After the loss
Aim to provide information sensitively about examinations and tests which may be recommended or can be offered, and about options for certification, cremation and burial.
Women and partners tell us they didn’t always understand the benefits and limitations of the examinations and tests. They were not always given the option of certification and the explanation of cremation and burial was not always clear and objective or given at a time and in a format that was right for them.
What do we need to do?
Histology and post mortem
- Remember to keep within the scope of your practice when providing information, explaining procedures or answering questions. Be prepared to consult with or refer to suitably trained colleagues whenever necessary.
- Ensure that all discussions take place in a quiet, private place.
- If histological examination of pregnancy remains or the placenta is recommended, ensure the woman and partner understand why and also the limitations of the examination.
- If seeking consent for histological examination, aim to do so when obtaining consent for surgical management.
- Ensure that the woman and partner understand ‘fetal karyotyping’ or other investigations if being offered.
- Offer to explain options for cremation and burial of pregnancy remains.
- Ensure staff discussing post mortem examination with the woman and partner are trained to do so and are fully aware of the protocol for offering a full or limited post mortem and know how to complete the form.
- Allow sufficient time for discussing post mortem and gaining authorisation if appropriate.
- During the authorisation process, inform the woman and partner of the likely timescales for the return of their baby and how and when the results will be communicated and be as realistic as possible about these.
- Inform the woman and partner if the post mortem examination will take place at a different hospital and explain where and why.
- Explain that all transport arrangements and handling of the baby will be respectful and caring and who will be responsible for this. Identify a named pathology or maternity contact who will be responsible for following up on the results.
- Make sure anatomical pathology technicians and/ or pathologists are aware of any specific cultural or religious requirements or special requests from the family.
- Ensure any small objects or keepsakes such as a hat or cuddly toy that accompany the baby are returned following the investigation.
- Provide information about cremation and burial (see below).
- Offer to provide a ‘certificate of loss’, a template certificate is available.
- If the miscarriage occurred at home, refer to the Miscarriage Association's guidance for miscarriages that occur at home.
- If a baby was born after 24 weeks’ gestation but it is known or can be proven that the baby died before 24 weeks, the death cannot be recorded or registered as a stillbirth.
Cremation, burials and funerals
- Advise that a minimum standard by a hospital for sensitive disposal of pregnancy loss under 24 weeks is shared cremation. Individual cremation or burial may also be considered. The individual may also make private arrangements outwith the hospital, including burial at home.
- Advise that signed authorisation is required before the hospital can sensitively dispose of the pregnancy loss.
- Provide the woman and partner with written information about these options, including information about the recovery of ashes, but recognise that some women and partners will not want to read or discuss it or to make a decision. In this situation they may authorise someone else to make the decision or authorise the hospital to arrange for shared cremation.
- If the woman and partner do not want the information, explain that they can get back in touch if they change their minds (and provide the time frame for doing so).
- Verbal and/or written information should include:
- choices they have if they want the hospital to make arrangements and the costs, if any
- choices they have if they want to manage the arrangements, including burial at home and information on local funeral directors if available
- time frame for making and communicating that decision
- hospital process if they do not make or communicate that decision within that time frame.
- Bear in mind and facilitate where possible different personal, religious and cultural needs and do not make assumptions.
- Discuss the options for urgent burial and cremation where appropriate.
- Inform the woman and partner about the spiritual care/chaplaincy team as a source of additional support or advice.
- Record all decisions made by the woman in her medical records, including where information is declined, or no decision is made.
- See also Scottish Government guidance on the sensitive disposal of pregnancy losses up to and including 23 weeks and 6 days gestation and Miscarriage Association's guide Talking about sensitive disposal and RCN guidance on managing disposal of remains.
How will we know we have achieved our aim?
Women and partners will tell us this information was sensitively and clearly given, at a time and in a format (written or verbal) that was right for them.
Staff will say they feel confident and competent in providing information clearly, sensitively and able to do so at an appropriate time and in a suitable format.