 2 1/2, and 4 were introduced to baby "J". The older one was more cognizent of what was going on but thought his sister was asleep. The littlest one responded to the emotion in the room and was cranky. Grandma was weeping, while grandpa was quieter and tried to help manage the older children. Mom in fact seemed to be at the most peace.

Also interesting was provider interaction. The nurse was very hands-on, very actively involved, where the nurse midwife had so many calls on her time that she was unable to be there much for the pt. There was a grief counselor involved, and her interaction was fairly close after the fact. It seemed as if the hospital processes were intrusive, though necessary, and made it difficult for the different professionals involved to utilize their training to the fullest. In fact the parents were contacted by mistake by the lab the next day regarding a genetic test that had been ordered. This upset the parents no end--and was a simple error due to processing the sample that had already been collected.

So what I learned--developing rapport is key. Each of the providers had a different style. Some more empathetic, some more direct--each effective in these cases. Managing the relationship helped the pt/family deal with the decisions to be made and manage their emotional reaction to the content of the information they were given.
I also learned managing my own reactions was more difficult than I expected. I did get a bit teary-eyed. I did get a lump in my throat. When I was talking to the mom while she was holding her infant I did have to work at it a little bit. Dad was a bit easier, but mostly that was because I kept expecting him to pass out and I was ready to help keep him from falling and hurting himself.

The managing my inner self bit has been a theme this semester at least--keeping an open mind, giving pts the opening without leaping to conclusions... People don't always react the way you'd expect.