A 29-year-old primigravida at 30 weeks gestation comes to the office accompanied by her husband. She is concerned that she has not felt the baby move or kick for the past day. The pregnancy was planned, and her prenatal tests and fetal growth have been normal. The patient has no chronic medical conditions and takes a prenatal vitamin daily. On ultrasound, no fetal heartbeat is detected. The physician informs the parents about the loss of the fetus. They appear to be in shock, and the patient cries, "I can't believe this is happening. I was following all the recommendations, and I only missed one appointment. I should have come in sooner." Which of the following is the most appropriate response by the physician?

Question

A 29-year-old primigravida at 30 weeks gestation comes to the office accompanied by her husband.  She is concerned that she has not felt the baby move or kick for the past day.  The pregnancy was planned, and her prenatal tests and fetal growth have been normal.  The patient has no chronic medical conditions and takes a prenatal vitamin daily.  On ultrasound, no fetal heartbeat is detected.  The physician informs the parents about the loss of the fetus.  They appear to be in shock, and the patient cries, "I can't believe this is happening.  I was following all the recommendations, and I only missed one appointment.  I should have come in sooner."  Which of the following is the most appropriate response by the physician?

Quizplus · Accepted Answer

More than half of late fetal deaths occur in uncomplicated pregnancies, requiring physicians to convey the diagnosis of stillbirth to a mother/parents who is/are completely unprepared for this devastating news. Sensitive, patient-centered care includes empathic listening combined with verbal and nonverbal expressions of emotional support. This includes direct eye contact, acknowledging the loss and validating feelings in a private setting, and remaining with the patient and spending as much time as needed to listen to grief and answer questions. Because parents may blame themselves for the baby's death, it is important for the physician to respond with a clear statement that it is not their fault and there is nothing they could have done to prevent the loss. The physician should also avoid prematurely changing the focus of discussion to medical management and reassurance about future pregnancies. Referring to the fetus as their "baby" and avoiding medical terminology (eg, fetal demise) are helpful. (Choices A and C) Although these responses begin with empathic statements, they do not allow the parents time to process the news and grieve because they focus on the future. Providing reassurance about feeling better in time and future pregnancies may be perceived as dismissive and a failure to understand the devastating impact of the current loss. (Choice B) This statement does not allow the patient to process the news and quickly jumps to the next step in medical management. There is no urgent indication to perform an induction of labor. (Choice D) Although this response attempts to alleviate possible self-blame, it prematurely directs the conversation to obtaining further diagnostic tests and does not respond to the patient's acute emotional distress. (Choice E) A general statement that fetal loss occurs in otherwise normal pregnancies may help the parents feel they are not alone. However, this response fails to empathize with the patient's personal experience and emotional reactions and uses medical terminology. Educational objective: The loss of a fetus is a traumatic experience for parents that requires a direct and empathic response from the physician that alleviates self-blame. The physician should be prepared to stay in the room and tend to emotions that arise without prematurely providing reassurance or discussing medical management. References: Providing meaningful care for families experiencing stillbirth: a meta-synthesis of qualitative evidence. (http://www.ncbi.nlm.nih.gov/pubmed/26248132) The impact of stillbirth on bereaved parents: a qualitative study. (http://www.ncbi.nlm.nih.gov/pubmed/29364937) Silent loss and the clinical encounter: parents' and physicians' experiences of stillbirth-a qualitative analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23181615)

A 29-Year-Old Primigravida at 30 Weeks Gestation Comes to the Office