Providing compassionate careSuggestions for health-care providers
Emergency department best practices
Many families who are experiencing a pregnancy loss or threatened pregnancy loss will go to an emergency department. Even if it is not a medical emergency, it is very often an emotional emergency for the family. Waiting in a crowded room without information and the impression that anything is being done quickly is very difficult for families, who often hope the miscarriage can be stopped or prevented.
In many cases, families are hoping for information and answers. Families may be nervous about the amount of bleeding that is happening, even if it’s normal to health-care providers. Some families have experienced previous losses or infertility, and these experiences can heighten an already difficult and sad time. If a D&C is required, many families want for it to happen right away, which often is not possible. Meeting expectations and bereavement needs may be difficult in busy emergency departments, but there are some ways to improve bereavement care in these settings. Even small care changes can make a big difference to a family.
ED best practice suggestions
- When possible, provide the family with a private room or area. If it’s not possible, which is the most common scenario, let the family know by saying, “I’m sorry we don’t have a more private space for you right now.” Acknowledge what is happening.
- When possible, check on the family regularly and reassure them they haven’t been forgotten
- If the pregnant person is going to the washroom, provide them with a cup, urine hat, or other item in case the person loses the fetus in the toilet. This may be especially important for facilities that have automatic flush toilets. If families are being discharged home, ask them if they would like to take the cup/urine hat home. This may be especially important for families who choose to bury, cremate, or honour their baby in another way.
- Many families experiencing pregnancy loss will be upset and scared, even if it is an early pregnancy. What appears to us as a normal amount of blood can seem excessive to families. Reassure the family that they are in a safe place. Do not minimize the loss. Acknowledge what is happening. Normalize grief, fear and sadness.
- If it looks like the baby has died or will die, ask the person if there are any family members, friends, a chaplain, or social worker you can call for them
- Be genuine. Acknowledge the loss or the fear of loss. Say “I’m sorry.”
- Information on norms is often useful. How much bleeding is too much? How long will things take? Should there be follow-up blood work? When should they return to the emergency department?
- If they are waiting for OR time, is there someone who can provide updates for them, or a contact person at the hospital for follow-up questions?
- Discuss follow-up. Many families will be in shock and not sure what to do next. Should they see their primary care provider? When? Is there an Early Pregnancy Assessment Clinic in your community? If the loss is not confirmed, when should the family get follow-up, and where?
- Discuss time off work and required documentation
- Provide written information for families as appropriate. Refer to local community and online supports.
- PAIL Network offers written, online and in-person peer supports for families. PAIL Network’s general pamphlet or booklet “Miscarriage: Pregnancy Loss Before 20 Weeks” may be helpful for you to give to families on discharge.
- If the loss is not confirmed and families are sent home to wait, giving the family a bereavement pamphlet at the time of discharge will not be helpful. However, for the many families who will subsequently experience loss, most will receive no information on supports. This is where a general handout on what to do/expect may be helpful. At the end of the handout, you may wish to list some bereavement supports, including PAIL Network. You could also say to a family “I hope you don’t experience a loss, but if you do, I want you to know there are supports available if you need them.”
Sometimes hospital procedures and processes, while designed for functionality or cost efficiency, are frustrating and upsetting to families experiencing pregnancy or infant loss. As an organization, there are ways to provide compassionate, sensitive, and skilled care while still meeting organizational needs and priorities.
Best practice suggestions for hospital processes
- Include families in decision-making surrounding hospital procedures and processes. Ask for feedback. Initiate a patient/family advisory committee. Include families on your bereavement committee. Prioritize person-centred and family-centred care.
- Have a clear process for storage and disposal of pregnancy tissues/fetal remains, and ensure families know and understand your hospital’s processes should they decide to leave the baby/remains at the hospital. There have been reports of families leaving the remains behind and then returning for them, assuming they will be kept by the hospital. Some hospitals keep pregnancy loss remains and do a service/burial once or twice a year.
- Have a list of local funeral homes to give to families to assist with their preparations. Some funeral homes don’t charge for cremation of early pregnancy loss remains and have possible reduced costs for later pregnancy loss or infant deaths. This information is useful for families who are often overwhelmed.
- Develop a bereavement checklist for staff to use, to help ensure consistent care.
- Develop a process for required paperwork, including during weekends or after-hours. There have been reports of families having to wait longer than they would like because of a delay in the required paperwork for burials.