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
Whatever 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:
Feeling positive, looking forward to seeing their baby.
Feeling anxious – perhaps extremely anxious:
due to pain, bleeding or spotting or lack of pregnancy symptoms
due to previous experience of loss
if attending for a further visit after an inconclusive scan
Feeling distressed, if certain that the loss is occurring/ has occurred:
due to heavy bleeding and/or a negative pregnancy test
after expectant or medical management
The scan results may confirm or confound those expectations, and emotions are likely to be high.
During the scan
I sensed there was something wrong because there was a very heavy silence that fell on the room …
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.
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. You 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
Turn to face the woman when you are breaking the news. Include her partner too, if s/he is present.
Break the news gently, succinctly and with compassion.
Give as clear and honest an explanation as you can of what you see and what it means (or might mean).
Bear in mind that shock and distress can make it difficult for people to understand and digest information. You may need to repeat it.
Think about your language
When 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.
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.
Try not to minimise the loss. Referring to it as a ‘just a heavy period’, ‘back luck’ or saying ‘at least you know you can conceive’ can actually increase distress.
You many need to explain medical terminology that she has heard or read elsewhere.
Do not use the term ‘abortion’ (or threatened, missed or incomplete abortion) to describe miscarriage.
Women said they found terms like ‘products’, ‘blighted ovum’ ‘scrape’ and ‘vacuumed out’ hurtful and upsetting.
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.
Acknowledge the woman’s emotional response, whatever it is.
Say (and show) you are sorry for her/their loss, if appropriate, but …
… be aware that it might make some women feel worse.
Don’t assume that the shorter the gestation, the less the sense of loss.
Give time for the news to sink in and for her to ask any questions she has.
You may have had to break difficult news while the woman was still lying down or half dressed. Make sure that there is some time for discussion when she is dressed and sitting on a level with you – even if it is just to check that she understands what will happen next.
Some women really want to see the screen and have a scan picture. Others don’t. Ask her what she would like.
She will probably find it hard to see or wait with pregnant couples. You may not be able to do anything about this, but it can help to show you understand how hard it can be.
If you are able to help them leave separately or wait elsewhere, explain why so they don’t feel they are being ‘hidden away’.
Consider asking all women/couples with good news not to look at their scan pictures as they go through the waiting room.
Provide information about support and counselling options:
within the hospital: bereavement support staff, chaplaincy etc
beyond the hospital: local or national support and counselling services
The Miscarriage Association provides support and information via our website, phone, email and online groups. Pass on our information with a contact card (we can provide you with these)
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.
A practical poster
Consoder printing off the award-winning poster produced at Birmingham Womnen’s Hospital for sonographers (and others) delivering difficult news in obstetric ultrasound.
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
particular reactions that you find difficult to deal with:
tears: is there a point at which they become difficult or is it the kind of crying – silent tears or noisy sobs?
shock, numbness, no obvious response
disbelief and insistence on a second (better?) opinion
anger and blame – especially if directed at you
particular situations that are difficult or distressing:
where the scan findings require a further scan in a week or more
a patient you know from previous loss/es
a patient or loss that you identify with due to your own experience
your own views and values on the significance of some losses
fatigue – physical and emotional
the context, especially when there is also time pressure
the need to get another opinion
the need to move the patient on to discuss management options
needing to talk to the patient about management and disposal
Identify your sources of support…
Your most likely source of support will be your peers:
in your hospital/Trust
in staff meetings, training sessions and/or clinical supervision
peers from other hospitals, clinics etc
through existing or developing networks like the AEPU and the developing Bereavement Care Network.
You might also consider:
your partner, if you have one, or a trusted friend
talking to us at the Miscarriage Association in strict confidence.
… 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.
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.