An unexpected outcome in a birth center is something we are never prepared for. Those of us in birth centers truly believe that birth is a normally healthy process. We believe that we are providing care for women who have been well screened and that we expect a positive wonderful outcome. Unfortunately, if you have been doing birth long enough, even in a birth center, something unexpected can happen. I have some suggestions from our own experience with an unexpected infant loss after a birth.
Stillbirths can happen in birth centers unexpectedly, medical emergencies can happen unexpectedly and there can even be the kind of quiet grief that we as providers experience when the birth of a woman is not the optimal birth that she expects. However, the truly devastating outcome such as our unexplained infant death after birth is something very difficult to prepare for.
First, I would encourage you to know your laws. An unexplained death of an infant born alive may actually become a coroners case, as it did for us. This precipitated visits by police, coroners and even terminology such as "the death scene." We were considered almost like criminals because of this investigation. It made it a horrible experience for all of us involved. Your pediatrician or medical back-up doctor would probably serve as a resource for the knowledge about laws that occur in case of an unexpected outcome.
Second, you need to support the grief process of your staff. You need to begin making non-judgmental statements with the providers, with the family who is experiencing the loss and even with yourself. While those of us in a birth center rarely get sued, and we don't expect to get sued, it can happen. Just be careful not to incriminate your birth center, your staff or any providers by making statements that could later be taking out of context. Call in your other staff to support each other. There will be a real need for a critical incident debriefing process. It's going to require encountering our own grief and loss issues, which is the first step. I would suggest that you don't wait too long to do this critical incident debriefing. Try to do it within the first few days after the incident. If at all possible, try to find an outside neutral professional person to conduct the debriefing. This is not a critique of the actual process, but rather the opportunity to begin the healing. It should be an uninterrupted meeting time to discuss and explore feelings and concerns about the incident.
I would also recommend that you be prepared for the fact that a sudden death that occurs without warning is more difficult to grieve than other deaths. You are left with a sense of unreality about the loss and guilt feelings are very common. There's the kind of "if only" mentality "if only we'd picked it up earlier . . .if only we could have - or should have." You are going to need to test the survivor's issues of responsibility. In our situation a very, very competent nurse has taken upon herself the burden of feeling that she could have intervened or done something earlier to prevent this infant's death. Regardless of what the medical results say to the contrary, she still feels a huge issue and sense of responsibility. There is a need to blame, and it is extremely strong. Sometimes it is a self-blame by the provider. There maybe a lack of confidence inthat provider in the future, which may be somewhat long term and you need to be prepared for that. There maybe a sense of helplessness, as well as an incredible sense of rage. It is not unusual for the survivor to want to vent.
The survivors of this incident are going to need increased understanding and will need to begin to search for meaning and mastery in what has happened. I would encourage you to reference a book by J. William Warden called Grief Counseling and Grief Therapy, published by Springer Company in 1982. It is a quick reading, well-categorized book, which helps people to identify their own issues with loss and begin to move into a healing stage. Certainly, referencing Elizabeth KüblerRoss will also be helpful since she has led the way in helping us with issues on death and dying.
During the critical incident debriefing, I would encourage you to have a neutral leader. Stress confidentiality of the topics being discussed at the meeting. Try not to critique the incident itself. Begin with the statement such as, "I am sorry this happened to you." Establish some ground rules for the meeting which give people permission to express their feelings. Go through a fact-finding phase, moving the participants to discuss their emotional reactions. Look for each person's connection to the event. Then move into a transition from the cognitive to an emotion- focused stage. Encourage participants to describe their thoughts or feelings about the incident. Allow them to state what is on their mind, to listen and validate their feelings. However, this should be optional. There should be no pressure for people to participate who are not yet ready to do that. Try not to let statements of shock, anger and fear go without a response or a word of comfort. Look for symptoms of post-traumatic stress and focus on the unusual experiences during the incident. Describe ways in which the incident may have affected home life or work life. Move into a teaching phase, which will reassure people that the experiences of the group are normal reactions to a bad incident, and that they are not going crazy. Discuss the normal signs and symptoms of stress and then begin to validate positive coping mechanisms. Finally, move into a reentry phase. Participants should be able to ask questions, and clarify what has occurred. Provide a safety net for the future by offering to have more meetings, referrals or outside consultation.
It is extremely important for a birth center to establish a plan for rumor control. One of the things we learned from our experience was that the hospital and the community will become aware of this situation. You need to lay out a plan to discuss with the media and with the community what has happened, while still protecting the confidentiality of your staff and the family involved.
Please do not consider this discussion to be the absolute authority on grief. I am simply a nurse-manager of a birth center who has survived an unfortunate event. I encourage all of you to realize that you cannot always control what is happening around you, but you can control your response to that situation. First and foremost, is that you have to deal with the situation openly and with the same kind of care and concern and devotion we normally give to our families in the birth center.