Parents who lose a child during or after a multiple pregnancy where another child survives can be overwhelmed by conflicting emotions, according to a leading charity that offers support following the death of a child.
Pregnancy loss, stillbirth or a neonatal death is always traumatic, but when a multiple pregnancy is involved and another child survives there is an "added complexity" for parents, says Janelle Marshall, general manager of services at Sands Australia.
The organisation supports grieving families by connecting them with volunteers who have also suffered the loss of a child.
Ms Marshall says when one child is lost from a multiple pregnancy, there is often a spoken or implied expectation from health professionals, family and friends that parents need to focus on the "positives and needs of the surviving baby", effectively denying them the chance to grieve the baby who died.
This is despite research showing the intensity of grief experienced in multiple pregnancies is the same or even more complex as when a single baby is involved.
"It can be very difficult for parents to allow themselves to grieve when a baby dies and there is a surviving twin or triplets," Ms Marshall says.
"Their focus may be on the tasks of physically and mentally preparing for the birth of the surviving baby or babies and this may result in delayed grief and also impact on the emotional wellbeing and mental health of the parents.
"Managing the emotions of elation of having a brand new live baby, whilst grieving the loss of their twin or multiple, can be very confusing and difficult to deal with."
Nicole Marston knows first-hand the agony that comes with losing a child from a multiple pregnancy.
After struggling to conceive naturally and undergoing fertility treatment, she and husband Stuart were counting down to the birth of their twin boys, when complications arose 26 weeks into her pregnancy.
Lachlan and Harry were born a few days later via emergency caesarean.
"Lachlan was in distress from the beginning," says Nicole.
"He had a hole in his lung, which was allowing air to leak out of his lung into his chest cavity."
He underwent surgery and was placed on a ventilator and given morphine for the pain.
Over the next two weeks, he suffered a myriad of problems relating to his prematurity and other complications.
On day 14, doctors found Lachlan had suffered a brain haemorrhage. He was too unstable to undergo surgery and when tests showed he had suffered brain damage, doctors said nothing more could be done.
"I got to hold Lachy for the first time as his life support was taken off," recalls Nicole through tears.
But there was no chance to grieve, with Harry becoming gravely ill the next day and undergoing bowel surgery. Doctors gave him a 50 per cent chance of survival.
The couple left Harry's bedside just long enough to attend Lachy's funeral, which Nicole's parents arranged.
"Harry was very sick. Mum and dad took us to the funeral and we went straight back to the hospital," Nicole says.
"We couldn't go home and cry for six months."
Harry survived, eventually coming home from hospital two weeks before Nicole's due date. Nicole immediately fell apart, becoming terrified that Harry would die too.
Ms Marshall says it is common for parents to be overwhelmed by conflicting emotions when one baby dies and its sibling survives, which can make it difficult for them to bond with their new baby.
"The joy of carrying a surviving baby can be overshadowed by the heightened anxiety surrounding the surviving baby's wellbeing and the grief experienced from the death of the baby," she says.
Ms Marshall says birthdays and anniversaries can be particularly difficult in the case of a multiple pregnancy where a child has died "because they often involve children who have died on the same day, or a child that is growing older each year celebrating a birthday and another child who is not".
Six years on, Nicole finds her twins' birthday difficult. While she bakes a separate cake for Harry and Lachlan, Harry has never had a birthday party.
All his milestones, whether is it starting school or learning to swim or play sport are bittersweet because "he is meant to have another walking talking little boy with him".
Now the mother of another little boy, Toby, 14 months, she deals with her loss with the help of counsellors, psychologists and antidepressants, but says some days the grief overwhelms her.
"I have cried myself to sleep more times than I could count. Often, I cry in the shower," she says.
"We never had a chance to grieve.
"Grieving is something we have had to do along the way.
"Losing Lachy was the hardest thing I have ever done in my life. Nothing else comes close.
"It was torture, absolute torture."
Ms Marshall says families have to find their own way to cope, and it is important to remember "there is no right way to grieve".
She says bereaved parents who reach out to Sands say having their babies acknowledged by name is one of the most powerful things family and friends can do for them.
"Family and friends can help bereaved parents by remembering the baby who has died," Ms Marshall says
"By acknowledging that baby, by name if possible, perhaps writing a card or giving a small gift that expresses you are remembering the baby who has died, simply asking the parents if they are okay and if they would they like to talk.
"All of these gestures convey that the baby who has died is important, that you recognise them as a continuing important part of the family and that you remember."
Nicole says her family has always recognised Lachlan, but not everyone is as understanding.
While she tells people she has three children, one of whom is in heaven, she is often told she is 'lucky' that one twin survived.
"There is nothing lucky about losing a child," she says.
She says being connected to the Sands volunteers who have been through the same loss has helped her feel less alone, as has a Facebook group for bereaved parents.
Visit sands.org.au or phone the 24-hour support line for bereaved parents on 1300 072 637.