Six ways that breaking bad and difficult news in ultrasound is different to other settings

Not all pregnancies follow the textbook. Around 1 in 6 are lost to miscarriage or stillbirth and in 1 in 20 there is an unexpected finding on an ultrasound scan which could suggest the baby has a health condition (Ahman et al., 2014; Blohm et al., 2008; Skupski et al., 1996). Altogether around 150,000 families in England and Wales are affected by one of these complications each year (ONS; 2016). These events are deeply upsetting; parents who experience them are at higher risk for depression, anxiety and even symptoms of trauma (Blackmore et al., 2011; Cumming et al., 2007; Korenromp et al., 2005).

The role of ultrasound

Ultrasound is an important tool for diagnosing these complications and in the UK sonographers are the first to break the news to parents about what they have found. The way this is done is important, as it has a strong emotional impact on expectant parents (Bijma et al., 2008; Johnson et al., 2018). However, there is currently no evidence-based training to support sonographers with news delivery. The training which is available is generally based on research which has been conducted in oncology and other healthcare settings.

The need for an evidence-based training intervention

When I have suggested that new research is needed to understand how bad and difficult news can be better delivered via ultrasound, one question I have been asked is whether this is really needed. Isn’t there plenty of research in other settings to inform training? In this blog, I will present six ways that breaking bad and difficult news via ultrasound is different to breaking bad news in other settings.

1. There is no time for sonographers to prepare before delivering the news

A large body of research tells us that expectant parents study the sonographer’s face as they do the scan: they are attuned to their body language and facial expression and quickly sense when something is wrong. The sonographer is unintentionally communicating news before they even speak, and they have no time alone at all to mentally prepare before sharing what they have found with parents. In cancer care, this would be the same as a doctor having to open test results, read and interpret them while the patient watches them.

2. Having a baby isn’t primarily a healthcare event, it’s a rite of passage

Few people will spend years thinking about their future with a diagnosis of cancer, but many people, consciously or subconsciously, gather quiet expectations about what their future will be like with a child. When you deliver difficult news as a sonographer, you deliver it into a world of positive expectation, which is further fuelled by people sharing scan pictures on social media, and television shows like One Born Every Minute. Because of this, the situation is particularly high stress for both those delivering and those receiving the news.

 3. The need for a second opinion

When a sonographer identifies a miscarriage, stillbirth or fetal anomaly a second opinion is necessary to confirm his. The sonographer needs to leave the scan room to find another qualified healthcare professional who can confirm what has been seen. This is a difficult point, and one that is not encountered in other areas of healthcare. Sonographers are often torn over how much to disclose to the expectant parent before the second opinion has been gathered, especially if they are not confident themselves in what they have seen. Failing to disclose their concerns to the parent can result in parents feeling anxious when they find a second professional has been invited into the scan room without explanation. However, immediately disclosing concerns to parents that are then not confirmed can cause unnecessary anxiety. It’s a dilemma that sonographers regularly face which is not found in other difficult news delivery scenarios.

4. The news may be uncertain

When receiving difficult news in other settings, patients can rightly expect that the healthcare professional telling them this news will be informed about their condition and be able to provide detailed information on this. However, sonographers do not have this luxury. While scanning technology has advanced significantly in the last few decades, it is not always possible to provide accurate diagnoses and prognoses immediately. Because of this, sonographers are often communicating difficult news which is uncertain, and which could change in light of subsequent investigations.

5. Ultrasound presents opportunities and raises challenging choices

Unlike other areas of healthcare, ultrasound often provides a diagnosis before anyone’s health has been compromised. It can enable expectant parents to have missed miscarriages diagnosed and allow them to choose whether they want to shorten the length of their pregnancy by accepting a medical intervention. Ultrasound can also detect some fetal abnormalities.  If a baby is found to have a disability (or a possible disability) parents may need to decide whether to have invasive testing; whether to terminate the pregnancy; or in rare cases, whether to have prenatal interventions. These kinds of decisions introduce a huge weight of responsibility – could prenatal investigations and interventions put the baby or mother at risk? Is it morally wrong to terminate a pregnancy? Will not terminating a pregnancy detract energy from any existing children? When sonographers deliver difficult news they know they are often placing a burden of responsibility on expectant parents to make choices, in a way that is not encountered elsewhere in healthcare.

6. The warning shot is not always wanted

Most models for breaking bad news recommend the delivery of a ‘warning shot’ before the main news is imparted (e.g., Baile et al., 2000). This is designed to prepare patients that bad news is coming, and might run like this: “I’m afraid we have identified some concerning findings in your results”. My research has identified that this warning shot is not always wanted in ultrasound settings because parents have already received their warning shot from the sonographer’s body language and facial expression (see my blog on parent experiences here). These kinds of warning shots only extend the overall duration of the event and serve to increase expectant parents’ anxieties.  Furthermore, if the news being delivered is that the baby has a disability, this kind of warning shot can be taken as a negative value judgement by the healthcare professional, which may offend the expectant parent. Instead, parents prefer to be told things directly but kindly, in simple language. In my previous study in parents of children with limb differences, parents most preferred it when healthcare professionals simply said something like: “I can’t currently see your child’s arm below the elbow” (Johnson et al., 2018).

Summing up

There is strong evidence from other healthcare settings that training to improve news delivery is highly effective (see my blog on this here). However, there are clear differences between breaking bad and difficult news in ultrasound compared with other settings. Assuming that the same principles can be transposed from other healthcare settings into ultrasound without adaptation could at best reduce the effectiveness of training, and at worst, increase parental anxiety.


  1. Linda Treweek
    December 29, 2018 / 2:09 pm

    Oh Jude..this is an excellent article. You have just nailed the day to day experiences of sonographers so well. I was “aware” of all these points…but “not” aware..if you get my meaning. We almost take for “normal” the situations we find ourselves in…. being the first ever person to know that there is something terribly wrong with that kindly elderly grandad or that the beaming couple’s unborn child is not compatable with life.
    I would love to share this blog with my Australian colleagues if that is ok.
    Thank you so very much for sending me this link.
    Kind Regards Linda

    • judithnjohnson
      December 29, 2018 / 3:21 pm

      Thanks for reading and for leaving a comment Linda! Sonographers do such important, emotional work and I think this should be recognised! Yes please do share.

  2. Nick Cantlay
    February 1, 2019 / 5:48 pm

    Hi Judith, I wrote a PhD thesis back in 2011 entitled “Sonographers’ Experiences of Breaking Bad News in Prenatal Ultrasound (A Phenomenological Analysis)”. It answered the question of why current breaking bad news protocols are unsuitable for sonographers and how those sonographers that break bad news well actually do it. I used to teach a masters module on breaking bad news in prenatal ultrasound at the University of Cumbria. My thesis is in Lancaster University and should be available online if you’re interested.

    • judithnjohnson
      February 4, 2019 / 2:54 pm

      Hi Nick! Thanks for connecting. My collaborator Jane Arezina ordered a copy of your thesis, actually! We used this to inform the project she is currently leading, funded by the Society of Radiographers. Do you have any more plans to continue working on the topic?

  3. Linda Treweek
    February 7, 2019 / 8:29 am

    Hi Nick… any chance you could give me the details of how to find your thesis? I am a senior supervising sonographer in Australia and would love to read it.
    Kind Regards Linda Treweek

  4. Emma Cassell
    October 28, 2019 / 3:31 pm

    Hi Judith, I came across this article today and so glad I did! I am currently a student as Teesside University. Now in my second year of my MSc Medical Ultrasound. I am doing my dissertation around this exact subject. Burnout rate amongst sonographers and what we can do to try and eliminate such problem. To date all the literature I have found highlight the need for service users input. Gathering such data could be implemented into a training programme that you are suggesting. My proposal I am currently working on is gaining this feedback from service users, whom have experienced bad news. I am hoping that data received will allow me to go further with my research for next year. Such a relevant topic and so much that needs to be done on it.

    • judithnjohnson
      October 29, 2019 / 3:21 pm

      Hi Emma thanks for reading and for your comment- great to know you’re doing some research in it! Such an important issue.

Leave a Reply