A PATH IN THE CONTEXT OF PREMATURITY: FROM NEONATAL ICU TO HOME

ABSTRACT.

This study portrayed, through reports and clinical observations, the path taken by a mother to become support, harbor, or home, for her twin babies during admission to the Neonatal ICU and shortly after hospital discharge. Such investigation, based on Donald Winnicott's psychoanalytical approach, arose as a part of the first author’s master’s research. The research took place in two moments: I) Weekly follow-up of the mother and babies during the newborn’s admission to the Neonatal ICU of a general hospital in Porto Alegre, state of Rio Grande do Sul, for one month and nine days, and II) Follow-up after discharge through home visits. The second stage started one week after hospital discharge and occurred for one month and nineteen days, with a fortnightly frequency. For data collection, clinical diaries were used as a device to listen to the singularities observed in each service. The hospitalization represented experiences of (dis) continuity for the babies and the mother. The journey process to home was an important inflection about the bodily (and psychic) support of babies by the mother. Psychological care proved essential to support this mother throughout the journey and help her become a ‘home’ for her newborns.

Keywords:
Premature newborns; neonatology; psychoanalysis

RESUMO.

Este estudo retrata, através de relatos e observações clínicas, o caminho percorrido por uma mãe para tornar-se suporte, porto ou casa, para seus bebês gêmeos, durante a internação em UTI neonatal e logo após a alta hospitalar. A investigação, que teve como base a abordagem psicanalítica de Donald Winnicott, emergiu de um recorte da pesquisa de mestrado da autora principal. A pesquisa ocorreu em dois momentos: I) acompanhamento da mãe e bebês durante a internação do recém-nascido na UTI-neonatal de um hospital geral de Porto Alegre durante um mês e nove dias com frequência semanal e II) acompanhamento após a alta através de visitas domiciliares. A segunda etapa teve início após uma semana da alta hospitalar e ocorreu durante um mês e 19 dias com frequência quinzenal. Para a coleta dos dados foram utilizados diários clínicos como um dispositivo na escuta das singularidades observadas em cada atendimento. Observou-se que a experiência de internação representou vivências de (des) continuidade para os bebês e mãe. O processo da travessia para casa representou uma inflexão importante em relação à sustentação corporal (e psíquica) dos bebês pela mãe. Destacamos ainda que o acompanhamento psicológico demonstrou ter sido importante para sustentar essa mãe ao longo da travessia e ajudá-la a se tornar ‘casa’ para seus recém-nascidos.

Palavras-chave:
Recém-nascidos prematuros; neonatologia; psicanálise

RESUMEN.

Este estudio retrata, a través de informes y observaciones clínicas, el camino recorrido por una madre para convertirse en apoyo, puerto u hogar para sus bebés gemelos durante el ingreso a la UCI Neonatal y poco después del alta hospitalaria. La investigación se basó en el enfoque psicoanalítico de Donald Winnicott y se desarrolló en dos momentos: I) Seguimiento de la madre y los bebés durante la hospitalización en la UCI Neonatal de un hospital general de Porto Alegre durante un mes y nueve días con frecuencia semanal y II) Seguimiento tras el alta a domicilio. La segunda etapa se inició luego de una semana del alta hospitalaria y se desarrolló durante un mes y diecinueve días con una frecuencia quincenal. Para la recogida de datos se utilizaron diarios clínicos como dispositivo para escuchar las singularidades observadas en cada servicio. Se observó que la experiencia de hospitalización representó experiencias de (dis) continuidad para los bebés y la madre. El proceso de ir a casa representó una inflexión importante en relación al apoyo corporal (y psíquico) de los bebés por parte de la madre. También destacamos que la asistencia psicológica resultó ser importante para apoyar a esta madre durante todo el camino y ayudarla a convertirse en un ‘hogar’ para sus recién nacidos.

Palabras clave:
Recién nacidos prematuros; neonatología; psicoanálisis

Introduction

I may be in a muddle, and then I either crawl out of the muddle or else try to put things in order so that I may, at least for a time, know where I am. Or I may feel I am at sea, and I take bearings so that I may come to port (any port in a storm), and then when I am on dry land I look for a house built on rock rather than on sand; and in my own home, which (as I am English) is my castle, I am in a seventh heaven (Winnicott, 1975, p. 145).

The quote above points to Winnicott’s perception that, on our journey through life, we need a certain amount of security and confidence. However, the path towards this house on the rock is not always easy. Thus, we began to think about mothers and babies who experience premature birth and who begin their stories amidst the storms of a stay in the Neonatal ICU.

Schaefer, Donelli and Marin (2017) state that, with technological modernization in neonatology after the 1970s, we have, on the one hand, a reduction in infant mortality in neonatal intensive care units and, on the other, parents having difficulties in establishing an affective contact with children at an early stage. This is because families perceive the Neonatal ICU (NICU) environment as frightening, unwelcoming, and full of devices. The feelings arising from this context perceived as hostile can lead parents to feel incapable of caring for the newborn, leaving care as the exclusive task of the healthcare team.

According to Lima and Smeha (2019, p. 7), admission to the NICU tends to generate in the mother a feeling of loss of control over the functioning of the family, insecurities regarding the ability to regain balance, many doubts, and a “[…] roller coaster of emotions”. Therefore, difficulties may occur upon hospital discharge when parents are faced with the task of providing all care for the newborn. Although this can also occur with parents whose babies have not been to the NICU, this feeling of inability to care for the baby seems to be more intense in this context. In this vein, Mathelin (1999) recalls that if ambivalence is present in each birth, in the case of premature birth, a mother’s feelings about being dangerous to the baby may come to the fore. The author demonstrates this observation in the report she obtained from a mother: “You gave him life, stayed with him, I only knew how to give him death” (Mathelin, 1999, p. 67). Guilt is a frequent feeling among mothers and fathers when faced with premature birth (Carvalho & Pereira, 2017; Marciano, 2017), and can continue to have repercussions during hospitalization and after leaving the hospital.

Given the above, we hypothesized that the feeling of mothers and fathers of being ‘replaced’ by the health team in their parental roles is unlikely to dissipate with hospital discharge. Furthermore, the possible implications of this issue for the bond between parents and babies are indicated at a time of absolute dependence on the environment. Based on this hypothesis, we emphasized the intention to expand the follow-up of families after hospital discharge in this study.

Winnicott (2000b) argued that, when considering a baby, we must inevitably consider the environment. Although the author highlighted the mother as the matrix of this environment, we understand it is primarily constituted by the person(s) who primarily takes care of this new being. In other words, we cannot think about a baby without considering the person who takes care of it. In this way, we wonder about the implications regarding the psychic constitution at the beginning of life, which is so different from what was expected. It is a beginning marked by the replacement of the mother’s womb with mechanical care responsible for maintaining physical survival. On the other hand, we also have the baby’s ‘absolute dependence’ of the baby on the mother (or whoever performs this role), which is extremely important for psychic development. Furthermore, absolute dependence also occurs in relation to medical care. Without this assistance, the lives of many premature babies could be compromised.

In addition to the baby, fathers and mothers commonly feel dependent on the NICU team, seen as those who know how to provide the necessary care to maintain the baby’s life (Leão, Silva, & Lopes, 2017). On the other hand, difficulties with the care provided by the staff seen as not very empathetic and affective are frequent (Marciano, Evangelista, & Amaral, 2019; Zanfolim, Cerchiari, & Ganassin, 2018). Other studies observed that, even though the NICU environment did not favor interaction between dyads, mothers were able to perform the maternal role (Henrich, Schaefer, & Donelli, 2017; Fernandes & Silva, 2019). Therefore, the conflicting results point to the different possibilities of experiencing motherhood in the NICU environment.

In light of the above, we recall what Winnicott (1993) described about the beginning of the psychic life of a newborn. He states that in the baby’s initial reality, there is a lack of differentiation between the newborn and its environment. Therefore, the baby is at a stage of non-integration, in which environmental support becomes essential. At this point, the author highlights the importance of mothering as a guarantee of the baby’s continued existence. For him, the strength of the infant’s ego is necessarily linked to the support of the mother’s ego.

In this context, we reflect on the specificities of this beginning of life and the path taken by a mother to become a mother - support, harbor, or home for her baby (or babies) - during hospitalization in the NICU and immediately after hospital discharge. To this end, we followed a mother and her premature twin babies in two stages. The first occurred during the newborns’ admission to the NICU, lasting one month and nine days with a weekly frequency, and the second began soon after hospital discharge through home visits, lasting one month and 19 days with a fortnightly frequency. Psychological support was provided by the first author, forming part of her master’s thesis and a larger research project entitled ‘Psychical Constitution of Premature Babies: Follow-up by the IRDI Methodology in Neonatal ICU’ (Constituição psíquica de bebês prematuros: um acompanhamento através da metodologia IRDI em UTI-Neonatal), coordinated by the second author. The research project was approved by the Research Ethics Committees of the Psychology Institute of UFRGS and Hospital da Criança Santo Antônio.

Neonatal ICU: house or boat adrift?⁴

The followed-up case involves premature twin babies who were born at 29 weeks and six days of gestation due to the premature rupture of the amniotic sac of one of the babies. The family of the newborns is made up of the mother, Rosa⁵, 35 years old, and the father, Vinícius, 44 years old, both of whom have completed higher education. The couple also have another three-year-old son, Bruno. Ângelo was the first baby to be born, weighing 1.236 g and Apgar 08/08⁶, and Henrique, the second to be born, weighing 1.590 g and Apgar 08/08.

This family was followed-up weekly in the first stage (babies’ admission to the NICU) for one month and nine days, totaling seven meetings. The second stage (home visits) began one week after hospital discharge. This stage lasted one month and 19 days, with fortnightly breaks in the first three meetings and weekly breaks from the third to the last two meetings due to the parents’ demand to work more closely towards the end of this stage. The home visits totaled five meetings. Importantly, family follow-up took place from the second week of the babies’ admission to the NICU. However, Rosa was already hospitalized for 11 days before giving birth. The mother’s hospitalization while still pregnant was due to the premature rupture of baby Ângelo’s amniotic sac during the 28th gestational week.

At the beginning of the study, psychological care was offered to the parents, but most of the care was provided to the mother as she was the caregiver who was most present during Ângelo and Henrique's hospitalization. The father participated in some meetings. During the first stage, the service was provided next to the babies’ incubators inside the Neonatal ICU and/or in a room reserved for psychological assistance when the admission room was busy. In general, the hospitalization room was also occupied by other hospitalized babies, other mothers who accompanied them, and health professionals providing care to newborns. During the second stage, most care was provided only to the mother and the two babies. Usually, the father was working, and the couple’s other son spent the day at an early childhood education school.

The care consisted of attentive listening to the mother and father (when he was present) and observation of the babies, including some careful interventions (through speech or even by looking, some gesture), always aiming to hold the parents’ suffering and help with the formation of the bond with babies. After each of these meetings, a clinical diary was produced, which initially consisted of audio recordings of the first author’s own reports, constituting a testimony of the care with clinical observations. The recordings were made at the end of each meeting. After the end of psychological support, the audio was listened to and transcribed. The diaries were discussed with the second author and the research group, and such discussions make up part of the elaborations presented in this article. The research work, based on the production of clinical diaries, has been a practice of the Center for Studies in Psychoanalysis and Childhoods - NEPIs/UFRGS/CNPq, and was presented in detail in another study (Silva, Oliveira, & Ferrari, 2022).

In the case of Rosa, Ângelo, and Henrique, the NICU represented an ‘attempt to be a home’. This may be due, at least in part, to the stance of the neonatology team accompanied here, which tends to naturalize hospitalization, acting as if the unit could be a ‘temporary uterus’ or the replacement of the womb/house/belly of the mother who was unable to support the baby until the end of the pregnancy. When problematizing this issue, we recall a passage from Bachelard’s work, in which he reflects on the notion of home as a possible support to psyche and subjectivation:

Every truly inhabited space brings the essence of the notion of home. We will see in the course of our work how the imagination works in this sense when the being has found the smallest shelter: we will see the imagination build ‘walls’ with impalpable shadows, and comfort itself with illusions of protection (Bachelard, 2008, p. 200, author’s emphasis).

From this, we started thinking about the first session with Rosa in which we had the feeling when listening to her that the walls of the NICU were made of glass. This image tells us a lot about the ‘home’ that the hospital unit was for Rosa and her babies. An extremely controlled and observed place, and, at the same time, fragile. The house (NICU) that shelters these families is permeated by a universe of encounters, disagreements, helplessness, fears, possibilities of life, possibilities of death, and nameless traumas.

The excess of observations and mechanical controls made the experience in there somewhat difficult for Rosa as a mother. On many occasions, she and Vinícius spoke of the difficulty in feeling that the babies were theirs due to the lack of spontaneity. They described a space empty of meanings, and experiences, and full of mechanical relationships. They seemed to ‘force’ the relationship with their babies so that some exchange could occur with them within the hospitalization unit. We had the impression that they were describing a house under construction. However, it is as if it were a temporary and fragile construction like the glass wall I imagined. The house with glass walls exemplifies how we perceive the first meetings of Rosa, Vinícius, and babies Ângelo and Henrique. At first, they managed to build something less solid. Both the relationship and the babies existed, but this could be broken with a stronger collision or destroyed with an unexpected impact. Furthermore, the glass walls also highlight how the NICU context represented a transparency in which the intimacy and privacy so necessary for an authentic relationship to be built is lost. Additionally, the real possibility of death and loss permeated Rosa’s entire experience with her twins during hospitalization.

In many moments, the hospitalization of the twins Ângelo and Henrique also resembled a family on a boat adrift. Rosa seemed as fragile as the babies, and Vinícius seemed very worried. Along the way, they were surprised by complications, tachypnea, and fears. It is as if they were traveling on a boat that was attacked by strong winds and turbulent waters at all times. They seemed distressed and felt that it was difficult and terrifying to think about how the trip, amid the storm, would end.

There were many questions and almost no hint of answers. And we watched a couple under freezing. I believe that, in the initial moments when I was following them up, the relationship with Augusto and Henrique occurred in a scared and almost forced way. I had the impression that, before adapting to babies, they were adapting to the NICU. Hereupon, we began to think about the intersubjective encounter between Vinícius, Rosa, and the twins inside the NICU amidst the turmoil. These were moments when they could barely talk about anything other than their own pain, especially Rosa. The look at Ângelo and Henrique was either somewhat forced and desperate, or it occurred through my interventions to direct their attention to the babies amidst the chaos. When considering the possibilities for parents to build a common rhythm with their babies, we think about what Victor Guerra (2017) describes about a baby’s disconnect with his/her environment. He compares it to the mismatch between a poet and words, which would produce the effect of ‘dysrhythmia’: “Rhythm does not act as a ‘support bed’ for the encounter, and the word and this would imply a risk in subjectivation” (Guerra, 2017, p. 33, author’s amphasis).

For the author, rhythm is a first psychic organizer, just like words. According to him, when we come into contact with a baby, the first thing we do is establish rhythmic bodily communication. This can occur through movement or even with repetition of a word. The rhythm would be given by the repetition of an experience at regular intervals, which allows organizing an experience and provides an experience of continuity, but with the progressive integration of discontinuity, the unexpected (Guerra, 2017; Silva, Martins & Lisboa, 2017).

In view of the above, I believe that Ângelo and Henrique’s experience with their parents in the NICU could not, in many moments, provide a progressive integration of discontinuity. Unlike the rhythm description above, it seems to us that a good part of Rosa’s experience with her babies in the NICU occurred abruptly starting with premature birth. The events, considering what she described to us about her hospitalization while still pregnant, the birth, and the initial days in the NICU, seem to be permeated by a certain imbalance, in which little rhythmicity was observed. Winnicott (2006, p. 54) stated that the right time to deliver a baby is the full-term period and when referring to a premature baby, he also says that an incubator is suitable for this. However, at “[…] the date of birth, the baby’s degree of maturity already requires human care”. It turns out that the incubator makes an attempt to replace the womb in terms of biological needs, which is important and necessary for survival. And in most cases, it is quite effective. But with regard to the baby’s existential continuity, we can think of a discontinuity in the process that was taking place in the womb. In this vein, Winnicott states that

From the baby’s point of view, nothing exists beyond itself, and, therefore, the mother is, initially, part of the baby. In other words, there is something here that people call primary identification. This is the beginning of everything and gives meaning to a very simple word, such as ‘being’ (Winnicott, 2006, p. 9, emphasis added).

In another passage of his work, Winnicott (2000a), when referring to childbirth, mentions that the baby is already prepared before birth for some environmental intrusion. He describes this moment as a temporary reaction and a major interference with ‘continuing to be’. However, in terms of a full-term birth, it is not such an intense or prolonged experience to interrupt the continuity of an existential process. On the other hand, he states that “At the moment of birth, the baby is not yet prepared for a prolonged environmental intrusion” (Winnicott, 2000a, p. 265). In this sense, he states that the central issue is the trauma represented by the need to ‘react’. He further argues that a reaction at this stage of development means the “[…] temporary loss of identity” (Winnicott, 2000a,p. 265).

We believe a ‘prolonged environmental intrusion’ was observed in Rosa’s case with her twins. The intrusion seems to have started right at the beginning of Rosa’s hospitalization while she was still pregnant and continued until the moment of birth and the admission of the babies. The reactions to such intrusion were observed in Rosa’s reports about the different moments. Regarding the period in which she was hospitalized, she says that she already felt the need for psychological support, but the state of deep suffering left her immobilized. And even though she knew that the hospital had psychological assistance, she was only able to identify her need in a few moments. She even talked about it with the sonographer a few times, but the physician was unable to provide adequate support for her request, as she never contacted the psychology team. Reactions to the intrusions also appeared when she recounted the moments in which she was admitted to the obstetric center to prepare for childbirth. During the pre-delivery period, Rosa described the feeling of ‘going crazy’ and even told Vinícius that she wanted to run away. We recall here what Donelli, Caron and Lopes (2012) observed in a study about the experience of childbirth as a moment of profound helplessness not only for the baby. But the authors also developed the issue that the mother, in her identification with the baby and, precisely for this reason, in a state of retraction, also finds herself in a helpless situation. We emphasize that the focus of this study was not on mothers of premature babies. However, we believe that this state of helplessness occurs even more intensely in the case of a premature birth.

The helplessness was quite evident when Rosa spoke of the pain she experienced every time she had to be separated from her babies and that she felt like she was abandoning them. The traumatic aspect also appeared when she spoke very strongly that ‘mothers were nursing technicians’. In this sense, Rosa also seemed to feel out of place in that space, when she said that she felt like she was ‘not a mother at all’ of the babies and that they were ‘nothing’ of hers. Here, she seemed to be talking about the immense emptiness generated by her being separated from her twins early and having empty arms. Other studies also emphasize the traumatic potential of early separation between mother and baby in the event of premature birth with hospitalization in the NICU. These are studies that reveal the need for mothers to defend themselves psychically due to separation from their newborn, which can cause emotional consequences for both the mother and the baby (Ferrari & Donelli, 2010; Marciano et al., 2019).

In addition to the above, Rosa had a lot of difficulty in identifying her place and role within the NICU and said that the children ‘should still be in my womb’. Along with this, she also had difficulty naming what she was feeling. Such issues are similar to what Henrich et al. (2017) observed with mother-infant dyads before and during the hospitalization of premature newborns. In one of the cases analyzed by the researchers, the mother spoke of a feeling of emptiness due to her baby being away, as well as demonstrating difficulties in describing her feelings, saying only that she thought the baby was “[…] very small and defenseless” (Henrich et al., 2017, p. 76).

Still talking about the feeling that she should still be pregnant, Rosa said: “I have the impression that this is not right. I think I should be close to my babies because the baby needs the mother as much as the mother needs the baby”. In this speech, Rosa seemed to demonstrate that she felt extremely identified with her babies. Therefore, despite the difficulties presented during hospitalization, she was able to maintain protection for them through their identification. Several times, during the babies’ hospitalization, Rosa mentioned the idea that they had not yet been born and that this would happen when they went home. In fact, upon receiving the news of Henrique and Ângelo’s discharge, the first thing Rosa said to us, crying, very emotional, was: “I’m having my babies; they’re being born”.

If, on the one hand, using the NICU as a ‘surrogate belly’ was intrusive, on the other hand, it was also a way for Rosa to ‘continue living’ as a mother to her babies, even though she did not feel it consciously in many moments. It was possible to observe some statements and attitudes towards the twins that preserved her mothering: “[…] he wants me to cover his eyes with the sheet because the light bothers him”. Here, she was referring to something the baby addressed to her. Possibly, Rosa had identified the baby’s subtle and silent communication, as described by Winnicott (1994). After all, inside her womb, the babies would have no contact with light, and it would be dark all the time. In this sense, it was evident that the light could only bother them. On many occasions, she was also bothered by the excessive stimulation that Ângelo and Henrique needed to experience during their hospitalization. When she started breastfeeding Ângelo, she said she was pleased to be able to offer the breast to him, but that she noticed him tired and believed that he was not enjoying a lot of stimulation. She once said: “I’m going to stop offering the breast and I don’t want to talk to him much now. He needs to sleep and is very tired with so many things at the same time”. Furthermore, I often saw both Rosa and Vinícius quiet, next to the twins’ incubators, watching over their sleep. And in these situations, Rosa always told me that she felt relieved to see them resting. She said that this way they could recover faster and gain more weight. And would not that be how they should be inside her womb? Sleeping most of the time to gain weight and prepare for birth?

Back home

Here, we return to some of Bachelard’s (2008) reflections described in ‘Casa’, from Cellar to Garret - the Significance of the Hut chapter of A poética do espaço, as we believe they make a lot of sense in the story of Rosa and Vinícius with their babies Augusto and Henrique. The author states that the most precious value of the house is to shelter the daydream, protect the dreamer, and allow them to dream in peace. In this sense, he states:

Past, present, and future give the house different dynamisms, which often interfere, at times opposing, at others, stimulating one another. In the life of a man, the house thrusts aside contingencies, its councils of continuity are unceasing. Without it, man would be a dispersed being. It maintains him through the storms of the heavens and through those of life (Bachelard, 2008, p. 201).

In this way, it seems that the experience of Rosa and babies Ângelo and Henrique of leaving the NICU and going home represented a certain rescue of the previous home (womb/belly) experience. After discharge, Rosa began a movement of trying to make sense of the experience of ‘discontinuity’ that the NICU represented. It is as if the trauma experienced had created a gap in the babies and their mother’s ability to ‘continue living’. After all, the NICU days seemed like disintegrated parts of a story that was happening in another way before hospitalization. It is worth noting that, when addressing the traumatic issue arising from these experiences, we refer to the Winnicottian concept of trauma. Fulgencio (2004), when clarifying the differences in the conception of trauma in Freud and Winnicott, highlights that the understanding of trauma depends on the moment in life in which the subject is in their growth process, which goes from absolute dependence, moving to relative independence, and continues towards independence. Therefore, we work here with the idea of trauma related to the earliest moments of life, considering a moment of absolute dependence of the baby on the mother and, consequently, of the mother on the baby due to her identification with her child.

Before discharge, we noticed that an important change and redirection occurred when the babies were transferred to the intermediate unit. We observed more exchanges between the babies and Rosa and we saw her more comfortable as the mother of the twins. Handling the babies also seemed to occur in a more spontaneous and carefree way on the part of the mother. She changed her children’s diapers without fear and without asking the nursing technicians for permission. It seems that a very subtle process occurred there when she began to take ownership of care and her position as a mother, thus authorizing her to recognize herself as the main facilitator of her babies’ developmental process.

Therefore, we emphasize how much Winnicott stresses the relevance of maternal care during primitive emotional development. The ‘holding’ concept includes the entire care routine appropriate to each baby. It is also related to the mother’s ability to identify with her child. It protects the baby from physiological aggressions, taking into account skin sensitivity. Moreover, it also considers the baby’s lack of knowledge about anything other than himself. ‘Holding’ enables the newborn to develop reliability in the environment through maternal care. Therefore, through the physical and psychological support of the environment, the baby will be able to find internal comfort. The concept of ‘handling’, which may be differentiated or included in ‘holding’, is a type of care that allows the psyche to be housed in the body and psychosomatic integration. Through ‘handling’, which also enables the integration of muscle tone, the baby can have the experience of a true existence to the extent that it allows the notion of a ‘real’ as opposed to the ‘unreal’ (Winnicott, 1993).

During home visits, Rosa gradually began to give meanings and names to the traumatic experiences she had lived with the twins in the hospital. However, at first, she seemed quite fragile and traumatized by the experience she had lived in the NICU. The intensity of things she had experienced in that context seemed to follow her very intensely during her first days at home. It was as if the NICU was inside her home, in the sense that it seemed to have carried her internally after they were discharged from the hospital. This appeared in her fears, insecurities, and the difficulty of feeling close to the twins. All of these issues appeared accompanied by a strong desire to take ownership of their maternal role and to feel emotionally closer to her babies.

At home, something new started to happen and narratives began to be built little by little. During the first home visits, Rosa expressed how strange she felt about being used to stay away from her babies for a few moments. This caused her discomfort and the feeling that something was wrong with her. In those first moments at home, she still seemed to feel dangerous to the babies. This appeared when she said that, at night, when waking up to feed the babies, she needed Vinícius to stay with them, watching while she held them. Rosa said the initial idea was for them to take turns doing the nighttime task, but when it was her turn to get out of bed, she felt a huge fear of letting the babies fall on the floor. She thought she could fall asleep with them on her lap and needed Vinícius to ‘watch’ her as a way of protecting the babies.

After being discharged from the hospital, Rosa was able to talk more about her experience in the NICU with her babies. In many moments and several times, she repeated that throughout the babies’ hospitalization, she did not think they were hers. And the fear of losing them only began to diminish after they were discharged from the hospital.

Another change that appeared during the visits is the observation that during the twins' hospitalization, Rosa did not feel authorized to produce any knowledge about Ângelo and Henrique. But at home, this process began to occur discreetly. For example, Rosa began to disagree with the nursing technicians, showing different - and her own - perceptions about her babies: “During hospitalization, the nursing technicians said that Ângelo is mad. And when we were there, I thought the same. At home now, I can observe better and don’t think that about him. I think he’s a calm, calm baby”.

Rosa also started choosing clothes for Ângelo and Henrique. Both Rosa and Vinícius noticed her insecurity about this, and apparently, this was related to the fact she was beginning to take ownership of the care of her babies. She said: “I had never thought about that. About choosing clothes for them. At the NICU, they didn’t wear clothes, only diapers”. It is worth noting that the intensive care environment in neonatology also does not seem to facilitate the constitution of the subject based on the singularization of each baby. All priorities highlight the privilege of biological survival, and the psychic issue seems to be on the margins of all this. And the fact that they do not wear clothes or anything from their parents seems to give more emphasis to this issue. Another example is that most medical records are identified with the mother’s name and not the baby’s name. The twins only received their own names in the last week of their hospitalization. Most of the time, Ângelo and Henrique were identified as Newborn I and Newborn II of Rosa. The staff also referred to them as ‘Rosa’s babies’ or the ‘bed x and y’ babies. This also made it even more difficult for us to distinguish between who was Ângelo, and who was Henrique. We rarely called them by their names because besides being very similar, such characteristics of the unit’s context did not help in differentiation.

At home, after some strangeness and initial difficulties, she began to develop intimacy with her babies, which provided an important moment in the relationship between the three and the movement of Ângelo and Henrique’s psychic constitution. When they arrived home, Vinícius had a few days off with Rosa and the twins. Nevertheless, when he needed to return to work, although very scared, Rosa expressed a huge desire to be alone with the babies. Vinícius was worried, thought the task would be difficult, and told her that the paternal grandmother would be available to help her if she wanted, but Rosa did not want any help. She saw these moments of concern as a way to develop the intimacy she did not have with her babies during their stay in the NICU.

In the mother’s moments of solitude and intimacy with her babies, important movements began to happen. We talked about how much she had not yet been alone with them after being discharged from the NICU and how important this was to take ownership of her maternal role. She reported the first moments at home were difficult and that she was very distressed the first time that Ângelo and Henrique requested her at the same time. She said that in such a situation she was breastfeeding Henrique and in the meantime, Ângelo woke up crying. She said it was a long 20 minutes in which she felt anxious and did not know what to do. But during the home meetings, Rosa once said:

Remember what I told you about how scared I am of both of them crying at the same time? I think I found a way to calm them down. There was a day when I was holding Ângelo on my lap, and then Henrique started crying. So I tried rocking Henrique’s stroller with my foot while I started talking to them. I realized that talking to him worked really well because I managed to calm him down and I calmed down too.

From Rosa’s moments of care with the twins, it seems that the rhythmicity of the three began to (re)construct itself. After she managed to (re)find her own way of caring, a very beautiful relationship emerged. She was more affectionate, spoke more in Motherese with them, and said she already felt more like their mother, which was also visible in the triad relationship. She talked a lot about the three of them meeting and said things like “I never imagined it would be possible to take care of two babies at the same time. Some days, I end up being alone with them and Bruno”. She said it was impressive to see that the ‘bros’ (as she affectionately called them) were getting used to waiting each other’s turn. She commented they even seemed to understand when one of them needed her more and exemplified this by talking about the moments when one of them had colic. We believe that in this sense, she felt very supported, encouraged, and sustained. This happened both on the husband’s side and in relation to the follow-up with us. We think it was no surprise that the first times she was alone with the babies were moments before our meetings. Furthermore, it also seems to us that it was no coincidence that, at the last service at her home, she welcomed us with the twins and her son Bruno. I think Rosa also wanted to show us, proudly, where she and her children had already reached.

Final considerations

In the first stage of the study, during hospitalization in the NICU, we felt, in many moments, that we were following up a shipwreck process in which the passengers (mother, father, and babies) sought (sometimes desperately) any glimpse of a harbor or dry land. During the process, we sometimes saw them moving away from this harbor, such as when they were extremely insecure about the survival of their children and were overcome by the fear of losing them. There were times when they were barely able to pay attention to the twins’ needs and reactions to the intensive treatment. When working as facilitators of a journey towards the harbor and home, we were able to perceive the approximation of what this image represents: the very peculiar and intersubjective process of a mother who seeks to be the support, harbor, dry land, and home concerning the being of her babies. This journey began in a sea of turbulent waters, so characteristic of a premature birth.

During the days of hospitalization, the follow-up highlighted Rosa’s feeling that she was not actually a mother in that context. The possibility of removing her babies from the incubator and taking them home seems to have represented the solidification of their existence. In the NICU, the existence of babies - and, consequently, of the mother - was something uncertain, vulnerable to the adverse circumstances of the context, and the instabilities of the health status of premature babies. The tone of the relationship between the dyads was also marked by the possibility of death and the non-existence of babies dependent on mechanical care. The mother was unable to see herself as essential in that context, in addition to suffering daily from the threat of remaining with empty arms if a stronger gust of wind occurred. Therefore, the image of the Bachelardian house (Bachelard, 2008) represents the sedimentation of the mother’s relationship with her premature babies. The moment she was with them in the shelter of her ‘home/lap/holding’, she could begin to feel like a mother to her babies. In this way, the experience of babies’ hospitalization represented not only health instability but the fragility of a relationship. Thus, we perceive the hospitalization experience of Rosa and her babies as a process that, although marked by mismatches and the difficulties of the context, enabled important environmental support conditions in terms of facilitating the psychic constitution of the newborns. This seems to have occurred in a continuum in the sense of continuing to be from the encounter with a Winnicottian gerund clinic.

The clinical service to this mother and her babies reminded us of what Bachelard (2008) says about the house in A poética do espaço. The author addresses the issue of the house by relating it to the places where we find shelter, pointing out the singular value of the image of the places where we find protected intimacy. In this regard, we began to think about traumatic premature birth, when a mother prematurely no longer represents a home, about the hospitalization of babies, and about going home after being discharged from the hospital.

The question about what was happening in the relationship between mother, father, and babies from the moment of discharge crossed our minds. Would it be possible to (re)build intimacy beyond the hospital walls? How could the house/mother/father/environment be a shelter or home for babies after such painful experiences in the hospital? Or couldn’t it?

Winnicott’s ideas, considering a look at the mother-baby dyad relationship, guided the study. This gerund clinic, which highlights the process, permeated all the work with the family. We point out here the role of the psychoanalyst both in neonatology and in different clinical contexts, such as home visits. The ‘setting’ and the place of the analyst here dialogue with what was described by Boukobza as the ‘holding of the holding’, as support so that the mother can have this function with her babies. The importance of psychological support in the NICU has been highlighted in the literature (Fernandes & Silva, 2019; Mata, Cherer, & Chatelard, 2017). From our experience, we highlight the power of the presence of the psychoanalyst, or psychology professional, in the context of prematurity, whether at home or in the Neonatal ICU. This means allowing, through support for creative living, mothers, fathers, and premature babies to experience “[…] life experiences” (Winnicott, 1975, p. 139) and confidence in a potentially disturbing context.

The journey from hospital discharge to the babies’ home demonstrated that many of the traumatic experiences that occurred in the NICU continued to reverberate in the first moments after discharge. As the days passed at home, it seemed that the mother and babies were finding each other and establishing their own rhythm. We believe that this process was helped by openness to possible narratives and the construction of meanings about the traumatic experiences at the NICU. The integration of the babies’ life power into the care of their attentive parents, supported by reassuring listening, seems to have allowed these supposedly fragile babies, initially, to withstand great storms, and that their mother could become a home at the beginning of their lives.

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• 4
  This and the following sections of the work report the follow-up of mothers and babies and were written mostly in the first person singular, as they describe the ‘singular’ encounter between the first author of the work and the participants.
• 5
  All names used in this study are fictitious in order to preserve the identity of the participants.
• 6
  This is an assessment (with a score from 0 to 10) carried out in the delivery room during the first and fifth minutes of the newborn’s life. It consists of a method used to quantify vitality and information about the baby’s general condition.

Publication Dates

• Publication in this collection
  05 Apr 2024
• Date of issue
  2024

History

• Received
  07 Oct 2020
• Accepted
  01 July 2021