My husband and I learned that I was pregnant and were given a due date. My first ultrasound was at 7 weeks, which showed that our baby had a strong heartbeat. A few days later, I woke up at 0130 with vaginal bleeding. My husband took me immediately to the ER. The doctors could not account for the bleeding but told us the baby was OK.
Nine days later, I noticed more spotting and had some mild cramps, so I called my obstetrician's office. The nurse who spoke with me said, "Well, I don't mean to sound callous; but if you miscarry, there's nothing that can be done."
Although this may be true, I felt that when I called for help, I had not been treated with respect and dignity.
Two days later, I started bleeding even more heavily. My husband and I sped back to the ER. Four hours later, we learned that I had a miscarriage. I was sent home to wait, and the next day, I gave birth at home. My husband was greatly distressed to watch me in pain and bleeding but not being able to do anything to help.
After an interminable week, my husband and I went to the obstetrician to make sure I was physically OK. We were shocked when yet another nurse and the doctor treated me without respect or compassion. In some ways, it was like we had to start grieving all over again.
Regardless of the setting, any nurse may feel ill-prepared to provide appropriate emotional care to a grieving mother.1,2 Even nurses who have had education in perinatal bereavement care may feel uncertain and hesitate, afraid of saying the wrong thing.3 This article explores the emotional and psychological effects of miscarriage, and strategies for nurses to support the needs of patients and their families after a miscarriage.
Understanding a woman's needs after a miscarriage
A common misconception is that miscarriage is a rare occurrence, yet 1 in every 5 pregnancies (about 20%) ends in miscarriage.4,5 This statistic corresponds to approximately 1 million miscarriages each year in the US.6 Women may perceive early pregnancy loss as the loss of hope for the family or as specific as the death of their baby, son, or daughter.7 Once pregnant, a woman's identity can be permanently altered as she starts to define herself as a mother, whether she has living children or not.8 When nurses providing care for these patients fail to comprehend and acknowledge the significance of the loss or even try to minimize it, it increases women's feeling of social isolation and reinforces their guilt and self-blame as they wonder what they did to cause this.4,9
When pregnancy is unsuccessful, it is not uncommon for a woman to blame herself, to feel like a biological failure, or to need to understand "why?"10,11 More than half of early pregnancy losses are due to fetal or chromosomal abnormalities, although there are many other risk factors, including metabolic or endocrine disorders, smoking or illicit drug use, infection, or maternal anatomic anomalies.1 Some women find comfort in thinking of miscarriage as a natural process when the pregnancy is not progressing well (for example, thinking that "it wasn't meant to be"). Others feel guilt or self-blame and may wonder "What did I do wrong?" or fear future infertility, asking "Will I ever be able to have a baby?" Rather than minimize the loss, nurses can validate the significance of the loss, the woman's feelings, and the uncertainty about the future.9 By normalizing her emotions and explaining that loss at any gestation can trigger grief, nurses can reduce shame, suffering, and trauma.4,8
Despite multiple studies demonstrating poor understanding of women's needs after miscarriage, there is considerable room for improvement in how nurses render care after early pregnancy loss.1,9 Communication skills are of the utmost importance to convey compassion, empathy, and understanding of how the loss impacts a woman and her family. While medical terms such as "products of conception," a "blighted ovum," or "pregnancy failure" have been used by healthcare professionals, such language may convey that healthcare professionals have little empathy for a patient's grief.9,12 According to Clement, et al., using the preferred term "miscarriage" and/or "early pregnancy loss" increases patient satisfaction by expressing sensitivity and empathy.13
In a recent interview after her miscarriage, Meghan Markle said that an honest and heartfelt way to express concern for a woman experiencing early pregnancy loss is simply to ask, "Are you OK?"14 This gentle inquiry indicates that nurses acknowledge the distressing incident and sets the stage for an open and honest dialogue to recognize that everything is not okay. Another helpful and therapeutic communication strategy is to begin statements with "I wish." For example, nurses can say, "I wish I had better news," "I wish I could tell you everything is going to be okay," "I wish that the bleeding would stop," or "I wish that we could find a heartbeat... but we can't."
Even finding a quiet physical space presents challenges in care. Owing to the design of EDs, pre- and post-anesthesia care areas, and even office waiting rooms wherein patients are separated only by a curtain or a short distance, women experiencing early pregnancy loss may not have a quiet and private space to cry. This set-up may perpetuate the minimization of the loss. Women and their partners/family members should be offered a private room or area away from other patients to allow them time and space to mourn.9
Trauma-informed care
A significant part of providing compassionate, sensitive, and appropriate care is to assess the meaning of the pregnancy, as the nature of the loss is not as significant as what the loss represents to the woman.15,16 A simple assessment technique is to ask questions like "What does this mean to you?" or "I wonder how this miscarriage feels for you?"17 Assessing the meaning of the pregnancy and the pregnancy loss provides a framework to address her concerns. Whether her needs are physical care, education about interconception care/subsequent pregnancy attempts, or emotional/grief support, meeting individual needs is connected to excellence in clinical nursing practice, patient satisfaction, as well as staff self-confidence and efficacy.6,15
A step further is to render care using the principles of trauma-informed care, with the understanding that an early pregnancy loss is a significant event that may have lasting effects. Care for these vulnerable patients should recognize signs of trauma and respond to the woman's needs, while also keeping under consideration the possibility of retraumatization.18,19
The father's/partner's grief can go unacknowledged as the focus is often on the woman as the patient. The family's distress over the loss may be neglected.20 In addition to grieving for the loss of a child and/or the role of fatherhood, fathers, who are traditionally viewed as a family's protector, may endure feelings of helplessness as they witness their partner in physical and emotional pain but are unable to do anything to fix it.21 Worse, they may be asked to step outside or leave during exams or procedures, rendering them unable to offer and receive comfort. They may also not receive timely updates on their partner's condition, leading to anxiety and fear for the woman's health.22 As parents transition from "We're going to have a baby" to "We are losing/have lost our baby," enlisting the family in the decision-making process and ensuring their preferences are honored is a critical piece of the patient's plan of care.15
Having inadequate information about the cause of miscarriage increases the woman's anxiety and distress. In a study by Lariviere-Bastien, deMontigny, and Verdon, they describe "professionals' lack of support, insensitivity, and failure to provide essential information and advice during and after miscarriage."5 Women need clear explanations in lay terminology regarding care options, medications, pain, bleeding, and warning signs.5 Nurses need to provide clear discharge instructions, detailing the amount of bleeding, intensity of pain, time until the miscarriage is complete, when to call their provider with questions or signs of complications, and recovery time, as well as information on future pregnancy. Providing compassionate care that acknowledges the grief of early pregnancy loss helps women feel supported, enhances their ability to cope, and promotes their healing.14,23
Acknowledging perinatal grief
Unrecognized grief, called disenfranchised grief, further devalues and stigmatizes the grieving woman.24 An early pregnancy loss is invisible. The growing baby is noticed and nurtured by the mother, who feels the changes to her body as life grows within, but this person is hidden, not yet known by anyone else. When the baby dies during pregnancy, the infant's presence disappears, leaving no tangible evidence the baby ever existed, and the mother's grief can be unrecognized.16 A helpful way to acknowledge perinatal grief is through a tangible memorial item. A special bracelet charm, a garden, or a tattoo may prove comforting.8 Women might even request one final ultrasound picture or footprints for a later gestation miscarriage. The nurse can ask "What might you find helpful/comforting to remember your baby?" or be willing to respond to "What else is there?" or "There's nothing left." and offer suggestions of something which she may find meaningful.
Take the time to listen carefully to patients' questions or comments which might indicate spiritual seeking or a yearning to find meaning or purpose in grief and loss and then be willing to help address these needs.25 (See Ways to address women's needs after early pregnancy loss.) Spirituality is an integral part of grief care, so consider how interdisciplinary care might enhance grief support. Consulting a chaplain or personal religious leader can help the woman find dignity and closure by honoring the life she carried.7 A woman may ask "What will happen to my baby?" or may not know she can ask about private arrangements. The nurse should offer information, help coordinate respectful handling of the remains and offer empathetic memorial options. Some women would be surprised to know they could request a prayer, blessing, or make private arrangements after a miscarriage. Other parents who request a ceremony or ritual to seek a way to welcome and concurrently say goodbye may find nurses who are uncomfortable, uninformed, and ill-prepared. Drawing on the knowledge and support of the chaplain and/or perinatal social worker can empower the nurse with increased confidence to support parents' final decisions.
Depression screening
Nurses should consider depression screening when a woman presents to the office for a visit after a miscarriage as best practice in follow-up care after a perinatal loss.26 The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend using the Edinburgh Postnatal Depression Scale (EPDS) for postpartum depression (PPD) screening. The EPDS is the most commonly used and reliable screening tool for detection of PPD as early as the first week post-partpartum.27 Situational depression is common after early pregnancy loss. Referral information should also be readily available if she (and/or her partner) desires counseling. This can be individual, couples, pastoral, group, or online counseling/support.8 Being honest, recognizing and acknowledging their grief, uncertainty, anger, guilt, fear, and depression after miscarriage helps in normalizing their feelings, reducing any sense of isolation.5,17,23 Furthermore, nurses should also reflect on how caring for a grief-stricken patient may affect them personally. Getting social support from colleagues, especially after caring for a patient with distressing circumstances, sustains one's mental health and emotional well-being and helps prevent burnout.15
Many nurses are not comfortable offering support to women after pregnancy loss, and feel that they lack the necessary communication skills and confidence to provide quality care during a devastating time.9,15 Failing to address a woman's distress during and after early pregnancy loss leaves them feeling even more isolated at a time when they need compassionate nursing care.4,8 As frontline healthcare professionals, nurses are ideally positioned to provide genuine and thoughtful, empathetic care, as well as model best practices for others who are less comfortable with perinatal grief.
Ways to address women's needs after early pregnancy loss
* Recognize perinatal grief at any gestation/circumstance.
* Ensure privacy.
* Offer opportunity to say goodbye/one final ultrasound.
* Inform them of the option of private cremation, burial of the remains, or ritual/ceremony.
* Consider tangibles, like memorial jewelry, which can be personalized.
* Be present for the entire family.
* Nurture self-care and education.
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