Silent birth

Intra-uterine death, or IUD

When the baby has died in the uterus after you have reached your 20th week of pregnancy.

Stillbirth

The birth of a baby who is born without any signs of life at, or after, 20 weeks of pregnancy and/or weighing more than 500 grams.

Perinatal death

Includes stillbirths and deaths in the first week of life. The perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.

Early neonatal mortality

The death of a live-born baby within the first seven days of life.

Late neonatal mortality

The death of a live-born baby after seven days of life up until 28 days of life.

Postneonatal and infant mortality

The death of an infant beyond 28 days of life up to one year.

Sudden infant death syndrome (SIDS)

The unexplained death, usually during sleep, of a seemingly healthy baby less than a year old.

Grief and loss

Grieving is an important step in the healing process. In this case is it likely a different experience from grieving other losses in your life. It is sometimes difficult for friends, family, and sometimes even your parents, to understand why there is so much pain surrounding the death of a baby. As parents, you begin to form an attachment to your baby long before the baby is born. Your hopes and dreams for your little one begin when you find out you’re pregnant, or maybe even when you decide to start trying to conceive. When you lose the baby, you are grieving the loss of your baby and the future you imagined.

Grief is a normal, healthy, healing and loving response to the loss of a loved one. You may mourn for your baby deeply, a little, or somewhere in between. Each person feels grief in a different way. It may take you a short time, many months, or years to work through your feelings of grief. There is no right or wrong way to grieve. Grief is a process that can be affected by many other life events.

You may experience many feelings, including numbness, shock, confusion, exhaustion, disbelief, anger, fear, isolation, emptiness, aloneness, pining, yearning, responsibility, guilt, sadness and depression. The intensity of these feelings can range from mild to overwhelming. There is no correct order or sequence to grief. Different feelings surface at different times in the grieving process.

Your partner is grieving, too

If you have a partner, you may find that you each experience grief differently. No two people grieve the same way or at the same time. This is normal. However, it can place a strain on your relationship if this is not recognized and acknowledged. Couples are encouraged to be respectful of each other and where each person is on their grief journey. Talking about your feelings and differences with each other can be helpful.

In some cases, your partner may feel that they are expected to remain outwardly strong to support you. This can hide feelings of sadness as they try to cope with the loss. It is important that partners not blame themselves or each other, as you are both grieving the same difficult loss.

Partners may also play an important role in telling the other family members (including children) what has happened and what will happen in the immediate future. It is important to discuss with your partner how you will handle questions from children, family and friends.

Children and grief

Today, parents recognize that children are better able to cope if they are prepared and informed about a death. It is up to the parents to determine the appropriate details to be shared with the child depending on their age and past experiences with death. Children should be provided the same opportunities to grieve and heal as adults. Parents can try to address any concerns and fears about death with their children. Very young children will react to the disruption caused in the family and not necessarily to the loss. As caregivers, we can support children by allowing them to express their feelings.

It may be helpful to request support from family and friends to help you with the day-to-day tasks of caring for your children, as this may help you to be more emotionally available to them. Reassure your children that you are upset that the baby has died and that this does not affect your love for them. By openly expressing your emotions you are modeling to your children that it is okay to grieve and to be sad.

Following the diagnosis of fetal death, you will most likely experience a range of emotions, and admission to hospital for medical care can be quite scary as you face many unknowns.

Every hospital will have its own policies and procedures, and once admitted you will be cared for by a variety of healthcare professionals. They will be able to explain the process, answer any questions you may have, and provide the support and resources needed to help you cope during this time.

Once admitted to hospital you may request:

• To be admitted to a private room
• To have a symbol of loss, such as a butterfly or equivalent symbol (hospital-specific) placed on the outside of your door
• To be introduced to your primary healthcare team (doctors, nurses, anesthetist, social worker, spiritual care provider, etc.)
• To be given the opportunity to identify support people to be with you, or comfort measures (including a birth plan) to help cope during the time leading up to, during and after delivery
• To have the process of labour, induction of labour, and what to expect after delivery explained and to you, and to be given options for pain management

If your baby has died in utero, your healthcare team may need to induce labour to enable your body to deliver the baby and placenta. Many women experiencing a loss cannot imagine the pain of a full labour, and will request a caesarean section. Your healthcare provider will discuss the risks and concerns of a caesarean section surgery with you.

It may take several days or longer for your healthcare provider to schedule the induction of labour. You may also choose to discuss the possibility of waiting for labour to happen naturally. While the wait may be very difficult emotionally, it can also allow time for you to create a goodbye plan, to arrange for family members or loved ones to be with you, for a photographer to be present for the birth, and for you to consider what religious services or other ceremonies you would like performed.

The process

Before beginning an induction, your healthcare provider will check your cervix for dilation. If your cervix has not yet started to dilate, you will require medication or medical techniques to help this happen. There are a number of ways this can be done depending on the facility you are in. Medical management may include a cervical ripening medication placed near your cervix — such as cervidil or misoprostol — or it could involve placing a luminaria (a device used to gently open the cervix) in your cervix. Another option is the insertion of a Foley catheter, which may be used as a medical technique to begin to open your cervix. Any of these options will cause cramping and may lead to active labour.

If the methods used above do not bring you to active labour you will receive a medication through an IV called oxytocin. You may also have your water broken (membranes ruptured artificially).

To aid in pain management there may be a number of options available to you. It is common to be offered an epidural. Other options include a narcotic through your IV, or you may also be offered a PCA (patient controlled analgesia) pump, which allows you to push a button and administer pain medication as needed. Generally oral medications are not effective enough for labour pain.

Throughout labour your vital signs and labour progression will be monitored. While these medications are generally quite effective, in some cases labour fails to progress. If the above approaches don’t result in delivery of your baby and the placenta you will be reassessed by the physician or midwife taking care of you.

Following delivery, if it is something that you and your partner would like to do, ask the healthcare team for the opportunity to spend unlimited time with your baby.

Some parents may receive a life-limiting diagnosis for their baby during pregnancy or after delivery. The baby may be admitted into the neonatal intensive care unit (NICU) and you may be asked to make some difficult decisions regarding comfort care, also known as palliative care. This entails the removal of life-sustaining interventions and focuses on making your baby as comfortable as possible, enabling your family to be together before, during, and after your baby’s death. Many families take this time to introduce the baby to family members, perform meaningful rituals and create memories. The staff in the NICU can help you arrange for spiritual care, create mementos and take photos, and contact support services. Palliative care may last minutes, hours, days, weeks, or even months.

Perinatal hospice

Perinatal hospice and palliative care may be options available to you when you have found out that the baby you are carrying has a life-limiting diagnosis. As long as there are no maternal medical reasons for ending the pregnancy at a specified time, it may be possible to carry the pregnancy until labour naturally occurs. It is helpful to have a conversation about this topic with your healthcare provider.

Seeing and holding your baby

Many parents are comforted by contact with their baby. There is nothing wrong with wanting to see, hold and touch your baby. Many parents value the opportunity to say hello before they say goodbye. You may decide to hold your baby right after birth or you may wait several hours before deciding to be with your baby. There is no wrong decision. Parents make different choices and it is common for parents to change their minds about their decisions. However, few parents ever regret the decision to see and hold their baby. If you have fears about what your baby might look like, ask your healthcare provider to describe your baby’s appearance. You may prefer to only have pictures of your baby.

You and your partner are encouraged to participate as much as you wish in the care of your baby after birth. This care may include bathing, dressing and bundling your baby in a blanket. Your healthcare provider will be available to assist, or if you prefer, your healthcare provider can perform this care alone or with someone you would like to be part of this care.

Once your baby has been taken to the hospital morgue, it may be possible to have your baby brought back to you to see and hold, unless the funeral home staff have already come to pick up your baby

Naming your baby

Deciding to name your baby may be a difficult decision, but many parents find this meaningful. There may be cultural or ethnic traditions surrounding the naming of your baby. Having a name for your baby may enable you to talk about your loss in a personal way. You are openly acknowledging that you love this child and will always remember him or her. You may find it meaningful if you can refer to your baby by name.

Rights of the baby

• To be acknowledged by name and sex
• To be treated with respect and dignity
• To be with the grieving family whenever possible
• To be recognized as a person who has lived and who has died
• To be remembered with specific mementos (footprints, handprints, pictures, clothes, name-band, ultrasound picture)
• To be nurtured (bathed, dressed, wrapped)
• To be buried or cremated
• To be remembered

Women’s College Hospital, Toronto, 1984
Source: Health Canada, 1999 Family-Centred Maternity and Newborn Care, Pg. 8.7.

Rights of the parents

• To see, to touch, to hold, to nurture their child with no limitation as to time or frequency
• To be fully informed about the baby, the cause of death, and the process of legitimizing the death (i.e. the funeral)
• To have written and verbal information about:
  • Choices available for the burial or funeral
  • Supports available to family members
  • Necessary legal information (e.g. timing of burial, birth registration)
• To receive mementos of their baby (e.g. footprints, picture, certificate of life)
• To acknowledge the life and death of their child, a person in a family
• To choose any type of burial, cremation, or other funeral service
• To be heard and listened to by caring professionals without judgment or prejudice
• To have staff who are empathetic, caring, and sensitive to individual responses, behaviour, and choices
• To be treated with respect and dignity
• To have the support of family and/or friends at any time (if the parent wishes)
• To seek religious or cultural support for their choices and to be treated with cultural and religious sensitivity
• To be aware of the grieving process.To be able to grieve openly or quietly and to be informed of, and understand, the feelings and emotions generated by loss
• To understand their future options regarding autopsy and genetic counseling
• To be informed about parent support groups
• To receive follow-up supportive care (at the hospital, primary care practitioner’s office, and/or home) by telephone or by visit
• To have an opportunity to evaluate their hospital and community experience

Adapted from Women’s College hospital, Rights of parents at the hospital:
At the time of the baby’s death. Toronto: Women’s College Hospital, 1984.

Gather important keepsakes

Many families find having a keepsake of their baby helpful. Your care provider can help you gather mementos of your baby.

You may want to keep some or all of these:

• Photographs of your baby
• Your baby’s footprints and/or handprints
• Your baby’s identification bracelet
• Information about your baby’s birth
• A bassinet card
• A blessing or baptismal certificate
• A tape measure to show the size of your baby
• A lock of your baby’s hair
• Your baby’s clothing
• Hand and foot molds

Other mementos you may add to your baby’s memory package:

• Poems and notes you may collect or write to or about your baby
• An ultrasound picture
• A certificate of life
• Certificate of death or stillbirth
• Cards
• Mementos from the naming or religious ceremony, such as candles

If you are unsure about whether or not you want to take mementos home with you, talk with your care provider before you leave the hospital. It may be possible for your mementos to be kept at the hospital until you are ready to bring them home.

It is difficult to say goodbye before you had a chance to say hello. You may wish to acknowledge your loss by having a memorial service or a private gathering with family and close friends. Writing a poem, lighting a candle or planting a tree in a garden may be helpful ways of beginning emotional and spiritual healing.

The hospital nurse, spiritual care provider, your own religious leader from the community, or a family member can bless, baptize or provide a special ceremony for your baby. This may be done in your hospital room, in a nearby room, or in the hospital spiritual care space. If you wish to talk with the hospital’s spiritual care provider, please ask your nurse to contact them for you. This can also be arranged through the funeral home. Depending on the type of ceremony, it can take place now or in the future when you are ready.

If you have questions or need help, please talk with your caregivers.

What arrangements need to be made for your baby?

Here are some of the arrangements you may wish to make, or may be required:

• An autopsy to possibly explain the reason for your baby’s death
• A burial or cremation
• A memorial service

Who can help with arrangements?

The hospital social worker, spiritual care provider, celebrant, clergy, or your own religious leader can offer information and assistance with burial or cremation. You or your representative can contact a funeral home of your choice. The funeral director will explain your options, including costs, and will help to make the arrangements that you seek.

With some religious faiths, or because of personal choice, planning and arrangements may take place at the religious centre or in a private residence rather than at the funeral home.

Burial or cremation?

Your healthcare provider will discuss with you when burial or cremation is required by law. In Ontario, this is after 20 weeks of pregnancy.

Some parents may find comfort in making these arrangements. Parents may take a few hours or several days to make decisions about burial or cremation before requesting assistance from a funeral home and/or cemetery.

Is a funeral service necessary?

No. A traditional funeral service is not required by law.

A funeral is a way of giving testimony to the life and death of your baby. The funeral is a traditional way for you to express your grief to others. While the loss may not be experienced the same way by partners, children and grandparents as it is the birth mother, creating opportunities to say goodbye through a funeral or other ritual can help these parties acknowledge the loss as real.

Parents may choose not to have a service, or they may choose a private memorial service, a graveside service or a larger service.

If you decide to have a burial, you may choose to have your baby placed in an existing family burial plot, in a cemetery area set aside for infant burials, or in a newly purchased cemetery site.

If you decide to have a cremation, you may choose to have your baby’s ashes returned to you to keep, to sprinkle at a location which is important to you, or to bury at an existing grave site. You or the funeral director may seal the ashes in a container, however, on occasion, a very limited amount of ashes will be returned.

How much does burial/cremation cost?

The cost of burial or cremation varies by community and by company. It is advisable to price out the different options. Some funeral homes offer some reduced fees for the cremation and/or burial of children.

If you have a burial, you will need to pay for a cemetery site and the opening and closing of the grave. The cost of these services varies by community.

How does my baby reach the funeral home?

It is within your rights to bring the baby to the funeral home, or to your home, yourself. You may also choose to hire the services of the funeral director to transport the baby. You may be required to sign a hospital release form if you choose to transport your baby. The healthcare institution should provide you with burial and transportation guidelines.

Organ donation

In the province of Ontario, the Trillium Gift of Life Network (TGLN) oversees eligibility for donation of organs from an infant who is recently deceased, who is anticipated to die within a certain period of time, and who was born at greater than 36 weeks completed gestation. The healthcare team caring for you and your baby will make the required initial screening phone contact to the TGLN representative. If the TGLN representative determines that your baby is eligible for organ donation, you will be approached by your healthcare provider to speak with the representative within 24 hours. You will be fully supported and your questions regarding your baby’s eligibility for organ donation will be answered in a timely and sensitive manner. In many situations, infant organ donation is limited or not possible.

According to Ontario law, the birth of any live-born baby, regardless of gestational age, will be registered with the province’s Registrar’s Office. Birth registration will be completed in order for your baby’s death to be registered by the funeral home of your choice. Your healthcare provider will give you the information required to complete your baby’s birth registration. There is no fee to register your baby’s birth. If you choose to apply for a birth certificate for your deceased baby, you will be required to pay the current fee and will be entitled to receive only the long-form birth certificate (a certified copy of the birth registration).

An autopsy involves an examination of the baby’s internal organs to help understand why the baby died. The baby is treated with respect and dignity. If you wish, this examination can be limited to the organs of most concern, referred to as a limited autopsy. A limited autopsy allows for an examination of the outside of the baby, x-rays, and testing of the baby’s chromosomes if needed. An autopsy can confirm the sex of a very premature baby. If you chose to forgo an autopsy, your care provider may decide that the placenta, membrane and cord should be sent for examination.

The doctor or midwife will usually schedule a follow-up appointment, approximately two to three months after your delivery, to discuss the results of the autopsy. Often the results are inconclusive and no known cause is found to explain the baby’s death.

After delivering your baby, your body will gradually return to a non-pregnant state. You will probably still have vaginal bleeding, similar to a heavy menstrual period, for the first few days. This will taper off over a couple of weeks.

During this time, it is important that you prevent infection by:

• Using sanitary pads while you are bleeding
• Not using tampons
• Not having sexual intercourse until the bleeding has stopped completely
• Not douching
• Not swimming or taking baths

Consult your healthcare provider if any of the following occur:

• Vaginal bleeding that is heavier than soaking one pad per hour
• Vaginal bleeding that lasts two weeks or longer
• Vaginal bleeding or discharge that has a bad smell or clots
• Severe pain in your abdomen
• Chills or a fever over 38.5°C (101.3°F)

Menstruation

You can expect a menstrual period in about four to six weeks. Talk to your healthcare provider if this doesn’t happen. It is possible to become pregnant immediately after a pregnancy loss, even before your menstrual period has returned. Healthcare providers recommend using birth control methods, such as condoms. 

Lactation and caring for your breasts

Sadly, after the loss of a baby, your breasts will still make milk. To alleviate breast discomfort, you may lightly hand-express milk. Doing this simply for comfort will not increase milk production and it will help you avoid blockages and infection (mastitis). A warm shower may help the milk leak. Applying cold compresses or a bag of frozen vegetables may also help relieve discomfort, and can be left on for the duration of the day. Repeat as necessary. Discomfort should only last two or three days and be gone within a week.

Considering donating your breast milk

The process of weaning in these circumstances can be physically and emotionally painful. Instead, you may wish to enquire about milk donation to a Human Milk Bank. Some women take comfort from knowing that their milk can help another baby.

In order to become a donor, there is a screening process, which typically involves an intake phone interview or questionnaire, blood tests, and a form for your doctor to complete. To begin this process, speak to a lactation consultant, or visit the Human Milk Banking Association of North America’s website at hmbana.org to find a Human Milk Bank near you.

Getting support

Family and friends want to do the right thing but often are unsure of how to help or what to say. Let them know how you feel and what you need during this time.

Support from family and friends may not be enough. If you feel you need someone to talk to, there are skilled people who can help. Discuss a referral with your healthcare provider. You will be supported by your caregiving team while you are in the hospital. A hospital social worker or spiritual care provider is also available to help. PAIL Network’s peer-led support services are also available through self-referral by filling out our support intake form.

You may find that making decisions about future family planning is difficult at this time. It may take time for you to work through these decisions. Some families have found it helpful to wait a few months before considering another pregnancy.

What are the implications for future pregnancies?

If there was no explanation for the death, it may be reassuring to know there may not be any increased risk of having another loss. If the baby has a proven or suspected genetic abnormality, genetic counseling will be important for future pregnancies.

A subsequent pregnancy can be a stressful experience, physically and mentally, especially with increased monitoring and testing. Developing a support network and coping mechanisms are encouraged. Contact PAIL Network to find a support circle for subsequent pregnancies.

Grieving and remembering

It is important to allow yourself to grieve the loss of this pregnancy. The experience of grief is powerful and you may feel physically and emotionally drained. Remember that, by grieving, you are helping yourself heal. You may find that planning for the future is difficult during this time. Some parents have found the following things helpful to provide comfort and begin the healing process:

• Take care of yourself
• Take a break from your regular schedule
• Make a memento scrapbook to commemorate your baby and the pregnancy experience
• Write a poem or letter to your baby or about your baby
• Keep a diary or blog about your experience
• Name your baby
• Have a ceremony to recognize your baby
• Wear a special piece of jewelry to commemorate your baby
• Light a candle in memory of your baby
• Plant a tree or create a memorial garden
• Talk to family, friends, religious leaders, or healthcare providers
• Talk to families that have had a similar experience
• Attend a bereavement support group

You are not alone on this journey of grief and loss. We encourage you to reach out for support.