Accident and emergency
Caring for women and their partners experiencing pregnancy loss*
* miscarriage, ectopic or molar pregnancy
A note of caution This film includes scenes and conversations that some viewers might find upsetting, especially if they have been through pregnancy loss themselves. You may prefer just to use the good practice guide alone.
I knew you couldn’t stop it, but you could still help me get through it.
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.
If they have come to A&E they may be bleeding heavily, in pain and very frightened for their baby and perhaps for themselves.
You’re unlikely to be able to change the outcome of this pregnancy, but your approach can make a positive difference to the patient’s experience.
We spoke to patients and A&E staff about what helps and what makes things harder. Here’s a summary of what they told us.
Listen to the patient and her partner
Taking a good history includes listening to additional information that the patient (and perhaps her partner) gives.
Not only can it aid diagnosis, but good listening can also makes patient and partner feel respected and cared for at a vulnerable time.
Consider how she might be feeling
Whatever the patient’s situation, she is likely to be very distressed and anxious and see this as an emergency requiring urgent intervention.
- She may think, or hope, that swift treatment can save her pregnancy.
- She may feel that the longer she has to wait, the less chance there is of a positive outcome.
- She may be very distressed and tearful and find it hard to wait in a noisy, crowded waiting area.
- She is likely to be embarrassed if she is bleeding heavily.
- She may be in pain – possibly severe pain.
- Even if you mean to reduce her distress, try not to make light of her feelings or offer false reassurance.
- Don’t assume that the shorter the gestation, the less the sense of loss.
- Say (and show) you are sorry for her loss, if appropriate.
- Do your best to maximise her privacy, however difficult that can be in A&E.
You might not be able to meet all her expectations but understanding, kindness and acknowledging her feelings can make her situation easier to bear.
I didn’t like being left to sit in the waiting room, covered in blood from the bottom down.
Give whatever practical support and care you can
- If vaginal bleeding is visible to those around her, offer a blanket to wrap around her and sanitary pads if she wants.
- If you can, find her a more private space to wait.
- Give her as much information as you can about how long she will have to wait.
- Try to pass on her information so she doesn’t have to explain her situation more times than necessary.
- Offer pain relief if/when appropriate.
- If she is still bleeding when she is discharged, offer a sanitary or incontinence pad for the way home.
Think about your language
It may have been ‘products of conception’ to them, but to me it was my baby.
When it comes to pregnancy loss, women and their partners are often acutely sensitive to the words you use. They may not understand some medical terms. The language you use should be clear, sensitive and understandable to the average lay person.
- 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.
- Referring to ‘just a heavy period’, ‘spontaneous abortion’ or ‘products of conception’ is upsetting to most women.
- Don’t use complicated medical language if a simpler explanation will do.
- If you have to use medical terminology, be ready to explain it in lay language.
- Some patients will need interpreters, signers or helpers. We have leaflets in several languages, and for people with reading, learning and other communication problems.
Give her clear, honest information about what is happening now…
A&E staff have told us that it can be difficult to give clear information without access to scanning facilities and/or specialist staff. However, anxious and distressed patients may not understand that and might think you are withholding information.
I wish they had been honest with me instead of saying ‘it’s probably fine’.
- Be honest if there’s something you don’t know (for example, processes and systems in other departments) and say what, if anything, needs to happen to find out more.
- Acknowledge that not having answers or having to wait longer without knowing more can be very difficult and upsetting.
- Don’t be tempted to give false reassurance in order to make the patient feel better.
- If you have to break bad news, do it gently, succinctly and with compassion.
… and about what might happen next
I had no idea I would get contractions and it was scary as hell.
As you saw in the film, women tell us they are often upset or frustrated by processes and timing. Although you may not be able to change this, you can help by empathising with your patient’s feelings and explaining more about processes and next steps.
- If she cannot be offered a scan there and then, explain why.
- Uncertainty is always difficult and she may find it very hard to have to wait or return for a scan at a later date.
- She may be frightened about going home and what might happen. She will appreciate information about:
- what might happen in the meantime if she begins to miscarry: strong, perhaps severe abdominal cramps, heavy bleeding, passing clots
- what she might see: possibly a recognisable sac, fetus or baby
- how to manage that: pain relief, large sanitary pads, coming back to hospital if she feels safer there
- She will not be upset or angry if the process doesn’t happen or is not that bad.
- If she has to make decisions about next steps, give her information about options and timing. Allow time to consider any options and to ask questions.
- The Miscarriage Association provides support and information (but not medical advice) 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?
These additional resources might be helpful.
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).
A short teaching video on ectopic pregnancy, by Professor Tom Bourne (courtesy of BMJ Learning).
Have a look at this example of good practice on Patient Opinion.
View other films in this series.
Consider your needs too
Working in A&E can be hugely rewarding but there’s no denying that it can also be very stressful.
I find it very difficult breaking bad news without the appropriate privacy. The patient is usually very anxious and upset.
Patients who attend because of suspected or obvious pregnancy loss are unlikely to be viewed as emergencies. By the time they reach you, their levels of anxiety, distress and possibly pain may be very high. You might encounter some difficult emotions not only from the patient but also from anyone accompanying her.
We hope some of the following suggestions will help – for miscarriage patients and perhaps others too.
Identify the difficulties
These may include:
- coping with fatigue – physical and emotional:
- especially given that patients are focused on their own needs, not yours
- particular reactions that you find difficult to deal with:
- anxiety, desperation for you to ‘do something’, solve the problem
- insistence on a second (better?) opinion
- anger and blame – especially if directed at you
- particular situations that are difficult or distressing:
- a patient or loss that you identify with due to your own experience
- your own views and values on the significance of some cases, especially compared with other A&E presentations
- the context, especially when there is also time pressure:
- the need to confer with colleagues
- explaining and organising referral to other departments, especially:
- when you have no control over time-lines
- when you have little information about next steps there for the patient
- lack of follow-up – never knowing the outcome of your care
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
- individually, informally
- through existing or developing networks via the RCEM
You might also consider:
- your partner, if you have one, or a trusted friend
… 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.
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.
To the doctor I saw at 7 am who couldn’t do much until the EPU opened, thank you for finding me a quiet room to wait in.