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Clinical: Supporting women through miscarriage, ectopic or molar pregnancy

Key learning points

 

  • Early pregnancy losses provoke a wide range of physical and emotional experiences
  • Assumptions cannot be made about how parents will feel, or what care they will require in a subsequent pregnancy
  • Listening to parents and responding to their expressed needs is key

It is estimated that around one in five pregnancies ends in miscarriage,[1] and up to 75% of miscarriages occur in the first trimester.[2] Early pregnancy losses are therefore, sadly, quite a common occurrence. However, there is a wide range of experiences within this group, both in terms of the type of pregnancy loss and in the emotional reactions to these experiences. These complexities can present difficulties for practitioners trying to deliver sensitive care.

This article focuses on general practice nurses and how effective communication can help to ensure that parents receive appropriate care. While definitions of early pregnancy loss can vary, this article will focus on losses before 14 weeks’ gestation. Practitioners should be aware that parents who have experienced a termination for foetal anomaly might require similar forms of care. 

Forms of early pregnancy losses

There are different forms of miscarriage and early pregnancy loss. A miscarriage will typically be characterised by vaginal bleeding and may include cramping and pain in the lower abdomen.[1] It may involve the spontaneous expulsion of all pregnancy tissue from the uterus.[3] In other cases, some tissue may remain in the uterus (often referred to as an incomplete miscarriage).[3]

A missed or delayed miscarriage occurs where a foetus has not continued to develop, but remains in the uterus.[3] The term can also refer to situations where a foetus has not developed within the pregnancy sac. 

In addition to miscarriage, ectopic pregnancies are a form of pregnancy loss where the ovum develops outside of the uterus, usually in the fallopian tubes.[4] Ectopic pregnancies occur in about one in 90 pregnancies in the UK.[2] Molar pregnancies are a rare form of tumour that grow from pregnancy tissue in the uterus, occurring in approximately one in 600 pregnancies.[5] In very rare cases, molar pregnancies can become malignant.

Treatment options

NICE guidance [6] currently recommends that expectant management of the miscarriage should be used for seven to 14 days before consideration of further treatment options, with some exceptions (such as for those that have experienced a previous childbearing loss, or those at risk of haemorrhage or infection). This process can vary a lot between different cases, particularly in terms of the amount of time it takes for the miscarriage to occur, the amount of bleeding and the degree of pain experienced.[3] For patients who are not suitable for expectant management, or do not want it, medical and surgical options are also available.[3] Medical or surgical options are recommended in cases of ectopic pregnancy,[6] and surgical management is the main treatment option for molar pregnancy.[7]

Bereavement and early pregnancy loss

Assumptions should be avoided when working with those that have experienced an early pregnancy loss. Parents’ feelings will be intensely personal and are not necessarily determined by the gestation stage at which the loss takes place.[8]

Parents may experience a wide range of emotions during and following an early pregnancy loss, including grief, distress, confusion, shock, regret, anger, relief, guilt, blame, stress or
a mixture of emotions.[4]

The intensity of these feelings can vary immensely between different people and some may not experience any of them.[9] Some who experience a miscarriage may consider themselves to be parents, and some may not. Others may feel that they have lost a baby, while others may not conceptualise their experience in the same way.[4] This can make some healthcare professionals unsure of how to address these losses when providing care, or even whether they should do so.

While the emotional response to early pregnancy loss can have long-term implications, people who experience early pregnancy losses often do not receive appropriate aftercare.[10] Although not all people who have experienced an early pregnancy loss will want or require a lot of contact with healthcare professionals, others will.[8] It is crucial that the care offered matches the parents’ individual needs, as this can have a significant impact on their long-term wellbeing.[4]

Some parents do not feel that their emotional needs are fully recognised.[11] This is where the significance of bereavement care in early pregnancy losses becomes apparent. 

Principles of bereavement care

A general practice nurse may come into contact with a woman experiencing an early pregnancy loss when they consult for pain or bleeding. Nurses may also see these women as part of aftercare and follow-up appointments in the community or the loss may be discussed in a subsequent pregnancy. Some of these encounters may not appear to be ‘bereavement care’, as you will not necessarily be discussing the loss in detail or the parents’ feelings about it. However, our experience in supporting bereaved parents is that small details can make a big difference, and positive or negative experiences with practitioners can stay with parents for many years. This means that all interactions with healthcare professionals directly impact upon the parents’ experience of bereavement.

Sands has developed 10 key principles of bereavement care, which should inform all care provided to parents who have experienced a pregnancy loss or the death of a baby, whether recent or not. These are:[12]

  1. Care should be individualised so that it is parent led and caters for their personal, cultural or religious needs. 
  2. Clear communication with parents is key and should be sensitive, honest and tailored to meet the individual needs of parents. 
  3. In any situation where there is a choice to be made, parents should be listened to and given the information and support they need to make their own decisions about what happens to them and their baby. 
  4. No assumptions should be made about the intensity and duration of grief that a parent will experience. 
  5. Women and their partners should always be looked after by staff who are specifically trained in bereavement care and in an environment that the parent feels is appropriate to their circumstances. 
  6. A partner’s grief can be as profound as that of the mother. Their need for support should be recognised and met. 
  7. All staff who care for bereaved parents before, during or after the death of a baby should have opportunities to develop and update their knowledge and skills. In addition, they should have access to good support for themselves. 
  8. All parents whose babies die should be offered opportunities to create memories. Their individual wishes and needs should be respected. 
  9. The bodies of babies and foetal remains should be treated with respect at all times. 
  10. Ongoing support is an essential part of care and should be available to all those who want it and should continue to be made available to all women and their partners during a subsequent pregnancy and after the birth of another baby.

Principles in practice 

General practice nurses caring for parents who experience an early pregnancy may encounter a wide range of circumstances. As outlined in the principles of bereavement care, communication and awareness are critical to deliver sensitive care to bereaved parents. Those who have experienced early pregnancy losses may react in a wide variety of ways, and practitioners need to be able to listen and respond to these to deliver care appropriate for their particular needs. 

One of the key issues of early pregnancy loss, whether during that pregnancy or in a subsequent one, is uncertainty. There are likely to be periods of time, possibly extended periods, where parents will not know if their baby is alive or dead. The difficulty of this, both for parents and practitioners, needs to be recognised. 

While it is a natural instinct to try to focus on the positives and hope for the best, honesty is a crucial facet of communication. Healthcare professionals should avoid assurances that may not be accurate, acknowledge the difficulties of the position that parents may be in and clearly outline the process by which they will be able to clarify their situation, if possible. 

Parents may fear that their anxiety could impact upon their pregnancy; any such fears should be listened to and taken seriously, and parents should not be made to feel like they are causing a fuss unnecessarily.[4]

It is important that practitioners are familiar with a mother’s medical history before attending an appointment, so that the parent does not need to explain their situation repeatedly. They will probably encounter a wide range of healthcare professionals at the time of and subsequent to their loss and having to repeat details to a succession of new people can be a distressing experience. Checking the medical history also helps practitioners to avoid accidentally causing offence through misunderstandings, and ensures that parents are more likely to feel their experience is being recognised and respected. 

Many practitioners often tell us that they are unsure whether they should bring up the subject of previous losses when they see expectant parents. While these concerns are understandable, the avoidance of these conversations can give parents the impression that they should not discuss them, heightening the anxiety that they may already feel. 

Staff should encourage parents to talk about their previous experiences if they will find this helpful, but not force the issue if the parents do not want to. 

Language matters – if parents named their previous child or use words such as baby, general practice nurses should also use these terms. If parents do not, then you should follow their lead and mirror the language they are using. 

Where a miscarriage occurs at home without a medical practitioner present, parents can experience difficulties in obtaining a certificate or letter of confirmation. This can prevent them from arranging a burial or cremation if this is what they would like to do, causing distress. 

Parents can take the remains to the hospital or GP they are registered with, and explain the circumstances.[13] They can then request a certificate from the medical practitioner confirming that in their professional opinion the baby died before 24 weeks’ gestation, which can be provided to a funeral director, cemetery or crematorium to enable burial or cremation to proceed.

Conclusion

Delivering care to parents who experience an early pregnancy loss can present significant challenges to practitioners, who will be keen to provide sensitive care, but concerned about unintentionally triggering additional distress. While the particular requirements of women and their partners may vary dramatically, the basic principles underpinning this care will remain the same. 

It is critical that parents’ concerns are listened to and respected, and that care is tailored to their expressed needs, rather than their assumed needs. 

While no level of care can remove the pain of an early pregnancy loss, sensitive, individualised care can best support parents through a potentially very difficult, uncertain time. 

Resources

References

  1. NHS Choices. Miscarriage. nhs.uk/conditions/Miscarriage/Pages/Introduction.aspx (accessed 26 January 2017).
  2. Tommy’s. Miscarriage statistics. tommys.org/our-organisation/why-we-exist/miscarriage-statistics (accessed 26 January 2017).
  3. Miscarriage Association. Management of miscarriage: your options. miscarriageassociation.org.uk/wp/wp-content/leaflets/Management-of-miscarriage.pdf (accessed 26 January 2017).
  4. Sands. Pregnancy Loss and the Death of a Baby: Guidelines for professionals 4th edition. 2016
  5. Miscarriage Association. Molar pregnancy (hydatidiform mole). miscarriage association.org.uk/wp/wp-content/leaflets/Molar-Pregnancy.pdf (accessed 26 January 2017). 
  6. NICE. Ectopic pregnancy and miscarriage: diagnosis and initial management. CG154. nice.org.uk/guidance/cg154  2012 (accessed 30 January 2017).
  7. Miscarriage Association. Molar pregnancy: Treatment and beyond. miscarriageassociation.org.uk/information/types-of-pregnancy-loss/molar-pregnancy/treatment-and-beyond/ (accessed 30 January 2017).
  8. Murphy F, Merrell J. Negotiating the transition: caring for women through the experience of early miscarriage. Journal of Clinical Nursing 2009;18:1583-91.
  9. Miscarriage Association. Feelings after pregnancy loss. miscarriage association.org.uk/support/feelings-after-pregnancy-loss/ (accessed 30 January 2017).
  10. NHS Improving Quality. A review of support available for loss in early and late pregnancy. Leeds: NHS Improving Quality. 2014. Available at webarchive.nationalarchives.gov.uk/20160805123905/http://www.nhsiq.nhs.uk/resource-search/publications/pregnancy-loss.aspx (accessed 30 January 2017). 
  11. Rowlands IJ, Lee C. The silence was deafening: social and health service support after miscarriage. Journal of Reproductive and Infant Psychology 2010;28:274-86. 
  12. Sands. Sands principles of bereavement care. uk-sands.org/professionals/principles-of-care/sands-principles-of-bereavment-care (accessed 30 January 2017).
  13. Miscarriage Association, Sands, ICCM. Guidance for miscarriages that occur at home. 2015. Available at sands.org.uk/sites/default/files/Guidance%20for%20miscarriages%20that%20occur%20at%20home_0.pdf (accessed 8 February 2017).