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Tuesday Dec 01, 2015

Stillbirths: Mourning the Children I Never Got to Know

It was one of those weeks. You know what I mean. I had returned from a great weekend spent as a family medicine delegate to the annual meeting of the California Medical Association House of Delegates, and I felt like my energy had been restored.  

Then I opened my laptop.

I had 25 patients on my schedule, including an induction for a first-time mom who was past her due date. After seeing a few patients, I headed next door to the hospital to review the induction process with my patient. She had a couple of risk factors that are all too common nowadays. Smoking and being overweight, I reminded her, could make jump-starting her body into labor take a bit longer.  

I returned to the clinic to see other patients, answer phone calls, catch up on paperwork and attend meetings, but I stayed in close contact with the labor-and-delivery nurse and watched the fetal tracings remotely. Nothing about the scenario to that point struck me as out of the ordinary. However, after two days of induction and a subsequent cesarean section for fetal intolerance of labor, the result was not as expected.

I recalled going to simulation labs in med school and learning how to give bad news to patients. We were taught how to deal with poor outcomes in residency. I have held the hands of many patients' family members as they said their final goodbyes to loved ones. Death is a natural part of the circle of life. As a family physician, one of my roles in the family context is to usher my patients -- and their families -- into that next part of their journey. I feel great privilege in being there at both ends of the life spectrum, and I strive to honor that life to the best of my ability.  

Birth and death are two of the most vulnerable experiences we face. A woman must essentially relinquish herself to the process of labor as she charges her baby into life.  Similarly, those last moments of life also create an atmosphere where one bears only the necessary. The space for insecurities eventually dwindles. What if, though, life and death happen in a matter of minutes? What if for some unforeseen reason, a neonate is delivered without the breath of life?

Before going into private practice, I experienced only one stillbirth during residency. A young, independent mother made the decision to bring life into the world even after the father of the baby refused to take his part. She came to all her appointments and asked good questions. One day, she presented to labor and delivery after not feeling a previously boisterous baby girl move for two days. I still remember the silence around her as she cried in emotional and physical agony. I still remember the intense grief that filled the room. At the time, I had a toddler of my own waiting for me to get home, but I could not help but pause to ponder why these events happen.   

My hardest experiences are still in these rare but tragic moments. I don’t think any amount of training can completely prepare someone for such a situation. Even when a clear-cut answer comes back via autopsy or placental pathology, a much harder -- and, I think, deeper -- question remains unanswered.


As I look into the eyes of a woman whose dreams have been crushed, the "why" they ask is organic. "Why did you let this happen?" or "Why am I a mother without ever mothering a child?"

I will never have an adequate answer to these questions because I am just as human as my patients.  

As a physician, I deal with two losses. I have lost a life that never really had a chance to begin, but I also have likely lost that mother as a patient. Often, I do not see the parents any longer. Of the stillbirths that I have been a part of, only one mother returned to continue care with me. I understand how coming to an office filled with pregnant women and young families can torment them. As one mother put it, seeing me forced her to relive her pain.

As a mother myself, I am not sure how I would react if I were in their shoes. There remains such an emotional void from these abrupt farewells that I wonder how we can better support these families.  

What about the patient I started this post with? Well, the father of the baby burst out with hateful words that night. A large family had spent those two days waiting, and they wanted answers.

I stayed. I took the hot words as daggers to my heart. I spoke with the rest of the family, I cried with them, and I hoped they believed me when I told them how sorry I was for such tragedy. The nurses, house supervisor and I created a small area where the family could see the baby and cry out to God for a life lost before it began. I sang an old hymn with them, and I prayed with them and for them. I made sure that my patient was cared for and actually stayed in the hospital the entire next day.  

Everyone at the hospital, from start to end, performed to the highest standards. I am so proud to be able to work with these nurses, respiratory therapists and staff. They truly care about this little community, and so do I.

Mothers and fathers undergo a tremendous amount of stress during these situations. I have found that although there are online support groups, parents and family members affected by such loss need more tangible resources.

We must do a better job as a society to remove the stigma behind death, especially the death of children. I encourage my colleagues to talk about these issues and have close followup with patients who live with loss. We must resist the urge to count ourselves omnipotent and not be afraid to say "I'm sorry." Sometimes the best thing to do is admit one's humanity.

As the holiday season comes into full swing, I urge you to remember how hard this time of year can be for those suffering a loss. Take a moment to think of those who will have their first Christmas without a special person, and hug your loved ones tightly.

I register a star with the name of each baby lost and send the certificate to the parents as a remembrance of a child I never got to fully know.

To The Child I Never Knew

I was there when they heard your heart for the first time
The sheer joy and shock of having new life
The hope you brought
The joy

I was there when you would play hide and seek
Running away from my Doppler as I searched
Throughout the pregnancy
Gauging the time
Precious time

We spoke of their hopes for you
Your name, its meaning
How you would look and when you would walk
The lives you would change

I was there when you came
Without the breath of life
Still beautiful, still sacred

I was there with tears of mourning
Dreams now faded
Reality seems blurry
To the life that did not yet live

I thank you
For teaching me to live in every moment
For bringing hope and beauty even
Before you were born

I hope you dance among the stars
The Milky Way, now your table
Your presence still present

Be the comfort that I cannot become
Fill the void that I cannot fill
Bring peace once more to a heart that my sutures cannot mend
Shine on brightly

Marie-Elizabeth Ramas, M.D.,  is the new physician member of the AAFP Board of Directors.

Posted at 03:00PM Dec 01, 2015 by Marie-Elizabeth Ramas, M.D.

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