Stillbirth and late termination of pregnancy: Women in 'agonizing' situations need 'empathic, supportive care'

"For the eager, expectant mother, the diagnosis of stillbirth or of severe fetal anomalies comes as an unexpected and deeply traumatic loss," write Dr. Michael G. Richardson and colleagues of Vanderbilt University School of Medicine, Nashville. "The decision making and events that rapidly follow diagnosis are confusing and difficult to navigate for these vulnerable patients." The special article provides an introduction to the unique medical, legal, and ethical issues involved in caring for patients in these difficult situations.

Stillbirth and Fetal Anomalies -- Medical Care and Emotional/Psychological Effects

About six out of 1,000 pregnancies end in stillbirth, while some type of severe, "life-limiting" anomaly is diagnosed in another three out of 1,000 cases. Obstetric care has evolved to address the medical challenges encountered, as well as the psychological and emotional aspects of care. For some medical providers, lack of knowledge or difficulty coping with these issues "may hinder their ability to provide empathic, supportive care."

Dr. Richardson and colleagues provide perspective on these issues for obstetric anesthesia providers and others caring for women who suddenly find themselves facing these "insufferably hard" situations. The article includes two case examples illustrating the medical challenges and need for compassionate care of mothers whose fetuses have died, or are expected to die soon after birth. In both cases, the healthcare team honored the mother's wish to spend time with her baby after a difficult delivery.

In stillborn pregnancies, labor is often induced soon after diagnosis. In cases of severe, life-limiting anomalies, many women will opt to terminate the pregnancy, but others may wish to continue their pregnancy -- to deliver a live infant, if possible. In these situations, current obstetric care guidelines call for a "supportive, nonjudgmental, nondirective approach," Dr. Richardson and colleagues write. "Providers must be prepared to fully support a mother's decision...to continue a pregnancy with known severe fetal anomaly and to address the [newborn's] comfort and dignity, however short his or her life may be."

Both groups of women are at risk of lasting psychological effects. Mothers of stillborn infants face an "agonizing" experience -- from the first sign of a problem, to the diagnosis of fetal death, through delivery and beyond. Being treated on the same maternity unit as women with healthy newborns only adds to their emotional stress. Throughout their ordeal, women value "honesty, clarify, empathy, availability, information, and guidance" from healthcare providers.

Severe fetal anomalies may have an even greater emotional impact -- including the difficult decision whether to continue the pregnancy. Women who want to end their pregnancy may face barriers to insurance coverage and health care access, including legal restrictions. In contrast, those who choose to continue their pregnancy -- sometimes against their obstetrician's recommendation -- may meet with insensitivity on the part of health care providers.

"Weighing the psychological, emotional, and physical benefits and risks of live birth and obstetric interventions is complex," the authors write. "[U]ltimately, it is a value judgment best reserved for the mother after honest and open discussion with her health care providers." They also discuss the anesthesiologist's role in providing pain control for women undergoing these difficult deliveries.

Dr. Richardson and colleagues hope their article will help to introduce the obstetric options and issues, the range of maternal preferences, and the legal and ethical aspects affecting the ability to provide "fully empathic, nondirective, and value-neutral care" for women with pregnancies affected by stillbirth of severe fetal anomalies. In addition to providing safe and effective anesthesia and pain control, "[T]he obstetric anesthesia provider is uniquely positioned to establish supportive and healing relationships with these women and their families, who feel very alone in their suffering,"