Conveying Missed Miscarriage Information at Obstetric Ultrasounds: Patient Experiences and Trauma-Informed Considerations

Abstract

Health system changes are needed to improve the care of people experiencing miscarriage, including patients receiving missed miscarriage information at obstetric ultrasounds. This study included policy research on prenatal care guidelines, policy research on employment legislation for bereavement leave, interviews with people who had lived/living experience with miscarriage recovery in British Columbia, Canada, and a dialogue with patients. Missed miscarriages are commonly diagnosed during routine obstetric ultrasounds, requiring ultrasound technicians and other healthcare providers to communicate missed miscarriage information to patients. Compassionate care and communication are needed to support patients and partners during this often-difficult time. Trauma-informed training should be provided to ultrasound technicians and other healthcare providers who communicate information on miscarriage to patients in clinics and hospitals, including emergency departments. Additionally, health systems can consider policy recommendations discussed in this article to place trauma considerations at the center of the patient/provider experience, such as allowing a support person to be present during the full duration of the obstetric ultrasound and inviting the patient to make the decision on receiving, or not receiving, the ultrasound picture.

Introduction

Miscarriage is the most common form of pregnancy loss, with 15% to 25% of pregnancies ending in miscarriage. ¹ A missed miscarriage is a type of miscarriage that is commonly diagnosed at a routine obstetric ultrasound when no heartbeat is detected for the embryo or fetus.^2,3 Instead of bringing home an ultrasound picture of their baby, ⁴ patients and partners learn their pregnancy is not viable due to early embryonic or fetal death. ² As such, missed miscarriages may result in poor mental health outcomes.^4–7

Pregnancy loss care remains underresearched and underfunded, ⁴ including critical gaps in missed miscarriage research. Of the research that exists on missed miscarriages, the majority focuses on clinical trials and the management of treatment option.^3,8–14 More research and health services are needed to improve miscarriage care and social determinants of health (SDOH) related to pregnancy loss. ⁴ In response to the need for SDOH research related to pregnancy loss, a study on miscarriage recovery was conducted in the province of British Columbia (BC), Canada. ⁴

In addition to the miscarriage recovery findings previously published (see Van Tuyl, 2024), patient experiences of missed miscarriage at obstetric ultrasounds emerged as a theme and warranted this separate article/research brief to discuss trauma-informed considerations while conveying missed miscarriage news to patients and partners. Currently, the majority of studies on delivering unexpected news at obstetric ultrasounds are focused on fetal abnormalities. ¹⁵ Few studies exist on delivering miscarriage information at obstetric ultrasounds,^5,16–18 with only one focused explicitly on missed miscarriages. ⁵ This article presents the patient experience perspective in BC, Canada and discusses trauma-informed considerations that can inform global obstetric ultrasound policies and practices.

Method

This primarily qualitative study included policy research on prenatal care guidelines, policy research on bereavement leave, interviews with people who had lived/living experience of miscarriage recovery in BC (n = 27), and an optional dialogue with other participants (n = 4). Participants were purposefully recruited through outreach to health and community organizations across BC, Canada, by using physical posters, digital strategies (e.g., e-newsletters, emails, and social media), and snowball sampling. ¹⁹ The question guide was drafted by the principal investigator/first author who has lived experience of miscarriage and then reviewed by two researchers with lived experience of miscarriage and two additional researchers without lived experience. To support a trauma-informed approach, participants were provided with the question guide and mental health resources ahead of the interviews and dialogue. The interviews were conducted and recorded through teleconferencing, and the dialogue was also recorded via teleconferencing.

The data were analyzed thematically in NVivo using a coding tree of patient experiences, prenatal guidelines, and bereavement leave legislation, including priori and emerging codes. Thematic saturation was achieved. Obstetric ultrasound was an emergent code from the interviews and dialogue, highlighting the impact of missed miscarriages on patients. Upon completion of the initial analysis, a policy brief was drafted and shared with participants for member checking (in lieu of transcripts) prior to mobilizing the findings to health authorities and government agencies. The second author, a perinatal health leader and woman with lived experience of miscarriage, also reviewed the obstetric ultrasound findings.

Results

Twenty-six patients and one partner participated in the interviews (n = 27). Four of the patients also opted to participate in a dialogue with other participants. Of the 26 miscarriage patients that participated, 62% (n = 16) of patients disclosed having missed miscarriage(s). A variety of emotions were reported upon learning that their pregnancy was not viable. Learning about missed miscarriage by obstetric ultrasound was described by patients as “devastating,” “traumatizing,” and “shock(ing).” The obstetric ultrasound theme presented at two timepoints: (1) during the obstetric ultrasound with the ultrasound technician, and (2) post-scan interactions. Subthemes by timepoint are presented in Tables 1 and 2. As shown in Table 1, subthemes during the obstetric ultrasound include communication by the ultrasound technician, receiving the news while alone (informal information in the room), and the ultrasound scan picture. As shown in Table 2, post-scan subthemes are the waiting room after the ultrasound scan, receiving the formal diagnosis, and canceling future prenatal appointments.

Table 1.

Patient Experiences: During the Obstetric Ultrasound.

Subtheme	Representative patient experiences
Communication by the ultrasound technician	A patient and her partner were only told the words “Too little” and then directed to call their doctor (first trimester miscarriage patient Q). Another patient recalled a lack of information and empathy provided when the ultrasound technician said: “Oh, sorry like there isn't a baby,” but like they didn't explain anything, they just said like you have to go see your family doctor, but it was at the end of the day on a Friday. So, then we had to like race across town, and the doctor was closed. Yeah, it was just very like no empathy at all (recurrent pregnancy loss patient J).
Receiving the news while alone (informal information in the room)	Patients noted the experience was made more difficult by protocols that did not allow their partner to accompany them during the initial part of the obstetric ultrasound, with partners (a) only allowed to join briefly at the end of the ultrasound appointment as per standard practice in BC, or (b) not at all during the COVID-19 pandemic. As a patient shared, “I just had to deal with it myself until I got home, and I could basically collapse into my husband's arms…I would say that the medical system made it worse in a lot of ways” (second trimester miscarriage patient R).
The ultrasound scan picture	As a patient shared, after an ultrasound technician was unable to find a heartbeat and the pregnancy was confirmed as nonviable by a physician, the ultrasound technician ended the conversation by saying, “Oh, look, there's your cute baby. Do you want me to print out a picture for you?” This resulted in shock to the patient who just learned her baby had died 2 to 3 weeks previously and was still retained in her uterus (first trimester miscarriage patient I). Another patient, however, noted she wished the ultrasound technician would have asked if she wanted the ultrasound picture in memory of her baby to be “provided some closure” (recurrent pregnancy loss patient K).

Table 2.

Patient Experiences: Post-Scan Interactions.

Subtheme	Representative patient experiences
The waiting room after the ultrasound scan	A patient shared how no information was provided to her, when the ultrasound technician told her, “I need you to just get dressed and go sit in the waiting room.” She sat in the waiting room for 40 min before the ultrasound technician came to tell her to call her maternity care provider (recurrent pregnancy loss patient K).
Receiving the formal diagnosis	Recurrent pregnancy loss patient K then needed to wait for her midwife to track down the obstetric ultrasound scan before learning her baby had no heartbeat. Another patient recalled how “I wouldn't leave the hospital until they told me what was going on because nobody would talk to me… I was also demanding that somebody, anybody come and talk to me” (recurrent pregnancy loss patient G).
Canceling future prenatal appointments	Patients who had additional ultrasounds already booked were commonly required to call and cancel future appointments due to processes not being in place for the health authority to initiate the cancellation on behalf of the patient, contributing to additional distress among some patients.

Communication from ultrasound technicians varied significantly while conveying missed miscarriage information. Some patients received compassionate communication, while others received limited or no communication while waiting for a radiologist, maternity physician, or midwife to formally communicate the diagnosis. While ultrasound technicians are directed to not provide patients with diagnoses in BC, Canada, patients commonly determine something is wrong based on the ultrasound screen and/or the response of the ultrasound technician. As a patient shared, “I know the difference…You can feel the tangible difference in the room…Out of the 2 miscarriages that one was probably the most devastating” (recurrent pregnancy loss and infant loss patient O). As a result of these types of experiences, patients reported having a difficult time returning to the same clinic or hospital for other obstetric ultrasounds during future pregnancies. As one patient shared, “It was very hard actually because I had the same ultrasound technician when I was pregnant with my son, so I had to see again … It was like I couldn't even really enjoy the experience because I just was very resentful of seeing her” (recurrent pregnancy loss patient J). In contrast, compassionate healthcare providers play an important role in delivering this unanticipated news to patients. As one patient shared, “The technician that I got was amazing…If it wasn’t COVID, she would have hugged me” (recurrent pregnancy loss patient T).

Discussion

Learning about early embryonic or fetal death at an obstetric ultrasound can be a devastating, traumatizing, and/or shocking experience for patients and partners. Communication by ultrasound technicians and other healthcare providers while conveying missed miscarriage news may contribute to further distress if not handled with care. ⁵ As such, ultrasound technicians play a critical role in the patient's miscarriage journey when compassionate communication strategies are enacted.^16,18 This includes providing clear information and being a navigator to help connect the patient with a radiologist, maternity physician, or midwife to discuss the diagnosis. Leading with compassion, this conversation can include an invitation to receive, or not receive, an ultrasound picture as a memory.

While waiting for the formal diagnosis, providing patients with a private room is recommended. Bereavement rooms for pregnancy loss have been implemented at seven hospitals in the United Kingdom. In addition to supporting patients experiencing pregnancy loss, this recommendation of providing a bereavement room can also benefit other patients who receive unfavorable medical diagnoses and require time before leaving the clinic or hospital. Health authorities can also consider introducing a process that engages ultrasound technicians and clerks to initiate the canceling of future obstetric ultrasound appointments to minimize distress for the patient. Additionally, health authorities can consider changing practices that prevent partners or other support people from being present during the initial part of the obstetric ultrasound.

These findings highlight how SPIKES, a 6-step protocol for healthcare providers on how to convey unfavorable information to patients, has limitations for conveying missed miscarriage information at obstetric ultrasounds. The 6 steps include: (1) Setting up the interview, (2) assessing the patient's Perception, (3) obtaining the patient's Invitation, (4) giving Knowledge and information to the patient, (5) acknowledging the patient's Emotions with empathic responses, and (6) Strategy and Summary. ²⁰ When ultrasound technicians and other healthcare providers are unable to show a heartbeat to the patient, there is no time to rehearse step one, and steps 2 and 3 are often not possible as the patient determines something is wrong from the ultrasound screen and/or response of the healthcare provider conducting the scan. Lastly, step 4 is challenged because ultrasound technicians are not allowed to provide diagnoses in BC and must seek this support from a physician. Moreover, trauma-informed training and practical applications that are specific to pregnancy loss are needed to support patients and partners.

Limitations

In this largely qualitative study, 62% (n = 16) of the 26 miscarriage patients had experiences with missed miscarriage(s). It is important to note this number may not be reflective of the general pregnancy loss population. It does, however, highlight the need for Canada and other countries to improve pregnancy loss data practices. Another limitation is that obstetric ultrasounds were not the primary focus of the miscarriage recovery study; patient experiences of missed miscarriage diagnoses at obstetric ultrasounds emerged as a theme, warranting this separate article to discuss trauma-informed considerations. Further, the application of obstetric ultrasound recommendations for pregnancy loss should consider the sociocultural and health system context of the country providing care, including considerations for publicly funded versus privately funded healthcare and the respective implications for funding and resourcing such recommendations.

Conclusion

Missed miscarriages are commonly diagnosed during routine obstetric ultrasounds, requiring ultrasound technicians and other healthcare providers to convey missed miscarriage news to patients. Compassionate care and communication are needed to support patients and partners during this often-difficult time. Trauma-informed training should be provided to ultrasound technicians and other healthcare providers who convey miscarriage information to patients in clinics and hospitals, including emergency departments. Additionally, health systems can consider adopting these policy recommendations: (a) allowing the patient's partner or other support person to be present during the full duration of an obstetric ultrasound; (b) enabling ultrasound technicians as navigators to connect patients with a radiologist, maternity physician, or midwife to discuss the missed miscarriage diagnosis; (c) designating bereavement rooms in clinics and hospitals; (d) inviting the patient to make the decision on receiving, or not receiving, a picture of the ultrasound scan; and (e) canceling future prenatal ultrasound appointments on behalf of the patient. Communication and policy changes, underpinned by compassionate care, can support patients and partners during their recovery after pregnancy loss.

Supplemental Material

sj-docx-1-jpx-10.1177_23743735251343497 - Supplemental material for Conveying Missed Miscarriage Information at Obstetric Ultrasounds: Patient Experiences and Trauma-Informed Considerations

Supplemental material, sj-docx-1-jpx-10.1177_23743735251343497 for Conveying Missed Miscarriage Information at Obstetric Ultrasounds: Patient Experiences and Trauma-Informed Considerations by Rana Van Tuyl and Kathryn Berry-Einarson in Journal of Patient Experience