Miscarriage
Question
I am a RTS Coordinator at Providence St. Vincent Hospital and Medical Center. We want to put together
a 15-20 minute presentation for nurses who work in our “Short Stay” unit who frequently care for
patients with an early loss. We already have an early loss packet that they will give to patients that
includes the Miscarriage RTS brochures. Do you have a PowerPoint or other information that would be
specific to nurses caring for these patients that we could buy?
Any other thoughts or ideas? I already read your response to the small hospital that wrote in requesting
reading material for nurses to view when they are not busy.
View the answer
Thank you for this question about a unit that care providers may not consider when thinking about RTS
education, the “Short Stay Unit.”
I encourage you to identify a few slides from the PowerPoint you purchased for the 2-day RTS training
for this brief training. When you have a limited time, it is critical to identify two or three key points that
you believe should be included. Broadly defined, I believe these are to help staff members 1) recognize
their own feelings about caring for these women, 2) understand how to assess the meaning of the
miscarriage experience, and 3) learn how to offer reading material, keepsakes, and follow-up. You will
find information on working with families experiencing early miscarriage in your RTS manual.
For your own preparation, look through the miscarriage sections of the RTS manual and PowerPoint;
review making a follow-up phone call; and read the following articles:
 Limbo, R., Glasser, J., & Sundaram, M. (2014). Being sure: Women’s experience with
inevitable miscarriage. MCN, The American Journal of Maternal/Child Nursing, 39(3),
165-174 [CE: 174-175].
 Limbo, R., Kobler, K., & Levang, E. (2010). Respectful disposition in early pregnancy loss.
MCN, The American Journal of Maternal Child Nursing, 35(5), 271-277. [CE: 278-279]
 Wojnar, D. M., Swanson, K. M., & Adolfsson, A. (2011). Confronting the inevitable: A
conceptual model of miscarriage for use in clinical practice and research. Death
Studies, 35, 536-558.
I believe these are to help staff members 1) recognize their own feelings about caring for these women,
2) understand how to assess the meaning of the miscarriage experience, and 3) learn how to offer
reading material, keepsakes, and follow-up.
1. Recognize their own feelings: It is common for a nurse to feel some amount of anxiety
when caring for someone who has had or will have a miscarriage. The first words of
introduction are important because the nurse may not know how the woman is feeling,
that is, what the miscarriage means to her. Therefore, the words of introduction can be
something like this: “Hello, Arianna. My name is Katherine, and I am the nurse who will
be taking care of you this shift. I know that your midwife had you come to this unit
because you are having surgery for a miscarriage. I’m wondering how you are doing
with all of this.” Suggest that the nurse rehearse how he/she will greet the patient and
learn how the woman is feeling. This is the first step in establishing a relationship, which
forms the foundation for care. Even if the time the patient and nurse are together is
brief, the relationship is a primary concern. Point out the importance of transition times
(e.g., when the woman leaves for her procedure, when she is discharged) and suggest
that the nurse say, “I’ll be thinking of you” or “I’ll be waiting for you to return.”
2. Assess the meaning of the miscarriage: a) Watch for tears. Crying usually means the
woman is feeling grief. The loss she feels could be the ending of the pregnancy or the
loss of a baby. Listen for the content of her response to “I’m wondering how you are
doing with all of this.” She may say, “I’ll be glad to get this over with. I’ve been spotting
for days and wondering what’s going to happen.” Or the nurse may hear, “I can’t believe
that my baby is dead.” The nurse should avoid using the terms “baby” and “mother”
unless the woman/mother uses them first.
3. Learn how to offer material, keepsakes, and follow-up: If the nurse determines that the
woman isn’t grieving, the nurse may say, “I have some things you may want to read. You
can see if they feel right for you. If not, just set them aside.” The Remembrance of
Blessing and baby ring are two keepsakes that many women and their families choose
when they experience the miscarriage as the death of a baby. Offering options can begin
with, “We have some keepsakes available to you. I’m wondering if you and your partner
[use the person’s name] may each like a baby ring. That’s a memento that many families
find comfort in.” Follow-up: “It’s routine for someone from our staff to contact you
within the first week of your miscarriage just to see how you’re doing and if we can help
with anything. Would you prefer a call or email or neither?”
In summary, you could emphasize to your staff that they let patients take the lead, but encourage the
nurse to create a path that they can follow together. The feeling on the patient’s part should be that she
is not alone. Despite a brief time together (the “short stay unit”), the patient should believe the nurse is
competent in caring for women experiencing miscarriage and specifically, he/she relates to this
particular patient as someone special.
_____________________________________________________________________________________
Question
I attended the RTS trainings some years ago and would appreciate knowing what you do at Gundersen.
For miscarriages in our hospital system, we have memorial/burial services for those babies under 20
weeks’ gestational age. However, we occasionally are uncertain as to whether the mother experienced a
miscarriage or a stillbirth.
Here are two hypothetical situations:
1. A woman with irregular periods gives birth to a baby born still. The baby is 19 weeks by dates
(which are unreliable) and weighs over 600 grams at delivery.
2. A baby dies in utero and the mother’s due date based on last menstrual period indicates that
the baby is 21 weeks’ gestation, although an ultrasound shows the baby to be the size of a baby
at approximately 17 weeks.
View the answer
In Wisconsin, the statute pertaining to defining stillbirth is written in this way:
"When fetal death reporting is required:
If a death is a miscarriage and 20 weeks or more have elapsed between the mother’s last normal
menstrual period and delivery or the stillbirth weighs 350 grams or more, one of the following shall
submit, within 5 days after delivery, a fetal death report to the registration district where delivery
occurred: . . . “(Wisconsin Statutes 69.18 (1) (e)1)
To reiterate the Wisconsin state statute, if one of the two criteria is present (20 weeks or 350 grams),
the baby is stillborn, and a fetal death report is required. In this case, the baby weighed 600 grams, well
above the 350 grams required to determine stillbirth. Final arrangements for the baby’s disposition
would be made by parents.
Referring back to the state statute that miscarriage and stillbirth are defined by one of two criteria
(weeks gestation or weight), this baby was stillborn because the mother was 21 weeks pregnant.
Whether the baby died 4 weeks previously or is small for gestational age is not relevant to the diagnosis
of stillbirth because of the baby's gestational age.
State statutes vary. For example, in a few states, miscarriage is considered to be gestational age less
than 22 weeks, rather than 20 weeks. The best way to determine what is or is not required in your state
is to simply do an Internet search using words such as "state statutes stillbirth" or "state statutes
miscarriage."
We encourage all who offer support to parents at this difficult time to always ask them what they would
prefer to do, if there are options. An excellent resource for you is an article included in the 2012 edition
of the Resolve Through Sharing Training: Perinatal Death manual and available from your library: Limbo,
R., Kobler, K., & Levang, E. (2010). Respectful disposition in early pregnancy loss. MCN, The American
Journal of Maternal Child Nursing, 35(5), 271-277. [CE: 278-279]
_____________________________________________________________________________________
Question
Our labor and delivery (L&D) unit is changing practice on gestational age of women admitted into L&D
for a loss. The second hospital in our system is keeping the current gestational age guidelines. One
admits patients into triage and L&D with a confirmed pregnancy 12 weeks and over; the other admits
women who are over 17 weeks’ gestation. Some nurses work in both hospitals and must adjust to the
different philosophies of care. What is the norm at Gundersen Health System, where RTS is
headquartered? I would appreciate any help you can give me.
View the answer
Our current protocol is that women who are 16 weeks and over come into L&D. We have, on occasion,
admitted earlier gestations based on circumstances. For example, we recently cared for a woman with
an early second trimester miscarriage who began to deliver, had complications, and needed medication
only given in L&D to complete the delivery. This is an example of a complication that increased acuity
and at the same time, required that care of someone at 13 weeks should deliver in L&D.
As the new lead educator for RTS, I have worked in high risk obstetrical care for over 30 years and cared
for many families experiencing perinatal death. I’ve learned that to provide the right care in the right
environment means the need to be flexible. The pregnant woman’s presenting problem should
determine where she receives care, whether the presenting problem is OB-related, such as a
complicated miscarriage, or non-OB related condition (e.g., a fracture, pancreatitis, kidney stones, etc.)
As a RTS coordinator, you have an opportunity to provide necessary education to nurses who will be
caring for patients with loss, no matter where the nurse works. Having standard operating procedures or
policies on “Care of the Patient Experiencing Perinatal Death” can be a starting point for the specifics of
how to provide evidence-based, relational care to women, no matter where they receive care. Nurses
are fearful that they will do or say the wrong thing. Education can increase competence and confidence.