A miscarriage, also known as a spontaneous abortion, is the expulsion of an embryo or foetus from the uterus before it is able to live outside the womb. If it occurs within the first 12 weeks of a pregnancy, it is referred to as an early miscarriage. Between the 12th and 20th weeks of pregnancy, it is called a late miscarriage. After the 20th week it is possible for the foetus to live outside of the womb with medical intervention and this is called a preterm birth. A stillbirth occurs when a baby is born dead after the 20th week. Early miscarriage is very common. It is estimated that as many as 40% of all conceptions result in miscarriages. Some doctors estimate that virtually every woman will have one at some point in her reproductive life, though not all will realise it.

Causes and Risk Factors

The most common cause of miscarriage is a lethal genetic defect of the foetus that arises spontaneously. Other factors have been identified, however, that may increase the risk of miscarriage. These include exposure to rubella, or another teratogenic disease¹; radiation; harmful drugs; high fever; or an IUD in place at the time of conception. Other factors to consider are poor maternal nutrition, smoking, hormonal insufficiency, or a malformed uterus.

Signs and Symptoms

Symptoms of miscarriage are bleeding with cramps and/or pain in the centre of the lower abdomen. There may be variations on this theme. For example, some women may experience light staining for three or more days while others have heavy bleeding with no pain, and still others experience pain without any bleeding at all. Regardless of the specifics, it is imperative a pregnant woman experiencing any of the above call her practitioner immediately.

I'd just found out that I was pregnant, the week previously. I awoke with incredible pain in my abdomen. My husband called the doctor who told me to stay in bed and he would visit. This was 1982, and there was a strike of health workers on. My doctor visited, checked me over, told me to stay in bed. I had two young daughters, so my husband had to stay off work to help. I got up once to go to the toilet and it was there that I lost my baby but I didn't know that at the time.

My husband went out for sanitary towels and called the doctor again, who came straight back. He called for an ambulance from my home, then left. My husband held my hand as we waited for the ambulance... he said he would rather lose the baby now, than near the end, if we were going to lose it {we had previously suffered a stillbirth, our first son}. I knew what he meant, but I still didn't want to lose my baby. I remember being carried down my own stairs in a chair by the ambulancemen... and my husband's face as I was being hoisted up into the ambulance... and my little girls crying.

As the ambulance arrived at the hospital, the entrance was covered by people picketing. They moved aside to let the ambulance through, though. I was taken straight to surgery, as I was haemorrhaging badly.

I remember coming round on the ward, {after my D and C}; a nurse giving me a sip of water through a straw, then asking me if I wanted to see my husband. I felt light-headed, drunk almost. The pain was gone, and so was my baby, I felt... numb. The life within me was gone, and I hugged my husband and sobbed. The nurse said we could have another baby... I didn't answer her.

As luck would have it, the time I was due with that baby, {Christmas}, I found out I was pregnant again, which helped get us through that painful time. I gave birth to a healthy baby boy in August 1983.
- Galaxy Babe

Treatment

Miscarriage in the first few weeks of pregnancy very often is assumed to be an unusually heavy and/or crampy period. This represents the greatest number of early spontaneous abortions. After this time, however, an early miscarriage can present more complicated medical and emotional scenarios. In all cases prompt medical attention is of utmost importance.

If bleeding and/or cramping are present in a pregnant woman, a doctor will first do an examination to determine whether the cervix has dilated. If it has, it is generally thought that a miscarriage has either occurred or is underway. At this point, the embryo generally has already died.

If the cervix is still not dilated and the foetus is still alive (demonstrated by ultrasound or Doppler) then it is possible that the miscarriage may be averted. Some practitioners will impose bed rest while others will feel that a healthy pregnancy will survive and an unviable one will not regardless of what is done. Occasionally, in some rare cases, the female hormone progesterone may be administered to help preserve the pregnancy.

In some cases, a doctor will discover that the foetus has died but the actual miscarriage has not yet begun. In these cases, as well as in cases where a miscarriage was incomplete (not all the tissue was discharged), a practitioner will usually recommend a procedure known as a 'dilation and curettage', or 'D & C'. All medical procedures can be frightening. Patients should ask their practitioner any questions they might have and voice their fears and concerns. Taking an active part in treatment will help patients retain as much of a sense of control as possible. This is particularly important at a time when they might be feeling helpless.

A 'D & C' takes about 20 minutes, if there are no complications, and requires general anesthesia. During the procedure, the cervix is then mechanically dilated and any remaining placental and fetal tissue is removed from the uterus. This tissue can then be evaluated in a clinical laboratory to determine clues as to the cause of the miscarriage.

Immediately after the surgery, patients are given hormones to help the uterus contract. This helps to stop the bleeding. Patients are monitored for a few hours and, if progress is satisfactory (ie, the bleeding has attenuated or stopped), will usually be allowed to go home that afternoon. Lots of bed rest should follow, and strenuous activities are not permitted until the risk for post-operative bleeding has passed.

While a D & C is a fairly routine procedure, there is always a risk of complications. The most common complication after a D & C is that the uterus fails to contract enough to prevent bleeding. This requires immediate medical attention and can either be treated in an emergency room, or, in less urgent cases, at home. In this situation a hormone is prescribed that will cause the uterus to contract. This will stop the bleeding in most cases. It must be noted that these contractions can be extremely painful. For some women, they feel almost like labour pains. Given the context, this can be devastating. Women should always ask their doctor about pain management in this situation.

In some rare cases, the bleeding cannot be controlled with medication and a hysterectomy will have to be performed in order to preserve the life of the mother.

Everyone at the hospital was wonderful to me. My nurse told me she had been in the same bed for the same reason three months ago. She gave me some pamphlets to read when I felt up to it. My doctor was waiting for me when they brought me down to surgery. He stayed there and held my hand while he was waiting to go in to perform the procedure that was scheduled before me. Another nurse came by and actually brought me warm sheets fresh from a dryer and wrapped me up in them and put big fluffy socks on my feet. I felt really taken care of, but there was another woman ahead of me who was being largely ignored. Her doctor wasn't even there. I felt really badly for her because she was being really emotional and kept saying she wanted to go home. The anesthesiologist was really short with her. I didn't understand if she had told everyone to leave her alone or what.

The anesthesiologist came over to me and I could see he was agitated. I started asking him some questions about the drugs he was giving me and what they were for out of curiosity. He seemed to relax, and as soon as he relaxed he started joking with me. He brought over another anesthesiologist and they both stayed with me while the drugs started to make me more relaxed. I couldn't help thinking about the other woman in the corridor. I wanted to ask why no one was paying attention to her, but I didn't.

The other woman went in before me. I had brought a picture with me my daughter had made for me that said 'I love you, Mommy' on it. While I was waiting I looked at it whenever I started to feel scared. I was getting scared that I wouldn't come out of the operating room, or that I would come out without my uterus. Finally the nurse came over to me and took the picture from me and tucked it under the gurney for safe keeping. She winked at me and I knew it would go into the operating room with me. I told myself that I had to be fine for my daughter's sake.

My doctor was there. He patted my hand and told me he would take good care of me, then he held my hand while I went to sleep. The next thing I remember, I woke up in recovery. It had been 25 minutes. There was a small sample jar between my feet that had some red tissue in it. I knew my baby was in there and I had an urge to ask to hold it. I took some deep breaths. My doctor was on one side of me, still holding my hand, the nurse was on the other. I noticed the other woman was there as well, still asleep, and no one was with her.

My doctor told me everything went fine and that he would see me soon. I felt wide awake and remarkably all right. After the doctor left, I asked the nurse if the other woman was all right. She looked surprised and said, 'Yes, she's fine.' I felt this almost uncontrollable urge to wait next to her until she woke up. I don't even know what she was in for, but I just wanted to reach out to her for some reason.

Back in my room, my nurse let me rest and checked on me often. She brought me food and I was able to eat. My partner was there and had bought me a huge stuffed dragon. I felt physically all right, but emotionally I felt... detached. I had survived. Somehow, that was my first order of business. But I don't think I was allowing myself to feel anything emotionally yet. I was completely dissociated.

My nurse finally came in and told me it was OK for me to go home after I had been there about six hours. She gave me lots of instructions and finally she told me that the emotional impact would probably hit me some time later. I had no idea at the time how right she was. She encouraged me to read the information she had given me. I am so grateful for the excellent care I got. The nurses and doctors all made me feel really cared for and confident that everything would be fine. But then, the bottom kind of dropped out on me when I started to move out of this very supportive environment and had to face the emotional whirlwind that followed.

Healing After Loss

Everyone deals with loss and grief differently. When a woman suffers a miscarriage it is important for her, her partner and the people around them to acknowledge that they have experienced an actual death. The grieving and healing process following a miscarriage is frequently very long and fraught with set backs, but often a complicating factor is the inability for people to recognise why they feel the way they do. Because very often there isn't a body or a formal funeral service, people often feel that they don't have a right to grieve this loss as the death of a child. In fact, for these couples, it is very much a death of a child.

The grieving process in a miscarriage follows the same pattern that has been observed in any traumatic loss: first there is a stage of denial followed by anger and finally acceptance. Each successive step along the way frequently takes longer to process than the former. There is also a tendency for women who suffer miscarriage to 'fall back' to a previous stage or to 'get stuck' in one unless there is proper care and support provided.

Denial

I was about 12 weeks pregnant when I started to have some light spotting that lasted for a few days. I convinced myself it was nothing. But I think, deep down, I knew something was wrong. One afternoon I walked over to the phone and called my general practitioner about something totally unrelated, like a sore shoulder. He immediately asked me how I was feeling otherwise and how the pregnancy was going. I said, 'Oh great! Everything is fine.' I then casually mentioned to him what was happening. I could tell by the pause on the other end of the phone that he was concerned. He told me he thought it was important to call my ob/gyn, but I still resisted. I said something like, 'Well, I'm sure its nothing.' He then absolutely insisted I call. When I did the nurse told me to come right over. I hated the urgency everyone was exhibiting, because it made me face the possibility that something was really wrong. I still was clinging to the hope that everything was fine. Maybe if I ignored it, everything would actually be OK.

The doctor saw me as soon as I got in the office. He quickly did and ultrasound and very quietly told me that there was a problem. I saw it too. The baby's heart that just last week had been beating so strongly was very slow and irregular. I was watching my baby die.

The doctor was very good, very kind. He quickly turned the screen so I couldn't see the image of the baby. Then he got me lots of tissues and put and arm around me so I could cry. After I got dressed, and he was telling me about what had to be done next, I was just feeling like I was listening but not really hearing him. I felt like I was in some sort of nightmare that I really wanted to wake up from. This just couldn't be happening.

I carry that image of my baby to this day, tiny legs and arms seeming to reach out to me. I still miss that I never got to hold my baby.

For a woman in the initial stages of a miscarriage, existence becomes a storm of emotions including fear (sometimes bordering on panic), overwhelming sadness, real physical and emotional pain, anger and a tremendous sense of helplessness. Everything in her being is crying out for her to protect her baby and yet there is nothing she can do to prevent it. All of the parents' hopes and dreams for this child are dying. Yet, it is imperative for a women experiencing a miscarriage to acknowledge that it is happening. The first priority must be to get proper medical care. Denying the loss of a pregnancy or the possible implications of the symptoms can cost the mother her own life. Often this stage of denial can endure throughout the time of hospitalisation and medical intervention, though it frequently blends into the next stage.

Anger and Guilt

One Researcher shared the following experience:

About 11 months after my miscarriage, I ran into an old friend I hadn't seen in years. She had just had a beautiful baby girl. When I was holding the baby, it was all I could do not to cry. I automatically did the math in my head... my baby would have been four months old. I said all the usual things, but I was so ashamed because part of me was really jealous and angry... I wished with all my heart it was my own baby in my arms.

For the longest time, I couldn't shake the feeling that somehow it was my fault, that I had done something wrong. Maybe if I had started taking prenatal vitamins sooner... maybe if I had lost more weight before I got pregnant... I knew it was irrational, but still.... the guilt that somehow my baby's death was my fault was there.

This is a very difficult stage to negotiate. Expectant parents have been spending weeks or months anticipating the birth of their child doing things like planning the nursery, choosing names, buying clothes and now its all gone. Worse, if they have told people they were expecting, they now have to contend with telling them about the miscarriage.

To compound the problems, women and their partners often grieve very differently. Women tend to want to talk it through over and over and process the attendant feelings slowly over time. The majority of men tend to be more silent in their grieving and far more 'action oriented.' They seem to have a 'lets get over it and move on with our lives' attitude. Most women find this jarring and experience it as being insensitive even though it is not intended as such.

Women must recognise that this difference does not mean that men are not grieving for the loss of their child too; they just are doing it in a different way. Very often, if given the opportunity, men will express tremendous guilt after their partner suffers a miscarriage. They feel helpless and almost extraneous to the whole event. They are watching a woman they love go through a painful and frightening experience. Often they are afraid that they might lose their partner as well as the child.

Say what you will about gender stereotypes, but almost all men express a strong desire to 'protect' their families. This seemingly innate sensibility is challenged when their partner loses a child. They feel helpless, angry and impotent. It's vitally important to include male partners in the healing process after a miscarriage. Not only do they have their own grief to work through, but they are often the key to real healing for their partner.

A father shared his story:

I felt various emotions during my partner's miscarriage. My personal feelings were that of devastation at the loss of our baby and frustration of not knowing why it had happened. Was it my fault? I wanted to take on the physical pain of my partner but knew there was nothing I could do. I had lost a baby too and all I could do was sit there and watch my beloved in agony. I could only talk with her and try to comfort her but that seemed so inadequate.

After all the initial heightened emotions had abated, perhaps one of the most distressing things for me was the lack of support from my colleagues. Being a male and working in a predominately male environment, the general attitude was an expression of regret for my partner's loss but not of mine. My partner's colleagues (predominately female) were much more understanding towards her. It is important to realise that the potential father has emotional scars from such an event too. I loved the baby too. Not a day goes by without thinking about the baby and the emptiness that child has left permanently in both mine and my partner's hearts.

Often, well meaning people will say thoughtlessly hurtful things to the grieving couple. The most commonly reported are, 'Well, you can always have another child' or, 'At least you know you can get pregnant!'

I had just told someone that I had a miscarriage. She looked very sympathetic and said, 'Well, you know, these things happen for the best.' I was furious! I just wanted to shout at her, 'No, this definitely was NOT for the best!' She meant well, and I just nodded quietly and turned away in tears.

People do not generally intend to be cruel. Often they simply do not recognise that to the couple who has just experienced a miscarriage, this child already existed. It was neither a 'potential' child, nor was it a 'flawed' foetus. It was their baby that they already loved.

Often, as with any death, people simply don't know what to say. A simple, 'I'm so sorry this happened. Please let me know if there is anything I can do' is often the best thing. Or, sometimes actions speak louder than words. For example, during the period of post-operative recovery when a woman's activities are restricted, a generous offer to help do some grocery shopping, or to bring over a casserole for dinner would probably be very appreciated.

Acceptance

One woman shared this story:

It was almost a year after my miscarriage that I was even able to discuss my miscarriage with my therapist. We had been skirting the issue entirely, talking about weight management... why was I eating so much? I came up with a thousand and one excuses for an answer... stress, poor eating habits, you know, everything but the real reason. Finally one day I blurted out, 'I think the reason why I can't stop eating is that I am trying to fill this empty place where there used to be a baby. Except there isn't a baby anymore. I just sat there and cried for the rest of the session. I couldn't get past that. Every time I try to talk about it, I cry. It's been a year and I'm still crying. But I'm finally starting to be able to at least talk about it.

At some point, with love, care and support, parents who suffer a miscarriage move on to accepting that this did happen to them. They realise that it wasn't their fault, and they begin to fully realise that while neither of them will ever be the same, they can move into the future together while still holding onto the memory of their child.

Some Healing Suggestions

There are several things that couples facing the aftermath of a miscarriage can do to facilitate the healing process. This can include naming the baby, having a memorial service or performing some other ritual that is meaningful to them. Some families plant trees, or make donations to charities in the name of their child. Some couples quietly light a candle on the due date of their child every year. The important thing is to find something that is meaningful to you to help you acknowledge the loss and actively heal.

Couples going through this experience need to give themselves the time they need to heal. They also need to recognise that setbacks will occur every step of the way. Very often, they will take spring out of nowhere. For example, a year after a miscarriage a woman might be shopping and suddenly find herself in the baby section of a department store crying. Or, as the Researcher above related, she might feel guilty that after a friend gives birth she feels jealous and terribly sad. It's important to acknowledge these feelings and recognise that they are signposts along the healing process.

Every couple going through a miscarriage should get help in dealing with the aftermath of the experience. Even if they have excellent and caring medical treatment, after they go home and the physical healing is complete, there is still much emotional healing that needs to be attended to. They should talk to family and friends if they are supportive, nurturing and understanding. Most important they should talk to each other. Counsellors and support groups can be an invaluable resource during this time as well. If a woman who has gone through a miscarriage finds herself alone and without support there are a number of excellent books available as well as several on-line groups, detailed below.

During this time, couples experiencing the loss of pregnancy may feel that they are only learning about and experiencing death, but it's important to remember that eventually they will re-focus on life and the future, and as part of their life, they will carry the love for their child with them forever.

Some Related Reading Materials

• Empty Arms . . . Coping with Miscarriage, Stillbirth and Infant Death by Sherokee Ilse

• Trying Again: A Guide to Pregnancy After Miscarriage, Stillbirth, and Infant Loss by Ann Douglas, et al.

• A Silent Sorrow: Pregnancy Loss - Guidance and Support for You and Your Family by Ingrid Kohn, et al

• Always Precious in Our Memory: Reflections After Miscarriage, Stillbirth or Neonatal Death by Kristen Johnson Ingram

Dedicated to Alex.