Reflection of a Stillbirth: Clinical Scenario Analysis - Research Paper Example

Reflection of a Stillbirth: Clinical Scenario Analysis Abstract This reflection took birth because of the understanding that by using reflection, a nurse can look into his or her own experiences, and this knowledge acquired through an effective reflective process like Gibb’s Reflective Cycle will be beneficial in handling patients with more confidence and skill in similar situations. This reflection is based on my first experience of witnessing a stillbirth, the grievances of the parents, and the way the dead baby was handled after taken away. My mentor showed how a nurse can be of immense support through proper listening and reassurance to the people who are in grief. Description of the event In fact, nursing is a practice discipline. That means nurses can continue developing their skills and knowledge throughout their professional lifetime. It is at this point that the importance of reflection arises. Reflection can be defined as reviewing ones experience from practice in a systematic way so that after proper description, analysis, and evaluation, the insight gained can be used to inform and change ones future practice. According to MacLaren et al (2002), reflection helps bridge the gap between theory and practice. Admittedly, there are various models of reflective practice. In this reflection, Gibbs model (Gibbs 1988) is used because it incorporates phases like description, feelings, evaluation, analysis, conclusion, and action plan. That means one gets the chance to think through all the phases of an experience or activity. On that Monday morning, I was ready to work with my mentor in the labour ward. As we were given the client of the day, a chill passed through my spine because for the first time in my life, I was going to care for a woman who had a dead baby in her womb. The patient was an Asian lady named Ah Kum (name changed) and her husband accompanied her. As we entered the room, we found the husband and the wife both in severe mental agony. The woman expressed various feelings ranging from guilt, shame, and anger. My mentor engaged in communication with the woman and her husband and she proved herself an effective communicator and listener. She offered the lady every possible help and listened to her grievances carefully. In fact, she was adhering to the Nursing & Midwifery Council (NMC) code that patients should be treated as individuals and their dignity should be respected (Nursing & Midwifery Council, Code 1). In addition, it was found that my mentor properly followed code 8 that the midwife should listen to the people under care and respond to their concerns and preferences (NMC Code 8). Admittedly, I was not in a position to communicate as I found it difficult to communicate with them. A woman with a critical condition like having a stillborn in the womb is prone to fatal infectious issues. All these complications were only heard in lectures, but the patient’s condition gave a clear picture as to how more dangerous situations can be than those being described. I was really astonished to realise that in thirty eight week time, a mother develops great emotional attachment with the forthcoming offspring, and therefore the parents are sure to build expectations about the childbirth. Soon, the woman gave birth to the baby and when the baby was ready, it was given to the woman and her husband. Also, my mentor acknowledged the baby as a human being and even said to the lady “He is beautiful!” Also, my mentor directed me to see the baby and hold it. Here, the mentor was following the NMC directive that a midwife should facilitate students to develop their competence (NMC Code 23). However, I found myself unable to talk to the lady and her husband who were sad beyond description. I felt an unusual sympathy to the couple as they looked severely broken. Although I didn’t want to interrupt, I just stood by the lady’s side and told her, “The baby looks so cute; he is so fair and chubby”. I only wanted to console them as I am easily disturbed by such situations. A rather painful smile appeared on her face as the father told me, “You know, our parents have bought many gifts for him; they even made a list of beautiful names.” On hearing this, I felt a terrible spark of sorrow passing somewhere in my heart. Then, the baby was handed over to them and photographs of them were taken. After that, they were given privacy to sit alone with their baby. Apparently, they were crying loudly in our absence. They were given the instruction to use the buzzer to call us when they are ready to give the baby for post-mortem examination. It was a great astonishment for me to see how professionally and how effectively my mentor offers care and compassion to the people in distress. However, as the parents handed over the baby, we took the baby to the sluice room. There, we placed it in a blue mental box which was kept on top of the waste bin. There, I fell into an ethical dilemma as the parents certainly would expect a better treatment for their offspring. When I asked my mentor whether it is right to show this lack of respect to the dead, the response was that there was no better place available to keep the box and that porter would come and collect the box away. I came to know that though she informed the hospital authorities on the problems associated with keeping stillborns well in accordance with the NMC code that any working condition that does not meet the standards set by the NMC code or other national laws should be reported to people in authority (NMC Code 33). Feelings As I came to know that I would be caring for a woman who was going to give birth to a dead baby, I fell into mental agony because that situation could be compared to witnessing somebody’s death. As I reached the woman who was profoundly sad and distressed, I realised that I lacked the words and deeds to soothe her, and I learnt the need to achieve those skills to become a good midwife in future. However, I found my sadness and distress mounting as the delivery neared. One could clearly see various emotions on the woman’s face, ranging from guilt, sorrow, and anger. At that time, I thought about the various thoughts that might be passing through the woman’s mind, but I also thought about my responsibility as a nurse. As time passed, I regained some control over my own adrenaline rush. However, as the child was handed over to the parents, emotions again rose high. The parents thanked us for the service we rendered but it seemed unfair for them to thank us for something that turned a tragedy. Also, at that point of time, I felt some guilt developing in my mind as I felt that we had failed the parents. However, I had to shake the fear off when I found that my mentor was handling the baby like any living baby; with due respect and affection. I too started caring for the baby with sensitivity and respect as if it was alive. At that point of time, I realised that I was growing as an effective midwife, and in such future events, I would be able to offer better care and more compassionate treatment as I shook off my fear through this experience. However, as the baby was put in a box and placed alongside dust-bin as the parents handed it over for post-mortem, I found a kind of distress developing in my mind. The points that troubled me at that time were many. First, I wanted to know as to how long should a dead person be treated with dignity. The question arose because the same midwife who treated the baby with utmost care and compassion in front of the parents was now keeping the body amidst waste materials. Also, I was distressed by the fact that the babies who are born dead receive no respect and their bodies are treated anyway. Also, I was becoming aware of the need for a legislation ensuring respect for stillbirths as I found myself how emotionally attached the parents were with the dead baby in womb. I went truly very emotional about the way the baby was put in the box and kept near the waste bin. I was not willing to deny the spiritual dignity of the baby even as it was stillborn. It was rather frustrating to expect such inhuman reactions to a divine being after its death. I know, treatment of the dead body has to be performed with absolute respect in every civilised society. As a general belief, it is because the body is the temple in which the soul and divine spirit of life exists. That is the reason why every cultural and legislative norm teaches individuals to respect the human privacy and dignity. In many of the hospitals, as I heard, the general expectations of patients about the quality of treatment and the ethical standards of the staff members are generally considered conflicting. Evaluation The first half of the incident showed how greatly a midwife can offer care and emotional support to a woman with a miscarriage. Also, the experience helped me come out of the fear I had about meeting patients with emotional distress. Thus, the best thing about the experience was the knowledge about handing people who are in high emotional distress like those who are going to give birth to a stillborn. Another insight was regarding how to offer support and how to listen with empathy. In addition, I learnt that it is necessary to handle the dead baby with utmost respect and care as if it is alive taking into consideration the great degree of distress the parents feel at that time. In fact, this goes well in accordance with the International Code of Ethics for Midwives that the midwives should respond to the psychological, physical, emotional and spiritual needs of women seeking health care. However, the second half of the incident shattered my expectations about the degree of holiness involved in the profession. Though my mentor exhibited great degree of compassion to the parents and due respect and affection to the stillborn as if it is alive, once the child was handed over, she could not find a place to keep the body in a way that befits a human being. Though she was reluctant to leave the body in that situation as she evidently was guided by the holiness of the profession, she was forced to do so as the circumstances did not allow a better treatment. Also, my attention goes to a wide range of questions placed in challenge to the legal rights of a baby that has never breathed or showed signs of life. This conflicting concept may be challenged ethically as the child is the result of the emotional and spiritual union of two cognitively capable individuals apart from the mere aspect of their biological unity. In this context, it indicates that a stillborn has to be treated as any living child. Thus, the second half of the incident made me pass through some ethical dilemmas which made me distressed and confused. Analysis As Andre and Velasquez (n. d.) state, in a developed society where the pregnant women are legally forced to follow the advice of doctors in order to protect the health of the offspring, the responsibility of hospitals to treat the stillborn with acute respect is restated with the evidences of increasing number of legislative hospitalisation cases of pregnant women. It is in this situation that we have to think whether foetal care is confined to parents or is it a wide social responsibility involving the careful concern of the healthcare centres. The situation in which a stillborn is ill-treated by the hospital staff makes one look into the link between morality and professionalism. A number of scholars are of the opinion that the stillbirth is a condition in which the matrimonial attachment is tilted with the unexpected loss in many cases. In such a situation, as McKinley (2012) points out, the midwives of the patient have to support both parents from different angles ranging from personal, societal and cultural areas with their specific attention to implement the moral side of the profession. Therefore, it is generally accepted that the midwives can play a pivotal role in the rehabilitation process of the parents after they have lost their child. In fact, my mentor showed how ‘reassurance and listening with compassion’ can be used effectively in such circumstances, and this reassurance is more effective than that from relatives or friends (Frith, 2004, p. 65). It also becomes clear that midwives are the symbolic spiritual leaders of childbirth-related issues. Not in the case of the stillborn, but also in the case of neonatal babies, they have to give a lot of moral support to the parents regarding their appearance, health conditions and expected term of recovery from usual diseases on a regular basis (Jones and Jenkins, 2004, p. 115). According to Cunningham (2012), the most difficult emotional stress suffered by a mother is during the time she takes to accommodate to the fact that the her child is gone; and in the context of a child loss, the parents have to be assured that the child’s body receives all due respect as long as it is physically evident to have taken birth. Therefore, the body of the stillborn reserves as much right as a living child after birth does. I think the reason for the frustration among midwives is that hospital conditions are growing miserable with the reducing number of staff in many cases where the existing limited human power has to take care of various aspects irrespective of the workload. This situation puts the existing staff into ethical and moral dilemma as evident in this case. My mentor wanted to handle the baby with dignity to the end, but the limited facility at the hospital made her unable to treat the baby with the degree of respect it deserves or the degree of respect my mentor wanted to show for her own personal and professional satisfaction. According to NMC guidelines, if a nurse finds any practice below the stipulated standards, the same should be reported to higher authorities. However, in this case, despite the report, the authorities did not take any steps. At that juncture, according to the International Code of Ethics for Midwives, midwives possess the right to refuse to participate in activities for which they hold moral opposition (International Code of Ethics for Midwives, III-C). That means if the authorities do not respond to such ethical issues, the midwife possesses the right to not to take part in the practice. From the spiritual angle, the dignity never finishes after death; in fact, it increases on the other hand. Some studies (Cohn, 1940, p. 233) look into the history behind the crematory decorations and the value added efforts of the modern generation to pay tribute to the dead and demonstrate the exemplary patterns of paying tributes to the dead. However, the paining fact is that there is little amount of literature which goes in pursuit of the concerns for the stillborn and the neonatal deaths. The recent developments in the medical science and the related social responsibility concerns focus to the fact that natural calamities and manmade disasters can contribute to malicious foetus formations, and in such a scenario, philanthropist organisations across the world demands respective governments to hold the responsibility to control the increasing incidents of stillborn and neonatal deaths (Shultz and Draper, 2008, pp.71-73). However, it seems that the legal framework is not strong enough to support the cause of the stillborn and their parents. According to United Nations Conventions on the Rights of the Child, ‘childhood is entitled to special care and assistance’; and it requires “special safeguards and care, including appropriate legal protection, before as well as after birth” (cited in Alderson, et al. 2005). However, in Britain, this is not emphasised as a right, because “states that allow legal abortion would reject the United Nations Convention on the Rights of the Child”; moreover, according to UK’s legal views, only since birth the childhood begins (ibid). It is also important to understand that the parents are not supposed to withdraw the medical care provided for the life support of the foetus under clinical conditions. According to certain generalisation (Mullings et al 2004, p. 221), the case of abortion is a context in which the act of the doctor to terminate the pregnancy is a legislative deed in assistance to the patient’s right to private choices on acceptable grounds of excuse. However, the situation is different here; the right of a child after death is the prime factor and it is evident from all factors that a foetus over a considerably recognizable growth is to be treated as a baby, and has every legislative right to be treated with dignity. And in a general concept, “if the human body in general is a powerful symbol, it is arguable that the foetus is even more so” (Lee and Morgan, 1996, p. 7). However, it seems that there is a lack of rules and regulations to make it necessary for hospitals to have specific strategies for the storage and burial of the dead foetus with the involvement of parents and relatives after due consideration for the personal choice of the party involved. In order to understand the legal side of the issue, it is wise to see the various laws in UK. According to the Births and Deaths Registration Act 1953, Section 41 of England, any ‘child’ a expelled or issued forth from its mother after the 24th week or pregnancy that did not breathe or show any other signs of life should be registered as a stillbirth (Midwives magazine: June 2005). The government admits that after 24 weeks of gestation, the foetus deserves to be called a ‘child’. It is at this juncture that one understands the importance of the ethical arguments put forward by the Campaign for the Rights of Stillborn Babies and Support Group (Message From Kym Marsh, n. d). They argue in their website that a baby that is 24 weeks old is almost like a full grown baby with fully functional ears and full sense of balance. Also, if the baby is grown at that time, ht has good chances of survival (ibid). However, what happens in practice is that if there is a stillbirth, the parents only receive a certificate of stillbirth, and it only adds more woes to the already disheartened parents. Such a stillbirth can receive neither birth certificate nor death certificate because its birth as a baby is not recognised under the UK legislation. Thus, the mother who protected the baby in her womb and amassed a lot of expectations is not even allowed the right to call what she delivered a baby. This only exacerbates the feeling of guilt and shame. The parents of a stillborn too will expect the most humane treatment to their stillborn. Thus, showing total negligence towards a stillborn is against the principles of ethics. Conclusion Evidently, stillbirth often induces feelings like guilt, shame, anger, frustration, and sorrow in the parents. So, it becomes necessary for a midwife to be a good supporter. Also, the way the midwife handles the dead baby can also have a huge impact on the way the parents perceive about the care they received. Hence, it is necessary for a midwife to handle the dead baby with the same care, respect, and affection given to a normal baby. However, the way the stillborn are handled once taken away from the parents is disgusting. Due to lack of rules and regulations regarding the handling of dead foetus, some hospitals do not show the kind of respect usually shown to dead adults. When such situations arise, midwives fall into ethical dilemmas in the absence of clear rules and regulations. In fact, nurses can overcome the dilemma as it is clearly expressed in the International Code for Midwives that they have the right to refuse to do something if they have a moral opposition for the same. It was such a situation that resulted in frustration and dilemma in me. The mere fact is that the dead foetus and the living children are equally divine as both are the result of similar biological and spiritual consolidation. Action plan First of all, I will be able to show the same qualities as exhibited by my mentor when I have to deal with stillborn and perinatal deaths. I can be a good spiritual and emotional supporter at that time of distress, and I will be able to handle the dead baby with the same level of care and affection as if it is alive as the reflection made me realise the fact that the dead babies too deserve respect from aesthetic, ethical, legal, and religious points of view. Secondly, I will take care to ensure that the dead babies are handled with care and respect after taken away from parents and that parents are informed how their dead baby is being treated after taken away from them because the reflection made me realise the great degree of attachment the parents develop with the weeks of gestation. References Alderson, P., Hawthorne, J and Killen., 2005. ‘Are Premature Babies Citizens with Rights? Provision Rights and the Edges of Citizenship, Journal of Social Sciences. (9), pp. 71-81. Andre, C and M. Velasquez., n. d. Forcing Pregnant Women to do as They're Told: Maternal vs. Fetal Rights, [Online] Available at: [Accessed 6 June 2012 ]. Cohn, D. L., 1940. The Good Old Days: A History of American Morals and Manners as Seen Through the Sears Roebuck Catalog. UK: Ayer Publishing. Cunningham, K. A., 2012. Holding a stillborn baby: does the existing evidence help us provide guidance?, Medical Journal,196(9) p. 558. Frith, L & Drapper, H. 2004. Ethics and midwifery issues in contemporary practice. Elsevier Health Sciences. Jones, SR and Jenkins, R.2004. The Law And the Midwife.  UK: Blackwell Publication. Lee, R. G and Morgan, D (eds.)., 1996. Death Rites: Law and Ethics at the End of Life. US: Routledge, Mullings, J., Marquart, J. W and D. J. Hartley (eds)., 2004. The Victimization of Children: Emerging Issues, Volume 1. US: Routledge. McKinley, T. L., 2011. Stillbirth—A Journey in Birth. Midwifery Today, 99. [Online] Available at: [Accessed 20 June 2012]. Midwifery Today., 1996. International code of ethics for midwives: How do they fit your practice?, [Online] Available at: [Accessed 20 June 2012]. Message From Kym Marsh. I Have Rights Too. [Online] Available at: [Accessed 20 June 2012]. Midwives magazine., June 2005. Registration of stillbirths and certification for pregnancy loss before 24 weeks’ gestation, [Online] Available at: [Accessed 20 June 2012]. McLaren, J., Smith, J., Gilbert, J., Dlomo, C and Villar-Hauser, L., 2002. Reflecting on your expert practice, Nursing Times. Net, 98(9), p. 38. Nursing & Midwifery Council., 2012. The code: Standards of product, performance and ethics for nurses and midwives.[Online] Available at: [Accessed 20 June 2012] Shultz, J and M. Draper., 2008. Dignity and Defiance: Stories from Bolivia's Challenge to Globalization. US: University of California Press. Read More