“The pregnancy was uneventful and until this morning she had always felt the baby move.  Today was different; the baby was quiet, very quiet.  By lunchtime she noted she had not felt the baby move all morning.  A visit to her doctor’s office revealed that at thirty-eight weeks’ gestation the baby’s heartbeat could not be found.  She was immediately sent to the hospital’s birthing center.  While this mother was experiencing a fog of emotions, her labor was induced.  Ten hours later, she gave birth to a beautiful daughter: eight-pounds three-ounces, perfectly formed, yet stillborn” (shared by a bereaved family).  

There is no universally accepted definition of fetal age to define stillbirth.  It varies from twenty to twenty-eight weeks of gestation.  “The reported incidence of stillbirth varies significantly between studies from different countries and depending on the definitions used, but generally ranges from 3.1 to 6.2/1000 births or 1 in 160 deliveries” (Tavares Da Silva et al., 2016). Pregnancy loss even as early as the beginning of the second trimester can result in an unexpected lactation occurrence.

Stillbirth or perinatal death is a very difficult and emotional occurrence for the family, as well as for the health care professionals caring for them.  The nurse who assisted during labor, the midwife, or doctor who was present at the birth of the stillborn baby will also experience a grieving process. The International Board Certified Lactation Consultant (IBCLC) is also part of this team and will likely be called to talk with the family about what happens when the milk comes in.  The discussion will be about sharing with the mother what to expect and what she can do.

“The bereaved mother should be informed that she will experience Lactogenesis II between 30-40 hours following the birth/loss of her baby…Inquire if she would like to take her breast milk home, discard it, or donate it to a human milk bank. Provide contact details for the nearest milk bank, if desired; families can contact the milk bank directly. Mothers will be asked to take (free) blood tests in order to donate” (Parkes et al., 2016).

These health care professionals may also have been caring for an infant that died while in their care.  Even when it is known that the infant’s situation is not compatible with life, it is always difficult to experience a newborn death.  A memory or bereavement box might be prepared and given to the parents who have lost their baby so as to acknowledge the child's life. The box is filled with keepsakes of the baby, photographs, footprints, a lock of hair, a baby blanket, and even hospital documents. It is usually the nurse or social worker that will prepare the memory box for the parents.  This box is an important part of the family’s and health care professional’s bereavement process.

An area of loss rarely discussed is the fetal death of a twin.  Mothers who lose a twin often don’t have the time to grieve the loss, as focus is generally concentrated on maintaining the other twin.  The Center for Loss in Multiple Birth website has the following statement:

 “One twin” – it seems like a contradiction in terms…It was not something we ever would have imagined at the time of learning that we were expecting twin babies, and everything became "twos". Yet for so many of us, because of the high risks in pregnancy and birth, it is the way it turned out: we have one to care for and raise while missing and mourning for his or her twin.  We experience all the realities of becoming a parent at the very same time as all the realities of becoming a bereaved parent, and all in one package” (Kollantai & Center for Loss in Multiple Birth (CLIMB) Inc., n.d.)

Parents who have lost one twin have a constant reminder of this loss when in the presence of the surviving infant.  That loss does not go away.  As the surviving twin grows and passes milestones, there is always that subtle reminder of what might have been.  “Parents get through the loss of a twin: they do not get over it.  The presence of the living co-twin is a flesh and blood reminder of the dead child” (Swanson, 1988, p. 80)        

Going home with empty arms takes courage.  The parents will need emotional support to enter the baby’s room, to touch the baby’s clothes, and to slowly put things away.  This may take days, weeks, months, or even longer. The funeral arrangements may need to be organized.  This event, though difficult, is part of the grieving process.  “Many more friends and co-workers of ours came to the funeral than I ever could have imagined.  Even strangers came.  This public show of community support turned out to be one of the critical ingredients in my moving through the grieving process” (Woods and Esposito Woods, 1997, p. 527).  

The mother will most likely experience breast engorgement and will need help during this stage.  Information on how to manage engorgement should have been given prior to this moment whether the mother chooses to lactate and donate, or to suppress her milk supply.     

To learn more about lactation after perinatal loss, consider enrolling into our Expert Lecture XL51: Lactation Choices following Peri and Postnatal loss, by Kathy Parkes.

 

References

Carroll, K. E., Lenne, B. S., McEgan, K., Opie, G., Amir, L. H., Bredemeyer, S., … Polverino, J. (2014). Breast milk donation after neonatal death in Australia: a report. International Breastfeeding Journal, 9(1), 23. doi:10.1186/preaccept-1782472017139037

Kollantai, J., & Center for Loss in Multiple Birth (CLIMB) Inc. (n.d.). Loss of a twin. Retrieved from http://www.climb-support.org/lossofatwin/

Lawn, J. E., Blencowe, H., Waiswa, P., Amouzou, A., Mathers, C., Hogan, D., … Cousens, S. (2016). Stillbirths: rates, risk factors, and acceleration towards 2030. The Lancet, 387(10018), 587-603. doi:10.1016/s0140-6736(15)00837-5

Parkes, K., Ricci, E., Harrison, G., Ives-Baine, L., Limbo, R., Porter, S., . . . Taylor, K. K. (2016). Pregnancy Loss and Infant Death Alliance (PLIDA) position statement on lactation after perinatal loss requires education and specialized care. Retrieved from the PLIDA website: http://www.plida.org/position-statements/

Swanson, K. (1988). There should have been two: Nursing care of parents experiencing the perinatal death of a twin. Journal of Perinatal and Neonatal Nursing, 2 (2), 78-86.

Tavares Da Silva, F., Gonik, B., McMillan, M., Keech, C., Dellicour, S., Bhange, S., … Munoz, F. M. (2016). Stillbirth: Case definition and guidelines for data collection, analysis, and presentation of maternal immunization safety data. Vaccine, 34(49), 6057-6068. doi:10.1016/j.vaccine.2016.03.044

Woods, J. R. & Esposito Woods, J. L. (1997). Loss during pregnancy or in the newborn period: principles of care with clinical cases and analyses. Pitman, NJ: Jannetti Publications Inc.