Medicolegal Issues

Traumatic childbirth: Address the great emotional pain, too

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How do you treat incomplete grief and traumatic stress disorder amid the pressures of practice?


 

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Mary Jo Foster, herself a physician, sat down to pen a letter to her former obstetrician. Words flowed easily because, for months, she had thought of little else besides the events of the previous year.

Her letter has been abbreviated, with names and dates altered.

Eric David Foster
Born: May 15, 2003, Died: May 18, 2003

Does that name or do those dates mean anything to you? They should, but I doubt that they do. I, on the other hand, have been haunted by painful and awful memories of those 4 days, as I will be every day for the rest of my life. I hope that you have the courage and integrity to read this letter completely, because this is the only chance I have to reach you.

Do you remember my first visit? I had the impression then that you listened and understood when I related my complicated obstetric history, but that was the first and last time I felt that way. You seemed to forget about the uterine septum until I called you at 25 weeks’ gestation to report that I had gone into labor. My husband and I were so terrified, we left our sleeping 2-year-old son alone in the house to await the nanny in order to get to the hospital as soon as possible. Although we arrived there at 7 AM, we had to wait 2 horrifying hours for you to show up. By then it was too late, and Eric was delivered prematurely with extensive brain damage from ischemia and hemorrhage. Distraught, my heart breaking and my brain dazed from shock, trauma, surgery, and lack of sleep, I then had to plead and fight at the ethics committee meeting for the discontinuation of life support so Eric’s suffering could end.

A strongly worded letter if ever there was one; the patient’s emotional pain comes through loud and clear. Bear in mind that the obstetrician’s voice is silent; we do not hear his perspective.

That is intentional. The aim of this article is not to pass judgment or offer defense, but to draw attention to two specific consequences of a major traumatic experience—incomplete mourning and traumatic stress disorder.

In an earlier article, “The nightmare of litigation: A survivor’s true story,”1 I presented the case of an obstetrician who was sued for medical malpractice. The trauma of the experience led him to develop an acute stress disorder, which evolved into posttraumatic stress disorder (PTSD). In this article, the focus is on the patient, who also develops PTSD after an adverse outcome—specifically, premature delivery and neonatal death.

A mourning process stuck in the anger stage

Letter continued

For the past year I have wanted to ask you…

  • Why did you make me feel invisible during my pregnancy, after I went to so much trouble to explain my special situation?
  • Why didn’t you seem to notice how terrified we were when I started bleeding? Instead, you took your time getting to the ER.
  • Why didn’t you come to talk to me later in the day after the cesarean section? When you spoke to my husband, you mentioned that you had removed the uterine septum so I could go on to have a normal full-term pregnancy. How could you begin to talk about another pregnancy while my son was in pain, bleeding into his brain? You wrote him off the minute you left the OR, just like you peeled off your gloves and dropped them into the trash.
  • Why didn’t you ask the chaplain to be at the ethics hearing as a support for us?
  • At my postoperative checkup, why did you rip off the dressing and declare me “beautifully healed”? And why did you walk off before I could say anything?
A healthy mourning process comprises several stages, including denial, anger, sadness, and meaning-making, followed by acceptance and healing. This harsh letter is an indication that the patient is stuck in anger; healing is a long way off. Beneath the anger are other emotions, including sadness, shame, and guilt.

When the obstetrician ripped off the dressing and declared the patient healed, he was addressing the physical abdominal wound, but he completely overlooked the deeper, invisible, psychospiritual wounds arising from loss of a child—and from loss of safety, power, trust, faith, and meaning. The patient’s feelings are striking in their potency, but the obstetrician remained unaware of them. At the time of her postoperative visit, these psychological wounds had not even begun to heal. The self that had been preparing to be a mother had not yet integrated all the losses and realigned to the grim reality that she was now the parent of a dead baby.

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