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1.1 Family Care Checklist One-on–one nursing care during labor, delivery and immediate postpartum care if possible. Mark the door with a card or symbol to alert staff of a loss (such as a butterfly card). Respect Privacy. Try to place the patient in a room away from the hub of your unit,minimalizing the sounds of babies crying and joyous visitors. Discuss end of life wishes with the family. What is their understanding of the process? Howdo they want to spend time with their baby? Who do they want present? Would they likemusic? You may suggest what other families have done. Ask the parents the baby’s name and refer to the baby with this name. It is a sign of respectand caring. Offer to call the chaplain or faith leader for spiritual care or other religious practices. Offersupport if they choose to baptize or bless the baby. If chaplain is not available, a nurse orstaff may perform baptism if requested. Prepare the family for the experience and potential for a D&C. What to expect, includingmedications, delivery expectations, and condition of the baby. Give families the gift of time. Allow them the right and privacy to grieve. Encourageproviders to give family time. Don’t rush the admission process. Allow parents to hold and be with their baby. Give the opportunity for the parents andextended family to spend time with their baby without rushing the baby away, includingalone time with their baby. (See article reference in Resource Section 5.2: “Resolve throughsharing position statement on cooling a babies body after death”). Let the parents bathe and dress their baby, if possible. Offer heirloom photography. If parents are unsure, encourage them to allow pictures to bemade and stored until they are ready for them. Often there is a change of heart in the weeksafter the birth, and pictures are treasured. Be sure to take a picture of the patient’s ID sticker BEFORE you take additionalphotographs, so that pictures are associated with the correct patient.(For photograph distribution and storage see Family Care Section 1.1.4).1.1 Family Care Checklist Continues on the Next Page

1.1 Family Care Checklist Continued Give as many mementos as possible. Consider special blankets, size appropriateclothing, handprints, footprints, and a lock of hair. Many other items are appreciated; babybeads, tape measure marking the baby’s length, clay casts of feet, etc. Also give parentsa stuffed animal, beanie baby or comfort cub and take picture with the toy so that it“becomes” their baby’s toy. (See Resources Section 5.1) Offer a courtesy cart from dietary for the family. Give the mother the option of an early discharge, if appropriate. Be sure an autopsy or genetic testing is offered. Make sure to inform the family they willbe responsible for the cost. Offer a variety of educational materials to read and take home for mom and family ongrief and postpartum care (see Resources Section 5.2). Develop a worksheet to guarantee continuity of care that works for your unit.(See Policy Section 3). Make sure parents have been given bereavement resources. (See Resource Section 5) Ensure quality care is continued at postpartum visits, by notifying the providers.1.1.1 Postpartum Care Follow the plan of care for OB postpartum care and discharge instructions. Should the patient be transferred to another unit for recovery, assign an OB nurse toperform postpartum assessment per unit protocol and document. Provide anticipatory guidance about lochia; uterine involution and cramping; breast engorgement; and care of the perineum and any incisions. See Breast Care Section 1.1.2for more information. If the mother is Rh-negative, RHOGAM is administered within 72 hours after a pregnancyloss. Educate the mother and her family regarding blood complications which could affectfuture pregnancies causing hemolytic disease in the newborn.1.1.1 Postpartum Care Continues on Next Page

1.1.1 Postpartum Care Continued Address physical discomfort and pain. Use standing orders or unit protocol forpostpartum medications such as analgesics; stool softeners; iron supplements and othercomfort items like witch hazel pads, ice packs and breast pads. Discharge teaching should include the “Save Your Life” (AWHONN) or similar instructionsheet for post-birth warning signs.These include: Call 911 if chest pain; shortness of breath; seizures, thought of hurting yourselfor someone else. Call the healthcare provider or go to an emergency room if: saturating onepad per hour or blood clots the size of an egg or larger; incision that is nothealing; red or swollen leg that is painful and warm to touch; temperature of100.4 or higher; or a headache that does not get better; vision changes or epigastric pain (heartburn). Advise the patient and family:“If visiting a regular clinic or emergency room or talking with any paramedic, orprovider, be sure to tell them that you have had a miscarriage or a baby and thedate of delivery. You may need specialized care.”(See AWHONN Infographic in Resource Section 5.5). Situational depression and/or postpartum depression is common. Advise patient and herpartner/family that there are options for treatment and to contact the healthcare provider. Assess for post-traumatic stress disorder especially after an unexpected outcome. Follow up care with her provider should be in 2 to 3 weeks or sooner. Establish a safe, therapeutic relationship and work with her perception filling in missingdetails. Review the labor management and any questions concerning interventionsduring her intrapartum period.1.1.1 Postpartum Care Continues on Next Page

1.1.1 Postpartum Care Continued NutritionSupplemental Nutrition Program for Women, Infants, and Children (WIC) eligibility Advise postpartum mother that if she is currently on WIC, or qualifies for WIC,she can still receive benefits for 6 months after the loss (miscarriage,spontaneous/elective abortion). If she had not received WIC, but qualifies, WICcan serve her if she has adequate documentation of the pregnancy loss. Advise the mother that rest and eating well, avoiding high sugar content, highcaloric foods will help her body heal. Taking a multivitamin and ferrous sulfate, ifanemic, will speed the recovery process.1.1.2 Breast Care Suggestions for the mother: Use cold compresses (e.g. frozen peas in a damp cloth or chilled cabbageleaves) or ice packs to relieve swelling and pain, for 20 minutes at a time. Thiscan reduce inflammation and help reduce milk production. Wear a comfortable supportive bra that does not restrict circulation. Adviceto ‘bind” the breasts with tight cloths or wear a very tight bra, or to ignore soretender breasts without expressing to comfort can lead to breasts becomingengorged. If engorgement is ignored it can lead to painful blocked ducts ormastitis. Avoid touching or stimulating nipples, as this may cause breasts to producemore milk. Avoid standing in a hot shower and allowing the water to run over the breasts. Take a pain reliever such as acetaminophen or ibuprofen. If mom has an established milk supply, stopping the pumping abruptly maycause engorgement. Advise to decrease the number of pumpings slowly untilthere are no more pumpings.1.1.2 Breast Care Continues on Next Page

1.1.2 Breast Care Milk DonationAs an alternative to stopping lactation, the mother may choose to pump and donate hermilk. Some grieving mothers find this process healing as they help a baby in need. Theinformation for donor milk banks is as follows; The Mid-Atlantic Mother’s Milk BankWebsite: http://www.midatlanticmilkbank.org/Address: 3127 Penn Ave.Pittsburgh, PA 15201Phone:(412) 281-4400Email:[email protected] The Mothers Milk Bank of OhioWebsite: http://www.ohiohealth.com/mothersmilkbank/Address: Eastside Health Center4850 E. Main St. Suite 140Columbus, OH 43213Phone:(614) 566-0630Email:[email protected] The King’s Daughter Milk Bank at CHKDWebsite: www.chkd.orgAddress: 400 Gresham Dr suite 410Norfolk, VA 23507Phone:(757) 668-6455Email:[email protected] CHOP Mothers’ Milk BankWebsite: ss: 3401 Civic Center BlvdPhiladelphia, PA u

1.1.3 Sibling Care Support the family if they choose to include siblings. Encourage siblings to draw pictures, write letters, read books, and sing songs to baby. Allow siblings to participate in care and memory making. Encourage family to use open and honest communication with concrete words such as“died” or “death” when talking to children. Avoid phrases such as “went to sleep”, as thiswill make some children afraid to go to sleep, that it might happen to them. Also avoid“went bye-bye” or “lost”, as children may think the baby is coming back. Encourage family to reinforce that the sibling didn’t do anything wrong to cause the babyto die. Encourage family to share emotions, as a role model, that it is ok to cry and grieve withtheir children. Refer to additional resources for siblings in Resources Section 5.2.3 & 5.3.1.1.4 Heirloom Photography Encourage parents to have pictures taken with the unit’s digital camera, the hospital photography company, or a professional photography company (Now I Lay Me Down ToSleep (NILMDTS.org)). (See Resources Section 5.1) Pictures can be stored for parents that are unsure if they want them on a CD or SD card.It is not uncommon for families to have a change of heart within the coming weeks. Hospital staff/employees CANNOT take pictures without the parent’s signed permission. You can find a suggested hospital posing guide on NILMDTS.org website. Encourage and include siblings and extended family in photos.

1.2 Post Mortem Body Care Bathe and dress the baby, wrap in a baby blanket and then wrap it in a chux or place inappropriate vessel. Refer to your hospital policy regarding body identification. Offer to call the Funeral Home to provide family information. If a funeral is a financial hardship please see Guidelines Section 2.8. For DHHR locationlistings and information see Resource Section 5.6. Refer to your hospital body removal policy.1.3 Follow Up Family Care After Discharge Provide a follow up call or a card from the institution/unit (“Thinking of you” or“Sympathy”) to let the family know they are still thought about. RTS (Resolve ThroughSharing) guidelines recommend calls following a miscarriage or ectopic pregnancy within1 week, at 3 weeks or 4 months and at the due date. For stillbirth and newborn death,the suggested time is within 1 week, 3 weeks, due date, 6-10 months and anniversarydate. These are only suggested timelines. Offer a remembrance service, to allow families to come together to honor their child. Contact the patient’s doctor’s office and your hospital’s billing or financial office, to informthem of the loss.

1.4 What to Say and Do for Grieving Parents: After entering the room, pull up a chair or stool at the bedside. Reassure them that they are not to blame for the loss of their child. Collecting mementos (refer to Family Care Section 1.1 and Resources Section 5.1 forsuggestions of mementos). Explain to them that the feelings of shock and anger are normal. There are many emotions that are experienced with grieving that will come and go. Explain to them the importance of allowing themselves time to grieve. Give them permission to take as muchtime as they need to grieve and that there is no timeline. Grieving parents may cry a lot. Silence is okay, even if it is uncomfortable. Sometimesholding their hand or offering a tissue will help. While some people will grieve the loss oftheir child by crying, not all will cry in front of you. That does not mean that they are“better” or “over it”. They will never be “over it”. Not all grief looks or acts the same. Grief can be very uncomfortable. If you begin to feel uncomfortable around your grievingpatient and family, it’s okay, but don’t allow yourself to avoid staying with them, if that iswhat they need. Follow the lead of the parents. Discuss what they want. Reassure the family that they are not alone, there are resources available. (Include a listof local resources-see Resource Section 5 for listings and contact information). Askthem who will be their support when they go home. It’s okay to acknowledge the unfairness. Say things like, “I am so sorry” and “I wish thiswere different”. Do not rush them. Allow them as much time as they need to hold and be with their baby.Let them know that there is no time limit. This will be the only time they will have withtheir baby.

1.5 What to NOT Say and Do for Grieving Parents: If your patient doesn’t want to discuss the loss of their child or their feelings, respect theirwishes. Provide a supportive presence. Avoid statements that make us feel better such as; “It is for the best”, “I know how youfeel”, “I don’t know how you’re doing it”, “God needed another angel” or “God neededyour baby more”. Don’t be offended if parents say something mean or hurtful. Anger is a part of grief. Dobe patient and compassionate. Don’t try to put a time-table on grief. No one knows how long it will take to grieve the lossof a baby. Don’t tell them they will simply “get over it” in a specific period of time. Don’t refer to the child in impersonal ways. Instead, use the child’s name. It may feel uncomfortable to you, but it will remind them that the world has not forgotten their child. Don’t forget about the siblings. Not only have they lost a brother or sister, but also theirparents during the grieving process. (See Family Care Section 1.1.3) Don’t be afraid to show emotion. You may think you have to be strong for the family, andtherefore shouldn’t cry or show emotion. You can be strong and be emotional at thesame time. If tears come, don’t fight them. This shows that you share in their sadness. Avoid words like “demise” or “expired”. Do not be afraid to say “Your baby has died”.