Miscarriage and Pregnancy Loss

Miscarriage is the loss of a pregnancy before 20 weeks, and pregnancy loss after 20 weeks can be a stillbirth or delivering a baby that doesn’t survive outside the womb. Miscarriage and pregnancy loss are common among all pregnant individuals, including pregnant women who use substances. Jail staff must be prepared for the medical and mental health needs of a pregnant patient who experiences miscarriage or pregnancy loss while in custody. 

Screenshot of pregnant women experiencing pregnancy distress
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Key Points

HOW

  • Jail medical staff and custody staff who oversee pregnant patients should be aware of the signs and symptoms of miscarriage and pregnancy loss. The most common signs of a miscarriage or pregnancy loss in the 1st and 2nd trimester include:
    • Bleeding from the vagina, either light or heavy
    • Cramping or severe abdominal pain
    • Passing tissue from the vagina
    • Gushing or leaking fluid from the vagina
    • Fever and racing heart rate
  • Take women seriously if they report decreased fetal movement and they are more than 24 weeks pregnant, as sometimes this be a sign of fetal compromise, that could end with a stillbirth.
    • They need an evaluation by a qualified provider and may require special fetal monitoring.
  • If someone is showing signs of a miscarriage or pregnancy loss, alert medical staff immediately so the patient can be evaluated by a qualified provider or transported offsite for medical evaluation.
  • People who remain in custody after a pregnancy loss have unique physical and mental health needs.
    • Provide patients with unrestricted access to menstrual pads for vaginal bleeding, showers, and toilets for hygienic needs.
    • Some patients will need pain medication.
    • Provide patients with qualified counseling and support to process emotions like grief, sadness, and guilt regarding pregnancy loss.
    • Patients should be seen for follow-up with a qualified provider within 1 week, or sooner if indicated.
  • Show compassion and support, and do not blame her for the pregnancy loss. Most miscarriages are caused by things out of the pregnant individual’s control. MOUD/MAT in pregnancy does not cause a miscarriage or pregnancy loss.
  • Continue MOUD after a miscarriage or pregnancy loss, though the dose may need to be adjusted.
  • Give women access to resources and pregnancy loss support groups.

WHY 

  • Miscarriage and pregnancy loss are common, including among people who use substances. About 1 in 10 pregnancies end in a miscarriage.
  • Some women may have a stillbirth, where the fetus dies while still in the womb. Or they may deliver a baby that then dies soon after birth. This can happen even for a full-term pregnancy and is very traumatic. It must be managed in a hospital setting.
  • Jails must be equipped to identify, triage, and care for patients who experience a pregnancy loss in custody.
  • Some people with miscarriage or pregnancy loss are bleeding heavily or may have a severe infection that requires emergency treatment at a hospital with a surgical procedure or medication.
    • If they don’t get timely care, this can lead to serious harm to the patient and even death.
    • Without timely treatment, some patients may pass the pregnancy on-site at the jail—which is not equipped to handle this. This can also be difficult for staff.
  • Losing a pregnancy is traumatic, and being in jail, away from your usual support, makes it even more traumatic. They need non-judgmental, qualified, supportive mental health care to help them process their emotional trauma.
  • People with OUD experiencing pregnancy loss may be at higher risk for relapse as a way to cope with their grief. Stopping their MOUD could make that even worse, so they should continue on their MOUD– but may need dose adjustments since the pregnancy has ended.

KEEP IN MIND 

  • ANY BLEEDING DURING PREGNANCY IS ALARMING AND SHOULD BE REPORTED TO MEDICAL IMMEDIATELY SO THAT THE PATIENT CAN BE EVALUATED BY A PROVIDER WHO IS QUALIFIED TO ASSESS PREGNANT PATIENTS.
    • If your jail does not have an onsite medical provider, the patient should be taken to the nearest hospital.
  • Women may not know they are experiencing a pregnancy loss. Take medical complaints and requests to see medical seriously. No one wants pregnancy loss to occur inside their jail.
  • In the first few days and weeks after someone has a miscarriage, jail staff should look out for these warning signs that the patient is unwell: bleeding through a pad every hour; fever; severe abdominal pain, and other signs of appearing “unwell.”
    • If they show any of these signs, they could have complications and need to see a qualified clinician (Ob/Gyn) immediately 
  • It takes time for an individual’s body and emotions to return to a pre-pregnancy state after a miscarriage. Be mindful of work and other requirements in custody.
  • Many women carry a lot of guilt and grief after a pregnancy loss. Show kindness and compassion. Saying “It’s not your fault” can go a long way.

Deeper Dive

HOW 

How can jail staff identify if someone is experiencing pregnancy loss while in custody?

  • Depending on the stage of pregnancy, pregnancy loss and miscarriage symptoms can vary. Common symptoms include light spotting, heavy bleeding, cramping, severe abdominal pain, passing tissue or fluid from the vagina, and fever. Vaginal bleeding (with or without pain) is the most common sign of miscarriage.
  • Sometimes, people who don’t even know they are pregnant may miscarry and may instead think they are getting their period.
  • Some women with pregnancy loss may have no symptoms at all, and it may be diagnosed by an ultrasound done by a professional.
  • For women who are over 24 weeks pregnant, they should be keeping track of their baby’s movements. If they notice that it has decreased compared to what it was the day before, this is concerning and can be a sign of a fetal compromise, which in some cases leads to a stillbirth. Patients reporting decreased fetal movement should see a qualified provider who can do fetal monitoring, which usually happens in a hospital.

ANY BLEEDING IN PREGNANCY should be evaluated immediately by a qualified provider (e.g. obstetrician, family physician, certified nurse midwife).

If you are worried a pregnant woman with bleeding or other labor signs needs to be transported offsite, but a colleague disagrees, go up the chain of command. No one wants a baby, especially a preterm baby, born at their facility!

What should jail staff do if someone has signs or symptoms of a pregnancy loss in custody?  

  • Someone who may be experiencing a pregnancy loss needs immediate medical evaluation by a qualified provider, usually an obstetrician gynecologist (Ob/Gyn). The Ob/Gyn may do several tests to diagnose a pregnancy loss, such as a pelvic exam, ultrasound, or a blood test to measure pregnancy hormone levels.
  • If a miscarriage or pregnancy loss is diagnosed, the Ob/Gyn and the patient will determine what kind of treatment is needed, depending on the patient’s condition. This may require a surgical procedure, medications, or an overnight hospital stay.

What physical health care needs do patients who experienced pregnancy loss have?

  • It’s important that jails are prepared to take care of pregnancy loss patients and that they follow the instructions from the Ob/Gyn.
    • Some patients with pregnancy loss may be managed with medication to help them complete the passing of the pregnancy. This may temporarily cause heavy bleeding. Follow instructions and guidance from the Ob/Gyn for warning signs.
  • Patients should expect to experience abdominal discomfort, but not severe pain, and some light to moderate vaginal bleeding for about 1-2 weeks.
  • Pregnancy loss patients will need unrestricted access to menstrual pads for bleeding, showers and toilets for hygienic needs, and may need pain medication.
  • Patients who have had a stillbirth or other pregnancy loss later in the pregnancy may experience lactation (milk production). This can be very distressing. They can get a one-time dose of a medication (cabergoline) to suppress lactation.
  • Complications can happen in the first few days and weeks after a pregnancy loss. Jail staff should contact the Ob/Gyn immediately if the patient experiences:
    • Heavy bleeding (soaking through more than one pad an hour)
    • Fever
    • Chills
    • Severe pain
    • Other symptoms of appearing “unwell“

What if the local hospital diagnoses someone with a miscarriage or pregnancy loss but sends the patient back to jail without providing treatment?

  • Some states have laws that restrict procedures and medications used for abortions. Those procedures and medications are also used to treat people having miscarriages and pregnancy loss. This has made things confusing for many doctors to know when they can provide emergency care to someone having a miscarriage or other pregnancy complications.
    • Complications of untreated miscarriage can include life-threatening hemorrhage, infection, septic shock, emergency hysterectomy (removal of the uterus that means no future pregnancies), and even death.
  • If a pregnant patient at your jail is showing signs of a miscarriage or other pregnancy loss, you should still transport them to the hospital for emergency care, even if you are unsure about what kinds of treatment your state law allows.
  • If the hospital sends a pregnant patient back to your facility without necessary treatment and she is unwell, sick, or getting worse, consider transporting the patient to another hospital, even if it is far away. You may want to consider consulting your legal team.

What mental health care needs do patients who experienced pregnancy loss have?

  • It is common for patients who experience pregnancy loss to experience emotions like grief, sadness, depression, loss and guilt. Patients should have access to counseling to process these feelings.
  • If possible, connect the patient to a support group so they can talk to others who have experienced the same thing. See Share: Pregnancy and Infant Loss Support.
  • Allow the patient to engage in a symbolic gesture that may help with remembrance. This could be keeping an ultrasound picture of the pregnancy, or sometimes the hospital can give them a memory box.
  • Jail mental health staff should be equipped to talk with patients about pregnancy loss or connect them to outside support and resources.
  • Staff should avoid saying things that seem well-meaning but can make them feel worse, like “at least you weren’t that far along,” “you can have another baby,” or “everything happens for a reason.” Instead, offer judgment-free words like “This must be hard,” and “It’s not your fault.”

WHY 

Why should jail staff be prepared to take care of patients who experience pregnancy loss while in custody?

  • Pregnancy loss affects 1 in 10 pregnancies. Jails will likely have a pregnant patient in custody who experiences a pregnancy loss.
  • Jails must be equipped to identify and care for a pregnant individual who experiences a pregnancy loss in custody because they may need life-saving treatment, depending on what stage of the pregnancy the loss occurred.
  • Any pregnant patient who experiences a pregnancy loss should be evaluated immediately by a qualified provider, usually an Ob/Gyn to determine and counsel patients on the appropriate treatment.
    • Expectant management – the remaining tissue from pregnancy will pass out of the body without medical intervention. Usually, this is associated with heavy bleeding and pain that eventually stops, but sometimes people need emergency intervention if it doesn’t stop.
    • Medical management – medications taken to cause the patient to pass the pregnancy. Usually, this is associated with heavy bleeding and pain that eventually stops, but sometimes people need emergency intervention if it doesn’t stop.   
    • Surgical management – a procedure (“D&C” or “D&E”) that removes the pregnancy tissue from the uterus.

Why do miscarriages or pregnancy losses occur?

  • Miscarriage is usually a random event. It is not the woman’s fault and is typically not because of something she did or didn’t do.
  • First-trimester miscarriages are most common and occur because the fetus doesn’t develop normally. There are many genetic reasons a fetus may not develop normally.
  • Some medical conditions, like poorly controlled diabetes, can cause miscarriages and pregnancy loss.
  • Opioid use in pregnancy does not directly cause miscarriage or stillbirth. However, some pregnant patients with OUD have other factors that increase their risk of miscarriage and stillbirth.
    • Other substance use is common among people with OUD. For example, tobacco use (i.e. cigarette smoking) has been clearly shown to increase the risk of stillbirth.
    • Poor nutrition, lack of access to prenatal care, and other negative environmental factors may increase these risks.
    • Opioid withdrawal (detox) in pregnancy increases fetal exposure to stress hormones, which may increase the risk of stillbirth and miscarriage.

Resources

  • Urgent Maternal Warning Signs – information on urgent maternal warning signs to look out for and includes 1-page flyers in 14 languages
  • National Maternal Mental Health Hotline – Access to the national maternal health hotline used to answer questions before, during, and after pregnancy. They also can connect you to resources. 
  • Early Pregnancy Loss – FAQS from the American Colleges of Obstetrics and Gynecologists
  • Share Pregnancy and Infant Loss Support– National support group for people who have had a pregnancy loss- in person and by Zoom.  They also have printable education materials for patients and can send a “comfort kit.”