Clinical Practice Handbook For Safe Abortion - WHO

Characteristics of abortion procedures12–14 weeksMedical abortion voids surgeryA 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, andpotentially some other side-effects (nausea, vomiting) May require more clinic visits than VAMay be preferred in the following situations: F or 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 unwantedVacuum aspiration Quick procedure Complete abortion easily verifiedby evaluation of aspirated POC Takes place in a health-care facility Sterilization or placement of anintrauterine device (IUD) may beperformed at the same time asthe procedure Requires instrumentation ofthe uterus Small risk of uterine or cervicalinjury T iming of abortion controlledby the facility and providerMay be preferred in thefollowing situations: If there are contraindicationsto medical abortion If there are constraints forthe timing of the abortionContraindicationsP revious allergic reaction to one of the drugs involvedInherited porphyriaChronic adrenal failure K nown or suspected ectopic pregnancy (neithermisoprostol nor mifepristone will treat ectopic pregnancy)Caution and clinical judgement are requiredin cases of: Long-term corticosteroid therapy (including thosewith severe uncontrolled asthma) H aemorrhagic disorder S evere anaemia Pre-existing heart disease or cardiovascular risk factorsIUD in place (remove before beginning the regimen)12Section 1 Pre-abortionT here are no known absolutecontraindicationsCaution and clinical judgementare required in cases of:I UD in place(remove before beginningthe procedure)

12–14 weeksMedical abortionDilatation and evacuation (D&E) voids surgeryA 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, andpotentially some other side-effects (nausea, vomiting) Women remain in the facility until expulsion of thepregnancy is complete Women with a uterine scar have a very low risk(0.28%) of uterine rupture during medical abortionbetween 12 and 24 weeksMay be preferred in the following situations: F or severely obese women T he presence of uterine malformations or fibroids,or previous cervical surgery If the woman wants to avoid surgical intervention If skilled, experienced providers are not availableto provide D&E Q uick procedure Complete abortion easily verifiedby evaluation of aspirated POC Takes place in a health-care facility Sterilization or placement of anIUD may be performed at thesame time as the procedure Requires cervical preparationin advance of procedure Requires instrumentation of the uterus Small risk of uterine or cervical injury T iming of abortion controlledby the facility and providerMay be preferred in thefollowing situations: I f there are contraindicationsto medical abortion If there are time constraintsfor the abortionContraindicationsP revious allergic reaction to one of the drugs involved Inherited porphyria Chronic adrenal failure K nown or suspected ectopic pregnancy (neithermisoprostol nor mifepristone will treat ectopic pregnancy)Caution and clinical judgement are requiredin cases of: Long-term corticosteroid therapy (including thosewith severe uncontrolled asthma) Haemorrhagic disorder S evere anaemia Pre-existing heart disease or cardiovascular risk factors IUD in place (remove before beginning the regimen) T here are no known absolutecontraindications for the use of D&ECaution and clinical judgementare required in cases of:I UD in place (remove beforebeginning the regimen)1.1 Information, counselling and decision-making13

1.2Medical historyIn addition to estimating the duration of pregnancy, clinical history-taking shouldserve to identify contraindications to medical or surgical abortion methods and toidentify risk factors for complications.Elements of medical historyPersonal data N ame, age and contact information, if possible.Reason forseekingmedical care Circumstances of the pregnancy, including pregnancy symptoms orpossible complications, such as vaginal bleeding.Obstetrichistory D etails of previous pregnancies and their outcomes, including: ectopicpregnancy, prior miscarriage or abortion, fetal deaths, live births andmode of delivery.Gynaecologichistory First date of LMP and whether the last period was normal. M enstrual cycle pattern. Gynaecologic issues, including previous gynaecologic surgery, historyof female genital mutilation, or other known physical abnormalitiesor conditions. Contraceptive history:current contraceptive use;c ontraceptive methods used in the past and experience (positive ornegative) with these methods.Sexual history Current partner(s) and whether current partner(s) may have other partner(s). istory or symptoms of any sexually transmitted infections (STIs)Hincluding human immunodeficiency virus/acquired immunodeficiencysyndrome (HIV/AIDS).14Section 1 Pre-abortion

Elements of medical historySurgical/medicalhistory Chronic diseases, such as hypertension, seizure disorder, blood-clottingdisorders, liver disease, heart disease, diabetes, sickle-cell anaemia,asthma, significant psychiatric disease. D etails of past hospitalizations. D etails of past surgical operations.Medicationsand allergies Daily medications. Use of recent medications or herbal remedies, including any medications andthe details of their use (dose, route, timing) if self-abortion was attempted. A llergy to medications.Social history Marital or partner status. Family environment. V iolence or coercion by partner or family members. O ther social issues that could impact her care. History and current use of alcohol and illicit drugs.Note: Health-care providers may encounter women with complicatedsocial situations in the context of providing medical services. Facilitatingreferral to services to meet women’s needs is an important aspect ofquality abortion care; however, social history (e.g. marital status) shouldnot be used to create additional barriers to care.1.2 Medical history15

1.3Physical examinationElements of physical examinationGeneralhealthassessment G eneral appearance.Vital signs.Signs of weakness, lethargy, anaemia or malnourishment.Signs or marks of physical violence.General physical examination (as indicated).AbdominalexaminationPalpate for the uterus, noting the size and whether tenderness is present. Note any other abdominal masses. Note any abdominal scars from previous surgery.Pelvicexamination(speculumand bimanualexamination)Explain what she can expect during the pelvic examination.E xamine the external genitalia for abnormalities or signs of diseaseor infection.Speculum examination Inspect the cervix and vaginal canal: look for abnormalities or foreign bodies;l ook for signs of infection, such as pus or other discharge from thecervical os; if pus or other discharge is present, sample for culture,if possible, and administer antibiotics before aspiration;c ervical cytology may be performed at this point, if indicatedand available.Bimanual examinationNote the size, shape, position and mobility of the uterus.Assess for adnexal masses. ssess for tenderness of the uterus on palpation or with motion of theAcervix, and/or tenderness of the rectovaginal space (cul-de-sac), whichmay indicate infection.Confirm pregnancy status and pregnancy duration.16Section 1 Pre-abortion

Pregnancy datingby physical examination*After 15–16 weeks’ gestation,the uterus reaches the midpointbetween the symphysis pubisand the umbilicus.After 4 weeks’ gestation,the uterus increases in size byapproximately 1 cm per week.2481216203040Uterine size ( in weeks )After 12 weeks’ gestation,the uterus rises out of the pelvis.At 20 weeks’gestation, the uterusreaches the umbilicus.Limitations to datingby uterine size on physicalexamination Uterine malformations /fibroids. Multiple gestation. Marked uterineretroversion. Obesity. M olar pregnancy.After 20 weeks’gestation, fundalheight in centimetresmeasured from thesymphysis pubisapproximates theweeks of gestation.Key considerationsA uterus that is smaller than expectedmay indicate:t he woman is not pregnant; inaccurate menstrual dating; ectopic pregnancy or abnormal intrauterinepregnancy, e.g. spontaneous or missed abortion.A uterus that is larger than expectedmay indicate:i naccurate menstrual dating; multiple gestation; uterine abnormalities, such as fibroids; molar pregnancy. oodman S, Wolfe M and the TEACH Trainers Collaborative Working Group. Early abortion trainingGworkbook, 3rd ed. San Francisco: UCSF Bixby Center for Reproductive Health Research & Policy; 2007.*1.3 Physical examination17

1.4Laboratory and other investigations(if necessary and available)The following tests, when available, may be performed on the basis of individual riskfactors, 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; H IV testing/counselling; S TI 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 ofthe pregnancy.IMPORTANTRoutine laboratory testing is not a prerequisite for abortion services.18Section 1 Pre-abortion

Discussing contraceptive options1.5Immediate initiation of contraception following abortion has been shown to bothimprove adherence and reduce the risk of unintended pregnancy.Provide information and offer counsellingI nform 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 toassist her in choosing the most appropriate contraceptive method to meet her needs. Understand that some women prefer to discuss options for contraception after theabortion is completed.I f a woman is seeking an abortion following what she considers to be a contraceptivefailure, discuss whether the method may have been used incorrectly and howto use it correctly, or whether it may be appropriate for her to change to adifferent method. Ultimately, the final decision about whether to use contraception, and identificationof a method to use, is the woman’s alone.IMPORTANTA woman’s acceptance of a contraceptive method must never be a precondition forproviding her an abortion.1.5 Discuss contraceptive options19

2sectionAbortionS ummary of methods:medical and surgical abortion Infection prevention and control Pain management Medical abortion: 12 weeks (or 84 days) of pregnancy 12 weeks (or 84 days) of pregnancy Surgical abortion:Cervical preparation Drugs, supplies and equipment12–14 weeks of pregnancy 12–14 weeks of pregnancy

Summary of methods:2.1medical and surgical abortionMedical abortionUp to 9 weeks (63 days)9–12 weeks (63–84 days)Mifepristone 200 mgMifepristone & MisoprostolOralSingle doseMisoprostol 800 µgVaginal, buccal or sublingualSingle doseORIf no more than 7 weeks (49 days)Misoprostol 400 µgOralSingle dose Use 24–48 hours after taking mifepristoneMisoprostol AloneMisoprostol 800 µgVaginal or sublingualEvery 3-12 hours up to 3 dosesSurgical abortion12–14 weeksVacuum aspirationMethods of vacuum aspiration include:manual vacuum aspiration (MVA)electric vacuum aspiration (EVA)22Section 2 Abortion isoprostol 800 µg, then 400 µgMVaginal, then vaginal or sublingualE very 3 hours up to 5 dosesS tart 36–48 hours after takingmifepristone

12 weeks (84 days) Misoprostol 800 µg, then 400 µg Vaginal, then vaginal or sublingualOR Misoprostol 400 µg, then 400 µg Oral, then vaginal or sublingual Every 3 hours up to 5 doses Start use 36–48 hours after taking mifepristoneMisoprostol 400 µgFor pregnancies beyond24 weeks, the dose ofmisoprostol should bereduced, owing to thegreater sensitivity of theuterus to prostaglandins,but the lack of clinicalstudies precludes specificdosing recommendations.Vaginal or sublingualEvery 3 hours up to 5 doses 12–14 weeksDilatation and evacuation (D&E)D&E is the surgical method for abortion 12–14 weeks of pregnancy.2.1 Summary of methods: medical and surgical abortion23

2.2Infection prevention and controlSince abortion procedures and care involve contact with blood and other bodyfluids, all clinical and support staff that provide these services should understand andapply standard precautions for infection prevention and control, for both their ownprotection and that of their patients.Standard precautions, also called universal precautions: should be applied in all situations where health-care workers anticipate contact with:blood; any body fluid other than perspiration; non-intact skin; and mucous membranes; should always be followed, regardless of a person’s presumed infection statusor diagnosis; minimize or eliminate transmission of disease from patient to health-care worker,health-care worker to patient, or patient to patient.Standard precautions Hand-washing; hand washing with soap and running water should be routine before and aftereach contact, including after contact with potentially contaminated items, evenif gloves are worn; gloves should be worn and replaced between contacts with different clients andbetween vaginal (or rectal) examinations of the same woman. After completingcare of one woman and removing gloves, the health-care provider shouldalways wash their hands, as gloves may have undetected holes in them. Wearing barriers such as gowns, gloves, aprons, masks, protective eyewear and footwear: it should be noted that use of auxiliary supplies, such as sterile booties, doesnot make a significant difference in infection rates, although it increases costs. A septic technique: prior to any surgical abortion procedure, the woman’s cervix should be cleanedwith an antiseptic (e.g. betadine). Proper handling and disposal of sharp instruments (“sharps”) – blades and needles. Proper handling and processing of instruments and materials.Caution: Aspirators, cannulae and adaptors are not safe to handle with bare handsuntil cleaned.24Section 2 Abortion

Pain management2.3Almost all women will experience some pain and cramping with abortion. Neglectingthis important element needlessly increases a woman’s anxiety and discomfort,potentially lengthening the procedure and compromising her care. T he amount of pain that women experience with uterine evacuation or pregnancyexpulsion, and their response to that pain, varies greatly. It is necessary to individually assess each woman’s pain-management needs. Both non-pharmacological and pharmacological methods may be helpful inreducing pain associated with abortion. Close attention should be paid to a woman’s medical history, allergies andconcurrent use of medications that might interact with any available analgesic oranaesthetic agents, to optimize the safe use of all pain medications.Understanding pain with abortion A woman having an abortion may feel anxiety, fear or apprehension. Anxiety can increase sensitivity to pain. A highly anxious woman may not be able to lie still on the procedure table fora surgical abortion, potentially compromising her safety if this is not treated.P ain related to both physiological and mechanical cervical dilatation and uterinecontractions is common among women undergoing abortion.IMPORTANTOffer all women appropriate pain management before medical or surgical abortion.2.3 Pain management25

Pain-management optionsSURGICAL ABORTIONMEDICAL ABORTIONNon-pharmacological methods Respectful, non-judgmentalcommunicationPharmacological methods Respectful, non-judgmentalcommunication Verbal support and reassurance Verbal support and reassurance entle, smooth operative techniqueG dvance notice of each step of theAprocedure (if the woman desires it)T he presence of a support person whocan remain with her during the process(if the woman desires it) T horough explanation of what to expect nalgesia (non-steroidal anti-inflammatoryAdrugs [NSAIDs], e.g. ibuprofen 400–800 mg) nalgesia (NSAIDs, e.g. ibuprofenA400–800 mg) A nxiolytics/sedatives(e.g. diazepam 5–10 mg) nxiolytics / sedativesA(e.g. diazepam 5–10 mg)L ocal anaesthetic (paracervical blockusing lidocaine (usually 10–20 mL of 0.5to 1.0%) djuvant medications may also beAprovided, if indicated, for side-effectsof misoprostol (e.g. loperamide fordiarrhoea).T he presence of a support person whocan remain with her during the process(if the woman desires it) Hot water bottle or heating pad Encouraging deep, controlled breathing L istening to music Hot water bottle or heating pad onscious sedation or generalCanaesthesia in some cases, not routinely 12 weeks’ gestation In addition to NSAIDs, offer at least oneor more of the following:oral opioids;i ntramuscular (IM) or intravenous (IV)opioids; epidural anaesthesia. Paracetamol is not recommended to decrease pain during abortion.T o ensure that oral medications will be most effective at the time of the procedure,administer them 30–45 minutes before the procedure.26Section 2 Abortion

Example of how to administer a paracervical block* Inject 1–2 mL of anaesthetic at the cervical site where the tenaculum will beplaced (either at 12 o’clock or 6 o’clock, depending on the preference of theprovider or the presentation of the cervix). N ext, stabilize the cervix with the tenaculum at the anaesthetized site. Use slight traction to move the cervix and define the transition of smooth cervicalepithelium to vaginal tissue, which delineates the placement for additional injections. Slowly inject 2–5 mL lidocaine into a depth of 1.5–3 cm at 2–4 points at thecervical/vaginal junction (2 and 10 o’clock, and/or 4 and 8 o’clock). M ove the needle while injecting OR aspirate before injecting, to avoidintravascular injection. T he maximum dose of lidocaine in a paracervical block is 4.5 mg/kg/dose orgenerally 200–300 mg (approximately 20 mL of 1% or 40 mL of 0.5%).IMPORTANTGeneral anaesthesia is not routinely recommended for vacuum aspiration or D&E.Medications used for general anaesthesia are one of the few potentiallylife-threatening aspects of abortion care. Any facility that offers generalanaesthesia must have the specialized equipment and staff to administerit and to handle complications.When IV pain management, conscious sedation or general anaesthesia is used, aclinician trained (and certified, if legally required) to monitor appropriate respiratory,cardiovascular and neurologic parameters, including the level of consciousness,must be present. The practitioner administering IV pain management must beprepared to provide respiratory support in the event of respiratory suppression.Following the recommended dose-range limits reduces greatly any risks associatedwith these medications. If drugs are used that cause sedation and, potentially,respiratory depression, their antagonists must be available, preferably on anemergency cart, along with instructions on treating adverse reaction.* M altzer DS, Maltzer MC, Wiebe ER, Halvorson-Boyd G, Boyd C. Pain management. In: Paul M,Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors.

7 Contents 1 Pre-abortion 1.1 Information, counselling and decision-making 10 1.2 Medical history 14 1.3 Physical examination 16 1.4 Laboratory and other investigations (if necessary and available) 18 1.5 Discussing contraceptive options 19 2 abortion 2.1 Summary of methods: medical and surgical abortion 22 2.2 Infection prevention and control 24 2.3 Pain management 25