Caring for women and their partners experiencing pregnancy loss*: the booking in scan

* miscarriage, ectopic or molar pregnancy

A note of caution: this film includes scenes and 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.

Thank you for acknowledging loss

Our good practice guide

compassionate sonographerFrom 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. That can be true whether they suspect something is wrong or if it comes as a complete shock, for example at the booking-in scan.

You may be the one who has to break this news. Your approach can make a positive difference to their experience.

We spoke to women and sonographers (including nurses, midwives and doctors who scan) about what helps and what makes things harder.

 

 

Before the scan

Whatever the context – an Early Pregnancy Unit, Emergency Gynae clinic or booking-in clinic – women come to their ultrasound scan with a range of concerns, expectations and emotions:

  • Couple waiting for scanFeeling positive, looking forward to seeing their baby.
  • Feeling anxious – perhaps extremely anxious:
    • due to pain, bleeding or spotting or lack of pregnancy symptoms
    • due to previous experience of loss
    • if attending for a further visit after an inconclusive scan
  • Feeling distressed, if certain that the loss is occurring/ has occurred:
    • due to heavy bleeding and/or a negative pregnancy test
    • after expectant or medical management

The scan results may confirm or confound those expectations, and emotions are likely to be high.

 

 

During the scan

EPU4Women told us that they start to guess something is wrong if you go quiet or turn the screen away – and they find that silence very difficult to cope with.

Sonographers told us that it can take time to assess scan images, especially if they suggest or confirm a problem.

 

Good communication, clarity, honesty and sensitivity can help everyone involved.

  • Set the scene by telling the woman that you will be quiet for a few minutes until you can get a clear image.
  • Talk directly to the woman (and her partner, if present). If you talk primarily to colleagues or trainees, this can cause distress.
  • sensed something wrongIf the scan shows a pregnancy smaller than dates, consider how you check the dates with the woman without implying that she’s got them wrong.
  • If there is clearly a discrepancy, explain what this might mean.
  • If you need to consult a colleague, tell the woman what you are doing/where you are going and why.
  • Try to minimise the time that women/couples are left alone, waiting and uncertain.
  • Don’t be tempted to give false reassurance in order to make the woman feel better.Sonographer would not acknowledge
  • If you cannot give definite answers and a further scan or other test is needed, acknowledge how difficult uncertainty and unexpected problems can be.
  • Provide information about next steps, including:
    • the timing of a further scan – and why
    • what might happen in the meantime
    • whom to contact if she needs help or information before then

 

 

Breaking bad news

EPU3Breaking bad news can be difficult. You may be worried about causing pain and distress, having to deal with difficult reactions and perhaps about being blamed. Because of these concerns, some health professionals try and maintain a professional distance, staying brisk and detached. But this can come across as uncaring.

We suggest the following:

 

Beginning the conversation

  • Turn to face the woman when you are breaking the news. Include her partner too, if s/he is present.
  • Break the news gently, succinctly and with compassion.
  • Give as clear and honest an explanation as you can of what you see and what it means (or might mean).
  • Bear in mind that shock and distress can make it difficult for people to understand and digest information. You may need to repeat it.

Think about your language

nurse in scan roomWhen it comes to pregnancy loss, women and their partners are often acutely sensitive to the words you use. They also might not understand some medical terminology.

  • 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 the patient 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.
  • You 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 said they found terms like ‘products’, ‘blighted ovum’ ‘scrape’ and ‘vacuumed out’ hurtful and upsetting.

Show understanding and empathy

You might not be able to meet all her expectations but understanding, kindness and acknowledging her feelings can help.

  • not just a pregnancyAcknowledge the woman’s emotional response, whatever it is.
  • Say (and show) you are sorry for her/their loss, if appropriate, but
  • … be aware that it might make some women feel worse.
  • Don’t assume that the shorter the gestation, the less the sense of loss.
  • Give time for the news to sink in and for her to ask any questions she has.

 

 

Afterwards

  • Leaflet coverYou may have had to break difficult news while the woman was still lying down or half dressed. Make sure that there is some time for discussion when she is dressed and sitting on a level with you – even if it is just to check that she understands what will happen next.
  • Some women really want to see the screen and have a scan picture. Others don’t. Ask her what she would like.
  • She will probably find it hard to see or wait with pregnant couples. You may not be able to do anything about this, but it can help to show you understand how hard it can be.
  • If you are able to help them leave separately or wait elsewhere, explain why so they don’t feel they are being ‘hidden away’.
  • Consider asking all women/couples with good news not to look at their scan pictures as they go through the waiting room.
  • 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)

 

EPU scan

 

 

Got more time?

Lecture photoThese additional resources might be helpful.

Online lecture ‘Talking about Miscarriage’; available free of charge (20 mins).

The e-learning module Sensitive communication and breaking bad news produced by the Association of Early Pregnancy Units in association with the Miscarriage Association (available with AEPU membership) and/or…

The e-tutorial Early pregnancy loss: Breaking bad news, produced by the RCOG. ‘Gynaecological problems and early pregnancy loss’ (requires subscription).

Take a look at the Miscarriage Association’s leaflets Your feelings after miscarriage and Management of miscarriage: your options.

Take a look at our training resource on talking about management of miscarriage.

In this short teaching video for GPs and junior doctors, Professor Tom Bourne discusses both the medical and emotional aspects of ectopic pregnancy.

View other films in this series.

 

 

 

Consider your needs too

consider your needsScanning in early pregnancy can be like a roller-coaster – giving good news to one happy patient and then potentially devastating news to the next. Dealing with those emotional extremes can be very stressful.

 

The following suggestions might help.

Identify the difficulties

These may include

  • particular reactions that you find difficult to deal with:
    • tears: is there a point at which they become difficult or is it the kind of crying – silent tears or noisy sobs?
    • shock, numbness, no obvious response
    • disbelief and insistence on a second (better?) opinion
    • anger and blame – especially if directed at you
  • particular situations that are difficult or distressing:
    • where the scan findings require a further scan in a week or more
    • 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
  • the context, especially when there is also time pressure
    • the need to get another opinion
    • the need to move the patient on to discuss management options
    • needing to talk to the patient about management and disposal

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, clinics etc

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. But it might be worth considering that when it comes to your peers especially, the chances are that they will be facing similar issues and concerns and they might benefit too.

The comments below, from a GP who had herself been through miscarriage, are a good example of this.

Long quote from GP

 

 

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.

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