Supporting families with a subsequent pregnancy

Supporting families in a pregnancy subsequent to loss

Perinatal loss has a pervasive impact on families, which often extends to a subsequent pregnancy. During this time, families have unique care needs that may not be adequately addressed by current pregnancy management processes or systems. Knowledgeable care providers can help support the health of the pregnant person and their family and have a significant impact on the pregnancy experience and beyond.

Understanding subsequent pregnancies

In subsequent pregnancies:

There is a greater risk for anxiety and depression, which continues into the postpartum period. Anxiety is the most widely reported state in pregnancies after loss.
Families may be more isolated from their normal support networks
Families may avoid attachment to the pregnancy and preparing for the baby, including avoiding prenatal education
Families may seek reassurance through interactions with care providers. There is growing evidence that these interactions do not meet their needs or expectations.
Families will frequently encounter care providers who are unaware of their history and who are dismissive of their concerns, worries, and fears. These encounters often remain with families for a very long time.
Ultrasounds and pregnancy tests are often stressful, especially if they are how the issue or death was discovered previously. Despite this, most families will request and want extra monitoring.
Families are not necessarily reassured by extra monitoring. Improved psychosocial supports and collaborative relationships are important to families. Families who had ‘perfect’ pregnancies up to the loss or who had a loss through a rare event will often not be reassured by healthy test or monitoring results or statistics. Their risk evaluation may be different than yours. They know bad things do happen: they have been the 1 in 1000 before.
Families may be less confident in their ability to safely carry a pregnancy, have a healthy baby, provide for an infant (breastfeeding, knowing if an infant is well), and parent. Some transient newborn issues, such as jaundice or hypoglycemia, may be especially distressing for families. Skilled and sensitive support from healthcare providers, including anticipatory guidance, is important.
Families may request early planning for delivery and early delivery, which presents challenges for healthcare providers. When possible, include families in discussions and decisions.
Families often want more frequent visits, flexible options for care, time to discuss their worries and fears, and reassurance
Families do not want to repeat their history of loss or story of loss over and over to the same healthcare team
Families may require more postpartum supports and tailored education

Care considerations for subsequent pregnancies

Care considerations include:

Offer flexible care options, including more frequent visits. This may be especially helpful around the gestation of the previous loss or losses.
Identify the family to the care team whenever possible so they don’t have to repeat themselves, but don’t shy away from discussing their loss when needed.
Use their baby’s name
Ask the family what would be helpful or useful. Individualize support.
Share with the family details that indicate how you know their baby is well. Make time for questions even after the family has gone home from their appointment.
When possible, provide a contact person for between appointments
Discuss the difficulty of “regular” prenatal education for families. Offer alternatives, including online prenatal education and private tours of the facility where the family will give birth. If a family wishes to go to “regular” prenatal classes, discuss the option of talking with the educator ahead of time to share details about their loss.
Provide mental health supports as needed. Screen for mental illness. Do not minimize anxiety, concerns or fears. Talk about feelings of isolation, anger and guilt. Normalize experiences, but do not minimize them. Ask families regularly how they are doing. Refer to mental health professionals as appropriate.
Refer to Healthy Babies Healthy Children programs antenatally. People with a history of mental illness, or who are at increased risk (i.e. people who have experienced perinatal loss), may qualify for antenatal support. This has the benefit of connecting families with community supports and avoiding the postpartum wait-time. It also provides longer-term community support. If families decline, discuss the option for self-referral, available at any time if they change their mind.
Provide anticipatory guidance to families: infant feeding supports, possible thoughts and feelings during delivery and postpartum, healthy newborn norms, postpartum supports, prematurity, etc.
Provide a follow-up plan after birth and discharge from regular pregnancy care
If a family has experienced an infant loss, discuss strategies for postpartum support. Many primary care providers, including nurse practitioners, family doctors, midwives and pediatricians, will agree to see a family more frequently in the initial postpartum period and provide reassurance and education about healthy infant norms.
Consider education and training for staff working with families who experience perinatal bereavement
Use sensitive language. For many families, being asked “Is this your first pregnancy?” or told ‘Don’t worry about that” by a healthcare provider is very upsetting.
Utilize PAIL Network’s booklet for families: “Pregnancy After Loss” and refer for peer support. PAIL Network provides peer support for families during pregnancies after loss.