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The booking-in scan

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.

Thank you to the lady who took her time to explain everything on the screen to me and acknowledged my loss.

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. 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.

The lovely lady who did my scan was compassionate, kind and gave me the information but knew I wouldn’t take it in.  [She told me] to read the leaflets when I was ready and call back for a chat.  She made a horrible situation a bit easier.

Before the scan

epu7Whatever 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:

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

During the scan

Women 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.epu4

  • 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.
  • If 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.
  • 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

The sonographer would not even discuss the option that I might miscarry, just said my dates might be wrong.  For her just to acknowledge that miscarriage was a possibility would have helped me prepare myself.

Breaking bad news

Breaking bad news can be difficult. epu3You 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

 Think about your language

languageWhen 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.

Show understanding and empathy

This isn’t just a pregnancy I’ve lost, it’s a potential child that would have changed my life.

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

Afterwards

I had a scan at EPAU yesterday, everything was fine…  What I was most impressed with was that they gave me a picture, but made me promise to keep it in my bag until I was out of the hospital.  They said it wasn’t fair on other mums waiting who might not have good news.    Having previously been the mum given bad news it was so nice to see they are thinking of everyone and encouraging sensitive practices.

Got more time?

These additional resources might be helpful.

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).

Jess’s story – a powerful account of what really helped her through – and what didn’t.

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

Scanning 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.

One minute you’re scanning a lady who has had recurrent miscarriages and for the first time ever, she sees her baby’s heartbeat – she is elated!  The next minute you have to tell a lady in her first pregnancy that she has miscarried – she is devastated.

The following suggestions might help.

Identify the difficulties

These may include

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. 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.

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.

We really need your feedback…