Perinatal Nurses Advocating for Bereavement Care for Women who Miscarry in the Emergency Department

by Joyce Merrigan, RN

"If we don't do it......it will never be done."

The image will be forever ingrained in my memory: the remains of a miscarriage scooped up by a gloved hand in the emergency department, tossed into a plastic specimen container and left on a counter. No condolences were offered to the woman who had experienced this loss. This memory haunts me to this day but also drives me to advocate for change.

"If we don't do it......it will never be done."

In the United States, 1 in 4 pregnancies ends in miscarriage. It is likely that you know of someone, or have personally experienced a loss. . The gestational age at the time of pregnancy loss appears to determine not only the setting for care, the emergency department (ED) or labor and delivery (L&D), but also the standard of care when it comes to addressing bereavement. This difference demonstrates that miscarriage continues to be treated as a physical complaint and is not acknowledged as the loss of life with emotional dimensions.

Labor and delivery units across the country have incorporated evidence-based practice standards, educated the bedside nurses, and rewritten policy and procedures to apply the principles of perinatal bereavement care into the standard of care for women experiencing loss after 20 weeks gestation. We have done a terrific job responding to the unique emotional, spiritual and cultural needs of this population. However, there is another unique group of women who may be slipping through the cracks; women who miscarry before 20 weeks gestation and receive emergency care in our EDs.

"If we don't do it......it will never be done."

Historically nursing care of women experiencing a miscarriage in the ED concentrated on the medical interventions to correct hemodynamics and nursing care to promote physical recovery. The plan of care was devoid of bereavement support and the communication and activities to validate the miscarriage as the loss of life. Bereavement care acknowledges miscarriage as the loss of life and demonstrates that the products of conception need to be handled with respect and dignity. Bereavement care considers the spiritual, emotional and cultural expression of the pain that accompanies the loss of a baby. The depth of this pain does not correlate with the duration of the pregnancy. It cannot be assumed that because it was an eight-week pregnancy, the woman will not mourn the loss. This stated we cannot conclude that all women who miscarry will cry or require perinatal bereavement support. However, nurses must explore the personal meaning of the pregnancy loss being mindful of offering choices and accommodating individual requests.

The emergency department is fast-paced, has high nurse: patient ratios and often the standard operating procedure for the woman whose chief complaint is vaginal bleeding and not far enough along to send to L&D, is hemodynamic stabilization and discharge home. Perinatal nurses are sometimes asked to tend to the emotional needs of a distressed woman in the ED. Although perinatal nurses may happily accommodate the request, they may also be reluctant to leave the L&D unit and disrupt patient care there. ED and perinatal nurses working together in this regard could be viewed as collaborative but this approach can lead to fragmented care when women who are miscarrying are in need of continuity.

There are barriers to implementing perinatal bereavement care as the standard for women who miscarry in the ED. Besides time and culture, the most significant barrier is the inexperience with and knowledge of perinatal bereavement care communication skills and activities (Burkey, 2014; Chan, Chan, & Day, 2003; Evans, 2012; Rowlands & Lee, 2010; Zavotsky, Mahoney, Keller, & Eisenstein, 2013). Emergency nurses acknowledge they should provide specialized emotional care and support after a miscarriage but believe they lack the communication skills and knowledge to provide the best care (Chan et al., 2003). Fearful of saying something wrong, some ED nurses choose to remain silent, however, saying nothing may be as harmful as saying the wrong thing (Chan et al., 2003; Merrigan, 2016).

"If we don't do it......it will never be done."

The good news is there is a solid correlation between the comfort and ease in the delivery of perinatal bereavement support and formal education in the principles and methodologies! The ED nurse could be best prepared to meet the individual emotional, spiritual and cultural needs of these families if they had the opportunity to participate in a formal perinatal bereavement care education program (Evans, 2012). And who is better suited to lead this education but perinatal nurses. After all, if we don't do it, will it ever be done?

Joyce is a NCC certified OB RN and bereavement care coordinator. She presented perinatal bereavement care in the labor and delivery and most recently emergency room setting throughout the State of NJ. NJ MCH Consortia Perinatal Bereavement Committee and Fetal Infant Mortality Review Committee. Member of Organization of Nurse Leaders, NJ, ANA, NJNA, AWHONN, Hospice & Palliative Nurses Association (HPNA), Pregnancy Loss & Infant Death Alliance (PLIDA) and National Perinatal Association (NPA). She is currently pursuing her certification in perinatal loss (CPLC) through the Hospice & Palliative Credentialing Center (HPCC) and is also a fulltime DNP student focusing her doctoral project on the principles and methodologies of perinatal bereavement care for ED nurses with specific application to miscarriage.

Originally posted on AWHONN Connections.

REFERENCES

Bereavement and Advance Care Planning Services Gundersen Lutheran Medical Foundation, Inc. (2008). RTS bereavement care training in early pregnancy loss. In M. Daley & R. Limbo (Eds.), RTS bereavement training in early pregnancy loss, stillbirth, and newborn death (7th ed.). La Crosse, Wisconsin: Bereavement and Advance Care Planning Services Gundersen Lutheran Medical Foundation, Inc.

Burkey, D. (2014). Evidence-based perinatal bereavement education for women treated for miscarriage in the preadmission testing unit: A pilot of system change. Available from ProQuest Dissertations & Thesis Global (1528574664). Retrieved from http://search.proquest.com.library.capella.edu/docview/1528574664?accountid=27965

Canadian Paediatric Society Statement. (2001). Guidelines for health care professionals supporting families experiencing perinatal loss. Paediatric Child Health, 6(7).

Carlson, R. (2012). Helping families create keepsakes when a baby dies. International Journal of Childbirth Education, 27(2), 86-91.

Chan, M., Chan, S., & Day, M. (2003). A pilot study on nurses' attitudes towards perinatal bereavement support: A cluster analysis. Nurse Education Today, 24, 202-210.

Conry, M. J., & Phil Prinsloo, D. C. (2008). Mothers' access to supportive hospital services after the loss of a baby through stillbirth or neonatal death. Health S. Gesonheid, 13(2), 14-24.

Evans, R. (2012). Emotional care for women who experience miscarriage. Nursing Standard, 26:42, 35-41.

Gundersen Lutheran Medical Foundation, Inc. (1984-2013). Resolve through sharing bereavement education model position paper [Position paper]. Retrieved from Gundersen Health website: http://www.gundersenhealth.org/upload/docs/Bereavement/RTS-PPA-Educational-Model.pdf

Hannah, K., & Goodall, U. (2013). Perinatal bereavement care: Are we meeting family's needs?. British Journal of Midwifery, 21:4, 248-253.

Kobler, K., & Limbo, R. (2011). Making a case: creating a perinatal palliative care service using a perinatal bereavement program model. The Journal of Perinatal & Neonatal Nursing, 25(1), 32-41.

Merrigan, J. L. (2016). Perinatal bereavement care for women who miscarry in the emergency department. Unpublished manuscript, School of Nursing and Health Sciences, Capella University, Minneapolis, MN.

Rowlands, I., & Lee, C. (2010). 'The silence was deafening': Social and health service support after miscarriage. Journal of Reproductive and Infant Psychology, 28(3), 274-286.

Zavotsky, K., Mahoney, K., Keller, D., & Eisenstein, R. (2013). Early pregnancy loss and bereavement in the emergency department: Staff and patient satisfaction with an early fetal bereavement program. Journal of Emergency Nursing, 39(2), 158-161.