Caring for women and their partners experiencing pregnancy loss: management of miscarriage*

* Our film and the guidance notes that follow focus on miscarriage. However, the principles of care and communication apply equally to women diagnosed with ectopic pregnancy in cases where there is a choice of management approaches.

A note of caution: this film includes conversations that viewers might find upsetting, especially if they have been through pregnancy loss themselves.  You may prefer just to use the good practice guides alone.

Ask how I was feeling

Our good practice guide

From a medical perspective, miscarriage is a common and generally minor complication of pregnancy, but for patients and their partners it can be distressing, frightening and lonely.

MAN1This can be even more so when the physical process of loss has not yet happened and women are faced with making a choice between options for management. Your approach can make a positive difference to the patient’s experience.

We spoke to women and health professionals about what helps and what makes things harder.

Women told us that they wanted clear and honest information, presented with kindness, sensitivity and acknowledgement of the emotional impact of miscarriage. They also talked about the importance of overall care at this time.

Health professionals told us that they sometimes found it difficult to have these conversations, particularly when patients were already very distressed. They could feel pressured by time constraints and the needs of other patients.

We look at all these points below. You may also find it useful to have a look at our films on scanning in pregnancy and on talking to patients about the sensitive disposal of pregnancy remains as these are often linked in practice.

 

 

The context

doctor talking about managementAfter miscarriage has been confirmed you may need to talk to the woman and her partner about management options.

Key things to think about are:

    • The woman’s (and maybe her partner’s) emotional state:
      • shock (no idea anything was wrong) and disbelief
      • prepared (due to symptoms or previous scan) but still upset
      • extremely distressed
      • no obvious show of distress
      • relieved
      • angry
    • When’s the best time for the conversation? Does it have to be now? If so, is this for:
      • clinical reasons (e.g. bleeding, risk of infection) or
      • administrative reasons (record-keeping, guidelines, time pressure) or
      • personal reasons (your fatigue, wanting to get it over with)
    • Can they actually cope with it now?
    • Can you offer alternatives? Perhaps a first brief conversation aboCalm silence doesn't mean I'm okut what the next steps are and the option of having that discussion:
      • in the next few minutes/hour etc (helpful to indicate how long it might be if someone is to be called in)
      • later that day, by appointment if possible
      • another day, by appointment
    • Consider asking if the woman/couple would value having written information before the conversation or after.

 

 

Consider how she (or they) might be feeling – be sensitive and compassionate

Emily talking

 

For most women (and their partners), miscarriage means the loss of a baby, whatever the gestation. They want you to recognise and understand
the emotional impact of their loss, showing empathy and acceptance of whatever they are feeling.

 Women (and their partners) may also find it very distressing to have to make a decision at all about their next steps, as all options involve the final loss of their baby.

realised what 3 options meant

 

 

Think about your language

  • Most (but not all) women think of their pregnancy as a baby. Most (but not all) prefer you to refer to it that way.
  • If you’re not sure what term to use, mirror what she uses (baby, fetus, pregnancy) or ask her what she’d prefer.
  • Try not to minimise the loss. Referring to it as a ‘just a heavy period’, ‘back luck’ or saying ‘at least you know you can conceive’ can actually increase distress.
  • discussed with colleguesYou many need to explain medical terminology that she has heard or read elsewhere.
  • Do not use the term ‘abortion’ (or threatened, missed or incomplete abortion) to describe miscarriage.
  • Women also said they found terms like ‘products’, ‘blighted ovum’ ‘scrape’ and ‘vacuumed out’ hurtful and upsetting. 

 

 

Provide clear information about each option and time for questions

  • thank youIn the film Emily says “I was all over the place” and Catherine says, “that’s when you go a bit numb and don’t take anything more in”. Women who are feeling distressed and shocked may find it hard to process information and make a decision.
  •  Give clear, accurate and unbiased information about each option and an explanation as to why one or more might not be possible or advisable (e.g. for clinical reasons).
  • It’s inappropriate to over-emphasise the risks or disadvantages of one option while minimising those of a different option.
  • Women told us that they wanted more information about what each option means in practice, to help them make an informed choicscreenshot-2016-09-23-07-48-11e.
  • Avoid inaccurate information (‘like a heavy period’) or vague/confusing information (‘torrential bleeding’).
  • If she is likely to miscarry at home, explain that she may have strong to severe pain and heavy bleeding that may contain large clots. If you do not provide pain medication, advise her what she might need and remind her that she’ll also need sanitary pads.
  • Leaflet coverYou may feel as if you are scaring her by being honest about possible pain and bleeding. But being clear about what might happen will help women decide and prepare.  Nobody is going to make a complaint if the pain and bleeding aren’t as bad as you said they might be.
  • Provide written information for women to take away and read. The Miscarriage Association leaflet Management of miscarriage: your options provides clear information about the different options:what happenspain & bleeding
    • risks
    • benefits
    • disadvantages
    • disposal of remains

 

 

Important practicalities

management picSome practical aspects may be out of your control, but it can help to show you understand how hard it can be.

Time. Women and their partners need time to talk and understand what is happening next both before and during your conversation. They don’t want to wait too long but neither do they want to be rushed. If possible, turn your bleeper off and make sure there is time to answer questions.

Place. Many women remember the place where they had this conversation for a long time afterwards. Talk to the woman when she is dressed and sitting down. Use a clean, tidy, private room (if possible without pregnancy or baby posters on the walls).

It can be very difficult tostill remember wait in a room where lots of pregnant women are waiting for a scan and couples who have had good news are leaving. If possible, find the woman and her partner a private space to wait. As Catherine notes in the film, this can help those waiting too.

 

 

Other aspects of care

It is important to show acknowledgement and understanding of distress throughout the provision of care.

 

Be aware that the practicalities of day surgery can be harder for women waiting for management procedures:

  • they may have to day staffwait without food and water while still feeling pregnancy nausea
  • they may find it very difficult if their partners are not allowed to wait with them
  • they may be on a ward with patients having terminations and some women find this upsetting
  • surgery consent forms that require an answer to the question “are you or could you be pregnant” are almost certain to cause distress. Staff completing the form should know that the woman is having surgical management of miscarriage – and fill in the appropriate answer if that is permissable.

Be careful of the language you use during follow up. The procedure going well medically still means the woman has lost her baby.

consultant big smileConsider how you might re-phrase the following comment made to a woman who returned for a scan after conservative management:

“That’s fine – all the products have passed.”

Remember that body language is also important.

 

 

Provide information about what happens next

forget me notDiscussion about the disposal of pregnancy remains often happens at the same time as conversations about management options. You may find it helpful to have a look at our training materials on talking about the sensitive disposal of pregnancy remains.

Make sure the woman (and her partner) understand what to expect in the weeks during and after management.

Provide information about support and counselling options:

  • within the hospital: bereavement support staff, chaplaincy etc
  • beyond the hospital: local or national support and counselling services
  • The Miscarriage Association provides support and information via our website, phone, email and online groups. Pass on our information with a contact card (we can provide you with these)

 

 

Got more time?

You might find these resources helpful.

Lecture photoOnline lecture ‘Talking about Miscarriage’ available free of charge (20 mins).

E-learning module Sensitive communication and breaking bad news produced by the Association of Early Pregnancy Units in association with the Miscarriage Association (this requires a subscription)

The Royal College of Obstetricians and Gynaecologists has produced a course called Early pregnancy loss: Breaking bad news (there is a cost for non-members).

Miscarriage Association leaflets on Management of miscarriage and Your feelings after miscarriage.

The Miscarriage Association is a resource for you as well as for your patients.  If you have any questions or would like to talk anything through, please do get in touch.

 

 

Consider your needs too

difficult HPTalking to patients about management of miscarriage can be difficult and distressing – for them, of course, but also for you. Whether or not you have done the scan that has confirmed a pregnancy loss, you are probably delivering a lot of information to someone who is already in distress and that can be upsetting for you too.

The following suggestions might help.

 

Identify the difficulties

The context:

  • if this is your first encounter with this patient
  • where the conversation takes place
  • time pressure: the need to give the information and get a decision
  • needing also to talk to the patient about disposal

Particular situations that are difficult or distressing:

  • where the patient (and perhaps her partner too) is still reeling from confirmation of her loss
  • if she doubts the diagnosis and is not ready to make a decision
  • anxiety that you might be increasing her/their distress
  • a patient you know from previous loss/es
  • a patient or loss that you identify with due to your own experience

Your own views and values on the significance of some losses.

Fatigue – physical and emotional.

Identify your sources of support …

Your most likely source of support will be your peers:

  • in your hospital/Trust:
    • individually, informally
    • in staff meetings, training sessions and/or clinical supervision
  • peers from other hospitals or clinics:

You might also consider:

  • your partner, if you have one, or a trusted friend
  • talking to us at the Miscarriage Association in strict confidence.

… and make use of them

It’s one thing to know where you can find support. It’s another thing to do something about it. It’s worth considering that your peers may have similar concerns and might also benefit from talking about these issues together.

 

And finally

Miscarriage is never easy – for the woman or couple involved or for the staff who are tasked with looking after them. You may not get it right for everyone, but patients will always remember your care, kindness and compassion.

 

Nurse gave us five mins

 

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