For many weeks, you have delighted in carrying your precious babies beneath your heart. Feeling them move and watching your belly grow. Beating hearts are visible on the ultrasound and perhaps legs, arms or spines, depending upon which way they are lying, are also visible. One of the babies though is smaller (usually called 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 too early and the pregnancy 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. Many questions leap into the parents’ minds in an attempt to understand what has occurred and why. Following are some commonly asked questions:

-What is going to happen to my surviving baby(ies)?
-Will my dead baby hurt my living baby?
The death of a multiple before 16 weeks of pregnancy generally creates no increased risk for the remaining baby. A later 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 most do well. With the death of a fetus when there is a survivor(s), the mother will be closely monitored until birth. Your doctor can discuss your particular situation and explain a management plan for your pregnancy until birth. Many women continue their pregnancy and have a healthy survivor(s).

-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. Through ultrasounds, it is sometimes possible to diagnose that one baby is weaker and has a compromising health problem(s). In those cases, 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. It isn’t always possible, however, and one baby dies.
Sometimes a reason for the death cannot be explained until the baby and the placenta can be examined after birth. Depending on when a fetus passed away and how many days or weeks later the mother gives birth, it is not always possible to tell the reason as to why the fetus died due to deterioration of the fetus and/or placenta. The odd time there is no discernable reason as to why a baby dies in utero.

-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 trouble.

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.

-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. 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.

-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 if death occurred after the 14 th week of pregnancy. There will likely be some distortion of features and discoloration. 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. You can spend time with your deceased baby, if you want to. Let the staff know if this is what you want to do and how long you want or need to take with your baby. 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:

• The Ultrasound Technician can show you the deceased fetus(es) during ultrasounds. Inform the technician if this is not what you want to happen.
• Doctor’s appointments may be booked when no other parents of multiples will be there. 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.
• Decide on whether you wish an autopsy to be performed and inform your doctor of your decision.
• Make plans for burial, cremation, or hospital disposition of your deceased baby's body.
• 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 wrapped in a blanket. This relieves the aching arms felt by many grieving parents.
• You can have photos taken for you to look at later if you ever choose to do so. The hospital can keep them on file for when you are ready to view them.
• It may comfort you to hold and photograph your dead and living children together after birth. Include yourselves, and any older siblings, in photos so you have a record of the whole family together should you wish to do so. Such photos can be comforting later and for some families confirm that they truly gave birth to multiples and reduce later feelings of confusion.
• A sensitive artist can create sketches of the multiples together if photos together cannot be obtained.
• Computer programs can create a combined photo from two or more separate images.
• Ask for the survivors' birth certificate to clearly state that the child was one of the original number of multiples. The death of a triplet does not create twins.
• Obtain an honorary birth certificate for the child who died.
• Contact Multiple Births Canada’s Loss Support Network. You are not alone. Other families have gone through the same thing and it is 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

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

Support Organizations and Web Sites:
Multiple Births Canada’s, Loss Support Network – www.multiplebirthscanada.org

Multiple Birth Families – www.multiplebirthsfamilies.com

Centre for Loss in Multiple Birth (CLIMB) – climb@pobox.alaska.net

Twin and Multiple Birth Loss NZ (Inc.) – twinloss@xtra.co.nz

Multiplicity: Resources for Loss, Prematurity and Special Needs - www.synspectrum.com/multiplicity.html

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