Unexpected outcomes – mentioning the unmentionable

by Andrea Robertson One of the most fascinating aspects of birth is its total unpredictability. No one knows what will happen and how those involved will fare. Moreover, no amount of preparation will ensure a given result or birth outcome. It’s this uncertainty that makes giving birth both exciting and frightening! Every pregnant woman has moments of doubt about the health of her baby. Fears about death and handicap are common. These are the worst-case scenarios and are often sources of great anxiety as the pregnancy rolls on. Talking about them can help and even though it is impossible to allay all fears. Also, sharing concerns with others puts problems into perspective.

The whole issue of “expecting the unexpected” is an essential topic for pre-natal programs. Encouraging and supporting the uncertainty of birth helps parents realise that anything can happen. Another is that experience suggests that there will be aspects of every birth that result in disappointment and perhaps grief. Ignoring or discouraging discussion around these topics may also have unexpected outcomes for the educator. The group may feel that an unrealistic picture is being painted; an unwillingness to get involved may be interpreted as a lack of empathy or care, and the educator’s personal discomforts may create an unintended barrier with the group.

There is no doubt that talking about these topics, especially the worst possible birth outcomes, is difficult and uncomfortable for everyone. No one wants to initiate a discussion around the possible death of a baby. But, these may be the very fears that parents desperately want to talk about. There are ways of introducing these issues gently and sensitively into your program.

• Cultivate the theme that all birth outcomes, whatever they are, cannot be predicted and are therefore “unexpected”. There will be many opportunities to introduce and expand on the uncertain nature of birth. From the simple (imagining what the baby might look like – boy/girl, his hair or her eyes; discussions about the baby’s birthday; choosing birth companions) to the more complex (effects of labour drugs on the newborn baby; unplanned home birth; adaptations to parenthood). Each time there is an opening, gently add in the thought that it would be nice to know what was coming, but who can tell…..
• Offer specific activities where group members can explore their feelings. Feelings about being pregnant; what they think labour will be like; what they hope their partner will do. Additionally, you can include their feelings about what changes are occurring in their lives and relationships. Also, you can include what their fears and hopes are regarding the baby. Small groups can work well to encourage people to talk more freely. Your role will be to purely facilitate good communication and sharing, both essential skills in dealing with the unexpected.
• Be aware that the heavy topics of death and disability must be included somewhere in the program. You must look for a chance to tack this on as a natural extension of some other topic. There will be many possibilities, for example, as part of the session on fetal growth and development, premature labour, visiting the hospital (“did you have a look at the neonatal nursery?”), complications during pregnancy or birth, getting started with breastfeeding. Avoid presenting it as a separate issue (“tonight we will talk about what happens when a baby dies”) as this is likely to create instant anxiety in the group and create mental resistance. It is also very hard for you, since leading any discussion around this topic will be difficult. Especially if you are steeling yourself in advance (“tonight is the awful night, I must brace myself”).
• Draw on group members’ personal experiences whenever possible. It is surprising how many adults have known someone whose baby either died or was born with a handicap. Their feelings when they heard the news and the action they took as a result can form a useful starting point for thinking about practical strategies for coping with this kind of disaster.
• Avoid exercises in projecting or predicting outcomes and especially feelings. It is not helpful to encourage couples to imagine how they would feel about an event like this in the future. Many people naturally fear the worst and this kind of exercise may escalate their anxieties. Instead, encourage the idea that there will be a whole range of emotions and reactions whatever the outcome and all of these are natural and normal. There is no set way of grieving and every individual will have their own way of coping.
• Try not to raise these topics towards the end of the session. No matter how well you handle the discussion, everyone (including you) will be feeling depressed. They will be anxious by the end and sending people off in this frame of mind is poor practice. Try to include it before a break or early in the class. Also, as soon as you finish with the subject, acknowledge the feelings it has generated. (“it’s hard to talk about these things – I think we are all a bit saddened by these thoughts”). Lift the mood by moving on to something that is fun and involving, such as a practical session.
• Prepare a resource list for parents with the names of all the local parenting services that they might find useful. Amongst the list include the local contact for SANDS, the post-natal depression group (if there is one). Include any other group that provides specific parent support for particular circumstances. You can give this list to the class with the suggestion that they need it to keep handy. Because you never know what help you may need and there are many resources available.
• When you are planning the reunion, make sure you know the outcomes of all the births before the meeting starts. If any parent has had a baby die or was born with a disability, ask them if they want to attend. If they don’t want to see the others again, ask them what they would like you to say on their behalf. You must respect their confidentiality, yet the other group members will be naturally curious about their birth. If you are able to pass on a message from the absent parents, you need to prepare yourself to deal with the inevitable feelings this will generate amongst the other members of the group (another unexpected outcome for the educator!).

Dealing with these topics is not easy and our own personal feelings play a large part in how we handle the topic with our clients like birth outcomes. If you have unresolved griefs of your own it may help to get some counselling before you embark on assisting others. There is always something positive that you can gain from life’s experiences and including these often painful subjects in your program can have worthwhile outcomes for everyone. This article appeared in The Practising Midwife, Vol 2 No 6 June 1999.