Miscarriage Care and Facilities in Scotland: Scoping Report NHS Orkney

Management options

In NHS Orkney, Balfour Hospital strongly agreed that women are free to choose their preferred management approach based on their needs and preferences. They neither agreed nor disagreed that women are offered only the management approaches provided on this site or that women may be referred to another site depending on the management approach they choose as they indicated that most management options are available locally, however depending on clinical presentation some women may require onward referral to tertiary support at Aberdeen Maternity Hospital.

All treatment options for miscarriage care are offered at Balfour Hospital, however these are only offered in the first trimester, for second trimester care women are transferred to Aberdeen Maternity Hospital. Although the options below are available locally in NHS Orkney, certain clinical presentations may require onward referral to tertiary support at Aberdeen Maternity Hospital. All options offered are listed in Table 12 below.

Expectant management in NHS Orkney

If women choose expectant management as the preferred option of management, women are advised of the criteria for proceeding with this. They are also required to have a reliable telephone for incoming and outgoing calls. Staff ensure that women have a full understanding of the procedure and are aware that they may need to return to the clinic for further assessment or treatment. Women who choose expectant management are given written information and also have 24 hour access to support by phone or in person via the Maternity Unit at Balfour Hospital where both midwifery and obstetric and gynaecology advice can be accessed.

Medical management in NHS Orkney

Medical management is provided at Balfour Hospital. If women are considering medical management they are required to be medically fit, have a responsible adult with them throughout the day of the process and overnight and have a full understanding of the procedures and the potential need to return to the clinic for further treatment.

Women are given mifepristone to start the process. They may be offered this tablet at their clinic visit and should arrange for a responsible adult to remain with them that day and night if they chose to be treated as an outpatient. If they are sick within two hours of taking the tablet they are advised to take another dose that day. Some women will have light vaginal bleeding and a few will fully miscarry at this stage. Women are advised that if they experience abdominal cramps they can take painkillers such as paracetamol or ibuprofen. If they do not experience heavy bleeding they are advised to phone the Maternity Unit at Balfour Hospital.

If being treated as an outpatient, before leaving the clinic, women will be given the second tablet called misoprostol and get a prescription for dihydrocodeine for pain relief as well as anitbiotics (doxycycline). They are advised to take the first dose of dihydrocodeine, with something to eat about 20-30 minutes before the next stage of treatment. Women will take the misoprostol tablets, as instructed by the doctor or nurse, 36 to 48 hours after taking mifepristone at the clinic. They will be given written information to remind them of the agreed date and time to take misoprostol. They will take a second dose of misoprostol (2 tablets) 4 hours later. The tablets cause the uterus to contract and pass the pregnancy.

The uterine contractions may start quite soon after taking the tablets or may not begin for 2 or 3 hours. Some women feel sick, have diarrhoea or feel hot and cold for a few hours after the tablets. They are recommended to stay at home until the pregnancy has come away and take their first dose of antibiotics an hour or so after this.

Women who are treated as an inpatient are given both medications on the maternity ward and are observed by staff regularly.

Women are advised to contact the Maternity Unit at Balfour Hospital if they have any concerns or experience bleeding which continues after two weeks.

Surgical management in NHS Orkney

Before surgical management at Balfour Hospital, women are provided with an explanation of the procedure as well as risks of the treatment (infection, continuing pregnancy, cervical injury, uterine perforation, haemorrhage).

Women are admitted on the morning of the procedure and are seen by a consultant gynaecologist and anaesthetist. Consent is then checked and a theatre preparation checklist done. Women would receive the procedure under general anaesthetic or local anaesthetic if they chose surgical management with MVA. The procedure involves dilation, curettage and suction, with recovery in day surgery post operation. Women then have a conversation with gynaecologist before discharge, with access to midwifery support as directed by the women. A further gynaecology follow up is required if any complication arise or discussion regarding history is required.