Armstrong's findings additionally relate that due to previous research and the influence of perinatal loss on postpartum depression on partnered relationships. Armstrong states that differences in continued psychological stress between mothers and fathers after a subsequent birth is another area requiring further evaluation. Specifically stated is that it is necessary to evaluate "...the strength of partnered relationships during future childbearing experiences is important to identify any potential influence of the loss on couple, as well as family, outcomes. Understanding possible gender differences may help neonatal nurses and other healthcare providers to recognize couples at risk for discord." (2007)
Neonatal nurses are those who work closely with infants and parents and in the best position to make identification of depression and to pose questions about the individuals symptoms including:
3) energy or fatigue levels;
4) ability to concentrate; and 5) as well the neonatal nurse is in the unique position to counsel with the parents. (Armstrong, 2007)
The healthcare provider should not hold an expectation that parents will offer up this information or ask for assistance but should encourage neonatal nurses to ask questions and to assess the psychological needs of parents experiencing perinatal loss including parents who are becoming parents to a healthy newborn since the impact of perinatal loss is many times ongoing and continues to contribute negatively to the parent's psychological state of mind. Armstrong specifically states that neonatal nurses comprehend the necessity to "...assess adaptation to parenthood and continued psychological distress for both parents in the weeks after birth. Neonatal nurses working with these families should be aware of the potential for continued psychological distress after the birth of a healthy infant and educate parents about this possibility." (2007)
The work of Gold, Dalton, and Schwenk (2007) entitled: "Hospital Care for Patients After Perinatal Death" reports a systematic review of the experiences of parents with hospital care following perinatal loss. The study reports having evaluated in excess of 1,100 articles from 1966 to 2006 in order to identify studies of fetal death occurring the second or third trimester as well as neonatal death during the first month of life. The studies were limited to English studies evaluating care in United States hospitals and those containing direct data or opinions of parents. Results reported by Gold, Dalton and Schwenk (2007) are reported to be compiled in regards to five aspects of care recommended including the following:
1) obtaining photographs and memorabilia of the deceased infant, 2) seeing and holding the infant, 3) labor and delivery of the child, 4) autopsies, and 5) options for funerals or memorial services. (Gold, Dalton and Schwenk, 2007)
Gold, Dalton and Schwenk note that before the decade of the 1970s "parents were typically not allowed to see or hold their deceased babies. In the last 30 years, psychology experts have led the way in recommending that parents have more contact with their deceased infants and commemorate the deaths. Several national guidelines have been published with recommendations for hospital care after perinatal or neonatal death.9-11 However, the recommendations differ significantly in scope and focus, and there is little understanding of whether such policies are used in practice, how parents feel about the interventions, and whether certain interventions could be changed to better reflect the real-world preferences and experiences of bereaved parents." (2007)
Gold, Dalton and Schwenk additionally state that when perinatal loss is diagnosed prior to birth the decision must be made by parents and doctors as to whether to "induce delivery right away, to delay induction for days or weeks or to wait for spontaneous labor."(2007) Another issue described as controversial is where postpartum care should take place following fetal demise. Findings state "It appears that few parents choose where to have their postpartum care; in one study, the numbers ranged from 6% to 33% of parents, depending on infant's gestational age. A common theme was that mothers who stayed on a labor and delivery unit described the exposure to healthy infants and mothers as emotionally difficult, but parents moved to general surgical or gynecology units often reported dissatisfaction with care." (2007)
Another issue was the level of pain control during delivery. Findings reported by Gold, Dalton and Schwenk include that studies state findings that holding the infant was "important to parents" and that "46% of parents with second-trimester loss, 86% of parents with third-trimester loss, and 78% of parents with neonatal loss rated holding the baby to be an essential bereavement option.19 a theme across the qualitative studies was that parents who had initially been hesitant to hold their infant later reported that holding had been a good choice and they wished they had held their baby longer or more than once. Of parents who initially declined to see or hold, many later said they probably would have accepted if they had been asked more than once." (2007) in addition it is reported that "authors of one key study found that health professionals played a key role in whether or not parents saw or held their infants." (2007) it is stated that presently it is common in the practice of hospitals to photograph infants following death and that these are generally offered to the parents and when parents decline these they are offered one more time and then placed in a file for a number of years. The study reported by Gold, Dalton and Schwenk states findings that "parents overwhelmingly found that having photographs of their infants was important to them, and across all qualitative studies, only parents without photos expressed regrets." (2007) it is also reported that findings include the fact that parents report valuing being offered burial options and that fathers were the parent most likely to discuss these options with hospital staff. Additionally stated as an emerging them from several studies that were qualitative in nature was that parents "sometimes felt they had little control over the infant's disposition after death.. Researchers described parents who had not been given a choice about a funeral, felt the hospital had whisked the infant away, or were unsure what happened to their infant's body." (2007) Gold, Dalton, and Schwenk report that often in the case of perinatal death when the infant dies before or during delivery, the cause is not clear at the time of the event." (2007) Autopsies were agreed upon by 20 to 100% of parents and two studies stated findings that 60-80% of families "were offered the option, but it is unknown whether or not they accepted." (2007) However, it is related that "a large number of parents complained that they were never given results of the autopsy, did not know they were entitled to these results, or did not know how to go about obtaining the records." (Gold, Dalton, and Schwenk, 2007) Arising from the study conducted by Gold, Dalton, and Schwenk are the following recommendations to improve hospital care following perinatal death:
Allow parents to help decide when to deliver a deceased fetus.
Provide parents the option for post delivery care on or off a maternity floor.
Be sensitive to physical pain during delivery and offer adequate pain control. Avoid over sedation when possible. Minimize use of tranquilizers as a treatment for grief.
Encourage parents to see and hold their infants for extended periods and at multiple sittings, and offer parents who initially decline additional chances later.
Take nonclinical photographs of cleaned-up infants as soon as possible after delivery. Include a photograph of multiples together even if one or more babies has died.
Collect memorabilia about the baby. If parents decline these items initially, offer them again later or hold the materials for a future time.
Discuss options for burial with both parents when possible, and allow parents to participate in the final decisions. Offer resources for financial support when available.
Ensure autopsy results are provided to parents promptly.
Educate other members of a patient's obstetric team about interventions valued by bereaved parents.
Ask other team members to perform key tasks (such as collecting memorabilia or taking pictures); this is particularly useful if the hospital does not routinely employ the intervention and if the attending physician or midwife makes the request and models sensitive care.(Gold, Dalton, and Schwenk, 2007)
The work of Hughes, Turton, Hopper and Evans (2002) entitled: "Assessment of Guidelines for Good Practice in Psychosocial Care of Mothers after Stillbirth: a Cohort Study" reports that most maternity units "have good practice protocols, advising that after stillbirth parents should be encouraged to see and hold their dead infant." The aim of the study reported by Hughes, Hopper, Turton, and Evans is to make assessment of "whether adherence to these protocols is associated with measurably beneficial effects on the psychological health of mother and next-born child." (2002) Findings in this study state that behaviors promoting contact with the infant that was stillborn "were associated with worse outcome. Women who had held their stillborn infant were more depressed than those who only…