Grief 

The way a a person tries to respond and adapt to a loss.

Mourning

• Expressing deep sorrow for someone who died by incorporating the experience of loss into their lives.
• Example: wearing black clothes
• Can take over one year

Stillbirth 

Fetus born dead after 20 weeks

• Labor begins 2 weeks after death
• Risk of sepsis and endometritis
• Prevent by induce labor 2 days after death 

Perinatal Loss: Grief Phases

Phase 1: Shock & Numbness

Phase 2: Disorientation, Searching  & Yearning

Phase 3: Accepting, Confronting or working through the pain or grief

Phase 1: Shock & Numbness

•       Forgetfulness, denial, disbelief, and desperation
•       Feel like this is a : “bad dream”
•       lasts 2 weeks

Phase 2: Disorientation, Searching  & Yearning

In this grief phase the woman feels:

Depressed

Blame self or others, why me?

Search for answers

Phantom perceptions:

feel like they are losing their minds

hear or feel baby move

Last  4 weeks

Phase 3: Accepting, Confronting or working through the pain or grief

In this phase of grief the woman feels

Feels less emotional

Some chronic sorrow & never get over it

Regrieve on anniversary of death or holidays.

Reorganization- family may support or alienate each other 

physical or somatic symptoms of grief

palpitations

SOB

stomach ache

loss of appetite

exhausted

difficulty sleeping

“Aching arms”

 difficulty concentrating, confusion, disoriented

Psychological symptoms of grief

• difficulty concentrating
• flat affect to anger to sadness
• hallucinations of infant
• withdrawal

 Interventions to Perinatal Loss

• Say:  “ I’m sorry “How are you doing with all of this?”; I’m here to listen if you need me”
• Quiet environment to be with infant
• Sit with family or cry with them
• Repeat information
• Encourage speak of  loss
• Tell that it's okay to grieve
• Help them cope 
• Refer to a support group

  Maladaptive responses to perinatal loss

• ·      Drinking
• ·      Affairs
• ·      Overprotection with other children
• ·      Withdrawal from other children
• ·      Prolonged lack of intimacy with partner
• ·      Obsessed with having another child
•       Afraid of becoming pregnant again

Cultural Competence

Providing services support and assistance that is responsive to:

            Beliefs
            Attitudes
            Languages
            Personal preference
            Cultural differences

Culture

• Distinct way of life that characterizes a particular community         
• Includes shared practices, beliefs, values and customs passed through generations           
• Provides a sense of identity or belonging

Values
Beliefs
Wold view
Disease Etiology 
Time orientation 
Personal space
Direct eye contact 
Family organization
Power structure

values

freely chosen set of beliefs and attitudes

World view

how human life fits into a “bigger picture”

may be religious in origin

Disease etiology

 explains the occurrence of illness

• Americans - biological
• Africans - spirit possession
• - soul loss;
• Latin - breach of taboo
• Indians - ancestral displeasure
• Asian - body not kept in balance (Yin and Yang) 

Acculturation

Integration into mainstream culture:

-Affected by: age at time of arrival in a new setting, reason for moving, and  residence in a predominantly other ethnic neighborhood

      -Usually takes 3 generations 

Ethnocentrism

Belief that one’s own culture is best

-- Nurses must be aware of own feelings about birth & parenting 

--Never minimize a person’s belief system

--Allow patients to practice cultural norms as long as it doesn’t harm        self or fetus.

generalizations

Consider characteristics group of people with similar attributes.

Gives space for individual variation

they “might”

Streotypes

Oversimplifications that limit the possibility for variation

They “all will”

"They are all"

Health and Genetic Conditions Populations 

¨African American- sickle cell

¨American Indian- Type 2 diabetes

¨Amish- PKU, hemophilia

¨Arab/ Eastern Mediterranean- sickle cell, thalassemia

¨Asian- hepatitis B, sickle cell in malaria areas

¨Caribbean- sickle cell

¨Filipino- glucose-6-phosphate dehydrogenase deficiency

¨Greek- thalassemia

¨Jewish- Tay-Sachs, Gaucher’s disease

¨Mexican- diabetes, Listeriosis 

Childbearing Assessment: 

¨How is childbearing valued? What does it represent to them?

¨Does the woman view childbearing as a normal physiologic process or a state of illness?

¨Are there expected maternal behaviors: diet, pharmacology, activity, restrictions or precautions?

¨Does the woman see the birth process as private or a social event?

¨How is pain managed? How do they cope with it?

¨What support is provided for her in the labor & delivery process?

¨How is the newborn viewed? Who cares for them? Precautions or restrictions?

¨Postpartum, is there a period of recovery? Who cares for her?

¨Is breastfeeding or bottle feeding preferred?

¨ Are there precautions or restrictions for the newborn? Circumcision?

¨How is contraception viewed? Restricted or prohibited? Precautions or restrictions?

Factors that prevent screening & assessment of Domestic Violence

Health care providers play an important role but…

•       uncomfortable asking women about source of injury

•       DV not taught in schools

•       Skeptical about the severity of DV

•       Fear of opening “Pandora’s Box”

Domestic violence

• It's always about power, not love
• Physical: scratch, hit, shove, bite, shake or restrain
• Sexual: use of physical force, unable to understand
• Emotional or Psychological: humiliate, degrade, use of fear, isolation and ridicule

results in domestic violence 

Physical- death, broken bones, head trauma, STD, PG

Complications of PG- stillbirth, LBW, trauma, mental

Mental- depression, PTSD,  alcohol/drug  abuse & suicide

Children- injured trying to protect their mother;  mental and emotional and become abused or abusers themselves; equate love with violence/love hurts

Signs and symptoms in battered women

q      Lack of grooming

q      Depression

q      Somatic complaints

q      Inappropriate explanation of bruises 

q      Bruises in multiple stages of healing

q     Delay in seeking help/care

q      Overly protective spouse

q      Verbalizes powerless and helplessness

q      Drug or alcohol problem

Characteristics of potential batterer

1.   Man physically or psychologically abused as a child.

2.   Man's mother often battered by his father.

3.   violent,  loses his temper, very jealous, drinks and abuses drugs . 

4.   plays with guns and uses them to protect himself from others.

5.   He has rigid ideas of male/female sex role stereotypes.

6.   He expects you to spend all of your free time with him or keep him informed of your whereabouts.

    7.  Has  a dual personality.

 8.  Iverkill in his cruelty or in his kindness.

    9.  You fear his anger. You are extremely careful not to make him angry.

10.  You feel like you can not please him no matter what you do.

  Contributing Factors to Domestic Violence

–      Cultural tolerance for privacy

–      Institutional inconsistency with legal actions

–      Women’s economic insecurity

–      Religious pressure to maintain family integrity

–      __Feel they deserve it _ and/or won’t be believed

–      Shame, embarrassment and humiliation

–      Believe he will change or feels sorry for him

–      Traditional family roles

–      Isolation and/or ___

–      Knowledge deficit of help system

phases of violence

 Phase 1: Conflict Building 

Phase 2: Battering  - (hours to days)

Phase 3: Honeymoon - man remorse, apologizes, promises it will never happen again.

Interventions for domestic violence

·      Encourage them to speak about the violence

·      Tell her it’s not her fault

·      Empower the victim to regain control of her life

·      Help them accept that, no matter the provocation

·      Give limited information

·      Document abuse

·      List options

·      Seek an Emergency Protective Order f

Develop a safety plan

Most dangerous time is when they try to leave

Never leave your kids or plan to come back

Tell neighbors to call police if they hear anything

Devise a code for help

Inform school and rehearse with kids the safety plan

Devise a plan for when you leave work

Gather supplies

anger rape

Attack is used to express feelings of rage; brutal and degrading

Confidence rape

Assailant is known and previously had a nonviolent relationship

Power rape

Assailant wishes to feel dominant and uses only enough force to subdue the victim

Sadistic rape

Planned assault characterized by torture, mutilation, and often murder

myths about rape

·      Women love to be “taken”; rape fantasy

·      They provoked by how they dressed or acted

·      They were really into it and now are embarrassed

·      They didn’t fight

·      The man just became overwhelmed and couldn’t stop

·      It was impulsive (planned)

·      Rapists are hard up for women

stages of rape 

·  Acute Confusion /disorientation - fear, shock, disbelief, embarrassed, humiliated, helpless, hopeless

·  Outward Adjustment - denial, suppression, fears lack of control, anger, guilt, crying, difficulty concentrating

·  Reorganization- coping fails, anxious, flash backs, sleep/eating disorders, PTSD;  Seek counseling and try to become empowered

·    Collect samples within 72 hours

·    Emergency Contraception- 98 % effective

·    STD screen and treatment

    Counseling