 Good evening everybody and welcome to this mental health professional network webinar. We're talking tonight about supporting parents when there's a child or a death around child birth. So we would like to begin by acknowledging the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We recognise and pay our respects, the oldest past, present and future for the memories, the traditions, the culture and hopes of Aboriginal and Torres Strait Islander Australia. Steve Trumple's my name. I'll be facilitating tonight's session. I'm a general practitioner by background but my role in the later years has been as head of medical education at Melbourne University where I finished up in that role last year. I'm on a very tenuous internet link tonight unfortunately. So if I freeze, I'll be dropped out and the webinar will go on in my absence which is absolutely fine. You're here tonight to hear from the professionals we have online tonight and I would also acknowledge that everybody attending tonight is doing so as a mental health professional but there will be times with this topic in particular when we do touch on issues that carry personal pain and memories for some. So I'd encourage you to keep in touch with your own feelings during tonight's presentation and if you do need a break, step away from the webinar for a period of time and come back when you're ready or catch up with the recording at a later time. And obviously if any content in tonight's webinar causes you to stress, please do seek care from your general practitioner or your mental health clinician or contact Beyond Blue. So let's now have a look at tonight's panel. There they are. We're starting most appropriately with Bonnie Carter who is a peer worker and educator with lived experience of this topic. So welcome Bonnie, it's fabulous to have somebody with your experience in the group tonight. Can you tell us a little bit about your work at Red Nose in particular? Yeah, so I came across Red Nose through my own lost experience after losing our second daughter to Silver in 2017 and I've since grown to be very much part of the Red Nose family, if you will. My key role with Red Nose at the moment as a volunteer is on the Red Nose National Community Advisory Committee is essentially a group of three parents from around Australia and we advise Red Nose CEO, the Red Nose Board on the various initiatives and programs that Red Nose are doing across Australia and really trying to grow that community engagement, community advocacy for parents that experience loss, miscarriage, stillbirth, but also through to parents who might be new parents and sleep education and research into a lot of the medical reasons behind loss. So my role sort of encompasses a bunch of that and I am very proud to be part of the Red Nose family. We appear to have lost D, so I'll introduce myself next. I'm Dr Nicole Hall, I'm a GP in Sydney and I work in high risk obstetrics at Liverpool Hospital also in Sydney. My main thought tonight is about how the GP is involved with bereaved parents and we are the core of the caregiving team fundamentally. We're there before pregnancy, during pregnancy to support during the loss and for all the years after that when the rest of the mental health care team and bereavement team may have no longer be involved in care and that includes when families try and get pregnant again and all the emotions that come along with that. So I'll be speaking mainly to that tonight. And next, I'd like to introduce Eliza. So can you explain how a bereavement midwife is different to a non bereavement midwife, I guess? Yeah, absolutely. Look, there's certainly overlaps. I mean a midwife going into that profession needs to be prepared to support families that have experienced a perinatal loss. I suppose a bereavement midwife is just a bit more focused on the very specific needs of that family around their loss and their grief experience. You know, I personally help them with the very difficult decisions around consenting for post-mortem, whether to see and hold the baby down to how to register the baby's birth and death and Centrelink payments. And there's some psychoeducation because I also have a bereavement counselling qualification. So there's that psychoad around grief, what to expect, return to work advice, referral to the community, and then obviously the clinical care in labour and birth or caesarean. So it's just a bit more specifically focused. Fantastic. And Dr Matthew Roberts, if you can have a chat to us about how important it is to include fathers in the bereavement process. Oh, thank you, Nicole. I guess it's as important as it is for dads to be involved in any process in family life. I'm a dad myself. My kids are much bigger now, but I won't forget the experience of going through the perinatal periods with my children. And just how incredibly vulnerable I think I can recall feeling, particularly as a medically trained dad to be, knowing what the possible outcomes were. I think that's, it's a mark of your investment as a dad or as a parent full stop, that you are vulnerable in that way. And I think it's incredibly important to involve fathers as much as possible really. It absolutely is. So tonight we're going to start with a presentation from each of our panelists. And then we will follow up with a Q&A session towards the end of the webinar. So let's talk about the learning outcomes which are on your screen in front of you. So this webinar will provide participants with the opportunity to describe the complex relationship between grief and loss and mental health for bereave parents, discuss risk factors and warning signs of mental illness, have a discussion about ways to guide conversations regarding bereavement and bereaved parents' mental health, and of course provide some strategies to assist health professionals to make appropriate referrals in this space. And sometimes as a health professional that's the hardest bit. Who do I speak to? Who do I ask? Who do I call? But that's going to be a really, a really useful part of tonight. But now I will gladly hand over to Bonnie for her presentation. Thank you, Dr Nicole. So thank you for having me here. I'm super humbled and very grateful to be amongst these incredible professionals. I don't have that professional background. I'm definitely talking from a lived experience tonight, but I hope that's powerful for you in many ways. A common theme or thread that I think you'll pick up on tonight is that very much the grief of a bereave parent is non-linear, non-textbook, messy, confusing as hell. And there are a lot of layers of complexity to it. And that's dealing with the loss of a baby and then supporting the broken families that are left behind in their grief journey. There's definitely no one-size-fits-all approach to this. There's no one right way of grieving for a lost pregnancy or a lost baby. There's no real calendar or plan to follow as such. And also note that I am only one voice. If you've met one bereave parent, you've only met one bereave parent. But I think I can speak solidly about my experiences after experiencing so much grief and loss. So after two stillbirths and two miscarriages over a few years, failure after failure, I think I've come now over time to have a pretty good idea about what you can do to better support families through grief, through pregnancy loss. It really does become a lifelong journey as well. So I'll talk a little bit about that lifelong focus. As a bereave parent, one thing I spent months grappling with was searching for the right way forward, searching for the answers, searching for the right way to grieve, searching for a way to get the answers and wanted solutions to fix my broken heart and to help those hurting around me as well. Some of the professionals here tonight will certainly have amazing ideas and experiences and ways of providing those solutions. But I don't think that anyone out there has it all in one book, in one guide, in one program, in one policy or process. There's many tools and tricks that you can tap into. But I just note that if you go away tonight with a lot of unanswered questions, that's okay because there is a lot through this. In my effort to make sense of a little bit of that for you, and I am a bit of a visual strategic thinker, and I love words, I'm a bit of a writer. The first slide, all of that together, to kind of explain the life of a bereave parent. That picture that you see in front of you could well be me in 2016 after our first stillbirth, could well be me in 2017 after our second stillbirth, 2018, 2019. But it could also be me tonight after this webinar. It could also be me next year, and maybe when I am a grandmother and in many years to come. This is the bereave parent in its most raw form. The rocks you see are representative of all the words and feelings that I've listed there. Those rocks are sometimes bigger, sometimes there are more of certain rocks, sometimes they change over time. But they're rock solid and they're not going anywhere. And they're trapped in that cage of that bereave parent's body for a very long time. But perhaps we can smash those rocks apart a little, break them down so they're not so heavy and easier to depict and figure out. They will weigh you down. They're always going to be there for a very long time. And often they infiltrate and vibrate throughout your whole body, from your head to your toes, a physical response and an emotional response. They bring a crippling effect as well. They become so heavy, so insurmountable that it can bring you to your knees, gasping for air. That has been me in many experiences. And that could be in the moment of learning that someone has just lost a baby. The words that there is no longer a heartbeat could be in the aftermath of saying goodbye to your baby at the hospital or in a funeral, or in the many years to come after something that might trigger the bereave parent. It could be a bereave parent tonight. Statistically speaking, six babies are still born in Australia every day. The numbers get even higher for earlier loss and different types of loss. And the numbers are still too high for those who lose a newborn or infant in the first five months of life. And that's the reality of the reality of the picture I'm trying to paint for you tonight. And it can last for a very long time. Next slide, please. So, guiding conversations, it's no wonder why bereave parents experience the most intense form of human grief that someone can respond to. And of course, we need folks like you to help us in that. We need your support at our darkest times. We need you as part of our village. Just like you have a village when you bring a baby into this world, a living child, we probably need that village even more so when we lose a baby. And that absolutely includes our mental health professionals that band around us and our other health professionals that band around us too. Bereave parents, once you know of your loss, you're sucked into this deep, dark vortex of grief and darkness very, very quickly. You're pulled all over the place. You don't know which way is up anymore. And you don't know what to do next, who, call, what's right or wrong. There's a big flurry of awfulness. So you need someone to be a backbone, a voice of reason, a support. I have a lot of that through my family and friends support. But in the instance of the case study with Cameron and Melissa, they didn't necessarily have that support around them as such. Also, that support and that flurry of awfulness can become quite clunky. And that becomes quite clunky, I think, when we are trying to explain to bereave parents what their options are from here. So you've learned of your loss, but what do we do next? What are the options and how we give bereave parents a sense of control over that experience of loss and how that grief might pan out? They're professionals to take their time with it as well. I think in the essence of this case study, the time was not there. It was a rushed process and a rushed grief journey then. They weren't simply given the plethora of options that are available through them. They weren't given even the chance to learn about those options or question what is right or wrong for them. There was, I guess, a lot more that their village could have done for them. So we need you as the professionals around us to help paint that picture, give us the options, tell us what to expect and what we can opt in and out of. So I'll give you a very quick example of my experience in that to sort of paint that picture. My experience with any type of grief at all, any funeral to attend was the stillbirth of our first born, our first daughter. The beautiful midwife that we have, similar midwife to Eliza who you'll hear from later. Our beautiful midwife Alison talked us through the next steps of what to expect with the birth of our beautiful baby Grace. I was terrified but I had a plethora of information there to know what I was getting into. What I wasn't prepared for was my response to that grief, to the death and to what I was about to face. My entire life I had been terrified of seeing a dead body even in movies. I never wanted to attend an open casket funeral and I most feared the death of my own husband, parents or sister and I prayed that they would outlive me so I wouldn't have to deal with the grief of losing them. It's a true fear that I held from probably when I was a child. So when the midwife started talking to me about birthing my stillborn baby and then meeting her and holding her. I'm not sure if I laughed or almost vomited in her face. There was no way in hell that I was going to be able to do that. And I begged her to let me birth her and then take her away to someone else to keep her cosy and warm and let the professionals do their job. The midwife then did something quite profound and she didn't force me. She didn't try to persuade me with more caring words or nice statements of sympathy. She did one thing. She shared the story of another bereaved family who had been very similar issues to me in recent times who had thought they also didn't want to see their baby. But she told me that one thing had changed that for them and that was their instinct. The maternal and paternal instinct, the animalistic instinct that kicks in when you have a baby to love that baby, nurture that baby, cherish that baby. Let me tell you now as a mum to also a living child and to our two stillborn daughters, that maternal instinct when you lose a baby and when you birth that stillborn baby is fierce when it comes to losing them. You crave to hold them, drink them up, take in their every inch of little being, their turries, their fingers. The protection obviously doesn't come from a survival instinct to keep them alive and well. Their life is no longer. The protection comes immediately from preserving their memory, honouring their little legacy and being their voice forevermore. And I think that actually grows, that fierce instinct grows more over time. So with all that in mind, it breaks my heart with this case study to know that the parents in this, Melissa and Cameron, missed the opportunity to find that out for themselves and to be given that option. And also to give the option of cherishing and loving and nurturing their baby Oliver. It really makes me so sad because I know there are plenty of other families out there in a non-fictional sense that have experienced this same experience that Cameron and Melissa had. So I think I can say now that even if it was for a short time, meeting our girls, holding them, cherishing, making those memories, taking those photos, I think that's helped me heal today and why I'm able to speak so openly about our story today. Next slide, please. So then it's back to reality. Leaving the hospital, making the walk out of that hospital back to your car, the journey home, getting through the front door, arriving inside your home, your comfort zone, your sanctuary, then realising what you've left and what is now gone. The reality of that new normal hits very hard. The level of detail and supporting parents through those next steps, through those next experiences of returning home and back to reality are often missed and I certainly wasn't prepared. And in this case study we're talking about tonight, they definitely weren't prepared for it either. A friend once said to me after hearing our news that I can't and don't ever want to imagine what you've been through Bonnie. You've lost your baby and I can't deal with that anymore. And that's where her brain switched off. She would have absolutely no idea or able to fathom the parts that I've just said about leaving the hospital, returning home, getting home to an empty nursery and the aftermath of all of that. And definitely the same again for Cameron and Melissa. So what do I mean a little bit more about that? Well living in the hospital it wouldn't be nice to have someone to hold our hand, even to wheel me to the car because I emotionally wasn't able to walk myself out of that hospital and leave our baby girls behind. Literally guide us in the most basic acts of humankind. Even to join us in the car ride home perhaps. Then at home being met there by someone who can guide our next steps. Show us we're not all down alone. Help us make those calls clean, cook, close that damn nursery door that is now empty. Now it's not all doom and gloom. So I missed out on a lot of these things. Cameron and Melissa missed out on a lot of these things. But in recent years since the time of my loss, Red Nose have brought to life an amazing program called the hospital home program. You can Google it. It's all available on the Red Nose website. There isn't too much detail, but it's available throughout Australia. Outreach support is usually within the first three months of their loss. And that is that back to reality first three months after loss. It's face to face phone calls, video calls, and it's tailored to individuals. And it helps parents make all of those decisions, give them the plethora of options that I've been talking about. And professionals can refer, but also bereaved parents can self refer to it. I really think that was the program that was the missing piece for my own grief puzzle, but also for Cameron and Melissa and the case study too. And there are so many other supports out there. It's not all about the hospital to home program. There are so many amazing organizations and professionals who do this stuff day in, day out. But I just know that that is one piece of my puzzle that was missing. And I wanted to flag that here tonight. Next slide, please. So facing the future, I'm talking now about the months and the years ahead. And it's more about that emotional response rather than those practical things. Kids say the dandest things and you can get away with it as a kid. Adults, mature, grown, educated adults can say the most stupid and silly things at the worst times I've found. And Cameron and Melissa definitely face that in the case study as well. Just when you're feeling at your lowest of lows, you're already down, alone, isolated. Like these weird people whose baby has died and no one wants to talk to them anymore. No one else gets it. And then bam, someone says something stupid. Like keep trying. It's for the best. Or in my case, no more pretending. Let's do the real thing next time. In that moment, you want to scream at them. You want to scream that you just don't get it. And I still have those interactions now, but I've been able to find ways around interacting with those and dealing with those now over time. I guess one way forward in terms of facing those weird interactions was my red nose counselor. My red nose counselor absolutely saved the day and helped guide me forward in dealing with the future that is life as a brief parent and my new normal. Another point here is dates and anniversaries. They can be a hard one in moving forward with the future. Brief can come rushing back and smack you in the face very quickly and quite often out of nowhere. For me personally as a lived experience, if I can say the hardest dates are mother's day, father's day, my birthday and Christmas Eve night. I won't go into why, but they are dates that I'd never expect would be the hard ones for me. I thought it would be the girls' birthdays or October 15 being international pregnancy and infant loss remembrance day. But it's on the girls' birthdays and those other special days where I feel most love and most support and most peace in remembering our girls. And everyone has different dates and different triggers, but I just wanted to flag that tonight as something a little bit different to what you might normally hear about. In terms of moving forward with the future but still being in that healing mode, what I've really come to rely on in healing over time is leaning into that peer support and leaning into other bereaved parents networks of people who just get it. Red Nose have been an amazing connection with a lot of those peer support networks but also online through the power of things like social media have been able to connect with bereaved parents. The last two points I'll mesh together because I'm very cautious of time. The support services, we all go through a lot tonight in terms of who you can seek out professional support from and the amazing charities. On that topic of support though, returning to work. I'm a very career-minded person. Melissa and Cameron are teachers, very professional minded as well. Work isn't really the least, it's the least of your worries at a time of loss. But actually it's also not because you want to get back to your workload. You think about your team, in their case you probably think about your students as well. It does also pay the bills and you have financial stresses around taking leave. So work is paramount in returning to that future new normal and returning to the community as a valued citizen. So I'm trying to figure out that my return to work and my return to normal routine. I turned to my red nose counsellor again and she guided me through all of that. She stepped me through the options of how I can do that. It went from being gently, gently returned to work, meeting with my boss. My boss doesn't meet at home to meeting with the team eventually to walking back into the building but just to the cafe because I wasn't quite ready to step right back into the office yet. And then over time I was able to meet more of the team and tell them about what had happened and then I started a graduate return to work. My red nose counsellor guided me through all of that. I wouldn't have known what to do otherwise. Likewise with other, like other bereaved parents. I could have said that I didn't want to talk to my boss. I didn't want to return to work. It is a very individual decision as well. So I keep that in mind, take it with a grain of salt with what I've just said too. But I think in terms of the case study they would have benefited from a guidance piece like that from someone like a counsellor. Last slide. Now this last slide is a good place to end my part in presenting before I hand over to my wonderful panel peers. Before this slide I was talking a little bit about the future and leaving the hospital, returning to your new normal. It puts that messiness, all of what I've said I hope, puts that messiness of grief into a nice little box, covered the practical bits for you and you can implement some of the things that I told you and you think that maybe after doing all of that a bereaved parent is pretty good to go. They'll be right mate, let's move on to the next patient. But it's not quite like that and unfortunately lightning in my experience and in the case of this case study, lightning does strike twice. Sadly grief doesn't end always for bereaved parents. It can go on and on and for me on and on and on. When it comes to occurring losses people might think of a bereaved parent having survived it before. You can do it again in list the same coping mechanisms that you did before when you lost previously. But pregnancy after loss, parenting after loss is a whole new level and a very different dynamic. I'm not going to go into it tonight. In fact I think it could be a whole presentation in itself. Parenting after loss and pregnancy after loss. But please take away those three last points there that I've raised. That was my experience for nine to ten months with our pregnancy in 2021 when our rainbow daughter was born who is now crying out there and we can't hear her. She's two years old in those terrible two stages. But what saved me is the picture on your screen. This is a book that I wish I could place in the hands of every single bereaved parent facing pregnancy after loss. I don't know the author. I'm not sponsored for this. It genuinely helped me throughout the whole nine to ten months of my pregnancy. It's a day by day plan to guide a parent. You can journal. You can workshop your thoughts. It gives facts. It gives figures about pregnancy after loss. And I kept that in my handbag at all times on my bedside table at all times and journaling through that I was able to chart my way forward through this crazy life as a bereaved parent but a crazy life as a bereaved parent now pregnant in the hope for a better future. So I'll end there. But I want to end on one just last message in light of all of what I've just said. I know that people can live in hope and even though Melissa and Cameron are false identities, I can relate to them and there are a bunch of bereaved families out there that have this experience and I just want them to know and anyone listening tonight who might have a bereaved parenting experience themselves that brighter days do come. That might mean future living children or it might be in many other ways as well. But for me, there's always a rainbow after a storm and I really want in all of my sharing of my story, I really want people to know that they don't have to give up and feel alone that there is hope to hold on to. Thank you. Thank you very much, Bonnie. And the empathy you show for our fictional characters I think does show why you're such a wonderful practitioner in this field and for sharing with us tonight. Those of us who are on this end of the seminar, webinar can't see the chat that's going on amongst the participants. Unfortunately, I can't see that. But I'm presuming that there'd be lots of feedback for you from the participants about what you've shared tonight that we might be able to catch up with later on. So thank you for everything you've said. And what you just finished on then is really important. I must confess to everybody here, I'm actually one of the many recently retired Australians who's nicked off to Europe for the winter. So I'm doing this presentation from Greece, which is why my connection dropped out because I've not got a very strong signal and I didn't actually get to mention at the beginning of the webinar how important it is that although as you mentioned, people are attending tonight as mental health professionals, there will be times that we touch on topics that carry personal pain for some and I've seen that in some of the questions already. And I would encourage people to keep in touch with their own feelings if they need a break from the webinar to step away and come back when they're ready or to watch the recording later when they've got a bit more emotional bandwidth to deal with. What are some very, very important topics if anybody is distressed, get in touch with their mental health care professional GP or whatever. Now speaking of GPs or whatever, Nicole, I owe you at least one racina when we meet for stepping in and taking on the hosting responsibilities. I will now throw to you though to move to the next stage of the presentation where you're starting off with a really important word. So over to you, Dr Nicole Paul. Thank you so much. I wish I was also in Greece but I am not, sadly. So from a GP perspective, I guess the first thing I want to say is listen. Listen to what people have to say. I think sometimes as a mental health professional you want to find the right thing to say to somebody. You want to have this long list of things that you can say to someone who's a bereaved parent and you want to make everything okay. But as a patient said to me once and I've never forgotten it, sometimes you just need to listen. You just need to listen to everything going through their head, all their thoughts, all their emotions, everything they've been through, all their questions, all their hopes, all their fears. And I really find that with bereaved parents I try not to do a lot of talking at the start. I just try and listen. And that gives you a really good idea of the mental health professional about how to approach things from then on in with a bereaved parent. And of course, empathy is key. And yes, Bonnie, you showed amazing empathy for people in this case study. And I'm going to flip it a little bit. I'm showing empathy for the GP in this case study. I've been in the situation multiple times where someone's come in and I've said, oh, how's the baby? How's the pregnancy? And I've had absolutely no idea that they've had a stillbirth. And that's really, really hard for them. As the Melissa and Cameron, they had to go through the story again. And it's really hard as a health professional because it puts you off guard and you feel like you just say really silly, clumsy things stumbling over because you weren't expecting that news. So from my point of view, if you take anything out of this, it's please, please, please, if someone has a bad outcome, please pick up the phone and call that person's GP. I cannot emphasise that more. It's absolutely critical. Next slide, please. So the other thing I wanted to talk about is why questions. So a lot of the time, there are many stages of grief. We all know that, but there are so many why questions that come up. And I sometimes find it difficult as a GP to answer all of those why questions because I wasn't at the hospital. I don't necessarily have access to all the information. So again, please give the GP of a patient, or read family, all the information you can. Even today, I was on the phone to pathologists madly chasing autopsy results and things. And it would, you know, parents want to know that information. They may need to go through that information over and over and over again. And I think as a GP, it's okay to say, I don't know, but I'll find out. But expect the why question. And yeah, as I've said, that slide, because I keep really reiterating this point. It's really, really important that you let the GP know what's going on. Give them the results of the autopsy available. Give them the results of the placental swabs, the bloods. It's really critical to allow us to care for our bereaved patients as best as we can. Next slide, please. Grief is normal. And grief is a process, as Bonnie said, and everybody grieves differently. And I think a GP can be really, really critical in terms of caring for a bereaved family, because we've usually known that family for quite a long period of time. And that gives us extremely good insight into how people grieve. I'm caring for a bereaved family at the moment who are also teachers. And their way of coping is to know every single scientific reason as to why things may have happened and also every single scientific thing that I can possibly do so that even when they get pregnant again, we can hopefully prevent this from happening again. That's their way of grieving with it. Other people do not want to know that level of scientific detail. And a GP is really well placed, knowing a patient extremely well to know how people grieve. And Melissa and Cameron's GP, I'm sure would have been an excellent support because they know them the best. I tend to schedule regular follow-up appointments as there's so much to say to so many feelings, so many emotions. So I generally liked, again, depending on the patient preference, of course, I like to schedule regular follow-up appointments with my bereaved parents. Just knowing that they've got that person that they're touching base with on a regular basis, in addition to the counsellors and everyone else, can be really, really helpful for someone who's grieving. Next slide, please. As I'm sure everyone else will touch on a lot today, there are lots of options. There are lots of things we can do. As a GP, sometimes it's hard to even know what those options are. It's hard to know who to talk to. Red Nose is a fantastic resource, but sometimes you're sitting in your office and you think, oh, my goodness, I know I need to organise all these things for this patient and I have no idea where to start. So, you know, Red Nose is a great place to start. Your local perinatal health service is a great place to start. So, don't be afraid if you don't know what to do. I think being honest with the patient and finding out is okay. The other reason I like to bring people into regular review, of course, is to watch for symptoms which weren't urgent review. And I'll let Matthew touch on that later, but there are lots of resources out there. As a GP, it's okay if you don't know what all of them are. It's okay as any mental health care professional or all of them are. And it's okay to say to a patient, I'm going to look into this for you. I'm going to figure out the best option and I'm going to come back to you with that information. Next slide, please. The other thing I want to mention is that, of course, grief doesn't stop without pregnancy and Bonnie, you alluded to this as well. Grief is an ongoing process. And if and when there are further pregnancies or further episodes of grief for other things that happen to someone's life, it's going to be a rollercoaster of emotions. And as a GP who's been on this journey with the patient, we're extremely well placed at managing this and offering regular support. It's really critical to be aware of deteriorations in mental health. Bonnie mentioned that there are times when it hits her harder. And again, as a GP who knows their patients really well, we're in a really good place to be able to pick that up and deal with it. So I guess I really just want to stress the importance of a GP in managing a bereaved parent's care. And also as a health professional speaking to other health professionals, please don't forget how important we are in that circle. Next slide, please. And that's it for me. Thank you. Thank you very much indeed. And you might have answered some of the questions people had about what to say. It sounds like sometimes saying nothing is the best thing you can say if it's the right time for listening. But it's about being attuned to each individual person's needs, as you say. And as also Bonnie said, every parent is different. So we have to be flexible in that. Absolutely. Thank you so much. Now, without further delay, let's move on to Eliza, our bereavement midwife, to talk about her perspective. Thanks, Eliza. Thanks, Steve. Look, I've probably focused quite heavily on how I care for and support families where I work. I think it's always really important whenever a family is in front of you understanding what the story is when they come to you with another loss. There's implications obviously for coping mechanisms and obviously Melissa and Cameron, we've all read the case study had many difficulties. It took 12 months to conceive and they also suffered a miscarriage at 12 weeks and that can inform the support from there on with this sadly this subsequent loss with Oliver. So every couple that I support, validation and normalization is hugely important and I suppose sadly I probably don't witness validation enough from friends, family, colleagues, health professional. It's a matter of just saying I'm so sorry that you were going through this. I'm so sorry that Oliver's died and not be afraid to use that language. They know their babies died and there's a lot in validating that loss with very specific words. Always asking what they need. Parents might look at you and say why are you asking me this but really deep down they often know what they need at the time of the loss. It's just giving them time and space to work that out and supporting them through that and we all know that platitudes don't work. Platitudes minimise the thoughts and feelings and emotions on the back of the loss and Bonnie touched on that with her experience. Next slide please. For me, as a bereaved midwife, I suppose this would always be a very difficult scenario. I've certainly been in it where in less than one day they, Melissa and Cameron happily pregnant in the morning she goes into hospital because her membranes have ruptured. Oliver was diagnosed as having died and then hours later he's born so it really doesn't give you opportunities for lengthy discussions around what to expect because the whole focus is on getting them through the labour and the birth and there's really only going to be time for preparation of whether or not they want to spend time and see Oliver. A knee-to-it reaction is really quite common to find there's ways to sort of work around that if parents have such a quick labour and birth and then want to leave then it's a matter of what a lot of my job is obviously supporting them to go home but really we need to work out a way to still offer them all those memory making opportunities and those parenting opportunities and that can come in the days following there's certainly no rush to do all that within the day so that's definitely something I would encourage any of you out there that's in similar situations supporting families decisions can always be left and you can always revisit them at a later time even if there was no post-mortem performed that can still be done a couple of days later if they want to go home. Next slide please. The difficulty with anyone experiencing a pregnancy or newborn loss at that particular moment is the intensity of the feelings that they're experiencing and usually they're in that state of shock so their heads in a fog they can't think straight there's so much fear around what's going to happen what is happening and then I think what I find with parents is they really dread the meeting of their baby and I loved hearing your story Bonnie because 99.9% of the time parents that say no to meeting their baby end up reversing that decision again given time and space and maybe multiple conversations to revisit and it's very rare that parents regret that decision. Next slide please. So look there's a lot of things that could have been different done differently but you know the horse has bolted it was a quick labour and they and Melissa and Cameron decided to go home so as I mentioned you know I would be saying go home and let's chat again tomorrow the next day and I've certainly been in that situation where parents have gone home because it's been such a whirlwind and then they've come back into hospital and we've had many more opportunities for discussions and everything that I would have done initially with them in the hospital I've been able to do it a later day and the GP notification I just wanted to mention yeah I know at our hospital we have an electronic way of notifying GPs it's automatic we do have to fill in the form but yeah I would encourage anyone to set that up I'm not an IT specialist but it's a very simple form that we do and it spits off to the GP with the whole history of that pregnancy or newborn loss. Next slide please. Memory making is a huge part of what I do with our families it's never too late a lot of you would understand the importance of memory making it acknowledges parenting it encourages a new and ongoing relationship with the baby who's died and allows parents to pack many memories for their grief for the future and you know the only thing I suppose that you might miss out on if parents leave you might miss the opportunity for photos and foot and hand prints but there is so much more you can do and I've had parents ring me and say I didn't do any of this and I wondered if it's possible and it can be years later and all it means is pull the medical history get what you can make a beautiful memory folder and that allows them to have some memory making opportunities. And next slide I think I don't know if it's up but that's not for me to discuss it was just there for this is more for later down the track memory making ideas. Thank you very much. Thank you so much Eliza and I think as both you and Bonnie have said it's such a transformational experience that the person and their feelings before the birth can be very different to the person and their feelings afterwards so being a student and helping the person through that transformation just seems so important. So thanks for your insights there. We'll move to our final presenter now who is Matthew Roberts as I think we met him earlier Victorian psychiatrist psychotherapist who's going to talk to us particularly about the psychiatric aspects of mental health of perinatal grief. Sorry Matthew I've given you a very poor introduction there but Nicole did much of the job earlier I'm sure. Nicole did a terrific job I wanted to call her Steve just to keep some continuity but thank you and it is it's an honour to be here alongside these women who've spoken so beautifully about an area that I'm drawn to and have been really interested in since before I started as a perinatal in the perinatal field I worked on a spinal unit in my training the Austin and that was one of the where I received an amazing lesson in how people adapt and how their brains sort of I guess process information every single spinal injury patient who came through the unit would be allocated to see us from the mental health team it wasn't a matter of waiting until there was a question of mental illness it was actually just everybody and that was so helpful one of the things that I learnt there was that people who'd had a spinal injury would often dream of themselves as in their pre-injury bodies for some months three to six months before acute grief can run for as a throw away figure on a PowerPoint slide it's a very steep curve at that stage but I'm really careful about making generalisations about that I just think the idea of allowing for the fact that the deeper structures in our brains don't have a clock or a calendar and can take a long time at the procedural memory level that is how to be with something that's where relationships live and that's how to play the violin lives it's in the procedural memory and that's where grief has to do its work because you can have your episodic memory this is what's happened to me you can have your semantic memory which is the sky is blue the grass is green and I have this loss that has happened in the world this is how I'd be with that it takes months and years and in some ways it is always going on I think if you've got a why for that if you've got some sense of what's gone on and your brain has been able to organise that experience and you have meaningful suffering that is a lot more doable than meaningless suffering and that's why that nature quote is there but I'll go back to that middle point on that slide the mental health of bereaved people depends greatly on how they're particular that is individual grief processes supported next slide please this is a tricky balance to get as a psychiatrist particularly the point at which I'm called called in I still want to recognise the wellness the health and the vibrancy of a remarkable natural phenomenon if unspeakably painful but I also don't want to miss major mental illness that can overlap with grief of course major depression but also post-traumatic stress disorder anxiety disorder substance use disorders other disorders we're learning to speak less and less I think these days in the language of disorder the illness model has definite limitations I'm a psychiatrist I'm just like a therapist and the therapist part comes linguistically from health from and health has in it the word heal that's what I was naming for that grief is a healing process and I think it's important to kind of muddle through to be patient to find out what's going on to make an assessment of risk factors such as those listed there on the slide but it can feel a little bit heartless poking away with long lists of questions so I tend to couch any sort of list of symptoms that I'm checking off in very much a sort of a meta way to say look I know that this is perhaps going to sound like a bit of a checklist but I need to ask you and so on next slide making a safe space is going to really depend it's horses for courses like so many of these things to do with grief what a safe space is going to look like for one person the silence could be just what one person needs the silence could be terrifying for the next person but 30 minutes I want to just make mention of if it's possible in your line of work to allow 30 minutes I think the difference between what seems to happen at an almost interpersonal neurobiological level between less than 30 minutes and more is a case of going from exchanging greetings and short stories to really having a sense that your nervous system is actually really connected with the other persons that's why we have comedies that go for 22 minutes on Netflix but if we want drama we generally go for more than half an hour again horses for courses it may be all you have that's less time but also maybe what somebody ideally tolerates is a bit less as well I think my predecessors here have spoken so beautifully about the idea of prioritising people's experience of issuing education I'm less comfortable in this role speaking now than I am sitting with somebody and listening and just trying to understand what's going on for them of course bereavement is complex it's common to finish a session feeling there's much left unaddressed I think that's magnified that's bereavement generally but perinatal bereavement is way more complex there are ripple effects for a perinatal loss where we're looking at there's mum, there's dad there may have been other people in the close circles and I like to try and think of the ripple effects of something that's going wrong in this way on the people around as well next slide please I think this is a really important point that there's no loss, adversity, trauma or suffering that can't be helped by the right team in good communication some of the most hair curlingly difficult cases that I've worked on have shown me this that in dark places if you're together with some other people you can do amazing work that you can be incredibly proud of you don't need to call yourself a grief specialist to be able to help and so I think bringing your humanity and bringing a clinical framework a set of boundaries and professional standards of course but I do think being allowed to approach and be present for a family going through this sort of thing is really very important I think my previous slide covered this a bit consider all affected by perinatal loss parents other children grandparents etc next slide please I wanted to touch on dads and grief I'm a member of the Australian fatherhood research consortium and the concept of psychological birth I find very helpful in working with parents of all kinds where you have two people who set out on the journey of starting a family where they're equally invested the concept of psychological birth is how a baby is born in your mind and they they begin to be born the day that as a kid you work out one day you could become a parent yourself that's when the psychological birth of your baby begins so however it works out whether it's infertility or loss on any step of the way further down the track a baby has been born in your mind already and it's 50-50 mums and dads or 50-50 between the parents so when there's a loss it's fair to assume that that's going to be 50-50 too much of this may not be conscious for men they may not feel that they have the permission to feel the loss or they may as boys have been raised to shut down their inner experience but it's safer to assume that their body is not about the loss that it's a stress experience that can come out through things like overwork anger overeating overexercise exhaustion those sorts of physical things as well working out how what's going to be acceptable form of help is going to work for each different dad is certainly a challenge in my work but the thing that a lot of dads will often say is that they weren't even asked so asking is a great start I think that's my final slide thank you thank you so much Matthew and I do want to acknowledge that we have given the presenters more time this evening than usual to present because there's just so much stuff to say so we are going to keep the discussion reasonably tight I'm going to skip this slide as well just to say for those of you with interest in this area keep an eye out for upcoming announcements about the opportunity to join a new Perinatal Network if you're quick you can hit the QR code but we will move on to the next slide now and I've been transfixed by the discussions or by the presentations being done but we have been trying to some make the questions that have been coming in one thing I want to acknowledge before we start there have been several questions before the webinar and even now about other times that children have been lost such as during the stolen generation and also forced adoption in more recent decades and we'd love to spend time talking about it it's really beyond the bounds of what we could discuss you've given us a great idea for further MHPN webinars but we won't be talking about that topic tonight particularly one thing that has come up though that I do want to explore with the panel is the issue about when a health worker himself has a Perinatal loss and then has to re-enter the workplace and whether anybody on the panel has any thoughts about what that person can do in terms of their own self-care while they go back to supporting other people through childbirth Bonnie you must have something to say about this Yes I mean there are some obvious things that I will say to start with for one I can't further the experience of a person returning to a workplace where this is so ingrained in what you do every day and it's also then ingrained in your life I have an office job in Canberra and I just can't compare but what I would say from my experience is to take the time to heal to walk away if you need to to remove yourself and to practice some of that self-care and I mean the basics of fresh water shelter, warmth eating well fresh air getting back to basics in terms of healing your body and your soul again I would say that to any bereaved parent but especially someone working in this space I think that is so important to do and not feel afraid to walk away but I just want to share a little story about my best mate in Canberra I met her after the loss of our first daughter she had just lost her first daughter and we connected through that bereaved parent community I've talked about tonight and we've become soul mates since then so this is seven years in the making around that time before I met her she'd sort of been thinking about becoming a midwife and knew that was something that she wanted to do but her stillbirth experience rattled her and she didn't know if she would really want to do that or could do that in future so she gave it time she left it for a while stuck with her office job in Canberra fast forward a year or so I was pregnant and we lost our second daughter she was also stillborn my best mate naturally came to visit me in hospital and she was brave she was actually her only friend that came to visit and meet our stillborn daughter she used that experience as a bit of a test to see if she could handle seeing dealing with another stillbirth experience seeing another stillborn baby and it was her meeting my daughter Matilda her moment where she realised she has to do this she is made to be a midwife and so she spent a couple of years sort of trying to get into the university studies and last year she graduated and she's now an amazing midwife in one of our Canberra hospitals and she definitely uses her bereavement experience in her everyday work whether it's the compassion for a bereaved parent or just the compassion for a parent going through birth it's definitely changed who she is so I guess there's two sides to that question go easy go slow take your time step away but also think about how that can shape your career and future and maybe make you bigger and better going forward that's what I would add to that Thanks so much Bonnie and Eliza this is very much your workplace do you have any thoughts to add to what Bonnie said I think communication is key I mean I'll only speak to the midwifery profession obviously being a midwife and a lot of midwives are of childbearing age so many many midwives have pregnancy and newborn loss and have to come back and pick up newborn babies and be happy for families you know it's an extremely challenging profession when you yourself have had a loss a perinatal loss so communication is key I think you need to speak to somebody senior at your workplace and make it very clear that there'll be situations and there'll be families that you will opt out of not supporting and not caring and I think they need to be given freely that permission to you know confidently ask for that and for the staff you know supporting them that that is absolutely completely acceptable it's going to be based on their timeline and their time frame and for many midwives they actually can't return to the profession because it is just too difficult Thanks Eliza and this case has been very much about an unexpected stillbirth or fetal death in utero there's been some conversation in the chat room about whether there's a different approach in your line of work when there's maybe a pregnancy that's been terminated late for medical reasons and whether you'll find parents react or you approach them differently in those situations The quick answer is for me personally supporting a family the reason for the loss is slightly unimportant slightly irrelevant and I know that might sound strange but it is how that family is presenting to me what their particular and unique needs are for what support I can give to them so the only thing I would add and the majority of the families I support are actually second trimester later second trimester terminations for medical reasons the only thing I would add is guilt and self-blame are probably more huge for that cohort of parents who have made that extremely difficult decision to end their pregnancy because of a major anomaly or a difference being found and usually that's on that 24 that 20 week morphology scan and then they come to us to be induced around the 2021-22 week mark but no answer is definitely no the support anybody gets regardless of the type of loss that they've had is the same as far as I'm concerned okay thanks for that there were some also there's been a question about when we're leading into the webinar there are lots of questions about what differentiates I guess normal grief if we can call that out from what could also be called a maladaptive response this is for Matthew I guess or maybe Nicole about whether there are certain approaches dealing with prolonged grief which we understand does have its own diagnostic categorization and any particular approaches to that and Matthew I'm going to particularly ask you about fathers who experience prolonged grief just to narrow it a little bit any thoughts from you I think the framework that lets us ideally get to get to know our patients a bit longitudinally rather than cross-sectionally is certainly helpful we can go through the diagnostic checklists to see if there's a comorbid depression substance use anxiety problem etc but I think that I'm most curious if someone's grief is going on for a long time I'm most curious to provide a space in which they can talk about that and to try and understand what at the level of meaning might be behind it and not just verbal meaning I also think that when you get to observe somebody in a safe enough space and you see what their bodies are going through there can be somatic elements that have been presented to a GP or in the blokes case often not but that trying to get a sense of where this loss is being experienced in a patient's body those sorts of things help make sense of somebody and I'm treating them very much like not so much a patient but a full human suffering for a long time and I'm trying to make sense of that so yes if there's depression anxiety substance use problems post-traumatic stress disorder we're going to seek to treat those symptoms but making sense of prolonged grief in a narrative sense I think I'm going to be very curious about too Okay, thanks and Nicole I don't know whether Matthew broke your GP heart of the idea or the truth that 30 minutes is a great time to spend with people getting into deeper material the 15 minute GP consultation I guess if Netflix is 15 minutes 30 minutes then we're talking about tiktok I guess with the way GP's funded any thoughts from you what do you do somebody needs time and you've got a fully booked list Yeah, look if I know that they're coming in for bereavement I tend to put them in my last appointment of the morning so that if I go into lunch it is what it is that's fine also I'm not scared and I know this can be hard to do but I will often say to someone you know I don't want to feel like maybe you are I rushed in this situation you know let's have our consult today and I'm going to I'm going to make time tomorrow or the next day or whatever I'm going to bring you in for a longer consult then and I'll do some rearranging to make that happen so I think people are really appreciative of that and you know it's stressful if I I'm running two hours behind it doesn't happen very often and it's really stressful as a health professional isn't it when you know you're running really late and you think oh jeez I'm going to be in here for 45 minutes so I'm really up front with people quite early on in the consult and I say let's chat today and then let's really make sure we allocate time for you to sit down and continue this conversation the next few days right thanks for that this might seem a very specific question for the panel but it came up several times before the webinar I think it will summarise a number of other issues that remain unaddressed and we are running out of time unfortunately but the question was what experiences of panel members had with one twin dying and the others surviving and what specific strategies have you used in that situation if it's a good functioning Eliza it might have happened in your practice yeah absolutely yeah quite semi-frequently and as as we're obviously getting older as a population and more and more IVF we are seeing more and more multiple loss so it's a really really difficult one for the parents they there's this push-pull they want to grieve and spend time with the baby who's died often in my experience the other twin is actually unwell and often in the nursery or the Niku so they sort of look at you and they don't know whether they should be in Niku spending time with the baby or whether they should be in their room on the ward spending time with the baby who's died I think the important thing and the way I approach it is I give them that permission to at that moment that hour that day to try to work out what is the priority at that moment so if the other twin is not so is struggling or unwell in the Niku then sometimes it just takes someone to say feel free to go and spend time with your baby your baby needs you in Niku and giving them that permission that they're not abandoning the other baby the other twin that has actually died I sometimes give them this this wonderful analogy that someone gave me years ago of you can't wear two backpacks on your back at the same time you take one off and put it next to you that's the baby who's died that backpacks going to be there always and you can come back to it and dedicate the time to grieve when there's that time that's needed to grieve your baby but dedicate time to love and support and continue caring for your baby and a lot of decisions can wait so the baby who's died all the decisions around the baby and funeral and paperwork and registering all that can wait until the priorities are worked out and the timing according to the other twin right thanks for those insights we unfortunately do need to bring things to a close and going to ask each person for just one minute wrap up of their last word and Bonnie it has to be you starting thank you Bonnie yeah I promise I'll be quick I think you've been given a whole bunch of information today and I want you to take it all the way with you and arm yourselves hopefully with more guidance and support for bereaved parents now but it's a rapidly evolving space I know since my experience of stillbirth 2016 2017 you know we're talking six seven years ago so much has changed even in that short amount of time the government's really stepped up their efforts to support hospitals and Australian communities supporting bereaved parents we're hearing about it more in the media and the news I certainly hadn't heard much about infant loss before it happened to me and then in the last few years I've definitely had my door knocked down by journos talking about our story and it's been in the media a lot more about stillbirth and infant loss people are really committing to doing something about it now I think so with that I would just ask all of you to keep abreast of all of the information keep an eye on the news keep an eye on the articles that are hitting your networks and the professional journals that will probably talk more about infant loss now more so than in the past stay tuned on the rednose website there's regular events, regular news items and just a quick plug rednose day next month is one day one way you can get involved in this and it's just in the next few weeks really in August that's from me thank you thank you Nicole your summer I guess my main point again is please don't forget someone's GP in all of this it sounds like Eliza where you are you're all over it but unfortunately where I work we are not so please don't forget a patient's GP and their role in this and also speaking as one health practitioner to another we need to be kind to ourselves as health practitioners so if you feel as though you see a bereaved parent and perhaps you felt like you didn't deal with it as well as you'd like don't be too hard on yourself there will be lots of opportunities to offer support and perhaps say what you think is the right thing next time you see them right thanks for that Eliza your last words I'll be very short and sweet my take home for everyone is just remember the parents of the experts in their baby's bereavement care ask them what they want, ask them what they need they might not know it at the time but they will get there right thank you very wise and Matthew your last words yes look I'd say I like a good healthy question I think that hopefully we've answered a few tonight but hopefully with for every question we've answered we've generated a few more and some good conversation please feel free I'm on LinkedIn and I'm very happy to receive any questions which I've not been able to address it was such a huge area to try and cover tonight and I wanted to tell you absolutely everything I've ever known about grief because particularly perinatal grief is just such an important topic and very dear to my heart finally if somebody needs help or if you need help around perinatal grief and loss find someone who gets grief ideally someone who gets perinatal grief but more importantly find someone who gets you and if I had to choose the one thing it would be find someone who gets you the rest you can educate them if you have to Thanks Matthew I must confess I'm running out of Eurocoins to feed into the internet slot here in this internet cafe in Hanyo that I'm in so we're going to have to finish up right on time I won't go through in details these final slides but I will ask you to please fill out the evaluation that's really important so we can make these webinars better and make sure that we're hitting the mark for the people who are attending remind you the recording is available if you wanted to review it or to recommend it to other people who might not have been able to attend tonight and there are a number of other webinars coming up you can see them listed there I particularly point out the podcast series and in fact there's one there which relates to Pete Walker who's been experts by experiences the latest ones are definitely worth listening to I don't want to close this but I will have to but before I do I would like to acknowledge the lived experience of people and carers who have lived with mental illness and the consequences of life's experiences in the past and those who continue to do so and so we thank you to obviously our fantastic panel tonight but also to all of you who have attended and we wish you all the very best for the evening ahead and please stay well thanks so much, good night