What ERs can do to provide better care for patients dealing with pregnancy loss

A registered nurse who has studied the experiences of people dealing with early pregnancy loss in emergency departments says more education and empathy is needed to help patients navigate a traumatic time.

Kate MacWilliams completed her master's degree at Dalhousie University, and published a study in 2016 based on interviews with eight women who sought care in the Halifax area while having a miscarriage.

"To me, it really highlighted the need for privacy and to create a space of dignity and respect, and the importance of treating the family as a whole," she said. 

She's spent the last several years working in Toronto, implementing changes in emergency departments so patients have more support.

"These patients would come in and they would be in the busiest area of the department. They'd be moved in and out of the waiting room," MacWilliams said.

"They'd wait for really long periods of time for blood work and ultrasound results, and I just couldn't imagine what it would be like to be in their shoes."

In Halifax, women who are less than 20 weeks pregnant can't go to the IWK Health Centre in an emergency, and often end up spending hours in the busy emergency department at the Halifax Infirmary.

Some, like Lauren Howe, wait long hours only to be transferred to the IWK where they're able to get the care they need. Howe and her husband Nick opened up about their experience with pregnancy loss last week and are calling for an adult emergency department to be set up at the IWK.

Hear Lauren and Nick Howe talk about waiting 14 hours in a busy ER earlier this month:

A doctor at the Halifax Infirmary has said the hospital is reviewing the care people like Howe receive, and, on Tuesday, Health Minister Zach Churchill responded to questions in the legislature from MLA Elizabeth Smith-McCrossin about the couple's experience.

"We do lean heavily on clinical advice when it comes to setting up the criteria for our emergency department, but this is of course a situation that requires involving a deeper dive," Churchill said, adding that he'll discuss the issue with his staff.

Overlooked and overwhelmed

MacWilliams said what the Howes went through is heartbreaking and also not surprising — she's heard similar stories many times before. 

Some participants in MacWilliams's study, which was published in the Journal of Emergency Nursing, talked about feeling dismissed by staff and unprepared to deal with what was happening.

"Having a miscarriage and receiving treatment for a miscarriage in the emergency department was a traumatic experience that had a lasting emotional impact on all the women in this study," the researchers wrote. 

Some of the women also recounted experiences where health-care professionals minimized their symptoms, abruptly delivered the news that they'd miscarried, and didn't spend enough time preparing them for what could happen after they were discharged.

One participant was told she'd likely experience period cramps, and instead had severe abdominal pain and vomiting, leaving her fearful that something was very wrong, MacWilliams said.

"As an emergency nurse myself and knowing who my colleagues are and co-workers are … the intention is never to create a negative experience for your patients," she said. "It's not about the nursing staff, but almost in a sense, it's like the environment is just not the correct environment."

The intention is never to create a negative experience for your patients.- Kate MacWilliams, registered nurse

In her study, MacWilliams points to the U.K. and Sweden, where care for early pregnancy complications is more streamlined than it is in Canada. 

It is standard for hospitals in those countries to have either dedicated early pregnancy assessment units, or telephone screening, with increased access to gynecology appointments, the study stated.

While the IWK has an early pregnancy complications clinic, it's only open limited hours during the week.

MacWilliams said even though people experiencing a miscarriage feel they don't belong in the ER, it's often the only place they can go when they're dealing with pain or bleeding early in their pregnancy.

"If that's always a part of the piece of the puzzle, we can do a better job of care when they come to emergency departments," she said.

What emergency departments can do

MacWilliams has worked in emergency departments in Ontario to implement training for staff and develop protocols that not only treat people's physical symptoms, but help them cope with the emotional loss of a pregnancy.

She said staff should understand what the pregnancy means to a person and their family "so that we can have more sensitive, compassionate care."

MacWilliams helped develop a bereavement checklist for staff, which she said helps guide care and ensure that they don't miss anything even when they're working in a busy department.

In one ER where every stretcher was in its own room, staff placed a purple butterfly — the symbol of perinatal loss — on the door so staff knew the patient was dealing with pregnancy loss, MacWilliams said.

There can also be services offered to people and their families if their pregnancy was over 12 weeks where they can take a photo of the fetus to preserve the memory, she said.

Hear Kate MacWilliams talk about her research into care for early pregnancy loss:

MacWilliams said ensuring ultrasounds can be done more quickly will also mean fewer people need to return to emergency departments later on.

She believes the changes she's implemented in Ontario are making a difference.

"I remember the first time we implemented this in one of the departments ... we would be getting written letters from families about the quality of care they received," she said.