Friday, July 30, 2010

The Picture Album

I love doing psych consults so much that I just did an extra elective. Something cool about hanging out with "real doctors" and seeing all the medical/psychiatric interactions. Or something. Anyway, I find that most consults are pretty interesting, and I've seen every imaginable kind of delirium, suicide attempt, drug withdrawal, etc. Or so I think. It's those stories outside of my normal comfort zone that make it to this blog.

Warning: Those with kids, especially moms, especially if you're a pregnant mom, be forewarned. You may not want to read this one.

Getting a psych consult to the Labor and Delivery floor can never be good. Usually it's some case of post-partum depression/psychosis, usually requiring a report to be filed with appropriate child welfare agencies, moms with 10 kids and no way to care for them, etc. Today, it got dialed up to an 11 for me.

A G6P3 21 y.o. female presented 2 days ago with acute pelvic pain. She was at 34 weeks' gestation. Sono showed intrauterine demise of the fetus. While waiting to spontaneously deliver, she got very labile, asking to go to a different hospital, etc. Basically, she was angry that the primary team didn't just surgically remove it. Seems reasonable to me, but damned if someone shows some normal human emotion in a hospital or else psych gets called in.

I saw this lady the day after she delivered. She is understandibly sad, tearful, and grieving. Her life had not gone according to plan, as evident in her age, 6 pregnancies, and 3 total miscarriages now. She reported her prenatal care, psych history, support network, etc., as I obtained a complete history and mental status exam. I gave her referrals to several different grief counselors and recommendations for meds and follow-up.

As I was wrapping up the interview, she asked me if I wanted to see pictures of her baby. I felt this twinge in my gut, telling me to say no. No human part of me wanted to see a dead baby. However, I knew it would be better for her therapeutically to show interest in her plight in this way. The patient needed her doctor to do this. To connect with her. It was going to be hard.

She brought out a small album. Her and her mom had put a new little red dress with a matching cap on the baby. They took 6 or 8 pics. Different poses. Closeups of face, hands, feet included. At first glance, it looked like a normal newborn album. But the reality of it all could be seen in the skin color and turgor. I was able to manage "She's beautiful" or somesuch, quickly tied up any loose ends, and left her room.

I just hope I helped her in some way. Because those pictures are gonna stay with me for a while.
-Psych Doc


Anonymous said...

Wow... No hospital is just going to "wait around" days after discovering a baby is dead in utero. They are going to immediately do a c-section or give medication to induce the mother.

Seriously, how stupid do you think your readers are? I hope no one believes this garbage you're spewing. Oh wait. They do.

Maybe you should take yourself off to a psych consult darlin. You obviously are too lost in the world of imagination.

OB/RN said...

R u kidding anonymous. They leave dead babies in all the time and induce labor. That is the PREFERRED method over a c section. They will NOT do an immediate c section. Could the other medical readers please back me up

Anonymous said...

This happened to my sister 3 months ago. She was 33 weeks along. They let her have the baby vaginally. It took 2 days. They said the body will know what to do and starts the labor process. Once she started contracting they gave her meds to help push the baby out. NO c section. The first commentor is a dumb idiot

SerenityNowHospital said...

whoever keeps reading and thinks we aren't real doctors (first comment), get a freaking life. stop reading this blog if you have such a problem. who poses as doctors and makes up blogs for no reason. what kind of looser has that time.

2 of the most well respected, best medical doctors (erstories and white coat) read and comment on this blog. never have they made your accusations, so take their word or opinion.

i have laughed at your dumb ass comments over the months, but it is getting old. just stop reading we dont need you or your shit. i hate pieces of shit like you. get a life.

im proud of what i do. today i helped save 2 people on the brink of deal. intubated and central lines and chest tubes on both of them due to their trauma. felt like a real doc today, and them come home and read this stupid ass comment. no wonder so many people quit blogging.

not every hospital is like the burbs. we work in county hospitals, high acuity, where we see shit you wont believe. go work in one for a few days then get back at me

ER Doc

Anonymous said...

Psych Doc,

You are probably the ONLY doc who cared for her emotions and listened to her. Thanks for caring for her and looking at her pics, which she probably desperately needed to feel like a mom again

Anonymous said...

how said

Anonymous said...

i mean how sad. haha

Anonymous said...

NIce pic!

RuralMD said...

Rush the patient to the OR for a C section??? I dont think so, not unless there is a medical emergency causing danger to the mom. Nice try, anon, but you are way off base and owe these bloggers an apology.

Anonymous said...

I am a small town FP who does OBGYN. I have had many a fetal demise and have never had to rush a patient for C section due to it. Let the body, and nature, take its course.

AtYourCervix said...

Very rarely is a c-section indicated to deliver a deceased fetus. The mother has labor induced and goes on to deliver vaginally. Sometimes it does take several days for the induction process though.

C said...

Thank you for being there for her.

SerenityNow said...

To the first Anonymous...

You may not always agree with our opinions. But why would I have any reason to make up a story about a dead baby? This was truly one of the most disturbing cases I've seen (trust me, that's saying a lot). I didn't post this to get readers or for any accolades. I don't give a shit how many people read this blog. The fact is, this blog is a type of therapy for us in addition to providing some insight into the lives of real doctors. I almost didn't post this because it upset me so much.

I'm sorry you didn't get into medical school, or whatever axe it is that you feel the need to grind. If you were rejected by med schools, it seems rightfully so.

I hope your wife or your sister never face the same fate as the patient I saw this week. If I treat them, I will show them the same compassion I showed the one in this post. What would you do?

I feel sorry for you. And anyone who ever gave a shit about you. Because I bet those people are few in number.

Thank you for re-defining the word "asshole".

-Psych Doc

arzt4empfaenger said...

You did the best one could do for her in that situation. Thank you. I'm a bit appalled at the American health system every now and then* - as soon as a birth seems slighty prolonged (or if it doesn't fit the time table), a C-section is pushed, but in cases like this, there's no forensic risk of damage to the infant, so hey, let her deliver vaginally. Of course it's a matter of preference for the woman, but I would not want to deliver a dead infant. Although I'd never go for a C-Section otherwise, I would in this case.
Naturally this wouldn't be an emergency C-Section, but if the mother feels emotionally unable to birth her dead child, I think she should be granted the wish to get surgery (after a consult, optionally).

Btw., did she tell you afterwards, whether or not she was glad to birth naturally in the end? Maybe she changed her mind retrospectively? Or was she still angry about the denied section? (I could imagine her grief being too much to still be troubled with this.)

*There's more and more elective C-Sections in Germany, too, sadly, so I guess it's an international problem. Locums in L&D/OBGYN also have insane insurance rates.

Anonymous said...

Browsing the internet over the years I have seen many grieving parents/families with pictures of babies who did not survive. It is very therapeutic and obviously has great meaning for those in mourning.

tracy said...

Thank you for being such a help to this very, very sad mother, Psych Doc. It must have been very difficult, but as another reader pointed out, you were there for her and that is what mattered most.
Again, thank you for your goodness.

Anne LeMar said...

However difficult it was for you to view those pictures, I can assure you that it meant the world to that mother. You showed her compassion and kindness that few people will do. No matter what, that is her *baby,* and she is grieving for her, just as the family I know who lost their 20yo daughter this week is grieving for her.

For your (and anyone else's) future use, there is an organization of professional photographers who volunteer their time & services to provide portrait-quality photographs of babies who are stillborn or die shortly after birth. Not sure of the exact web site, but if you do a search for Now I Lay Me Down To Sleep, the organization's name, you'll find it with no trouble.

Very often photos taken by hospital staff or parents are very stark (as you have found out), but the NILMDTS photographers are able to take the images and soften them. Sometimes just changing them to black & white makes a world of difference. They are skilled at posing the baby to emphasize the more normal parts, hands and feet, for instance, and may add things to the photos, such as parent's wedding rings, the bassinet card, etc., in addition to taking photos of the baby with the parents. The photographer that took the pictures of my granddaughter was able to photoshop one, so that we have a picture of her with her twin brother.

Thank you again for showing that mother such compassion. You said the images will stay with you a long time. She will never forget your kindness.

hof said...

I'm not in medicine, but I am in medical education. We have stories all the time like this, but worse from docs in class. Not only is it not uncommon for the parents to want to see their child, or take pictures when it's normal, but also when it's abnormal. To me, it's striking the number of people who have a child still-birthed with anencephaly or other horrible massively disfiguring defects that just want to see their child. To me this is no different than the family member who wants one last picture with their grandpa/ma even though they're sedated in hospice (personal experience with a family member), or the parent who wants to see their child's body in the morgue after a car accident. It's closure and pride in the same thought. We know the baby is dead, but we are still proud to be parents of the offspring we made, even though it did not survive. I hope I am never in her position and I have no idea what I would do.

Also first anonymous, you are the epitome of every first year super gunner... that I fucking hate.

Kat said...

The first Anonymous commenter, a few years ago I stood in my kitchen as my best friend walked through my door and collapsed into my arms sobbing that her cousin's baby was dead. For two whole days she sat on my sofa, her phone in her hand waiting for news, and all the time she cried.
Her cousin finally went into full blown labour after those initial two days and it took her another 37 hours to deliver her child.
After her son was delivered her entire extended family visited that hospital room and posed for photographs with that baby boy.
Afterwards my best friend sat and talked to me about this cousin for months, how she would sit and hold her son's photo album and talk to him about his older sister and other things from her day.
I think seeing his face like that every day made it harder for her move on in the grieving process, it certainly made it difficult for her family because she wanted them to talk to her son as well.
Anonymous, I think that perhaps you need to expand your universe just a bit more and perhaps not be so judgemental. Things like this do happen, sadly all the time.

Anonymous said...

It's hard for me to understand, but those pictures do seem to mean the world to people. I remember one case where the family didn't do them, then later decided they wanted them - after pathology had the body. In the path department, they were trying to arrange this now long-dead fetus in an ok way, covered with blankets mostly. I think the pictures were ok, as far as the circumstances allowed.

And - no one does a C-section because the mother doesn't need to have the damage to the uterus for a child that has no chance of being in distress. There is a limit to the number of C-sections a womb can take - they don't "waste" one on a stillborn infant.

Anonymous said...

I don't usually comment on the blog though I enjoy reading it, but having had 2 friends that have lost babies (one stillborn, other died shortly after birth) I can tell you how much it meant to her that you looked at those pictures.

arzt4empfaenger said...

Anne Le Mar has a point. I've read about Now I Lay Me Down To Sleep, and what I've seen of sample pictures looked tasteful and touching. I can imagine that it means a lot, although I'm not sure what I'd want.

As for the risks of a C-Section and future births, that's true, and I considered this. However, if (and that doesn't mean it's mandatory) someone feels like a deceased baby's birth would be far too traumatizing, the taking of the risk should at least be talked about.
On the other hand I could imagine that a very kind, good midwife could lead one through the process of actively birthing a dead infant, even if it means a lot of hours crying (from the sadness) in labour. If I had to choose that way, I'd make sure to get myself a walking PDA - 37 hours labour, which surely isn't the norm, sounds terrifying.

[Sorry for commenting sparsely - always shows up an error when I try to leave a comment with the open ID option, grr.]

littlewings11 said...

I know it might have hurt to look at the pictures but it was the right thing to do. You will never know how much it helps those grieving to acknowledge their grief and the life of the infant. I myself went through this with my sister over a year ago and it was very traumatic. Unfortunately the hospital staff was not as nice as you were which made the whole ordeal more traumatizing. Keep up the wonderful work as patient care always includes compassion!

-crazy med tech

Kat79 said...

When my sister lost her baby at around 32 weeks he was already over 10lbs. They did a c-section but only after her blood sugar sky rocketed(reason the baby was so big) While visiting her in the hospital they brought the baby in for her to hold. She insisted on me holding him and I did it to help her but it still haunts me 9 yrs later. She also gave me pics but I threw them away.

Anonymous said...

At the hospital in my town, there is a nurse who specializes in helping grieving families after a fetal demise,a stillbirth, or a neonatal death.

Anonymous said...

Just to add, as a psychiatric nurse and having had a second trimester miscarriage, it is better to allow time before induction, not to do c section or to give general anaesthetic. Otherwise it is much harder psychologically to accept if you are put to sleep / section etc. Altho in those first couple of days you do really wish for anything.

Pictures / footprints etc are really important like psych doc says for grieving. It's the first thing people panic about in death is that they will forget someone.

I'm in the UK but over here sands (stillbirth and neonatal death society) has good info on website / forum and helpline.

Anonymous said...

I'm a nurse and also someone who delivered a 39.5 week stillborn son 8 years ago. They absolutely do not rush you to deliver, and in fact offer the option to go home, take some time to grieve, and then decide what is best for you. I chose immediate induction, but certainly did not have to.

CornflakeGirrlRN said... a L&D/antepartum nurse who cares for quite a few women and families experiencing perinatal loss, thanks for your compassion and being willing to see the pictures of her baby. It's difficult to see, and it's heartbreaking, but those simple gestures go a long way.

Oh, and anonymous commenter are a clueless douche.

Anonymous said...

Thank you so much for putting that mom's needs before your own; that is what a great doctor does.

rnraquel said...

Thank you for the kindness you showed that patient. I had a fetal demise in 2008 in the 3rd trimester. It is horrible. The MD gave me a choice of being induced immediately or coming back the next day. I chose immediately. The pictures meant a lot.

sara r. said...

I know that i'm late to this, but I just wanted to say that I'm sure the mother greatly appreciated the respect that you showed to her and her baby. My mother lost a set of twins 30 years ago, and the doctor at the time (who didn't believe that she was in premature labor when she called him initially) didn't even offer her the option of seeing their bodies, even though one did survive the birth for a short period of time. Later she was devasated that she never even saw them after carrying them for 26 weeks; it was her first pregnancy. (My sister and I were born at 31 weeks about a year later, and both did well, so there's a happy ending to that one). I hope that your patient also found solace, but also...maybe she should let off having babies so close together...that is just not healthy for mom or baby!