- On How to Have a Safe and Empowered Miscarriage
- More Reasons to Know Your Miscarriage Options
- The Signs and Symptoms of Miscarriage (aka Early Pregnancy Loss)
- Know Your Miscarriage Options
- Empowered Miscarriage
- Miscarriage-at-Home: What Happens and How It Feels
- What to Expect Later in the First Trimester
- What If the Miscarriage Doesn’t Start or I’m Not Completing It?
- Red Flags: When to Seek Medical Care
- After Your Miscarriage
- When Can I Try Again?
On How to Have a Safe and Empowered Miscarriage
For decades, both as a midwife and as a women’s health MD, I have guided women through miscarriage. But because miscarriage is often a fearful topic for women who become pregnant, and a painful topic for women who have experienced one or more miscarriages previously, it remains on the list of taboo topics that so many health care providers, women podcasters, and journalists avoid rather than discussing openly, for fear of being perceived as negative about pregnancy.
Yet it’s as important that we understand and know how to take care of ourselves when it comes to this phenomenon that occurs more commonly than one might expect, in 1 in 10 or more pregnancies, as it is to know how to take care of ourselves when we have our periods, become pregnant, or enter menopause. There has been too much silence around it and historically, too often, women haven’t received the psychoemotional support we need should we experience an early pregnancy loss,
When you’re pregnant, there’s no shortage of happy chatter about becoming a mom, nor shortage of options for childbirth education classes. However, there’s very little that prepares us either emotionally or physically for something that remains a hushed topic, and yet which 1 in 4 women will experience: miscarriage. Miscarriage remains so absent from conversations, hidden and secret, that few women really understand what it is or what happens. It's also so routinely treated as a medicalized event, that most women believe that it’s a dangerous process that requires hospital treatment. So let's talk about it and bring it into the light.
As I discuss in more depth in this article and corresponding On Health episode (which initially aired in 2020, early in the COVID-19 pandemic, so women could manage their miscarriage at home when possible), that you can listen to via the podcast player above or wherever you listen to podcasts, when someone is experiencing a miscarriage, she should be offered three options for managing it:
- A watchful waiting approach, in which the miscarriage is allowed to progress on its own,
- A medication approach, in which medications are used to expedite and complete the process more quickly, or
- A surgical approach, in which one of a couple surgical methods are used to empty the tissue from the uterus.
There are pros and cons to each approach, which is why, as long as there aren’t medical factors that dictate which direction to go, women should be given the option to choose which approach is right for them.
For the majority of miscarriages, watchful waiting is a safe option – and in the vast majority of cases, first trimester miscarriages can happen safely in the comfort of your home, with no complications at all. This is entirely contrary to what you might expect. Many of the numerous women I’ve guided through miscarriage at home over many decades have described their miscarriage as a sacred process that allowed a sense of emotional completion and resolution, rather than the trauma and grief so many found themselves with after a medically managed miscarriage. That's why if it’s an option that my patients are interested in, and there are no medical reasons not to, I consider home the optimal place to be.
In this article + episode I offer the information needed to demystify the process of miscarriage at home, as well as tips for making the experience more comfortable, with simple steps you can take, including supportive herbs many midwives find helpful in easing discomfort.
More Reasons to Know Your Miscarriage Options
In this post-Roe reproductive health landscape, accessing medical care for miscarriage has become infinitely more complex for women living in many states in the US. Thus, it's all the more important that we, as women, be prepared with the knowledge about what to expect should we – or someone close to us – miscarry, so that they can do so safely and comfortably at home if they choose to or are forced to – and so we know the red flags to watch out for so we’re empowered to demand and receive medical intervention when it’s needed.
Earlier this year an Idaho woman named Carmen Broesder took to TikTok to speak out about her experience having a miscarriage in the wake of Idaho’s new abortion ban. Despite having heavy bleeding and extremely painful cramps that brought her to the ER multiple times, it was 8 days before she was even given any medicine to manage her pain. While she asked repeatedly for a surgical procedure (called a D&C) to complete the miscarriage, she was denied. A doctor finally explained that there was “some trepidation” about performing a D&C given the state’s new abortion ban.
Like Idaho, numerous states have passed bans or tightened restrictions on abortion following the reversal of Roe v. Wade last year. While the laws are technically intended to apply only to abortions, the treatments for an abortion and a miscarriage of a wanted pregnancy are exactly the same.
And in this new, legally uncertain environment, some doctors and hospitals, worried about being accused of facilitating abortion, have been reluctant to offer the standard care to patients having a miscarriage. Some pharmacists have refused or delayed filling prescriptions for the medications used to complete a miscarriage. The result is women like Carmen who face unnecessary hurdles to getting the care they want – and sometimes medically need – during an already emotionally distressing experience.
In recent months, many stories like Carmen’s have come out.
In Ohio, a woman was sent away from the ER without treatment, even though she had a confirmed miscarriage and was bleeding so heavily that it had filled up the bottom of the bathtub. Eventually she passed out from the rapid blood loss and the paramedics had to take her back to the hospital.
In Texas, a woman came into the hospital screaming from passing large blood clots but was sent home with instructions to return only if she was bleeding so much that her blood filled a diaper more than once an hour.
The risk that abortion laws will prevent women from receiving prompt miscarriage care is even higher when it comes to cases where the pregnancy is no longer able to be maintained medically, but there is still fetal cardiac activity – for example, when a woman’s water breaks or there are other complications. In these cases miscarriage is inevitable but may take days – or even weeks – before it begins. And in some cases, a delay in getting medication or a surgical intervention to treat a miscarriage is dangerous, possibly leading a woman to face hemorrhaging, infection, or sometimes even life-threatening sepsis.
A recent study from Texas reported on 28 women who had rupture of membranes, or other serious complications before 22 weeks’ gestation that made miscarriage inevitable. But because of the conflation of miscarriage with abortion in the state’s abortion laws, they didn’t receive medical intervention until there was an “immediate threat” to their lives or fetal cardiac activity stopped. As Julie Kay and Kitty Kolbert, the authors of Controlling Women: What We Must Do Now to Save Reproductive Freedom discuss in my interview with them, in some states, the decision to facilitate the miscarriage may be predicated on the mother’s chance of survival should no intervention be done.
On average, in the study I just mentioned, the women waited 9 days and 57 percent ended up with serious infections, bleeding, or other medical problems.
If you are living in a state with strict abortion laws where it’s difficult to access the medications needed for a medication miscarriage approach at home, be sure to check out my podcast interview with Imani Wilson-Shabazz of Plan C, an organization dedicated to helping women easily and affordably get mifepristone and misoprostol – the medications used to manage both an abortion and a miscarriage.
Even when it is medically safe to miscarry at home, no one should be forced to make that choice as a default in the absence of access to their preferred method, especially when they are in pain, or live in a situation not conducive to miscarriage at home (i.e., lack of a clean, safe space, lack of support at home for herself or possibly other children), when there are safe and effective medications and procedures available to complete the process more quickly.
But in this post-Roe landscape, too many women are having their choices taken away, being forced to wait for the miscarriage to complete on their own rather than choosing that approach as an informed choice. I hope this information is an antidote to this condition being forced on women in many states.
The Signs and Symptoms of Miscarriage (aka Early Pregnancy Loss)
Miscarriage, medically known as early pregnancy loss (EPL), a term I actually prefer because I feel it is more emotionally and medically accurate, whereas miscarriage almost puts the blame back on the woman – as if her body did something wrong) occurs in 15 to 20% of recognized pregnancies and accounts for 80% of all miscarriages. In most early pregnancy losses, fetal demise occurs around 6 or 7 weeks into the pregnancy, though the definition includes any miscarriage through 13 weeks. The most common symptoms that suggest you could be miscarrying include:
- Vaginal spotting or bleeding
- Low back ache
- Abdominal pain, uterine cramping, or contractions
Some women also report noticing a decrease in pregnancy symptoms (for example, they no longer feel nausea or breast tenderness goes away, though this is by no means a definitive sign that you're going to miscarry). If you are having these symptoms, meet with your midwife or OB who can confirm, based on an ultrasound, whether the baby has stopped growing or if there is a heartbeat.
If you’re very early in the pregnancy, it might not be clear on ultrasound whether a fetus has formed, or whether it is still living. In this case, you may need further assessment to help put the question to rest. This might include transvaginal ultrasound, measuring blood levels of beta-HCg, and a repeated ultrasound at a near future date. It may also be necessary to rule out an ectopic pregnancy, a complication in which the fertilized egg implants and begins to grow in one of the fallopian tubes – which needs to be managed either with medications or sometimes surgery.
Sometimes, a woman doesn’t initially experience symptoms of miscarriage, and finds out she’s lost a pregnancy when a routine ultrasound shows that no fetus ever formed, that the fetus has stopped growing, or that there’s no heartbeat.
Know Your Miscarriage Options
There are 3 options for how to go about starting and completing a miscarriage:
- Watchful waiting (at home or in a medical setting)
- A medication approach (at home or in a medical setting)
- Suction (uterine aspiration) or dilation and curettage (D&C) in a medical setting
‘Watchful waiting’ means you do just that – watch and wait for miscarriage to get underway spontaneously. It's the most natural approach, but can take days or up to several weeks between when you learn that you're going to miscarry and the onset of symptoms or completion of the miscarriage. This waiting is frustrating, and for some may feel unbearable. Once it does get actively underway, however, a miscarriage is usually complete within five or six hours. Most miscarriages do not need intervention and can be managed this way. If the miscarriage doesn’t kick in on its own within a few weeks, or you get tired of waiting, one of other options will be required. If at any time, heavy bleeding, persistent pain, or any signs of infection develop, then the 3rd option will be needed.
A medication approach involves taking either a combination of two pharmaceuticals, mifepristone (a progesterone receptor antagonist) and misoprostol (a synthetic prostaglandin), or just misoprostol alone if mifepristone isn’t available, which is sometimes the case. This option allows you greater control when you start the miscarriage process (you can choose which day you want to take the pills) and allows you to expedite and complete the miscarriage process, all of which can be done at home. In 84% of cases, the pill combination leads to a completed miscarriage in two days; if not completed in two days, 89% of the time the miscarriage will be completed within a week. If you can’t obtain the mifepristone, misoprostol alone works within two days 67% of the time and within a week 84% of the time. The medication method is considered safe to do at home through the 13th week of gestation.
Here's how this process works:
- Your medical provider will give you one 200 mg tablet of mifepristone at their office, which you can take in the office or at home.
- About 24 hours later, at home, you'll insert four 200 mcg misoprostol pills preferably into your vagina (wash hands first, lay down when inserting and remain laying down for 30 minutes after; they can be inserted in any location in the vagina). About an hour before you do this, take 600 mg of ibuprofen – it can really help to buffer the misoprostol's side effects. Sometimes, if the mifepristone is unavailable, you just start with the misoprostol pills.
- After 30 minutes, you can just go about your biz – even if the pills fall out it’s okay – you’ve absorbed what you need.
Overall this is a very low risk option and is also the same process for doing a safe first trimester medication abortion at home.
Common misoprostol side effects include nausea, diarrhea, or chills. These symptoms should improve a few hours after using the pills. Mifepristone can cause serious interactions with a number of medications, so discuss use with your medical provider before taking it. If there is no response to the initial dose of misoprostol, a repeat dose may be taken one week later.
Suction (uterine aspiration) or dilation and curettage (D&C) are procedures done in the hospital in which your cervix (opening to your uterus at the top of the vaginal canal) is dilated and one of a couple of methods are used to empty the uterus of the products of conception. A suction procedure or D&C is effective 100% of the time with any type of miscarriage. These methods are the go-to if miscarriage isn’t able to start or be completed spontaneously or with medications, if there is heavy bleeding or any complications, or if you just want to get on with it. In the latter case you schedule your procedure, go in and have it done, and you’re usually back at home in a matter of hours. Suction is preferable to D&C for early pregnancy loss because it's quicker to perform and there's less risk of scarring the uterine lining which can be problematic for future pregnancies. Disadvantages to either of these methods include the need for a procedure in a hospital and the risks of anesthesia.
The Most Effective Treatment May Depend on the Type of Miscarriage
How you choose to handle your miscarriage experience is largely a personal decision, though it may be dictated by medical factors (heavy bleeding, for example) or what type of miscarriage you’re having, which I discuss below.
Miscarriage isn’t a one size fits all phenomenon – there are three main types, each of which influences how long a miscarriage might take to get started spontaneously, and how effective each strategy might be. Your midwife or OB can usually tell you which type you're having, based on an ultrasound, and this can help you decide which approach you’d prefer.
Incomplete miscarriage is when the pregnancy tissue begins to pass on its own. Using the watch-and-wait option, it will pass on its own over 90% of the time, but the whole process can take weeks. With misoprostol, the tissue passes up to 84% of the time in within 2 days, and over 90% of the time within a week.
Fetal or embryonic demise is when the pregnancy has stopped growing but is not passing on its own. Using the watch-and-wait option, this type of miscarriage will pass on its own about 75% of the time, but it too, can take weeks. With misoprostol, the tissue passes close to 90% of the time within a week.
“Empty sac” (anembryonic pregnancy) is when the pregnancy stopped growing before the fetus developed. Using the watch-and-wait option, this type of miscarriage will pass on its own only 66% of the time and may take many weeks. Using misoprostol increases the rate to about 80% of the time within a week.
Many women prefer to start out with a watch and wait approach, but you can choose to switch options if things are just taking too long to get started. An herbal approach can also be considered as part of a watchful waiting approach before going to medications or a medical procedure, but should be done under the guidance of a midwife or physician skilled in herbal miscarriage support.
Empowered, Healthy Miscarriage at Home
If there are no medical reasons not to, and you choose to stay at home, here’s how to create an optimal experience for yourself. Plan for and create:
Time: During your miscarriage, you’ll want to be at home, rather than out at work or running errands, so clear your calendar for a few days, or ideally up to a week, once your miscarriage symptoms have started or on the days you plan to take the induction medications.
Support: I recommend you create a bit of a cozy nest at home. Go about your life as if you had a weekend to yourself to lounge, watch movies, or read a favorite book. In other words, pamper yourself.
Also, have your partner or a close friend with you so you have the support you might need physically and emotionally, but also a watchful eye should problems arise that require you to get quick medical care.
Nourishment: Stay well hydrated, and have light, healthy foods on hand that you enjoy and will help you to stay nourished. Eating lightly is also important if you’re using medications to get the miscarriage going, or if you need to take pain medication – otherwise you’ll get an upset stomach. Sip red raspberry leaf (RRL) tea which many women use to encourage healthy contractions and uterine tone in labor. Steep 4 TBS. of dried RRL and 2 tsp. dried peppermint leaves in a quart of boiling water for 1 hour or use 4 RRL tea bags instead. Strain and drink up to a quart daily for a few days.
Comfort: As cramps or contractions become more intense:
- A hot water bottle on your lower back or lower abdomen can be comforting and pain relieving.
- Have somebody massage your feet or your lower back, especially applying firm pressure to the area over your sacrum.
- Use deep breathing techniques and visualize them emptying your womb, your womb contracting down, and a healing light around your uterus. This is very similar to effective hypnobirthing techniques.
- Take warm showers and let the water crash onto your lower back.
- If needed, use pain relieving herbs like CBD, cramp bark, and ginger, or take ibuprofen (i.e., Motrin or Advil) 600 mg every 8 hours (take with food to avoid nausea).
- Sip relaxing herbal tea like lavender, chamomile, or lemon balm.
- As uncomfortable as this may feel physically – and emotionally – try to remember that your body knows how to do this. Understanding the process and what to expect can help put your mind at ease and give you some ‘reference points’ for the experience.
Creating Sacred Space for Miscarriage Healing
Miscarriage brings a wide array of emotions. There’s no one right way to feel during or after. You may feel anywhere from grief to relief, depending on your unique hopes and goals at this moment in your life. It’s important to know deep inside yourself that there’s nothing you did wrong, from that glass or wine to those ambivalent feelings you may have had, to cause the pregnancy loss and that there’s absolutely nothing to feel embarrassed about. Over the years, I’ve learned that when we allow time for and create sacred space around our women’s life cycle experiences, our brains, hearts, and psyches integrate these with less trauma – we can experience the loss, yes, but with this also a powerful sense of completion and even inner peace. Also, if we open up to our sisters – the women in our lives who honor and love us through our experiences – the joyous and painful ones alike – we can share our loss and grief with those who will help us carry it, and we open up a conversation about pregnancy loss that is waiting to be had by so many women.
How can you create sacred space around miscarriage:
- Treat the experience as if it was a birth – have candles, music, twinkle lights, sip tea, rock your hips through the cramps, and if you have a partner, engage her/him/them in the process.
- Have a burial ceremony if in fact there was a fetus (or even if not, because you may feel you’re losing hopes or dreams right now). Commemorate the burial place with a special stone, feather, or herbal offering.
- Write a letter to yourself or journal about your experience.
- Mark the date on the calendar so in a year you can honor the passage of time.
Of course, if this is a more private experience, or one you feel more ‘matter of fact’ about – you may not wish to share the experience, or you may wish to just have it be ‘another day’ and move on. Again, no right or wrong – just what feels good to you.
Miscarriage-at-Home: What Happens and How It Feels
A miscarriage entails a combination of uterine cramping, which forces the uterus to empty out what’s inside of it, and bleeding as the contents of your uterus is shed. The cramping is typically like a very painful period or slightly worse, and the bleeding may be like a heavy period, or considerably more, which can all still be entirely normal. I’ll explain when it’s not later in the article.
If you’re taking a watch and wait approach, miscarriage symptoms may build up for several days or even weeks before the miscarriage kicks in full on, with cramping and spotting occurring intermittently during this time, ultimately building in intensity to the actual last hours when your uterus empties itself out. The actual final stages of miscarriage, with regular cramping and heavier bleeding, usually takes place within a few couple of hours, or up to about five hours. Initially, there is light to moderate bleeding and cramping, both of which become increasingly heavy and are eventually accompanied by the passage of some solid tissue through the vagina. Sometimes a miscarriage will begin with a fury – heavy cramping and bleeding right from the beginning, and happen in a matter of five or six hours from start to finish.
If you’ve taken misoprostol, the cramps usually start 2-4 hours after you insert the pills in your vagina and may last 3-5 hours. Bleeding may be heavy, but as long as you’re not soaking through menstrual pads as described under When to Seek Medical Care below, heavy bleeding is expected and is not risky. It means the pills are doing their job.
What to Expect Later in the First Trimester
The further along the pregnancy is, the heavier the bleeding and cramping will be, and you may notice that you are passing tissue along with blood and clots. If the miscarriage is occurring very early in pregnancy, the tissue may simply look like clots; after about 8-weeks gestation, and a fetus had formed, fetal tissue may be apparent in the form of a very small rudimentary placenta and a small sac that looks a bit like a thin grape skin. Passing visible fetal tissue can be very emotionally demanding – so it’s something to be aware of that many providers don’t warn you about in advance. Sometimes you will see material that looks like wet toilet paper covered in more or less blood coming from the cervix if it is being examined, or the vagina – this is part of the membranes. Saving the tissue that comes out to show to a midwife or doc can be really helpful in determining if everything has cleared out of the uterus, and in case tissue samples are needed for chromosomal testing. You can put a sieve in the toilet to catch this tissue as it comes out, or if need be, someone can retrieve it from the bowl.
What If the Miscarriage Doesn’t Start or I’m Not Completing It?
If a few weeks go by on the watchful waiting plan, you can always go back to your clinician’s office and opt for the medication or suction or D&C option. If you’re taking the medications and they don’t kick in, talk with your clinician about doing another round of the medications. If this doesn’t work the second time, or you’re just tired of waiting, you can choose the suction or D&C option.
A Midwife's Herbal Approach
In my midwifery practice, I’ve often used herbs to initiate contractions in cases where a woman is getting tired of watchful waiting but wants to try something natural before going onto medication options. A protocol from my textbook, Botanical Medicines for Women’s Health, is:
Mix the following amounts of tinctures in a 2 oz. amber glass bottle with a dropper top.
- Blue cohosh (Caulophyllum thalictroides) 20 ml
- Black cohosh (Actaea racemoa) 15 ml
- Motherwort (Leonorus cardiaca) 10 ml
- Cramp bark (Viburnum opulus) 5 ml
- Total 50 ml
Instructions: Beginning in the morning take 3 mL (about ½ tsp.) of the above tincture combination every 4 hours to stimulate uterine contractions. If no contractions ensue, repeat the next day. Contractions usually begin after the first 24 hours, but it may take as long as 48 hours. The process can be repeated for a third day; if I ever have to do this, I usually allow a one-day break between the second and third days of using the protocol. Wait for the miscarriage symptoms to begin. If they do not, you can move onto the medication option.
Additional supportive herbs once the miscarriage begins:
- Strong yarrow infusion can be kept on hand and taken in cupful doses for 30 minutes as long as the woman is stable and blood loss is within the 2 pads/30 minute or 2 pads/hour for 2 consecutive hours rule.
- Sip a tea of dried basil or of cinnamon throughout the miscarriage to promote contractions and prevent excessive bleeding. Steep 1 tsp. of either herb in 1 cup of boiling water (cover while steeping) for ten minutes. Strain and sweeten lightly with honey. Dose 2 cups/day.
- Sip a calming cup of tea made with chamomile and lavender blossoms (1 tsp. total of dried herbs to 1 cup boiling water, steeped covered for ten minutes, strain and sweeten lightly with honey.
Red Flags: When to Seek Medical Care
Most women who allow nature to take its course and who receive support through the process will miscarry with no complications. But miscarriage should not be taken lightly – it does carry risks of hemorrhage and infection.
Here’s what to look out for and when you need to get immediate medical care:
- You’re bleeding heavily enough to soak two maxi pads per hour for two hours in a row.
- You have a fever over 101°F (38.3° C) if you did a watchful waiting approach, or over 102°F (38.3° C) if you did a medication approach (a slight fever of 102°F or less is a common side-effect of misoprostol use).
- You start to feel very unwell at any time, or have lower abdominal pain after the cramping is done.
In this case, a D&C or suction procedure and antibiotics may be necessary to fully complete the miscarriage and prevent or treat infection. If at any time in the few weeks after the miscarriage you develop heavy bleeding, are passing large clots (larger than a quarter), have abdominal pain, fever, or bad smelling vaginal discharge, you could have retained tissue or an infection, and need prompt medical attention.
After Your Miscarriage
Once the miscarriage is completed, the cramping will completely subside, however vaginal bleeding typically lasts as long as 1-2 weeks after, much like a moderate or heavy period, getting lighter over time. It may even start and stop a few times over those couple of weeks. During the first few days after your miscarriage you may also pass a few small clots. This is all normal. Get plenty of rest, eat nourishing foods such as hearty soups and stews, and drink plenty of fluids. Change your menstrual pad every couple of hours to avoid infection from bacteria in the pad. A follow-up visit to your medical provider is recommended within two weeks of the medication approach to confirm that the miscarriage is complete – meaning everything has been passed from your uterus.
When Can I Try Again?
Most women will ask when they can try to become pregnant again – believe it or not, if they want to, they can try as soon as they feel like it – and for unknown reasons, fertility is actually increased in the month after a miscarriage. Make sure to take a prenatal vitamin, especially one with 400 to 1000 mcg of methylfolate. Having a miscarriage does not affect future fertility so the woman can be reassured of this as well.
I hope this article helps you to feel more knowledge and empowered. Please share it with the women in your life, so we can heal the stigma, and increase support, tools, and understanding. It’s really time that we change this culture of fear and shame around miscarriage, and honor our experience as part of the spectrum of what can be both painful and powerful experiences as women, that we can support each other through.
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