Miscarriages are very common in pregnant people with a staggering statistic that 1 in 4 pregnancies will end in a miscarriage. Miscarriages come with a spectrum of emotional, and physical symptoms as well as social context. My question that I propose here, is how do we care and have resources for those who are possibly in a rural first aid setting, or at an event where a hospital is far? In this article I break down what is normal, what are red flags, pain relief options, hospital options as well as medication that can be used to expel a pregnancy or be used for miscarriage management.
What is a miscarriage? Miscarriages also known as spontaneous abortions, happen in around 25% of pregnancies in the first trimester (before 13 weeks). There are many different kinds of Miscarriages, but here we are focusing on first trimester miscarriages. Some basic terminology that is useful to know.
“missed abortion” or “missed miscarriage” is when the pregnancy stops developing but the body doesn’t expel the tissue. This is seen mostly when a person goes to get a dating sonogram and there is no heartbeat. The person may think they are ten weeks but the fetus dates younger like 7 weeks. This is because the fetus stopped growing at 7 weeks without the person knowing. There can be brown discharge, but a lot of the time there are no symptoms. There are a few reasons, and sub categories within a missed miscarriage, but for the sake of simplicity we will just cover the broad term “missed miscarriage”.
Threatened miscarriage– when the body is starting to show signs they might miscarry they may experience-abdominal pain, light bleeding, but the cervix is closed. There are two outcomes usually. They either continue to carry the pregnancy with no issues, or miscarry. Unfortunately there aren’t a lot that anyone can really do (herbs are a possibility but require experience). However it isn’t uncommon for people to spot, during the early days of pregnancy.
An ectopic pregnancy is when a pregnancy grows outside of the uterus. This can be life threatening and usually isnt caught until it ruptures and the person needs emergency surgery to remove the tissue. If someone is dealing with an ectopic pregnancy then seeking medical care is important. The management for ectopic pregnancies is surgery or an injection of Methotrexate and someone to monitor blood HCG levels. Unfortunately the symptoms of an ectopic pregnancy are tricky because they range from a missed period and being asymptomatic, to painful stabbing pain in the stomach, or side, and flu like symptoms.
Incomplete miscarriage– some pregnancy tissue can remain in the uterus and could cause infection like sepsis and needs to addressed. Vaginal bleeding and lower abdominal cramping would continue to try and expel the tissue from the uterus. Please read the red flags below so that you’re informed on when to seek medical treatment.
Complete miscarriage– vaginal bleeding for several days, the uterus empties fully, cramping and labor like pain is common, it is still advised to check in with a medical provider to confirm the miscarriage is complete. However some people may not feel safe going to a medical provider, and this is up to the individual.
Three common ways to manage a miscarriage and their pros and cons. These are all variable depending on gestational age.
Watch and wait– This is one of the most common responses to miscarriages, and in 90% of cases the body will naturally expel the pregnancy. However this can sometimes take weeks, and some people are uncomfortable with waiting. Pros- people feel like this is more natural and the body will do what it needs to do. They can have privacy in their own home, and it is not clinic based. This is also accessible for people who can’t get to a clinic. Cons-waiting for the pregnancy to expel, No health care providers guiding or helping along the way.
Medication– medication that is explained below is given to people to expel the pregnancy. The pro to this is no waiting, medication usually takes effect in a few hours, they can still be at home and have privacy. Cons- sonogram sometimes vaginally, side effects from the medication like prolonged bleeding, nausea, diarrhea, and possible fever. (fever when you first take miso, or mif, is common, however long lasting fevers over 24hrs is not)
Suction/ vaccum aspiration– A in clinic procedure. pros- fast procedure, sometimes less bleeding, healthcare providers with you. Cons-acessibilty, insurance issues, either sonogram or vaginal sonogram which is uncomfortable and triggering for some folks. Sometimes sedation is used. Sedation can be looked at as a pro for some and a con for others. People with a history of sexual abuse might be triggered by being sedated while providers do an invasive procedure.
There are different medications that are used for miscarriages. Perhaps in your first aid setting, someone took them beforehand, took them while they were at the event your working, or they could’ve had a d&c to empty the uterus, or it could’ve been a spontaneous abortion, and they are just now realizing they are having a miscarriage. These situations are all different with slightly different management. Let’s talk about three different common medications that are used to manage a miscarriage, that can also be sourced by the person if they desire to not use a clinic to manage their miscarriage.
Mifepristone
Mifepristone is a really safe, well studied pill that is used to halt progesterone. In abortion care it is usually the first pill that is given before taking Misoprostol. Mifepristone ENDS the pregnancy because it is anti-progesterone, it softens the cervix, and helps slough off endometrial tissue. This is why its used in miscarriage management as well.
Misoprostol-The second step for managing a miscarriage or abortion is misoprostol. Misoprostol is a prostaglandin analogue that binds to myometrial cells, causing contractions of smooth muscle tissue. Miso essentially EXPELS the tissue. Miso goes by other names one common name is Cytotec. It is commonly prescribed for stomach ulcers.
Methadextrate- Is a drug developed for oncology (cancer care). It is a folate antagonist that works by halting DNA synthesis, repair, and cell replication in rapidly replicating tissues, such as cancer. It is used for molar pregnancies, ectopic pregnancies, and sometimes intrauterine fetal demise. It is an injection almost always injected by a healthcare provider.
D&C- dilation and curettage is a surgical procedure that is usually done under sedation, (optional) that removes any remaining tissue from the uterus before 13 weeks. Recommenced if there is an incomplete miscarriage, also recommended if there are signs of infection, heavy bleeding, or if medical management didn’t work.
What is normal bleeding after/during a miscarriage?
Everyone who is experiencing a miscarriage will experience some bleeding. The amount will be different for each person. Some factors that will effect the amount of blood is how far along they were, if there was medication used to induce a miscarriage, or promote the uterus to expel the tissue, and that individuals body.
Likely the pattern goes as follows. If it was a spontaneous abortion (miscarriage) then the bleeding will likely be heavy. It typically starts off slow, and then works its way to a peak when the uterus is contracting to expel the tissue, and then there will likely be blood clots and heavy bleeding. Once the tissue is expelled from the uterus then the bleeding tends to slow back down and resemble more of a normal period or spotting. Remember normal for that person, which isn’t always text book normal. Heavy menstrual bleeders tend to have heavy bledding with a miscarriage or abortion/ light menstrual bleeders tend to have less bleeding. Bleeding after a miscarriage can continue for up to 4-6 weeks. This is usually light or spotting.
However there are standards that we want to keep in mind when it comes to blood flow after a miscarriage/abortion.
Red flags when it pertains to bleeding are:
- Soaking a maxi pad every 30 mins after the expulsion of the tissue should not be happening. No white showing on pad at all, blood covers back to back and side to side, and blood is bright red is a cause for concern. Hemorrhaging is described as a faucet of blood.
- Blood clots should be smaller then the palm of your hand. During peak of expulsion there might be large blood clots this is fine, but blood clots should not be that large after the expulsion of tissue.
- Foul smelling blood or discharge can be a red flag that there is an infection (try to seek medical care for antibiotics).
- If the person is ok with allowing you to palpate their uterus and there is extreme pain, flinching, and stabbing pain, this is a sign that there could be an infection. however dull, “bruise” like pain isn’t uncommon. Generally if there is an infection there will be a fever, as well as foul smelling discharge, but not always!
Things to be aware of:
advise the person to watch for normal blood flow. If they feel weak from loss of blood, then supporting them with iron is best. Heme iron is the most bioavailable, but supplements like floradix (liquid iron + herbs) is generally taste tolerant and does the trick as well. Nettle infusions is also a great plant based iron source. If the person is soaking through the pad every 30 mins and feeling really dizzy, weak, pale, faint, then this could be a serious complication known as a hemorrhage, and needs medical care right away. If you are somewhere very rural, then in the meantime you can try some hemostatic herbs, along with iron supplements while trying to get to a hospital. Some hemostatic herbs (though I personally don’t feel like these work super well) are: yarrow, Shepards purse, and cinnamon. One herb that I learned about from 7song who has extensively worked in rural first aid situations is a Chinese herb called Yunnan baiyao, this herb comes in tincture, or powder. This seems to work better as a hemostatic herb.
Advise the person not to put anything in the vagina in order to avoid an infection for up to two weeks or until the bleeding has stopped. (this is semi controversial, but it doesn’t hurt to err on the safe side)
Pain is normal during a miscarriage and can vary person to person. If the pain is excruciating then helping with herbs if they want is appropriate. Over the counter medication like ibuprofen can also be really useful here. Sometimes during a miscarriage the uterus is contracting to expel the tissue, but the cervix hasn’t opened enough and this can be painful. Some things that can help ease pain, is practices used for birth. Changing positions, moving (walking, squatting) and some pressure points can help.
Herbs that can be used for pain relief are herbs we would use for other smooth muscle spasming.
Jamaican dogwood, pedicularis, valerian, California poppy, betony, skullcap, lobelia(drop dose), silk tassel, black cohosh, *black haw, or *cramp bark.
*We want the uterus to do its job of expelling the tissue, so we don’t want to halt cramps, but we also want people to be comfortable. It’s ok to take these herbs in smaller amounts to help with the pain if its unbearable. Make sure to monitor that progression is still happening while using anti spasmodics. If medication was taken it’s unlikely that herbs would be strong enough to stop the body from expelling tissue. However herbs work differently for everyone so keep this in mind.
Another great tool to have is a TENS machine. These can be bought online for as low as 30 dollars. A TENS machine which stands for transcutaneous electrical nerve stimulation, is commonly used for birthing people to help manage pain, it’s also used for menstrual pain relief, and other chronic pain sufferers. It is a machine that involves the use of mild electrical currents, that is battery operated and has leads connected to sticky electrodes you can place on the body.
heating pads, hot water bottle, blankets, hot tea, castor oil packs and other topical herbal salves/oils rubbed over the uterus can all help with pain and induce relaxation.
Emotional distress- A large range of emotions are experienced with pregnancy loss, and none are mutually exclusive. People can experience grief alongside relief. When your body abruptly goes from being pregnant to not, there is also a lot of hormones at play. The feelings that people get when they are newly postpartum can be experienced by people who are experiencing a pregnancy loss. People can have postpartum depression, postpartum rage, postpartum OCD (obsessive compulsive thoughts), postpartum anxiety or psychosis. Herbs that are nourishing as well as foods are foundational. Herbs would be dependent on what the person is specifically feeling. Making sure the person follows up with a therapist if it seems like they need and want additional support, as well as seeing what kind of local services/ support groups they might be able to use. Be practical by having local resources to refer folks to, know some options counseling, But what is critical is just seeing the person, affirming them and their lived experience.
some example of formulas: (this is talking about tinctures).
Grief support herbs
hawthorn berry+flower
rose
cinnamon
tulsi or lemon balm
motherwort
linden
mimosa flower or bark
Anxiety
Passionflower
skullcap
blue vervain
motherwort
lavender
chamomile
Nourishing and uplifting
milky oats
lemon balm
motherwort
st johns wort
Immune support-when we are stressed, our immune system can get repressed. So it’s important to support our body through such shifts. When working with people experiencing pregnancy loss, I will advise on bone broths with astragalus, calendula, mushrooms, as well as some echinacea, and probiotics if antibiotics were given.
liver support-If taking medication then I usually recommend just some gentle liver support. This can include dandelion tea/tincture, milk thistle tincture/capsules, turmeric and burdock. Nothing super fancy!
Nourishment/rest-This is our foundation. Maintaining hydration, resting as much as they need, as well as incorporating nourishing teas, tinctures and food. Electrolyte drinks to help with dehydration if needed. Dehydration will make cramping worse.
Nourishing tea blend
nettle leaf
red raspberry leaf
oats/oatstraw
burdock root
red clover
TO REALLY PULL THE NUTRIENTS OUT OF THESE PLANTS MAKE A HERBAL INFUSION. AN HERBAL INFUSION IS WHEN THE HERBS ARE STEEPED FOR UP TO 24 HOURS AND THEN STRAINED. You can prepare this in any vessel but some are easier than others. French presses work nicely, as well as bodum tea strainers, or you can just use a cheesecloth in a mason jar.
Talking/counseling – When talking with people going through pregnancy loss I use the same outline as I would for someone having an abortion. Open ended questions, never interjecting my stories, or my experiences, validating, witnessing, seeking understanding, never come from a place of power, or an agenda, and maintaining boundaries while speaking from a place of compassion. What does this look like? lets run through some examples
- What kinds of things have you been feeling today? can you say more about that? why do you think you feel that way?
- I appreciate you sharing with me, and your honesty, are you ready for me to give you aftercare instructions?
- encourage them to share their feelings, and ask questions like, how do you normally handle grief? Do you have support when you get home? what’s your coping tools?
- I can see you are sad…its ok to cry here
*inspired by my training from Alissa perrucci who wrote decision assessment and counseling in abortion care.
If the person is headed to a clinic prepping them for the possibility of healthcare workers referring to their miscarriage as an abortion or using that word is advised especially if this was a wanted pregnancy.
Telemedicine-There are many amazing organizations who make it possible for people to source their own medication to manage pregnancy loss. The medication people can commonly source is Misoprostol. Its important to know that currently it is likely considered illegal to source the medication out of clinic. Sourcing can also be from friends who are doctors, nurses, or midwives.
So for example if a person knows the pregnancy ended and is no longer viable and then took Misoprostol on their own to expel the tissue. In general the places that provide this medication online do a consultation first to make sure the proper dosage is given. I believe its important as herbalists to know these organizations, considering lack of accessibility for some people to get to clinics, or if people choose to not have a clinic involved. But the legal issues are a bit mucky. However we are discussing a first aid situation where someone has already sourced the medication themselves.
Apps-didn’t think I was going to go there? well, there are some amazing apps out that are encrypted and completely confidential to use. They educate people on where to get pills, danger signs, when to seek help, common symptoms, dosing and more.
One is called Euki and the other is called Hesperian (safe Abortion)
