Any Medical Professionals about? Management of Miscarriage question

[MargaretGarlic]

I recently had surgical management of a miscarriage after expectant management failed. The operation itself went really well and relieved my pain, but I have been left with questions about what happened around the procedure rather than the surgery itself.

I think the NHS does an excellent job of explaining medical risks and safety but is much less clear about how patients' dignity and privacy are protected in practice. I have a severe phobia of surgery and loss of bodily autonomy, so not knowing the details has left me ruminating. I contacted PALS and the Subject Access team, but each referred me to the other and neither could answer questions about theatre practices. This didn’t really reassure me and I have fed back to them this is a gap for patients.

What I would really like to understand is how dignity is maintained during this type of procedure, and I can't find any specific guidance or information on this. For example, how and when are the gown and disposable underwear removed, how is the patient positioned and draped, who is present at that stage, who would actually be at the operating end, and how much movement of staff in and out of theatre is typical? Who could have seen what? In fact, I don’t know if/ when the gown was removed or if it would have been folded up and my chest left covered.

Before anyone replies, I know the likely responses – I want answers to my actual questions!

• "They're all professionals." I know they are, but that doesn't address my phobia or answer my questions.
• "They've seen it all before." They haven't seen my body before. I find this response dismissive and lacking in empathy because it overlooks the fact that many people find exposure deeply distressing for a variety of reasons. Staff being comfortable with seeing nudity isn't the same as a patient feeling their dignity has been protected. I hope doctors and nurses don't respond like this to people too often but it does happen and leaves you feeling worse!
• "What do you think happened, it’s a room full of people?" Rationally, I think everyone behaved professionally and simply carried out the operation. But for me, understanding exactly how privacy and dignity are maintained is an important part of processing what happened. Knowing the practical details would help reduce the uncertainty that my mind keeps filling in.

I’ll add in comments with my experience of the natural management and surgical management of miscarriage too. I think I read every Mumsnet thread on this, and I hope my experiences and reflections will be helpful.

Thank you in advance to anyone who can help me!

Natural Management of Miscarriage (Warning: Graphic details.)
I was around 8 weeks pregnant when I miscarried, although an earlier scan showed the baby was measuring smaller. This may have affected my experience.

The miscarriage began with light spotting, which gradually progressed over three days to period-like bleeding. At first, the pain was manageable, but as I got closer to passing the pregnancy tissue it became extremely severe.

The NHS describes natural miscarriage as being like a heavy period, but I found this to be a significant understatement. The bleeding was far heavier than any period I have experienced, although it never reached the threshold (soaking two pads an hour) that would require emergency assessment. The pain felt much more like early labour, which makes sense because the uterus contracts and the cervix dilates to pass the pregnancy tissue – up to about 3cm in my case.

For me, paracetamol, ibuprofen and a heat pad were nowhere near enough. I was eventually prescribed tramadol, which helped more, but I wish I had been warned how intense the pain could be. NHS guidance says pain is considered severe if you cannot concentrate on a book or television programme. I didn’t find this a helpful way to understand how much pain was considered too much and ended up pushing through and experiencing more pain than I needed to. If you are trapped in the bathroom/ bed/ on the sofa because of the pain and/ or standard pain relief isn't helping, seek further medical advice rather than trying to push through it.

When I passed the gestational sac, it came out intact and was much larger than I expected - roughly the size of the palm of my hand. I couldn't identify what would have been the baby, which I found easier emotionally. It appeared as a large mass of red/ pink/ grey tissue accompanied by many blood clots. Once it passed, the pain reduced almost immediately. Around six hours later I experienced another episode of severe pain and passed another large piece of tissue, about four inches long. I assumed this was the remaining pregnancy tissue and thought the miscarriage was complete.

Over the following week, however, I continued to have agonising, contraction-like pain. At times I could actually feel tissue pressing against my cervix. The Early Pregnancy Unit diagnosed retained tissue. Although my body was contracting and my cervix was dilating as expected, the remaining tissue and clots were becoming trapped rather than passing naturally. Because of the ongoing pain, medical management with misoprostol was unlikely to help, so I was advised to have surgical management instead.

What I wish I'd known

• The pain can be much worse than advised. If you choose expectant management, consider asking whether stronger pain relief than over the counter tablets would be appropriate before the bleeding begins. I would say this is the worst pain I have ever experienced in my life and it is disappointing that this element was so underplayed.
• Heavy bleeding can still be normal. Seeing so much blood is frightening. I found it much heavier than my normally heavy periods. I would recommend using standard ‘normal absorbency’ sanitary pads during the day rather than period underwear or extra-heavy pads (unless you're leaving the house), as this makes it easier to monitor your bleeding against NHS guidance. If you are soaking more than two pads an hour, seek urgent medical advice. If you have passed significant amounts of tissue but bleeding has not decreased, seek advice as well. You can still expect to bleed for a few weeks but the really heavy bleeding should drop off after the passage of the main bits of tissue, and if it doesn't this is a concern to get checked.
• The pregnancy tissue may be larger than you expect. Mine passed in one piece over several minutes. It was jelly-like but also quite solid, with red, pink and grey tissue. Everyone's experience is different, and it may not happen this way. If you wish, you can keep the pregnancy tissue and ask the EPU about options for respectful disposal or burial. I chose to flush it away but appreciate that others may feel differently.
• Persistent contraction-like pain after passing tissue isn't normal. If days later you are still having severe wave-like pain, you may have retained tissue. This is common and medical assessment is needed. Don't try to remove tissue yourself, even if it seems to be protruding, as it may still be attached to the uterus and attempting to pull it away could cause severe bleeding. However, milder cramping (more like period cramps) is normal as your uterus needs to shrink back down.

Sorry about your loss. I work in theatres. You would have been covered at all times apart from when the surgeon was performing the procedure. Your gown would have stayed on and underwear would have been removed when you were positioned into the stirrups but we would have used an inco to keep you covered until the surgeon needed to clean and put the drapes on. The same at the end. As soon as the surgeon is finished we cover you to maintain dignity.

With regards to people, the anaesthetic team are always at your head end. There will be a scrub practitioner and the surgeon in the surgical field and usually 2 to 3 circulators and we are down the operating end. Movement is usually just the theatre team only.

We are your advocates in theatre and will do all we can to maintain privacy and dignity as much as we can and keep patients covered as much as possible. Honestly we treat people how we would like to be treated. I hope this helps you.

firstly I’m sorry for your loss. I hope you’re doing ok.

When I was a student midwife I saw a surgical management of miscarriage in theatre.

iirc the people in theatre were two doctors, an anaesthetist and their assistant. A nurse and myself. The anaesthetist and assistant stayed at the head end. There were drapes placed over the woman’s abdomen which extended to the top of her vulva. Her gown was left on so breasts were covered. The woman’s legs were in stirrups.

The two doctors would have seen everything for sure. The nurse was more focused on paperwork once the woman was asleep and I stayed with her and from where I was i couldn’t see anything. I didn’t feel the need to go and look as ultimately i wasn’t learning how to do the actual procedure. There might have been a scrub nurse assisting as well, it was a while ago so can’t quite remember. Nobody else came in or out of theatre.

From other procedures I’ve seen in theatre there is a big effort to make sure dignity is maintained as much as possible even when patients are asleep.

Surgical Management of Miscarriage (My Experience)
You can have surgical management under either local or general anaesthetic. My preference, for many reasons, was local, but my hospital couldn't offer it quickly because it required two consultants - one to perform the procedure and one to scan at the same time to confirm all the tissue had been removed. Because I was in such extreme pain, I opted for a general anaesthetic instead. As you can probably tell, I still find that decision difficult because of my phobia, but despite that I would recommend surgical management over expectant management purely because the pain was so much less and recovery has been so fast.

If you want to understand the procedure itself, I found the Medscape article Dilation and Curettage with Suction very helpful.

I hope that this is helpful to anyone else in the very sad situation of needing help with their miscarriage.

Before the operation
Once I chose surgery, the Early Pregnancy Unit booked me in. They took my height, weight and bloods. The blood tests are to confirm your blood group in case blood products are needed, while your height and weight help the anaesthetist calculate the correct medication.
I explained how frightened I was, and the nurses were incredibly kind. They talked me through the process and were compassionate about both my anxiety and the loss of my pregnancy.
I was given a pre-operative leaflet, although it was quite high-level and didn't answer the practical questions I had. I was also asked what I wanted to happen to the pregnancy tissue removed during surgery. You can usually choose hospital cremation, arrange your own funeral or burial, or take the remains home, depending on your hospital's policies.

On the day
I had to stop eating and drinking from 6am, although I drank plenty beforehand. You will usually be asked to remove jewellery and any piercings that can be removed (others can normally be taped), along with nail varnish or gel polish. This it allows staff to accurately monitor your oxygen levels and spot changes in circulation e.g., if your nail beds start turning blue.
You'll also need someone to take you home afterwards and stay with you for the next 24–48 hours so get a partner/ friend/ parent – a taxi driver cannot be that person for you.

The Day Surgery Unit
At my hospital, the Day Surgery Unit wasn't exclusively for miscarriage management that morning. There were patients having lots of different procedures, including many men. Looking back this seems obvious, but I wasn't expecting it, so if this would upset you it may be worth asking your hospital beforehand.
I was visibly terrified, and I think that actually helped because the staff immediately recognised I needed extra reassurance. I'd really encourage anyone feeling frightened to say so rather than push through - people were much more supportive because they understood how anxious I was.
My husband was also allowed to stay with me until I went to the anaesthetic room, despite the usual preference for companions not to wait. If having someone with you is important, it's worth asking.
The nurses checked my blood pressure, pulse, oxygen levels, height and weight again. I met both the surgeon and the anaesthetist, who explained their roles and what would happen during the operation.
One useful thing I discovered was that my hospital followed the newer "Sip Till Send" guidance, meaning I could continue taking small sips of water until I was called to theatre, even though the written leaflet hadn't been updated. If you're likely to have a long wait, especially in hot weather, I'd recommend asking whether your hospital does the same as it will massively improve your comfort levels.
Throughout the morning there were constant checks, conversations and paperwork, so I never felt I was simply sitting waiting. I was also given an identity wristband.
The waiting rooms had patients and their companions in, so I did feel quite upset being around so many people when I was so distressed. Once all patients had been checked in, the nurses did put me in one of the side rooms given how upset I was and I really appreciated this.

Getting ready
Shortly before theatre I changed into an open-backed gown and disposable mesh underwear with a maternity pad. I was offered a second gown to cover my back, although I'd brought my own dressing gown.
I was measured for compression stockings, which help reduce the risk of blood clots during and after surgery. I also brought slippers to wear.
I wasn't allowed to keep on my soft, non-wired bra. The explanation actually reassured me: when you're unconscious, even something small pressing against your skin can cause pressure injuries because you can't adjust your position. Sports bras can also be difficult to remove quickly in an emergency. This is why you might be asked to stay naked under the gown.
I was pleased by how much attention the nurses paid to privacy. They held blankets up while I removed my dressing gown and got onto the theatre trolley so I wasn't unnecessarily exposed, although the male porter could have turned away for example. A real issue was that patients were asked to get on the trolley in a through corridor, so the nurses tried to manage this by stopping people outside the doors as a patient was prepared.
I was transferred to theatre on the trolley, although I've since read RCOG guidance suggesting patients can sometimes walk to the anaesthetic room if they prefer. Given the choice again, I think I'd have preferred to walk.

The anaesthetic room
This was the hardest part for me because of my phobia.
My husband stayed until I went to sleep, which I really appreciated.
The anaesthetist talked me through everything. A cannula was placed in my hand, and I was allowed to hold the oxygen mask myself rather than someone else holding it over my face.
The male anaesthetic assistant placed the ECG stickers on my chest and ribs, saying, "I'll just put these on." Personally, I would have found "Is it OK if I put these on now?" much easier. It was a small difference, but when you're feeling vulnerable it matters, and makes you feel less like ‘a body’ that they are interacting with.
The scrub nurse introduced herself, and the theatre assistant completed the final identity checks by confirming my name, date of birth, operation and consent form. This is an important safety check to make sure the right patient is having the right procedure.

Waking up
The general anaesthetic itself was incredibly strange. One moment I was talking, and the next I woke up in recovery with a nurse chatting to me. I had absolutely no awareness that any time had passed.
I woke up covered by blankets, which reassured me that I hadn't been left exposed while being transferred.
I did know beforehand that the disposable underwear would have been removed during surgery, but I still found waking without it upsetting. I was lying on a pad instead. Before checking my bleeding, the recovery nurse pulled the curtains completely around my bed. She also helped me change into a clean gown after I had a little blood from the breathing tube and removed the sticky residue left by the ECG pads.
Recovery staff continuously monitor your observations, but they also chat to you because they're assessing how awake and alert you are. It's apparently quite common to drift in and out of sleep several times before you're fully awake.
I was back on the ward after about 20 minutes.

Going home
Back on the ward I was given tea and biscuits. Before discharge I had to eat, drink and have a wee, after which I got dressed. The nurses closed the curtains but stayed nearby in case I felt unsteady.
After another set of observations and removal of my cannula, the surgeon came to see me. She confirmed everything had gone well, explained what had been removed and talked through my recovery.
Unfortunately, I was still far too groggy to ask the questions I really wanted answered about dignity and privacy in theatre.

Recovery
I was very lucky and my recovery was quick. I had no pain afterwards apart from mild cramping. My bleeding was light spotting which stopped after four days, and my pregnancy test was negative within a week, although my earlier natural miscarriage probably contributed to that.
My throat hurt more than anything else because of bruising from the breathing tube. Chloraseptic spray helped a lot and it might be worth having some throat lozenges at home too.

Things I wish I'd known

• If privacy and dignity are important to you, ask about them beforehand. That remains my biggest unanswered question, and staff should be happy to explain how these things are managed. I do think it is a shame that it’s expected people are just ‘content’ this is looked after and, especially with intimate procedures such as this, women may have very good reasons for finding it traumatising or violating even if the surgery is medically necessary. It is also unfortunate that this information isn’t given out as standard.
• Don't be surprised if the Day Surgery Unit includes patients having many different operations.
• Ask whether your hospital uses "Sip Till Send", especially if you'll be waiting a long time.
• If you need support or are frightened, make this clear. The staff were very kind and compassionate and did their best to try and reassure me.
• If you're frightened, ask staff to slow down, explain what they're doing and ask before touching you. I wish I'd felt able to do this.
• Waking up after a general anaesthetic is a very odd experience because you have no sense that time has passed and. it is very disorienting when you wake up in a different room. It doesn’t feel like waking up either, it does feel like you have time travelled.
• Do ask about pain relief during the operation or after. I think some hospitals give a pain relief suppository although mine didn’t – but I would have felt very violated if this had happened because I didn’t give consent.
• If you'll need a sick note, ask before your operation so it can be arranged while you're in hospital.
• Losing a pregnancy is very upsetting. It can take a while for the feelings to sink in, especially if you’re coping with getting through the physical side of miscarrying or having an operation. It’s completely normal and reach out for support if you feel you can.

Thank you @DaveMinion and @JulietteHasAGun this is helpful to know! I wish I had had more of a discussion about it beforehand with the people doing my surgery, but it is comforting to know that there are very clear expectations for the staff about how dignity is protected and that you have both seen this in action.

I'm an anaesthetist, have been involved in probably hundreds of SMOMs in my career by now. As has already been described, while theatre staff have "seen it all," we do still work to maintain patient's dignity as far as possible.

In answer to your questions:
How and when are the gown and disposable underwear removed?
We don't remove the gown. Underwear comes off once the patient has been transferred onto the operating table, before we put their legs up into stirrups.

How is the patient positioned and draped?
Once the anaesthetist is happy that the patient is stable, the patient is positioned in what we call "lithotomy position" - legs up in stirrups/boots, with the bottom end of the table removed, so the patient's bottom is at the end of the remaining table (if that makes sense?) This is done by two of the theatre staff - they have to move both legs at the same time to reduce the risk of injury to the patient. The gown is left covering the genitals until the surgeons are ready to prep and drape, at which point it's folded up onto the patient's stomach/chest. The surgeon then cleans the area and puts on sterile drapes - "boots" that cover the legs, one drape under the patient's bottom and one on their abdomen.

Who is present at that stage, who would actually be at the operating end, and how much movement of staff in and out of theatre is typical?
It varies slightly, but there will usually be something like: -

• 1-2 anaesthetists
• 1 anaesthetic assistant (nurse or ODP) - the anaesthetic team mostly stay up at the head end
• 1-2 surgeons
• 1 scrub nurse, who stands next to the surgeons with a trolley of equipment.
• 1 circulator (someone who is not scrubbed and sterile and can fetch additional equipment when needed).

A SMOM is generally a fairly minor operation that does not take very long, so there is not usually a lot of movement, people don't need relief for breaks, there's not a lot of specialised equipment to be fetched etc. Obviously if an emergency develops e.g. excessive bleeding, then more people will come in.
The operating table is positioned so that when the patient's legs are up, they are facing away from the doors through which most people come into theatre, so anyone coming in to e.g. ask me a question is not going to see anything.

Once the procedure is done, the surgeon and scrub nurse will clean the patient, remove the drapes, and then put the bottom of the table back on and put the patient's legs down. The gown is then pulled back down to cover them, and they are transferred back onto a trolley/bed to go to recovery, covered with sheets/blankets.

I hope that is helpful?

Thank you @SockQueen this is really thorough and I appreciate you taking the time to respond to me.