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Talking about management of miscarriage

Caring for women and their partners experiencing pregnancy loss *

* 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.

I wish they had asked how I was feeling.  Everything was focused on what happened next but I was feeling too raw to think ahead.  It was devastating – I was absolutely distraught.

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 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.

man1We 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

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

Calm silence doesn’t mean I’m OK with it.  It can be shock, still processing it or internal chaos.

Key things to think about are:

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

man3For 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.

I started to realise what the three options really meant.  I would essentially have to bleed everything out of me, but this could take 2 or 3 weeks to happen; I could have some medication to make this happen faster; or I would have to have it surgically removed.  None of these options appealed to me at all.

Think about your language

I discussed this with my colleagues.  We agreed that different women feel differently, and find different things helpful at different times.  [We should] be guided by them rather than trying to deliver the perfect ‘one liner’.

Provide clear information about each option and time for questions

Thank you to the nurses for their kindness and sensitivity, listening to my concerns, never making me feel silly and explaining all options with compassion.

For medical management at home we give codeine phosphate and an anti-emetic.

Important practicalities

The room where we spoke was awful and I can still picture the mess and food crumbs.

man5Some 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 to 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.

I wish the staff in day surgery had considered the operation I was in for.  I wasn’t just there for a bunion removal so it wasn’t routine to us, it was the removal of our baby and all the emotions behind it.

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

Be careful of the language you use during follow up…

The consultant scanned me after the delivery and said ‘you’re completely empty’ with a big smile, like it’s what I wanted to hear.

The procedure going well medically still means the woman has lost her baby.

Consider 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.”

… and remember that body language is also important.

Provide information about what happens next

Discussion 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.

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

Provide information about support and counselling options:

Got more time?

You might find these resources helpful.

Positive patient feedback on her care, via Patient Opinion.

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

Talking 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.

It’s difficult knowing how to phrase words, having confidence in my own knowledge to be able to sufficiently answer questions, and not feeling I have the experience to be able to clearly explain what the patient should expect (physical symptoms, emotional features).

The following suggestions might help.

Identify the difficulties

The context:

Particular situations that are difficult or distressing:

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:

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.

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.

The nurse gave us five minutes to ourselves immediately after the scan; she had a box of tissues ready (important!!), she actually seemed sad for our loss rather than clinically impartial.  She must see it all the time but for us it was a life-changing event and we appreciated her sincere sympathy.

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