Counselling after the loss of a baby.


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1.     Introduction

2.     Do you need to be able to counsel such families?

3.     Topics to deal with.

4.     Feedback.




The page is mainly for fetal death in utero (FDIU), stillbirth and neonatal death.

But much of it is appropriate for miscarriage and termination of pregnancy for fetal abnormality.


Miscarriage can cause severe reactions.

One of the worst bereavement reactions I saw was after miscarriage.

The lady was a local GP and already had several children.

She had an early miscarriage and was astonished to find that she rapidly became seriously depressed.

She said afterwards that she was really surprised at her reaction:

    she knew the incidence of miscarriage and the risk that it would happen to her,

    she knew that most miscarriages are due to lethal chromosome abnormalities,

    she had counselled loads of patients after miscarriage.

But none of this protected her from her own very basic human reaction.


You might think that the woman having an abnormal pregnancy terminated would be relieved.

In fact, she is at risk of serious psychological morbidity.

The first paper on this subject was written by my old buddy Paul Donnai and colleagues: BMJ(C Res Ed)1981; 282(6264): 621-2.

They found that about two thirds of women having TOP for fetal abnormality had substantial adverse psychological reactions.

The numbers in the study were small.

But later papers showed the same results and the need for support.

Lloyd and Laurence found that TOP for fetal abnormality produced severe and prolonged reactions, with many women still ill at 6 months.

These reactions were much worse than those experienced by women having miscarriage, stillbirth or TOP for social reasons.

Make sure that your patients get good support before and after the event.

The woman who terminates an abnormal pregnancy has a "double whammy":

    guilt that she "failed" the baby, her partner and her family by not ensuring it was normal.

    then added guilt that she chose to "kill" it.

She may well have had to endure the horrors of the baby having an intracardiac injection to stop its heart beating.

How do you get your maternal head around that?


The following is based on my experience.

As with counselling, I don't claim to be an expert.

If you are to do bereavement counselling, you should go on a course.

There are numerous books and websites giving advice.

Click here for a website giving sensible advice in a succinct, practical form. 

In the meantime, I hope the following is of some use.


It is probably best to read the page about communication skills before this one.


I found these the hardest situations to handle.

They are so painful our natural tendency is to shy away from them.

The situation might be a problem for you, but it is a million times more so for her.

So get on with it ASAP.


I usually allocated an hour to seeing the woman and her partner.

It would never take less than half an hour.

My preference was to see them early, preferably on the day of the loss.

This means seeing the woman with FDIU as soon after diagnosis as possible.


Common sense tells you that you need:

       to be absolutely sure you have the right patient 

       to be absolutely sure you have all the facts and there is no possibility of error

 not to be disturbed, so arrange cover for your duties if you are not free - easy enough in the unreal world of the exam

       to choose a location in which she will be comfortable

       to ensure that the conversation is not overheard

       to arrange to have a supportive relative or friend present

       to have a nurse or midwife present, especially if you are male:

            they can give the motherly / sisterly hug,

            in midwifery it is best to use the bereavement sister:

                    she will probably have training in counselling

                    she will have experience in dealing with families in these most difficult circumstances

       to have tissues to mop up tears

       to be sensitive to her emotional reactions

       to respond to her questions

       to be acutely aware that she may feel someone is to blame:


            a doctor or midwife,

            but, very often, herself

       to go at her pace and not rush her

       to prepare her for the stages of bereavement and problems like how she is going to tell others

       to discuss the painful issue of post-mortem examination

       to discuss future pregnancy, usually at a later date when possible causes of the disaster have been identified.

       to allow your own emotion to show, but not to be a drama queen grabbing centre stage.

In the exam I would address the examiner at the start and spell out the key pre-requisities:

being sure you have the correct patient and the full facts

seeing her in a suitable place - most labour wards have a separate area for bereaved mothers so they cannot hear babies crying

having husband, partner or other support with her

having the bereavement midwife

having someone take over your duties so that you are not disturbed


Often the patient would ask to see you again before going home.

Even if she didn't, I would pop in each day to say "hello".

I always made a follow-up appointment for six weeks or so.

I normally made the appointment in my office.

These patients should not be seen in the antenatal or gynaecology clinic.

The ante-natal clinic would be criminally cruel.

The gynae clinic puts you under time pressure which is incompatible with dealing properly with the situation.

My office was in the maternity building.

Some patients could not face being back in this building so soon.

I used to see them in my private consulting rooms.

Ask how big the bill was and you get your legs smacked!


Usually I saw the patient and her partner with the specialist bereavement midwife.

She would also see them on her own.

She and I would give contact numbers so that they could phone or arrange an early consultation at any time.

The specialist midwife at Stepping Hill Hospital was brilliant at caring for these couples.

She saw them in the hospital, visited them at home and was available to talk anytime by phone.

This is a very demanding and emotionally stressful job for a midwife.

They need to be right for the job and to have good support.

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Do you need to be able to counsel such families?

I believe that good counselling at these times (and after TOP for fetal abnormality) helps reduce severe psychological problems.

It could feature as a station in the MRCOG Part 3 and it is definitely one to practise in your study group.

There is too much to deal with, as you will see from the list in the next section.

So you would need just to do the basics, but it would be a nightmare if you had done no preparation.

It is communication in the most difficult of circumstances!


You are more likely to see such a patient in real life.

You could be asked to get permission for a post-mortem; as an SpR it should be within your capability.

You would be mad to do this without training or preparation.

As a GP, you should automatically go to see these patients.

What are you for if you do not support patients in distress?

If you are good at counselling, they will benefit.

You will also forge a bond with the family that will last for life.

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Topics to deal with.

Bereavement is painful enough if it is your ancient parent or grandparent.

But the loss of a baby seems particularly cruel and pointless.

There are loads of issues to cover:

     expressing your sympathy,

    the cause of the death, if it is known,

    the stages of adaptation to bereavement and the ubiquitous maternal feeling of guilt,

    how the experience of bereavement is different for mothers and fathers,

    the different rates of adaptation to bereavement for mothers and fathers,

    how to tell existing children,

    seeing and handling the baby,

    how it interacts with their faith if they are religious,

    physical recovery,

    lactation suppression,

    the tests that are needed to try to establish the cause of the baby's death,

    the case for post-mortem,

    funeral arrangements,

    registering the birth,

    how to deal with aberrant reactions by family, friends and colleagues,

    support groups,

    when she can safely get pregnant again,

    the management of the next pregnancy,

    sowing the seeds for them to create something good from the disaster.

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Expressing sympathy.

You need to find words that ring true and suit you.

"I am really sorry to hear about your baby" is not always true.

Not knowing the patient and the way we are groomed into professional detachment mean that you may have little emotional reaction.

Your feelings might even be dread at having to deal with this most difficult of circumstances.

You will have an emotional reaction when you have talked to her for an hour or more, got to know her and met her distress!

However, to start with, I felt more genuine with a statement of the obvious:

    "this is a terrible thing that has happened to you,

    you must be absolutely devastated".

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The cause of the baby's death if known.

This is pretty straightforward.

Most hospitals have a check-list of the tests needed.

Only give known facts.

It is tempting to try to ease her pain by stretching the facts.


Avoid the pitfall of medical jargon.

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The stages of bereavement.

There is probably a learned literature that disputes the following.

However, it is what I used for patients and it seemed to fit with their experience when I talked to them months or years later.

I liked to give as much information as I could muster.

They could easily find something strange going on in their heads in the weeks and months ahead.

They might fear they were going mad.

I felt that they would cope better if forewarned that it might happen.

My feedback from them was that this was valid.


I would point out that the time-scale to adjust to bereavement is lengthy.

I quoted the Victorians, whose widows wore their mourning "weeds" for at least a year.

There are lots of interesting articles on the subject on the Internet. Click here for examples.


I refer to "she", the mother, but the partner is involved too.

Initially she is overwhelmed with grief, remorse, guilt etc.

She can think of nothing but the loss of the baby.

She endlessly recycles the "what ifs".

"What if I had gone to the hospital earlier?"

"What if I hadn't smoked?"

She will also go over and over the possible reasons for the death of her baby.

This unceasing churning  may cause her to  fear for her sanity.


If no explanation for the baby's death is forthcoming, she is likely to blame herself.

My experience is that this is universal.

I usually explain this along the following lines.

"Mothers have a powerful instinct to protect their babies"

"If I had seen you the day before the baby died and said the baby would survive if I chopped off your legs, what would you have told me to do?"

The reply is always that they would have told me to get on with it.

I explain that this is a measure of how mothers would sacrifice themselves for their babies.

I explain that this powerful emotion can subconsciously turn against the mother.

"It was my job to deliver a healthy baby into the world."

"I didn't do it, so I failed in this most important task."

"I have let down the baby, my husband, my family and myself."

This almost always develops into "I am being punished for past wickedness".

Usually she can identify no obvious wickedness, but that is no palliative.

Previous termination of pregnancy for social reasons is especially potent.

It is seen as an obvious sin worthy of punishment.

It may also revive the emotional pain she may have suffered at the time.

I would normally invoke the patient-to-counsellor role-switch discussed in the communication skills section.


It is important to stress that any or all of this stuff may crop up in the weeks ahead.

The next stage is when her thoughts are no longer dominated by the baby's death.

Initially she has a short time when she thinks of something else - it might only be a few minutes or seconds.

This could be something pleasant.

She might even find herself laughing.

Then the guilt bites.

"Here I am laughing and having a good time and my poor baby is dead".

"What an evil, uncaring person I am."

Again, if she knows this is coming, she is better placed to deal with it.

I used to handle this with the following: "your baby is likely to have been like you or your husband / partner".

"Do you think he / she would have wanted you to torture yourself for the rest of your life?"

This is almost rhetorical and gets the expected response.


I explain that this is movement towards the final stage of bereavement.

In this, "the baby will always have a special corner in your life".

"It is not a corner that you will visit every day."

"That is healthy as it lets your life continue."

"There will be times you will inevitably remember: the anniversary of the baby's birth, Christmas and so on."

"You will also find that things unexpectedly make you remember."

"It is as though you had a strong elastic string connecting you to the special corner."

"The string can be plucked at any time and take you instantly back."

"All the old memories and feelings will flood back."

"It could be seeing a mother playing with a baby the age yours would have been."

"It could be hearing of someone losing their baby."


I would tell the story of a mother who lost twins.

She thought she was recovering well.

Pregnant with her next baby, she went to buy some things for the layette.

She saw a woman buying a pram identical to the one she had bought for her twins.

She was immediately totally overwhelmed by grief and stood howling in Mothercare.

I would explain that these sudden flashbacks are normal, though disconcerting.


The mother needs reassurance that not thinking about the baby all the time does not mean she will forget it altogether.

I always quoted a story, told me by Ruth Jamieson, a consultant paediatric colleague.

She established an annual memorial service for "lost babies" with a local lady vicar ".

It was not religious, so anyone can go.

Needless to say, it is an emotionally-charged event. 

One year Ruth was at the back of the church welcoming people.

A lady who must have been at least eighty came in on her own.

Thinking she might be lost, Ruth went over and asked her if she knew what the function was for.

The old lady replied: "Oh yes, it is to remember the dead babies".

Ruth asked which family she was with, assuming the child had been a grandchild or great-grandchild.

The lady replied that she had come "to remember my Jack"; the child having been stillborn sixty years before.

This was the first time she had openly grieved.

Those were the days when it was thought that the best thing was to say as little as possible.

Contact with the baby was discouraged and the mother was discharged ASAP.

Well intentioned, but wrong!

I used the story to explain that the baby will never lose its importance to her, but that its death does not need to rule her life.


It also leads in to another common and frightening experience.

At some point the mother will find that she cannot remember what the baby looked like.

This causes overwhelming panic and guilt.

If she is forewarned, she will cope.

It also makes a case for always taking photos of the baby, even if the mother feels at first that she doesn't want any.

Similarly, some keepsake or memento.

I would also introduce the theme of trying to get something good out of the tragedy.

See the section below.

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How the experience of losing a baby is different for mothers and fathers.

The following is an obvious generalisation and perhaps idiosyncratic.

I remember dealing with a couple where the father had a much more protracted and severe reaction than the mother.


I explain that the mother identifies with the baby from early in pregnancy.

She fantasises about it, plans for its arrival, enjoys its movement and kicks and finds that much of her time before its birth is taken up with thoughts, plans and dreams of the baby.

For men the baby is a bit more remote: their focus tends to be on their wife.

Fathers and they will often say that they did not fully bond with a new baby until it smiled at them.

They take this as the baby showing recognition of "Daddy", though this may not be an accurate interpretation.

This disparity in bonding makes for different intensities and durations of bereavement.

In addition, the father will soon be back at work and plunged back into the distraction that inevitably brings.

I think it important to explain this in detail.

The mother must not see the father as a psychopath because he has gone for a pint with his friends.

He must not see her as being unduly morbid if she continues to think and talk about the baby all the time, when it is no longer dominating his thoughts.

I also sensed that understanding and helping each other through the trauma could strengthen the relationship.

However, you must allow for the possibility of a severe reaction in the father.

Rosemary Tomlinson, a midwife in Maidstone with a special interest in bereavement counselling has been in touch about this section.

She has encountered fathers who struggled when family and friends asked about the mother.

And ignored the possibility that he, too, might be in difficulties and in need of support.

This is a useful reminder that paternal postnatal depression is now a recognised disorder.

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Telling the children.

Very young children probably had little concept of what was going on even if diligently prepared for the new arrival.

Older children should have the facts.

I imagine that some children cope badly and need help, but I have no experience with this.

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Seeing and handling the baby.

Received wisdom is that it is best for the mother to see and handle the baby.

But there is evidence to the contrary.

Turton et al published data suggesting that women who did not see or handle their babies might do better emotionally than those who did.

I have no doubt that we will see further research along these lines.

She should not be pressured if she does not want to see and handle the baby.

If she does want to see the baby, it should be nicely dressed, with care to cover obvious abnormalities: you don't want to give her the horrors.

If she wants to see a birth defect for herself, she can be helped to undress the baby.

I think it is a good idea to take photographs of the baby dressed as it is when the mother sees it.

A photograph of her with the baby would do no harm so long as she wants the contact.

If she doesn't want to see the baby, photographs should still be taken.

She may be grateful for them in the months ahead.

Rosemary Tomlinson, a midwife in Maidstone with a special interest in bereavement counselling has been in touch about this section.

She has found it useful to draw parents' attention to the baby's hands.

Whatever other problems the baby has, the hands are usually perfect.

This leads on to taking handprints as a memento.

It could be particularly comforting in the years ahead for the parent to be able to touch something the baby had touched.

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How the baby's death may interact with the couple's religious faith.

It is important, if they wish it, that the religious leader be involved.

Most will have experience of bereavement and training in how to provide support.

I imagine that most religious people find their religion helpful at these times and their faith strengthened.

However, it can raise faith-threatening questions and you will hear them voiced.

You will hear God cursed or statements that the existence of God is no longer believable.

If God is infinitely good, infinitely caring, infinitely knowing etc., how come He lets an innocent and perfect baby die?

Any answer is usually along the lines of: "God moves in mysterious ways" or "can the bee understand the beekeeper?".

I think I would find such comments negative, fatuous and irritating.

So keep well away from this area! It's a minefield.

Having one's faith shattered can be very distressing for the individual.

It can also impact on family dynamics and acceptance in the wider faith-community.

By and large people have religious faith because it was the faith of their parents.

I don't think many Eskimos come to Hinduism through a study of comparative religion.

If an individual were to develop serious doubts or lose their faith, devout parents would be likely to be horrified or worse.

"Never darken my door again!"

Members of their community could shun them.

Friends of mine, eminently good people of strong religious faith, had a daughter about to be married.

Her fiancé was divorced and this caused delay in setting up a church wedding.

The young couple arranged a civil service. 

Nuclear war broke out.

The parents refused to attend the service and treated the daughter as "living in sin".

The father came close to assaulting me as I tried to act as intermediary.

Mind you, it was at the end of a long evening and we had had a few whiskies!

This would not have done my communication skills much good.

Nor his temper!

Many years have passed and babies have been born.

But the relationships between the parents and the young couple remain strained & resentful for years.

What a renunciation of the religion would have caused I dread to think!

Fortunately, my unwelcome efforts have been forgiven  or forgotten.

The possible impact on family relationships is probably another good reason for early involvement of the religious advisor.

Let them deal with it.

It is wise to keep out of this arena yourself!


Some decades ago a senior colleague of mine was seen to be a "bit wobbly" in clinic one afternoon.

He was enormous, smoked and drank too much, etc. and had probably had too convivial a lunch.

He was seen by a very religious cardiologist, Dr Z, who had him admitted to the private wing.

Worried that he might have had a coronary and be liable to alcohol withdrawal problems, he ordered heavy sedation.

My colleague, a considerable wag, revelled in telling, with more expletives than below, of waking up a few days later.

"I woke up and thought: ‘I have gone to Heaven’. 

I was in a room that was all white.

The air seemed unnaturally still.

Golden sunlight suffused the room.

There was a murmur of  voices and distant music.

Then I turned my gaze and there was that bastard Z, kneeling by my bed praying.

I thought: ‘I must be dying!’”

The joyous irony was that the narrator was himself highly religious.

This story is completely irrelevant, but I include it because it makes me laugh.

Another favourite story about prayer concerns my dear friend David, now sadly deceased.

He was a good man, very religious, highly intelligent and a judge.

One spring morning he felt an upsurge of bonhomie and joie de vivre.

He decided that he would commune with the common man.

This entailed travelling to court on the bus rather than his official car.

He arrived in good time in Manchester and decided he had time to pray.

He took himself off to the "Hidden Gem", a beautiful old church in the city centre.

He was immersed in prayer, when what he described as a bleary, red face, reeking of alcohol appeared over his shoulder.

"Can you spare some change for a cup of tea?"

David's response was immediate and automatic.

"Fuck off! Can't you see I'm praying."

And this from a man of great goodness and charity.

It still brings tears to my eyes of laughter and the poignancy of his early death a few years later.


I will now eschew further irrelevant digressions.

In centuries gone by much medical care was dispensed by the religious.

Nowadays people expect religion and medicine to be kept separate, unless they have volunteered for faith healing or the like.

So you follow suit.

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Physical recovery, lactation suppression.

She needs a realistic timescale for her physical recovery.

Feeling physically under par will not help her emotional state.

Lactation may be uncomfortable.

Additionally, it may seem an irony too cruel to bear.

If it is a problem that cannot be managed with simple measures, consider lactation suppression.

But note my words of caution about the risks attending the use of drugs like bromocryptine. 

If a drug is to be used, cabergoline is usually preferred to bromocryptine.

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The tests needed, including post-mortem examination.

The cause of fetal death may be apparent, e.g. massive placental abruption.

So a detailed analysis of the pregnancy is necessary.

Risk factors such as advanced maternal age, smoking etc. may be identified.

But these cannot be adduced as the cause in the individual case.

Sometimes a family history may give clues.

Often there is no apparent cause.

There should be a protocol detailing the necessary tests.

These should be explained to the mother and the fact that some time will be needed to get the results.

She should be assured that she will be told all the results when she comes for follow-up.

Talk of post-mortem examination may induce "the horrors".

"Has my poor baby not suffered enough?"

It is useful to use the analogy of an exploratory operation.

This makes post-mortem examination more normal.

"When we are ill our doctors may need to do an operation to look inside to find out what is wrong with us."

The same applies when a baby has died.

"We can do lots of tests on the mother, x-rays and scans of the baby, but still not find out what happened to the baby.

A post-mortem examination is like an operation.

A specially-trained doctor looks inside the baby to see if the cause of death can be found.

It is the test that is most likely to identify a cause if one is not immediately apparent."

You need to discuss biopsies and organ retention.

There is further discussion of this in the MRCOG OSCE section.

You need to discuss biopsies and organ retention.

An explanation of its contribution to getting an accurate diagnosis and the management of the next pregnancy is usually persuasive.

You need to get proper consent.

Usually there is a special form for consent.

What tests might a protocol include?

Some tests need to be done as soon as fetal death is diagnosed.

Feto-maternal haemorrhage is a possible cause

But fetal cells are likely to be destroyed pretty rapidly if there is ABO compatibility.

So a Kleihauer test should be done ASAP.


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Funeral arrangements.

This is well covered in the SANDS website.

They have a comprehensive, downloadable document covering all the options.

Basically, the parents can leave it to the hospital to dispose of the body.

Or they can make arrangements for a funeral and disposal themselves.

There are issues about cremation or burial, costs and benefits.

All of it is dealt with in the SANDS document.

Unfortunately the site does not facilitate direct links.

Go to the SANDS website.

Click on "Support" then "Important practical issues".

This takes you to a page with links to all the important issues: PM, funerals, benefits, maternity & paternity leave etc.

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How to register the baby's birth.

The General Register Office has details of how to register a stillborn baby.

The Royal College of Midwives has produced a detailed document.

This covers issues like:

    what if a baby born at 20 weeks shows signs of life?

    what if a baby dies before 24 weeks but is not born until after 24 weeks?

    what happens if twins are born at 26 weeks, one alive, but the other dead at 22 weeks?

A baby suffering neonatal death must be registered as having been born. 

And then be registered as having died.

The College has asked in a DRCOG MCQ about who can register a birth, stillbirth etc.

So you need to know the basics.

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The reaction of family, friends and colleagues.

Most will be distressed and hugely supportive.

Some will discuss every subject under the sun, except babies and anything to do with them.

They may even see a friend cross the street to avoid talking to them.

I explain that these people probably carry a burden of unresolved grief of their own.

They feel incapable of adding the grief of the patient.

I usually speculate that most will one day reveal why they behaved as they did.

Others may simply feel awkward, uncertain of what to do and terrified of exacerbating her grief.

It may be her first experience of being non-judgemental - see below.

I advise the husband to get the news out early, not just to family and friends, but to their bosses at work.

TOP for fetal abnormality usually means the telling of “white lies”.

I think the true facts should be kept to a small inner circle of family and genuinely close friends who are going to be supportive and not judgemental.

Others should just be told that she has "lost the baby", which is not even a lie.

The last thing she needs is to be badgered by the curious for more information when she is striving to come to terms with things.

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Support groups.

The best person to deal with this is the bereavement midwife.

She will know the local groups and how well they work.

They can be fantastic, but there is always the risk that they are dominated by people who have not recovered well from their loss.

They could be bad news for someone in the early stages of these disasters.

There are stacks of web sites dealing with bereavement in general.

You can even get support after losing your pet.

Can you imagine phoning: 

    "I'm really upset; I don't think I can go on..."

    "My budgie / snake / ferret has passed to the Other Side"?

In fact, if it is some lonely old soul losing a loved canine companion, you can understand the grief.

But to more serious matters.

Specific stillbirth and neonatal death support is the business of the Stillbirth and Neonatal Death Society. SANDS.

It has loads of information about everything you can think about:

    funeral arrangements,

    post-mortem examination,

    birth and death registration,

    maternity and paternity leave,

    social security benefits etc.

A similar organisation is: Babyloss.

DirectGov is  government branch designed to give information.

It has a section on stillbirth, and links to sites with further information.

E.g. on how to register a stillborn baby. 

There are stacks of other support groups and organisations.

Google "bereavement+support+stillbirth". 

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Management of induction/ delivery/ miscarriage/TOP.

You need to discuss all of the practical matters about the options available.

She may wish time before anything is done.

Usually most want to get it over and done with.

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When can she get pregnant again?

In general it is best for her to wait until all the results are back.

You'll then know if she needs any special investigations by a physician, geneticist etc.

The biggest determinant is normally her emotional recovery.

I would usually advise that she gives herself time to recover from the loss of the baby.

And enough time to be sure that she will be able to cope with the stress of the next pregnancy.

Turton et al  found, as you might expect, high levels of anxiety and post-traumatic stress disorder (PTSD) in women who were pregnant after stillbirth.

The levels were higher if the interval from the stillbirth to the next pregnancy was short - less than 12 months.

Most symptoms cleared in the 12 months after the arrival of a healthy baby.

Turton et al found that fathers suffered:

    anxiety and PTSD,

    but less so than mothers

    and with symptoms resolving completely with the arrival of a healthy baby.

The bottom line is you advise, but it is her time-scale.

My experience is that few want to wait for 12 months.

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The management of the next pregnancy.

The cause of the stillbirth is obviously crucially important.

It could be a "one-off" rare chromosome abnormality that is unlikely to recur.

Trisomy 13 would fit the bill.

If the chromosome tests for her and her partner are normal, her risk of recurrence would be little more than the average rate.

This is about 1 in 10,000 births.

At the other extreme, she could have serious health problems that cannot be improved.

She might have antiphospholipid syndrome that had been perfectly managed in the first pregnancy.

Yet the baby died in utero at 26 weeks.

She would be at high risk of an adverse outcome.

So, you need:

    detailed information about the previous pregnancy,

    and to check that all the relevant investigations have been done.

If she delays the next pregnancy, make sure she comes for pre-pregnancy counselling.

Even if the cause of death and management seemed clear at the time, this is still worth recommending.

Obstetrics is a fast-changing specialty and something new might crop up.

If you are recommending changes in her life-style, stopping smoking or alcohol, for instance, be exceedingly tactful.

Be careful not to add to her burden of guilt.

The management will be determined by the cause of the stillbirth.

Often no explanation is forthcoming.

These "low-risk" patients still have a risk of recurrent stillbirth that is four or five times the average.

There are various articles on the subject.

The most recent I could find is by Sharma et al.

For the exam, remember that the risk is increased by a factor about five.

But it is still a small risk numerically.

Sharma et al found the risk of recurrence to be 19 per 1,000 births.

It appears that risk of recurrence is higher for Afro-Caribbeans than for Caucasians by a factor of about three.

The next pregnancy will be a time of great anxiety for the couple.

Agree a management plan at the outset, or even when providing pre-pregnancy counselling.

The management plan will need to be determined by the consultant obstetrician.

It will usually be regular scans for growth with some form of fetal welfare monitoring in the later weeks.

Early delivery often features, particularly when the fetal death occurred in the last week or two of the pregnancy.

The plan has to be agreed with the mother to ensure that it provides her with ample reassurance.

Additional tests, such as screening for gestational diabetes, should be explained to the couple.

Don't give false reassurance.

You can't guarantee that she will have a live baby!

She must have easy access to the hospital for days when the baby's movements are reduced.

Or if she becomes overwhelmed with anxiety, even if there are no particular grounds on that day.

She is not going to be reassured until the baby has been born and been given a clean bill of health.

So make sure that it is examined soon after birth.

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Trying to salvage something positive from the disaster.

Creating a phoenix!

One of the most depressing aspects of the loss of a baby is its negativity and futility.

The new life snuffed out, all the excitement of pregnancy negated, all the love bubbling up for nothing.......

Early on in my career I met a mother who reckoned that the loss of her baby had made her a better person.

She had become more tolerant of others and aware that their odd behaviours could be driven by emotional problems.

This was useful education for me.

Subsequently I "planted the seeds" of this kind of outcome during the early counselling.

By the time I saw them for follow-up, most women were already aware of something happening to them.

They derived great consolation from it.

"My baby had a very short life and I never got to know her or show her my love.

But it was n'o in vain.

I am a better person and good will come into the world through that little life."

I always found it moving listening to these revelations.

This adjustment to bereavement often leads to the individual training to be a counsellor.

I felt that this kind of development led to the best recovery.

My heart sank when I met the woman still immersed in bitterness and woe months and years later.

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You might find this a bit homespun and folksy, even sentimental,  but it has been useful for me and, I hope, my patients.

I'll be pleased to get feedback of your experience.

I will also be pleased to hear of any improvements you devise.

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Tom McFarlane.     

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