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Clinical Practice Handbook for Safe Abortion. Geneva: World Health Organization; 2014.

Cover of Clinical Practice Handbook for Safe Abortion

Clinical Practice Handbook for Safe Abortion.

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1PRE-ABORTION

OBJECTIVES

  • Provide information and offer counselling in a way that a woman can understand, to allow her to make her own decisions about whether to have an abortion, and, if so, what method to choose.
  • Confirm pregnancy status and determine intrauterine location and gestational duration.
  • Evaluate for any medical conditions that require management or may influence the choice of abortion procedure.
  • Provide an opportunity to discuss future use of contraception.

1.1. Information, counselling and decision-making

Provide information

Information is a necessary component of any medical care and should always be provided to women considering abortion. At a minimum, this should include,

  • the abortion methods and pain management options that she may choose from;
  • what will be done before, during and after the procedure, including any tests that may be performed;
  • what she is likely to experience (e.g. pain and bleeding) and how long the process is likely to take;
  • how to recognize potential complications, and how and where to seek help, if required;
  • when she will be able to resume her normal activities, including sexual intercourse;
  • follow-up care, including future prevention of unintended pregnancy;
  • any legal or reporting requirements.

Most women who have a safe abortion will not suffer any long-term effects (e.g. adverse outcomes in subsequent pregnancies, negative psychological consequences, breast cancer) on their general or reproductive health as a consequence of the abortion.

Offer counselling

Counselling is a focused, interactive process through which one voluntarily receives support, additional information and guidance from a trained person, in an environment that is conducive to openly sharing thoughts, feelings and perceptions. When providing counselling, remember to:

  • communicate information in simple language;
  • maintain privacy;
  • support and ensure adequate response to the questions and needs of the woman;
  • avoid imposing personal values and beliefs.

Decision-making

If the woman chooses to have an abortion and a choice of abortion methods is available, she should be allowed to choose among available methods that are appropriate, based on the duration of pregnancy and her medical condition. Adequate and scientifically accurate information about potential risk factors and the advantages and disadvantages of each available method is key to helping her make a choice.

Recommended methods of abortion by pregnancy duration.

Recommended methods of abortion by pregnancy duration

Characteristics of abortion procedures

≤12–14 WEEKS>12–14 WEEKS
Medical abortionVacuum aspirationMedical abortionDilatation and evacuation (D&E)
  • Avoids surgery
  • Mimics the process of miscarriage
  • Controlled by the woman and may take place at home ( < 9 weeks)
  • Takes time (hours to days) to complete abortion, and the timing may not be predictable
  • Women experience bleeding and cramping, and potentially some other side-effects (nausea, vomiting)
  • May require more clinic visits than VA
  • Quick procedure
  • Complete abortion easily verified by evaluation of aspirated POC
  • Takes place in a health-care facility
  • Sterilization or placement of an intrauterine device (IUD) may be performed at the same time as the procedure
  • Requires instrumentation of the uterus
  • Small risk of uterine or cervical injury
  • Timing of abortion controlled by the facility and provider
  • Avoids surgery
  • Mimics the process of miscarriage
  • Takes place in a health-care facility
  • Takes time (hours to days) to complete abortion, and the timing may not be predictable
  • Women experience bleeding and cramping, and potentially some other side-effects (nausea, vomiting)
  • Women remain in the facility until expulsion of the pregnancy is complete
  • Women with a uterine scar have a very low risk (0.28%) of uterine rupture during medical abortion between 12 and 24 weeks
  • Quick procedure
  • Complete abortion easily verified by evaluation of aspirated POC
  • Takes place in a health-care facility
  • Sterilization or placement of an IUD may be performed at the same time as the procedure
  • Requires cervical preparation in advance of procedure
  • Requires instrumentation of the uterus
  • Small risk of uterine or cervical injury
  • Timing of abortion controlled by the facility and provider
May be preferred in the following situations:
  • For severely obese women
  • Presence of uterine malformations or fibroids, or previous cervical surgery
  • If the woman wants to avoid surgical intervention
  • If a pelvic exam is not feasible or unwanted
May be preferred in the following situations:
  • If there are contraindications to medical abortion
  • If there are constraints for the timing of the abortion
May be preferred in the following situations:
  • For severely obese women
  • The presence of uterine malformations or fibroids, or previous cervical surgery
  • If the woman wants to avoid surgical intervention
  • If skilled, experienced providers are not available to provide D&E
May be preferred in the following situations:
  • If there are contraindications to medical abortion
  • If there are time constraints for the abortion
ContraindicationsContraindications
  • Previous allergic reaction to one of the drugs involved
  • Inherited porphyria
  • Chronic adrenal failure
  • Known or suspected ectopic pregnancy (neither misoprostol nor mifepristone will treat ectopic pregnancy)
  • There are no known absolute contraindications
  • Previous allergic reaction to one of the drugs involved
  • Inherited porphyria
  • Chronic adrenal failure
  • Known or suspected ectopic pregnancy (neither misoprostol nor mifepristone will treat ectopic pregnancy)
  • There are no known absolute contraindications for the use of D&E
Caution and clinical judgement are required in cases of:
  • Long-term corticosteroid therapy (including those with severe uncontrolled asthma)
  • Haemorrhagic disorder
  • Severe anaemia
  • Pre-existing heart disease or cardiovascular risk factors
  • IUD in place (remove before beginning the regimen)
Caution and clinical judgement are required in cases of:
  • IUD in place (remove before beginning the procedure)
Caution and clinical judgement are required in cases of:
  • Long-term corticosteroid therapy (including those with severe uncontrolled asthma)
  • Haemorrhagic disorder
  • Severe anaemia
  • Pre-existing heart disease or cardiovascular risk factors
  • IUD in place (remove before beginning the regimen)
Caution and clinical judgement are required in cases of:
  • IUD in place (remove before beginning the regimen)

1.2. Medical history

In addition to estimating the duration of pregnancy, clinical history-taking should serve to identify contraindications to medical or surgical abortion methods and to identify risk factors for complications.

ELEMENTS OF MEDICAL HISTORY
Personal data
  • Name, age and contact information, if possible.
Reason for seeking medical care
  • Circumstances of the pregnancy, including pregnancy symptoms or possible complications, such as vaginal bleeding.
Obstetric history
  • Details of previous pregnancies and their outcomes, including: ectopic pregnancy, prior miscarriage or abortion, fetal deaths, live births and mode of delivery.
Gynaecologic history
  • First date of LMP and whether the last period was normal.
  • Menstrual cycle pattern.
  • Gynaecologic issues, including previous gynaecologic surgery, history of female genital mutilation, or other known physical abnormalities or conditions.
  • Contraceptive history:

    current contraceptive use;

    contraceptive methods used in the past and experience (positive or negative) with these methods.

Sexual history
  • Current partner(s) and whether current partner(s) may have other partner(s).
  • History or symptoms of any sexually transmitted infections (STIs) including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).
Surgical/medical history
  • Chronic diseases, such as hypertension, seizure disorder, blood-clotting disorders, liver disease, heart disease, diabetes, sickle-cell anaemia, asthma, significant psychiatric disease.
  • Details of past hospitalizations.
  • Details of past surgical operations.
Medications and allergies
  • Daily medications.
  • Use of recent medications or herbal remedies, including any medications and the details of their use (dose, route, timing) if self-abortion was attempted.
  • Allergy to medications.
Social history
  • Marital or partner status.
  • Family environment.
  • Violence or coercion by partner or family members.
  • Other social issues that could impact her care.
  • History and current use of alcohol and illicit drugs.
Note: Health-care providers may encounter women with complicated social situations in the context of providing medical services. Facilitating referral to services to meet women's needs is an important aspect of quality abortion care; however, social history (e.g. marital status) should not be used to create additional barriers to care.

1.3. Physical examination

ELEMENTS OF PHYSICAL EXAMINATION
General health assessment
  • General appearance.
  • Vital signs.
  • Signs of weakness, lethargy, anaemia or malnourishment.
  • Signs or marks of physical violence.
  • General physical examination (as indicated).
Abdominal examination
  • Palpate for the uterus, noting the size and whether tenderness is present.
  • Note any other abdominal masses.
  • Note any abdominal scars from previous surgery.
Pelvic examination (speculum and bimanual examination)
  • Explain what she can expect during the pelvic examination.
  • Examine the external genitalia for abnormalities or signs of disease or infection.
Speculum examination
  • Inspect the cervix and vaginal canal:

    look for abnormalities or foreign bodies;

    look for signs of infection, such as pus or other discharge from the cervical os; if pus or other discharge is present, sample for culture, if possible, and administer antibiotics before aspiration;

    cervical cytology may be performed at this point, if indicated and available.

Bimanual examination
  • Note the size, shape, position and mobility of the uterus.
  • Assess for adnexal masses.
  • Assess for tenderness of the uterus on palpation or with motion of the cervix, and/or tenderness of the rectovaginal space (cul-de-sac), which may indicate infection.
  • Confirm pregnancy status and pregnancy duration.
Pregnancy dating by physical examination.

Pregnancy dating by physical examination*

*

Goodman S, Wolfe M and the TEACH Trainers Collaborative Working Group. Early abortion training workbook, 3rd ed. San Francisco: UCSF Bixby Center for Reproductive Health Research & Policy; 2007.

Limitations to dating by uterine size on physical examination

  • Uterine malformations/fibroids.
  • Multiple gestation.
  • Marked uterine retroversion.
  • Obesity.
  • Molar pregnancy.

Key considerations

A uterus that is smaller than expected may indicate

  • the woman is not pregnant;
  • inaccurate menstrual dating;
  • ectopic pregnancy or abnormal intrauterine pregnancy, e.g. spontaneous or missed abortion.

A uterus that is larger than expected may indicate

  • inaccurate menstrual dating;
  • multiple gestation;
  • uterine abnormalities, such as fibroids;
  • molar pregnancy.

1.4. Laboratory and other investigations (if necessary and available)

The following tests, when available, may be performed on the basis of individual risk factors, findings on physical examination, and available resources:

  • pregnancy test if pregnancy is unconfirmed;
  • haemoglobin (Hb) or haematocrit for suspected anaemia;
  • Rhesus (Rh)-testing, where Rh-immunoglobulin is available for Rh-negative women;
  • HIV testing/counselling;
  • STI screening (usually performed during the pelvic examination);
  • cervical cancer screening (performed during the pelvic examination);
  • other laboratory tests as indicated by medical history (kidney or liver function tests, etc.);
  • diagnostic ultrasound, if indicated, to confirm pregnancy dating or the location of the pregnancy.

IMPORTANT

Routine laboratory testing is not a prerequisite for abortion services.

1.5. Discussing contraceptive options

Immediate initiation of contraception following abortion has been shown to both improve adherence and reduce the risk of unintended pregnancy.

Provide information and offer counselling

  • Inform all women that ovulation can return within 2 weeks following abortion, putting them at risk of pregnancy unless an effective contraceptive method is used.
  • If the woman is interested in contraception, she requires accurate information to assist her in choosing the most appropriate contraceptive method to meet her needs.
  • Understand that some women prefer to discuss options for contraception after the abortion is completed.
  • If a woman is seeking an abortion following what she considers to be a contraceptive failure, discuss whether the method may have been used incorrectly and how to use it correctly, or whether it may be appropriate for her to change to a different method.
  • Ultimately, the final decision about whether to use contraception, and identification of a method to use, is the woman's alone.

IMPORTANAT

A woman's acceptance of a contraceptive method must never be a precondition for providing her an abortion.

Copyright © World Health Organization 2014.

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob).

Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution – should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html).

Bookshelf ID: NBK190097

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