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General practice

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 viewers might find upsetting, especially if they have been through pregnancy loss themselves.  You may prefer just to use the good practice guides alone.

My GP couldn’t do anything to change what had happened but she listened.

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.

This may be even more so for ectopic and molar pregnancy, which are much less common and can carry additional complications.

Patients may present with symptoms or worries during pregnancy, or they may come after a loss, or during a subsequent pregnancy. Some may present with other problems, such as anxiety or depression, and it becomes clear that these are related to pregnancy loss.

In all of these situations, your approach can make a positive difference to their experience.

My GP was fabulous.  She knew what we’d been through to get pregnant at all and was so supportive.

We spoke to women and GPs about what helps and what makes things harder. Here’s a summary of what they told us.

Listen to the women (and her partner, if present)

Taking a good history includes listening to additional information that she (and perhaps her partner) gives, as well as reading her notes. Not only can it aid diagnosis, but good listening can also make her feel respected and cared for at what might be a vulnerable time.

If a woman of child-bearing age presents with acute abdominal pain, ectopic pregnancy should always be considered, even if she does not know if she is pregnant.

Consider how she (or they) might be feeling

gp2Everyone reacts individually to pregnancy loss. Some women may accept it and some might feel relieved. But many women (and partners) feel:

After ectopic pregnancy, women may also feel shocked by the speed of events in diagnosis and treatment, especially after emergency surgery.

After molar pregnancy, women may also feel very frightened by the association with cancer, and very upset by having to delay trying to conceive again because of the follow-up process.

Everything happened so quickly I never had time to think about it until after the operation.  I had so many ‘what ifs’ running through my head.

Show understanding and empathy

gp-4You might not be able to meet all her expectations but understanding, kindness and acknowledging her feelings can help.

Sometimes just having someone listen to how you feel, the guilt and the heartbreak, helps to ease it.

Think about your language

natalieWhen it comes to pregnancy loss, women and their partners are often acutely sensitive to the words you use or that they hear in hospital. They also might not understand some medical terminology.

It doesn’t matter how far gone you were – it’s still my baby I’ve lost.

Give clear information about what is happening now…

 … and about next steps

Many women will seek information and advice.

why-me

Causes and treatment

Management options for miscarriage

Pregnancy remains

Options for disposal

*The RCOG recommends referral for investigations following three or more first-trimester miscarriages or one or more second trimester miscarriages.  Many women find these criteria hard to accept, especially if they are older or have problems conceiving. They are searching for an explanation for their losses and treatment to reduce the risk of recurrence and may be especially vulnerable to treatments which are not evidence-based.  Clear information and support can help.

Give her information about additional support available

Thank you for the follow up call a week after my miscarriage – it meant so much to me.

Women told us that they often underestimated the impact of pregnancy loss on their mental health. You can help by providing additional information and follow up.

Got more time?

These additional resources might be helpful.

Lecture photoThe BMJ Miscarriage: Management in Primary Care podcast (requires subscription)

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 Royal College of Obstetricians and Gynaecologists module Early pregnancy loss: Breaking bad news (requires subscription)

Take a look at the Miscarriage Association’s leaflet Your feelings after 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

It’s difficult explaining how little can be done during a miscarriage.  Consultations are hard sometimes.

natalie-leafletCaring for patients with pregnancy loss can be stressful.  They are likely to be anxious, distressed, grieving or even angry. They may express wants and needs that you just can’t meet.

What’s more, you are their central port of call, even if they also have hospital care. However good that care is, it is brief. It’s the GP who is going to be looking after them after their loss and in the longer term.

Considering your needs may seem like a pipedream, given the increasing demands of general practice, but we hope the following suggestions might help.

Identify the stressors

These can include:

Identify your sources of support…

Your most likely source of support will be your peers:

But you might also consider:

… 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.

The comments below, from a GP who had herself been through miscarriage, may be the best example of this.

After my experiences I did a peer teaching session with my colleagues with an emphasis on communication.  We concluded that there is no ideal one size fits all explanation or way of expressing condolences in these situations – even a blanket expression of how sorry you are or referring to the baby can be wrong! …

Also … statements such as ‘it’s very common’ or ‘at least you can conceive quickly’ can be helpful or hurtful to different women…

Basically our conclusion was to acknowledge the woman’s emotional response,  to ask open questions about what they feel/what information they want next and then to be guided by their responses – rather than just trying to give a perfect one liner that might be more hurtful.

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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