One is Alive, One is Not

Please note that the information contained herein is general in nature and does not cover every possible situation. If you have concerns about any aspect of your pregnancy, please consult your doctor.

For many months, you have delighted in carrying your precious babies beneath your heart. They are very active and your belly grows almost daily. Beating hearts have been visible on the ultrasound screen as perhaps have legs, arms or spines, depending upon which way they are lying. One of the babies though is smaller (usually referred to as small for gestational age) and a little weaker than his co-multiple(s).

Then the unthinkable happens: the smaller one has passed away. It is still early enough in the pregnancy that it needs to continue for several more days, or even weeks, to give the survivor(s) the best chance at survival outside the womb.

This unbelievable and devastating situation is almost too much to absorb, let alone comprehend. Shock as well as many questions leap into the parents’ minds in an attempt to understand what has occurred and why. Following are some frequently asked questions:

Q: What is going to happen to my surviving baby(ies)?

The death of a multiple before 16 weeks of pregnancy generally creates no increased risk for the remaining baby or babies. An after 16-weeks death of a multiple with a separate placenta from the other(s) is also not too likely to cause any problems. When a deceased fetus’s placenta is shared with a co-twin (monochorionic), there is some risk of problems for the survivor, but not always. With the death of a fetus when there is a survivor(s), the mother can expect to be closely monitored until birth. Your doctor can discuss your particular situation and explain a management plan for your pregnancy until birth. While the mental strain can be very taxing, many women continue their pregnancy and have a healthy survivor(s).

Q: Will my dead baby hurt my living baby(ies)?

If the surviving multiple(s) is healthy itself, there will be no affect on the living baby(ies).

A deceased baby’s body begins to be broken down in utero and is reabsorbed by the mother’s body and/or the survivor’s placenta. Depending upon how long after death it is delivered, depends upon what its appearance will be like when it is delivered. Delivery can be expected to be earlier than previously planned if the babies share placentas and/or sacs. Mom is carefully monitored until birth, so that the doctors can make timely decisions if needed.

Q: Did my baby ‘kill’ his sibling?

No, one baby didn’t ‘kill’ the other. The deceased fetus usually has substantial health problems through no one’s fault (e.g. anomaly within a larger organ such as the heart). Through ultrasounds, it is sometimes possible to diagnose that one baby is weaker and has a compromising health problem(s). In twin-to-twin transfusion syndrome (with monozygotics), for example, the mother is closely monitored to try and prolong the pregnancy as long as possible in order to give both (or all) babies the best chance. With some medical issues within the womb, however, it isn’t always possible to successfully intervene and one baby dies. Sometimes the death cannot be explained until the baby and the placenta can be examined after birth and even then, the reason for the death may not be identified. Depending on when a fetus passed away and how many days or weeks later the mother gives birth, it is not always possible to identify the cause of death due to deterioration of the fetus and/or placenta.

Q: How is this going to affect my own health and emotions?

Physical complications for the mother after one multiple dies in the womb are uncommon. Careful monitoring of both mother and surviving baby(ies) during the rest of pregnancy can detect any signs of concern. Delivery may occur earlier than previously planned because of this changed situation.

Emotionally the situation can be quite different. Some women report feeling fear, isolation, confusion, devastation or horror. Some report feeling particularly close to their dead multiple because they know this is the only time they will have him/her. They report a great sadness through the rest of pregnancy, unable to find any joy in the approaching birth because they will need to give up that baby. Others push grief aside, fearing it will harm the remaining child(ren) or cause preterm labor. They dedicate their energy to hopeful thoughts about the survivor(s). Some hang on to a belief that there has been an error and at delivery, there will be two (or more) healthy and alive babies. All of this is normal.

Q: What will the delivery be like? What will happen?

Your doctor, hospital staff and grief counselors can help you plan a birth experience that honors your deceased child while meeting the medical needs of your living baby. Depending upon at which stage the baby died, you may need a death plan as well as a birth plan. Communication with your doctor about the delivery will help clarify what will happen and how things will proceed. Don’t be afraid to discuss with your doctor your needs and fears.

Q: What will our dead baby look like at delivery?

Your baby’s body will be small (as compared to its co-multiple[s]) but recognizable as a baby if death occurred after the 14^th week of pregnancy. There will likely be some distortion of features and discoloration (bruising). Discussion with your healthcare provider or a grief counselor can sensitively prepare you for your baby’s appearance, and help you choose whether to view him/her after birth or not. Some families choose to view their baby regardless, some don’t want to view the baby. Don’t be pressured into doing anything that you don’t feel comfortable doing. Whatever you decide to do is what is right for you. You may wish photos to be taken either by yourselves or ask the staff to take them for you, should that be easier. Photos can be an important consideration as this is the only time both (all) multiples will be together, should you wish to do so. The baby can be wrapped in such a way as only a foot or feet, hands or face is visible for the photos. The hospital staff will be able to guide you. You may chose to have the photos taken, but put them away and not look at them until a later date when you feel more comfortable viewing them. Sometimes one parent will wish to see the baby and/or photos and one will not. People do not all grieve in the same way so understand that your partner may make a different choice from yours. There is no right or wrong way to proceed, only the way that works for you.

Q: Can we spend some time with our baby?

Yes, you can spend time with your deceased baby, if you want to. Be sure and let the staff know ahead of time if this is what you want to do. Have a note written in your file indicating that this is what you wish to have happen. You can take as long you want or need to take with your baby. In addition, some parents have hand and foot prints taken as a keepsake if it is possible.

Some options to consider for the remainder of your pregnancy:

If you do not wish to view the deceased fetus(es) during ultrasounds inform the technician. The monitor can be turned to another direction.
Doctor’s appointments may be booked when no other parents of multiples will also be present. If this is better for you, then you can request it.
More frequent doctor visits and/or testing will occur in view of your situation. This may be reassuring to you.
Talk with your doctor if you have any fears about the surviving baby’s health.
You can see your baby(ies) at delivery should you wish to do so. If you do not wish to do so, that is OK too. The hospital staff, at delivery, can help you with the decision, if that works for you.
If you do not wish to view your deceased baby, you still can hold him/her, usually wrapped in a blanket. This relieves the aching arms felt by some grieving parents.
If you wish an autopsy to be performed discuss it with your doctor.
You may need or wish to make plans for burial, cremation or hospital disposition of your baby’s body.
Consider if you have photos taken, they may also be important for your surviving multiple(s) to view and to help you begin the discussion of how he/she began life.
In any photos you may wish to include yourselves and any older siblings so you have a record of the whole family together. For some families photos confirm that they truly gave birth to multiples and reduce later feelings of confusion.
Computer programs can create a combined photo from two or more separate images. Some parents who did not take photos of the babies together, can thus create a combined photo.
Ask for the survivor’s birth certificate to clearly state that the child was one of the original number of babies conceived. The death of a triplet does not create twins.
Some hospitals offer an honorary birth certificate for the child who died. Ask for one if you would like one.
Children are not interchangeable and you do not have to listen to such comments as “As least you still have one” or “You couldn’t have handled three.” Feel free to inform the speaker that such comments are painful and only add to your grief.
Contact Multiple Births Canada’s Loss Support Network which offers a monthly e-newsletter, Forever Angels. You are not alone. Other families have gone through the same thing and it can be very helpful to connect with them.

Sources

Bereavement in Multiple Birth, Part 2: Dual Dilemmas, Elizabeth Pector, MD; Michelle Smith-Levitin, MD, The Female Patient, Vol. 27, May, 2002

Reading Resources

Twins, Triplets and More, Elizabeth M. Bryan, M.D., St. Martin’s Press
Guidelines for Professionals: Bereavement, Bryan, EM; Hallett F, Multiple Births Foundation, London England http://www.multiplebirths.org.uk
Living Without Your Twin, Betty Jean Case, Tibbutt Publishing
Bereavement in Multiple Birth, Part 1: General Considerations, Elizabeth Pector, MD; Michelle Smith-Levitin, MD, The Female Patient, Vol. 27, November, 2001
The Worst Loss: How Families Heal from the Death of a Child, by Barbara D. Rosof, Henry Holt
Empty Cradle, Broken Heart: Surviving the Death of Your Baby, Deborah L. Davis, Fulcrum Publishing
Men & Grief, Carol Staudacher, New Harbinger Publications
Trying Again: Guide to Pregnancy After Miscarriage, Stillbirth and Infant Loss, Ann Douglas and John R. Sussman, M.D., Taylor Trade Publishing
Empty Arms: Coping with miscarriage, stillbirth and infant death, Sherokee Ilse, Wintergreen Press