The Villain or the Comfort: How to Deliver Care to a Patient Experiencing a Miscarriage
Author:
Rachel Campbell (she/her), BSN, RNC-OB
Photo credit: @gettyimages.com/PeopleImages.
The emergency department is not always the best place for a miscarrying person to be, but the health care system sends them to us - and will continue to do so. It’s neither our fault nor theirs. Our system is flawed, women are often undereducated about their reproductive health, choices are limited, people in minority groups are systemically underserved, and pregnancies can end traumatically. This is our unfortunate reality. As health care providers, owning the care that we provide and the impact we ultimately make on our patients is critical. These people aren’t just bodies we are caring for: we are humans caring for other humans. They are our friends, neighbors, family, and fellow health care professionals—and they’re vulnerable. When we mistreat anyone, we mistreat everyone. We are obligated to educate ourselves, grow our practice, and hold fast to our humanity. My objective is to provide guidance regarding appropriate care for patients and families experiencing pregnancy loss. Good care is predicated on remembering our shared humanity and looking past today to see people in their context as the whole person they are.
When I educate others about caring for individuals experiencing perinatal loss, I like to remind them of a few important things. First, perinatal loss is a form of sexual trauma. It is a loss of control over reproduction, is highly intimate and personal, and impacts people in a myriad of ways. Whether experiencing an early or late pregnancy loss, in the hospital or at home, surgical or spontaneous, their gravida and para will always reflect each loss. Second, while there are many variables—physical, emotional, and social—one thing is consistent: a miscarrying patient does not want to be in that situation. They don’t want to be bleeding. They don’t want numerous people looking at their genitals. They’re scared and may be in pain. And third, while these patients are typically medically stable, the potential for physiologic instability always exists and the opportunity for emotional trauma is tremendous. So, before you make any judgments or generalizations, remember that these people are very much at your mercy.
Keys to Communicating with Families Experiencing Pregnancy and Infant Loss
Anyone experiencing pregnancy loss likely already feels disempowered. As health care providers, we need to find ways to express empathy and validate their feelings without belittling. Here are a few tips:
Saying you will do your best is fine, but then you should commit to doing your best. I recommend that this include checking in with the patient when you can to provide updates and assess if their condition is changing. A miscarrying patient can hemorrhage or rupture a tube while waiting; the condition of an obstetric patient can change very quickly. At the end of the triage interview, give your patient space to add anything else they may not have had a chance to mention yet. We can’t provide complete care without the complete story. Since not all patients are comfortable speaking up, we need to make sure they have the space to do so.
The Preferred Emergency Department Experience for a Miscarrying PatientWhen reading the blog post “Miscarriage During a Pandemic,” I saw a familiar story. Miscarrying people, unfortunately, often have experiences like this. If I could rewrite her story, it would be more like the following: On arrival at the emergency department, she is triaged in privacy with her vitals taken. and the whole story of why she is presenting heard, including her doctor’s recommendation. At the end of triage, the nurse asks if there is anything else she didn’t get a chance to mention and listens attentively to the answer. The nurse makes eye contact when the patient speaks and offers a wheelchair when she says she’s feeling lightheaded and dizzy. The nurse gives her an idea of what to expect and asks the patient to notify the staff if she feels her condition change. When sent back to the waiting room, the patient is shown where the bathroom is and is told that pads are available. She is educated to save any soaked pads in case the provider wants to evaluate the amount of bleeding, and she is provided a specimen bag and a brown paper bag for the pads. If a urine test is needed, she is given collection instructions. During her long wait, the patient receives updates around every 90 minutes, and each update is a chance for her to notify staff of any changes she is feeling. While this may seem like a lot, it should take less than five additional minutes to provide this care—and it has the potential to make an enormous difference.
Once roomed, she is placed in a closed-door room far from any crying babies; using a hallway bed is avoided. A falling leaf card or other signifier is placed on the door to indicate she is there for an OB complaint consistent with miscarriage. This signifier is a heads-up to anyone entering the room that 1) they should only enter if necessary because the patient is undergoing something highly sensitive; 2) visibly pregnant people should consider delegating their task to another team member, and 3) everyone entering the room needs to be thoughtful in their words and actions. While waiting for the provider, her labs are drawn and her needs met by staff who are calm, who make eye contact, and who respect her privacy without avoiding her or her husband.
Following her sonogram, the discussion with her provider is matter-of-fact and realistic but sensitive to the nature of the situation. At least once while she is there, her nurse or provider sits next to her at her bedside, holds her hand, looks her in the eyes, and says, “I’m so sorry you’re going through this. If there is anything I can do to support you while you’re here, any questions I can answer, or any way for me to make you more comfortable, then please don’t hesitate to say so.” They might even say, “I don’t know what to say, but I am here for you” or “Do you need to have a good cry? Would you like me to sit with you for a minute?”
Her discharge plan includes follow-up with the high-risk pregnancy clinic, as well as resources for support. Her discharge education includes signs and symptoms of complication, when and how to call for advice, and instructions on what to do if she miscarries at home. She is offered keepsakes, sonogram pictures, and a kit of supplies for use at home. The kit includes peri pads, a peri bottle, mesh underwear, and a hat for the toilet to avoid accidentally flushing her pregnancy. She is offered the opportunity to meet with social work, spiritual care, or the bereavement coordinator and is given their contact information upon discharge. A staff member makes a follow-up call about a week later to see how she is doing. When telling the story over and over to family and friends, the only trauma she has to relive is the trauma of her loss—not the care she received.
To paraphrase Maya Angelou, once you know better, you are obligated to do better. You need to do the best you can with what you have and hold yourselves and those around you accountable. Our patients, friends, family, and colleagues deserve at least that much. Remember that their life is changing the day you care for them. Whether or not they lose their pregnancy, this is part of their story. They will remember your name, your face, and your words. You are a part of their story. Try not to be the villain, but rather their comfort.
Guest Contributor
Rachel Campbell (she/her), BSN, RNC-OB
Rachel Campbell (she/her), BSN, RNC-OB, is a Labor and Delivery nurse, OB High-Risk Transport nurse, and Perinatal Grief and Bereavement Liaison. She has more than 10 years’ experience as a labor nurse at a Level III Perinatal and Level I Trauma Center. She has revolutionized the Perinatal Bereavement Program at her facility in her two years in the role, and was just awarded the honor of Nurse Exemplar in 2021. Rachel is passionate about inclusivity, intersectionality, and providing comprehensive and impactful perinatal health care. She specializes in the “overlap between birth and death,” in all of the ways that it impacts families, staff, and providers.
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