FEATURES OF THE ORGANIZATION OF MEDICAL AND PSYCHOLOGICAL ASSISTANCE IN THE SITUATION OF PERINATAL LOSSES

. Features of the organization of medical and psychological assistance in the situation of perinatal losses (literature review). Astakhov V.M., Batsylyeva Puz I.V., Shudrikova N.V. The article reveals the organiza-tional features of medical and psychological assistance in cases of perinatal losses in modern conditions. The paper presents the peculiarities of perinatal loss, psychological condition of women’s health during the onset of subsequent pregnancy as well as experiences of the women who have lost a child at different stages of pregnancy. The article notes that the majority of pregnant women with a history of perinatal loss are in a state of chronic stress, which can lead to the emergence and development of various medical and psychological complications. The peculiarities of the experience of grief in the situation of perinatal loss, as a serious mental trauma for the woman's psyche were analyzed. It has been substantiated that the experience of perinatal loss is a non-normative crisis in marital relations, and the process of providing psychological assistance should be directed not only to the woman, but also to the married couple as a whole, which will reduce the risk of rupture of relations, promote their harmonization, which can be considered as an effective resource for a constructive experience of the situation of loss. The main tasks of psychologists and medical staff during the organization of medical and psychological assistance for women and married couples experiencing perinatal loss are also revealed. It is crucial to comprehend the feelings women experience in such cases, which makes medical and psychological care more effective in the process of working with those who are through child loss or have had such an experience previously. The conclusion notes the priority of organizing and providing comprehensive medical and psychological assistance not only to women, but also to married couples in a situation of perinatal loss;

Despite the significant progress, continuous development and modernization of medical technologies, one of the most actual problems of modern obstetrics is still being the issue of perinatal loss -the death of a fetus at different stages of pregnancy (miscarriage), during the delivery, death of a newborn before 28 days of life, and an unfavourable outcome after the supplementary reproductive technologies have been applied. It is well established that for a woman of the reproductive age, who wants to be a mother, it is not only the process of conceiving that matters, but safe gestation finishing with an alive and healthy baby birth. That is why most cases of miscarriages to the desirable pregnancy or a newborn's death are featured by severe crisis, the consequences of which affect not just physical, but psychological and social well-being of both a woman herself and her close environment [1,18].
The analysis of the researches conducted, which coincides with the existed literature evidences, demonstrates that the majority of pregnant women having perinatal losses in their medical history are under the state of chronic stress indicated by highlevel psycho-emotional tension, anxiety, various fears, etc. [2,8,13,14,18,21,23,24,25,30]. Quite often such women are diagnosed with depression development, the leading symptoms of which are considered to be apathy, irritation, indifference, suspicion and mistrust towards people around, feeling worse caused by sleep and eating disturbance and excessive psychoactive substances intake. In the case of intensive anxiety about the loss accompanied by guilt and a baby loss obsession, the development of post-traumatic disorder is becoming possible. Moreover, it is worth noting that women having traumatic experience in preceding gestations are in the high-risk group on occurrence and development of various complications of both medical and psychological nature in subsequent pregnancies [2,3,5,24,27,31,35,36]. Despite the absence of somatic disorders and the evidence of healthy pregnancy, there is often a high risk for these women to have premature delivery and, consequently, low birth weight of a baby, along with mother's deviant overprotective behavior; that is why these females require special attention on the part of not only physicians but psychologists as well. According to aforementioned, it is getting obvious that the issues related to the arrangement of the professional medical and psychological assistance not only for women but the families being through the prenatal loss are becoming of utmost urgency from both scientific and social value viewpoints, since timely assistance enables the risk of various negative consequences of going through the situation to be lowered; this, in turn, will foster the prevention of obstetric and perinatal complications in consecutive pregnancies and the improvement of the reproductive performance in a modern family.
The purpose of the article is to reveal the peculiarities of the organization of medical and psychological assistance in the situations of perinatal losses on the basis of modern literature data and the results of own records of the years of work at the joint scientific laboratory of reproductive sphere, prenatal and perinatal psychology, Department of Obstetrics and Gynecology Donetsk National Medical University of the Ministry of Health of Ukraine, Department of Psychology, Vasyl' Stus Donetsk National University and G.S. Kostiuk Institute of Psychology of the National Academy of Educational Sciences of Ukraine.
Analyzing the presented problem, it is important to note that the perinatal loss comprises both physical loss, which is related to the actual baby's death, and a symbolic loss associated with the failed attempt to gain new social roles of a mother, a father, and parents [10,30,34]. Perinatal loss might be considered a serious psychological trauma for it causes anxiety that has prolonged exposure on woman's psyche. Psychic trauma as the result of stress is widely known to be more severe than stress itself and can determine the evidence of self-destructive behavior. In most cases woman's response to the perinatal loss depends on the nature of the loss itself and a number of contributing factors, the main of which appear to be woman's attitude towards the pregnancy and motherhood in whole, a term of miscarriage happened, individual and psychological features of a woman, the quality of the wife-husband and woman-family relationships [11,12,26,30,36]. Thus, the cases of early pregnancy losses, for example, may be quite difficult to be realized and ambiguous to go through due to the abruptness and unawareness of what has happened associated with the absence of physical feeling of being pregnant [6,10,17,22]. Anxiety in the result of prenatal loss, as a rule, appears to be far more intense in the midpregnancy and the third trimester of На умовах ліцензії CC BY 4.0 pregnancy, when a woman feels the fetus move, has a certain image of a future baby and actively gets ready to be a mother, in comparison with the first trimester [20].
The diagnosis of various congenital abnormalities in a future baby during the prenatal screening is psychologically difficult for most pregnant women [10]. Such a situation has a sufficient psycho-traumatic impact on the psyche of a female, who despairs of giving birth to a healthy child, and this stage might be a beginning of the process of being emotional over the loss, which is accompanied by hypertrophic feeling of responsibility for the health and life of a future baby. However, ambivalent anxiety is a characteristic feature of the majority of parents who make a decision to terminate a pregnancy due to the pathology of an unborn baby found. Thus, on the one hand, they feel relieved because birth of a seriously ill child was timely prevented, but, on the other hand, they may feel guilty about having decided to terminate a desirable pregnancy in spite of the medical evidences existing [18].
In the case of intranatal or early neonatal loss, women's anxiety arisen is determined mainly by the development of a deep inner conflict which is caused by the fact that a baby could be born or it is born, but its birth turned to be different from the reality; yet, accusations for what has happened might be directed towards a woman herself (for wrongdoing and improper behavior) and others, primarily medical personnel and inner circle [18,21].
It must be mentioned that the gestation age, at which the loss occurs, does not matter since it means a personal tragedy for most women [10,15]. That is why while working with the women who are going through the baby loss or who have such an experience before, it is of a great importance to be aware of the emotions and feelings arising, since it encourages the provision of more efficacious assistance and support avoiding additional traumatic experience.
In terms of psychology, the perinatal loss experience is abnormal crisis in the relationships between spouses. If the relationship of a couple is harmonious, sorrow occurred unifies the spouses who are eager to support each other. Additionally, the external relationship with people surround the married couple consolidates fostering further support in an emotionally delicate situation from others. Otherwise, the situation might lead to the significant worsening of the relationship, to accusation of each other in what has happened and to the social isolation from the inner circle. The statistics indicates that about 12% of married couples decide to break up after the perinatal loss [18]. Hence, it is obvious that the psychological assistance should be provided for not only a woman, but spouses as a whole, enabling the mitigation of the risk of the divorce; and it will foster the harmony as an efficacious source to cope with the loss constructively [4,9].
The peculiarities of work with the parents who are going through the perinatal loss. Currently, the issue of grieving by a woman caused by miscarriage and a baby loss in particular might be claimed underestimated by both close family and the society in a whole. Unfortunately, there are not precise algorithms to solving the cases of perinatal losses in medical practice; that is why the collaboration of a doctor and a perinatal psychologist acquires particular relevance. The psychological work not only with a woman but parents as a whole, who are going through the perinatal loss, has its peculiarities [12,16,20,23]. It is of great importance to understand that the spectrum of emotions parents, who lost a baby, are experiencing is rather complex. Along with, it should be considered that a baby loss does not end for a woman and spouses in a medical institution, there is the necessity to learn to live with the fact that they have become parents but without a child.
The process of the going through the baby loss is accompanied by the range of inevitable complicated moments which must be considered while working with a family, namely coming back home without a child, solving a problem with baby stuff purchased in advance, informing close family about the loss, physical feelings a woman experiences after miscarriage, including delectation, the beginning of the menstruation, return to work, sexual relationships with a partner, meaningful dates (the presumed due date, children's and family celebrations), and subsequent pregnancies. For the majority of women such occasions trigger new intense and painful anxiety that must be specifically considered in the work [24].
From our perspectives, the medical and psychological assistance in the case of perinatal loss is required to be holistic and based primarily on support and acceptance, and the key objectives in the integral work of perinatal psychologist and obstetrician accompanied by a medical team are, firstly, the conducting the proper communication; secondly, making common decisions -partnership; thirdly, recognition of the parenthood; and fourthly, the respect shown towards the baby died.
Thus, the communication between a psychologist and a family should entail not only the usage of the relevant words and figures of speech, but the expressing empathy and compassion using appropriate nonverbal communication. These aspects and the form of their delivering must be considered. Everything aforementioned refers towards both the work of a psychologist and medical staff. 22/ Том XXVII / 3 Awareness of the importance of grief being experienced and acceptance of the fact of parenting, it is necessary to choose the words in the process of communication which enable the rehabilitation of spouses to succeed. The researches illustrate that parents, who have got through a baby loss, remember the words which hurt them and the words which made them feel supported in hard times. Due to this it is of great importance to talk with the parents about a baby, to hear and be careful to their comments, to demonstrate respect and compassion to the loss, to provide with the opportunity to say good bye to it [11,15]. Sometimes, at the first stages of work with a family, just silence and physical support might serve as a resourceful moment. It is vital to deliver to the married couple that they are not alone in their sorrow and that they will get used to living with the experience and will be able to feel happy about becoming parents again.
Working with the couple, which has lost a baby, the psychologist should remember not to use the words "fetus", "miscarriage", to ignore the fact of them being parents, to focus on only a woman's anxiety, to catalyze the guilt parents have, to seek for the positive in what has happened, to interrupt, to avoid conversations about the incident, to block the emotions release and feelings expression, to decline the value of the loss, to look for excuses, and to hide the reality [10]. It is important to inform how sorrow commonly develops and about the stages of mourning work [7]. The information should be delivered verbally, on paper or in an electronic version (in the form of brochure, specialized literature) in order to get a couple acquainted with it when they are ready to.
It is well-known that stress fundamentally impacts the cognitive sphere of a human, nevertheless, the descent of the concentration span, inhibition of the thinking processes, memory impairment occur, that is why it is vital for a psychologist to deliver the information acutely, sequentially, in simple terms reiterating important episodes and verifying them to be accurately perceived. The investigations show that the quality and quantity of the information provided for parents, who are in the situation of perinatal loss, considerably impact their psycho-emotional state, the process of the reality perception, and the going through the stages of grief [11].
During the work, the atmosphere, which will encourage parents to express their emotions and anxiety, must be created. Their reactions to the situation happening must be realized as the one that might involve shock, disappointment, emptiness, anger, self-accusation, and guilt. Despite all the presumable emotional and behavioural patterns parents manifest, a psychologist must remain calm, balanced and supportive. It is of high priority to deliver the parents that their emotions, including anger, are absolutely decent in the situation.
The parents being in the situation of perinatal loss have certain quantity of decisions to be made agreeing their actions in accordance with the medical staff and a psychologist. Being in the state of shock in the moment of the loss, parents are not able to comprehend which decision made will be the right for them. That is why it is particularly important to acquire all the necessary information in a sufficient volume having the choice of time and place to conduct the talks and counselling offered. On the contrary, parents might regret on the decisions made or find them wrong later on. One of the most important decisions, which parents have to face with after the loss of baby, is the determination to see and hold their own child. Escorting parents at the current stage it is necessary to prepare them to meet a child having warned them about the peculiarities of the appearance, temperature, and the weight of a baby. The analysis of the results of the researches conducted shows that the parents, who have not seen their dead baby and who were not able to spend time with it, regretted and felt guilty about that thereafter [9,10,12,15,16].
The world's medicinal and psychological practice testifies that the time spent with a dead baby and the memories stored have prognostic value for the parents to the further grieving. Among the main actions which justify child's existence and, indeed, enable the parenting recognition the following might be singled out: the possibility to learn more about a baby (or about the pregnancy pathology); to see and hold a baby, to store the memorable things; to assist in the funeral arrangements. Moreover, the opportunity to contact a dead child physically enables the gestalt of childbearing and the fulfilment of the parental duty to be completed [12].
Grieving caused by perinatal loss presumes showing respect towards a lost child; this substantially helps to recognize and stabilize the emotional state of parents, and the collaboration of a psychologist and medical staff facilitates the support and compassion provision to the parents who are emotionally stressed [15].
The questions of the future pregnancy often arise while working with the spouses who are going through the perinatal loss. Parents, who have lost their first baby, in most cases are prone to get pregnant as soon as it is possible after the loss. It should be considered that it is a personal decision and a couple should make it on their own, but taking the medical prescriptions into account. The following aspects must be considered when the subsequent pregnancy occurs: the awareness of the certain time value needed for the woman's body to recover from the На умовах ліцензії CC BY 4.0 previous pregnancy; the discussion the stages of grief after the loss experienced in order for parents, primarily for a woman, to realize the readiness to face the worries connected with a new gestation; the necessity of the required assistance at the stages of pregnancy which coincide with traumatic events.
Organizing the holistic medical and psychological counselling, a special attention should be paid to a new pregnancy and gestation of a woman with the medical history of perinatal losses which might involve sufficient difficulties with establishing emotional bonds in the "mother-child" system, the reduction of the general background of mood, the existence of various fears and phobias, the obsessions connected with carrying and delivering a baby [4,9,12]. Such women are to obtain the high-levelled psycho-emotional tension and state anxiety, which is caused by the fear of the situation of loss to repeat [8]. Yet, parents might experience certain constraints with accepting a new child and establishing the adequate parental attitude.

CONCLUSIONS
Analyzing everything mentioned above, we may conclude that perinatal losses occurs to be a quite solemn psycho-traumatic aspect which causes a real threat to health and life of a woman and well-being of a family as a whole. Considering current studies in the field of perinatal psychology, the issues connected with the systematic organization and introducing the effective medical and psychological assistance to women and spouses in a perinatal loss situations in order to stabilize their somatic and psycho-emotional state and to prevent various maladaptive states, which cause the lowering of the quality of life and violation of their sequential personal functioning, must become a priority area in obstetrical practice nowadays. In addition, targeted training of both perinatal psychologists and obstetrician-gynecologists is an integral part to provide the complex medical and psychological assistance in the situation of perinatal losses in order to enhance the quality of life of the women at their reproductive age as well as harmonization of the relationships within a family, which is a non-trivial aspect for resolving demographic issues the modern society faces. Funding. This research received no external funding.
Conflict of interests. The authors declare no conflict of interest.