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Expecting the unexpected: What does it mean to carry death instead of life?
Abstract Number: F-26
Abstract Type: Case Report/Case Series
A 20 year old G2P0100 with poorly controlled type 1 diabetes mellitus, and pregnancy complicated by severe cardiac and intracranial anomalies presented in labor at 34 weeks and 4 days EGA and was diagnosed with stillbirth shortly after admission. She initially requested cesarean to expedite delivery, but the obstetrician dissuaded her. Subsequently, she underwent a 52 hour labor complicated by chorioamnionitis, which culminated in a very difficult, physical, and emotionally exhausting breech extraction, ultimately necessitating cephalocentesis.
A week later, a 29 year old G1P0 with a 7 year history of infertility presented to the labor and delivery floor for induction of labor at 37 weeks EGA for lethal fetal anomalies. These including severe hydrocephalus and hypoplastic left heart syndrome, which were initially diagnosed at 20 weeks and 4 days EGA. Initially, she refused to have cesarean delivery or any potentially fetal destructive procedures, such as cephalocentesis. She had outlined a very thorough birth plan designed to allow her and her family to spend quality time with their baby regardless of how long she would live. Her induction lasted 3 days, finally necessitating cesarean delivery for arrest of dilation. After a brief assessment by the neonatologist, their were able to hold and bond with their baby until she died 5 hours later.
Although very different, both cases present very similar emotional and psychological challenges. While pregnancy and childbirth are typically joyful experiences, 6 of 1,000 expectant mothers face the harsh reality of stillbirth, with an additional 3/1,000 expectant mothers learning they are carrying fetuses with significant anomalies. Diagnosis of stillbirth or lethal fetal anomalies is overwhelming traumatizing for women, often leaving them feeling isolated, abandoned and misguided with a loss of personal autonomy. Consequently, they are at a five times increased risk of prolonged psychological effects. Obstetric management has evolved to address many of the medical challenges, and knowledge regarding the psychological aspects has grown exponentially during the past decade. Yet, anesthesiology literature has not kept pace with this evolving knowledge and contains little guidance on the care of these mothers. As obstetric anesthesiologists, we serve a pivotal role in reducing physical pain and suffering these women experience during labor described as "insufferably hard". Likewise, we find ourselves uniquely positioned to serve as healers in a different sense. Developing a deeper understanding of the obstetric and ethical challenges and a greater awareness of women's experiences and the psychological effects, the obstetric anesthesiologist is better equipped to attend to the physical, psychological, and emotional suffering these mothers experience during the peripartum period.