Practitioner (GP). The first signs of a possible miscarriage can .... management (Turner et al 1991). The aim of the ..... Cullen S, Maguire R, Strange J M 1991 The.
Miscarriage counselling an Accident and Emergency perspective C. A. Ramsden
Many women attend the Accident and Emergency department with vaginal bleeding as the first signs of a possible miscarriage. This study was undertaken to identify the views of Accident and Emergency nurses with regard to counselling these women in the Accident and Emergency department, and who should be undertaking the counselling. 50 questionnaires were distributed to IO Accident and Emergency departments within the Yorkshire region, to qualified nurses of various grades and experience. 50% of the counselling during the department.
respondents said that should be undertaken couple’s stay in the
This paper discusses where and when counselling should be undertaken, by whom and also focuses on the feelings, thoughts and needs of the couple.
A Ramsden ENG. RGN, ENB I99 and 998, Sister, Accident and Emergency Department, Leeds General Infirmary, Great George Street, Leeds UK (Undertaking the ENB I99 Course at time of wrltlng). Cl&
Correspondence to: 9, Dawlish Road, East End Park, Leeds LS9 9D5, UK. Manuscript accepted IO March I994
INTRODUCTION Miscarriage can be defined as the spontaneous delivery of the baby before 28 weeks gestation and is common in early pregnancy (Lachelin 1985). Miscarriage is the most common complication of pregnancy, occurring in about one pregnancy in five (Oakley et al 1984). Many women, some with their partners, attend the Accident and Emergency (A & E) department
Amdent and EmergencyNursing (I 995) 3.68-73
0 Pearson Profewonal Ltd I995
with vaginal bleeding. They range from 2 days pregnant to 28 weeks. The majority of the females attending the A & E department will not yet have booked into the maternity hospital in their area, or have visited their General Practitioner (GP). The first signs of a possible miscarriage can cause women intense and legitimate anxiety. It is important that professionals show they understand this, and treat any signs of impending miscarriage with proper concern (Tippett et al 1989).
CASE STUDY In 1991 a young couple attended an A & E department. The woman was 10 weeks pregnant, with her fourth pregnancy. She had had one previous miscarriage and 2 young sons surviving. The women had started to bleed heavily, whilst at home. The GP was contacted and advised bedrest, but if the bleeding increased or pain commenced to attend the local A & E department. At 19.30 hours that same evening the couple attended A & E. After thorough examination, she was eventually informed that the pregnancy was no longer viable and that she needed an operation to remove any retained products of conception. The couple were left alone, no-one came into the cubicle to check on them, or to explain what was happening. They could hear nursing staff chatting outside the cubicle. After 1 hour they were taken to the ward by a nurse whom they had not met before and who did not know of the woman’s full previous gynaecological or obstetric history. The couple were devastated that they had again miscarried. A year has passed by and the couple have had another baby boy, but they still remember their visit to the A & E department. They understand about the miscarriage, but cannot understand why the staff did not give them information or check on them. They understand the reason for being left alone for a short while, but would have appreciated some psychological support during this initial period. Having heard their point of view, the author decided to increase her own knowledge about the needs of couples during miscarriage in the A & E department. Oakley et al (1984) emphasise the need women and men have for information during and after a miscarriage. On reading this, the author decided to find out how much information the nursing staff imparted when caring for females and their partners in the A & E department.
Miscarriage
counselling
- an Accident
and Emergency
perspective
disappointed, but often his concern the welfare of his partner. A review of the literature showed that there has been no similar study performed, that is, asking nursing staff about their views on counselling miscarriage clients in the A & E department. Parkes (1985)) concluded that bereavement counselling services ‘are capable of reducing the risk of psychiatric and psychosomatic disorders resulting from bereavement’. The loss of a baby, whether 2 days gestation or 9 months, can stimulate the grieving process. The true incidence of miscarriage is unknown, many pass unrecognised as a late heavy period, but estimates suggest 40% of conception ends in miscarriage (Oakley et al 1984). The experience of a miscarriage is unique, the intensity of the emotional response is not related to gestation age (Peppers 81 Knapp 1980). A mother may be as distressed at 8 weeks as at 22 weeks. There have been few studies of the psychological consequences of miscarriage, but evidence suggests that many women experience intense emotional distress (Siebal & Graves 1980; Oakley et al 1984; Waal-haas 1985). When a baby dies at birth, help and advice are given to the bereaved family, social workers are on hand, and there are support groups where counselling is available. When a baby has been lost through a miscarriage, little help is likely to be given or offered. It seems that a baby is regarded as a fetus until birth. However, to a pregnant woman that fetus is a child with a range of possible names, a future and a personality (Wilkinson 1987). Modern technology enables parents to bond with their baby very early on. They can see a heart beat on the screens as early as 8 weeks and recognise a miniature baby a couple of weeks later, which makes subsequent miscarriage all the harder to deal with (Herz 1983).
69
is for
3. Guilt. Those concerned may feel guilt. ‘If only I hadn’t done...‘. Women may tend to think that there is something wrong with them, ‘can’t I have children?’ Feelings of worthlessness can be very strong, women tend to go over past events to see if there was anything they could have done to prevent the miscarriage. There is also guilt that they have let people down, i.e. husband, grandparents and other children. 4. Despair. The sadness of miscarriage is not helped by wel!&neaning people telling them to ‘cheer up’, and using inappropriate words like, ‘you can try again, you are still young.’ Often at this stage all the couple want to do is to wallow in their own despair. There is also a danger of suffering from postnatal depression, because the body has been in a state of pregnancy. 5. Fear. The woman may feel frightened. The fear may be due to the prospect of going to theatre for an evacuation of retained products of conception. Fears may follow for future pregnancy. 6. Grief. Finally a couple must be allowed to grieve and must work through the grieving process at their own pace (Miscarriage Association 1989).
The psychological response after a miscarriage may consist of 6 stages.
The process of mourning after miscarriage can be more difficult than usual bereavement because the person who is mourned was never known to them (Oakley 1986). The Stillbirth and Neonatal Death Society (SANDS) have recently (1991) published guidelines covering miscarriage, stillbirth and neonatal death. They state that the place in which a woman is cared for during a miscarriage affects how she manages her loss - and that it is not appropriate for a woman to miscarry in the A & E department. GPs should noti@ hospitals and bypass the A & E department. Those women admitted through A & E departments should be transferred to the ward as quickly as possible. At no time should a woman who is miscarrying be 1eEt alone on a trolley in a public area.
1. Anger. This may be directed at the doctors and nurses who could have done more to help. It may be directed at her partner or herself.
ON BREAKING
2. Disappointment. Parents often feel disappointed as they may have been trying for a baby for a long time. Plans have often been made because a baby is on the way. The pain caused through disappointment can be very intense. It is easy to forget the male partner’s emotions. He too will be
An important point to remember about bereavement is that it is easy to inadvertently make matters worse; careless talk can hurt. Bereaved parents often remember the exact words used to break the news (Symes 1991). When the doctor is about to break the news to the woman that she is losing her baby, the
PSYCHOLOGICAL
RESPONSE
THE
NEWS
70
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and Emergency
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doctor should tell both parents together, if possible. Mutual support is important and the meeting with both parents can be used to give permission for the father to openly grieve, mourn and cry (White et al 1984). The father should be allowed to stay with the mother during this stage. The physical surroundings during and following the miscarriage can facilitate or hinder the expression of grief. The diagnosis should not be given on the ward, in the corridor, in the lobby of the hospital or any place where the parents cannot express emotions without embarrassment (Peppers & Knapp 1979). The emotional pain a miscarriage brings should never leave the mind of the carer. ‘The unsympathetic physician has no place in the management of miscarriage’ (Wells 1991). Women who have experienced miscarriage seem to have an insatiable need for information about what is happening or has happened. Siebal & Graves (1980) reported that more than 75% of the patients they questioned wanted to know what caused their miscarriage, and almost as many felt that knowing more would make them feel better. Giles (1970) studied women who had experienced prenatal death and they complained that they were unable to get the information they wanted. Information is important in helping the patient accept what is happening. A lot of self-destructive guilt can be avoided if accurate information is provided to patients about their miscarriage (Herz 1983). Friedman (1989) suggested from his study that GPs accentuate the psychological problems of women following miscarriage, by failing to explain to a woman that medical intervention can do little to prevent miscarriage. This left women feeling dissatisfied with their management. Giles (1987) and Leroy (1988) also noticed that there are indications that women who miscarry get insufficient support from healthcare professionals including obstetricians. A survey by the Miscarriage Association revealed that 80% felt angry and bitter. Of these, 66% felt medical care was inadequate due to the lack of information, counselling and advice. Healthcare professionals’ failure to provide adequate support stemmed from: regarding miscarriage as normal; a sense of involvement in the failure of a pregnancy; fears about the inability to cope in a bereavement situation (Jones 1990). Professionals play a vital role in explaining, helping couples and preparing them for the difficult time ahead. The care a woman receives during and after miscarriage depends not only on the hospital but the personality of the carer. Community midwives have recently put forward a motion to the Royal College of Midwives proposing that midwives be involved in the care of women who have miscarried.
They suggested this because they believe that women felt they were abandoned by everyone when they miscarried, and that their problems were not taken seriously. A few maternity hospitals do provide a service of counselling for couples who have miscarried, for example Grimsby; St Mary’s Hospital, London; Alder Centre, Liverpool; St George Hospital, London. For those areas where counselling is not provided for couples, according to Kennel & Klaus (1982), the most important intervention is listening. Realistic support is offered when the nurse can encourage the mother to express herself, and when she can listen patiently without having to ‘do something’ (Seitz & Warrick 1974). Anyone who is concerned about, and interested in, parents who have experienced a miscarriage can help by being sympathetic and compassionate listeners for as long as the parents feel the need to talk about the tragedy. Those providing the care should communicate explicitly that they consider the loss significant. The carer needs to be sensitive to differences in race, culture and religion. Printed information, which can be taken home at the time of discharge, can supplement the value of the usual verbal explanation (Hamilton 1989). In a study by Forrest et al (1982), it was shown that the duration of bereavement reaction was appreciably shortened by support and counselling which were fairly intensive. Parkes (1985) showed that counselling helped after bereavement. Healthcare professionals and the general public need more information about the psychological impact of miscarriage, and further clinical research is required to determine the best management (Turner et al 1991).
The aim of the study was to show that couples attending the A & E department with PV bleeding during pregnancy do not receive adequate psychological care from nursing staff. A further question was ‘who should be counselling these patients?‘.
METHOD Fourteen open questions in a questionnaire were distributed to 10 A 81 E departments in Yorkshire, 5 to each A & E department totalling 50. The senior nurse in each department was asked to distribute the questionnaire to qualified staff of different grades.
Miscarriage
RESULTS The response rate to the questionnaire was 76%. All the respondents said that they cared for pregnant females attending the A & E department with vaginal bleeding. Of those who completed the questionnaires, 96% were Registered General Nurses (RGN), 4% were Enrolled Nurses (ENG) and 15.8% were male. Amongst the returned questionnaire, 44.7% had undertaken a counselling course: l
l
l
l
Basic counselling course: 34.2% Intermediate counselling course: 18.4% Advanced counselling course: 7.9% Bereavement counselling course: 10.5%
On asking the respondents if they allocate a nurse to stay with these patients, 5.3% answered that they never allocate a nurse, 7.9% said that they always do and 68.4% sometimes allocate a nurse depending on the amount of blood loss or pain the patient had on assessment. The status of the nurse depended again on the condition of the patient, but 31.4% were learners with no counselling experience, 26.3% were qualified or learners, 22.9% were learners or auxiliaries and 17.1% were qualified. Six out of the 10 hospitals to which the questionnaire was distributed had a suitable room in which to care for these patients, leaving 4 hospitals caring in unsuitable rooms. When asked whether the patient attending the A 81 E department should or should not receive counselling in this setting. 50% answered ‘Yes’ and 50% answered ‘No’. When asked whether they had a qualified nurse available to counsel these patients, 10.8% said always, 29.7% said never. Therefore, the majority of the time there was not a nurse to counsel, and then only 44.7% had counselling skills taught to them (10.5% specific bereavement counselling training) Only 1 nurse felt that her counselling skills were adequate to cope with the reaction of the female when told she is losing her baby. In response to the final question, nurses working in the A & E departments feel that counselling should be performed by the professionals listed below. l
l
l
l
l
l
Trained counsellor: 58.8% Trained RGN: 20.6% GP: 8.8% Psychologist: 5.9% Doctor: 2.9% Midwife: 2.9%
DISCUSSION The United Kingdom Nursing and Midwifery
Central Council for and Health Visiting
counselling
- an Accident
and Emergency
perspective
7 I
code of professional conduct (UKCC 1992) states that ‘each registered nurse, midwife and health visitor is accountable for his/her practice’. Parts 1, 2, 4, 5, 7, 11, 13 are relevant to the psychological care of the patient who has miscarried. If a nurse is unable to help a patient during this time, she can decline by quoting part 4 of the code of conduct, which ‘acknowledges any limitations of knowledge and competence and declines any duties or responsibilities unless able to perform them in a safe and skilled manner’. But part 3 states ‘the nurse shall take every reasonable opportunity to maintain and improve professional knowledge and competence’, leaving no reason for an experienced nurse to refuse miscarriage counselling in the A & E department. From this study, out of the 38 respondents, 44.7% had completed a counselling course, yet 50% of the respondents stated that counselling should begin in the A & E department. Many women who miscarry report symptoms typical of grief that commonly follows bereavement; yet only 10.5% of the nurses had bereavement counselling skills. Despite the fact that diagnosis of miscarriage is often not known until after pelvic ultrasound, these women and their partners still require support and information. Friedman (1989) states that women’s main area of dissatisfaction concerned the lack of, and conflicting, information. Only 21.1% of the nurses impart written or verbal information to the couples, yet we know these people search for information. The room in which a patient is cared for can leave a lasting memory (SANDS 1991). 4 out of 10 hospitals in this study do not have suitable rooms available to provide the care. The room should be a private room away from the main area of a busy A & E department, preferably with a door which can lock from the inside. The room should not contain children’s toys, mobiles, cot, etc. to upset the already grieving couple. Since the Patient’s Charter (1991), all patients attending the A & E department should be assessed by a qualified nurse. The Yorkshire study showed that one respondent stated that patients are not always assessed by a qualified nurse. The woman is emotionally disturbed at this time and the need to talk can be increased, therefore the support of a nurse to explain would be greatly n.eeded. 7.9% always allocate a nurse to stay with these patients. 68.4O/;, sometimes do depending on ‘physical condition of the patient’, but one of the respondents mentioned the emotional or psychological condition of the woman. Staff who are allocated to these patients feel that their skills are inadequate to cope with the reaction of the woman when told she is losing
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and Emergency
Nursing
her baby. When a patient does require counselling in the A & E department, 28.9% answered that they do not have a nurse available to counsel and 10.5% always do. This 10.5% are those who have undertaken a bereavement counselling course. Many respondents commented on the questionnaire that time is not available to undertake counselling, and priority in the departments is to admit the patient to the appropriate ward, once physiologically stable, and that counselling would be commenced on the ward. Post discharge counselling usually takes place 4-6 weeks after discharge. The counselling sessions can be from 20 minutes to 2 hours long depending on the clients’ needs. Couples vary greatly in the number of sessions they need, and see the same counsellor each time. Therefore a nurse counselling a patient in the A & E setting could be considered to be inappropriate, as the nurse could not counsel the patient later in the home environment unless employed specifically to undertake this. The proportions in which written and verbal information were not given to patients was 78.9%, and some respondents wrote that the ward staff should be distributing counselling contact numbers and self help group numbers on discharge. For those not admitted, their GP may need to counsel. Prettyman (1992), in his study of the primary health care team, stated that GPs accepted the need for psychological support and counselling, yet only 42% thought that they were the most appropriate people to provide this care, and only 21% felt confident to provide such routine counselling. Bowman (1986) said listening is a most essential part of the communication process, not least because where the nurse fails to listen and pay attention to what the patient is saying, information might be lost. It is particularly important to listen to the emphasis that is placed on the words or phrases, as this provides vital clues which otherwise may be missed or misinterpreted.
CONCLUSION As a result of the review of literature and the study, the author suggests that women should not be miscarrying in the A & E department; these women should by-pass the departments and be admitted or assessed on appropriate wards. Obviously, some women do attend the department, and, as seen in the study, the nursing staff feel that counselling should not be
commenced in the A 81 E department, as it is inappropriate in time and place. Their priority lies with getting the patient physically stable and onto the ward quickly and safely The British Association of Counselling (1969), stated that ‘Counselling is a process through which one person helps another by purposeful conversation in an understanding atmosphere. It seeks to establish a helping relationship in which the counselled can express his thoughts and feelings, in such a way as to clarify his own situation, come to terms with some new experience, see his difficulty more objectively and so face his problem with less anxiety and tension. Its basic purpose is to assist the individual to make his own decision from among the choices available to him’. From the above statement, it would appear that to counsel a patient in the acute setting of the A & E department would not fulfil the criteria of the British Association of Counselling. Therefore, giving the patient more support and information, a nurse being available to listen and answer questions correctly, to emphasise and state that she is ‘sorry’ would help during this period. The patient will feel her loss is not ‘routine’. A room should be available in which to care for the patient and partner with appropriate facilities, and without toys and mobiles etc. All women who miscarry should be given the opportunity for counselling whether on admission or discharge, since the duration of bereavement reaction is appreciably shortened by support and counselling. This could be provided by a counsellor or liaison midwife to be attached to an A & E department, so that women can be followed up on discharge and approached for counselling. If the woman declines counselling at that time, then a contact number and address for support or self help groups, such as the Miscarriage Association, should be given to them. When the women do want help they will not feel isolated and will be able to contact appropriate agencies in their own time. Written information should be given to them, to satisfy their need for information, explaining the types of abortion, how long they will bleed for, how they may feel, their thoughts and when they can start a family again. This can then be read at home to reinforce what was said in hospital whilst they were distressed. There is a need for more research to be carried out in this area, including a bigger sample of the one undertaken. A study is also necessary to find out the needs of women and their partners who attend the A & E department. This would help the couple’s stay in the A & E department to be a positive one, with nothing said or done to prolong their grieving process.
Miscarriage
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