First Trimester Abortion Pocket Book for Health Care Providers
First Trimester Abortion Pocket Book for Health-Care Providers First Trimester Abortion: Pocket Book for Health-Care Providers ISBN 978-92-9020-977-5 © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/ mediation/rules/). Suggested citation. First Trimester Abortion: Pocket Book for Health- Care Providers. New Delhi: World Health Organization, Regional Office for South-East Asia; 2022. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http:// apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http:// apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in India
Contents Foreword iii Acknowledgments v Acronyms and abbreviations xv 1. First trimester abortion: an overview 1 1.1 Definitions: types of abortions 1 1.2 Key reproductive health indicators in countries of the South-East Asia Region 4 1.3 Barriers to access abortion services 7 2. Medicolegal aspects of abortion 8 2.1 Abortion and rights of women 8 2.2 Legal grounds for abortion 10 2.3 Country-specific legal framework 11 3. Counselling a woman seeking first trimester abortion 23 3.1 Definition of counselling 23 3.2 Guiding principles for women seeking first trimester abortion 23 3.3 Essential components of counselling for first trimester abortion 25 3.4 Counselling special groups of women 26 3.5 Consent 27 viii FIRST TRIMESTER ABORTION 4. Pre-abortion evaluation 29 4.1 Components of pre-abortion assessment 29 4.2 Medical history 30 4.3 Physical examination (including pelvic examination) 32 4.4 Laboratory and other investigations 36 4.5 Evaluation for contraception 38 5. Methods of first trimester abortion 39 5.1 Recommended methods of first trimester abortion 39 5.2 Method-specific regulatory policies for first trimester abortion 42 5.2(a) Eligibility of the provider for medical/ surgical method of first trimester abortion 43 5.2(b) Eligibility of the site where MMA/ surgical method can be provided 44 5.3 Abortion method in pre-existing medical/ surgical conditions 45 6 Medical methods of abortion for first trimester (MMA) 47 6.1 Method-specific counselling 47 6.2 Clinical considerations for medical abortion 49 6.3 Drugs for MMA 49 6.4 Pharmacokinetics of drugs 50 POCKETBOOK FOR HEALTH-CARE PROVIDERS ix 6.5 Drug regimen for induced first trimester abortion 51 6.6 Medical management of incomplete abortion 52 6.7 Medical management of missed abortion 52 6.8 Antibiotic prophylaxis for medical abortion 53 6.9 Rh isoimmunization 53 6.10 Pain management 53 6.11 Expected symptoms after administration of MMA drugs 54 6.12 Success of medical abortion 54 6.13 Follow up after first trimester MMA 55 6.14 Warning symptoms after first trimester MMA 56 6.15 Side-effects and complications of MMA and their management 56 6.16 Management of failure of abortion following MMA 57 6.17 Management of incomplete abortion following MMA 57 6.18 Recording and reporting for MMA 59 7 Surgical methods of first trimester abortion 61 7.1 Method-specific counselling 61 7.2 Clinical considerations for surgical abortion 62 7.3 Equipment for vacuum aspiration 63 x FIRST TRIMESTER ABORTION 7.4 Instruments required for vacuum aspiration 64 7.5 Cervical priming prior to surgical procedure 65 7.6 Pain management plan for surgical abortion 65 7.7 Antibiotic prophylaxis 67 7.8 Anti-D prophylaxis after first trimester abortions 67 7.9 Infection prevention practices for surgical abortion 68 7.10 Steps of surgical abortion <12 weeks of pregnancy 68 7.11 Expected symptoms after discharge 76 7.12 Warning symptoms 76 7.13 Follow-up visits after first trimester surgical abortion 77 8 Infection control practices 79 8.1 Sources of infection 79 8.2 Transmission 79 8.3 Infection prevention 79 8.4 Elements of standard precautions 80 8.4 (i) Hand hygiene 81 8.4 (ii) Respiratory hygiene (etiquettes) 81 8.4 (iii) Personal protective equipment/attire (PPE) 82 8.4 (iv) Processing instruments 82 8.4 (v) Safe injection practices, sharp management and injury prevention 85 POCKETBOOK FOR HEALTH-CARE PROVIDERS xi 8.4 (vi) Environmental cleanliness 86 8.4 (vii) Safe handling and cleaning of soiled linen 87 8.4 (viii) Segregation of waste and disposal 87 8.5 Maintaining asepsis and infection prevention for surgical abortion 89 9 Post-abortion complications 91 9.1 Complications associated with abortion 91 9.1 (i) Haemorrhage 92 9.1 (ii) Continuation of pregnancy/ failed abortion after medical/ surgical abortion 93 9.1 (iii) Incomplete abortion 94 9.1 (iv) Post-abortion infections 95 9.1 (v) Uterine perforation, uterine rupture, cervical and vaginal injury 97 9.1 (vi) Anaesthesia/ drug-related complications 99 9.1 (vii) Long-term sequelae and other complications 100 9.2 Referral linkage for post-abortion care 100 10 Post-abortion contraception 102 10.1 Rationale 102 10.2 Counselling for post-abortion contraception 102 xii FIRST TRIMESTER ABORTION 10.3 Guiding principles of post-abortion contraceptive counselling 103 10.4 Options for post-abortion contraception 104 10.5 Medical eligibility recommendations for post-abortion contraceptives 104 10.6 Time of initiation of contraceptive methods after abortion 106 10.7 Post-abortion IUCD 108 10.8 Post-abortion female sterilization 109 10.9 Contraception in special situations 110 10.10 Myths and misconceptions 111 11 Documentation, record-keeping and reporting for first trimester CAC services 112 11.1 Documentation of first trimester CAC services 112 11.2 Reporting of first trimester CAC services 114 11.3 Monitoring of first trimester CAC services 115 12 Telemedicine and self-management of first trimester abortions 118 12.1 Definition of telemedicine (or telehealth) 118 12.2 Types of interactions 118 12.3 Telemedicine provision models 118 POCKETBOOK FOR HEALTH-CARE PROVIDERS xiii 12.4 Advantages of telemedicine 119 12.5 Limitations of telemedicine 119 12.6 Technology models for telemedicine services 119 12.7 Telemedicine for MMA 119 12.8 Concerns regarding telemedicine for MMA 121 12.9 Self-managed abortion 121 List of annexes Annex 1: Spontaneous abortion 124 Annex 2(a): Information sheet 127 Annex 2(b): Informed consent for first trimester abortion (sample form) 130 Annex 3: Manual vacuum aspirator (MVA) kit 134 Annex 4(a): Hand hygiene 139 Annex 4(b): Personal protective equipment/ attire (PPE) 140 Annex 5: Overview of contraceptive methods after first trimester abortion 141 Annex 6(a): Monitoring tool for first trimester CAC services 145 Annex 6(b): Checklists for first trimester CAC services 147 References 150
Foreword The WHO South-East Asia Region (SEARO) continues to accelerate reductions in preventable maternal mortality as one of the eight Flagship Priorities in the Region and a key Sustainable Development Goal (SDG) target. In low- and middle-income countries globally, unsafe abortion is a significant cause of maternal mortality, despite being easily preventable. Between 2015 and 2019, there were an estimated 121 million unintended pregnancies annually, or around 64 unintended pregnancies per 1000 women aged 15–49 years. An estimated 61% of unintended pregnancies ended in abortion, or 39 abortions per 1000 women aged 15–49 years, globally. Barriers to accessing safe abortion include restrictive laws, poor availability of services, out-of-pocket costs, and stigma. Lack of trained abortion providers is one of the most critical issues. To help fill the gap, this pocketbook aims to support health care providers who are engaged in first-trimester abortion services. It can be used as a quick guide for both surgical and medical methods of abortion. It can be used by all service providers who offer comprehensive abortion care as per national guidelines. It xvi FIRST TRIMESTER ABORTION is aligned with and reflects new WHO guidelines on abortion care, and is an important tool for ensuring all women and girls have access to quality abortion care, delivered by designated health workers with the right skills, resources and information. I look forward to the impact this pocketbook will have in all countries of the Region, in line with national legal provisions. I urge health leaders to sensitize all stakeholders on their role in providing respectful care and addressing stigma and bias and to ensure this pocketbook is utilized in rural and hard-to-reach areas, helping close the urban-rural divide and reducing the risk of unsafe abortion for every woman everywhere. Towards that outcome, WHO will continue to provide its full support, for a fairer, healthier Region for all. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region The First Trimester Abortion Pocketbook for Health-care Providers is the product of the contribution of several individuals. The draft was reviewed by experts from Bangladesh, India, Maldives, Nepal, Sri Lanka, Thailand and Timor-Leste. Their contribution to the peer review of the Pocketbook and their valuable feedback has significantly improved the quality of this publication. Additionally, the participation of technical staff of WHO country offices is deeply appreciated. The development of the Pocketbook was coordinated by Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India, under the leadership of Dr Anjali Dabral, along with Dr Pratima Mittal and Dr Jyotsna Suri. We acknowledge the expert advice and technical support provided by WHO collaborating centres, professional associations of obstetrics and gynaecology and development partners. Overall guidance and technical oversight for the production of the Pocketbook was provided by Dr Neena Raina, Director a.i. and Dr Meera Upadhyay, Technical Officer–Reproductive Health from the Department of UHC/Family Health at the WHO Regional Office for South-East Asia. WHO would like to thank the coordination team and all the members of the Regional Expert Group who contributed to the development of this publication, while ensuring that it conformed to scientific rigour as well as relevant WHO Acknowledgments xviii FIRST TRIMESTER ABORTION guidelines and could be adapted for use across various countries. Members of the Regional Expert Group Bangladesh: Professor Ferdousi Begum, President- Obstetrical and Gynaecological Society of Bangladesh (OGSB), Dhaka; Professor Farhana Dewan, President-Elect OGSB; Professor Salma Rouf, Treasurer-OGSB, Dhaka. India: Dr Manju Puri, Director Professor and Head of the Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi; Dr Aparna Sharma, Associate Professor, All India Institute of Medical Sciences, New Delhi; Dr Achla Batra, Professor of Obstetrics & Gynaecology, Vardhman Mahaveer Medical College and Safdarjung Hospital; Dr Priti Kumar, Sunflower Medical Centre, Lucknow; Dr Jaydeep Tank, Obstetrician and Gynaecologist, Mumbai. Maldives: Dr Hawwa Inaya Abdul Raheem, Consultant, Obstetrics and Gynaecology. Nepal: Dr Meena Thapa, Gynaecologist, Kathmandu Medical College, Sinamangal; Dr Anjana Dongol, Gynaecologist, Dhulikhel Hospital, Kathmandu University, Kathmandu. Sri Lanka: Dr Mangala Dissanayake, Consultant, Sri Lanka College of Obstetricians & Gynaecologists (SLCOG), Colombo. Thailand: Dr Sanya Patrachai, Department of Obstetrics and Gynaecology, Ramathibodi Hospital. Timor-Leste: Dr Agusto Junior Gusmao, Gynaecologist, Dili National Hospital (HNGV). AIDS : acquired immune deficiency syndrome BP : blood pressure CAC : comprehensive abortion care D&C : dilatation and (sharp) curettage EVA : electric vacuum aspiration GBV : gender-based violence Hb : haemoglobin HIV : human immunodeficiency virus HLD : high-level disinfection HMIS : health management information system IUD : intrauterine device LMP : last menstrual period MMA : medical methods of abortion MMR : maternal mortality ratio MR : menstrual regulation MRM : menstrual regulation with medication MTP : medical termination of pregnancy MVA : manual vacuum aspiration Acronyms and abbreviations xx FIRST TRIMESTER ABORTION NSAID : non-steroidal anti-inflammatory drug OPD : outpatient department OT : operation theatre PGE1 : prostaglandin E1 (misoprostol) PAC : post-abortion care PAFP : post-abortion family planning PGF2 : prostaglandin F2 POC : products of conception PPE : personal protective equipment/ attire RTI : reproductive tract infection SDG : Sustainable Developmental Goal SRH : sexual and reproductive health STI : sexually transmitted infection WHO : World Health Organization
Goal of the pocketbook: Management of first trimester abortion Strengthening the knowledge and standardizing the skills of health-care providers, enabling them to provide women-centred, comprehensive abortion care (CAC) services, leading to a reduction in the complications of first trimester abortion. Scope of the pocketbook: Management of first trimester abortion The document “First trimester abortion – Pocketbook for health-care providers” highlights the key points and standard protocols for providing comprehensive abortion care (CAC) by a trained health-care provider (medical officer/ nursing personnel/ midwife/ primary health-care worker) who is authorized to provide CAC as per the country’s legal framework. Abortion is defined as spontaneous or induced termination of pregnancy before the period of viability. Viability varies according to a country’s health resources (WHO suggests the period of viability as <28 weeks). First trimester abortion refers to abortion within first 12 weeks of gestation. Abortion can be spontaneous or induced. 1.1 Definitions: Types of abortions Spontaneous abortion: Abortion is triggered spontaneously, without any external interference. Spontaneous abortion can be in the form of threatened abortion, inevitable abortion, incomplete abortion, complete abortion or missed abortion (Annex 1). Induced abortion: Termination of pregnancy is done intentionally, before the period of viability by the use of drugs or by surgical procedures. Safe abortion: Termination of pregnancy is carried out using a method recommended by WHO, appropriate to the duration of pregnancy and by someone with the necessary skills at recommended health facilities. Any abortion can be safe or unsafe. First trimester abortion an overview1 2 FIRST TRIMESTER ABORTION Unsafe abortion: Termination of pregnancy is done either by an unskilled person or in an environment not conforming to minimal medical standards or both. Unsafe abortion is a leading cause of maternal mortality and morbidity due to sepsis/ haemorrhage/ uterine perforation/ injury to the genital tract. It can lead to physical and mental health complications, social and financial burdens for women, communities and health systems. Sub-classifications for unsafe abortion (1) Less safe: Abortion performed by a trained provider who uses an unsafe or outdated method (such as sharp curettage), or by an untrained provider, who uses a safe method (such as misoprostol tablets) but without appropriate information or support from a trained person. LESS SAFE LEAST SAFE UNSAFESAFE This is nearly half of all abortions worldwide 1 out of 3 unsafe abortion occur in the worst condition (untrained persons using dangerous methods) MOST UNSAFE ABORTION OCCUR IN THE DEVELOPING WORLD POCKETBOOK FOR HEALTH-CARE PROVIDERS 3 Least safe: Abortion performed lacks both the criteria: providers are untrained and an unsafe method is used. Methods often involve ingestion of caustic substances, use of traditional concoctions, or insertion of foreign objects. Around 45% of all abortions are unsafe, of which 97% occur in developing countries. Of all unsafe abortions, one third are performed under the least safe conditions, i.e. by untrained persons using dangerous and invasive methods (2). An important cause of unsafe abortion is unintended pregnancy. The annual global rate of unintended pregnancies is 64 per 1000 women, aged 15–49 years; 61% of unintended pregnancies end in abortion (globally 73.3 million abortions a year). One in four women with unsafe abortion is likely to develop temporary or lifelong disability requiring medical care, leading to substantial emotional and financial cost to the woman. 8–11% of global maternal deaths are attributed to unsafe abortion. Maternal mortality due to abortion 61% Abortion UNINTENDED PREGNANCIES 64/1000 4 FIRST TRIMESTER ABORTION in countries of the South-East Asia Region ranges between 1% and 13% (less than 1% in Bangladesh to 13% in Timor-Leste (1). 1.2 Key reproductive health indicators in countries of the South-East Asia Region Co un try Un in te nd ed p re gn an cy % (e st im at es 20 15 –2 01 9) (3 ) Un in te nd ed p re gn an cy th at en ds in a bo rti on % (e st im at es 20 15 –2 01 9) (3 ) Un m et n ee d of fa m ily pl an ni ng (% ) Co nt ra ce pt iv e pr ev al en ce (% ) M at er na l m or ta lit y r at io (M M R) (2 01 7) U N M M IEG 20 19 De at hs d ue to a bo rti on s o f a ll m at er na l d ea th s ( % ) South-East Asia Region 152 8–11% Bangladesh 49 60 12 62 173 1% Bhutan 43 68 11.7 65.6 183 1.4% India 44 77 12.9 53.5 145 8% Indonesia 36 63 11 64 177 NA* Maldives 46 71 31 19 53 NA Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 5 Co un try Un in te nd ed p re gn an cy % (e st im at es 20 15 –2 01 9) (3 ) Un in te nd ed p re gn an cy th at en ds in a bo rti on % (e st im at es 20 15 –2 01 9) (3 ) Un m et n ee d of fa m ily pl an ni ng (% ) Co nt ra ce pt iv e pr ev al en ce (% ) M at er na l m or ta lit y r at io (M M R) (2 01 7) U N M M IEG 20 19 De at hs d ue to a bo rti on s o f a ll m at er na l d ea th s ( % ) Myanmar 35 74 16 52 250 16% Nepal 47 69 24 53 186 7% Sri Lanka 36 72 7.5 64.6 36 NA Thailand 51 64 6.2 78.4 37 10% Timor-Leste 27 68 25 26 142 13% Source: 1. Policies, programme and services for comprehensive abortion care in countries of the WHO South-East Asia Region, 2021 2. Abortion policy landscape: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste (Annex 2) 3. Bearak JM, et al. BMJ Global Health 2022;0:e007151. doi:10.1136/bmjgh-2021-007151 Continued 6 FIRST TRIMESTER ABORTION To provide safe abortion care, a health-care provider should focus on women-centred comprehensive abortion care (CAC) CAC includes: provision of information; abortion management; and post-abortion care (PAC). It encompasses care related to induced and spontaneous abortion. WOMAN CENTERED CAC CHOICE QUALITYAC CE SS POCKETBOOK FOR HEALTH-CARE PROVIDERS 7 1.3 Barriers to access abortion services Poor availability of services and lack of trained providers Stigma, making women reluctant to seek services and instead opt for secret, unsafe abortion; stigma can result in providers refusing to perform legal abortions Restrictive laws and inadequate knowledge of legal status Unnecessary requirements, third-party authorization, and instead option and unnecessary tests Cost to provide/ utilize services Quality of services The most doable component of providing safe abortion services is to focus on training the health-care providers. Health-care workers should provide safe abortion services by following women-centred CAC, to prevent abortion-related complications. Key message Objective: To understand women’s rights, laws, acts and policies related to abortion Laws and policies on abortion should protect women’s health and their human rights. Health-care workers should be well versed with the country’s legal framework related to first trimester abortion so that they can: provide accurate information to the woman seeking abortion; render advice in line with the provisions of law; and protect themselves from any litigation/ punishment when providing abortion services. 2.1 Abortion and rights of women Safe and legal abortion is a woman’s human right but countries vary in their reproductive health profile and sociopolitical context. Reproductive rights rest on the recognition of the basic right of all couples and individuals. 2 Medicolegal aspects of abortion POCKETBOOK FOR HEALTH-CARE PROVIDERS 9 Selected human rights, as specified in international laws and obligation of the countries, are relevant to sexual and reproductive health and rights, and abortion in particular. These are: right to the highest attainable standard of physical and mental health, including sexual and reproductive health and rights; right to non-discrimination and equality; right to life; right to privacy; right to be free from torture, cruel and degrading treatment and punishment including the right to physical and mental integrity; right to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so; right to information and education which should also include sexual and reproductive health; and right to benefit from scientific progress and its realization. Awareness of these basic rights by a health-care provider can definitely increase the demand and utilization of safe abortion services by women. A health-care provider can sensitize women regarding these rights. 10 FIRST TRIMESTER ABORTION 2.2 Legal grounds for abortion When there is a threat to a woman’s life When there is a threat to a woman’s health (physical or mental health) When pregnancy is the result of rape or incest When there is fetal impairment For economic and social reasons On request Risk to the life of the pregnant mother Rape or sexual abuse Serious fetal anomaly Risk to the health of the woman (physical or mental) Social and economic reasons On request Source: Policies, programme, and services CAC in the South-East Asia Region There are six legal grounds for abortion in most countries POCKETBOOK FOR HEALTH-CARE PROVIDERS 11 Abortion laws generally fall into five categories, from most to least restrictive. Most Restrictive Least Restrictive 1 2 4 5 Prohibited for any reason Permitted for any reason Permitted to save the woman’s life Permitted on broad socio-economic grounds 3 Permitted to preserve her physical heath Myanmar Sri Lanka Timor-LesteBangladesh India Nepal ThailandBhutan 2.3 Country-specific legal framework All countries permit abortion to save a woman’s life. Post- abortion care (PAC) is unanimously recognized to be an important component of the health delivery system irrespective of the country’s legal status on abortion. Legal provisions for abortions in countries of the South- East Asia Region Country Conditions permitted Gestation permitted Legal provisions Bangladesh To save a woman’s life Menstrual regulation (MR) up to 12 weeks A team of two health professionals to certify the need and consent to be approved by the Ministry of Health. Continued 12 FIRST TRIMESTER ABORTION Country Conditions permitted Gestation permitted Legal provisions Though abortions are illegal, but MR (procedure of regulating the menstrual cycle) is allowed. Consent: By woman herself, or guardian if mentally unstable or of young age. Provider: Specialist or non-specialist, and paramedical nurse (nurses can provide MR up to 8 weeks only). Method: MR by medication up to 9 weeks, vacuum aspiration (VA) 6–12 weeks. Place: All health facilities. Post-abortion care is an integral part of the MR programme. Essential medical list: Medications for abortion not in the list. Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 13 Country Conditions permitted Gestation permitted Legal provisions Bhutan To save a woman’s life Result of rape or incest To preserve the woman’s mental health Additional conditions approved in the “Management of complications” To preserve the woman’s health Fetal impairment Up to 180 days Two medical doctors need to certify that termination is essential. Consent: Compulsory consent of the spouse required. Provider: General practitioners and specialists can provide treatment of complications. Method: Medication with mifepristone and prostaglandin; VA and dilatation and curettage (D&C); illegal abortion, a serious professional misconduct and punishable. Place: Facilities where general practitioners and specialists are available. Essential medical list: Mifepristone and misoprostol in the list. Continued Continued 14 FIRST TRIMESTER ABORTION Country Conditions permitted Gestation permitted Legal provisions Democratic People’s Republic of Korea – – Birth control procedures and abortions banned, to reverse the country’s falling birth rate (October 2015). India To save a woman’s life To preserve a woman’s physical and mental health Resulting from rape or incest Serious fetal anomaly Contraceptive failure Up to 24 weeks Up to 20 weeks – opinion of one registered medical practitioner. More than 20 weeks up to 24 weeks – opinion of two registered medical practitioners. 20–24 weeks – is only for “special categories” as defined by MTP Rules 2021. No gestation limit in case of serious birth defect (determined by a medical board beyond 24 weeks). Consent: By the pregnant woman; if minor (<18 years) or mentally ill, consent of the guardian. Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 15 Country Conditions permitted Gestation permitted Legal provisions Provider: Obstetricians/ gynaecologists (specialists) and MBBS doctors (non- specialist physicians who fulfil training qualifications, as specified in the MTP Act and Rules). Method: Medical methods of abortion and surgical method on clinician’s judgement. Place: All public sector facilities and approved private facilities/ clinics. Essential medical list: Mifepristone and misoprostol in the list. Indonesia Pregnancy from rape Fetus not medically viable Not specified Mostly illegal. An ethical team of two health professionals (one a medical doctor), at the facility level to Continued Continued 16 FIRST TRIMESTER ABORTION Country Conditions permitted Gestation permitted Legal provisions Threatens the health of the woman determine eligibility for abortion. Consent: By the woman and her husband (except rape victim). Provider: Medical doctor (different from the ethical team). Method: Not specified. Place: Appointed facilities from the Ministry of Health. Punishment for providing, assisting in, or supplying information on illegal abortion. Essential medical list: Mifepristone and misoprostol not in the list. Maldives Save life of a pregnant woman Pregnancy from rape (including marital rape) Within 120 days of conception Consent: By the woman but with spousal authorization; if spouse not available, consent from the paternal father or guardian Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 17 Country Conditions permitted Gestation permitted Legal provisions Pregnancy as a result of rape by incest Pregnancy of a minor through rape The fetus is a thalassaemia major or a sickle cell major or if the fetus carries a disease that might result in a major permanent disability. Parents must be legally bound by marriage. Provider: Registered obstetricians/ gynaecologists. Place: In higher-level health facilities, the procedure is covered under the national health insurance scheme. Essential medical list: Mifepristone in the pre- authorization list (restricted for hospital use). Misoprostol pre- authorization list (25 mcg and exempt from the approval list (200 mcg). Myanmar To save the woman’s life Up to 22 weeks of conception Abortion illegal except when “performed in good faith for the purpose of saving the life of the woman”. Certification/ decision of medical board for each case. Continued Continued 18 FIRST TRIMESTER ABORTION Country Conditions permitted Gestation permitted Legal provisions Provider: Under the supervision of an obstetrician and gynaecologist. Method: Misoprostol only or VA. Place: Station hospitals, township hospitals, district hospitals and above. Criminal penalties – against the individual who performs an abortion/ causes a miscarriage. Nepal To preserve physical or mental health of woman Due to rape or incest Woman suffering from HIV Serious defects in the fetus On request up to 12 weeks As per indication 12 weeks on request 28 weeks (indications 1–4) Covered under the Right to Safe Motherhood and Reproductive Health Act, 2018. 12–28 weeks after the opinion of a licensed doctor. Consent up to 12 weeks, with the consent of the woman. Fetus (gestation) up to 28 weeks. Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 19 Country Conditions permitted Gestation permitted Legal provisions Consent: By pregnant woman; if minor (<18 years) or mentally ill, consent of the guardian. Provider: Specialist, non-specialist MDGP/ MBBS, nurses, senior Auxiliary Nursing Midwives (ANMs). Method: Mifepristone + misoprostol up to 10 weeks. Place: Listed facilities (up to 12 weeks) – government, semi- autonomous, non- governmental and private; 12–28 weeks not defined. Essential medical list: Mifepristone and misoprostol in the list. Sri Lanka To save the mother’s life No limit Causing an abortion is a criminal act and a punishable offence. Continued Continued 20 FIRST TRIMESTER ABORTION Country Conditions permitted Gestation permitted Legal provisions PAC provided at all health facilities. Incomplete abortions managed by manual vacuum aspiration, dilatation and evacuation, or medication by misoprostol. Essential medical list: Misoprostol not in the list. Thailand Save life of a pregnant woman Pregnancy from rape or incest Pregnancy threatens woman’s health Pregnant girl aged under 15 years Mental health requires certificate/ approval. Rape/ incest needs evidence. Fetal impairment needs examination and genetic counselling. Consent: By the pregnant woman. Provider: Medical practitioner is registered and has a licence. Place: Medical clinic up to 12 weeks – Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 21 Country Conditions permitted Gestation permitted Legal provisions government hospital or government agency or medical infirmary that has overnight facility for stay. Penalties for causing an abortion (with or without the woman’s consent). Essential medical list: Mifepristone and misoprostol in the list. Timor-Leste 1. To save the woman’s life Not specified Requires opinions from three physicians (an exception made by Parliament in 2009). Consent: By the pregnant woman (if possible two days before the abortion). Consent of spouse or partner when possible. In case of minors, consent is given by a legal representative. Continued Continued 22 FIRST TRIMESTER ABORTION Country Conditions permitted Gestation permitted Legal provisions Delay is suggested where possible, of at least two days between the consent from service providers and the procedure. Source: 1. Policies, programme and services for comprehensive abortion care in the WHO South-East Asia Region 2021 2. Abortion policy landscape: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste An enabling regulatory policy and environment is needed to ensure that every woman who can become pregnant and who is legally eligible has access to safe abortion care. Key message Laws and policies on abortion should protect women’s reproductive health. It should be ensured that every eligible woman has ready access to safe abortion care. Women-centred CAC should be implemented for providing quality safe abortion. All health-care workers providing CAC should be well versed with the laws of their country concerning CAC. Providers should also make women aware of their human and reproductive rights. Continued Objective: To provide information to the woman and/or couple for informed decision-making for continuation/ termination of pregnancy and post-abortion family planning. 3.1 Definition of 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 for sharing thoughts. It is a two-way communication between a health-care provider and a client, the goal being: facilitating an informed decision-making and addressing concerns of the client. 3.2 Guiding principles of counselling for women seeking first trimester abortion Essential elements of counselling are active listening, verbal and non-verbal communication. The counsellor should be: 3 Counselling a woman seeking first trimester abortion 24 FIRST TRIMESTER ABORTION warm and respectful, communicate in simple language, be a good listener and have a positive non-verbal body language; non-judgemental but compassionate without discrimination of the client’s status or reproductive behaviour; updated on technical knowledge and skills; and aware of national laws and, policies on abortion. Counselling of a woman should be done at a clean and comfortable place, where confidentiality and privacy is maintained. Appropriate time for counselling is spent during pre- abortion assessment, during and after the procedure and at the time of discharge. Local sensitivities regarding gender norms should be considered (e.g. it is appropriate for a male provider who is examining female patients to ensure the presence of female colleagues during examination). Counselling should be tailored according to the need of the individual. Clinical communication should be started with issues that are least sensitive and least threatening. The woman should be encouraged to ask questions. One should rephrase, summarize and clear the doubts and concerns of the woman patiently. POCKETBOOK FOR HEALTH-CARE PROVIDERS 25 The details of counselling should be recorded in the abortion register and client card. 3.3 Essential components of counselling for first trimester abortion Option of pain management: Risk of complications associated with the abortion method: Explanation of expected intensity/ duration of pain or menstrual-like cramps How to recognize potential side-effects and symptoms of pregnancy which may be temporary and where and how to seek help, if required Can provide telephonic contact of the facility for emergency Failure of abortion Options of abortion method based on: Procedure details: Duration of pregnancy Woman’s medical condition Potential risk factors Advantages and disadvantage of each available method Details of what will be done before, during and after the procedure Any tests that may be performed What she is likely to experience (e.g. menstrual- like cramps, pain and bleeding) Duration of the process 26 FIRST TRIMESTER ABORTION Offer contraceptive choices Details of what will be done before, during and after the procedure Any tests that may be performed When these can be started Duration of the process Provision of additional services: Where and how to access services in case of emergency Follow-up care including care regarding prevention of unintended pregnancy Expected time for return to normal activities including sexual intercourse and follow-up care 3.4 Counselling special groups of women Special group Challenges Counselling to be focused Unmarried Fear of lack of confidentiality and privacy Vulnerable to pressure Third-party authorization in case of adolescents Financial constraints Providing information and education Encouraging parents’ engagement through support Parents’ authorization not insisted upon, unless it is a legal requirement Adolescents Single woman Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 27 Special group Challenges Counselling to be focused With disadvantage and disabilities Subjected to coercion and exploitation due to their disability Information related to support services to be provided and accessibility to those to be facilitated Living with HIV/ AIDS Stigma and discrimination Provider to be sensitized about the mode of spread Facing violence at home Providers not sensitive enough to the human rights and client’s vulnerability Referral services for abuse support services to be facilitated 3.5 Consent The informed voluntary consent of an adult woman, or her guardian if minor, should be obtained (Annex 2a and 2b sample information sheet and consent form). Consent should have documentation regarding the points explained to the woman. It should be voluntary without any coercion or compulsion. In case of minors, consent from the guardian is required. Continued 28 FIRST TRIMESTER ABORTION Key message All women seeking abortion services must receive non- judgemental, complete information from a competent provider, to facilitate their decision-making for first trimester abortion. Informed written consent of the adult woman or her guardian if minor, is mandatory for providing abortion services. Health-care providers should provide empathetic, sensitive, client-centred care ensuring privacy and confidentiality. Objective: To confirm gestation and location of pregnancy and to evaluate any medical or surgical condition that requires management or may influence the choice of abortion procedure. 4.1 Components of pre-abortion assessment 4 Pre-abortion evaluation Detailed history taking General physical and pelvic examination Informed decision- making by the woman herself Informed Discussion about contraception options Investigations 30 FIRST TRIMESTER ABORTION 4.2 Medical history Personal data Name, age and contact information, if possible Reasons for seeking medical care Pregnancy symptoms Any vaginal bleeding Any drug taken for abortion If self-abortion was attempted Any intervention done for inducing abortion Menstrual history Length and duration of cycle, flow (excessive or normal), regular or irregular First date of last menstrual period (LMP) and whether the last period was normal Obstetric history Details of previous pregnancies and their outcomes, including ectopic pregnancy Prior miscarriage or abortion, fetal deaths, live births and mode of delivery Gynaecological history Gynaecological issues, including previous gynaecological 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 the methods Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 31 Personal and sexual history Any history of smoking, drinking or substance use disorder 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 disease, 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 procedures Medications and allergies Current and past medication history Allergy to medications Immunization Status of tetanus immunization: last dose received Social history Marital or partner status Family environment: assess family support 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 Continued 32 FIRST TRIMESTER ABORTION 4.3 Physical examination (including pelvic 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, note the size and abdominal tenderness 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 woman after she has passed urine Examine the external genitalia for abnormalities or signs of disease or infection Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 33 Speculum examination Inspect the cervix and vaginal canal: Look for abnormalities or foreign bodies Look for signs of infection, such as pus or discharge from the cervical os, take sample for culture, if possible and if infection is suspected administer antibiotics Cervical cytology/ HPV DNA testing may be performed at this point, if indicated and available Bimanual examination Note the size, shape, position of the uterus – anteverted or retroverted, and mobility of the uterus Assessment for adnexal masses Assess for tenderness of the uterus on palpation or with cervical movement and/ or tenderness of the rectovaginal space (cul-de-sac), which may indicate infection or ectopic pregnancy Continued Continued 34 FIRST TRIMESTER ABORTION Confirm pregnancy status and pregnancy duration Incidence of ectopic pregnancy is lower in abortion seekers than in the general population, but one must be careful regarding the possibility of ectopic pregnancy Calculation of the gestation period: Last normal menstrual period (LMP) known: One should calculate the number of weeks since the first day of the LMP in a woman with regular cycles. LMP not known or irregular cycles: The gestational age should be determined by physical examination and can be confirmed by ultrasound examination. The first trimester is generally considered to be the first 12 weeks of pregnancy Assessment of uterine size After 4 weeks of gestation the uterus increases in size by approximately 1 cm per week Weeks since the first day of LMP 2 4 8 12 Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 35 Approximate uterine size 6 weeks = Hen’s egg 8 weeks = Cricket ball size 10 weeks = Asian pear 12 weeks = Fundus just palpable above symphysis pubis After 12 weeks of gestation The uterus is out of pelvis >12 weeks Retroverted uterus Assessment of the uterine size and position Limitation of dating by physical examination Uterus smaller in size than the expected period of gestation Uterus larger in size than the expected period of gestation Wrong dates of LMP Secondary amenorrhoea/ irregular periods Lactational amenorrhoea Ectopic pregnancy Spontaneous abortion Missed abortion No pregnancy Wrong dates Multiple pregnancy Full bladder Uterine fibroid/ other tumours Uterine malformations Molar pregnancy Gestational trophoblastic disease (molar pregnancy) Pregnancy during lactational amenorrhoea 36 FIRST TRIMESTER ABORTION 4.4 Laboratory and other investigations Routine laboratory testing is not a prerequisite for abortion services. However, the following investigations may be offered Pregnancy test To confirm pregnancy Haemoglobin % or haematocrit Required if treating a woman with bleeding Haematocrit for suspected anaemia Blood group ABO Rh Testing of blood group including Rh group typing is not mandatory for first trimester abortion services. For both medical and surgical abortions at <12 weeks of gestation, the WHO guidance on abortion 2022 recommends against anti-D immunoglobin administration. HIV test May be done but not required for women to receive induced abortion services. All standard precautions must be taken during the surgical abortion method. Continued One should always be alert about the possibility of ectopic pregnancy as it is a life-threatening condition Key message POCKETBOOK FOR HEALTH-CARE PROVIDERS 37 Ultrasound* Ultrasound should not be a prerequisite for providing abortion services. There may be clinical reasons for using ultrasound scanning prior to abortion. Opportunistic screening STI screening Helps in early detection of STI in high- risk cases Cancer cervix screening Pre-malignant cases can be picked up early Other tests may be performed as per individual risk factors on history and examination. *Ultrasound scanning is not routinely required for the provision of abortion. A scan can help: to identify an intrauterine pregnancy and exclude an ectopic pregnancy; to determine gestational age; to know the viability of pregnancy; to diagnose molar pregnancy; and to identify any associated pelvic pathology as uterine fibroid, ovarian cyst, etc. Continued 38 FIRST TRIMESTER ABORTION A separate area should be provided where women seeking abortion can be scanned to maintain privacy and confidentiality. 4.5 Evaluation for contraception Health-care providers should: determine the suitability for the contraceptive method chosen by the woman; and counsel effectively to choose a suitable method of contraception. All the findings from history, examinations and investigations are documented in a woman’s case record and she should be apprised of these findings. Key message Systematic evaluation of a woman seeking abortion takes into consideration her medical history, physical and pelvic examination and investigations, which are the hallmark of providing safe abortion services. Health- care workers should evaluate the woman seeking first trimester abortion in a protocolized manner and identify high-risk cases. Objective: To provide a woman seeking abortion a choice of abortion methods that are available, appropriate, based on duration of pregnancy and medical condition. 5.1 Recommended methods of first trimester abortion 5 Methods of first trimester abortion Methods of first trimester abortion Medical methods of abortion (MMA) Surgical methods (vacuum aspiration) 40 FIRST TRIMESTER ABORTION Medical methods of abortion (MMA) Surgical methods of abortion Procedure Abortion induced by medications orally/ sublingually/ vaginally or by the buccal route Abortion performed using suction evacuation (MVA/ EVA) Effectiveness 95–99% 95–99% Products of conception (POC) Cannot always be examined Can always be examined Duration 8–13 days 15 min Advantages Avoids surgery mimics the process of spontaneous abortion Controlled by the woman and may take place at home Can be offered at an early stage No anaesthesia required Limited infrastructure needed Quick procedure Complete abortion can be easily verified by evaluation of aspirated POC Tubal ligation or placement of an intrauterine device (IUD) can be performed at the same time as the procedure Post-procedural bleeding minimal Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 41 Medical methods of abortion (MMA) Surgical methods of abortion Limitations Takes time (hours to days) to complete abortion (timing may not be predictable) Women experience bleeding and cramping, and potentially some other side-effects (nausea, vomiting) Post-procedural bleeding may be prolonged May require more clinic visits than the surgical method There may be side- effects of drugs If pregnancy continues after MMA drugs, pregnancy should be terminated as there is a risk of fetal malformation. Only a trained health-care provider can do the procedure Takes place in a health-care facility Requires instrumentation of the uterus Small risk of injury to the uterus or cervix Timing of abortion is dependent on the facility and provider Preferred method Severely obese women There are contraindications to medical abortion Continued Continued 42 FIRST TRIMESTER ABORTION Medical methods of abortion (MMA) Surgical methods of abortion Presence of uterine malformations or fibroids or previous cervical surgery There are constraints for the timing of the abortion Contraindications Previous allergic haemorrhagic disorder Severe anaemia Pre-existing heart disease Reaction to one of the drugs involved Inherited porphyria Chronic adrenal failure Known or suspected ectopic pregnancy There are no known absolute contraindications 5.2 Method-specific regulatory policies for first trimester abortion With task-specific training and functioning systems for monitoring and supportive supervision, a wide range of health-care providers can provide the services. Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 43 DR AF T Cadre of health-care providers Provide information Provision of counselling Medical method <14 weeks Surgical method VA <14 weeks Cervical priming with medication prior to surgical abortion Community health worker Recommend Recommend Recommend – Suggest Pharmacy worker Suggest Suggest Recommend – Suggest Pharmacist Recommend Suggest Recommend – Suggest Traditional and complementary medical professional Recommend Recommend Recommend Recommend* Recommend ANMs Recommend Recommend Recommend Suggest Nurse Recommend Recommend Recommend Recommend* Midwife Recommend Recommend Recommend Recommend* Recommend Associated/ advance associated clinicians Recommend Recommend Recommend Recommend Recommend General medical practitioner (GMP) Specialty medical practitioner Recommend Recommend Recommend Recommend Recommend *Only after task-specific training Source: WHO Abortion Care Guideline 2022 The country’s policies and guidelines on eligible service providers to provide medical methods/ surgical method must be followed. 5.2(a) Eligibility of the provider for medical/ surgical method of first trimester abortion 44 FIRST TRIMESTER ABORTION 5.2(b) Eligibility of the site where MMA/ surgical method can be provided Services should be available at the primary-care level, with a referral system in place for all requiring higher- level care. There should be a place where the woman can be counselled and provided with information, maintaining privacy and confidentiality. Surgical abortion should be provided at a place where resuscitation in case of emergencies and provision of sterilization of equipment are available. Additional services should be available to individuals seeking abortion as: iron tablets for anaemia; necessary pain medication; and emotional support. Referral facility for other services including complications of abortion should be available if required: physical/ sexual abuse support; counselling and testing for sexually transmitted infections (STIs, HIV); psychological or social support; and other medical/ surgical specialties. A country’s guidelines and protocols for approval of abortion facilities and protocol for MMA/ surgical abortion (VA) should be followed. POCKETBOOK FOR HEALTH-CARE PROVIDERS 45 5.3 Abortion method in pre-existing medical/ surgical conditions Pre-existing condition Medical method Surgical method Remarks Hypertension Yes, in controlled No, in uncontrolled Yes Hypertension should be controlled The usual dose of antihypertensive on the day of the abortion procedure to be taken Anaemia Yes Yes Surgical abortion in severe anaemia can be done only with availability of blood transfusion at the facility Diabetes Yes Yes Morning dose of medication is taken before the procedure Heart disease No Yes Support of cardiologist/ physician should be available Asthma Yes Yes Woman should not have an acute asthmatic attack prior to the procedure Epilepsy Yes, in controlled No, in uncontrolled Yes Usual dose of antiepileptic on the day of the abortion procedure to be taken Continued 46 FIRST TRIMESTER ABORTION Pre-existing condition Medical method Surgical method Remarks Blood-clotting disorders No Yes At a facility that is equipped to manage severe haemorrhage, anticoagulant to be stopped 48 hours prior to the procedure Previous caesarean section/ scarred uterus/ myomectomy Yes Yes Woman can be admitted on clinician’s advice IUD in situ with pregnancy Yes Yes Thread seen –IUD should be removed before the procedure Thread not seen – IUD should be removed during MVA; otherwise evaluate with USG Continued Key message Recommended methods of first trimester abortion are either medical or surgical methods. The woman’s decision should be respected regarding the choice of the method and clinical status. Medical methods or surgical methods both should conform to the country’s medicolegal framework. Health-care providers should inform the woman seeking first trimester abortion about the methods available and the criteria to choose a particular method. Objective: To provide a medical method of abortion (MMA) to a woman seeking first trimester abortion. MMA using mifepristone + misoprostol or misoprostol alone is one of the non-invasive, safe technologies for abortion care. The method can be used for: induced abortion; incomplete abortion; and missed abortion. MMA comes under the purview of abortion laws of the country, which should be strictly followed as per the country’s guidelines and protocols. 6.1 Method-specific counselling Women choosing MMA should be provided the following information: The process is similar to a natural miscarriage. She should be counselled about different routes of administration. She has to follow a definite drug protocol. 6 Medical methods of abortion for first trimester (MMA) 48 FIRST TRIMESTER ABORTION If a woman is lactating, she should withhold breastfeeding for 4 hours after misoprostol administration. Home administration of misoprostol can be allowed (provider’s discretion). She has to stay within the accessible limits of the appropriate health-care facility. She should not be left unattended at home. She has to be ready for surgical procedure in case of failure of the method or excessive bleeding. The symptoms that would be experienced by her should be explained, e.g. pain, expected bleeding pattern, etc. There could be teratogenic (harmful) effect on the fetus, if pregnancy continues after MMA especially with misoprostol. A small percentage of women (3%) may expel products with mifepristone alone, but a total drug schedule with misoprostol must be completed. During the abortion process, it is ideal to avoid intercourse to prevent infection, or use barrier methods. The woman should have arrangements for transportation to the hospital in case of emergency or she should be admitted for the MMA procedure. Voluntary informed consent should be taken for MMA after counselling the woman. POCKETBOOK FOR HEALTH-CARE PROVIDERS 49 6.2 Clinical considerations for medical abortion Medical abortion is a multi step process involving two medications (mifepristone and misoprostol) and/ or multiple doses of one medication (misoprostol alone). Mifepristone with misoprostol is more effective than misoprostol used alone, and is associated with fewer side-effects. Vaginal misoprostol is more effective than oral administration, and may have fewer side-effects than sublingual or buccal. Allowing home use of misoprostol following the provision of mifepristone at a health-care facility can improve the privacy, convenience and acceptability of services, without compromising on safety. 6.3 Drugs for MMA Regimens recommended can be: sequential use of tablet mifepristone followed by misoprostol; tablet misoprostol can be used alone; and a combination of letrozole plus misoprostol is also suggested. 50 FIRST TRIMESTER ABORTION 6.4 Pharmacokinetics of drugs Tablet misoprostol Misoprostol causes cervical softening, uterine contractions, expulsion of products of conception (POC). It can be used either in combination with mifepristone or alone. It is easy to handle and store in a dry place at or below 25 ºC. It is stable at room temperature. It can be administered by oral, vaginal, buccal and sublingual routes (side-effects and instructions for use through different routes differ). It is available as 25, 100, 200 mcg tablets. Tablet mifepristone Mifepristone is an antiprogestin. It inhibits action of progesterone. It interferes with continuation of pregnancy by withdrawing progesterone support. Mifepristone is always administered orally. It is available as 200 mg tablet. Key message Letrozole is a third-generation aromatase inhibitor and its action is to suppress estrogen production. The use of letrozole in combination with misoprostol showed higher rates of successful medical abortions. POCKETBOOK FOR HEALTH-CARE PROVIDERS 51 Pharmacokinetics of misoprostolBuccal and sublingual routes of misoprostol administration Buccal Sublingual Route Onset of action Duration of action Oral 8 min 2 hours Sublingual 11 min 3 hours Vaginal 20 min 4 hours Rectal 100 min 4 hours Source: Tang et al., Int J Gynecol Obstet. 2007;99:S160–S167 6.5 Drug regimen for induced first trimester abortion Regimen Dose Remarks Mifepristone + misoprostol Mifepristone 200 mg PO 1–2 days later Misoprostol 800 μg B, PV or SL Minimum interval between mifepristone and misoprostol should be 24 hours. Misoprostol 800 μg B, PV or SL Repeat dose of misoprostol can be considered when needed. Mifepristone + letrozole Letrozole 10 mg daily for three days followed by misoprostol 800 mcg sublingually on the fourth day Suggested by WHO, further evidence needed. PO: per oral; B: buccal; PV: vaginal; SL: sublingual 52 FIRST TRIMESTER ABORTION Combination regimen of mifepristone and misoprostol is recommended as it is more effective. There is no change in dosage of misoprostol as per gestational age of pregnancy, previous guidance advocated different regimens, which varied up to 7 weeks, 9 weeks and 12 weeks. There is no evidence and guidelines for maximum number of doses of misoprostol. Health-care providers should use caution and clinical judgement. Moistening of misoprostol tablets is not recommended as it does not improve their efficacy. Source: Abortion Care Guidelines WHO, 2022 6.6 Medical management of incomplete abortion For medical management of incomplete abortion at first trimester, the recommendation is: 600 μg misoprostol administered orally or 400 μg misoprostol administered sublingually. 6.7 Medical management of missed abortion Medical management can be recommended: Dosage and administration of the drug regimen (mifepristone and misoprostol) used is the same as that of first trimester induced abortion. POCKETBOOK FOR HEALTH-CARE PROVIDERS 53 If using the alternative regimen (misoprostol alone), repeat dosing of misoprostol is more efficacious at >9 weeks of gestation. Ectopic pregnancy: Mifepristone and misoprostol do not terminate ectopic pregnancy. 6.8 Antibiotic prophylaxis for medical abortion Antibiotic prophylaxis for medical abortion is not recommended. 6.9 Rh isoimmunization WHO guidance on abortion, 2022, recommends against anti-D immunoglobin administration for medical abortions at <12 weeks of gestation. 6.10 Pain management During abortion, pain management should be offered routinely and to be provided for the individual to use if and when required. Analgesia NSAIDs, e.g., ibuprofen 400–800 mg. Acetaminophen can be considered if NSAIDs are not available or not the option. Hot water bottle or heating pad can be advocated. Verbal support and reassurance and thorough explanation of what to expect is helpful in reducing the perception of pain. 54 FIRST TRIMESTER ABORTION 6.11 Expected symptoms after administration of MMA drugs Expected symptoms are usually self-limiting: Bleeding soaking of two thick pads within 1–2 hours after taking misoprostol is normal bleeding; more than this warrants medical attention; Pain/ cramps in the abdomen; Fever/ chills/ rigors; Nausea or vomiting; Diarrhoea; Headache; and Dizziness. 6.12 Success of medical abortion Combination of mifepristone and misoprostol has an effectiveness of 95–99% for termination of early pregnancy. Success of medical abortion is determined by signs and symptoms as experienced by the individual: bleeding with clots; passage of products of conception (POC); and pain that may be significantly stronger than menstrual pain. POCKETBOOK FOR HEALTH-CARE PROVIDERS 55 If ongoing symptoms of pregnancy are reported and/ or there has been minimal bleeding or no bleeding after taking the medications as directed ongoing pregnancy should be suspected and further evaluation should be done by pelvic examination (demonstrates growing/ same size uterus) or by ultrasonography. 6.13 Follow up after first trimester MMA Routine follow-up not necessary following an uncomplicated medical abortion using mifepristone and misoprostol. Routine follow-up visit is recommended only in case of medical abortion using misoprostol alone to assess the completion of abortion. Optional follow-up visits at 7–14 days may be provided after the procedure to provide contraceptive counselling and services, emotional support or address any medical concern. A woman’s recovery and risk for any signs or symptoms of ongoing pregnancy should be explained to her. Any symptom experienced since the procedure performed should be reviewed and a focused physical examination should be performed for any complaints. The woman should be informed that fertility may return as early as early as 8–14 days after medical abortion. Telephone number of the facility should be provided to the woman to contact in case of any emergency. 56 FIRST TRIMESTER ABORTION 6.14 Warning symptoms after first trimester MMA Excessive bleeding (soaking two or more pads per hour for two consecutive hours) Fever lasting >1 day with or without chills Worsening pelvic pain Signs of pregnancy as continued nausea and vomiting 6.15 Side-effects and complications of MMA and their management Bleeding Reassurance if it is within normal limits If bleeding is more than expected, then evaluation to be done for incomplete abortion Vacuum aspiration is advocated for profuse bleeding (incomplete abortion If there is evidence of haemodynamic compromise, intravenous (IV) fluids should be started Blood transfusion, if required (rare) Fever Antipyretic drugs, such as paracetamol Repeated doses of misoprostol may cause rise in temperature Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 57 If fever persists for more than 24 hours after misoprostol, further assessment is warranted Post-abortal infection is rare after MMA Nausea and vomiting Rule out continuation of pregnancy by pelvic examination/ ultrasonography Diarrhoea Self-limiting; reassure, anti-diarrhoeal medication can be prescribed Encourage oral hydration Adjuvant medications may be provided as loperamide for diarrhoea 6.16 Management of failure of abortion following MMA For failure of MMA, one should evaluate if the drugs were taken as directed. Either vacuum aspiration or repeat medical method of abortion is advocated. 6.17 Management of incomplete abortion following MMA Incomplete abortion can be diagnosed by the clinical presence of open cervical os and bleeding whereby all Continued 58 FIRST TRIMESTER ABORTION POC have not been expelled from the uterus. Common symptoms are: vaginal bleeding; abdominal pain; POC may be visualized or felt at the os; and expulsed tissue is not consistent with the estimated period of gestation of pregnancy. The mode of management of incomplete abortion should be based on the individual’s clinical condition and preference of treatment. For incomplete abortion in first trimester, either vacuum aspiration or medical management is advocated. The recommended dose for first trimester incomplete abortion is: 600 μg misoprostol administered orally, or 400 μg misoprostol administered sublingually. Expectant management of incomplete abortion can be tried; however, the possibility of continuous bleeding and pelvis sepsis remains. POCKETBOOK FOR HEALTH-CARE PROVIDERS 59 6.18 Recording and reporting for MMA MMA comes under the purview of abortion laws of the country and documentation and reporting should be as per country’s legal provisions. Recording of MMA in the hospital abortion records, register for case records, is mandatory. Management of failure or incomplete abortion following MMA Failure of MMA Offer vacuum aspiration Repeat MMA Incomplete abortion (Result of MMA) Observe unless heavy bleeding Bleeding resolved, uterus normal size Abortion complete Repeat misoprostol Heavy bleeding continues Offer surgical method of evacuation 60 FIRST TRIMESTER ABORTION MMA data should be included in the monthly reporting format with other hospital reports and should be shared with district/ province government authorities. The MMA data should be entered in the government’s health management information system (HMIS) data for inclusion in the global data of MMA and abortions. Key message MMA can be performed by tablets mifepristone, misoprostol combination or misoprostol alone for less than 12 weeks pregnancy. Counselling and ruling out contraindications is mandatory before initiating MMA. The woman must provide informed voluntary written consent for MMA. For all the regimens, health- care providers should be aware of the side-effects, expected symptoms, outcome and complications of MMA. Management should be as per country’s protocol and legal framework. Objective: To provide a surgical method of first trimester abortion. Vacuum aspiration is the recommended technique of surgical abortion for pregnancies up to 12 weeks. The method can be used for: induced abortion; incomplete abortion; and missed abortion. Surgical abortion using vacuum aspiration (VA) comes under the purview of abortion laws of the country, which should be strictly followed as per country’s guidelines and protocols. 7.1 Method-specific counselling The procedural details of what will be done before, during and after the procedure must be explained to the woman. She is likely to experience pain, and pain management options should be provided to her. 7 Surgical methods of first trimester abortion 62 FIRST TRIMESTER ABORTION Type of anaesthesia – paracervical block – how it will be administered and any complications as anaphylaxis can occur. Since it is an invasive procedure, there can be complications as perforation, injury to other organs as bladder/ intestine, etc., and laparotomy may be required. Voluntary informed consent should be taken for surgical abortion after counselling the woman. 7.2 Clinical considerations for surgical abortion Surgical abortion by dilatation and sharp curettage (D&C), including sharp curette checks (i.e. to “complete” the abortion following vacuum aspiration) is not recommended. WHO recommends manual vacuum aspiration (MVA) as the safest method for abortion up to 12–14 weeks of size. Routine use of general anaesthesia is not recommended for VA in first trimester abortion. POCKETBOOK FOR HEALTH-CARE PROVIDERS 63 7.3 Equipment for vacuum aspiration Manual vacuum aspiration (MVA) Electric vacuum aspiration (EVA) Hand-held aspirator used to generate vacuum Aspirator is attached to a cannula of 4–12 mm in diameter MVA syringe and cannula Electricity used to generate vacuum Electric vacuum is attached to a cannula of 4–12 mm in diameter EVA The procedure of abortion performed is same regardless of the type of vacuum used. 64 FIRST TRIMESTER ABORTION 7.4 Instruments required for vacuum aspiration Sims’ speculum/ Cusco’s speculum/ Auvard’s speculum and anterior vaginal wall retractor Tenaculum/ vulsellum Dilators Manual vacuum aspirator (with a cannula up to 12 mm, electric vacuum aspirator for backup) Sponge holding forceps Small ovum holding forceps Stainless steel bowl for preparing solutions Instrument tray Clear glass dish/ light box for tissue inspection Strainer (metal, glass or gauze) Equipment required for vacuum aspiration POCKETBOOK FOR HEALTH-CARE PROVIDERS 65 7.5 Cervical priming prior to surgical procedure May be considered to prepare the cervix. Some recommended methods of cervical preparation prior to first trimester surgical abortion can be: oral mifepristone 200 mg (24–48 hours in advance); misoprostol 400 μg sublingually 1–2 hours before the procedure; misoprostol 400 μg vaginally or buccally 2–3 hours prior to evacuate procedure; and use of osmotic dilator for cervical priming in first trimester is not recommended. 7.6 Pain management plan for surgical abortion Non-pharmacological Pharmacological Respectful, non- judgemental communication Verbal support and reassurance Gentle, smooth operative technique Pain management should be offered routinely and should be provided to those who want it Analgesia (non-steroidal anti-inflammatory drugs [NSAIDs], e.g. ibuprofen Continued 66 FIRST TRIMESTER ABORTION Information of each step of the procedure Encouraging deep, controlled breathing Encourage listening to music Use of hot water bottle or heating pad 400–800 mg) to be given 30–45 minutes prior to the procedure Paracervical block** Conscious sedation+ [S8] paracervical block should be offered wherever conscious sedation is available +Conscious sedation is a combination of medicines for relaxation (a sedative) and to block pain (an anaesthetic) during a medical procedure. Diazepam or midazolam can be used as they have both the effects. **Paracervical block A 10 mL syringe, with 22–24 gauge needle, is loaded with 1% plain lignocaine (10 mL). There is enough evidence that a sensitivity test before administering local anaesthesia is not mandatory. 2 mL of the solution is injected superficially into the cervix at 12 o’clock for placing the tenaculum. The cervix is grasped with the vulsellum/ tenaculum and slight traction is applied to expose the area between the smooth cervical epithelium and the vaginal tissue. Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 67 The remaining 8 mL is injected in equal amounts at the cervicovaginal junction at 4 and 8 o’clock position at a depth of 2–3 mm. 10 and 2 o’clock positions can be additional optional sites for injection. One should always aspirate to check, whether inadvertently any vessel is entered into. The maximum dose of lidocaine in paracervical block is 4.5 mg/kg/dose or generally 200–300 mg (approximately 20 mL of 1% or 40 mL of 0.5%). Rarely, there can be anaphylaxis to local anaesthetics. Small bolus doses of 0.5 mL of 1:1000 adrenalin should be administered. Dose can be repeated at five-minute intervals. 7.7 Antibiotic prophylaxis Antibiotic prophylaxis should be provided for first trimester vacuum aspiration. Single-dose administration of nitroimidazoles, tetracyclines or penicillin has been shown to be effective. 7.8 Anti-D prophylaxis after first trimester abortions Administration of the immunoglobulin to Rh-negative women is not recommended for medical/ surgical abortion of <12 weeks. Continued 68 FIRST TRIMESTER ABORTION 7.9 Infection prevention practices for surgical abortion All standard precautions for infection prevention should be followed throughout the procedure (see chapter 8 infection prevention). 7.10 Steps of surgical abortion <12 weeks of pregnancy 1. Preparation of the instruments The equipment for MVA should be assembled and charged (Annex 3). One should check that aspirator retains vacuum. If using an EVA, machine should be checked if it is functional. 2. Preparation of the woman for the procedure The woman is asked to empty her bladder and is helped into the dorsal lithotomy position on the procedure table. The provider should wash hands, and put on appropriate barriers, including clean gloves. POCKETBOOK FOR HEALTH-CARE PROVIDERS 69 The surgical field is prepared with all standard precautions for infection prevention (chapter 8 infection prevention). 3. Bimanual examination is performed to: determine the uterine size; and determine the position of the uterus. 4. Speculum insertion: The speculum is introduced gently to ensure adequate visualization of the cervix. 5. Cervical anti-septic preparation: The cervix is wiped with a non-alcoholic antiseptic solution starting at the cervical os with each new sponge wiping from inward to outward direction circularly until the os has been completely covered by the antiseptic solution. 6. Paracervical block is given using 10 mL of 1% lignocaine (or one can proceed to step 7 directly). 7. Cervical dilatation: The cervix is stabilized by placing the tenaculum on the anterior cervical lip and continuous traction is applied to straighten the cervical canal. 70 FIRST TRIMESTER ABORTION Dilatation of the cervix is assessed (if cervical priming has been done) to see if cervical os allows a cannula of appropriate size. The dilatation of the cervix should be 1 mm more than the size of the cannula needed for that gestation. If the cervix is closed or insufficiently dilated, then dilatation is done gently without using force and applying the no-touch technique, with successive mechanical dilators, starting with the smallest. 8. Suction cannula insertion: When appropriate cervical dilatation is achieved, the cannula of selected size as per gestational age is inserted just past the internal cervical os and into the uterine cavity, while gently applying traction to the cervix. The cannula should not be inserted forcefully, to avoid trauma to the cervix or uterus. *The procedure should be stopped if uterine perforation is suspected. POCKETBOOK FOR HEALTH-CARE PROVIDERS 71 Selecting the cannula size Uterine perforation is suspected if: There is a feeling of something giving away. There is sudden loss of resistance during cervical dilatation or vacuum aspiration. The instrument passes well beyond the expected length of the uterus. The woman has severe pain or persisting PV bleeding. There is an absence of POC in MVA syringe/ suction bottle. Uterine size (week since LMP) Suggested cannula size (mm) 4–6 4–7 7–9 5–10 9–12 8–12 Using a too-small cannula may result in incomplete abortion, retained product of conception and frequent clogging of cannula during the procedure. 9. Aspiration of uterine contents The suction cannula is held in one hand and the prepared manual vacuum aspirator/ electric vacuum connector is held in other hand and both are connected. The cannula is advanced to mid-uterus and the MVA/ EVA are connected. 72 FIRST TRIMESTER ABORTION The suction is initiated by MVA – releasing of the valve which leads to the creation of vacuum (Annex 3). EVA – after pressure of 60 cmHg is created. The contents of the uterus are evacuated gently and slowly, rotating the cannula in 180º in each direction. Blood and tissue are visible through the cannula. The opening of the cannula should not be withdrawn beyond the cervical os, otherwise suction gets lost. If the MVA aspirator becomes full, the aspirator is detached from the cannula, leaving the cannula in the uterus, the aspirator is emptied into an appropriate container, and the vacuum is re-established. This procedure is repeated until the uterus is empty. Signs of the completion of the procedure: red or pink foam appears, and no more tissue is seen passing through the cannula; a gritty sensation is felt as the cannula passes along the surface of the evacuated uterus; and the uterus contracts around the cannula. POCKETBOOK FOR HEALTH-CARE PROVIDERS 73 When the procedure is complete, the cannula and cervical tenaculum are removed. The cervix is wiped with a clean swab and bleeding is assessed. The practice of dilatation and sharp curettage (D&C), including sharp curette checks (to complete the abortion) following vacuum aspiration is not recommended. Disposable cannula should be discarded in the appropriate waste bin for contaminated plastic as per national guidelines. MVA aspirators and the cannula that will be reused should be kept wet until cleaning. These should be pre-soaked, rinsed or sprayed with water or enzymatic spray. One should not use chlorine or saline. 10. Inspection of the tissue Inspection of the POC is important; to inspect the tissue, the uterine aspirate is emptied into an appropriate container (aspirated contents should not be pushed through the cannula, as it will become contaminated). The quantity and presence of POC: villi, decidua and sac/ membrane should be assessed; after 9 weeks gestation, fetal parts are visible. One should see for the presence of grape-like hydropic villi, the presence of these may suggest 74 FIRST TRIMESTER ABORTION a molar pregnancy. The tissue must be sent for histopathological examination if molar pregnancy is suspected. If the visual inspection is inconclusive, the tissue should be strained, placed in a transparent container, immersed in water, and viewed with light from beneath. If no POC are visible or the tissue removed is less than expected for that gestational age, evaluation should be done for incomplete abortion/ failed abortion/ ectopic pregnancy/ uterine anomaly (in a bicornuate or septate uterus, the cannula may have been inserted into the side of the uterus that did not contain the pregnancy). Disposal of aspirate: POC and aspirates should be disposed of in the appropriate waste bin for contaminated biological material as per national guidelines. 11. Concurrent procedures When the aspiration procedure is complete, one should proceed with any concurrent procedure to be conducted such as IUD insertion, tubal ligation or repairing a cervical laceration, as necessary. 12. Recovery and discharge a) Immediate post-procedure care The woman should be reassured that the procedure is finished and that she is no longer pregnant. POCKETBOOK FOR HEALTH-CARE PROVIDERS 75 Vitals are monitored for any complications and management is provided as needed. In case of tachycardia or hypotension, the woman should be urgently reviewed and managed. She should be evaluated for bleeding per [S9] vagina and for abdominal pain, which should decrease over time. The recovery period may last for 30 min to one hour if procedure is done under local anaesthesia or may require longer if sedation or general anaesthesia is used. The woman may leave the facility when she is stable. Any emotional need of the woman should be assessed. Her anxiety immediately following the abortion should be addressed. All outcomes of the treatment, including any adverse events should be documented. b) Before discharge If the woman has any signs of complications such as fever, excessive bleeding or foul-smelling discharge, evaluation should be done and should be managed at the facility and discharge should be delayed. The woman should be provided with all the necessary medications before discharge. Pain medications can be provided such as NSAIDs or acetaminophen. Before the woman leaves the facility, clear, simple oral and written instructions should be provided 76 FIRST TRIMESTER ABORTION including instructions on diet (normal diet) and sexual intercourse (only after heavy bleeding stops). If any concurrent contraception is provided, instructions regarding that should be given. The phone number of the facility should be provided so that women may call for questions or concerns and can get appropriate guidance. 7.11 Expected symptoms after discharge Nausea and vomiting generally subside within 24 hours after surgical abortion. Cramping may occur which may be reduced with NSAIDs such as ibuprofen. Light vaginal bleeding or spotting for 2 weeks after completed surgical abortion is normal. 7.12 Warning symptoms Heavy vaginal bleeding Signs of pregnancy as a continuation of nausea or vomiting Increased intensity of cramping or abdominal pain Fever >38 ºC at least at the interval of 4 hours POCKETBOOK FOR HEALTH-CARE PROVIDERS 77 7.13 Follow-up visits after first trimester surgical abortion Routine follow-up visit after a surgical abortion is not recommended. Optional follow-up visits at 7–14 days can be considered for providing psychological support and advice on contraceptive use. The woman should be evaluated if: she has continued nausea and vomiting (symptoms of ongoing pregnancy); heavy bleeding; no bleeding at all; pain not relieved by medication; dizziness, fainting attack; and fever. Iron tablets should be given with instructions to use in cases of anaemia. The woman should be informed that decision to start contraceptives is important as: 78 FIRST TRIMESTER ABORTION fertility can return as soon as 2 weeks after abortion; and emergency contraception should be provided for dual protection. Referral to other services should be facilitated as per the assessment of her needs: STI/ HIV counselling and testing; and abuse support services (gender-based violence [GBV]), psychological or social services. Key message Vacuum aspiration (VA) is the safest method of first trimester abortions. The procedure should be performed by a trained provider after informed written consent of the woman seeking abortion. Asepsis should be maintained and standard protocol should be followed at every step. Health-care providers should be well trained in the task of surgical methods of abortion. Providers should explain to the woman undergoing the procedure when to report back to the health-care facility. Objective: To learn infection prevention measures while caring for the patient in the health-care facility or during a surgical procedure, and also learn how health-care providers should protect themselves while caring for the patient. 8.1 Sources of infection Endogenous source: Microorganisms present on or within the patient. Exogenous source: External to the patient such as health workers, visitors, patient-care equipment, medical devices, and the health environment. 8.2 Transmission Hands, droplet, instruments, blood 8.3 Infection prevention Standard precautions: All patients irrespective of their status are considered as potentially infected. Standard precautions are basic level precautions, when implemented and practised correctly and consistently at all times can reduce hospital-acquired infections (HAIs). 8 Infection control practices 80 FIRST TRIMESTER ABORTION Transmission-based precautions (TBPs) are used in addition to standard precautions when standard precautions alone may be insufficient to prevent transmission of infection. TBPs are used for patients known or suspected to be infected or colonized with epidemiologically important or highly transmissible pathogens that can transmit or cause infection as global pandemics (COVID-19, SARS-CoV-1, SARS-CoV-2 and MERS-CoV). 8.4 Elements of standard precautions Hand hygiene Respiratory hygiene (etiquettes) Personal protective equipment/ attire (PPE) according to the risk Safe injection practices, sharp management and injury prevention Safe handling, cleaning and disinfection of patient care equipment and instrument processing Environmental cleaning Safe handling and cleaning of soiled linen Waste management POCKETBOOK FOR HEALTH-CARE PROVIDERS 81 8.4(i) Hand hygiene (Annex 4a) Hand washing with soap and water (40–60 seconds). Hand rubbing with alcohol-based hand rub (20–30 seconds) (Annex 2.2). When to perform hand hygiene Before and after examining the woman (or having any direct contact). After exposure to blood or any body fluids (secretions or excretions), even if gloves were worn. After removing gloves because the gloves may have holes in them. Alcohol-based hand rub is the gold standard in all clinical situations (WHO). Hand scrubbing The hands should be scrubbed before wearing gloves when performing surgical abortion. 8.4(ii) Respiratory hygiene (etiquettes) Maintaining at least a 1-metre (3-feet) distance from other individuals in common waiting areas. Covering mouth/ nose when sneezing/ coughing. 82 FIRST TRIMESTER ABORTION Performing hand hygiene after soiling hands with respiratory secretions. Apply additional disease-specific TBPs as needed. 8.4 (iii) Personal protective equipment/ attire (PPE) (Annex 4b) PPE acts as a barrier between the direct contract of the health-care provider and the client. These are: Cap, mask, goggles, gown, gloves, apron and footwear. Country-specific guidelines for PPE during any health emergencies must be followed. 8.4 (iv) Processing instruments It is important to have clean, germ-free instrument for each client to prevent infection transmission. Therefore, after each procedure and at the end of each day the used instruments must be processed and stored to keep them ready for the next day. Disposable instruments/ equipment should not be used again. Steps of processing used or contaminated instruments: Pre-cleaning soiled instruments before washing. Washing with detergent and water. POCKETBOOK FOR HEALTH-CARE PROVIDERS 83 High-level disinfection (HLD) or sterilization. Storage. Pre-cleaning After using instruments, they should be opened if they have lock/ teeth/ hinges (vulsellum, sponge holder). The MVA syringe should be disassembled. Instruments should be kept moist till processing so as not to allow contaminants to dry because drying will hinder cleaning of instruments. The instruments can be kept moist by putting in water (saline not used), by covering with a moist towel soaked with water or foam, spray or gel specifically intended for this purpose. Instruments should be cleaned by wiping with a damp clean cloth before washing. Instruments should not be soaked in disinfectant (0.5% chlorine) prior to cleaning because: The instruments get damaged by the action of bleach solution. Any blood and body fluid has the potential to inactivate the disinfectant. This may contribute to the development of antimicrobial resistance to disinfectants. 84 FIRST TRIMESTER ABORTION Washing with detergent and water After pre-cleaning, all surfaces of instruments are washed in running water and with a detergent. A soft brush is used; nothing sharp or pointed should be used. Cleaning is done until no blood or tissue is visible. After washing, instruments are sent for sterilization or HLD. Sterilization/ high-level disinfection (HLD) Sterilization is a process that destroys all microorganisms (such as bacteria, viruses, fungi, and parasite/ protozoa) including bacterial endospores. Technically, there is a reduction ≥106 log colony forming units (CFU) of the most resistant spores. It can be done by using steam (autoclaving at 15 lb/ sq inch pressure for 20 minutes for unwrapped and 30 minutes for wrapped instruments and linen. It can also be done by soaking in a chemical solution such as 2% glutaraldehyde solution for at least 8 hours. HLD is a process that destroys all microorganisms excluding bacterial endospores. POCKETBOOK FOR HEALTH-CARE PROVIDERS 85 Technically able to kill 106 log microorganisms except for spores and is acceptable for processing instruments and other items for reuse. If sterilization is not possible, HLD can be achieved by boiling. It can also be done by soaking in a high- level disinfectant for 20 minutes such as 2% glutaraldehyde solution. Storage Autoclaved instruments should be stored in drums with closed lids. If they are not used, they should be autoclaved again after 7 days. The date of sterilization should be marked on the tray/ drum. HLD instruments if not used should be disinfected after 24 hours. Instruments should be stored when dry; wet instruments can generate microbial growth. 8.4 (v) Safe injection practices, sharp management and injury prevention Recapped, bent or broken before disposal, they are made unusable after single use by burning them in a needle destroyer and/ or in hub-cutter. 86 FIRST TRIMESTER ABORTION Syringes should never be burnt. They are disposed of in red coloured bins or, if the needle is attached, in a puncture-proof container. Broken glassware is disposed of in cardboard boxes with a blue-coloured marking. Do not reuse disposable syringes or needle. Always wear gloves for sharp disposal. (Follow national guidelines for segregation of waste and disposal.) 8.4 (vi) Environmental cleanliness Floors, corridors must be cleaned daily with a wet mop instead of dry sweeping. The floor should be kept dry. All examination/ operation theatre (OT) tabletops and surface-lamp shades, almirahs, lockers, trollies, etc. should be cleaned with low disinfectant (2% carbolic acid or 0.5% chlorine solution). Examination tables should be cleaned with low disinfectant after each use. Soiled areas on floor are cleaned with a mop dampened with a disinfectant cleaning solution (or as per national guidelines). POCKETBOOK FOR HEALTH-CARE PROVIDERS 87 All cleaning staff should wear PPE. At the end of the day, floors, corridors must be cleaned with low disinfectant. Blood/ infected spill Spills of infected or potentially infected material on the floor should be covered with paper towel/ blotting paper. Disinfectant (5% phenol or freshly prepared 1% hypochlorite solution) is poured on the spill and left for at least 10 minutes. The floor is then wiped with gauze or cloth with gloved hands. The gauze or cloth used to wipe is discarded as biomedical waste. 8.4 (vii) Safe handling and cleaning of soiled linen Linen (drapes, sponges, scrub suits, etc. are washed with soap and water and then autoclaved at 15 lb/sq inch for 30 min in a drum. The autoclaved linen should be used within one week but if the drum is opened, it should be used within 24 hours. 88 FIRST TRIMESTER ABORTION 8.4 (viii) Segregation of waste and disposal It is important to dispose of all kinds of waste properly as improper disposal of biomedical waste poses a health risk to health-care providers and the community. All waste in a health facility can be divided into: General waste: The waste that poses no risk of infections. It is similar to household trash. Medical/ biomedical waste: Material generated in the management of clients, including blood, blood products and other body fluids, bandages/ surgical sponges and organic waste such as human tissues, body parts, placenta and POC. Sharps: Like needles, blades, broken glass, etc. There are four steps in the waste management plan: Segregation: Segregation of the waste at the point of generation into colour-coded bins in accordance with local regulations is an important step. Collection and storage: Waste should be collected in covered bins and not filled more than three fourths. The waste should not be stored for more than 48 hours. Transportation: Transportation should be done in closed containers. Dedicated vehicles should be used for offsite transport of waste. POCKETBOOK FOR HEALTH-CARE PROVIDERS 89 Disposal of waste: Final disposal should be done as per country’s protocols. Sharps should be disposed of into leak-proof, puncture-resistant sharps containers. One should follow the national guidelines on the final disposal of health-care waste (e.g. incineration, burying, and autoclaving). 8.5 Maintaining asepsis and infection prevention for surgical abortion All standard precautions for infection prevention should be followed throughout the procedure Preparation of the skin Pubic hair should not be shaved. Cleaning the operative field Follow the clinical guidelines of the hospital The vagina should be cleaned with 2.5% betadine. Spirit or alcohol should never be used for the vagina. Draping the operative field The perineum and lower abdomen should be draped with sterile drapes, to avoid contact of instrument with body surface. During the procedure 90 FIRST TRIMESTER ABORTION The cervical os to be cleaned from centre to periphery The instruments going inside the uterus should not touch the vagina. After the procedure Disposable consumables should be discarded. Used reusable instruments should be soaked in water till cleaned and should be processed as per protocol. Key message Sepsis being an important cause of maternal mortality, all steps such as washing hands, wearing PPE, processing instruments and equipment, environment cleaning, handling of sharps and proper waste disposal practices should be followed diligently and as per national guidelines by health-care providers. Objective: To discuss the diagnosis and management of complications after first trimester abortions either by medical or by surgical method. 9.1 Complications associated with abortion Haemorrhage Continuation of pregnancy (failed abortion) Incomplete abortion Infection Uterine perforation, cervical injury, vaginal lacerations, abdominal injury, uterine rupture Local anaesthesia-related complications Drug-related complications Long-term sequelae Ashermann syndrome Infertility 9 Post-abortion complications 92 FIRST TRIMESTER ABORTION 9.1(i) Haemorrhage Assessment The clinical condition of the patient should be assessed. Pulse/ blood pressure (BP)/ respiration and amount of bleeding should be monitored. Assessment is done to see if patient is stable or unstable. Unstable woman will have tachycardia, hypotension, increased respiratory rate, cold and clammy skin, low consciousness level, low urine output. Haemorrhage can be due to: retained products of conception (POC) trauma or damage to the cervix and/ or uterus Management If the woman is stable, management is provided according to cause. If the woman is unstable: The woman should be stabilized. One should follow principles of ABC (airway, breathing and circulation). She should be resuscitated before/ while examination. Intravenous fluid replacement with NS or with 18–20 G cannula. Airway to be ensured. Oxygen 6–8 L/min by mask. Blood transfusion to be arranged. Response to treatment is assessed. If condition is not improving, the cause should be re-established. Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 93 coagulopathy (rarely) uterine perforation, uterine rupture, uterine atony. Every service delivery site must be able to stabilize and treat/ refer women with haemorrhage immediately. Management is provided according to the cause and severity of haemorrhage: re-evacuation of the uterus if retained POC repair of cervical/ vaginal tear uterotonic drugs replacement of clotting factors in cases of coagulopathy laparoscopy or exploratory laparotomy if perforation suspected. 9.1(ii) Continuation of pregnancy/ failed abortion after medical/surgical abortion Risk factors of continuation of pregnancy Early gestational age (<6 weeks) Provider’s inexperience Uterine anomalies such as bicornuate uterus Repeat MMA or surgical evacuation Rule out ectopic pregnancy Continued Continued 94 FIRST TRIMESTER ABORTION Diagnosis Continued signs and symptoms of pregnancy Menstrual cycles are not resumed Confirm by pelvic examination (demonstrates growing uterus) or by ultrasonography If suspected, uterine anomaly evacuation may be done under ultrasonography guidance. 9.1(iii) Incomplete abortion Diagnosis Common symptoms include: vaginal bleeding abdominal pain fever (sign of infection) When aspirated tissue not compatible with the estimated period of pregnancy in surgical abortion Management based on Clinical condition Preference for treatment, which can be either Expectant management: for clinically stable women and when POC are small (efficacy 82–100%) Vacuum aspiration if bleeding is excessive (efficacy 96– 100%) Misoprostol 600 μg orally/ 400 sublingually, 400–800 μg vaginally if bleeding is minimal (efficacy 61–100%) Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 95 9.1(iv) Post-abortion infections Diagnosis Signs and symptoms: Fever with or without chills, malaise Foul-smelling vaginal or purulent cervical discharge Abdominal or pelvic pain, abdominal or adnexal tenderness Prolonged vaginal bleeding or spotting Uterine tenderness, cervical motion tenderness An elevated white blood cell count Sepsis is defined as life- threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis causes 20% mortality and can rapidly progress to septic shock Management Treatment should be started immediately without waiting Depending upon the severity of infection, oral and IV antibiotics can be started Obtaining blood cultures prior to administering antibiotics Administration of broad- spectrum antibiotics Commonly used regimen: Ampicillin 2 g IV every 6 hours PLUS Gentamicin 5 mg/kg body weight IV every 24 hours PLUS Metronidazole 500 mg IV every 8 hours until the woman is fever- free for 48 hours Continued 96 FIRST TRIMESTER ABORTION Prevention of infection Surgical abortion should be performed using the aseptic no-touch technique procedure; prophylactic antibiotics should be provided Availability and accessibility of women- centred CAC services Provision of well- functioning referral systems of safe abortion Rapid fluid administration of 30 mL/kg crystalloid in case of septic shock (presented with hypotension) Vasopressors (noradrenaline) started, if hypotensive even after aggressive fluid resuscitation, to maintain a mean arterial pressure ≥ 65 mmHg Cause of sepsis should be addressed. If retained POC, evacuation is done as early as possible after loading dose of antibiotics The woman should be referred to a higher-level facility at the earliest, if facility is not well equipped to manage severe septic shock cases. Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 97 9.1 (v) Uterine perforation, uterine rupture, cervical and vaginal injury Uterine perforation Signs/ symptoms Nausea, vomiting, shoulder pain Fever Abdominal pain Distended abdomen, absent bowel sounds, rigid abdomen, rebound tenderness present When uterine perforation is suspected (not with a suction cannula), observation and antibiotic treatment (conservative management) Laparoscopy is the investigative method of choice If laparoscopy examination and/ or the status of patient show suspicion of damage to bowel, blood vessels or other structures, then laparotomy to repair damaged structures should be needed Cervical and vaginal injury and lacerations Diagnosis Bleeding/ pain/ infection Bleeding cervical and/ or vaginal tears, lacerations Management Locate the tear/ laceration and repair. Bleeding is controlled by repair under aseptic conditions Pain managed by NSAIDs Continued 98 FIRST TRIMESTER ABORTION Infection managed by broad-spectrum antibiotics to be continued after repair until fever/ infection-free for 48 hours Specific antibiotics may be provided after cervical/ vaginal swab culture and sensitivity test Abstinence advised until wound heals to prevent further laceration or possible infection Uterine rupture Rare complication in first trimester abortion It may be associated with unsafe abortions/ later gestational ages/ previous uterine scar Management as for uterine perforation Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 99 9.1(vi) Anaesthesia/ drug-related complications Local anaesthesia is safest for vacuum aspiration in the first trimester but can lead to: Anaphylactic reaction Convulsions Asthmatic reactions Anaphylaxis should be treated immediately with adrenalin Bolus doses of adrenalin (1 mcg/kg) 0.5 mL of 1:1000, every 10 min if necessary Hydrocortisone 100 mg IV Dipheylhydramine 50 mg IM or IV slowly then 50 mg orally every 6 hours when the woman is conscious and stable Repeated dose of hydrocortisone 2 mg/kg body weight IV every 4 hourly may be required Oxygenation should be ensured Convulsions: Benzodiazepines are the drugs of choice for seizure control Collaborative care with a physician required for asthmatic reaction 100 FIRST TRIMESTER ABORTION 9.1 (vii) Long-term sequelae and other complications Most women who have a properly performed induced abortion do not suffer any long-term effects on their general or reproductive health. Some may have: Asherman’s syndrome: Women with the condition present with amenorrhea due to formation of adhesions within the uterine cavity. Infertility: Infection either during or after the procedure can lead to infertility or increased risk of ectopic pregnancy. Psychological symptoms: Early detection of depression or other disorders. 9.2 Referral linkage for post-abortion care Well-functioning referral systems are essential for the provision of safe abortion care. Need for referral may be required for: management of complications after stabilization; contraception counselling and provision (tubal ligation); reproductive tract infections/ STIs/ HIV; and gender-based violence (GBV). POCKETBOOK FOR HEALTH-CARE PROVIDERS 101 Timely referrals to appropriate facilities: reduce delays in seeking care; enhance safety; and can mitigate severity of abortion complications. Key message Complications of abortions, performed as per standard guidelines and by trained providers, are rare. Incomplete, septic abortion, haemorrhage and trauma to reproductive tract are serious consequences of unsafe abortion and should be treated promptly. Health-care providers should be able to diagnose complications due to first trimester abortion at the earliest and should be able to manage these complications. Objective: To counsel and provide concurrent contraception to woman seeking first trimester abortion according to her choice. 10.1 Rationale Post-abortion contraception can avert unintended pregnancies and abortion-associated morbidity and mortality. Since ovulation can occur soon after an abortion, contraception should be provided immediately after the procedure, to help the woman prevent or delay pregnancy. 10.2 Counselling for post-abortion contraception Timing of contraception counselling Contraceptive counselling can be done before or after the abortion process is completed. Immediate initiation of post-abortion contraception is advocated as it: improves adherence for use, and reduces the risk of unintended pregnancy. 10 Post-abortion contraception POCKETBOOK FOR HEALTH-CARE PROVIDERS 103 10.3 Guiding principles of post-abortion contraceptive counselling Health-care providers at the time of counselling should: Provide accurate information to assist in choosing the most appropriate contraceptive methods to meet the client’s needs. Inform that fertility can return as early as 2 weeks after abortion with risk of unintended pregnancy unless an effective contraceptive method is used. Make available the chosen contraceptive method (or refer her if her chosen method is not available). Ensure that the client knows the mode of action, day to start and from where to get the selected contraceptives. Identify the cause: whether the woman seeking an abortion is following a contraceptive failure and correct it, if it was due to inappropriate use. Respect the decision of the woman to discuss or not to discuss contraceptive option after abortion. Understand that the woman’s acceptance of contraceptive must NOT be a pre-condition for providing abortion services. 104 FIRST TRIMESTER ABORTION Support the woman in selecting the contraceptive method best suited to her according to her clinical and personal situation. Provide method-specific counselling, if the woman chooses a contraceptive method. 10.4 Options for post-abortion contraception All methods of contraception including IUDs and hormonal contraceptives can be initiated immediately following surgical or medical abortion according to medical eligibility criteria. 10.5 Medical eligibility recommendations for post- abortion contraceptives Post-abortion contraceptive First trimester abortion Immediate post-septic abortion Definition of categories COC 1 1 CIC 1 1 A condition of which there is no restriction for the use of the contraceptive method Patch; vaginal ring 1 1 POP 1 1 DMPA; NET-EN 1 1 Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 105 Post-abortion contraceptive First trimester abortion Immediate post-septic abortion Definition of categories LNG/ ETG implants 1 1 A condition where the advantage of using the methods generally outweigh theoretical or proven risks. A condition where theoretical or proven risks usually outweigh advantages of using the methods. A condition that represents an unacceptable health risk if the contraceptive method is used Copper- bearing IUD 1 4 LNG-releasing IUD 1 4 Condom 1 1 Spermicide 1 1 Diaphragm 1 1 Continued CIC: combined injectable contraceptive; COC: combined oral contraceptive; DMPA/ NET-EN progestogen-only injectables: depot medroxyprogesterone acetate/ norethisterone enanthate; IUD: intrauterine device; LNG/ ETG progestogen-only implants: levonorgestrel/ etonorgestrel; POP: progesterone-only pill 106 FIRST TRIMESTER ABORTION Contraceptive method Spontaneous abortion or VA (for incomplete/ induced abortion After medical abortion by mifepristone and misoprostol COC Can be started immediately Can be started after the first pill of medical abortion POP Can be started immediately Can be started after the first pill of medical abortion Injection DMPA Can be started immediately Can be started after the first pill of medical abortion Contraceptive ring/ implant/ patch Can be started immediately Can be started after the first pill of medical abortion, but should be instructed to check for expulsion of the ring in the event of heavy bleeding during the medical abortion process [S10] Barrier methods From the first act of sexual intercourse after abortion From the first act of sexual intercourse after abortion 10.6 Time of initiation of contraceptive methods after abortion Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 107 Contraceptive method Spontaneous abortion or VA (for incomplete/ induced abortion After medical abortion by mifepristone and misoprostol Fertility awareness- based method (FAB) Should be delayed until regular menstrual cycles return but should be started with caution Should be delayed until regular menstrual cycles return but should be started with caution IUCD Can be started immediately but must rule out infection/ injury to the genital tract Can be inserted when the abortion is complete Provider must ensure completion of abortion by physical examination or by USG (around D15) but must rule out infection Tubal ligation Can be performed concurrently or within 7 days Can be performed after the first menstrual cycle Vasectomy Can be performed at any time Can be performed at any time Emergency contraception Emergency contraceptive pills or an IUD may be used within 5 days (120 hours) of an act of unprotected sexual intercourse Emergency contraceptive pills or an IUD may be used within 5 days (120 hours) of an act of unprotected sexual intercourse Refer to Annex 5: Overview of contraceptive methods Continued 108 FIRST TRIMESTER ABORTION 10.7 Post-abortion IUCD Assessment: Before the procedure, the woman’s general, medical, reproductive, contraceptive and obstetric history and eligibility for the method is assessed and also a preprocedural assessment is done. Assessment is again done immediately before insertion to rule out any current genital tract infection, haemorrhage or genital tract injury. Method of insertion after surgical method of abortion: No touch and withdrawal technique Use of uterine sound for measuring the length of uterus is not recommended, as it may cause perforation. After the confirmation of the completion of evacuation and before withdrawing the cannula, the length of uterine cavity is assessed using the cannula. The IUCD is loaded inside the sterile package and the blue guard is fixed at the length, measured by the cannula IUCD is then inserted using the withdrawal technique. Thread is cut 1 cm beyond the external os. POCKETBOOK FOR HEALTH-CARE PROVIDERS 109 Method of insertion after the medical method of abortion: No touch and withdrawal technique. The provider should be very careful while introducing uterine sound. Uterine sound should be introduced gently by holding it like a pen/ pencil, moving it in the right direction till the resistance is felt without applying any force. The technique of insertion is same as that of interval IUCD insertion. The back-up method is not needed if IUCD is inserted within 12 days of spontaneous or induced abortion and absence of infection. Follow up: Routine follow up of IUCD may be done after one month preferably after the next menstrual bleeding. At follow up, one must see the presence of string. 10.8 Post-abortion female sterilization Eligibility criteria Woman has received counselling and made an informed choice and has given informed consent. Provider is trained in post-abortion female sterilization and requisite equipment are available. Post-abortion medical eligibility for female surgical sterilization 110 FIRST TRIMESTER ABORTION Post-abortion condition Female surgical sterilization Uncomplicated A Post-abortal sepsis or fever D Severe post-abortal haemorrhage D Severe trauma to genital tract Cervical or vaginal tear at the time of abortion D Uterine perforation S Acute haematometra D Categories: A Accept; C Caution; D Delay; S Special (experienced surgeon and staff) Post-abortion surgical sterilization method: Female surgical sterilization, can be performed either by minilaparotomy or by the laparoscopic method. 10.9 Contraception in special situations Anaemia: All methods are safe including IUCD. Previous scar on uterus: All methods are safe including IUCD. Hypertension well-controlled: Progestin-only methods like injectables, implants, LNG, IUCD, POP are all safe; however, COCs patches rings are not to be used. Poorly controlled hypertension: All hormonal methods can be avoided, preference for IUCD, barrier, non- hormonal pill and natural methods. Well-controlled diabetes mellitus: All methods are suitable, MEC is category 2 for COC. POCKETBOOK FOR HEALTH-CARE PROVIDERS 111 With poorly controlled diabetes: COCs and injectable progestins are not suitable, MEC 3, whereas LNG IUS, implants, etc. are MEC 2, copper IUCDs are still category 1. 10.10 Myths and misconceptions Myths Facts IUCD after abortion may perforate and may go to heart or brain. There is no passage from the uterus to other organs of the body. Chances of perforation are very low with trained providers. Abortion can be used as a method of contraception. Repeated abortions can lead to increased morbidity. Having an abortion will make you infertile. Chances of infertility are very low with safe abortion practices. One will not be able to do heavy physical work if tubal ligation or IUCD insertion is done after abortion. Any contraception with abortion does not pose any challenge for physical activities. There is no correlation between the performance and the use of IUCD or getting tubal ligation done. Key message All methods of contraception including intrauterine devices (IUDs) and hormonal contraceptives can be initiated immediately following surgical or medical abortion according to medical eligibility criteria. Health-care providers should be able to counsel women for the contraceptives available in the country and facilitate their acceptability. Objective: To ensure that the services provided for first trimester CAC are documented and reported. 11.1 Documentation of first trimester CAC services The aim of documentation is to collect data of first trimester CAC services, to update it for local regional, national and international review so that trends can be observed to influence policy changes. Privacy and confidentiality of the clients to whom abortion services are provided should be ensured when documentation is done. Health-care providers should document regularly in the formats as per country’s laws for abortion. Documentation should include: demographic information of each client as age, parity, socioeconomic status, marital status, duration of pregnancy, etc.; informed consent in the prescribed format as per country’s rules; 11 Documentation, record- keeping and reporting for first trimester CAC services POCKETBOOK FOR HEALTH-CARE PROVIDERS 113 method advocated; provider’s details; anaesthesia/ pain medications used; cervical priming method if used; method used; contraception services provided; follow-up visits; adverse event if any; treatment of complications including blood; transfusion if needed cases referred to higher centres; and log books of medications used; Documentation is done in: OPD register; admission register; case record; procedure register at the labour room/ OT; complications of abortion including spontaneous abortion (inevitable, incomplete abortion; 114 FIRST TRIMESTER ABORTION adverse event register; discharge register; and any other official record prescribed by the country’s regulatory authorities. Storage of records The abortion and adverse events data need to be stored under safe custody at health facilities as per the country’s legal guidance. Confidentiality of data records and reports should be maintained at all levels. 11.2 Reporting of first trimester CAC services Every health facility providing abortion services MUST report the data of abortions regularly to each country’s national HMIS. The facility must report data to the head of facility who will send it to the district and state authorities for their information and records. Communicate with district, state/ province, national government officials regarding: proportion of first trimester abortions out of total abortions; trends over time for seeking abortion or seeking care for complications; POCKETBOOK FOR HEALTH-CARE PROVIDERS 115 adverse events during abortion care; unmet need of contraception; appropriate feedback to facilities; and support to strengthen national programmes for contraception and prevent unsafe abortions. The state/ province will share the data monthly/ quarterly with concerned: national officials; regional officials; and periodically to the global data recording system. 11.3 Monitoring of first trimester CAC services The aim of monitoring is to ensure that: the services are standardized and evidence-based; women are receiving CAC services with respect, dignity, confidentiality and privacy; service providers are non-judgemental, empathetic and compassionate, women are satisfied with the services; and all the requisite infrastructure and logistics are available. 116 FIRST TRIMESTER ABORTION Process of quality improvement The monitoring and review process must include all health- care staff involved in first trimester CAC services. This gives the team a sense of ownership of the results. A monitoring tool can be developed (Annex 6a). Records are reviewed periodically to help monitor first trimester CAC service provision and trends at the facility. Quality of care can be assessed by using checklists for essential infrastructure, logistics, counselling skills of the provider, procedural details, etc. (Annex 6b); and conducting exit interviews, focus groups, or client satisfaction feedback. Few simple indicators that provide critical and useful information on first trimester CAC service provision must be identified and reviewed over time. Number of procedures performed Number of women opting for contraception Number of adverse events Act PlanCheck Do POCKETBOOK FOR HEALTH-CARE PROVIDERS 117 Indicators chosen should be such that the measurement helps quantify activities and results, and it also reports on quality component of care. The overall gaps in terms of quality of abortion care, availability of commodities, logistics, trained human resource, recording mechanism, etc. should be ascertained. The action plan should address the gaps in service provision, the person responsible to implement the planned actions and the timeline. The implementation of plan is ensured to improve the quality of service provided. Review should be done so that the plans implemented improve the services. If the plan is not giving expected results, it should be suitably modified. Key message Health-care workers should understand the importance of regular and proper recording of the data for CAC services, which will identity gaps in abortion services to improve the qualities of care. Objective: To understand what telemedicine is and its role in provision of abortion care services. 12.1 Definition of telemedicine (or telehealth) A mode of health service delivery where providers and clients, or providers and consultants, are separated by distance (5). 12.2 Types of interactions Real-time (synchronously), e.g. by telephone or a video link. Store-and-forward (asynchronously) when a query is submitted and an answer provided later, e.g. by email or text/ voice/ audio message. 12.3 Telemedicine provision models Direct to client Site to site Engaging health-care workers in reaching out to communities 12 Telemedicine and self- management of first trimester abortions POCKETBOOK FOR HEALTH-CARE PROVIDERS 119 12.4 Advantages of telemedicine Provides support for self-management of health care. Nevertheless, it is highly acceptable to women and providers especially for medical abortion. Provides privacy and security Cost-effective 12.5 Limitations of telemedicine Policy barriers limit, especially for abortion 12.6 Technology models for telemedicine services Video-conferencing Telephone calls Text messages Internet-based messaging Interactive Apps, etc. Hotlines 12.7 Telemedicine for MMA Telehealth can be used for: provision of information on abortion care. Scientifically accurate information should be accessible and 120 FIRST TRIMESTER ABORTION understandable, including formats catering to low- literacy and differently abled populations; alternative to in-person interactions with the health worker, to deliver medical abortion services in whole or in part; assessment of eligibility for medical abortion; counselling and/ or instruction relating to the abortion process; providing instruction for and active facilitation of the administration of medicines; follow-up PAC; abortion pill prescription, which may be offered as an alternative to in-person appointments. WHO recommends it for improving access to MMA but country’s legal provisions should be followed for providing prescription; referrals for medicines (abortion and pain management); PAC; follow-up care (including emergency care if needed); and post-abortion contraceptive services. POCKETBOOK FOR HEALTH-CARE PROVIDERS 121 12.8 Concerns regarding telemedicine for MMA Acceptability: Medical abortion through telemedicine seems to be highly acceptable to women and providers (2). Efficacy: Success rate and safety outcomes are similar to those reported in the literature for in-person abortion care (6). Danger symptoms: Guidance about the danger symptoms should be clear and accessibility to health- care services should be facilitated. Legal issues: Laws related to telemedicine and abortion laws should be addressed before providing MMA services through telemedicine. 12.9 Self-managed abortion Self-management of MMA: WHO abortion guidelines (2022) recommend the option of self-management of the medical abortion process at <12 weeks (using the combination of mifepristone plus misoprostol or using misoprostol alone) in whole or any of the three component parts of the process. Self-assessment of eligibility (determining pregnancy duration; ruling out contraindications). 122 FIRST TRIMESTER ABORTION Self-administration of abortion medicines outside of a health-care facility and without the direct supervision of a trained health worker, and management of the abortion process. Self-assessment of the success of the abortion. Prerequisite for self-managed abortion Individuals engaging in self-management of medical abortion must also have access to accurate information, quality-assured medicines including for pain management. The support of trained health workers and access to a health-care facility and to referral services should be easily available to all women opting for self-managed abortion. Self-management of abortion should be within the regulatory framework of the health system of the country. Self-management of contraceptives, injectable contraceptives, over-the-counter combined oral contraceptives, over-the-counter emergency contraceptives and condom usage is also recommended in view of telemedicine, but it has to be under the legal/ regulatory framework of the country. POCKETBOOK FOR HEALTH-CARE PROVIDERS 123 Key message Telemedicine has a role in assessment of eligibility for medical abortion, counselling and/ or instruction relating to the abortion process, active facilitation of the administration of medicines, and follow-up PAC. Telemedicine can play a role in delivering post- abortion contraceptive services, which may apply to both medical and surgical abortion. Health-care workers should be aware of the newer developments in this field. Spontaneous abortion is when abortion is triggered spontaneously, without any external interference. Types of spontaneous abortion Annexure Spontaneous abortion1 Threatened abortion: Pregnancy is viable and the cervical os is closed. Pregnancy may continue. Inevitable abortion: Process of expulsion of products of conception has started. The cervical os is dilated. Pregnancy will not continue and will proceed to incomplete/complete abortion. Incomplete abortion: Products of conception are partly expelled. Complete abortion: Products of conception are completely expelled. Missed abortion: Products of conception are not expelled but fetal cardiac activity is absent. (Non- viability of intrauterine pregnancy without spontaneous abortion) Septic abortion: Abortion complicated by infection. Sepsis may result from ascending infection from the lower genital tract following spontaneous or unsafe abortion. Sepsis may be due to delayed evacuation or due to unsafe abortion involving instrumentation. Type of spontaneous abortion Source: Pocketbook of hospital care for mothers: guidelines for management of common maternal conditions 2017 POCKETBOOK FOR HEALTH-CARE PROVIDERS 125 Th re at en ed ab or tio n In ev ita bl e ab or tio n In co m pl et e ab or tio n Co m pl et e ab or tio n M iss ed a bo rti on Pa in Cr am pi ng Cr am pi ng Cr am pi ng Lig ht cr am pi ng M ay o r m ay n ot be o bs er ve d Bl ee di ng Lig ht He av y He av y Lig ht Bl ee di ng a lte re d, co lo ur ed b lo od Ut er us si ze Co rre sp on ds to p er io d of ge st at io n M ay co rre sp on d to p er io d of ge st at io n Sm al le r th an p er io d of g es ta tio n Sm al le r th an pe rio d of ge st at io n Sm al le r t ha n pe rio d of ge st at io n Ce rv ix Cl os ed Di la te d os Di la te d os Cl os ed Cl os ed Pr od uc ts o f co nc ep tio n Liv e fe tu s a nd pl ac en ta Fe ta l pa rts fe lt th ro ug h os or p ar tia lly ex tru di ng Re ta in ed pr od uc ts o f co nc ep tio n No ne Fe tu s a nd pl ac en ta Cl in ic al fe at ur es of va rio us sp on ta ne ou s a bo rti on s Co nt in ue d 126 FIRST TRIMESTER ABORTION Th re at en ed ab or tio n In ev ita bl e ab or tio n In co m pl et e ab or tio n Co m pl et e ab or tio n M iss ed a bo rti on Ul tra so un d Liv e em br yo Ra re ly su bc ho rio ni c bl ee d Di la te d ce rv ic al os Sa c pa rti al ly ex tru di ng in to va gi na Re ta in ed pr od uc ts o f co nc ep tio n Em pt y ut er us Di sc re pa nc y be tw ee n th e so no gr ap hi c ge st at io na l ag e an d w ee ks o f pr eg na nc y Ab se nt fe ta l he ar t W HO P oc ke tb oo k o f h os pi ta l c ar e fo r m ot he rs : g ui de lin es fo r m an ag em en t o f c om m on m at er na l c on di tio ns , 2 01 7) Co nt in ue d Abortion in first trimester can be conducted by two methods: medical and surgical Medical method is advocated by ingestion of drugs which are taken orally or sublingually, by vaginal or buccal route. These drugs may lead to side-effects as nausea, vomiting, fever, shivering and allergy reaction. Expected outcome and likelihood of success is very high. If this method fails for termination of pregnancy, there may be chance of some defect in the baby if pregnancy is continued. Surgical method will be performed using local anaesthesia, the cervix is carefully dilated until there is enough room to pass a suction cannula/ curette/ instrument into the womb. The products in the uterine cavity will be sucked out with suction cannula. The tissue may be sent to pathology laboratory for examination. The expected outcome and likelihood of success is similar for both methods and as high as 95 – 99% Annexure 2(a) Information sheet 128 FIRST TRIMESTER ABORTION One can resume their routine activities a day after the abortion. One will be required to report to the provider if there are warning signs as excessive bleeding, pain, fever or continued nausea and vomiting. There are risks and complications with this procedure. These include but are not limited to the following: Bleeding that can be so heavy that a blood transfusion may be needed. It may also need further surgery. Damage may occur to the uterus with rupture or perforation. This may require a laparoscopy and/or laparotomy, there is a risk of damage to other organs such as bowel or bladder, which may require further corrective surgery. This being a blind procedure, rarely evacuation may remain incomplete. Rarely the procedure may not be able to be completed, due to narrowing of the inside of the cervix. If the condition continues, further surgery will be necessary. Widening of the mouth of the uterus may lead to cervical incompetence (Uterus unable to hold pregnancy in future). POCKETBOOK FOR HEALTH-CARE PROVIDERS 129 Rarely adhesions may develop in uterus leading to amenorrhoea/sub-fertility. Infection can occur in the uterus. This can cause heavy bleeding or discharge, worsening cramps or high fever. The infection may affect the fallopian tubes and cause problems with getting pregnant in the future. Antibiotics are used to treat the infection. Allergic reaction can occur from medicines or due to blood transfusion. Excessive bleeding can occur. Option of choosing the Contraception during/after the procedure are oral contraceptive pills, POP, DMPA, IUCD, tubal ligation, vasectomy for husband, etc. Name of patient: ………………………………………………………………………………………………………………………. Sex:……………….……….Age………………. Registration no. :……………………….. Address: …..………………………………………………………………………………………..………………… …………………………………………………………………………………………………………… Diagnosis ………..………………………………………………………………………………………..………… ……………………………….………………………………………….……………………………….. Operation title……………………..………………………………………........................... I, ………………………………………………………………………………the undersigned give consent for MY OWN/AFOREMENTIONED PATIENTS operation and/or medication/investigation/anaesthesia/therapy, etc. Annexure 2(b) Informed consent for first trimester abortion (sample form) POCKETBOOK FOR HEALTH-CARE PROVIDERS 131 I acknowledge that the doctor has explained. My medical condition and the proposed procedure, including additional treatment If the doctor finds something unexpected. I understand the risks, including the risks that are specific to me. The anaesthetic required for this procedure. I understand the risks, including the risks that are specific to me. Other relevant treatment options and their associated risks. My prognosis and the risks of not having the procedure. That tissues and blood may be removed and could be used for diagnosis or management of my conditions, stored and disposed of sensitively by the hospital. I have been explained that excessive bleeding, infection, cardiac arrest, pulmonary embolism and complications like this can arise suddenly and unexpectedly while undergoing medication/ investigation/ operation/ therapy/ procedure or anaesthesia. I give consent for any change in the anaesthesia or operative procedure as well as for removal of any organ as deemed necessary by the doctors at the time of medication/investigation/therapy/surgical procedure. 132 FIRST TRIMESTER ABORTION I have been made aware that after the above procedure/medication/investigation/therapy and anaesthesia, some complication may arise and laparotomy may be required. I was able to ask questions and raise concern with the doctor about my condition, the proposed procedure and its risks and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand I have the right to change my mind at any time, including after I have signed this form but, preferably following a discussion with my doctor. I understand that image/s or video footage may be recorded as a part of and during my procedure. I accept that medicine is not an exact science and understand that no guarantees can be given to the result and understand these limitations. I have read the above writing/ the above writing has been read out to me, and it explained to me in the ……………………………………. language by ………………………………. (interpreter) which I understand. I have understood the aforesaid and I am giving my consent willingly with sound mental state without any coercion, undue influence, fraud, misrepresentation or mistake of fact. POCKETBOOK FOR HEALTH-CARE PROVIDERS 133 I request Dr ………………………………………………………………………………… to perform upon me the above-mentioned procedure. Doctor Sign.: ……..........................…………… Name: ……………………...........……… Address: …………………………………………………………. ………………………………………………………..… ………………………………………………………….. Age……………Date………....…….......... Patient/ Guardian Sign /Thumb impression.: .....................……........................................... Name: ……………………...........………….....…. Address: …………………………………………… ……………………………………………………………….… ……………………………………………………………….… Age………………..Date……..…....……..……… WHO recommends Manual Vacuum Aspiration (MVA) as the safest method for abortion up to 12-14 weeks of size Components of MVA kit are 1. MVA aspirator 2. Suction cannula 1. MVA aspirator Annexure 3 Manual vacuum aspirator (MVA) kit Parts of MVA syringe (assembled) Creating a vacuum POCKETBOOK FOR HEALTH-CARE PROVIDERS 135 Parts of MVA syringe (disassembled) Release of the vacuum button on the aspirator 2. Suction cannulas are available in different sizes (4 – 12 mm) and have permanently affixed base with wings. Healthcare worker should know how to assemble, disassemble and charge the MVA. Disassembling the MVA aspirator Cylinder and plunger are pulled apart from the valve assembly. Cap release tab is pressed, and the cap is removed in the valve assembly unit. Hinged valve is opened by pulling open the clasp. Valve liner is removed. 136 FIRST TRIMESTER ABORTION Collar stop is disengaged by sliding under retaining clip. Plunger is pulled completely out of cylinder. O-Ring is displaced by pressing its sides and rolling it down into groove below. Sharp objects should never be used for removing the O-ring as it can damage the O-ring. Reassembling the MVA aspirator Valve liner is placed in the valve by aligning ridges. The valve is closed ensuring it snaps into place. The cap is put onto end of valve assembly unit. Cylinder is pushed straight up to the base of the valve. O-ring is placed into groove near tip of plunger. One drop of sterile lubricant (silicon gel) is applied around O-ring with finger. Plunger arms are pressed and pushed straight into cylinder. Collar stop tabs are inserted into holes in cylinder. Plunger is moved in and out to lubricate (step 6 and 9 not required if it is a single use disposable MVA syringe). POCKETBOOK FOR HEALTH-CARE PROVIDERS 137 Charging the aspirator With open valve buttons plunger is pushed up to the base of valve. Valve buttons are pushed down and forward until they lock. Plunger is pulled back until both its arms catch up on the wide sides of cylinder Charged aspirator should never be grasped by the plunger arms as this can eject the contents. Aspirator should be checked for vacuum by pressing the valve buttons a rush of air indicates vacuum was created. Aspirator retains vacuum until it is 80% full after which the contents should be emptied and vacuum recreated. Sterilization/high-level disinfection of aspirator. Any of these methods can be used for sterilization of vacuum aspirator: Autoclave The instrument is disassembled fully. Parts of the aspirator and cannula are wrapped separately in paper/linen. The pressure autoclave is set at 121 °C/250 °F for 30 minutes with pressure of 106 kPa/15 lbs/in2. 138 FIRST TRIMESTER ABORTION Boiling Boiling the submerged aspirator, cannula for 20 minutes with boiler lid closed. Time should be counted after water has started boiling. No fresh instrument to be added after water is boiling. One should wait for the water to cool before removing cannula and handle only by the adaptor /base. Glutaraldehyde Instruments should be fully submerged in 2% solution for 20 minutes. Instruments must be thoroughly rinsed with sterile water before use. Solution should be changed as per recommendations. Aspirator should be thoroughly rinsed with sterile water after processing Sterilization/high-level disinfection of suction cannula: Each disposable cannula is presterilized (before packaging) with ethylene oxide (ETO) which remains sterile for three years. Cannula that can be reused should be sterilized as sterilization/HLD is done for MVA. Cannula should be replaced if it is cracked or bent, especially near the tip. Hand whygiene by washing Annexure 4(a) Annexure 4(b) PERSONAL PROTECTIVE Cap Mask Goggles Gown Gloves Apron Footwear Overview of contraceptive methods after first trimester abortion Annexure 5 Name Time of starting Advantage Side effects / limitations Failure rates per 100 women year Male condom At resumption of sexual activity Autonomy to start Safe Prevents STI/ RTI Irritation May slip or break 2 Female condom At resumption of sexual activity Autonomy to start Safe Prevents STI/ RTI Expensive Difficult to insert May make sex less enjoyable 5 COCP Immediately after VA Highly effective Daily dose No protection against RTI/ STI 0.3 Continued 142 FIRST TRIMESTER ABORTION Name Time of starting Advantage Side effects / limitations Failure rates per 100 women year Day 1 of MMA No interference with sexual activity Not suitable while breastfeeding Interaction with certain drugs (Rifampicin, Phenytoin, etc.) reduces effectiveness POP Immediately after VA Day 1 of MMA Highly effective No interference with sexual activity Fast reversibility Daily dose No protection against RTI/ STI may cause changes in menstrual pattern as irregular bleeding, spotting <1 Progestin- only injectable DMPA, NET- EN Immediately after VA Day 1 of MMA Highly effective No interference with sexual activity Must return for injections every two or three months 0.3 Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 143 Name Time of starting Advantage Side effects / limitations Failure rates per 100 women year May cause irregular bleeding, spotting, amenorrhea Delayed and unpredictable return to fertility after stopping use No protection against STIs/ HIV/HBV IUD Immediately after VA if no excessive bleeding or infection After surety of complete abortion after MMA Highly effective No interference with sexual activity Long-term contraception, effective for 5 – 10 years. Immediate return to fertility following removal Trained provider required May increase menstrual bleeding and cramping during the first few months No protection against STIs/ HIV/HBV 0.6 Continued Continued 144 FIRST TRIMESTER ABORTION Name Time of starting Advantage Side effects / limitations Failure rates per 100 women year Female sterilization Immediately after VA if there is no infection or severe bleeding Permanent method Highly effective immediately No interference with sexual activity No long-term side effects Requires trained staff Slight risk of surgical complication No protection against STIs/ HIV/HBV 0.5 Male sterilization Independent of abortion procedure Permanent No interference with sexual activity No apparent long-term health risks Alternate methods till azoospermia confirmed after 3 months No protection against STIs/ HIV/HBV 0.1 Natural family planning methods Fertility awareness based/ standard days method Only after next menstrual cycle No supplies required Under control of couple No protection against STIs/ HIV/HBV High failure rate Continued Continued Monitoring tool for first trimester CAC service facility Date Name of facility Name of the provider Name of Programme Manager visiting the site number of procedures performed No. of abortion care procedures provided at the facility in the last three months Methods/technology used for the procedures Contraception given (numbers) If NO service provide reason for non-provision/ Does the examination and treatment area have visual and auditory privacy? Does the facility have the necessary instruments and supplies for infection control and procedures? Annexure 6(a) 146 FIRST TRIMESTER ABORTION Are the following available at the facility: MVA kits; MMA drugs; all contraceptive methods; IEC material on abortion care; existing protocol and logistics for waste disposal; and documentation forms. Have the healthcare workers attached to the facility been trained in the specific tasks? Gaps identified for quality improvement in the facility Action plan for quality improvement – Person Responsible – Timeline Check Lists for First Trimester CAC Services 1. Check List Infrastructure and Logistics Examination room available Place for counselling where privacy can be maintained Procedure room with infection control practices exists Instruments needed available Resuscitation equipment available Sterilization facilities available Drugs & parenteral fluid available Supplies for infection control practice 2. Check List for Procedural Competency Counselling Privacy and confidentiality maintained Comfortable place to sit for the client Abortion- specific content, methods/complications, etc. explained Annexure 6(b) 148 FIRST TRIMESTER ABORTION Contraceptive counselling done Referral facilities facilitated if needed Enough time given to ask questions Pre-Procedural Evaluation History taken in detail Estimation of gestational age done Indicated investigations done Informed consent obtained Contraception chosen is available Procedural Competency Medical Method of Abortion (MMA) MMA drugs provided MMA drugs regime explained Expected symptoms, danger signs & complications explained Follow up instructions provided Surgical Abortion Instruments prepared Woman cleaned and draped Cervical antiseptic preparation performed POCKETBOOK FOR HEALTH-CARE PROVIDERS 149 Paracervical block administered Appropriate cervical dilatation assessed Suction cannula inserted with no touch technique Suction pressure checked in MVA /EVA Uterine contents aspirated inspected Concurrent procedure: IUD insertion, if opted, done Instruments processed as per guidelines Documentation Documentation done Procedure specific contents of counselling Consent Anesthesia/pain medications Procedure details Concurrent procedure if done Adverse event if any Advice at discharge Follow up instructions Entries in all relevant registers / HMIS 10. Monthly report prepared. References 1. Ganatra B, Gerdts C, Rossier C, Johnson BR Jr, Tunçalp Ö, Assifi A et al. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. Lancet. 2017;390:2372–81. doi: 10.1016/S0140-6736(17)31794-4. 2. Abortion [website]. WHO; 2021 (https://www.who.int/ news-room/fact-sheets/detail/abortion, accessed 25 June 2022). 3. Bearak J, Popinchalk A, Ganatra B, Moller AB, Tunçalp Ö, Beavin C et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. Lancet Glob Health. 2020;8:e1152–e1161. doi: 10.1016/ S2214-109X(20)30315-6. 4. World Health Organization. Regional Office for South- East Asia ( 2020) . Policies, programme and services for comprehensive abortion care in South-East Asia Region. World Health Organization. Regional Office for South-East Asia. License: CC BY-NC-SA 3.0 IGO (https:// apps.who.int/iris/handle/10665/338768, accessed 5 July 2022). POCKETBOOK FOR HEALTH-CARE PROVIDERS 151 5. Abortion care guideline. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO (https://www.who.int/publications/i/ item/9789240039483, accessed 25 June 2022). 6. Endler M, Lavelanet A, Cleeve A, Ganatra B, Gomperts R, Gemzell-Danielsson K. Telemedicine for medical abortion: a systematic review. BJOG. 2019;126:1094– 102 (https://obgyn.onlinelibrary.wiley.com/action/ showCitFormats?doi=10.1111%2F1471-0528.15684, accessed) Note