Miscarriage is a distressing event for both women and their partners. The grief associated with miscarriage may not only relate to the loss of their baby but also to the loss of future plans, hopes and dreams (Meaney et al, 2017). The expected outcome is of a live, healthy baby, and is much anticipated by a pregnant women and her partner. However, pregnancies that result in unintentional loss can have a devastating impact on women, their partners and extended families.
Although the universal definition of miscarriage centres around pregnancy loss before viability (Quenby et al, 2021), the specific cut-off gestation time varies across countries.The World Health Organization (2022) defines miscarriage as the spontaneous or deliberate termination of a pregnancy before the 28th week of gestation or when fetal weight is below 500g. In the USA (Lacci-Reilly et al, 2023), New Zealand and Australia (Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2021), it is defined as unintended pregnancy loss up to 20 weeks of pregnancy. In the UK, the cut-off extends to 24 weeks (Lee et al, 2023). In Brunei Darussalam, based on the authors’ professional clinical experiences, the cut-off varies across hospitals, typically ranging from 20–24 weeks.
A systematic literature review of seven studies related to spontaneous miscarriage treatment in the USA identified the emergency room as the most common healthcare facility that women attended when experiencing miscarriage (Ho et al, 2022). A survey of a large urban emergency room in New York (n=67) found there were three main reasons for visiting the emergency room in the case of a miscarriage (Baird et al, 2018): women considered miscarriage an emergency (40.3%), the emergency room was a convenient place to attend (25.4%) and they did not want to wait for an appointment (20.9%). These findings suggest that women commonly choose to attend the emergency room/department to receive information and emotional support from healthcare professionals in the case of a miscarriage. However, in international literature, women have also reported dissatisfaction with the information provided in the emergency room, viewing it to be insufficient, and that there is a lack of supportive staff, leading to inadequate emotional support (Meany et al, 2017; Baird et al, 2018; Ho et al, 2022).
A qualitative study in Canada reported that women experiencing miscarriage (n=8) chose to attend emergency departments because it was the only way to access healthcare services 24/7 or they did not know where else to go (MacWilliams et al, 2016). However, women have reported traumatic experiences with care and treatment in emergency departments, in part because of the fast phase nature of work in these settings (Larivière-Bastien et al, 2019). Furthermore, women have reported struggling to cope with their loss because they felt isolated and compelled to resume their normal life from the moment that they were discharged (MacWilliams et al, 2016).
These reports of negative experiences makes it critical to further explore the experiences of women who seek healthcare in the emergency department while having, or following, a miscarriage, in order to understand their needs, analyse factors that influence their experiences and identify how to enhance care. The care for and needs of women experiencing pregnancy loss are significantly different depending on the gestational age at which the loss occurs. Both the physical consequences as well as the psychological impact can differ immensely. Healthcare professionals, including midwives, should be sensitive to these differences to provide the most compassionate and appropriate care for women (Coomarasamy et al, 2021).
Healthcare facilities for miscarriage in Brunei Darussalam
Abdominal pain and vaginal bleeding are typical signs of pregnancy complications, and usually prompt women to seek healthcare (Mwilike et al, 2018). In Brunei Darussalam, women experiencing a miscarriage or symptoms of a miscarriage may seek initial care and treatment in any of several healthcare facilities. These include an antenatal clinic at a primary health centre or hospital, a gynaecological clinic, the labour room of a hospital or, most often, the emergency department (Saime et al, 2022). There are currently no published standard guidelines for care in Brunei Darussalam, and specific care pathways are thus hospital-dependent.
An antenatal clinic will usually refer pregnant women to the emergency department, gynaecological clinic or labour room for further medical care (Latiff et al, 2023). Following initial care at the emergency department, gynaecological clinic or labour room, depending on the probable outcomes of the pregnancy, different interventions may be recommended. For example, women in early gestation may not be considered viable and will be advised by healthcare professionals (usually doctors) to stay at home and let their pregnancy end naturally (Latiff et al, 2023). If a pregnancy is viable or there is difficulty in controlling bleeding, women may be advised to present for admission to the hospital ward for further medical management (Latiff et al, 2023).
In the authors’ professional experiences in Brunei, the emergency department is the first and most common place that women will seek healthcare when their pregnancy is at less than 23 weeks gestation, and in particular, when they feel unwell or have a concern related to their pregnancy, including if they suspect that they are having a miscarriage. In the authors’ experiences, a fetus is viewed as viable from the 23rd week of pregnancy onwards (Latiff et al, 2023), and so women presenting after 23 weeks are usually directed to seek healthcare in the labour room. Each public hospital in the four districts in Brunei includes labour rooms and emergency departments. Currently, nearly all births take place in hospitals and there are no standalone birth centres in Brunei, which are prominent in other countries (Homer et al, 2019).
Experiencing a miscarriage in the emergency department
Internationally, emergency departments are busy and fast-paced, and are typically the principal point of contact for women experiencing a miscarriage (Baird et al, 2018; de Montigny et al, 2020; Ho et al, 2022). In Brunei, women typically seek healthcare for a miscarriage at private clinics, outpatient departments, maternal health clinics or, most commonly, the emergency department (Latiff et al, 2023). While experiencing bleeding or miscarriage-related pain, women seeking treatment at the emergency department may feel uncertain or fearful about the outcomes of their pregnancy. Additionally, being rushed into a congested emergency department may be intimidating and contribute to anxiety (MacWilliams et al, 2016).
Studies have reported traumatic experiences, feelings of isolation and negative emotional impacts of care for women experiencing miscarriage in the emergency department (MacWilliams et al, 2016; Meaney et al, 2017; Ho et al, 2022). However, it is recognised that suboptimal care is not likely to be intentional, but instead results from the fast pace and emergency nature of emergency department. While the literature highlights the negative impacts, there is a scarcity of knowledge on how these concerns can be addressed. If women's attendance at the emergency department is commonplace and unavoidable in the case of miscarriage, it raises the question of how best these issues should be addressed. This article focuses on exploring initial supportive care during the transition period in the emergency department for women experiencing miscarriage. Specifically, the focus is on unintentional loss or spontaneous loss of products of conception before the 28th week of pregnancy.
Initial supportive care needs during transition in the emergency department
The ‘transition period’ is used in this article to refer to the time between when a woman arrives at a healthcare facility, primarily the emergency department, and transfer to a subsequent care pathway, either by being discharged, referred to another healthcare facility or admitted to the hospital ward.
Physical support
Studies have shown that unfavourable hospital experiences for women having a miscarriage can be caused by the management and/or physical layout of the emergency department (Punches et al, 2019; Ho et al, 2022). Emergency department rooms are complicated and medically focused, while women experiencing miscarriage have reported that they would appreciate a quiet, pleasant area for themselves and their partners, where activities are not rushed (Evans, 2021). Women have also noted that the physical space in the emergency department can heighten stress (Meaney et al, 2017). For example, they may overhear conversations among staff members or sounds from other women's fetal monitoring with audible fetal heartbeats, having only just learnt they have miscarried. This can be worsened when there is only a curtain to separate them (Meaney et al, 2017).
Informational support
It has been reported that women need sufficient information in a timely manner during the vulnerable period of a miscarriage (Alqassim et al, 2022). Information support and sharing can be divided into what is known and unknown concerning miscarriage during an emergency department evaluation, and what to expect following discharge (Evans, 2021). Since care in the emergency department can be rushed because of the fast-paced environment, it may be difficult for staff to provide detailed information. However, the provision of information remains vital. It is reportedly common for women in the emergency department to want information about investigations to determine the cause (Evans, 2021), length of time they may have to spend in the emergency department (Ho et al, 2022), and prognosis. Additionally, women may need support in relation to any misconceptions or personal beliefs surrounding miscarriage, such as the perception that it is their fault (Batool and Azam, 2016).
In a qualitative study based in a US hospital, the majority of the eight participants believed that healthcare professionals were aware of the miscarriage but either did not, could not or were unable to explain what was happening (Punches et al, 2019). Similarly, a study in Canada reported that women felt that they did not receive sufficient answers or explanations from medical professionals, particularly in relation to explanations of underlying conditions that could lead to miscarriage, which were either lacking or not explained clearly (Larivière-Bastien et al, 2019). The lack of information on procedures and the time needed to diagnose a miscarriage, which usually included the time required for blood test results to be available and to consult specialists as necessary to make a diagnosis, was described as agonising and irritating (Larivière-Bastien et al, 2019).
In the same vein, a grounded theory study with 11 women in Australia reported that they felt that their emotions and concerns were disregarded and unacknowledged. They observed that healthcare professionals displayed attitudes and behaviours that portrayed a lack of compassion and empathy, and disregarded their loss (Edwards et al, 2018). In the authors’ professional experiences, a lack of clarity and information may not be because of healthcare professionals having limited understanding of women's condition, but rather the result of either feeling unsure about how to approach women or having insufficient skills to support women in this vulnerable period.
Coping strategies: psychological and emotional support
According to Bellhouse et al (2018), women considered the emotional support they received as a crucial component of their hospital experience. It is important to recognise that healthcare professionals may have different perceptions of the situation than the women they provide care for. In the emergency department, miscarriage may be deemed not life-threatening, unless accompanied by complications such as heavy bleeding, and thus dismissed by the professionals working in an emergency setting. However, from the perspective of a woman experiencing a miscarriage, it is likely that this is felt to be an emergency, particularly in consideration of bleeding and abdominal cramping, especially if this is a first pregnancy.
Although healthcare professionals place great importance on caring for women's psychological needs, support from women's partners is also important (Galeotti et al, 2022). In a qualitative study in Canada, women expressed the need to confide in and express their emotions to their partner, as they felt unable to do so with healthcare professionals in the emergency department (Emond et al, 2019). Additionally, although nurses may acknowledge miscarriage as an emotionally intense situation, they are reportedly frequently inhibited by the need to provide urgent care around the clock in the emergency department, limiting their availability to provide emotional support (Qian et al, 2022).
Implications for midwifery/maternity nursing practice
Miscarriage or early pregnancy loss reportedly occurs in 15–20% of pregnancies (World Health Organization, 2022). Despite advances in maternity care, early pregnancy loss remains the most common pregnancy complication, with an estimated one in four confirmed pregnancies ending in loss (Lee et al, 2022). Although this implies that miscarriage is a persistent and widespread concern, healthcare professionals typically consider a miscarriage to be a non-emergency condition. This perception likely does not align with the perspective of a woman experiencing a miscarriage.
Vaginal spotting or bleeding and abdominal pain are common indicative symptoms of a threat to a pregnancy that prompt women to seek medical help (Rzońca et al, 2021). In Brunei, the fact that the emergency department is a common place to seek healthcare for a woman experiencing a miscarriage indicates the perception that miscarriage is an emergency that requires urgent care. At present, little is known about women's experiences when seeking care at the emergency department, and further research is needed to explore alternative routes for women to access the healthcare required in the case of a miscarriage. The emergency department may not be the most appropriate place to do so, as a result of the fast-paced environment and lack of capacity to provide emotional support, particular if the caseload is high. Healthcare professionals could be empowered to identify complications that necessitate medical help, instead of routinely admitting all miscarriage cases to the hospital.
The literature indicates that miscarriage care provided in the emergency department is not necessarily satisfactory (Baird et al, 2018; Ho et al, 2022). A number of shortcomings have been identified that women felt should be addressed, including long waiting periods during which they were not kept informed, being rushed for care in a fast-paced setting and feeling neglected by healthcare professionals (MacWilliams et al, 2016; Meany et al, 2017). Privacy, dignity, compassion and respect have been highlighted as crucial by women but reported as sometimes lacking in the emergency department (Helps et al, 2020).
Emergency department nurses have reported insecurities around their knowledge of women's health, mainly as a result of perceived limited knowledge of pregnancy and a lack of confidence in making decisions (Merrigan, 2018). Research has explored the experiences of nurses caring for women who have had miscarriages (Wallbank and Robertson, 2013; Jones-Berry, 2014; Merrigan, 2018). Lack of training for emergency department nurses in managing these women holistically is a recurrent theme, leading to dissatisfaction with the care provided and emotional discomfort for both nurses and women (Due et al, 2018). Hutti et al (2016) pointed to a need for bereavement education and training, staff debriefing and self-care opportunities, and preparedness that addressed compassion fatigue among nurses/midwives. It can be inferred that these are similarly fundamental for emergency department nurses. Healthcare professionals should be knowledgeable and have the skills required to create a supportive atmosphere for women experiencing miscarriage; these women are likely to be vulnerable as a result of the emotional nature of the issue (Jensen et al, 2019).
On discharge from the emergency department, both verbal and written instructions should be provided that specify precautions and what to anticipate in terms of pain, blood loss, blood clot passage and passage of products of conception (de Montigny et al, 2020). A detailed explanation should be provided of when women should return to the emergency department if they experience bleeding, soaking more than one pad per hour continuously, or lightheadedness, fainting, chest discomfort or shortness of breath, worsening pain or rising fever, which may be signs of infection (San Lazaro Campillo et al, 2019).
The demands on emergency department nurses at work are high and the environment is high-pressure. The role of a nurse/midwife is complex and multifaceted, which in itself may be a source of stress. Gaps in practice should be addressed, such as the discrepancy between perceptions of ideal practice and the actual scenario when caring for women with miscarriage in the emergency department. Reported underlying barriers to these discrepancies are related to time constraints from human resource limitations, which may be challenging to modify (MacWilliams et al, 2016).
Blurring scope of practice and severe workload are reported concerns, as these impact stress levels, leading to burnout and exhaustion among emergency department nurses (MacWilliams et al, 2016; Fernández-Basanta et al, 2020). Healthcare professionals should uphold their responsibilities in providing care to women who have had a miscarriage, making it vital that they understand their scope of practice. The scope for doctors and nurses/midwives should be clear, outlining who does what, when and how should it be done. Structured guidelines that illustrate the flow of care and provide detail on the roles and responsibilities of different healthcare professionals may prove facilitative. Furthermore, there should be clear direction on when women need to seek healthcare, and where they should go for care other than the emergency department, if appropriate.
Conclusions
Women experiencing miscarriage need sensitive and focused care. This paper highlights the importance of initial care for women experiencing miscarriage who seek care at the emergency department. Care should be supportive during the transition period, before transfer to further care pathways. Care can only be supportive if women's needs during the transition period are addressed. Transparency in communication is crucial and should include information on expected time in the emergency department, investigations and justifications, causes of miscarriage, and possible pregnancy outcomes. The key to communication lies in the delivery of appropriate information in a timely manner. It is essential for caregivers to be sensitive and competent in managing the psychological impact of miscarriage, in consideration of the fast-paced nature of the emergency department, which may be perceived as rushed and lacking compassionate and empathetic care. Further research is warranted on interventions and enhancements of the provision of care for women experiencing a miscarriage in the emergency department.
Key points
- Miscarriage occurs in one in every four pregnancies.
- Miscarriage is not typically considered an emergency situation, although women primarily seek healthcare at the emergency department.
- The emergency department may not be the most appropriate setting for providing care and emotional support to women experiencing miscarriage, given its fast-paced environment and limited infrastructure and resources.
- Standard workflow and guidelines for women on where to seek healthcare in the event of a suspected miscarriage should be clearly communicated.
- Structured and clear guidelines should be available that outline the care process and specify the roles of various healthcare professionals at the emergency department to avoid role conflicts.