From Perinatal Loss Trauma to Parenthood: Experience in a Maternity Hospital

Abstract

Working in a maternity hospital involves listening to the mobilizing effects of a baby’s arrival on parents' psychic condition. Waiting for a baby is also a parenthood-building time. The aim of the current study is to address the challenge of parenthood in perinatal loss cases. Parents face the real twice when it comes to stillborn babies, or babies who are born alive and live for a short period-of-time, since the baby’s arrival is also a farewell. We herein return to the concept of trauma in psychoanalysis to address some aspects of perinatal loss impact on parenthood.

Keywords:
parenthood; trauma; real; psychoanalysis; maternity hospital; clinical case

Resumo

Trabalhar em uma maternidade envolve a escuta dos efeitos mobilizadores que a chegada de um filho tem sobre a vida psíquica dos pais. O tempo de espera de uma criança também inclui um tempo de construção da parentalidade. A questão que aqui levantamos é o desafio da inscrição na parentalidade diante de situações de perdas perinatais. No caso de bebês natimortos ou que nascem e vivem por pouco tempo, os pais se deparam com um duplo encontro com o real: a chegada do bebê que é, por sua vez, também uma despedida. Propomos retomar a noção de trauma na psicanálise a fim de discutir alguns aspectos em torno dos impactos da perda perinatal para a inscrição na parentalidade.

Palavras-chave:
parentalidade; trauma; real; psicanálise; maternidade; caso clínico

The current study addresses a specific clinical situation based on psychoanalysis insertion in teamwork performed in a maternity hospital focused on high-risk pregnancies, namely: the silent childbirth of a woman pregnant with twins who faced the news that her babies would not survive. Gestational loss cases are anguish sources to both parents and family members, as well as to healthcare teams and to us. In these cases, the aim of therapeutic listening intervention is to promote traumatic-event elaboration and to favor parenthood-building.

Based on Buckle and Fleming (2021) and Marshall and Davies (2021), enabling the psychic elaboration of a traumatic event can also affect parents’ relationship with older children and the way they deal with future pregnancies. Accordingly, the current study followed the proposal by Alves and Martins (2021), who drew attention to the relevance of developing public policies to guarantee, in the long term, the possibility of building parenthood, mainly when traumatic events can hinder this process. In their own words, “it is essential developing policies to provide parents with the emotional availability necessary to fully care for their child” (p. 463). Currently, some laws have already been proposed to guarantee the right of women and families who have experienced gestational loss to receive psychosocial care in health units in order to have time to mourn and to say goodbye to their baby (Law n. 7.209, 2022).

Ansermet (2003) stated that being born or dying has no representation. A child’s arrival into the world brings forth a series of questions moored in the core of every neurosis: “What does a woman want? What is a father? Where do children come from? These questions are asked throughout one’s life” (Ansermet, 2003, p.21). The child implies an enigma, since its birth confronts us with a subjectively inassimilable situation that “cannot be reduced to either reproductive biology, nor to genetics, family history or subjectivation of parental needs [...] Where do children come from? Here is a question that has no answer.” (Ansermet, 2003, p.21). First and foremost, it is about following the transition from not-being to being.

Pregnancy is the power to conceive a life, i.e., the ability to inscribe a new human being in the dimension of life, although, at the same time, it also makes one face the inscription of both that human being and itself, in the mortality dimension. On the one hand, this aspect attributes a phallic power to motherhood, but on the other hand, it exposes women, as speaking beings, to subjective division and castration. This process often leads to concessions and guilt, given the fear of not having enough feelings for the child, of not being able to protect it and to give it what it needs, of dying and leaving the child defenseless, and of producing milk incapable of nourishing it. There is also the feeling of guilt or failure in cases of comorbidity during pregnancy.

Pregnancy is a time of intense psychic experiences. Parenthood does not stem from biological bond; it is built through the relationship among adult persons (as desiring subjects), social discourse and daily coexistence, and care provided to the child. We believe that the way of anticipating and narcissistically investing in a baby has to do with several aspects of the process to build a place for oneself as mother or father. On the one hand, the baby emerges as object in one’s fantasy: giving a child to the husband/wife, as well as giving a grandson, a sibling, among others. On the other hand, a baby’s arrival presupposes the baby-waiting process: “The anticipation of its arrival, which comprises identifications and fantasies, enables building something in the order of psychic domain in order to welcome it” (Iaconelli, 2007, p.616).

If one takes into consideration the “birth-related prematurity in man” described by Lacan (1949/1998, p.100), or the “primordial helplessness” condition referred to by Freud (1895/1996a, p.370), each human baby comes to the world unprepared to survive, unlike many other mammals and animals, in general. It seems like there was not enough accumulated instinctive knowledge for its survival. This essential feature lives up to the symbolic constitution of the human being, based on its bond to other humans, which enables its fellows to insert it in a given culture to form a network of both knowledge and records of experiences that are more complex than any instinctive inheritance.

More than just being born and developing, a human being is an effect of language. For a human being to emerge, it needs to be said, it has to be a place where it can insert itself in the order preceding it. Thus, “it is not the one pulling the symbolic strings. The sentence started before it” (Lacan, 1958/1999, p.192). The child is born from this ‘bath of language’ preceding it, from the story its existence begins in. These words both pre-exist and concern this human being, and it implies the story of each partner in its singularity and the story of the couple.

The project of becoming parents, in its turn, although shared, has different meanings and implications for each person, since each one is also father or mother, based on its own singularity. According to Szejer and Stewart (2002), the child’s prehistory is featured by the encounter of two partners, which is also the encounter of two family lineages. Each partner carries its said and unsaid story, as well as its stumbles and misunderstandings, which generate its specificities. Each member of each lineage - parents, grandparents, uncles, aunts, among others - has its own version of this story. In addition, each one of them also has its place (in relation to others) in this family lineage: they are the first child, the one who came after many attempts, the smart one, the devoted one... Regardless of the way this couple was formed, whether just for the time necessary to raise the child, or to stay together for years, this is the basis constituting the child as subject.

Thus, each partner lives the experience of the child who passed away and the relationship it had with its own parental figures. There are also their individual expectations about their offspring, and about what they want to pass on to them, from the perspective of continuity and extension of themselves; be it what they think is right to discipline and educate, or from the aspect of giving their offspring what they did not get during their childhood, or of encouraging their children to make their dreams and ideals come true. All these factors affect parents’ expectations about their children, even before they are born, and even before they are conceived.

There is an image built for the baby to be born, and it wraps the embryo or fetus in an imaginary scene. Among these images, one finds expectations about its physical or psychological features during pregnancy, right after birth and after growing up. Such expectations have to do with parents’ psyche and with their story. It is known that the construction of an image also demands covering up flaws and mistakes, in order to always point out an ideal that, in reality, does not come true. When this reality is revealed, we can see what Freud (1919/2010) had already identified as disturbing strangeness.

The Birth of a Child

Although the arrival of a child brings much joy, it can also give rise to strangeness: “A child, from its birth, from its insertion into life, can embody an unthinkable, inaccessible real that goes beyond itself” (Ansermet, 2003, p. 27). Several varying reactions can emerge during the pregnancy-puerperal cycle and trigger different psychological suffering types, such as postpartum depression, puerperal psychosis, among others.

These reactions can manifest themselves as euphoria produced by phallic equivalence, according to which, the baby represents the phallus (hence the popular expression “to be full of oneself”, which results from frequent observations of pregnant subjects who have a narcissistically inflated self-awareness), but also as reactions involving anguish and horror (Iaconelli, 2020; Soler, 2005; Szejer & Stewart, 2002). The news of pregnancy, of being pregnant, be it planned or not, involves coming across something so new that it cannot be imagined before and escapes any prior preparation.

At the same time, the baby born, as language being, is also attached to the mark it receives from the Other: “There needs to be language to enable the demand to be articulated, since it is the only factor allowing this body to be ‘corporealized in a significant way’” (Soler, 2005, p.92). In other words, it is necessary turning the symbolic factor capable of attesting to the power of constituting a given body in its erogenous aspect into an instrument - at the emergence of a being that mainly finds itself, specially at the beginning of its life, dependent on another being, who is able to meet its vital needs (Freud, 1895/1996a). If one takes into consideration that being a mother is not previously or automatically associated with the condition of being a woman and of getting pregnant, it is possible to say that a given subject may, or may not, play the maternal role for a baby, regardless of this condition.

Besides enabling the biological development of the fetus, pregnancy is a time of events that take place in the psyche of the person who will play this role for the newborn. What is at stake in the news of a positive pregnancy test? The plans of each partner and changes in each person’s position in the family, changes in the mother’s body and routine, financial concerns, doubts about whether she will be able to take care of the new baby, about whether the subject will be a good mother or father, if it will be able to love this child, if that was really the right time … We know that the exact time for one to feel prepared to do it does not exist. Given so many implications, Maldonado (1985) has pointed out that “no pregnancy is fully accepted or rejected” (p. 27).

The idea of maternal function is a guide for thinking about the initial operations to form a subject. Accordingly, Lacan’s (1969/2003) reading of the Freudian text enabled separating the mother figure from the function triggering the bond between the baby and the adult subject who takes care of it. Thus, the concept of maternal function points towards a function that may not necessarily be performed by a woman or by the biological mother. This bond works as foundation for the relationship to be developed between the subject under formation and the primordial Other.

Freud (1895), in his posthumously published text “The Project for a Psychology”, has identified this person as the Nebenmensch - the person next door, the complex of the Other. This Other is the person accountable for fulfilling the newborn’s first demands, which will be constituted as imaginary, symbolic and real. It is primordial because it is the Other in the dual relationship that enables building the image of one’s own body. It is symbolic because it transmits the treasure of signifiers through the function of providing signifiers in order to articulate the newborn’s demands. Finally, as barred Other, it provides the necessary failure, based on which the subject can emerge (Kosovski, 2001) from both discontinuity and from differences towards the primordial Other; in other words, by introducing the real failure to the child.

Concepts, such as maternal and paternal function, have been used to think about the constitution of a subject. By shifting the focus from babies to their parents or caregivers, it is possible to see the psychic work that parenthood, in its turn, requires from subjects who will call themselves mother or father. According to Iaconelli (2022), parenthood-building contingencies belong to the order of singular act, rather than to that of biology. It follows a path that goes from gestating a baby to likely calling oneself mother or father. Occupying this place is onerous for a baby, not only because it needs to be taken care of, but, above all, because this process requires psychic work.

According to Garrafa (2022), the body’s reproduction does not necessarily lead to parenthood. One’s introduction to parenthood does not directly result from pregnancy and childbirth; it is the act of a subject who invests in its singular desire and who takes the role of a child’s mother or father. Important elements are used to approach the density of this act, as well as its inherent ambivalences and vacillations.

Calling oneself someone’s mother or father has the power to change the family composition and to establish new kinship relationships: “Parenthood involves inserting the child into a family chain and occupying a ‘hinge’ place within it, between generations, as the articulating point of what will be transmitted through a given surname, or not” (Garrafa, 2022, p.59). It is a significant support for the nameless person who takes a position towards a child’s arrival; a position formed upon joining parenthood.

Thus, getting a positive pregnancy test does not mean that one already feels like a mother or father. The feeling of ambivalence - found in each and every bond of love - is quite common, mainly at the beginning of pregnancy, when the news brings along changes both in family life and in individual plans, regardless of whether the pregnancy was planned or not. Feeling pregnant is also not the same as having a psychic place for the child, or as perceiving it and seeing it as subject other than oneself.

According to psychoanalysis, maternal love, like any love, is structured by fantasy. The alienation inherent to love is taken to a higher level in the mother-child relationship, since, in the beginning, the baby is not yet a subject, but object in this relationship (Soler, 2005). According to Ansermet (2003), “the encounter with the child is, above all, the encounter with what remains of symbolization, which escapes any thought, any story, any representation called real by Lacan” (p.27). He relaunches the shift from the object to the subject position and invites each adult person experiencing this bond to deal with its own fantasy, with the place it occupies in its own family story and with the version of this story built by it.

According to Iaconelli (2020), loving and devoting oneself to a baby is a re-actualization of oneself wrapped in promises and narcissistic identifications. Based on projections and identifications, the baby is libidinally invested in by the narcissism of whoever occupies this position. After the baby’s arrival, this person must also mourn this fantasy. However, what happens when the baby is unable to respond to these projections and identifications? What if the baby suddenly dies? What if it is born with severe malformations? Perinatal losses lead to an abrupt break in the expectations and anticipations supporting the baby's place construction as one’s child, and it affects one’s self-perception as mother or father.

Freud(1914/1996b), in his text on narcissism, advocates that the parental attitude is a revival of one’s own narcissism: “parents’ love [...] is nothing other than their narcissism reborn that, once turned into object love, unequivocally reveals its previous nature” (p.97). This reborn narcissism can express one’s continuity in the legacy left through a child. That is the reason why the loss of a child is so inconceivable and so unspeakable.

Some studies (Braga & Morsch, 2003; Iaconelli, 2007; Muza et al., 2013; Soubieux, 2014) point out that failing to acknowledge parenthood in the case of stillborn babies or perinatal death affects the grieving process, given the hard time giving a baby’s death the status of death of one’s child. The current study aims at addressing aspects about one’s acknowledgement of parenthood in a perinatal loss case based on what was observed about psychic incidences in the case of stillborn babies or of babies who do not survive the early hours after childbirth. If, on the one hand, having a baby means meeting the real, on the other hand, losing a baby is a radical way to meet such a real.

Methodological aspects

The current study has followed the psychoanalytic clinical methodology associated with its theoretical elaborations. It was done to enable both deepening and going forward in the existing theory. According to Guerra (2022), the clinical practice works as paradigmatic foundation for psychoanalytic research. Freud (1923/1996d), in his turn, sees research, clinic and theory as inseparable elements. Theory, in psychoanalysis, is tested in the clinic and theoretical advancements resulting from this process. Thus, if the psychoanalytic theory guides the clinic, the clinic, in its turn, is essential to move the theory forward.

Lo Bianco and Costa-Goura (2013) raised a fundamental question for psychoanalysis research. It lies on how to create the conditions to enable and instrumentalize a research practice in tune with the distinct and original field resulting from Freud’s discovery of the unconscious. The experience of listening to a perinatal loss case, as well as the challenges linked to it, points out the clinical practice as testimony operating with the unconscious that is structured in the same manner language makes us come across with something that also escapes language. As a method, it is about positioning ourselves in the place of researchers who allow themselves to be affected by a given matter that, after all, guides the research. Thus, there is something in this matter that, by implicating the researchers, encourages their work.

The very work on a given concept in research starts from assuming this concept as unfinished. It is not a mere search for what has already been written. Such a concept is a field to be built and recreated at each time, at each situation; yet its possible conditions must be produced in each case. Freud and Lacan, who are fundamental to psychoanalytic research, did not directly address perinatal losses or the concept of parenthood. They laid foundations for the clinical practice, but they did not end the issues. Their paths allowed some publications on this subject (Braga & Morsch, 2003; Garrafa, 2022; Iaconelli, 2020, 2022) to make the theory, and its concepts, advance, based on new challenges found in contemporary times. Thus, the current article took this path to build formulations mainly based on practical actions in order to update this theory through clinical practices and not-knowing.

According to Wieczorek, Kessler and Dunker (2020), it is possible to put the theoretical framework of this movement to the test and recognize ourselves as tributaries of the discourse we are part of. It is the articulation of the psychoanalytic act in clinical practice and the subsequent theoretical act in the text. Clinical cases in psychoanalysis are an argumentative tool for its clinical effectiveness, which is the reason why psychoanalysts often use clinical entries in their texts, as observed in the herein presented case. Clinical effectiveness, in its turn, can be observed through its effects on the subject. This line of thinking is in compliance with Lo Bianco and Costa-Moura (2013), who argued that both theoretical and analytical acts depend on ethical positions whose effects will be found in a later on. It is mainly explained by the Freudian position of not backing down from the unusual facts introduced to him by the clinical practice.

Clinical practice for a Double Encounter with the Real

Larissa¹, 21 weeks pregnant with twins, was admitted to the emergency room upon recommendation from another hospital, so she could be assessed by the Fetal Medicine team. She was looking for a place to undergo morphological ultrasound. The ultrasound performed in the maternity hospital emergency room has indicated Twin-to-Twin Transfusion Syndrome². In addition, one of the babies did not show any heartbeat. She was about to be hospitalized when her water broke prematurely right in the emergency room. Then, she was taken straight to the Obstetric Center. If the babies were born at this gestational age, they would be medically unviable.

A psychologist was called by the Obstetric Center team, and he perceived the pregnant woman as impatient, tearful and aggressive towards the team. Larissa was in bed, feeling some labor pains. She said that she went to the maternity ward to have the babies assessed due to suspicion of heart issue in one of them. Then, she harshly asked “why don’t they just give me some medication? They are going to die anyways. How long will I have to stay here? I just want them to take this thing away from me, soon.”

The psychologist was not yet aware of the pregnant woman's medical condition; thus, it was necessary talking to the obstetrician to help better understand Larissa statements’ context. The obstetrician explained the situation and pointed out that one of the babies was still alive, so it was not possible to introduce medication to induce labor, which, in this case, would be abortive. Without knowing very well what could be done for the patient from the psychological intervention perspective, the following question emerged: What can be listened to in a situation like Larissa's: a sudden event that even hinders the possibility of putting it out in words?

Because Larissa was still pregnant, we took that direction and asked her to tell us a little more about her pregnancy. She reported that the pregnancy was planned and that it was strongly desired by her and her family. She said that she already knew the sex of one of the babies and that she had even chosen his name: André Luca. The possibility of talking about her pregnancy, unlike what she was experiencing at the time her water broke, gradually allowed Larissa to say that she was afraid of getting attached to them and, consequently, of suffering even more. Her harsh and aggressive attitude seemed to show her suffering in dealing with the reality that her water had broken and that there were no means to reverse the situation.

She had been informed that one of the babies was dead and that the other would not survive because she was in labor. Larissa said she had a three-year-old daughter who was born by caesarean section, so she had never been through labor until then. She was faced with an unknown childbirth experience, knowing that her children could not survive ... Where would she find the strength to undergo this delivery process?

This intervention took place when Larissa was lying on a hospital bed and surrounded by other women in labor. Just as Larissa placed the question on how to endure her own delivery process, the patient in the ‘box’ next to hers got to the expulsion stage. Other members of the team approached that ‘box’. We started listening to the patient's companion in the box next to hers, and the medical team, speaking louder and encouraging the parturient. They mentioned the baby and its name, asked her to think about the baby in order to gather strength, because it was already coming. Larissa listened to these lines in silence, until she heard the newborn crying.

Then, the psychologist tried to make Larissa talk a little about what was going on: the hard time going through labor knowing that the outcome would be quite different from that in next box. After hearing the baby cry, Larissa cried a lot too. Her husband, Washington, arrived at the hospital right after that, so it was possible to talk to them about the hard time they were facing. The information that one of the babies had already died, although the other was still alive, was revisited. We did not know how long it would live after childbirth, for a few minutes maybe; and that would give them time to be with it, to have a moment after delivery to stay with it, and to hold it in their arms if they wanted to. They could do the same with the other baby; they could see how their babies looked like. Both parents were quiet, but attentive.

Delivery happened at dawn. One of the babies was born alive, weighing less than 400g, and died shortly after childbirth. The other was stillborn. Receiving such a hard news and still having to go through labor ... What is it to give birth to a dead or unfeasible baby? It means facing death in a much real way.

Where do we find this real? This question was asked by Lacan (1964/2008) in his seminar on the four fundamental concepts of psychoanalysis. A meeting with the real, which is essentially at fault, escapes symbolization and, therefore, belongs to the order of meaningless and unbearable elements. According to Lacan (1964/2008), it is remarkable that, at the source of analytical experience - i.e., when Freud founded it - the real was presented in the form of what is inassimilable in it - in the form of trauma, as an event capable of unexpectedly affecting us as subjects. This process leaves us without resources to symbolize and elaborate it.

Could we resume this inassimilability aspect in Larissa's case and identify the encounter with this double real - giving birth to two babies and face their deaths - as traumatic situation? The concept of trauma must be revisited in order to answer this question.

The Concept of Trauma in Psychoanalysis

According to Berta (2015), since the early days of psychoanalysis, trauma has presented itself in its accident-like nature and imprinted an excessive excitation that is not processed by the psychic apparatus. More than a century ago, Freud analyzed hysterical symptoms and announced to the world the trauma housed in the unconscious. Simultaneously, the interest in this topic emerged in its association with culture, with railway accidents and, above all, with the impact of the World War I (1914-1918).

It is important highlighting the way Freud became interested in this issue and how he linked it to both language and the unconscious. According to Caldas (2015):

Trauma is not a term specific to psychoanalysis. It was likely brought in by Freud from the medical field, which describes different trauma types. However, it is necessary emphasizing the different way Freud applied this term. Trauma, in Greek, means “wound” and it metonymically came to indicate an event causing the wound. In psychoanalysis, Freud located trauma in the unconscious work on the wound [...]. It is necessary clarifying it because the violent event supposed to cause the trauma is often confused with trauma as psychic work. [...] The work of psychoanalysis is, precisely, to embrace trauma in its “elaboration” (p.1).

According to Soler (2021), from the very beginning, the idea of trauma was presented by Freud as hypothesis to try to decipher the emergence of symptoms. Freud thought of symptoms as effects of a given trauma - which took the form of an accident in history. Thus, it was something contingent.

In 1920, Freud introduced a definition of trauma based on the amount of excitation that cannot be tamed; in other words, he approached trauma from an economic perspective. This definition was not brand new. He had already developed some bases in 1895 / 1996a, as well as in 1917, when he said in a conference that “the term 'traumatic' has no meaning other than the economic one” (Freud, 1917 / 1996c, p.283). However, it was in 1920, with Beyond the Pleasure Principle, that Freud expressed the thesis that the impact of intense excitation can be considered traumatic:

In this case, the pleasure principle is initially put out of action. The flooding of the psychic apparatus by large amounts of stimuli can no longer be stopped. What happens is much more the emergence of another task, that of mastering the stimulus, of psychically linking the amount of stimuli that have erupted (p.113-115).

In other words, excitation needs to be contained through speech detours capable of bringing it from representation to representation. However, there are cases where the psyche is no longer able to contain the amount of excitation and, like a needle in a scratched vinyl record, it always returns to the same point. This is where Freud locates compulsion, which results from internal motions that can have impact similar to those deriving from external sources.

Thus, Freud aimed at showing that both external and internal motions can have traumatic nature and that their subjective effects on the individual are the factor determining the traumatic aspect; he differentiated the psychoanalytic concept of trauma from a version of traumatic neurosis conceived by the shock theory, which attributes this feature to external events. Based on the psychoanalytic concept, the etymology of trauma would be lesser linked to a purely external factor than to its psychic elaboration, such as the surreal need to elaborate terror and the threat to life.

Freud highlighted that the main weight of causation in trauma seemed to fall on the surprise factor. Accordingly, he stressed that fright³ “refers to the state one enters into when one faces danger without being prepared for it” (Freud, 1920/2020, p.73). This condition lies on lack of readiness to face distress, which includes overinvestment in systems firstly accounting for receiving stimulus. These systems are not in a position good enough to connect the amounts of incoming excitation due to lack or readiness; therefore, the consequences of breaking the protection set in much more easily.

In order to better describe it, Freud (1920/2020, p.71) distinguished 1) Angst (anxiety) - which designates a certain state, such as the expectation of danger and the preparation for it, even if it is unknown -, 2) Furcht (fear) - which requires a specific object to be feared-, and 3) Schreck (scare or dread) - which names the state one enters into when one faces danger without being prepared for it, and it enhances the surprise factor.

According to Freud, in economic terms, the traumatic moment can be read as encounter with danger, and the subject is deprived of the necessary means for operating the pleasure principle before it, as well as it is affected by an intractable excitation that he/she is unable to channel and redistribute. In Lacanian terms, it is the encounter with a real that has no correspondence in the symbolic domain, which assaults the subject and suspends the possibilities of symbolization and expression. Freud kept the subjective implication in suffering until the end of his work, and established trauma as non-generalizable element, although with unique aspects to each person.

Trauma as Encounter with the Real

We believe that trauma refers to a real that assaults the subject, a real that cannot be anticipated or avoided, the excessive excitation that is not processed by the psychic apparatus. Lacan (1964/2008) makes it clear that trauma has a structure, because there will always be something that cannot be processed, and it corresponds to the primordial lack of each person. Each subject creates its own ways to deal with the real, depending on its story, by making certain choices; it is the way subjects build their fantasy or, as Freud called it, their family romance (Freud, 1909/2015). Therefore, these situations refer to what Lacan has formulated - based on his reading of Freud's work - as the primordial trauma marking each subject in its relationship with the Other, which is joining language.

Language also implies the impossibility of translating everything into it. Hence, Lacan (1964/2008) says, “We must distinguish between the resistance of the subject and that first resistance of discourse” (p.72). It is essential to understand this differentiation at the time to conduct analytical listening. It echoes on the function of interpretation in analysis and on the idea of resistance. The limit presented by remembrance does not only concern a limit linked to the patient's resistance and defense. It is a limit of language itself, since language cannot say everything.

The current study addresses the birth of a child as encounter with a traumatic real that requires psychic elaboration to build parenthood. It delves deep into the relationship between this aspect and the experience of giving birth to stillborn babies and to babies who die right after birth. It was done by bearing in mind that we are faced with these events in hospital practice, at the very time they take place. This factor requires us, as psychologists, to make an effort to elaborate these events together with medical teams. We must deal with these situations and provide support in the preparation of those who experience the loss of a child (or children) as parents.

Encounter with sex and death are encounters with something real, which is also the origin of psychoanalysis. Death and sex are names of the real that language cannot express; these elements constitute something that has no inscription in language, at all, and that is always somehow found in the very core of phantasmatic elaborations, since the subject seeks to fill up this gap in its fantasy. Fantasy is an artifice that symbolically ensures the subject who faces constant encounters with the real. However, as Freud used to say, there are some encounter types capable of surprising us, and this is the aspect of trauma identified by Lacan (1964/2008) as rupture in the screen of one’s fantasy. We can say that traumatic situations are those where the subject does not find material evidence to support its fiction, and this is the time when the screen opens itself (Berta, 2015).

The subject faced with the real will try to deal with it through language, through the signifying chain, despite the fact that the real is meaningless, distressing, traumatic (Alberti, 2009) and always returns. This return appears to have two aspects. On the one hand, it summons the signifying chain movement; on the other hand, there is always something impossible to be symbolized, i.e., meaningless. Lacan addressed this aspect in 1964, when he borrowed two terms from Aristotle, in his investigation into the cause, namely: tykhê and automaton. Interestingly, Aristotle investigated the causes leading to different effects on reality and described these two elements, whose efficiency escapes due to lack of intentionality. It comes close to the discussion about the event that escapes any prior preparation and its traumatic effects.

Automaton would be the cause the subject is subjected to, in the same way it is subjected to the chain of signifiers, i.e., it is what determines us based on signifying determinations, from compulsion to repetition, “which led Lacan to identify the Zwang of the signifying chain” (Alberti, 2009, p. 184).

Lacan defined the function of tykhê as encounter of the real, or the real as encounter - encounter essentially seen as missing encounter. He related it to automaton in the following way: “the real is beyond automaton, the return, the coming back, the insistence of signs allowing us to see ourselves ruled by the pleasure principle. The real is what always lies behind automaton” (Lacan, 1964/2008, p.59).

Every encounter with the real necessarily has both aspects: tykhê and automaton. Automaton describes the way the subject deals with the real, in an attempt to inscribe it in the signifying chain, which always repeats itself: “It is, therefore, through automaton that the subject associates every new encounter with the real, which is traumatic by definition, in the series of Vorstellungsrepräsentanzen, i.e., the subject associates it with the signifying chain around trauma itself” (Alberti, 2009, p.194). However, there is something that escapes signification, which turns it into a re-actualization of trauma, namely: tykhê, which is “the moment when the speaking subject is unable to express itself and does not find representatives and signifiers to describe a given experience, be it sex-, pain-, death- or loss-related” (Alberti, 2009, p.191). Trauma lies on the fact that there is a gap in the fabric of signifiers.

As a psychoanalyst, it is challenging to come across a situation like Larissa's, to meet her at the time the traumatic event is taking place. According to Berta (2015), it is about the contingency of a given scene, at the time of the event, which reiterates itself and resists any elaboration. However, the way the subject talks about the event shows that it can be built through articulation with language. The event is told through the subject’s speech. The goal is, precisely, to give space to speech, to open room to rebuild the fantasy fiction and to generate conditions for the speech to arise: “It is necessary opening oneself up to the time of understanding, which is a way to respond to the action that can be promoted by the subjective suspension of trauma” (Berta, 2015, p.182).

Larissa's case has shown that operating with an unconscious structured like language in clinical listening also includes what escapes it. These are challenges and impasses faced by the psychoanalyst itself, but it was the path we were able to take together with her, as well as with Washington (the children's father), in order to provide the right conditions to work through the traumatic event and restore the parenthood construction, which was suddenly stolen from them.

The Early Times of Parenthood in Perinatal Loss Cases

Larrisa was back in the infirmary bed the morning after giving birth, but now she was accompanied by her sister. At first, Larissa had the same harsh expression in her face when we approached her again. As soon as we approached the bed, her sister moved away and turned to the other side, in silence. When we asked Larissa if she had been able to see the babies at the time of birth, if she had been able to see what they looked like, she started talking with interest. Her sister came close to her bed and said that she also managed to see the babies (when she arrived at the Obstetric Center to relieve Washington as companion, Larissa was still holding her children).

She said that André Luca was born first, that he was still alive and was the bigger one. She chose the name João Gabriel for the second baby, who was no longer alive and was the smallest one. She said, with a smile on her face, that the youngest one looked like his father. After the listening intervention, Larissa decided to make a video call with her three-year-old daughter. She was talking about her children, her offspring and she included her oldest daughter in the conversation. Because Larissa was able to talk about her children who passed away, she was able to introduce us to her status as mother during this video call with her daughter.

After she finished the call, she informed us about her desire to register her two children⁴. Shortly after, her husband arrived and they agreed to carry out the registration. Washington initiated the procedures to do so at the Registry Office.

According to Berta (2015), the construction of listening in psychoanalysis implies supporting traumatic events’ articulation by making them subjective. The subject's story is the story it revisits, builds and tells. What we tried to do in Larissa's case, despite the short listening time, was to open room for her to find something to tell about herself in that event. Assumingly, she was able to speak when she was able to see not only death in her babies, to see not only the strange and frightening aspect of death in those bodies, but to cover them with something that enabled her to see them as her children.

Taking them in her arms enabled her to nestle them in the place she had reserved for them when she desired them. Later on, in the infirmary, when she no longer had them, she was able to promptly tell, with a smile on her face, that she had held them in her arms. Some of what she had experienced could be conveyed through speech, although some of a mother's suffering at the loss of her babies remains impossible to say.

According to Caldas (2015), nothing else is done in analysis other than talking about what is impossible to speak, counting the uncountable: “Freud shows how speaking is relevant to contain the helplessness and radical horror experienced in trauma. However, it is necessary taking the speech for its gaps, rather than for the clarity of communication” (p.5). Thus, the listening intervention does not focus on communication, or on ruling out the trauma as an event. It is based on assuming the impossibility to put the real into words. Therefore, talking about the trauma is less about saying it than about building borders around something that is impossible to be said.

Larissa sought the hospital to have her babies assessed and, soon after that, the events that ended up in this extremely premature birth began to unfold quickly. First, there was the hard time delivering the baby, given the ongoing situation, namely: the information that one of the babies was already dead and that the other would die soon after birth, since there was no chance of post-childbirth intervention due to extreme prematurity.

However, from that moment on, she was able to talk about the place this pregnancy had in her heart. We also hypothesized that having someone she could show her suffering to, when she heard the birth of the patient's baby in the box next to her, helped the progress of her own labor. Being able to talk about the babies, to describe the story of that pregnancy, which already had a significant place for her and her family, seems to have been an important foundation that opened room to describe part of her suffering for not being able to take the pregnancy to full term.

Larissa managed to establish a parental role for herself before her children by opening to elaborate something about that pain. Difficulties in seeing as one’s child someone who did not even live outside the womb or who did not go beyond the neonatal period can often be observed. However, dedicating ourselves to listen to both the mother and the father of those babies helped reconciling the parental couple with the feeling of parenthood that was being built during pregnancy. The fact that Larissa introduced her oldest daughter to us at the time she was able to name the children who did not survive may have been an indication that her maternal condition had recovered, as well as Washington's paternal condition when he took on the task of registering the babies. Listening, in this case, worked as instrument for life, similar to the encouragements given to the parents of babies born without this complication type, at the time of birth.

Final Considerations

Engaging in parenthood refers to the possibility of calling oneself someone’s “mother” or “father”, as well as of sustaining these signifiers and the outcomes from such naming: “It is a significant support for the unnamable aspect of the being that appears from a position in relation to the child [...], due to the way they touch on the enigma of origin, which never ceases to disturb humans and humanity” (Garrafa, 2022, p.60). Parental inscription is a step that implies an initial disposition towards parenthood, but that is built on the relationship with the child; after all, one can only be someone's father or mother.

With respect to the mobilizing effect a child’s arrival has on parents’ psychic life, Garrafa (2022) highlights the act of the subject who names itself as a child’s mother or father. This act has “an inauguration value, a path of no return, which is drawn as a dividing line between 'before' and 'after', but it can only be validated in a second moment, based on its effects” (Garrafa, 2022, p.58). This logic implies the anticipation of a given certainty, without relying on any guarantee.

In Larissa's case, it was not possible to assume the maternal role she had been preparing for, due to the premature death of her children. However, she decided to request the registration not only of André Luca, who already had a name before she arrived at the emergency room, but also of João Gabriel, a name that was chosen when she met him at the time of birth, which was also the time of farewell. By taking this step, Larissa also established the babies’ place as her children, based on the desire to transmit her name. Thus, she legitimized the place that she had already been building in her narcissistic anticipation.

During the encounter, which was also a farewell, she was able to acknowledge them as her children. Thus, the babies’ registration was the way to formalize something based on a factor that is primarily subjective, psychic. On the other hand, it also substantiated social validation, when the registry office officially acknowledged her as mother and Washington as father.

If one takes into consideration that this inaugural act of parenthood is necessary for the loss of a baby to be registered as the loss of a child, this is an important aspect to be taken into consideration at the time to read this case, since this is a singular act of each subject, that also includes the support of one’ surroundings. The legitimacy of a social discourse that validates someone to be mother or father of a child is something that shapes the impossible-to-symbolize the real emerging at a child’s birth and that is even harder in cases of stillborn babies or perinatal loss.

Larissa knew that, at the end of the childbirth process, she would not find her children healthy. She did not even know if the son who was still alive would cry like the baby who had been born in the box next to her. What would she find at the end of labor? Death was imminently there, something impossible to bear. Some movement was possible when she managed to recover them, not just by seeing them, but also by taking them in her arms, by watching over them as her children, the way they presented themselves. The traumatic aspect of the real imposed itself in a double way, upon the children’s arrival and upon their premature death. From a psychic perspective, engaging in parenthood is already demanding, but it is even more so, when the subject takes the step of assuming itself as mother or father of either a stillborn child or of a child who died right after childbirth.

Something worked for both Larissa and Washington when they managed to express words and actions that allowed recovering the real of their babies' deaths: holding them in their arms, talking about their story, seeing what they looked like, their family traces, choosing their names and registering them. However, it took someone to open the way to make it happen, someone who helped putting into words the existence of those children through some possibilities, such as spending some time with the babies after their birth, for as long as they felt it was important. This offer allowed Larissa and Washington to decide on how they would like to experience this moment.

Since Freud's first considerations about trauma, there has been an approach to something that happened accidentally in life, something contingent. Soler (2021) talks about something real that falls on the subject, something impossible to anticipate, that the subject is faced with and excluded from. Excluded, in the sense of something that, by being contingent, suddenly catches the subject off guard without previous knowledge and leaves it without resources. Considering what can be done from this point on means knowing what allows applying psychoanalytic listening to trauma. Subjects hit by a “blow from the real” will be able to create a unique response to deal with what has affected them. Psychoanalytic listening led André Luca and João Gabriel's parents to make the accident imposed by contingent tykhê subjective by respecting the ethical orientation of psychoanalysis, since it includes the subject into the possibility of weaving its unique ways of dealing with trauma.

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• 1
  Fictitious names were used throughout the presentation of the clinical case to ensure participants’ confidentiality.
• 2
  In some translations, it appears as terror or dread.
• 3
  Twin-to-Twin Transfusion Syndrome (TTTS) affects Monochorionic Twin pregnancies when the placenta is shared between fetuses, and blood passes disproportionately from one baby to the other through the blood vessel connections in the shared placenta. When it is not timely diagnosed and treated (before 26 gestational weeks), it accounts for mortality rate close to 100% for both fetuses. Selective fetoscopy with laser photocoagulation, which is a procedure performed in utero, is its most effective traetment.
• 4
  There are different types of registry-office records for stillborns and newborns. In the first case, it is necessary registering a stillbirth based on the death certificate provided by the hospital; the legal guardian has the option to choose a name to be included in the register. In the second case, it is mandatory registering the birth, with the baby’s first and last name, and, subsequently, registering the child’s death.

• Data availability:
  Research data is available on request from the corresponding author.

Edited by

• Responsible editor:
  Márcia Cristina Maesso

Data availability

Research data is available on request from the corresponding author.

Publication Dates

• Publication in this collection
  14 Apr 2025
• Date of issue
  2025

History

• Received
  05 Apr 2023
• Accepted
  19 Sept 2023