Module 1: Foundation
IN THIS LESSON
Miscarriage is one of the most common types of pregnancy loss.
Early miscarriage happens within the first 13 weeks of a pregnancy. Approximately 10% of known pregnancies end in early pregnancy loss. 80% of these occur in the first trimester AND nearly 50% of EARLY pregnancy losses are from chromosomal abnormalities. (1)
Late miscarriage happens between 13 and 20 weeks.
Miscarriage is, unfortunately, a common experience- this in no way makes the pain feel less. SOMETIMES, it helps families to know that it may have been because the baby wasn’t developing properly. This coming from a scientific, bodily functioning way, it will never be okay losing our baby of course.
Early miscarriages can often look like a period and some women and birthing people may not even realize they are having a miscarriage, especially if they are unaware that they are pregnant.
Before we get started I want to talk about the types of management in miscarriage. Depending on a lot of factors, those will determine the treatment and management that are used in their individual experience.
The three types are:
Expectant or Supportive Management
Medical Management or Medicine Management
Surgical Management
1. Expectant Management is waiting for a miscarriage to happen by itself, without treatment. You don’t need to be at the hospital for expectant management. Expectant management could be an option for your client if they don’t want to take medicine or have surgery and don't mind some waiting and uncertainty about when things will happen. Often times another time of management will have to be used to make sure tissue is all gone from the uterus.
How to prepare them for expectant management? We want to make sure that they have everything that they need at home.
Extra absorbent pads, possibly old sheets on the bed or a towel where they lay down to prevent blood from getting on their bed.
We want to make sure they have a support person if we are not there especially when the bleeding and cramping are heavier and more painful when they aren’t able to do much, especially if they have other children or pets at home that need to be taken care of.
Knowing what to do next. Here are some questions they can ask their provider so that they know what they need to do.
When is my next appointment and who is it with?
Who should I contact if I am worried about my bleeding or in a lot of pain or I am worried about other symptoms? Do I need to head to the ER or make a same day appointment?
What if I change my mind and want to have surgical or medical management?
If I think I have passed the baby or pregnancy tissue, what should I do next? Do I save the baby/tissue? How do I keep it until I can bring it in? What can we determine from the baby/tissue?
2. Medical Management means taking medicine to help the remains of the baby and pregnancy tissue come away from the uterus. The tissue will leave the body through the vagina so this is also a non-surgical option. They will talk through options with their care provider to decide what the best and safest course of action is for them. If your client doesn’t want to wait for the miscarriage to happen by itself this is usually what they will be offered. Sometimes it is scarier to wait for a miscarriage to happen because they don’t know how long it will take and the unknown is often scarier than being given a timeline and knowing what is coming next. If the miscarriage hasn’t happened during the timeframe for the expectant management this may be offered as well. If they have had an incomplete miscarriage where some of the tissue has remained in the uterus, medical management will also be offered.
How to Prepare Them for Medical Management?
3. Surgical Management means having surgery to remove the remains of your baby and pregnancy tissue through your cervix, using a suction device aka vacuum aspiration or suction curettage, or a D & C. It’s likely to be a planned operation so you will have some time to prepare.
Surgery Managements are often used if
You are bleeding heavily and haven’t stopped
There are signs of infection
Medical management has not been successful
Dilation and Curettage, aka D & C
is a surgical procedure often performed during a first trimester miscarriage. In a D&C, dilation refers to opening the cervix; curettage refers to removing the contents of the uterus. Curettage may be performed by scraping the uterine wall with a curette instrument.
There are several options for anesthesia during a D&C:
General anesthesia, where you’re asleep for the procedure.
Regional anesthesia (like an epidural), which means you won’t have feeling from your waist down. You’re fully conscious with this type of anesthesia.
Local anesthesia, which means only your cervix is numb. You’re awake and have feeling in all areas of your body other than your genital area.
After they receive anesthesia, the provider will begin the procedure.
The steps of a D&C generally go like this:(If you client is the type of person who likes to understand the step by step of what will happen, this is an easy to follow step by step, there can be variations depending on where you go, the hospital/ provider, etc.)
They lie on a table with their feet in stirrups
The provider then inserts a speculum into their vagina. This device, shaped like a duck’s bill, helps open your cervix. A clamp helps hold your cervix open.
The provider will use dilators, which are thin metal rods that start small and then gradually increase in diameter. The rods gently stretch the cervix until it’s wide enough to accommodate the instruments that are needed to complete the procedure.
The provider uses a curette, a type of spoon-shaped scraping device, to clean out the tissue from your uterus. They sometimes use a thin suction device to get any remaining tissue.
They may send a sample of the tissue to a lab for analysis.( This will be something they talk about ahead of time or the client can ask about it if they are trying to determine the why around their loss.)
Surprisingly enough, I mean, I was surprised but the procedure takes about 5- 10 minutes. Prepping and administering the anesthesia takes longer, along with the wait in the recovery room, before they can go home.
****Vacuum Aspiration using the same initial stages of surgical management but suction is used instead.
Types of miscarriage
Missed miscarriage: You’ve lost the pregnancy but are unaware it’s happened. There are no symptoms of miscarriage, but an ultrasound confirms the fetus has no heartbeat.
Complete miscarriage: You’ve lost the pregnancy and your uterus is empty. You’ve experienced bleeding and passed fetal tissue. Your provider can confirm a complete miscarriage with an ultrasound.
Recurrent miscarriage: Three consecutive miscarriages. It affects about 1% of couples.
Threatened miscarriage: Your cervix stays closed, but you’re bleeding and experiencing pelvic cramping. The pregnancy typically continues with no further issues. Your pregnancy care provider may monitor you more closely for the rest of your pregnancy.
Inevitable miscarriage: You’re bleeding, cramping and your cervix has started to open (dilate). You may leak amniotic fluid. A complete miscarriage is likely.
How we can support them in Miscarriage.
This guide is a great tool to help your families make decisions on care!
There are 3 types of care, expectant management, medical management, and surgical management.
Expectant Management
Expectant management means waiting for a miscarriage to happen by itself, without treatment. You don’t need to be at the hospital for expectant management. Expectant management could be an option for your client if they don’t want to take medicine or have surgery and don't mind some waiting and uncertainty about when things will happen.
There is no clear timeline for when the baby’s remains/pregnancy tissue will start to come away, this can be distressing for mom or birth person, not knowing when it will happen and how long it will take. When it starts your client will feel the pain and cramping and often worse than their period. They will bleed quite alot and some people are shocked by the amount, they will also pass larger blood clots and tissue. They will have to start thinking about what they want to do with the baby’s body /tissue. Whether that is flushing the remains away or burying the body, it is a terrible decision to have to make but we can support them through what is best for them.
Help them prepare for expectant management.
You will need extra thick sanitary pads. It may also help to have old towels available or other material you don’t mind getting stained. You don’t need to stay in the house while you are waiting but have a supply of these with you in case it starts when you are out. Cramps usually start before or alongside the bleeding so have painkillers, such a paracetamol, to hand. Your doctor may be able to prescribe stronger painkillers too.
It’s a good idea to make sure that someone can be with you or able to come home to you when the bleeding starts to get heavier and the pain more intense. At its height you are unlikely to be able to do much. It would be good to have someone on call if you have caring responsibilities or other chores that need to be done.
You may find it helpful to ask your EPU/doctor these questions.
When is my next appointment and who is it with?
Who should I contact if I am worried about my bleeding or in a lot of pain or I am worried about other symptoms?
What if I change my mind and want to have surgical or medical management.
If I think I have passed the baby or pregnancy tissue, what should I do next? Do I need to contact the EPU?
Are there any risks to expectant management of miscarriage?
About 1-3 in 100 women or birthing people who have expectant management will develop an infection. This is a similar number to medical and surgical management.
About 2 in 100 women or birthing people who have expectant management will have a haemorrhage (severe bleeding) and may need an emergency operation.
How successful is expectant management of miscarriage?
Expectant management is successful in about 50% of cases. This means that half of women and birthing people who go through expectant management will have another form of management as well.
What happens after expectant management?
You’ll be given a follow-up appointment about 2 weeks after your previous appointment.
If the bleeding and pain has finished by then, the pregnancy has probably come away.
You’ll be asked to do a pregnancy test a week after this appointment. If it is still positive, you should contact your local Early Pregnancy Assessment Service.
If bleeding doesn’t start within 7–14 days, isn’t stopping or is getting heavier, you will be offered another ultrasound scan. If the pregnancy hasn’t completely come away, your doctor will talk to you about your options. These may include:
continuing expectant management
taking medicine to help the miscarriage start (medical management)
having surgery to remove the pregnancy (surgical management).
Find out more about what happens to your baby after miscarriage and remembering your baby after miscarriage.
Support for you
There is no right or wrong way to feel after pregnancy loss. It is a very individual experience. Many people feel a lot of complicated emotions including guilt, shame, sadness, anger and grief, that can sometimes last a long time. There is support available if you and/ or your partner (if you have one) need it. Have a look at our pages on support after a miscarriage.
You can also talk to a Tommy’s midwife free of charge from 9am–5pm, Monday to Friday on 0800 0147 800 or you can email them at midwife@tommys.org. Our midwives are specialists who can support you with any aspect of pregnancy loss that would be helpful for you. There is no way of knowing exactly when your baby’s remains, and pregnancy tissue will start to come away from your womb. You would usually be asked to go back to the hospital or Early Pregnancy Assessment Service (EPAU) if it still hasn’t started 14 days after the miscarriage was confirmed.
When it does start, you will feel pain and cramping, usually worse than it would be on your period. Some women and birthing people who have had a full-term baby describe the cramping as more like early labour pain and contractions.
You will bleed from your vagina, usually quite a lot. Women and birthing people have told us that they are shocked by the amount of bleeding. You may also pass large blood clots and tissue.
You will probably pass your baby’s body, perhaps in a pregnancy sac. This can be distressing, especially if you are not expecting it. You may want to think about whether you want to keep your baby’s body to bury. Not everyone wants to do this, it's a very personal decision. For example, some people prefer to flush their baby’s remains away.
You should avoid hot baths while you are bleeding heavily. These can make you feel faint.
Contact your hospital or EPU immediately if:
the amount of bleeding makes you feel unwell, dizzy, faint, frightened
you soak through more than 2 heavy sanitary pads per hour for more than 3 hours
you develop a high temperature (fever)
you experience severe pain or cramping that you cannot manage with normal painkillers.
A doctor or midwife will talk through your concerns with you and help you decide whether you need to go back to hospital.
Bleeding will be heaviest for the first few days after it starts. Then it should get lighter (although you may have times when it feels heavier again) and stop after 2-3 weeks.
Preparing for expectant management
You will need extra thick sanitary pads. It may also help to have old towels available or other material you don’t mind getting stained. You don’t need to stay in the house while you are waiting but have a supply of these with you in case it starts when you are out. Cramps usually start before or alongside the bleeding so have painkillers, such a paracetamol, to hand. Your doctor may be able to prescribe stronger painkillers too.
It’s a good idea to make sure that someone can be with you or able to come home to you when the bleeding starts to get heavier and the pain more intense. At its height you are unlikely to be able to do much. It would be good to have someone on call if you have caring responsibilities or other chores that need to be done.
You may find it helpful to ask your EPU/doctor these questions.
When is my next appointment and who is it with?
Who should I contact if I am worried about my bleeding or in a lot of pain or I am worried about other symptoms?
What if I change my mind and want to have surgical or medical management.
If I think I have passed the baby or pregnancy tissue, what should I do next? Do I need to contact the EPU?
Can I go to work while I wait for the miscarriage to happen?
You do not need to work while you are having a miscarriage, but some people prefer to continue working until it starts.
This should be done with understanding from your employer that you may need to stop working at short notice. If possible, working from home is the best option. Starting to bleed heavily and get cramps in an office, factory or shop would not be easy to manage.
You may also find it helpful to look at our information on your rights at work after miscarriage.
Are there any risks to expectant management of miscarriage?
About 1-3 in 100 women or birthing people who have expectant management will develop an infection. This is a similar number to medical and surgical management.
About 2 in 100 women or birthing people who have expectant management will have a haemorrhage (severe bleeding) and may need an emergency operation.
How successful is expectant management of miscarriage?
Expectant management is successful in about 50% of cases. This means that half of women and birthing people who go through expectant management will have another form of management as well.
What happens after expectant management?
You’ll be given a follow-up appointment about 2 weeks after your previous appointment.
If the bleeding and pain has finished by then, the pregnancy has probably come away.
You’ll be asked to do a pregnancy test a week after this appointment. If it is still positive, you should contact your local Early Pregnancy Assessment Service.
If bleeding doesn’t start within 7–14 days, isn’t stopping or is getting heavier, you will be offered another ultrasound scan. If the pregnancy hasn’t completely come away, your doctor will talk to you about your options. These may include:
continuing expectant management
taking medicine to help the miscarriage start (medical management)
having surgery to remove the pregnancy (surgical management).
Find out more about what happens to your baby after miscarriage and remembering your baby after miscarriage.
Support for you
There is no right or wrong way to feel after pregnancy loss. It is a very individual experience. Many people feel a lot of complicated emotions including guilt, shame, sadness, anger and grief, that can sometimes last a long time. There is support available if you and/ or your partner (if you have one) need it. Have a look at our pages on support after a miscarriage.
You can also talk to a Tommy’s midwife free of charge from 9am–5pm, Monday to Friday on 0800 0147 800 or you can email them at midwife@tommys.org. Our midwives are specialists who can support you with any aspect of pregnancy loss that would be helpful for you. There is no way of knowing exactly when your baby’s remains, and pregnancy tissue will start to come away from your womb. You would usually be asked to go back to the hospital or Early Pregnancy Assessment Service (EPAU) if it still hasn’t started 14 days after the miscarriage was confirmed.
When it does start, you will feel pain and cramping, usually worse than it would be on your period. Some women and birthing people who have had a full-term baby describe the cramping as more like early labour pain and contractions.
You will bleed from your vagina, usually quite a lot. Women and birthing people have told us that they are shocked by the amount of bleeding. You may also pass large blood clots and tissue.
You will probably pass your baby’s body, perhaps in a pregnancy sac. This can be distressing, especially if you are not expecting it. You may want to think about whether you want to keep your baby’s body to bury. Not everyone wants to do this, it's a very personal decision. For example, some people prefer to flush their baby’s remains away.
You should avoid hot baths while you are bleeding heavily. These can make you feel faint.
Contact your hospital or EPU immediately if:
the amount of bleeding makes you feel unwell, dizzy, faint, frightened
you soak through more than 2 heavy sanitary pads per hour for more than 3 hours
you develop a high temperature (fever)
you experience severe pain or cramping that you cannot manage with normal painkillers.
A doctor or midwife will talk through your concerns with you and help you decide whether you need to go back to hospital.
Bleeding will be heaviest for the first few days after it starts. Then it should get lighter (although you may have times when it feels heavier again) and stop after 2-3 weeks.
Preparing for expectant management
You will need extra thick sanitary pads. It may also help to have old towels available or other material you don’t mind getting stained. You don’t need to stay in the house while you are waiting but have a supply of these with you in case it starts when you are out. Cramps usually start before or alongside the bleeding so have painkillers, such a paracetamol, to hand. Your doctor may be able to prescribe stronger painkillers too.
It’s a good idea to make sure that someone can be with you or able to come home to you when the bleeding starts to get heavier and the pain more intense. At its height you are unlikely to be able to do much. It would be good to have someone on call if you have caring responsibilities or other chores that need to be done.
You may find it helpful to ask your EPU/doctor these questions.
When is my next appointment and who is it with?
Who should I contact if I am worried about my bleeding or in a lot of pain or I am worried about other symptoms?
What if I change my mind and want to have surgical or medical management.
If I think I have passed the baby or pregnancy tissue, what should I do next? Do I need to contact the EPU?
Can I go to work while I wait for the miscarriage to happen?
You do not need to work while you are having a miscarriage, but some people prefer to continue working until it starts.
This should be done with understanding from your employer that you may need to stop working at short notice. If possible, working from home is the best option. Starting to bleed heavily and get cramps in an office, factory or shop would not be easy to manage.
You may also find it helpful to look at our information on your rights at work after miscarriage.
Are there any risks to expectant management of miscarriage?
About 1-3 in 100 women or birthing people who have expectant management will develop an infection. This is a similar number to medical and surgical management.
About 2 in 100 women or birthing people who have expectant management will have a haemorrhage (severe bleeding) and may need an emergency operation.
How successful is expectant management of miscarriage?
Expectant management is successful in about 50% of cases. This means that half of women and birthing people who go through expectant management will have another form of management as well.
What happens after expectant management?
You’ll be given a follow-up appointment about 2 weeks after your previous appointment.
If the bleeding and pain has finished by then, the pregnancy has probably come away.
You’ll be asked to do a pregnancy test a week after this appointment. If it is still positive, you should contact your local Early Pregnancy Assessment Service.
If bleeding doesn’t start within 7–14 days, isn’t stopping or is getting heavier, you will be offered another ultrasound scan. If the pregnancy hasn’t completely come away, your doctor will talk to you about your options. These may include:
continuing expectant management
taking medicine to help the miscarriage start (medical management)
having surgery to remove the pregnancy (surgical management).
Support for you
There is no right or wrong way to feel after pregnancy loss. It is a very individual experience. Many people feel a lot of complicated emotions including guilt, shame, sadness, anger and grief, that can sometimes last a long time. There is support available if you and/ or your partner (if you have one) need it. Have a look at our pages on support after a miscarriage.
You can also talk to a Tommy’s midwife free of charge from 9am–5pm, Monday to Friday on 0800 0147 800 or you can email them at midwife@tommys.org. Our midwives are specialists who can support you with any aspect of pregnancy loss that would be helpful for you.
Medical Management
Here are some ways to make miscarriage at home just a bit more comfortable for your clients. And of course when your client thinks they are having a miscarriage or thinks they are the first step is contacting their provider and getting in as soon as possible. Before any over-the-counter meds are used always consult a doctor.
*** I am NOT a doctor. This is just information most people know or can read about.
Pain medication. They can use over-the-counter pain meds to ease cramping and any pain they may experience. (Again have them talk to their doctor so they can direct them)
Comfort Tools: A heating pad or hot water bottle is a way to help ease pain and cramping.
Environment: Try to make things comfortable by lighting a candle, and using a diffuser. If the bleeding gets heavy they can sit on the toilet or use pads.
Fluids: Keep Mom hydrated, warm broths and teas may be comforting. Maybe offer snacks if they seem hungry.
Rest: Make sure your client is getting as much rest as possible.
Have your client call their doctor or go to the emergency room if they experience any of these...
Bleeding that soaks more than two maxi pads per hour for two hours in a row.
Fever greater than 102°F (a slight fever of 102°F or less is common with misoprostol use).
Feeling very ill, with lower abdominal pain after the heavy cramping and bleeding are over.
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