When I was a medical student, I read the New York Times opinion piece, "How to Tell a Mother Her Child Is Dead." In it, Dr. Naomi Rosenberg, an EM physician who works in an underserved, inner city ER, chronicles the same patient encounter she experiences too many times a summer in North Philly. Along my rotations as a medical student, I re-read this piece many times, and even had the pleasure of hearing her perform it at the Philadelphia Inquirer’s “Telling Your Health Story” conference in 2019. As a resident physician in ob/gyn, I think of Dr. Rosenberg’s writing often. Here's my version.
Sometimes I get a notification from the on-call attending that a patient of theirs is coming into L&D triage, and sometimes I don't and they just show up. The patient’s name, obstetric history, and gestational age pop up in pink on the board once they've checked into the front desk. I quickly look over their history, and find that their chief complaint is "decreased fetal movement." The fetal heart monitor is centrally located in our doctor’s workroom, and we can see all of the strips at once, black with red and white gridlines. I see this new triage patient’s fetal heart strip pop up on the big TV screen in our resident workroom, labeled "Triage 4." I can imagine the triage nurse squirting a dollop of jelly on the pale blue fetal heart monitor and placing it on the patient’s belly. I can see the little green squiggles from the doctor’s workroom. She can't find the baby. Sometimes I sit next to my pager waiting for the call, but often I head straight back, tugging the ultrasound machine behind me. Sometimes it's a squirmy baby, hiding behind an anterior placenta, and it's hard to pick up the tones, and sometimes it's a dead baby.
I sanitize my hands, knock, and push the door open, saying, "Hi, I'm Dr. Ackert, one of the resident physicians. It looks like your little one is playing hide and seek. I'd like to do a quick ultrasound to help find them." Sometimes the mothers know exactly what is going on, and sometimes they are blissfully ignorant. I plop even more jelly on their belly, and hope for the best. But I encounter the worst. A beautiful four-chamber view of a heart that is not moving. I take a deep breath, and contemplate my next words, because I know that once I've said what I am going to say, I can't take it back. And then this will officially be the worst day of her life.
I often wonder what order I should say the words in. If I should say, "I'm sorry, but I don't see a heartbeat," or if I should say, "I don't see a heartbeat, I'm sorry," so that she knows the factual information she needs to know, and doesn't get caught up in the "I'm sorry" part. It's important that you say her name if you know it. And her partner's name, too, if they are there.
So, here I go.
Jennifer, Michelle, Laura, Kaitlyn (whatever her name is), as you look her in the eyes, I am not seeing a heartbeat. I am going to ask another physician to come confirm my findings. (Look at the nurse: Ask "Can you call one of the attendings?”) I am so sorry.
And she is trying not to cry, visibly vibrating with fear and grief and hoping that this random young resident physician, who looks like she could be in high school, who she has never met before in her life, is wrong. But I'm not. An attending physician comes and confirms my findings.
We give her some time to process, and then bring her to Room 209, the room furthest away from everything, and we start her induction of labor.
Laypeople use the term "stillborn" much more than we do, however, a practice bulletin published in 2020 by the American College of OBGYN discussed the term “stillbirth” and that it is preferred among parent groups. More recent research efforts have begun using this term in place of fetal death. But still among colleagues, we say IUFD (intrauterine fetal demise) or “dead baby.” I'm not sure why we say the words, “dead baby,” but we do. I was a bit shocked the first time I heard someone say it, but now it's a part of my normal vocabulary, and the phrase has ceased to bother me. “Another dead baby came in last night on call." "Wow, that's been three this week." A way to separate ourselves from the trauma that comes with delivering a stillborn.
A few hours after induction, she ambulates around her room, stopping to double over and breathe each time a contraction happens. Her room is eerily quiet. I am used to the sound of a baby’s heartbeat orchestrating my conversations with expecting parents, but all I see on her monitor are the white hills of the tocometer each time she has a contraction. I place more medication, she gets an epidural, and then it’s time to push. A beautiful term baby is delivered and placed on her chest, and I know that I will soon rip off my delivery gown, throw my gloves in the garbage, and walk back to our workroom, where I will write in my delivery note: “No spontaneous cry, APGARs 0 and 0 at 1 and 5 minutes.” My eyes well up with tears each time, because it never gets easier, no matter how many times I’ve done this. A purple leaf is placed on her door to signify a fetal demise, and the chaplain brings up a cart with coffee and tea — as if that makes what she’s going through any better. But I brush my jaded thoughts aside, as my phone inevitably will ring, and the nurse from next door will say, “My patient feels like she has to push.”
I will then have to wipe my tears on my scrub top, and pretend that I am once again my usual happy, perky, rainbows and sunshine self to go deliver a healthy baby, so that the mother next door — who is experiencing one of the best days of her life — will not know that I just cradled a dead baby in my arms.
It can be exhausting to experience such a wide range of emotions in such a short time. And you walk back into the resident workroom to try write your notes and do your orders, patiently saying, “Yes, that’s fine” and, “I’ll add it to my list” to the nurse whose patient wants liquid meds because she can’t swallow pills, and the nurse whose patient wants famotidine instead of pantoprazole, and the nurse whose patient wants acetaminophen, but it’s ordered as “headache,” and she’s only experiencing “mild pain,” so per the EMR, the nurse can’t give it, and all the other silly things you get interrupted for in a typical day, but they annoy you just a little bit more, because you just delivered a dead baby.
It’s hard to share this story because I feel like it does not belong to me. It belongs to the mom who pushed, or who underwent major abdominal surgery, only to drive home with an empty car seat strapped in the backseat. This story belongs to the family that will buy a tiny coffin for the tiny human they just brought into the world. This story belongs to Jennifer, to Michelle, to Laura, to Kaitlyn — whatever her name is. I am just a mere bystander in her story. A faceless petite brunette doctor wearing blue scrubs with a scrub cap that says “Totally Cuterus!” I am probably a reminder of their worst day. But I remember Jennifer, I remember Michelle, I remember Laura, and I remember Kaitlyn. They are part of my story too.
Each time I deliver a stillborn, I go home at the end of my shift, call one of my co-residents, water my plants, take a shower, and go to bed quietly, knowing that tomorrow is a new day. Tomorrow may also be some moms’ worst day. But it will also be some moms’ best.
How do you deliver bad news to your parents-to-be? Share your approach in the comments.
Kathleen Ackert is a resident physician in obstetrics & gynecology at St. Luke’s University Health Network. She is a graduate of the Philadelphia College of Osteopathic Medicine and Siena College. When she is not in the hospital, she can be found in coffee shops writing narrative medicine pieces or eating in restaurants that offer low-lit dining experiences. She enjoys exploring the latest fitness craze, watering her house plants, and instagramming pictures of fancy lattes at @caffeinewithkathleen. She is a 2021—2022 Doximity Op-Med Fellow.
Illustration by April Brust