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After completing this unit you will:
As a health professional working with women experiencing miscarriage you are likely to have to have difficult conversations with them and to convey bad news.
Bad news can mean different things to different people but it will virtually always disrupt people’s normal routine. Dreams can be shattered and relationships turned upside down, leading to different lifestyles and choices.
It is hard and upsetting to start difficult conversations. However, women tell us that they appreciate health professionals who are honest with them about what is going to happen and that information gives them more control of the situation.
I discussed with nurses what I could do with the baby and they were incredibly sympathetic and caring with their words, their tone and their time. They were also knowledgeable about what I could do with it, about bringing it back to the hospital.
We can all be better communicators. Good communication skills are key to obtaining information, conveying information, and enabling women to be able to take the decisions that are right for them.
Time spent listening helps you to understand the woman’s point of view and draws attention to her specific needs.
A simple, effective model of communication is the BEST model. It includes verbal and non-verbal ways of communicating along with emotional support.
* In the context of miscarriage, we would use ‘end’ rather than ‘terminate’.
Communication starts even before we start talking. More than two thirds of a face-to-face conversation is based on body language. There is non-verbal communication from when you are first with someone in the clinic or consulting room. It is particularly important to pay attention to the non-verbal aspect of your communication when giving bad news to a woman. Eye contact is the strongest non-verbal gesture and indicates you are listening to the woman.
The doctor asked me if I had any more questions. I did, but she was looking at her watch, so I just kept quiet.
Information gathering is an art. You need to aim to actively guide the conversation, not by talking more or stopping the conversation, but by moving your discussion towards relevant topics at the same time as interpreting what the woman is saying to you.
If you are examining the woman, it may be helpful to talk to her while you do this, as long as you are talking about the examination or the problem. It may help put her at her ease.
Women experiencing a miscarriage are likely to show a variety of emotions and may be distressed, withdrawn, disbelieving or even angry. How you communicate can make a significant difference.
Empathy is important in any trusting relationship. Your face, eyes, and gestures should all support you in demonstrating your continued interest in the woman. Listen to what she or he is saying and nod to show you are listening.
There is a Chinese proverb: ‘Words are just words and without heart they have no meaning’. Try to listen to the unsaid, be open to the expression of feelings and aim to enable non-verbal two-way communication.
It may be difficult, and possibly inappropriate, to try to end on a positive note when a woman is experiencing a miscarriage but it’s good to summarise briefly what you have discussed and ask if she has any questions.
You may find it useful to use phrases such as ‘I hope I have given you the information you need. Do you have any questions?’
* In the context of miscarriage, we would use ‘end’ rather than ‘terminate’.
As you watch this, think about what these films tell you about the challenge of giving difficult news to women.
Routine dating or anomaly scans can be a time when a problem with a pregnancy is discovered. It can therefore be challenging for the health professional carrying out the scan, not knowing whether all will be well or not. Even if you do not perform pregnancy scans yourself, you may find it useful to think about the issues below.
This film follows a couple as they attend for their dating scan.
As you watch the film, think about how the sonographer could have made the experience more manageable for the couple. In the next screen we will explore ways the experience could be better.
You may have noticed that the sonographer did not adequately introduce herself, or the purpose of the scan. Setting the scene at the very beginning with every woman will help if you have to go on to break bad news.
Women may start to guess something is wrong if you go quiet and they are likely to find that silence very difficult to cope with. At the same time, you need time to assess scan images, especially if they suggest or confirm a problem. Good communication, clarity, honesty and sensitivity can help everyone involved.
Next we explore some of the ways in which you can help make the woman’s experience better.
I sensed there was something wrong because there was a very heavy silence that fell on the room.
There are a number of ways in which you can make the experience more positive, or at least more manageable, for the woman or couple. Click on the images below to find out more about what you can do.
The NBCP sets out some Best Practice Points for delivering difficult news (page 12), as do the UK consensus guidelines for the delivery of unexpected news in obstetric ultrasound: The ASCKS Framework.
Talking with women about the disposal of pregnancy remains can be difficult and daunting. Women may already be distressed. They may have already had to make difficult decisions about how the loss is managed and perhaps are anxious about what is to come.
However, you have the potential to make a difference to how women experience this difficult part of a miscarriage. You may not get it right for everyone, but women will always remember your care, kindness and compassion. Women tell us that they want sensitivity and honesty and time to think.
Familiarise yourself with your hospital’s policy on the disposal of pregnancy remains and prevailing law and practice. (See Resources and references).
You may also wish to look at the NBCP guidance for sensitive disposal and funerals (pages 26-28)
We wouldn’t expect a decision but we like to make them aware of their choices so they can have some time in thinking what’s right for them.
Think about how you could have helped Corinne and Erin to have a less traumatic experience.
Think about how you can integrate some of Rachel’s advice into your own practice and the importance of being familiar with local guidance and policy.
