Expectant management of a miscarriage is also known as the “watch and wait” choice and is often referred to as a “natural miscarriage.” You may wait a few days or you may wait a few weeks from the time you learn your baby has died. Most women will deliver within two weeks. Also, once the active miscarriage starts, it may start slowly and progress over a few days or it may be over in a matter of a few hours. The length of time does not correspond to the length of the pregnancy. Especially in the first trimester, this is a reasonable option for most women. While you are waiting you may be asked to go into your doctor or midwife’s office for vital sign checks or lab work. If you start to feel ill during this time you need to call your practitioner immediately. (See When to Seek Medical Attention below.) If, after several weeks, you have still not delivered you will need to talk to your practitioner and review your options because your risks of infection and blood clots have increased.
Preparation:
- very large sanitary pads and a decent number of them
- a container to put the baby in, preferably ready with water or saline
- at least one old towel
- scissors (just in case)
- something to drink
- cold washcloth (for you)
- (optional) strainer to use while on the toilet
- (optional) absorbent underpads (chux)
Chux are recommended because there will be a lot of blood as well as sizeable blood clots, and the chux have a waterproof backing which makes disposing of them easier.
*Note: Although it is perfectly possible to undergo a natural miscarriage on your own, if you are more than a few weeks along it is advisable to have someone else in the house with you, if not in the same room. At best you will have moral support and at least you will have someone to call on in an emergency. If it is unavoidable that you are alone, have a phone within reach in case of emergency.
Signs of impending miscarriage:
- Cramping, period cramps or harder, sometimes approximating labor pains
- Spotting – will probably start brownish and then turn red
- Sometimes an upset stomach
Sometimes you will simply be surprised. If this happens it is at least likely to be quick. If you notice any signs of spotting or just ‘have a feeling’ it’s coming, go ahead and assemble your supplies and if you are alone, call someone to be with you. When the bleeding starts in earnest, it is very likely to be sudden and dramatic.
Managing the actual miscarriage:
**WARNING: Possibly graphic content. Everyone’s miscarriage will be different and we want to encompass most experiences.**
If you have been waiting for a while to miscarry, as in the case of a missed miscarriage, then you may be relieved to have the process finally starting. You may also be overwhelmed with grief or panic. Keep in mind that women have been miscarrying at home for thousands of years. This is where having a support person can be very helpful. Take a deep breath and say a prayer. If it helps, place an icon or crucifix where you can see it.
On dry land:
If you are most comfortable on your bed or the floor, then you will be very, very glad that you have chux available. It is a good idea to put down a layer of four or more chux so that one can be removed easily and another one waiting. There is no scripted position. Sit, crouch, kneel, whatever. The position that makes you the most comfortable is likely to change throughout. Do whatever feels better. Do be in a position that you have something to lean back against if you need to. This can be another person. You may feel faint at some point and need the support.
In water:
Most women find warm water eases the pain associated with cramps and the water helps support your weight so positions are easier to hold. The water may be psychologically helpful because after a very few minutes the water is mostly opaque and you cannot immediately see anything you’re not ready to see. The bathtub also provides a natural backrest and handholds. Changing positions when in the tub is the same as on dry land. When you are done delivering everything you can clean up right in the tub instead of transferring. Place a few chux on the floor next to the tub so you can keep everything tidy when you get out (and to provide a place to put things if necessary).
On the toilet:
Some women find this position to be most comfortable. It is recommended to have a strainer in place so you don’t have to retrieve the baby from the toilet; this can be emotionally painful. The advantage is that you can flush the clots rather than having to dispose of them otherwise. Do not flush the placenta unless it is fairly small. If you start to feel faint while on the toilet, then quickly move to the bathroom floor. Better that than to fall. Place a chux or two on the floor under your feet.
Regardless of your position:
Often there is a sudden rush of blood before you pass the amniotic sac containing your baby. You may pass several clots first. After delivering the baby feel free to “stop” and hold him or her. If he is in the sac, carefully open it up. Having wet hands helps hold the baby because of his or her fragile skin. Take some time to hold and talk to your baby, if you feel comfortable with that. You are not in any hurry. When you are ready, place him or her in the container so you can finish passing everything. It may happen that when you deliver the sac you notice the cord is still attached. Don’t pull on it; go ahead and cut it.
Between the time you deliver the baby and the placenta you are likely to pass several clots and a lot of blood. A word about the blood: Just as you don’t panic when you have a very heavy period, do not panic now. This blood is mostly endometrial lining sloughing off and not directly out of your blood vessels. As the placenta detaches you will have some “active” bleeding as well, discussed in the next paragraph. The clots are not tissue, they are just that – clots. Whenever blood sits for any time it clots. This is what it is doing inside you. Some will be large, the size of your palm. The blood will be a steady trickle with occasional gushes (as a clot is moved out of the way). If there is a problem later and you need to tell someone how much blood you passed, you will be able to mention the number of chux used. (This is the one disadvantage of an in-water miscarriage.)
The placenta may come out rather quickly or not. You do not want this to take a long time – say, not much more than an hour. The uterus will not stop bleeding until it is able to tightly clamp down (remember, it’s like a big muscle) and it cannot do that if anything is still inside. Thus, you will continue to bleed and pass clots until the placenta is delivered. If it feels like it’s been a while, you can do something very simple to encourage it to come out. (Do NOT pull on the cord. It won’t work at best and at worst you can cause damage.) You have probably already been able to feel your fundus, the top of the uterus. Find it now and massage it very firmly. Don’t punch yourself, but rub slowly and deeply until you feel strong cramps beginning. Continue to massage for another minute or so to make sure the cramps will continue. The cramps are the uterus contracting to try to expel the placenta. Go by how you feel here, but after a few minutes try bearing down. Do this a few times. If the cramping subsides, massage your fundus some more. This is almost certain to result in the delivery of the placenta in under ten minutes. If more than an hour has gone by, you are still bleeding copiously, and there is no sign of the placenta, consider getting medical assistance. Sometimes placentas are embedded very deeply in the uterine wall and are difficult to expel. (More about when to call for help below.)
When the placenta is delivered, if it is intact you will hopefully find it unmistakable. The maternal side (the side that was against the uterine wall) will look like raw hamburger. The baby’s side will be covered with a shiny “skin” and will look more purplish. Blood vessels will be seen leading toward the umbilical cord in the center. Put the placenta on a chux and have a good look at it. It should be round to ovalish in shape and will vary in size with the length of the pregnancy. There should not appear to be pieces missing from the edge (which would lead one to believe part of the placenta is still in place). If you are not sure what you are looking at, or if the placenta is complete or not, don’t hesitate to put the placenta in a watertight container to take to the doctor. If the placenta does not appear to be complete and if you have not delivered all the pieces, then you will need to seek medical attention. A D&C may have to be done to remove the remaining part(s). Alternately, your placenta may deliver completely but in pieces. You can tell the placenta from the clots because the clots are easily broken up. The placenta will feel more fibrous.
After the placenta is delivered you will still pass some more blood, probably a gush behind the placenta, and possibly some more clots. This should decrease quickly after the placenta is out. The cramping and pain should decrease significantly at this point too. If you are taking something over the counter for pain, take acetaminophen rather than ibuprofen because the latter can increase bleeding. Depending on how long it has been since the baby died, you may see something different in terms of the sac. Usually the amount of amniotic fluid decreases over time so depending on how much there was to start with, you may or may not see a nice, full “bubble.” Also, the uterus will form a clot around the sac/baby as time goes on. This means that you may deliver the baby in the sac very obviously, or you may deliver a sac with a clot attached, or you may deliver what appears to be a large clot or placenta but which is actually the sac enclosed in a clot. Especially if you feel as though you are completing the miscarriage but haven’t seen the sac, check inside the large clots. This might sound crude, but it will feel a little different when you are looking for your baby. The clot will be on the sac, not the baby (all things being equal) so you will still be able to remove the baby from the sac if you so desire.
Afterward:
When you are ready, clean up using cool (not cold, unless you want to) water. Warm to hot water will make the blood harder to remove. Put on a pad and lie down. If you have not been sipping all along, drink a full glass of something at this point. You will have lost fluid volume and need to replace it. Do not take this opportunity to clean the entire bathroom. If you do, you could wind up passing out.
At some point we recommend you take photographs of the baby. If you simply can’t do this, have someone else do it. Even if you don’t want to see the pictures now, you will probably want to see them later and it will be nice to have them. Take lots. Take photographs of details. Put wedding rings or something next to the baby for scale. You need never share these photos, but you may wind up treasuring them yourself. After taking photographs, place the container containing the baby in the refrigerator. This slows decomposition.
Recovery:
After you miscarry, call your doctor. They will almost certainly want to see you for a follow-up ultrasound (to see if the uterus is empty) or an exam. Expect to bleed for about two weeks. The pattern may be stop and start. Eventually the discharge will change from red to brown to tan. If the bright red bleeding persists after this, check with your doctor. There may have been something retained in the uterus that was not previously detected. Use pads, not tampons. Do not insert anything into the vagina until you have stopped bleeding. Do not do any heavy labor, strenuous exercise, etc., during the first several days at least. Get extra rest. Make sure you drink enough fluids. Take a few days off from work. Even if you have a desk job, you will probably not feel up to facing anyone yet.
One thing that people are not told to expect is some depression. Obviously, there is the grief from losing your baby, but there are other factors at play. When you deliver, whether at 8 weeks or 40, the hormones that have been very high during pregnancy drop precipitously. This is usually referred to as “the baby blues” or, if more severe or persistent, “postpartum depression.” What most people are not aware of is that women who miscarry are at as least as much at risk for postpartum depression as women who deliver live babies and usually more. If you have delivered a living baby you will be distracted by the care of a newborn and you will be surrounded by balloons and flowers and congratulations. After a miscarriage you not only do not have these, but you have the added grief of pregnancy loss. Do not hesitate to get help if this is becoming a problem. Pills will not make grief go away, but you may need some support for the physical causes of depression.
When to seek medical attention:
- Fever over 100 degrees F
- Severe abdominal pain or pain that is increasing (except the normal increasing of cramps until the baby is delivered)
- Nausea and vomiting (some women experience this during the actual miscarriage – that’s ok)
- Difficulty urinating
- Foul-smelling vaginal discharge
- Bleeding that saturates a pad an hour for more than a few hours straight after everything is expelled.
- If you think you did not expel everything from the uterus or if the placenta appears to be incomplete.
Something very important to consider is what to do with your baby after you deliver. We strongly recommend that you do not take the baby to the doctor’s office or hospital. If you are planning to take the baby with you, call before you go (unless it is a genuine emergency) and inform the staff that you will be bringing the baby but no one is permitted to touch him or her and he or she will remain in your custody. The reason is this: it has come to light that once the hospital takes possession, even for a moment, of your baby, they may refuse to give him or her back. They may insist on testing. There is no reason for them to do this unless you yourself wish to have testing performed. If you deliver in the hospital, you will automatically be up against this. Hospital disposal of babies varies with location but may include: cremation with medical waste before transport to a landfill, cremation with other babies with eventual burial (non-public location) and flushing into the sewer system. Babies under 20 weeks may be classified as medical waste or biohazard waste. This varies by state and by hospital. This is a hard truth, but it is better to know what you may be facing. People are working to change this.
If you want to reassure the medical personnel, bring photographs (on your digital camera or phone) that you have taken of the baby. When Matushka A. went to the doctor’s office for an exam and ultrasound the day after she delivered Innocent, she brought photographs of him. Not only were they able to see that she had indeed delivered a baby, but they were amazed at his beauty and detail. You can help change the medieval culture surrounding miscarriage.