Second Trimester Abortion: Pocket Book for Health-Care Providers

Second Trimester Abortion Pocketbook for Health-Care Providers

Second Trimester Abortion Pocketbook for Health-Care Providers Second Trimester Abortion: Pocketbook for Health-Care Providers ISBN: 978-92-9021-075-7 © World Health Organization 2023 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.. Suggested citation. Second trimester abortion: Pocketbook for health- care providers. New Delhi: World Health Organization, Regional Office for South-East Asia; 2023. 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.

Contents Foreword xi Acknowledgments xiii Acronyms and abbreviations xv 1. Second trimester abortion: An overview 1 1.1 Global situation of abortion 1 1.2 Regional situation of abortion 4 1.3 Situation of second trimester abortion 6 1.4 Reasons for seeking second trimester abortion 8 1.5 Barriers to seeking second trimester abortion 9 2. Legal provisions for second trimester abortions (country specific) 12 2.1 Barriers to access to quality abortion care 12 2.2 Facilitating access to safe abortion 13 2.3 Women’s reproductive and human rights 14 2.4 WHO recommendations related to regulatory, policy and human rights considerations on abortion 14 2.5 A woman’s six legal grounds for abortion 16 2.6 Country-specific legal frameworks 17 3. Counselling a woman seeking second trimester abortion 36 3.1 Definition of counselling 36 3.2 Guiding principles of counselling 37 3.3 Pre-procedure counselling 37 3.4 Essential components of counselling for second trimester abortion 38 3.5 Post-procedure counselling 40 3.6 Informed consent for second trimester abortion 41 3.7 Counselling for special groups seeking second trimester abortion 43 4. Pre-abortion evaluation 45 4.1 Components of pre-abortion assessment 46 4.2 Medical history 46 4.3 Physical examination 49 4.4 Laboratory tests and other investigations 52 5. Methods for second trimester abortion 54 5.1 Recommended methods of second trimester abortion 55 5.2 Comparison of methods of abortion 55 5.3 Who can provide second trimester abortion 57 5.4 Eligibility of the site where second trimester abortion can be provided 59 5.5 Second trimester abortion method in medical /surgical conditions 60 6. Medical methods of abortion in the second trimester 65 6.1 MMA regimens 65 6.2 Clinical considerations for medical abortion at advanced gestational ages 68 6.3 Pain management for medical abortion 69 6.4a Drug administration 70 6.4b Different routes of administration of mifepristone/misoprostol 71 6.5 Fetal/placental expulsion 72 6.6 Examination of the abortus 73 6.7 Warning symptoms after second trimester abortion 74 6.8 Before discharge after medical abortion at ≥12 weeks of gestation 74 6.9 Medical management of intrauterine fetal demise 75 6.10 Induction of fetal cardiac asystole before abortion 75 6.11 Potential challenges of medical abortion at advanced gestational ages 77 7. Surgical methods of second trimester abortion 80 7.1 Method-specific counselling 80 7.2 Instruments required for EVA (12–14 weeks gestation in the second trimester) 81 7.3 Cervical priming prior to second trimester abortion 82 7.3a Methods of cervical priming 83 7.3b Foley catheter 84 7.3c Method of insertion of an osmotic dilator 85 7.3d Characteristics of osmotic dilators 86 7.4 Pain management in second trimester abortion 86 7.5 Antibiotic prophylaxis 88 7.6 Anti-D prophylaxis for second trimester abortion 89 7.7 Asepsis – the no-touch technique 89 7.8 Steps of surgical abortion >12 weeks of pregnancy 90 7.9 Steps of surgical abortion at 12–14 weeks of pregnancy – vacuum aspiration 91 7.10 Steps of surgical abortion at >14 weeks of pregnancy – dilatation & evacuation 94 7.11 Surgical abortion in pregnancy with a previous uterine scar 100 8. Post-abortion care 102 8.1 Immediate post abortion 102 8.2 Further evaluation to confirm the success of medical abortion 103 8.3 Instructions at discharge 104 8.4 Psychosocial and emotional counselling post abortion 105 8.5 Additional services may need to be provided to individuals seeking abortion 106 8.6 Follow up 107 9. Post-abortion complications 108 9.1 Identification and management of post-abortion complications 109 9.2 Complications resulting from the method used to induce abortion 116 9.3 Complications that are not specific to the abortion procedure or method 116 10. Post-abortion contraception 118 10.1 Rationale 118 10.2 Goals of post-abortion contraceptive counselling 119 10.3 Guiding principles of post-abortion contraceptive counselling 119 10.4 Post-abortion contraception options 122 10.5 Medical eligibility recommendations for post-abortion contraception 123 10.6 Time of initiation of contraceptive methods after second trimester abortion 124 10.7 Special considerations while providing post-abortion contraceptives 126 10.8 Contraception in special situations 128 11. Monitoring, recording and reporting of second trimester comprehensive abortion care 130 11.1 Examples of abortion services monitoring matrix 131 11.2 Documentation and reporting of second trimester CAC services 133 12. Role of telemedicine and self-management in second trimester abortion 135 12.1 WHO definition of telemedicine (or telehealth) 135 12.2 What can be done via telemedicine 136 12.3 Self-management of abortion 137 12.4 What is included in self-management 137 List of annexes Annex 1a: Patient information sheet 139 Annex 1b: Informed consent for second trimester abortion (sample form) 142 Annex 2: Infection prevention practices for second trimester abortion 146 Annex 3: Contraceptive effectiveness 151 Foreword The WHO South-East Asia Region is committed to accelerating reductions in preventable maternal mortality as part of the eight Regional Flagship Priorities as well as a key Sustainable Development Goal target. In low- and middle-income countries globally, unsafe abortion is a significant cause of maternal mortality. Between 2015 and 2019, every year, there were an estimated 121 million unintended pregnancies globally. An estimated 61% of unintended pregnancies ended in abortion, equivalent to a global rate of 39 abortions per 1000 women aged 15–49 years. An estimated one third of all abortions were conducted in the least safe or most dangerous conditions. Second trimester abortions are not common, are performed for limited indications, and are generally managed by skilled human resources in standard facilities and as per national protocols. They are mostly performed to save a woman’s life, or for pregnancies resulting from rape or incest, and for pregnancies with grossly malformed fetus. Although second trimester abortions are mostly performed by trained health-care providers, abortion-related complications are still a major cause of maternal mortality in the Region. In 2014, at least 6% of all maternal deaths in Asia were from unsafe abortion. xii SECOND TRIMESTER ABORTION To help prevent such deaths, this Pocketbook outlines a series of WHO-recommended interventions for second trimester abortions, with a focus on strengthening health worker capacity and improving linkages with family planning and other reproductive health services. It contains detailed information on abortion counselling, clinical management (both surgical and medical methods), suitable post-abortion contraceptives, maintaining and reporting case records, self-management, and provisions for telemedicine. It also contains detailed information on the relevant legal situation in each of the Region’s Member States. The manual can also be used during in-service and pre-service competency-based abortion training in medical colleges. I urge all health leaders and health-care providers in the Region to appropriately leverage this resource, in alignment with national legal provisions, and with a focus on strengthening capacity in underserved areas, reducing the risk of unsafe abortion for every woman, everywhere. Towards that outcome, WHO will continue to provide its technical and operational support for a healthier and fairer Region for all. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region The Second trimester abortion: Pocketbook for health-care providers has emerged from the contributions of a group of experts from Member States of the WHO South-East Asia Region. This expert group also supported the development of the second trimester abortion training resource package for pre-service medical education. Their views have helped strengthen the management of second trimester abortion. We also acknowledge the expert advice and technical inputs by WHO collaborating centres and professional associations on obstetrics and gynaecology. Overall guidance and technical oversight were provided by Dr Neena Raina, Director, Department of Family Health and the Life-Course, and Dr Meera Upadhyay, Technical Officer for Reproductive Health, at the WHO Regional Office. We thank Dr Mekdes Feyssa Technical officer and other colleagues from PUA, WHO Head Quarters for their valuable inputs . The members of the Regional Expert Group to develop the second trimester abortion resource package whose contributions are hereby acknowledged are listed as follows: Bangladesh: Professor Ferdousi Begum, Professor Farhana Dewan, and Professor Salma Rauf of the Obstetrical and Gynaecological Society of Bangladesh (OGSB). Acknowledgments xiv SECOND TRIMESTER ABORTION India: Dr Manju Puri, Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi; Dr Pratima Mittal, Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences & Research Centre, Faridabad; Dr Aparna Sharma, All India Institute of Medical Sciences, New Delhi; Dr Jyotsna Suri, Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi; Dr Priti Kumar, Sunflower Medical Centre, Lucknow; Dr Jaydeep Tank, Obstetrician and Gynaecologist from Mumbai. Maldives: Dr Hawwa Inaya Abdul Raheem, Obstetrician and Gynaecologist. Nepal: Dr Meena Thapa, Gynaecologist, Kathmandu Medical College; Dr Anjana Dongol, Gynaecologist, Kathmandu University. Sri Lanka: Dr Mangala Dissannayake, Sri Lanka College of Obstetricians and Gynaecologists (SLCOG), Colombo. Thailand: Dr Sanya Patrachai, Department of Obstetrics and Gynaecology, Ramathibodi Hospital, Bangkok. Timor-Leste: Dr Agusto Junior Gusmao, Gynaecologist, Dili National Hospital (HNGV). ANM : Auxillary Nurse Midwife ART : Antiretroviral Therapy B : Buccal CAC : Comprehensive Abortion Care CICs : Combined Injectable Contraceptives COCs : Combined Oral Contraceptives CVS : Cardiovascular System D&C : Dilatation and Curettage D&E : Dilatation and Evacuation DMPA-IM : Depot Medroxyprogesterone Acetate (Injectable Contraceptive) DMPA-SC : Depot Medroxyprogesterone Acetate (Subcutaneous Form) ETG : Etonogestrel EVA : Electric Vacuum Aspiration Hb : Haemoglobin HPV : Human Papillomavirus IM : Intramuscular Acronyms and abbreviations xvi SECOND TRIMESTER ABORTION IUCD : Intrauterine Contraceptive Device IUFD : Intrauterine Fetal Demise IV : Intravenous LMP : Last Menstrual Period LNG : Levonorgestrel LSCS : Lower Segment Cesarean Section MA : Medical Abortion MBBS : Bachelor of Medicine and Bachelor of Surgery MDGP : MD in General Practice MEC : Medical Eligibility Criteria MMA : Medical Management of Abortion MPA : Medroxyprogesterone Acetate MTP : Medical Termination of Pregnancy MVA : Manual Vacuum Aspiration NET-EN : Norethisterone Enanthate NSAID : Non-steroidal Anti-inflammatory Drug Ob-Gyn : Obstetrics & Gynaecology PAS : Placenta Accreta Syndrome POC : Products of Conception POP : Progesterone-only Pill PPH : Postpartum Haemorrhage PP : Placenta Praevia PV : Per Vaginam RTI : Reproductive Tract Infection SAMM : Severe Acute Maternal Morbidity SBA : Skilled Birth Attendant SL : Sublingual STI : Sexually Transmitted Infection VA : Vacuum Aspiration WHO : World Health Organization Goal of the pocketbook Strengthening the knowledge and standardizing the skills of health-care providers, enabling them to provide client-centred, comprehensive quality abortion care services, leading to reduction in the complications and morbidity of second trimester abortion. Scope of the pocketbook The document “Second trimester abortions: pocketbook for health-care providers” highlights the key points and standard protocols for providing comprehensive abortion care (CAC) by a trained health-care provider 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 heath resources. Abortion is considered safe when carried out using a method recommended by WHO, appropriate to the pregnancy duration, and by someone with the necessary skills. Second trimester abortion is usually defined as abortion >12 weeks’ gestation (>84 days, as calculated from the last menstrual period [LMP] or by ultrasound if there is clinically relevant uncertainty about the pregnancy duration). 1.1 Global situation of abortion ™ In 2015–2019, there were 73.3 million abortions each year globally, corresponding to an annual abortion rate of 39 per 1000 women aged 15–49 years and Second trimester abortion: An overview1 To state the background of second trimester abortion and explain the importance of providing safe and comprehensive abortion care services. Objective 2 SECOND TRIMESTER ABORTION unintended pregnancy rate of 61%. Over a 30-year period, there has been a steady decline in the global unintended pregnancy rate. However, the proportion of unintended pregnancies ending in an abortion has increased by 18% (1). Global abortion and unintended pregnancy trends (2015-2019) 61% Unintended pregnancy rate 73.3 million Annual abortions 39 per 1000 Women aged 15–49 annual abortion rate ™ There were 29 abortions per 1000 women aged 15–44 years in developing countries, compared with 24 per 1000 in the developed world (2008) (2). While it was as low as 1.4–6.2% in the United States and 8.6% in England and Wales, it was as high as 25–30% in South Africa, 34% in Kenya, 10% each in Nigeria and Ethiopia (2,3). ™ Global estimates from 2010 to 2014 demonstrate that 45% of all induced abortions are unsafe, of which 97% take place in developing countries. This is inclusive of 14.4% of abortions (about one third of all unsafe abortions), POCKETBOOK FOR HEALTH-CARE PROVIDERS 3 which are performed under the “least safe” conditions, i.e. by untrained persons using dangerous and invasive methods (4). ™ Unsafe abortion is a leading but preventable cause of maternal deaths and morbidities. It can lead to physical and mental health complications along with social and financial burdens for women, communities and health systems. Approximately 4.7–13.2% of all maternal deaths are attributed to unsafe abortions globally (5). ™ Developing countries bear the burden of 97% of all unsafe abortions. Over half (53.8%) of all unsafe abortions occur in Asia (the majority in south and central Asia), while another quarter (24.8%) occur in Africa (mainly in eastern and western Africa), and a further fifth (19.5%) in Latin America and the Caribbean (4). Lack of access to safe, timely, affordable and respectful abortion care is a critical public health and human rights issue. ™ The legal status of abortion has no effect on a woman’s likelihood of seeking induced abortion, but it dramatically affects her access to safe abortion (5). The proportion of abortions that are unsafe is also significantly higher in countries with highly restrictive abortion laws than in those with less restrictive laws. 4 SECOND TRIMESTER ABORTION 1.2 Regional situation of abortion ™ During 2010–2014, an estimated 35.5 million induced abortions occurred each year in Asia. The annual rate of abortion for the region is an estimated 36 per 1000 women of reproductive age (15–44 years). The regional abortion rate is roughly 36 per 1000 for married women Figure 1.1: Global annual rates of unintended pregnancy and abortion per 1000 women aged between 15–49 years (shaded areas indicate 80% uncertainty intervals) (1) Ra te p er 10 00 w om en a ge d be tw ee n 15 a nd 4 9 ye ar s 100 80 60 40 20 0 1990-94 1995-99 2000-04 2005-09 2010-14 2015-19 79 40 72 37 67 35 66 37 65 39 64 39 Period (years) Abortion rateUnitended pregnacy rate POCKETBOOK FOR HEALTH-CARE PROVIDERS 5 and 24 per 1000 for unmarried women. Abortion rates in four of Asia’s five subregions (eastern, paho ,southern, southeastern and western) are close to the overall regional rate (6). Induced abortions in Asia (2010-2014) Induced abortions in Asia (2010-2014) 35.5 million Annual abortions 39 per 1000 Women aged 15–44 regional abortion rate 39 per 1000 Married women 24 per 1000 Unmarried women ™ An estimated 53.8 million unintended pregnancies occur each year in Asia. Of these, nearly two thirds (65%) end in abortion. As of 2010–2014, the majority (89%) of abortions in eastern Asia, including China, are safe. In southern and central Asia together, less than half of all abortions are safe. In 2014, at least 6% of all maternal deaths (or 5400 deaths) in Asia were from unsafe abortion. The most common complications from unsafe abortion are incomplete abortion, excessive blood loss and infection (6). 6 SECOND TRIMESTER ABORTION 1.3 Situation of second trimester abortion ™ Globally, mid-trimester procedures constitute 10–15% of all abortions being done (7). ™ Nearly all abortions in 2020 took place early in gestation: 93.1% of abortions were performed at ≤13 weeks’ gestation; a smaller number of abortions (5.8%) were performed at 14–20 weeks’ gestation, and even fewer (0.9%) were performed at ≥21 weeks’ gestation (8). The proportion of abortions performed in the second trimester has remained stable during the past two decades. ™ Second trimester termination of pregnancy is associated with a disproportionately high rate of maternal morbidity (8). Two thirds of abortion-related major complications and half of all abortion-related mortality occur in pregnancies terminated after 13 weeks of gestation. ™ Haemorrhage and infection are the most important preventable causes of mortality after second trimester abortions. Complications associated with abortions are haemorrhage (0.09–11.6%), infection (1.3–3%), uterine perforation (0.45–3.7%), uterine rupture (0– 4.8%), pulmonary embolism (0.1–0.2%), amniotic fluid embolism (0.000125–0.001%), coagulopathy (0.17–0.2%), bowel injury (0.53%), hysterectomy (0.00005–2.4%), POCKETBOOK FOR HEALTH-CARE PROVIDERS 7 incomplete abortion requiring dilation and curettage (D&C) (0.2-21%) (9). ™ Morbidity from the complications of abortion like bleeding and infection increases with gestational age. Analysis of severe acute maternal morbidity (SAMM) cases in the first trimester and second trimester has shown 2% mortality in the second trimester as compared to 0.3% in the first trimester (10). Mortality rate for women undergoing second trimester abortion increased with gestational age, from 2.4 deaths per 100 000 abortions at 14–17 weeks’ gestation to 6.7 deaths per 100 000 abortions at >18 weeks’ gestation (11). Influencing factors for risk of complications The method of termination procedure The skill and experience of the abortion practitioner Availability of referral facility in case of any complication General health of the woman 8 SECOND TRIMESTER ABORTION 1.4 Reasons for seeking second trimester abortion Reasons Late detection of pregnancy symptoms or amenorrhoea following recent pregnancy Pregnancy with fetal anomalies, which is commonly diagnosed late Victims of violence, who have a higher risk of late presentation Delayed decision- making in induced abortion due to social pressures, fear or religious reasons Ongoing pregnancy after failed abortion Financial issues to cover the cost of the procedure Difficult access to first trimester abortion services Diagnosis of maternal medical indications that worsen through the course of pregnancy, such as severe pre- eclampsia or preterm premature rupture of membranes 01 02 03 04 05 06 07 08 POCKETBOOK FOR HEALTH-CARE PROVIDERS 9 1.5 Barriers to seeking second trimester abortion Barriers 01 02 03 04 0506 07 08 09 Lack of access to accurate information Health-care providers attitude Stigma for those seeking abortion Imposition of mandatory waiting periods Third-party authorization requirements Restrictive laws and regulations that are not medically justified Lack of access to trained health-care providers Restrictions on the type of facilities or settings where abortion services can lawfully be provided Logistic challenges to the client who have limited resources and support as transportation, child care and time off from work 10 SECOND TRIMESTER ABORTION References 1. Bearak J, Popinchalk A, Ganatra B, Moller A-B, 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(9):e1152–e1161. 2. UNDP, UNFPA, UNICEF, WHO, World Bank. Preventing unsafe abortion. Evidence brief. Geneva: Human reproduction programme (hrp), World Health Organization; 2019 (https://www.who.int/publications/i/item/WHO-RHR-19.21, accessed 26 July 2023). 3. Safe abortion: technical and policy guidance for health systems, second edition. Geneva: World Health Organization; 2012 (https://apps.who.int/iris/ handle/10665/70914, accessed 26 July 2023). 4. Ganatra B, Gerdts C, Rossier C, Johnson BR, 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(10110):2372–81. 5. Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization; 2015 [WHO/RHR/15.04] (https://apps.who.int/iris/bitstream/ handle/10665/173586/WHO_RHR_15.04_eng.pdf, accessed 26 July 2023). 6. Fact sheet: abortion in Asia. New York: Guttmacher Institute; March 2018 (https:// www.guttmacher.org/sites/default/files/factsheet/ib_aww-asia.pdf, accessed 26 July 2023). 7. Mulat A, Bayu H, Mellie H, Alemu A. Induced second trimester abortion and associated factors in Amhara region referral hospitals. Biomed Res Int. 2015;2015:256534. 8. Kortsmit K, Nguyen AT, Mandel MG, Clark E, Hollier LM, Rodenheizer J et al. Abortion surveillance – United States 2020. MMWR Surveillance Summaries. 2022;71(10):1–27. To reduce the morbidity and mortality associated with abortion, we need to deliver quality abortion care that is effective, efficient, accessible, acceptable, equitable and safe. A focus on training providers is the most important component to address the barriers and to deliver safe abortion services. POCKETBOOK FOR HEALTH-CARE PROVIDERS 11 9. Monique Chireau Wubbenhorst, Midtrimester Abortion Epidemiolofy, Indications and Mortality Charlotte Lozier Institute on science issue 5, october 2021. 10. Atuhairwe S, Gemzell-Danielsson K, Byamugisha J, Kaharuza F, Tumwesigye NM, Hanson C. Abortion related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda. BMJ Glob. Health 2021;6:e003274. 11. Zane S, Creanga AA, Berg CJ, Pazol K, Suchdev DB, Jamieson DJ, Callaghan WM. Abortion-related mortality in the United States: 1998–2010. Obstet Gynecol.2015;126(2):258–65. Key message A comprehensive abortion care includes the provision of information, abortion management and post-abortion care, including family planning. When carried out using a method recommended by WHO appropriate to the pregnancy duration and by someone with necessary skills, abortion is a safe health-care intervention. Quality abortion care is a critical public health, equality and human rights issue. Legal restrictions and other barriers imply that many women find it difficult or impossible to access quality abortion services and hence are forced to resort to unsafe abortion. Safe abortion practices can prevent maternal morbidity and mortality. 2.1 Barriers to access to quality abortion care ™ Lack of access to accurate information ™ Laws prohibiting safe abortion care/criminalization of abortion 2 Legal provisions for second trimester abortions (country specific) To update health-care providers with the knowledge of laws/acts/policies related to second trimester abortion (country specific) Objective POCKETBOOK FOR HEALTH-CARE PROVIDERS 13 ™ Gestational age limit ™ Biased counselling ™ Imposition of mandatory waiting period ™ Third-party authorization ™ Restriction on the type of facilities or settings where services can be provided lawfully ™ Restriction on the type of health workers who can lawfully provide services ™ Breach of confidentiality and privacy. 2.2 Facilitating access to safe abortion Safe abortion initiatives Services are affordable Delivered without undue logistical and administrative obstacles Delivered timely by the skilled service provider Providers display respectful, caring and empathetic attitude Women are not denied services based on their economic status, age, educational/social background, religious/political views, race/ethnic group or sexual preferences 14 SECOND TRIMESTER ABORTION 2.3 Women’s reproductive and human rights (1) 01 02 04 05 06 07 08 03 2.4 WHO recommendations related to regulatory, policy and human rights considerations on abortion (2) The WHO abortion care guideline recommends supportive laws and policies for provision of safe abortion care. Seven specific, interdependent, and interrelated Right to life and survival Right to the highest attainable standard of physical and mental health, including reproductive health and rights Right to non-discrimination and equality Right to decide freely and responsibly on the number, spacing and timing of children and to have the information and means to do so Right to information and education, including on sexual and reproductive health Right to benefit from scientific progress and its realization Right to privacy Right to be free from torture, cruel, inhuman and degrading treatment and punishment, including the right to physical and mental integrity POCKETBOOK FOR HEALTH-CARE PROVIDERS 15 recommendations for the removal of regulatory, policy and programmatic barriers that hinder access to timely care are as follows:* ™ Criminalization: Recommends the full decriminalization of abortion; ™ Grounds-based approache: y Recommends against laws and other regulations that restrict abortion by grounds; y Recommends that abortion be available on the request of the woman, girl or other pregnant person; ™ Gestational age limit: Recommends against laws and other regulations that prohibit abortion based on gestational age limit; ™ Mandatory waiting period: Recommends against mandatory waiting periods for abortion; ™ Third-party authorization: Recommends that abortion be available on the request of the woman, girl or other pregnant person without the authorization of any other individual, body or institution; ™ Provider restriction: Recommends against regulation on who can provide and manage abortion, which is inconsistent with WHO guidance; * These recommendations refer to consensual abortion. Forced or coerced abortion would constitute serious assault and serious violation of human rights. 16 SECOND TRIMESTER ABORTION ™ Conscientious objection: Recommends that access to, and continuity of, comprehensive abortion care be protected against barriers created by conscientious objection. 2.5 A woman’s six legal grounds for abortion There are six legal grounds for abortion in most countries: Risk to the life of the pregnant woman Social and economic reasons On request Rape or sexual abuse Serious fetal anomaly Risk to the health of the woman (physical or mental) Source: Policies, programme, and services for comprehensive abortion care in South-East Asia Region. New Delhi: WHO Regional Office for South-East Asia; 2021. POCKETBOOK FOR HEALTH-CARE PROVIDERS 17 ™ Many countries have legalized induced abortions. Some countries prohibit abortion altogether except to save a woman’s life or to preserve her mental or physical health. ™ In countries where abortion is restricted, the proportion of unintended pregnancies ending in an abortion increased by 39% between 1990–1994 and 2015– 2019. In contrast, where it is largely legal, except India and China, the rate has fallen by 13% over the same period (3). ™ Second trimester abortion for cases with severe fetal malformation, not compatible with life is conducted as per the country’s guidelines. 2.6 Country-specific legal frameworks (4,5) Laws in the eleven countries of the South-East Asia Region vary from very restrictive to not so restrictive. All countries allow abortion to save a woman’s life. Post-abortion care (PAC) is unanimously recognized as an important part of the health-care system, regardless of countries’ legal status on abortion. Bangladesh, Bhutan, Myanmar, Indonesia, Sri Lanka and Timor-Leste have very restrictive laws, permiting abortion only to save a woman’s life. India, Nepal and Thailand allow a woman to terminate a pregnancy for a variety of reasons. Nepal also permits abortions up to the twelfth week of pregnancy upon request. The country 18 SECOND TRIMESTER ABORTION provides an additional reason for terminating a pregnancy if a woman is living with HIV or another incurable disease of this type. Bangladesh provides menstrual regulation (MR) services for first trimester abortion (Fig. 2.1). Figure 2.1: Abortions in countries of the South-East Asia Region Prohibited/allowed only to save mother’s life Available liberally Available with some restrictions POCKETBOOK FOR HEALTH-CARE PROVIDERS 19 SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Bangladesh Who ™ Specialists (Ob-Gyn) ™ Non- specialists ™ Paramedic nurses (up to 8 weeks) Not available Specialists, non- specialists, paramedic nurses When Induced abortion is permissible only to save a woman’s life ™ Care post- medical abortion is not defined ™ Care post- surgical abortion is available How MR allowed Continued 20 SECOND TRIMESTER ABORTION Continued Continued SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care ™ Using medications (mifepristone & misoprostol) – up to 9 weeks ™ Manual/ electrical vacuum aspiration (MVA/EVA) or dilatation & evacuation (D&E) between 6 to 12 weeks Where All health facility outlets District hospitals, medical colleges and primary health-care centres POCKETBOOK FOR HEALTH-CARE PROVIDERS 21 Continued Continued SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Bhutan Who Specialists Only facilities with general practitioners and specialists can offer treatment for complications of abortion When Only under 3 conditions: ™ To save the woman’s life ™ In cases of rape and incest ™ Where the mother is of unsound mental health How ™ Pharmacological induction with mifepristone and prostaglandin ™ Vacuum aspiration and D&C Where Hospital with blood transfusion facility India Who Specialists (Ob-Gyn) and non-specialists with applicable qualification and training criteria Registered medical practitioner with specified training and specialists (Ob-Gyn) 22 SECOND TRIMESTER ABORTION SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care When ™ With the medical termination of pregnancy (MTP) (Amendment) Act, 2021 MTP can be performed with the opinion of a registered medical practitioner (RMP) ™ To save the life of the mother ™ To prevent grave physical or mental injury to the mother ™ Risk of physical or mental congenital abnormality to baby MTP can be performed for up to 20 weeks with the opinion of an RMP and with the opinion of two RMPs between 20 and 24 weeks and is only allowed for special categories within the meaning of the MTP Amendment Rules, 2021. In addition, there is no pregnancy limit for major birth defects when approved Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 23 SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care ™ Rape survivor ™ Contraceptive failure by a medical board (applies beyond the 24th week) How ™ Medical: using mifepristone & misoprostol combination (up to 9 weeks) ™ Surgical: vacuum aspiration ™ Medical: abortion using misoprostol only ™ Surgical: dilatation & evacuation All public and private sector facilities Where All approved public/private sector facilities/ clinics Medical abortion up to 9 weeks can be prescribed by an outpatient clinic with an established referral access Secondary and tertiary public and private sector approved facilities Continued Continued 24 SECOND TRIMESTER ABORTION SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Indonesia Who Not defined When Essentially illegal, but can be provided in a few situations after approval from the feasibility/ethical team appointed at the facility: ™ Save a woman’s life (only up to 6 weeks of gestation) ™ Rape/incest ™ Fetal impairment (no gestational age limit) How Neither misoprostol nor mifepristone are part of the essential medicines list in Indonesia. Also, the use of misoprostol for abortions is off label. Where Facilities ranging from a primary health clinic to a hospital can provide abortion services but need to be appointed by the Ministry of Health DPR Korea In October 2015, DPR Korean authorities issued a directive banning medical professionals from performing birth control procedures and abortions to reverse the country’s falling births Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 25 SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Maldives Who Only by registered obstetricians/gynaecologists When Abortion is permitted: ™ To save a woman’s life (no limit of gestational age); and ™ If the pregnancy is a result of rape or incest (up to 120 days). How No national standards and guidelines for induced abortion and post-abortion care are available. Abortion-related drugs and supplies are not part of the registered products list. Mifepristone and misoprostol appear in the pre- authorization list, implying that pre-authorization (approval) must be taken prior to import and the approval is valid for one year. Where Only in higher-level health facilities and the procedure is covered under the national health insurance scheme Continued Continued 26 SECOND TRIMESTER ABORTION SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Myanmar Who ™ Specialists (Obs-Gynae) and ™ Non- specialists ™ Specialists (Obs- Gynae) and ™ Non- specialists (only under the supervision of an obstetrician and gynaecologist) Specialists (Obs- Gynae) and non- specialists When To save the mother’s life (no limit of gestational age) How ™ Medical method (misoprostol only) ™ Surgical method (manual vacuum aspiration [MVA]) Only medical method (misoprostol only) Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 27 SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Where Station hospitals, township hospitals, district hospitals and above (the policy documents do not mention private facilities) Nepal Who ™ Specialists (Obs-Gynae) ™ Non- specialists MD General Practice (MDGP) and Medical Graduate ™ Nurses (staff nurse, including senior auxiliary nurse midwives [ANMs]) only up to 9 weeks for Medical Abortion (MA) and 8 weeks for MVA ™ Specialists (Obs- Gynae) ™ Non- specialists (MDGP only) ™ Specialists (Obs- Gynae) ™ Non- specialists (MDGP and MBBS) ™ Nurses (staff nurse including senior ANMs) Continued Continued 28 SECOND TRIMESTER ABORTION SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care When ™ On request (up to 12 weeks) ™ Up to 28 weeks to save the woman’s life, poor physical and mental health, HIV and other incurable diseases, in cases of rape/incest and fetal impairment Up to 28 weeks: ™ To save the woman’s life ™ Physical health ™ Mental health ™ Rape/ incest ™ Fetal impairment ™ HIV and other incurable disease How Medical abortion (using mifepristone & misoprostol combination) up to 10 weeks Not defined Free of cost at public facilities up to 12 weeks Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 29 SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Where Listed facilities of all types (government, semi- autonomous, non- governmental and private sector facilities) that meet specifications of infrastructure Listed emergency obstetric care (EmOC) facility with an Obs- Gynae or MDGP specialist All CAC facilities where the providers are trained on CAC or skilled birth attendants (SBA) Sri Lanka Who Not specified Not specified Medical providers are not permitted to withhold post- abortion care services citing personal, moral and/ or religious beliefs Continued Continued 30 SECOND TRIMESTER ABORTION SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care When To save the woman’s life (no gestational age limit) How ™ Medical method using misoprostol (but misoprostol is not included in the Essential Medicines List of Sri Lanka) ™ MVA and dilatation and evacuation are recognized methods for incomplete abortion Where Not specified Not specified Primarily in specialist gynaecology units Thailand Who By a medical practitioner defined as someone who has registered and obtained a license for medical practice by the Medical Council When No limit of gestational age, conditions permitted are: ™ Economic/social reasons Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 31 SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care ™ Mental health: Certified or approved by at least one medical practitioner other than the one who will perform the medical termination of pregnancy (MTP) ™ Rape/incest: Required to have evidence or fact leading to a reasonable belief that the pregnancy is caused by the offence ™ Fetal impairment: Required examination and genetic counselling and acknowledged in writing by at least one medical practitioner other than the one who will perform the MTP How Combination of mifepristone and misoprostol was officially included in the National Essential Drugs list in 2018 Continued Continued 32 SECOND TRIMESTER ABORTION SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Where ™ At a government hospital or government agency that provides overnight an admission service to patients ™ A medical infirmary that has beds for overnight stay in accordance with the Medical Premise Act ™ At a medical clinic in accordance with the Medical Premise Act where the gestational age is not over 12 weeks ™ At a government hospital or government agency that provides overnight admission service to patients ™ A medical infirmary that has beds for patients for overnight stay in accordance with the Medical Premise Act Normally treated in public hospitals (while there are no guidelines) Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 33 SEAR countries First trimester abortions (uterine size up to 12 weeks from last menstrual period [LMP]) Second trimester abortions (uterine size greater than 12 weeks from LMP) Post- abortion care Timor-Leste Who By a medical doctor or other health professional under his/ her supervision and spousal consent is required. When Only when it is the only means to save the pregnant woman’s life (no gestational age limit) How In terms of medical abortion (MA), combination kit of misoprostol and mifepristone is unavailable but Misoprostol is approved Where In a public health facility or other officially recognized facility Medical doctors and other health professionals have the right to conscientious objection about any procedure related to abortion – it is required to be expressed and communicated by a written and signed document to the facility manager All the hospitals and community health centres (CHC) are to be equipped to handle and provide these services Continued 34 SECOND TRIMESTER ABORTION The following are the highlights from the legal perspective on abortion in the Member States of the Region: ™ Almost all countries allow abortion if it is necessitated to save a woman's life, with no limit on the gestational age in this circumstance. ™ Post-abortion care is unanimously recognized as an important component of the health-care system regardless of the legal status on abortion of a Member State. ™ Bangladesh, Bhutan, Indonesia, Myanmar, Sri Lanka and Timor-Leste have very restrictive laws: abortion is not legal in these countries, and it is allowed only to save a woman’s life. ™ India, Nepal and Thailand permit a woman to terminate a pregnancy for a variety of reasons. ™ Nepal allows abortions up to the twelfth week of pregnancy on request. It allows for termination of pregnancy up to 28 weeks of gestation if a woman is living with HIV or an incurable disease of this type. ™ Thailand does not have a specific gestational age limit, but conditions are specified for abortion. ™ India has upgraded its gestation limit for termination of pregnancy to 24 weeks in certain conditions. 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. POCKETBOOK FOR HEALTH-CARE PROVIDERS 35 References 1. Towards a supportive law and policy environment for quality abortion care: evidence brief. Geneva: World Health Organization; 2022 (https:// apps.who.int/iris/bitstream/handle/10665/364081/9789240062405-eng. pdf?sequence=1&isAllowed=y, accessed 26 July 2023). 2. Abortion care guideline. Geneva: World Health Organization; 2022 (https://www. who.int/publications/i/item/9789240039483, accessed 26 July 2023). 3. Bearak J, Popinchalk A, Ganatra B, Moller A-B, 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(9):e1152–e1161. 4. Policies, programme and services for comprehensive abortion care in South- East Asia Region. New Delhi: World Health Organization Regional Office for South- East Asia; 2020 (https://apps.who.int/iris/handle/10665/338768, accessed 26 July 2023). 5. Abortion policy landscape: Bangladesh, Bhutan, Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. New Delhi: World Health Organization 2021. Key message All health-care workers providing CAC should be well versed with their country's laws to provide comprehensive abortion services. This is especially crucial for second trimester abortion, which may not be permissible in certain countries and, even if permitted, may only be available in specific facilities for selected indications. The provider should also inform women of their reproductive rights. 3.1 Definition of counselling Counselling is a focused, interactive process through which a person voluntarily receives support and nondirective guidance from a trained person, in an environment that is conducive to open sharing of thoughts, feelings, perceptions and personal experiences. Counselling should be offered by a trained health-care professional. The decision of the woman should be respected. Informed voluntary consent of the adult woman or her guardian, if she is a minor, is mandatory for providing abortion services. The same should be documented after abortion. To provide information, offer counselling, facilitate decision-making and obtain informed consent for termination of pregnancy. Objective Counselling a woman seeking second trimester abortion 3 POCKETBOOK FOR HEALTH-CARE PROVIDERS 37 3.2 Guiding principles of counselling ™ Ensure that privacy and confidentiality are maintained. Medical information must be protected against unauthorized disclosures. ™ The Greet, Ask, Tell, Help, Explain, Return (GATHER) approach should be used. ™ The counsellor should have updated technical knowledge and skills along with awareness of the national laws and policies on abortion. ™ Clinical communication should be started with issues that are least sensitive and least threatening. ™ Ensure that all women receive information without any form of discrimination ™ The details of counselling should be recorded. 3.3 Pre-procedure counselling ™ Clear doubts and thoughts about termination of pregnancy by asking her the reason for termination and actively listen to expressed needs and preferences. ™ Inform that an early abortion is safer, where it is available legally as per country laws. ™ If the woman chooses to have an abortion, she should be given options of abortion methods (medical or surgical) and pain management. 38 SECOND TRIMESTER ABORTION ™ She should be informed about detail process of induced abortion, both surgical and medical methods. ™ She should be informed about the potential of getting pregnant again (as early as 8 days after an abortion) if she does not adopt a contraceptive method. Abortion services would still be provided, even if she is unwilling for contraception. 3.4 Essential components of counselling for second trimester abortion Options of abortion method based on: ™ Duration of pregnancy ™ Woman’s medical condition ™ Potential risk factors ™ Advantages and disadvantage of each available method Medical abortion using drugs or surgical abortion such as vacuum aspiration up to 14 weeks and D&E after 14 weeks. Risk of complications associated with the abortion method: ™ How to recognize potential side-effects and warning signs for when to return to the hospital POCKETBOOK FOR HEALTH-CARE PROVIDERS 39 Option of pain management: ™ Explanation of expected intensity/duration of pain or menstrual-like cramps ™ The type of pain management options available and could be provided Provision of additional services: ™ Where and how to access services in case of an emergency ™ Need for and method of lactation suppression ™ Expected time for return to normal activities, including sexual intercourse and follow-up care Procedure details: ™ Details of what will be done before, during and after the procedure (Section 5.2) ™ Any tests that may be performed ™ What she is likely to experience (e.g. menstrual- like cramps in the form of mini labour with medical abortion, pain and bleeding, passage of blood, clots, products of conception) ™ Duration of the process, which may vary in individuals 40 SECOND TRIMESTER ABORTION 3.5 Post-procedure counselling Offer contraceptive choices: ™ Options of contraceptives ™ Advantages and disadvantages of the methods ™ When these can be started ™ Expected side-effects and details of contraception chosen Self-care Rest for a few days Change pads frequently as they soak for every 4–6 hours Avoid sexual intercourse until bleeding stops Warning signs when she must return to hospital Heavy or continuous bleeding (More than 2 pads/hour for 2 consecutive hours) Fever with or without chills Dizziness or fainting Severe abdominal pain Vaginal discharge POCKETBOOK FOR HEALTH-CARE PROVIDERS 41 Use of breast support, tight bras and/or pharmacological inhibition of lactation may be helpful in relieving breast engorgement, which can occur in advanced gestation. She is provided with accurate information to assist her in choosing the most appropriate contraceptive method to meet her needs if willing for contraception. If not, a bridging method of contraception can be offered till she makes her choice. The final decision to use contraception is governed by woman’s choice only. 3.6 Informed consent for second trimester abortion (Annex 1) Information about the procedure Indication Mode of analgesia or anaesthesia Description, including additional procedure, if any Alternatives 42 SECOND TRIMESTER ABORTION Advantages of the procedure Alternatives for priming of the cervix and medical/surgical method Description of any additional procedure if required or opted for Guardian’s consent is required in case of minors or mentally differentially-abled client. National guidelines should be followed Risks of the procedure Excessive bleeding Excessive pain Infection Incomplete evacuation and, as a result, continuation of pregnancy Injury to surrounding structures such as bladder, ureter, bowel, blood vessels Anaesthesia risks such as vomiting, drowsiness, weakness Very rare: allergic reaction, shock, need for ventilation, formation of blood clot POCKETBOOK FOR HEALTH-CARE PROVIDERS 43 3.7 Counselling for special groups seeking second trimester abortion Special group Challenges Counselling to be focused Unmarried woman ™ Fear of lack of confidentiality and privacy ™ Vulnerable to pressure ™ Third party authorization in case of adolescents ™ Financial constraints ™ Start the clinical interview with issues that are least sensitive and least threatening ™ Encouraging parents’ engagement through support ™ Respect local sensitivities regarding gender norms (presence of female colleague during examination) ™ Ensure privacy (curtains are drawn, doors are shut and no unauthorized person enters the room during the examination) ™ Counsel regarding safe sexual practices, emergency contraception and post- abortion contraception Adolescent Single woman With disabilities Subjected to coercion and exploitation due to their disability Information related to support services to be provided and accessibility to these to be facilitated Continued 44 SECOND TRIMESTER ABORTION Special group Challenges Counselling to be focused Living with HIV/AIDS Stigma and discrimination Patient to be sensitized about mode of spread Counselling regarding safe sexual practices, emergency contraception and post-abortion contraception Facing violence at home Providers not sensitive enough to the human rights of the client and client’s vulnerability ™ Referral services for abuse support services to be facilitated ™ Ensure privacy (e.g. make sure that curtains are drawn, doors are shut and no unauthorized person enters the room during the examination) ™ Start the clinical interview with issues that are the least sensitive and least threatening Key message All women must receive nonjudgemental, relevant, accurate and easy-to-understand information about what to expect before, during and after the abortion, ensuring privacy and confidentiality from a competent health-care provider. Continued The focus of clinical evaluation is on: ™ Confirmation of pregnancy and assessment of correct gestational age; ™ Assessing if there is any associated factor pertaining to the woman’s health; ™ Assessing for any associated medical or surgical comorbidity. 4 Pre-abortion evaluation To describe the different components of pre-abortion assessment in women seeking second trimester abortion, including relevant history and examination that may influence the choice of procedure Objective 46 SECOND TRIMESTER ABORTION 4.1 Components of pre-abortion assessment 01 02 03 Detailed history-taking General physical and pelvic examination Investigations 4.2 Medical history Personal data Name, age and contact information, if possible Reasons for seeking medical care ™ Pregnancy circumstance ™ Pregnancy symptoms ™ Reason for seeking care in late gestationn ™ Any intervention before seeking current care ™ Any complications such as vaginal bleeding Menstrual history ™ Menstrual cycle pattern: Length and duration of cycle, flow (excessive or normal) regular or irregular ™ First date of last mentsrual period (LMP) and whether the last period was normal Obstetric history ™ Details of previous pregnancies and their outcomes, including ectopic pregnancy, molar pregnancy ™ Prior miscarriage or abortions, fetal deaths, live births and mode of delivery Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 47 Personal data Name, age and contact information, if possible Gynaecological history Gynaecological issues, including previous gynaecological surgery, history of female genital mutilation, or other known physical abnormalities or conditions ™ Contraceptive history: y Current contraceptive use y Contraceptive methods used in the past and experience (positive or negative) with the methods 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 infection (STI), including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) ™ Contraceptive history 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 ™ Use of recent medicines or herbal remedies, including the details of their use dose, route, timing and if used in attempt to self-abort the pregnancy ™ Allergy to medications Continued Continued 48 SECOND TRIMESTER ABORTION Calculation of gestation period LMP known: Calculate the number of weeks from the first day of LMP in a woman with regular cycles. LMP not known or irregular cycles: Gestational age (GA) can be determined by physical examination done in the first trimester and can be confirmed by pelvic ultrasound, if available. GA can be determined by clinical/physical examination (bumanual pelvic and abdominal exaamination) or by ultrasound or a combination of both physical examination and ultrasound. Personal data Name, age and contact information, if possible Immunization ™ Status of tetanus immunization: last dose received Psychological history ™ Any history suggestive of depression or anxiety disorder ™ Any history suggestive of psychotic disorder ™ Any history suggestive of suicidal tendencies ™ Any history of abuse in any form Social history ™ Marital or partner status ™ Family environment: assess family support ™ Any history of sexual or physical assault ™ 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 POCKETBOOK FOR HEALTH-CARE PROVIDERS 49 4.3 Physical examination General health assessment ™ General appearance ™ Vital signs ™ Signs of weakness, lethargy, anaemia or malnourishment ™ Signs or marks of physical violence – new or old bruise on genitalia or other body parts, unexplained burn mark, injury marks ™ General physical examination – CVS, CNS, chest Psychosocial assessment ™ Assess cognitive ability ™ Assess mental status Abdominal examination ™ Palpate for the uterus and note size ™ Note any other abdominal masses/abdominal tenderness, guarding or rigidity ™ Note any abdominal scars from previous surgery ™ During the second trimester uterus will be felt above the pubic symphysis 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 Speculum examination ™ Inspect the cervix and vaginal canal: y Look for abnormalities or foreign bodies Continued 50 SECOND TRIMESTER ABORTION y Look for any vaginal anomaly or septum y Look for signs of infection, such as pus or discharge from the cervical os, take sample for culture y Look for any polyp, growth or cervical anomaly. y Cervical cytology/HPV DNA testing may be performed at this point, if indicated and available Bimanual examination ™ Note the uterine size (for gestation age) ™ Cervix status – note the consistency and dilatation Continued Figure 4.1: Pregnancy dating by physical examination (bimanual pelvic and abdominal examination) 2 4 8 12 16 20 30 40 After 4 weeks of gestation the uterus increases in size by approximately 1 cm per week After 12 weeks of gestation the uterus rises out of the pelvis After 15-16 weeks of gestation the uterus reaches the midpoint between the symphysis pubis and the umbilicus At 20 weeks of gestation the uterus reaches the umbilicus After 20 weeks of gestation fundal height in centimetres measured from the symphysis pubis approximates the weeks of gestation Uterine size (in weeks) Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 51 Limitations to dating by uterine size on physical examination ™ Uterine malformations/fibroids ™ Multiple gestation ™ Marked uterine retroversion ™ Obesity ™ Molar pregnancy Key considerations A uterus that is smaller than expected may indicate: A uterus that is larger than expected may indicate: ™ The woman is not pregnant ™ Inaccurate menstrual dating ™ Ectopic pregnancy or abnormal intrauterine pregnancy E.g. spontaneous or missed abortion ™ Inaccurate menstrual dating ™ Multiple gestation ™ Uterine abnormalities, such as fibroids ™ Molar pregnancy Source: Clinical practice handbook for safe abortion. Geneva: World Health Organization; 2014, p. 17 (http://www.who.int/reproductivehealth/ publications/unsafe_abortion/clinical-practice-safe-abortion/en/); adapted from Goodman S, Wolfe M; TEACH Trainers Collaborative Working Group. Early abortion training workbook, third edition. San Francisco (CA): UCSF Bixby Center for Reproductive Health Research and Policy: 2007 (http://www.teachtraining.org/trainingworkbook/ earlvabortiontrainingworkbook.pdf). Continued 52 SECOND TRIMESTER ABORTION 4.4 Laboratory tests 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 Rh testing ™ For both medical and surgical abortion ≥12 weeks Rh status tested where available and Rh immunoglobulin offered for Rh-negative women (not compulsory) HIV test ™ All standard precautions must be taken during the surgical abortion method Ultrasound ™ Ultrasound is not a prerequisite for providing abortion services, however, it may be useful where access is available to confirm: y correct gestation age; y incomplete abortion; y placental localisation; and y uterine anomalies. Opportunistic screening STI screening ™ Help in early detection of STI in high-risk cases Cervical cancer screening ™ Pre-malignant cases can be picked up early Other tests may be performed as per individual risk factors on history and examination such as liver and kidney function tests. POCKETBOOK FOR HEALTH-CARE PROVIDERS 53 All the findings of history/examination and investigations are recorded in the woman’s case record and should be informed to the woman. Key message All women undergoing second trimester abortion must undergo a pre-abortion assessment so that health-care workers are able to confirm the diagnosis and identify high-risk cases. References 1. WHO Clinical practice handbook for quality abortion care. Geneva: World Health Organization; 2023 (https://www.who.int/publications/i/item/9789240075207, accessed 27 July 2023). Methods for second trimester abortion5 To provide a woman seeking second trimester abortion with an appropriate choice of abortion method based on the duration of pregnancy and her medical condition Objective Figure 5.1: Recommended methods of abortion by pregnancy duration Di la ta tio n an d e va cu ati on (D &E) afte r 14 we eks Vaccum aspiration (VA) up to 14 weeks Medical abortion≤12 weeks (or ≤84 days) of pregnancy PREGNANCY 1 2 3 4 5 6 7 8 9101112 13 14 Me dic al ab or tio n > 12 we ek s ( or >8 4 d ays ) of prega nacy Source: WHO Clinical practice handbook for quality abortion care, 2023 (1) POCKETBOOK FOR HEALTH-CARE PROVIDERS 55 5.1 Recommended methods of second trimester abortion (2) 12–14 weeks 14–20 weeks >20 weeks Medical abortion Surgical abortion Mifepristone plus misoprostol Vacuum aspiration Letrozole plus misoprostol Mifepristone plus misoprostol Dilatation & evacuation Misoprostole alone Induction of cardiac asystole 5.2 Comparison of methods of abortion Medical method Surgical method Abortion induced by medications Abortion performed by suction evacuation Women with a uterine scar have a very low risk (0.28% or approximately 1 in every 350) of uterine rupture during medical abortion between 12 and 24 weeks POCs can always be examined Continued 56 SECOND TRIMESTER ABORTION Procedure Procedure Mimics the process of miscarriage Quick procedure Takes time (hours to days) to complete abortion Complete procedure Women experience bleeding and cramping similar to labour Requires cervical preparation in advance of procedure Women remain in facility till expulsion is complete Preferred in the following situations Preferred in the following situations Severely obese women Uterine malformation or fibroid or previous cervical injury If there are contraindications to medical abortion If skilled, experienced providers not available to provide dilatation and evacuation (D&E) If there are time constraints for abortion Contraindications Contraindications Previous allergic reaction to one of the drugs involved Inherited porphyria Chronic adrenal failure Known or suspected ectopic pregnancy There are no known absolute contraindications Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 57 5.3 Who can provide second trimester abortion Recommend Suggest Medical abortion >12 weeks ™ General and specialist medical practitionerss ™ Traditional and complementary medicine professionals ™ Auxiliary nurses/ANMs ™ Nurses ™ Midwives ™ Associate/advanced clinicians Continued Caution and clinical judgement are required in cases of Caution and clinical judgement are required in cases of Long-term corticosteroid therapy (including those with severe uncontrolled asthma) An IUD in place (remove before beginning the regimen) Pre-existing heart disease or cardiovascular risk factors; Severe anemia Haemorrhagic disorder An intrauterine device (IUD) in place (remove before beginning the regimen) Continued 58 SECOND TRIMESTER ABORTION Continued Recommend Suggest Cervical priming prior to surgical abortion >12 weeks with osmotic dilators ™ Auxillary nurses/ANMs ™ Nurses ™ Midwives ™ Associate/advanced clinicians ™ General and specialist medical practitioners ™ Traditional and complementary medicine professionals Surgical abortion 12–14 weeks: vacuum aspiration by ™ Traditional and complementary medicine professionals ™ Nurses ™ Midwives ™ Associate/advanced clinicians ™ General and specialist medical practitioners ™ Auxiliary nurses/ANMs Surgical abortion ≤14 weeks: D&E by ™ General and specialist medical practitioners ™ Traditional and complementary medicine professionals ™ Midwives ™ Associate/advanced clinicians POCKETBOOK FOR HEALTH-CARE PROVIDERS 59 5.4 Eligibility of the site where second trimester abortion can be provided ™ Provision of both outpatient and inpatient services to manage second trimester abortion ™ Availability of space for counselling to provide required information in privacy and confidentiality ™ Facility providing 24/7 blood transfusion services, skilled human resources and emergency laparotomy procedures to ensure management of complications ™ Availability of referral facility for complicated cases of abortion with medical illnesses such as: y physical/sexual abuse support; y counselling and testing for sexually transmitted infections (STI, HIV); y screening for precancerous lesion of cervix; y psychological or social support; and y other medical/surgical specialties. 60 SECOND TRIMESTER ABORTION 5.5 Second trimester abortion method in medical/surgical conditions Medical condition Care of the woman Hypertension ™ In controlled hypertension, the woman should take her usual dose of antihypertensive medication on the day of the abortion procedure. ™ In uncontrolled hypertension or BP more than 160/100 mmHg, the woman should be referred to an appropriate level of health facility. Anaemia ™ Caution and clinical judgement required in cases of severe anemia. Surgical abortion is performed at a facility where blood transfusion facility is available. Diabetes ™ Women undergoing medical abortion should be continued on their regular diet and medication and the blood sugar monitored. ™ Deep sedation requires pre-procedure fasting and a common approach is to administer half of the patient’s usual long- acting insulin dose the evening before and omit the morning dose of short-acting insulin. ™ Ideally, a woman with diabetes is scheduled first or as an early case in the day. Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 61 Medical condition Care of the woman Heart disease ™ If asymptomatic, the procedure can be done after evaluation by the cardiologist / physician. ™ If symptomatic or there is severe disease, a surgical abortion procedure may be preferred. The woman is admitted and monitored in conjunction with intensive cardiac care. Asthma ™ The woman should be not having an acute asthmatic attack prior to the procedure. ™ The use of inhaled corticosteroids does not require “stress dose” steroids at the time of surgical abortion. However, if the woman has received repeated oral glucocorticoid therapy for asthma control (doses equivalent to at least 20 mg a day of prednisone for 5 or more days), stress dose(s) of hydrocortisone may be used to prevent acute adrenal insufficiency. ™ Inhaled corticosteroids are not contraindicated for MMA. ™ In a woman on long-term corticosteroid therapy for severe or uncontrolled asthma, mifepristone may exacerbate the underlying condition. ™ Local or regional anesthesia may be pregerable if severe, uncontrolled asthma is present in order to avoid bronchospasm during deep sedation or intubation. Continued Continued 62 SECOND TRIMESTER ABORTION Medical condition Care of the woman Epilepsy ™ The woman should take her usual dose of antiepileptic medication on the day of the abortion procedure. ™ MMA is contraindicated in uncontrolled epilepsy. Obesity ™ Surgical abortion for obese women may be associated with increased technical difficulty. ™ Ventilation difficulties with deep sedation may be more common with obese patients. A medical method is preferable. COVID-19 infection ™ Once a woman has recovered from infection, she can be offered termination of pregnancy. HIV ™ Women taking antiretrovirals should continue taking them without interruption. Women on anticoagulants ™ Women with a high risk of thrombosis maintained on warfarin may be transitioned to heparin, which can be given during surgery, and then warfarin may be restarted. This approach is time-consuming and complex. ™ Medication abortion is not recommended for women who are on anticoagulants. ™ The optimal period for discontinuation of antiplatelet therapy prior to any surgery is five days. It should be stopped after consultation with a cardiologist. Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 63 Medical condition Care of the woman Previous caesarean scar ™ Misoprostol is safe for second trimester abortion in women with one prior low transverse caesarean section. There is insufficient evidence of its use in women with 2 or more prior caesarean scars or a prior classical section (2). ™ Women with one prior lower segment caesarean section (LSCS) or myomectomy can be given mifepristone and misoprostol for second trimester abortion. ™ Mifepristone 200 mg is given, followed 24–48 hours later by misoprostol. WHO does not recommend reducing the dose of misoprostol beyond 24 weeks (3). ™ Monitoring for uterine rupture is essential, seen as sudden onset of abdominal pain, increase in pain, vaginal bleeding, loss of station of presenting part, haematuria, tachycardia, hypotension, increased or loss of uterine contractility. Placenta praevia ™ The optimal method for termination in pregnancies complicated by placenta praevia (PP) is unclear. Use of a medical or surgical method should be considered on an individual basis. ™ Women with prior caesarean section and PP should have focused imaging to rule out Placenta Accreta Syndrome. Continued Continued 64 SECOND TRIMESTER ABORTION Medical condition Care of the woman ™ A medical method is an acceptable alternative for cases with a placenta that is 11–20 mm from the internal os. ™ Uterine artery embolization or feticide prior to second trimester pregnancy termination may help to reduce blood loss. The evidence is limited. Continued References 1. WHO Clinical practice handbook for quality abortion care. Geneva: World Health Organization; 2023 (https://www.who.int/publications/i/item/9789240075207, accessed 27 July 2023). 2. Abortion care guideline. Geneva: World Health Organization; 2022 (https://www. who.int/publications/i/item/9789240039483, accessed 26 July 2023). 3. Costescu D, Guilbert E. No. 360. Induced abortion: surgical abortion and second trimester medical methods. SOGC Clinical Practice Guideline. 2018;40(6):750–83. 4. ACOG Practice Bulletin No. 135. Second trimester abortion . Obstet Gynecol. 2013;121(6):1394–406. Key message Recommended methods of second trimester abortion are either medical or surgical, depending upon the period of gestation. All second trimester surgical abortions should be preferably done as an inpatient procedure by a trained health-care provider at a facility where monitoring can be done. Pre-existing medical/ surgical conditions must be evaluated to decide on the method of abortion. To enumerate the drugs for second trimester medical abortion and discuss their use with procedural details for a woman seeking second trimester abortion. Objective Medical abortion offers a non-invasive, highly acceptable and safe option to pregnant women and reduces the need for skilled providers for surgical abortion. Mifepristone and misoprostol are now included in the WHO model list of essential medicines for abortion because of their documented safety and efficacy. 6.1 MMA regimens ™ Sequential use of mifepristone followed by misoprostol (preferred): A combination regimen is more effective than misoprostol alone as it increases the safety of second trimester abortion by reducing the procedure time significantly and reducing the total dose of misoprostol required, leading to lesser side-effects and morbidity. 6 Medical methods of abortion in the second trimester 66 SECOND TRIMESTER ABORTION ™ Misoprostol alone may be used in the dose of 400 μg every 3 hours. The decision to use misoprostol after five doses should be based on local policies, facility infrastructure and client preferences. ™ Combination of letrozole plus misoprostol is also suggested for abortion at 12–14 weeks of gestation. Letrozole in a dose of 10 mg daily for three days is followed by misoprostol 800 mcg sublingually on the fourth day. ™ Miscellaneous: ethacridine installation, mechanical methods supplemented with oxytocics (not recommended by WHO). Recommended regimens for second trimester abortion (1) Re co m m en da tio ns Combination regimen mifepristone + misoprostol Combination regimen letrozole + misoprostol** M iso pr os to l a lo ne M ife pr ist on e M iso pr os to l* Le tro zo le M iso pr os to l Induced abortion at 12–14 weeks 200 mg once 400 mcg buccal (B), sublingually (SL) or per vaginam (PV) every 3 hours 1 Letrozole 10 mg daily for three days Misoprostol 800 mcg sublingually on fourth day 400 mcg B, SL or PV every 3 hours Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 67 Re co m m en da tio ns Combination regimen mifepristone + misoprostol Combination regimen letrozole + misoprostol** M iso pr os to l a lo ne M ife pr ist on e M iso pr os to l* Le tro zo le M iso pr os to l Induced abortion >14 weeks 200 mg once 400 mcg B, SL or PV every 3 hours … … 400 mcg B, SL or PV every 3 hours Intrauterine fetal demise 14–28 weeks 200 mg once 400 mcg SL or PV every 4–6 hours … … 400 mcg SL (preferred) or PV Every 4–6 hours Continued * Repeat doses of misoprostol can be considered (or repeated at the noted intervals) when needed to achieve success of the abortion process. WHO guidance does not indicate a maximum number of doses of misoprostol. Health workers should use caution and clinical judgement to decide the maximum number of doses of misoprostol in pregnant individuals with prior uterine incision. Uterine rupture is a rare complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with advanced gestational age. The dose of misoprostol should be reduced for induced abortion beyond 24 weeks and intrauterine fetal death (IUFD) beyond 28 weeks, due to limited data. Clinical judgement should be used to determine the appropriate dosage, recognizing the greater sensitivity of the uterus to prostaglandins. ** Further evidence is needed to determine the safety, effectiveness, and acceptability of the letrozole plus misoprostol combination regimen at later gestational ages (>14 weeks), especially in comparison with that of the mifepristone plus misoprostol combination regimen (the available evidence focused on comparison with the use of misoprostol alone). 68 SECOND TRIMESTER ABORTION 6.2 Clinical considerations for medical abortion at advanced gestational ages ™ Abortion medicines can be administered in a health- care facility or at home, but women remain in the facility until expulsion of the pregnancy is complete. ™ Voluntary informed consent should be taken for MMA. ™ Antibiotic prophylaxis is not necessary for medical abortion. ™ Almost all women will experience some pain and cramping during and after an abortion. Each woman’s need for pain management should be assessed individually. ™ Uterine sensitivity to prostaglandins increases with gestational age. The appropriate dose of misoprostol therefore decreases as the gestational age increases. ™ If a woman is lactating, she should withhold breastfeeding for 4 hours after misoprostol administration. ™ Explain that there will be heavy bleeding with clots, passage of the pregnancy tissue, and pain that will be significantly stronger than normal menstrual cramps. ™ Offer supportive care while awaiting pregnancy expulsion. POCKETBOOK FOR HEALTH-CARE PROVIDERS 69 6.3 Pain management for medical abortion (1) ™ The degree of pain experienced varies with the age, parity, a prior vaginal delivery, history of dysmenorrhea, and anxiety/fear level of the individual undergoing the abortion. ™ The need for pain management increases with gestational age and time needed to complete the abortion. Non-pharmacological methods Pharmacological methods at any gestational age Pharmacological methods at >12 weeks ™ Verbal support and reassurance ™ Thorough explanation of what to expect ™ The presence of a support person who can remain with the woman during the process (if she desires it) ™ Hot water bottle or heating pad ™ Respectful, nonjudgmental communication ™ Gentle, smooth operative technique ™ Advance notice of each step of the procedure (if the woman desires it) ™ Anxiolytics/ sedatives (e.g. diazepam 5–10 mg) ™ Analgesia (NSAIDs, e.g. ibuprofen 400–800 mg) Adjuvant medication, if indicated, for side effects of misoprostol (e.g. loperamide for diarrhoea) In addition to NSAIDs, offer one or more of the following ™ Oral opioids (depending on availability, e.g. codeine, morphine) ™ IM or IV opioids ™ Certain anti- emetics and epidural anaesthesia, where available. 70 SECOND TRIMESTER ABORTION 6.4a Drug administration ™ Mifepristone is always administered orally. Misoprostol may be administered by different routes, including vaginal, buccal and sublingual. Vaginal misoprostol is more effective than oral administration and may have fewer side-effects than sublingual or buccal administration. ™ Ensure prompt administration of repeat misoprostol based on clinical judgement. Misoprostol may be given even if the person is experiencing bleeding and cramping/contractions. Cramping will often begin before the second dose of misoprostol is administered; however, the timing is variable. ™ Fever/chills can be a frequent side-effect of repeated doses of misoprostol; administration of paracetamol or ibuprofen will reduce discomfort in these cases. ™ Starting from the time of the first dose of misoprostol, women should be monitored every 30 minutes. ™ The expected time to expulsion and completion of abortion is higher in nulliparous women and increases in all women with gestational age. POCKETBOOK FOR HEALTH-CARE PROVIDERS 71 6.4b Different routes of administration of mifepristone/misoprostol (2) Pills are swallowed Pills are placed between the gums and cheek and swallowed after 30 minutes Pills are placed under the tongue and swallowed after 30 minutes Pills are placed in the vaginal fornices (deepest portions of the vagina) and the woman is instructed to lie down for 30 minutes Route Oral Buccal Sublingual Instructions for use Vaginal 72 SECOND TRIMESTER ABORTION 6.5 Fetal/placental expulsion ™ The placenta should usually be expelled within half an hour of fetal expulsion. If it has not been expelled: y repeat the dose of misoprostol; y give 20 units of oxytocin in 500 mL, 5% dextrose or ringer lactate at the rate of 50 mL/h; and y use the cord traction method: while awaiting placental expulsion, periodically use the forceps to grasp the base of the cord and apply slight tension on the cord, avoiding tearing of the cord. Routine ultrasound examination should not be used to screen for incomplete abortion; ultrasound appearances correlate poorly with the retained products of conception. ™ Routine uterine curettage following complete expulsion of the fetus and placenta is unwarranted. Uterine evacuation by vacuum aspiration (or curettage, where aspiration is unavailable) to remove the placenta should be performed only in individuals who have heavy bleeding, fever or a retained placenta beyond 3–4 hours following expulsion of the fetus. ™ Pregnancy tissue should be treated in the same way as other biological material unless the individual wishes or local rules dictate that it be managed otherwise. POCKETBOOK FOR HEALTH-CARE PROVIDERS 73 6.6 Examination of the abortus ™ Photographs of the abortus are taken from the front, back and sides. The following are noted while examining – weight, length, head circumference, external genitalia and any external congenital anomalies. ™ During examination of the placenta and cord, the following are noted: y Shape and size of the placenta y Weight y Cord insertion site y Number of vessels y Completeness of placenta y Any other gross anomalies ™ In case of congenital anomalies, the recommended investigations should be done as per country guidelines and availability. ™ If the fetus is born alive, resuscitation is not done. It should be ensured that cardiac activity is absent whenever the fetus is handed over to the relatives. 74 SECOND TRIMESTER ABORTION 6.7 Warning symptoms after second trimester abortion ™ Prolonged or heavy bleeding (soaking more than two large pads per hour for two consecutive hours) ™ Fever lasting for more than 24 hours after the last dose of misoprostol; fever that persists for more than 24 hours after the last dose of misoprostol should be evaluated ™ Feeling generally unwell more than 24 hours after misoprostol administration ™ Severe pain that persists (evaluation is needed to rule out uterine rupture, a rare complication, which is more likely with a history of prior uterine incision) 6.8 Before discharge after medical abortion at ≥12 weeks of gestation ™ Reassure the woman that the procedure is finished and that she is no longer pregnant. ™ Monitor her (bleeding, pain, blood pressure and pulse) and provide management as needed. ™ She may leave the health-care facility when she is stable and meets the criteria for discharge. ™ Document all outcomes of the treatment, including any adverse events. ™ Offer contraception as desired and link to any other service if needed. POCKETBOOK FOR HEALTH-CARE PROVIDERS 75 6.9 Medical management of intrauterine fetal demise ™ Intrauterine fetal demise (IUFD) or fetal death refers to situations in which the fetus is no longer alive, but the uterus has not yet started to expel its contents and the cervical os remains closed. ™ Diagnosis is by clinical findings: vaginal bleeding, absent fetal heart sounds on electronic auscultation, failure to feel fetal movements or a uterus that is significantly smaller than the expected size and confirmed by ultrasound scan. ™ Management is expectant, medical or surgical, depending on individual choice. ™ If mifepristone is taken as an outpatient, it is essential that the woman knows she must return to the clinic or seek care if the membranes rupture or if contractions begin before she has started to take any doses of misoprostol. 6.10 Induction of fetal cardiac asystole before abortion (1) For abortion after 20 weeks’ gestation, induction of fetal asystole can be considered to avoid signs of life either during medical abortion or if fetal expulsion occurs after cervical priming but before a planned dilatation and evacuation (D&E). Regimens used are: ™ Injection of potassium chloride (KCl, intracardiac, dose 4–6 mEq), on the day of abortion or one day before 76 SECOND TRIMESTER ABORTION ™ Injection of digoxin (intra-amniotic or intrafetal, dose 1–2 mg), one day before the abortion ™ Injection of lidocaine (intracardiac or intrathoracic, dose 200–240 mg)on the day of the abortion or a day prior Intracardiac injection of potassium chloride is highly effective but requires expertise for precise & safe injection. 2 Ask the patient to empty her bladder before the procedure. 3 Find the injection site by physical examination or ultrasound guidance, using a sterile technique. 4 A spinal needle (20–22 G) is used to slowly inject medication to be used for inducing asystole; use the smallest effective dose. 5 Confirm asystole ™ Immediate: intrafunic or intracardiac ™ 24 hours later: intrafetal or intra-amniotic 6 Ensure haemostasis. 7 Provide information about when to return for completion of abortion. Inform about the small risk of early labour, leaking per vaginam or intramural delivery. Take informed consent, highlighting the risks and benefits of the procedure.1 Steps to induce fetal asystole POCKETBOOK FOR HEALTH-CARE PROVIDERS 77 6.11 Potential challenges of medical abortion at advanced gestational ages ™ Membranes rupture before the cervix is fully dilated – if the membranes rupture during the course of the abortion process before the cervix is adequately dilated, the vaginal route for misoprostol may be less desirable and the sublingual or buccal routes may be used. ™ If the placenta has not been expelled spontaneously and 4 h have passed, the woman is haemodynamically unstable or desiring discharge, there are a few options for placental management. y Give uterotonics. If the next dose of misoprostol is due, then the dose should be given. If 1–2 hours have passed since the last misoprostol dose, give an additional dose of sublingual, buccal or oral misoprostol, 400–800 mcg. Vaginal dosing is less effective in the presence of vaginal bleeding, so buccal or sublingual dosing are advised. y Use a pair of forceps (sponge or sopher) to gently remove the placenta. Place a speculum in the vagina so that the cord comes out the middle of the speculum. Use two ring forceps to follow the cord, gently placing traction on the placenta. Avoid tearing the cord. 78 SECOND TRIMESTER ABORTION y Manual vacuum aspiration can be performed to evacuate the placenta, similar to the treatment for retained placenta in the postpartum period. If available, use a 12- or 14-mm cannula. Sharp curettage is not advocated. WHO recommendation is to not include the use of sharp curettage during abortion procedures. There is no evidence of the benefit of using sharp curettage during abortion, which may, in fact, do harm. y Continue misoprostol every 3 hours until expulsion It is rare following the regimen not to have an expulsion by 36 hours. Alternatively, if the cervix is dilated sufficiently and there is a skilled provider with appropriate equipment, a D&E can be performed. Ensure that alternative diagnoses, such as a morbidly adherent placenta, have been ruled out by ultrasonography. ™ If fetal expulsion does not occur within 24 hours from the initial dose, one should re-evaluate the woman and identify the cause by clinical examination. Ultrasonography can be done to rule out rupture of the uterus or abdominal pregnancy. The haemodynamic status of the woman should be assessed once these conditions are ruled out: y Stable – wait for 24 hours and then individualize the treatment. Either repeat the same regimen or terminate surgically; POCKETBOOK FOR HEALTH-CARE PROVIDERS 79 y Unstable – stabilize and terminate the pregnancy surgically; y Patient starts having hypertonic uterine contractions. Hypertonic uterine dysfunction is difficult to treat, but repositioning, short-acting tocolytics (e.g. terbutaline 0.25 mg IV once), discontinuation of misoprostol and analgesics may help. References 1. WHO Clinical practice handbook for quality abortion care. Geneva: World Health Organization; 2023 (https://www.who.int/publications/i/item/9789240075207, accessed 27 July 2023). 2. Clinical practice handbook for safe abortion. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/handle/10665/97415, accessed 27 July 2023). Key message Mifepristone has significantly decreased the induction- to-abortion interval and enhanced clients’ safety, acceptance and satisfaction in second trimester abortion. Hence, a combined regimen of mifepristone and misoprostol is preferred. Health-care providers should be aware of all the regimens, expected symptoms, outcome and complications of MMA. Management should be as per the country’s protocol and legal framework. Surgical methods of second trimester abortion7 To discuss the surgical methods used for second trimester abortion Objective The procedure for surgical abortion at 12–14 weeks of gestation is vacuum aspiration and at ≥14 weeks of gestation is usually dilatation and evacuation (D&E), after adequate pain management. In some settings, an “advanced vacuum aspiration” can be performed up to 16 weeks of gestation with a cannula of up to 16 mm in diameter, permitting termination up to 15–16 weeks of gestation. D&E requires preparation of the cervix using pharmacological agents and/or osmotic dilators and evacuating the uterus. 7.1 Method-specific counselling ™ The woman must be explained the procedural details, pain management options, type of anaesthesia used, how paracervical block will be administered and any complications that can occur. POCKETBOOK FOR HEALTH-CARE PROVIDERS 81 ™ Since it is an invasive procedure, she should be informed about the risks of perforation, injury to the other organs such as bladder/intestine, etc. and that laparotomy may be required. ™ Surgical abortion can be undertaken under the purview of abortion laws of the country only and guidelines and protocols should be strictly followed. ™ Voluntary informed consent must be taken for surgical abortion after counselling the woman. 7.2 Instruments required for EVA (12–14 weeks gestation in the second trimester) Steps to induce fetal asystole ™ Sims speculum and anterior vaginal wall retractor ™ Tenaculum or single- tooth vulsellum ™ Dilators of gradually increasing sizes ™ Manual vacuum aspirator with cannula, or electric vacuum aspirator Continued 82 SECOND TRIMESTER ABORTION Steps to induce fetal asystole ™ Sponge-holding forceps ™ Small ovum-holding forceps ™ Stainless steel bowl for preparing solutions ™ Instrument tray ™ Clear glass dish for tissue inspection ™ Strainer (metal, glass or gauze) 7.3 Cervical priming prior to second trimester abortion ™ Cervical preparation reduces the risk of cervical injury, uterine perforation and incomplete abortion. ™ It is beneficial for people with cervical anomalies, previous surgery to the cervix, previous caesarean section, adolescent age, advanced pregnancy. Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 83 ™ The use of medication for cervical priming prior to surgical abortion can be self-managed and can save travel time for the woman and avoid the use of staff for insertion of osmotic dilators. ™ If a woman undergoing cervical priming starts experiencing heavy vaginal bleeding, she should have the evacuation procedure without delay. 7.3a Methods of cervical priming Between 12 and 19 weeks At ≥19 weeks ™ Medication alone (a combination of mifepristone plus misoprostol is preferred). y Mifepristone 200 mg is given orally 1–2 days before procedure. y Misoprostol 400 mcg is used vaginally 3–4 hours or sublingually 2–3 h before the procedure. If the cervix doesn’t dilate after 1 dose of misoprostol, the dose can be repeated by a different route. ™ There should be a combination of both an osmotic dilator plus medication (mifepristone, misoprostol). ™ Osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both) should be given. y Natural osmotic dilators (laminaria sticks) achieve maximum dilation at 24 h. y Synthetic osmotic dilators (Dilapan- S) will achieve good dilation in 6 h but will continue to dilate up to 24 h and can be used for same-day procedures. Continued 84 SECOND TRIMESTER ABORTION Between 12 and 19 weeks At ≥19 weeks y The period between placement of the osmotic dilator and the procedure should not extend beyond two days. y Mifepristone may be given on the day of dilator placement and misoprostol should be given on the day of the procedure to minimize the risk of extramural delivery. y When fewer than the desired number of osmotic dilators have been placed initially, the procedure can be repeated, in 4 h or on the following day, to place the additional dilator(s). Laminaria tent 7.3b Foley catheter This can be used for cervical dilatation in some cases, may be supplemented later by oxytocics. Foley catheter is to be inserted through the cervical canal just beyond internal Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 85 os, taking care not to puncture the amniotic sac. It should be retained for at least 4–6 hours so as to get cervical dilatation of 2–2.5 cm. One should instil 5–10 mL of saline in the balloon of the catheter to prevent it from slipping out of the cervical canal. Patients in the mid-second trimester can effectively and safely undergo cervical preparation with a Foley balloon catheter and misoprostol to facilitate completion of D&E (2). 7.3c Method of insertion of an osmotic dilator ™ A speculum is placed in the vagina and the cervix is wiped with a non-alcoholic antiseptic solution. ™ Local anaesthesia is administered to the anterior cervical lip and is grasped with an atraumatic tenaculum to complete the paracervical block and allow some time for the local anaesthesia to act. ™ A paracervical block (PCB) is administered. ™ The end of an osmotic dilator (after coating it with lubricant jelly) is grasped with a pair of forceps (ring or packing forceps) and inserted into the endocervical canal such that the tip extends just beyond the internal cervical os into the uterus (using the “no-touch” technique). 86 SECOND TRIMESTER ABORTION ™ The osmotic dilators (may use multiple dilators) are placed sequentially adjacent to one another within the cervical os, so that they fit snugly in the cervical canal. 7.3d Characteristics of osmotic dilators Character Natural (Laminaria sticks) Synthetic (Dialapan-S) Size D (2–10 mm), L (60–85 mm) D (3–4 mm), L (55–65 mm) Material Natural, dried and compressed hygroscopic, type of kelp brown seaweed Synthetic hygroscopic made from aquacryl hydrogel Mechanism of action Mechanical Mechanical and chemical Extent of expansion from initial dry diameter 3–4 times 3–4 times Time between insertion and maximal dilation 12–24 h 6–24 h 7.4 Pain management in second trimester abortion The pain is primarily related to cervical dilatation (physiological, pharmacological and/or mechanical) and uterine contractions. POCKETBOOK FOR HEALTH-CARE PROVIDERS 87 Non-pharmacological methods Pharmacological methods at any gestational age ™ Verbal support and reassurance ™ Thorough explanation of what to expect ™ The presence of a support person who can remain with the woman during the process (if she desires it) ™ Hot water bottle or heating pad ™ Encouraging deep controlled breathing ™ Music ™ Analgesia (NSAIDs, e.g. ibuprofen 400–800 mg\, 30 min before procedure) ™ Paracervical block (PCB) ™ Conscious sedation + PCB ™ Anxiolytics/sedatives y Minimal sedation: midazolam 10 mg or diazepam 30-60 min before the procedure y Moderate sedation: combined analgesics and anxiolytic. Opioid (fentanyl 50– 100 mcg IV / pethidine 25-100mg IV/IM/ tramadol 50–100 mg IV/IM/morphine 0.1–0.2 mg/ kg IV) + initial dose of anxiolytic (midazolam 1–2 mg IV/diazepam 5–10 mg IV/lorazepam 1 mg IV) y Deep sedation: initial dose of anxiolytic + combination of propofol with fentanyl y General anaesthesia: propofol or nitrous oxide* Cervical priming ™ Paracervical block ™ Pain medication such as intravaginal gel *WHO recommends against the routine use of GA. 88 SECOND TRIMESTER ABORTION Paracervical block administration ™ A 10 ml syringe is loaded with 1% plain lignocaine (10 mL). A 22-gauge hypodermic needle is attached to the syringe; 2 mL of the solution is injected superficially into the cervix at the site where the vulsellum/tenaculum will be placed (12 o’clock or 6 o'clock). ™ The cervix is grasped with the vulsellum/tenaculum. Slight traction is used to push the cervix inward and to the side firmly to expose the tissue where the cervix meets the vagina, first on one side and then on the other side. ™ The remaining 8 mL is injected in equal amounts to a depth of 1.5–3 cm at the cervicovaginal junction at 4 and 8 o’clock (optional sites can be 10 and 2 o’clock position). One should aspirate to check if any vessel has inadvertently been entered. ™ Cervical dilatation can be started 2 min after the paracervical block. 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%). 7.5 Antibiotic prophylaxis ™ The presence of infection in the lower reproductive tract at the time of surgical abortion is factor for post-abortion reproductive tract infections (RTI). Therefore, the prophylactic administration of antibiotics prior tp procedure is recommended to prevent such complications after a surgical abortion. POCKETBOOK FOR HEALTH-CARE PROVIDERS 89 ™ Single-dose administration of nitroimidazole, tetracycline or penicillin has been shown to be effective when used as prophylactic antibiotics for surgical abortion. 7.6 Anti-D prophylaxis for second trimester abortion Administration of the immunoglobulin to Rh-negative women is recommended for surgical abortion ≥12 weeks. The dose of anti-D is 300 mcg given intramuscularly. 7.7 Asepsis – the no-touch technique The no-touch technique means that the parts of instruments that enter the uterus (i.e. cannula, forceps, dilators) should not touch objects or surfaces that are not sterile, including the patient’s thighs or vaginal walls or the provider’s hands/ gloves, before being inserted into the uterus. The provider can use clean, non-sterile gloves for the procedure – sterile gloves are not necessary. Thus, during the procedure, the health worker: ™ grasps and touches only the mid-portion of dilators, avoiding the tips; ™ attaches the cannula to the vacuum source without touching the tip of the cannula; and ™ keeps used instruments away from sterile instruments remaining on the tray. 90 SECOND TRIMESTER ABORTION 7.8 Steps of surgical abortion >12 weeks of pregnancy Ensure that all necessary equipment is properly sterilized and in working condition. If osmotic dilators were placed in advance, then refer to the documentation noting the number of dilators placed. The woman is asked to empty her bladder and is helped into the dorsal lithotomy position. The provider should wash hands and should put on appropriate barriers. Perform bimanual examination. Paracervical block is given using 10 mL of 1% lignocaine. 1 3 A speculum is introduced gently to ensure adequate visualization of the cervix. The cervix is wiped with a non- alcoholic antiseptic solution starting at the cervical os, with each new sponge wiping from inward to the outward direction circularly until the os has been completely covered with antiseptic solution. 6 2 4 Remove osmotic if it has been inserted either manually or with a ring forceps. Confirm the removed number of dilators is equal to the nomber that was placed. 5 Paracervical block is given.7 Steps to induce fetal asystole POCKETBOOK FOR HEALTH-CARE PROVIDERS 91 7.9 Steps of surgical abortion at 12–14 weeks of pregnancy – vacuum aspiration ™ Vacuum aspiration can be done either by a manual vacuum aspirator or by an electrical vacuum pump. One should make sure that the aspirator holds a vacuum and back-up aspirators are readily available, in case the first aspirator has technical problems. ™ Bimanual examination: Position of the uterus and cervix is examined. ™ Place the speculum: For adequate visualization of the cervix ™ Give paracervical block: As outlined in the steps of 7.6 and with the tenaculum placed on anterior lip of cervix, continuous traction is applied to straighten the cervical canal. ™ Cervical dilatation: The cervix is gently dilated till the cannula fits snugly. Dilatation is not needed when the cervix allows insertion of a cannula of appropriate size due to cervical priming. An insufficiently dilated cervix can lead to complications. ™ Dilatation is done gently without using force and applying the no-touch technique, with successive mechanical dilators, while stabilizing the cervix with gentle traction on the cervical tenaculum. 92 SECOND TRIMESTER ABORTION ™ Insertion of the cannula: When appropriate cervical dilatation is achieved, the cannula is inserted just past the internal cervical os and into the uterine cavity; 12–14 mm of the cannula attached to an aspirator is inserted if using MVA, or a 14–16 mm cannula if using EVA. The cannula should not be inserted forcefully and should not be advanced too high in the uterine cavity to avoid injury to the uterus or cervix. ™ Aspiration of the uterine contents: The prepared manual vacuum aspirator/electric vacuum is connected to the cannula. The tenaculum and the end of the cannula are held in one hand and the aspirator or vacuum connection in the other hand. y The pre-prepared vacuum aspirator is connected firmly with the cannula in the uterus, holding it with one hand. Then the vacuum button on the aspirator is released. y Suction is initiated when the cannula tip is mid-uterus; as the uterus contracts the uterine wall will feel firmer. Dilator Vaccum aspirator POCKETBOOK FOR HEALTH-CARE PROVIDERS 93 y The contents of the uterus are evacuated by gently and slowly rotating the cannula at 180° in each direction (use in-and-out motion). Blood and tissue will be visible through the cannula. One should not withdraw the opening of the cannula beyond the cervical os till all POCs are aspirated (otherwise suction will be lost) and be cautious and avoid holding a charged aspirator by the plunger arms. ™ 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 vacuum is re-established. This procedure is repeated until the uterus is empty. The signs of completion are as follows: y Red or pink foam appears, and no more tissue is seen passing through the cannula. y A gritty sensation is felt as the cannula passes along the surface of the evacuated uterus. y The uterus contracts around the cannula. y The woman may feel intensified cramping or pain, indicating that the uterus is contracting. ™ Disassembling the instruments: When the procedure is complete, the aspirator valve is released and the cannula is disconnected from the aspirator. The contents are emptied from the aspirator into a container. The cervix 94 SECOND TRIMESTER ABORTION is wiped with a clean swab and the amount of uterine or cervical bleeding is assessed. Do not perform sharp curettage to check if the abortion has been successful. ™ Inspection of the tissue: Inspection of the POC is important to ensure a complete abortion. 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 of POC is assessed. ™ Concurrent procedures: When the aspiration procedure is complete, one should proceed with a concurrent procedure such as intrauterine device (IUD) insertion or tubal ligation as necessary. 7.10 Steps of surgical abortion at >14 weeks of pregnancy – dilatation & evacuation ™ Follow similar steps of patient and instrument preparation as outlined above for all surgical abortion above 12 weeks. ™ Cervical dilatation: surgical abortion can be done only if the cervix is adequately dilated. The cervix is stabilized by placing the tenaculum on the anterior cervical lip and continuous traction is applied to straighten the cervical canal. POCKETBOOK FOR HEALTH-CARE PROVIDERS 95 y Mechanical dilators tapered, up to 37 French (Fr) (or up to 51 Fr for advanced gestational age) or equivalent circumference Pratt, 13-43 Fr (or 41-79 Fr for advanced gestational age) Hern, up to 98 Fr for advanced gestational age Dilation of the cervix is assessed (if cervical priming has been done) to see if the cervical os allows a cannula needed for that gestation. Bierer Froceps Sopher Forceps 96 SECOND TRIMESTER ABORTION y The adequacy of dilatation is checked by attempting to pass a large dilator, a large-gauge cannula (12–16 mm) or Bierer forceps through the cervix. If such an instrument cannot be passed, more cervical dilatation is needed, with repeat cervical priming or mechanical dilatation. Suction cannula insertion and amniotomy ™ A suction cannula is inserted just past the internal cervical os and into the uterine cavity. 12–14 mm of the cannula attached to an aspirator is inserted if using MVA, or a 14–16 mm cannula if using EVA. Amniotomy is performed (artificial rupture of membranes) to aspirate the amniotic fluid. ™ The appropriate-sized cannula (in millimetres) is generally equivalent to, or 1–2 mm less than, the gestation in weeks. At gestational ages ≥16 weeks, the largest available cannula should be used (14–16 mm, depending on the tubing and cannulae available), as the procedure will also include the use of specialized forceps. ™ Suction tubing for EVA can be used with a cannula up to 16 mm in diameter, permitting vacuum aspiration to be used up to 15–16 weeks of gestation or for women presenting with incomplete abortion and a dilated cervix where a larger size cannula is required to effectively remove the pregnancy tissue. POCKETBOOK FOR HEALTH-CARE PROVIDERS 97 ™ Suction is performed to aspirate the amniotic fluid by gently and slowly rotating the cannula 180° in each direction. The cannula is not to be removed from the uterus while suction is being done (removed only if blockage is suspected, to clean the cannula). When nothing more can be suctioned, usually after 1–2 min of the aspiration, the cannula is removed from the uterus. ™ If advancement of the cannula is difficult, one should not push it in the uterine cavity forcefully. The angle can be changed or bimanual examination repeated to verify the uterine position or changing the speculum to one with a shorter blade (straighten out the cervical angle). Finally, if dilatation or evacuation is particularly difficult, consider administering misoprostol and delaying the procedure for approximately 3 h. ™ Evacuation of uterine contents: Wherever possible, a pair of forceps is used to complete evacuation of the fetal parts and placenta from the lowest section of the uterine cavity. y Avoid advancing the instrument horizontally and deep into the uterus. y Avoid reaching high into the uterus, where the risk of perforation is greater. Instead, reinsert the cannula just to cross the internal os and use suction to bring tissue down from the fundus to the internal os. 98 SECOND TRIMESTER ABORTION y Intraoperative ultrasonography in second trimester abortion: real-time ultrasonographic guidance during D&E is not used universally and its utility depends on the training level of the provider, although intraoperative ultrasonography may be helpful. y In the unlikely event that the fetal parts cannot be readily removed for any reason, consider administering a uterotonic agent, such as one of the following: 400- 600 μg misoprostol sublingually or buccally; an ergot alkaloid, such as 0.2 mg methergine orally or IM; high- dose oxytocin 20 units in 500ml of normal saline or Ringer's lactate solution, run at 30 drops per minute and repeat the evacuation procedure after 3 to 4 hrs. Amniotomy Evacuations of Fetus Evacuations of Placenta POCKETBOOK FOR HEALTH-CARE PROVIDERS 99 y Do suction aspiration with 8-12mm cannula to remove blood clots and any residual tissue as a final step in the evacuation procedure. ™ Signs to indicate that the uterine cavity is empty y Red or pink foam appears and no more tissue is seen passing through the cannula. y A gritty sensation is felt as the cannula passes along the surface of the evacuated uterus. y The uterus contracts around the cannula. ™ The woman feels intensified cramping or pain, indicating that the uterus is contracting. ™ Inspection of the tissue: to confirm completion of the procedure examination of the removed products of conception should be done and all the following components must be identified: y Four extremities y Thorax/spine y Calvarium y Placenta 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, if necessary. 100 SECOND TRIMESTER ABORTION References 1. Abortion care guideline. Geneva: World Health Organization; 2022 (https://www. who.int/publications/i/item/9789240039483, accessed 26 July 2023). 2. Chandrasekaran S, Paul M, Ruggiero S, Monschauer E, Blanchard K, Robinson Y. Foley catheter and misoprostol for cervical preparation for second trimester surgical abortion. Contraception. 2021;104(4):437–41. doi: 10.1016/j. contraception.2021.06.015. 3. ACOG Practice Bulletin No. 135. Second trimester abortion Obstet Gynecol. 2013;121(6):1394–406. After any surgical abortion, reassure the women that the procedure is finished and that she is no longer pregnant, and document all outcomes of the treatment, including any adverse events 7.11 Surgical abortion in pregnancy with a previous uterine scar No changes in cervical preparation or D&E are necessary for women with a uterine scar. A uterine scar has not been associated with an increased perioperative risk of uterine rupture. Women with a uterine scar and placenta praevia are at increased risk for placenta accreta. Placental location by ultrasound must be documented in women with a previous uterine surgery to rule out placenta praevia. Key message The procedure for surgical abortion at 12–14 weeks of gestation is vacuum aspiration and ≥14 weeks of gestation is dilatation and evacuation (D&E). Both these procedures should be done by trained providers after obtaining informed written consent of the woman. Asepsis should be maintained, and standard protocols followed at every step. Adequate cervical dilation and gentle manipulation of instruments is necessary to prevent complications. Post-abortion care8 To help patients understand instructions at discharge and identify danger signs. Objective Patients should be informed about recovery time, normal duration and severity of pain or bleeding before they give consent for the procedure. Most clients can resume their normal activities except some exceptions depending on how the procedure went or if there no complication after both surgical or medical abortion. They should be made aware of danger signs so that they can return to the facility in time. 8.1 Immediate post abortion (1) ™ After a second trimester abortion, a woman should remain in the health-care facility for some time (around 4 hours) so that the health-care team can ensure that she is well enough to return home. ™ Bleeding, pain/cramps, fever, blood pressure and pulse should be assessed in the first hour after the abortion. ™ The client should be informed that vaginal bleeding for two weeks is normal after successful surgical or medical POCKETBOOK FOR HEALTH-CARE PROVIDERS 103 abortion. Women may experience light bleeding or spotting following surgical abortion, while heavier bleeding occurs with medical abortion and generally lasts for a week to 10 days on average (but can last up to 45 days in rare cases). ™ Nausea and vomiting generally subside within 24 h after surgical abortion. ™ Some abdominal cramping and mild pain are normal. She should contact the health facility/provider if the cramping increases or if associated with fever or severe abdominal pain. ™ Breast engorgement can occur after abortion at an advanced gestational age. Use of a breast bandage, tight bras and/or pharmacological inhibition of lactation may be helpful to improve comfort in such cases. ™ Document all outcomes of the treatment, including adverse events. ™ Explain the possibility of return of fertility within two weeks following abortion. ™ Provide contraceptive information and offer contraceptive counselling to women who desire it, along with access to the chosen method. 8.2 Further evaluation to confirm the success of medical abortion ™ If a woman reports symptoms of ongoing pregnancy and/ or had only minimal bleeding after taking the abortion 104 SECOND TRIMESTER ABORTION 04 05 07 06 medicine(s) as directed, ongoing intrauterine pregnancy should be suspected and further evaluation could include pelvic examination (to check for a growing uterus) or an ultrasound scan (to check for an ongoing pregnancy). ™ If these evaluations indicate ongoing intrauterine pregnancy, offer vacuum aspiration or repeat the administration of abortion medicines. 8.3 Instructions at discharge 01 02 03 Resume sexual intercourse when ready. Take iron tablets regularly (if needed) Take pain medications as advised. Return to the hospital if experiencing any warning signs, like: y excessive bleeding; y fever lasting for more than one day with or without chills or feeling unwell; y worsening of pelvic pain; and y signs of ongoing pregnancy. Provide emotional support, if needed. Can return to usual activities within a few days. If no contraceptive method was provided or started prior to discharge from the facility after the abortion, provide information on contraception, offer counselling and provide contraceptive services, if they are wanted. Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 105 08 Depending on the findings of the review and assessments refer to other services, such as STI/HIV counselling and testing, abuse support, psychological or social services. (mentioned below in 8.5) Continued 8.4 Psychosocial and emotional counselling post abortion Women may resort to second trimester abortion due to sexual assault, domestic violence, or foetal congenital anomalies that are incompatible with life. Woman victim of sexual assault, domestic violence: First-line support is the most important care that one can provide. First-line support involves five simple tasks. The letters in the word “LIVES” can remind us of these five tasks that protect women’s lives – Listen, Inquire about needs and concerns, Validate, Enhance safety, Support. The provider should provide appropriate care, tailor the treatment and counsel according to the woman’s circumstances. The provider should ensure that the woman gets treatment if she has received any injuries. Woman had abortion due to congenital anomalies in fetus: A provider should counsel that congenital anomalies are not her fault/shortcoming, allay her fear for future pregnancies and regarding the special care required for future pregnancy. 106 SECOND TRIMESTER ABORTION 8.5 Additional services may need to be provided to individuals seeking abortion Sexually transmitted infection (STI)/ reproductive tract infections (RTI) screening Vaccination (human papillomavirus [HPV] and hepatitis B) Immediate antiretroviral therapy (ART) for all women and their partners diagnosed with HIV Discuss the importance of safe sex, condom use HIV testing and risk reduction counselling Diagnosis and treatment of STI Pre- and post-exposure prophylaxis Steps to induce fetal asystole For services not available at the health facility, the woman may be referred to the appropriate facility for care POCKETBOOK FOR HEALTH-CARE PROVIDERS 107 8.6 Follow up ™ Routine follow up is not necessary after an uncomplicated surgical or medical abortion. ™ An optional follow-up visit 7–14 days after the abortion procedure may be offered to provide contraceptive services. ™ Any post-abortion medical issues should always be assessed and managed as soon as possible when concerns are raised. ™ Assess the individual’s recovery and enquire about any signs or symptoms of ongoing pregnancy. ™ Assess the individual’s fertility goals and need for contraceptive services. ™ Complete the woman’s record in the facility register and client card. References 1. Health worker roles in providing safe abortion and postabortion contraception. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ handle/10665/181041, accessed 27 July 2023). 2. Clinical practice handbook for safe abortion. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/handle/10665/97415, accessed 27 July 2023). Key message Women should receive clear and simple verbal instructions on what to expect after abortion and when to return to the facility. All women must receive emotional support at the time of discharge. Post-abortion complications9 To understand the diagnosis and management of complications after second trimester abortion. Objective ™ Potentially life-threatening complications are rare when abortion has been done safely, taking all the necessary precautions. However, complications are much more common when abortions are obtained from untrained providers, at unsafe locations, or using methods that are not recommended. ™ Emergency post-abortion care should always be provided, even in settings where abortion is illegal. Health-care workers should use clinical judgement to determine whether patients may need referral to a facility offering a higher level of care. POCKETBOOK FOR HEALTH-CARE PROVIDERS 109 9.1 Identification and management of post-abortion complications Type of complication Cause of complication Presentation Management Sepsis Infection in the uterus or beyond the pelvis. Organ dysfunction resulting from infection during pregnancy, childbirth, post- abortion or the postpartum period Signs include fever or hypothermia, foul-smelling vaginal or cervical discharge, abdominal or pelvic pain, uterine tenderness, plus any of the following: ™ Fast heartbeat ™ Low blood pressure ™ Respiratory distress ™ Jaundice ™ Decreased urination ™ Altered mental status ™ Individuals with infection require treatment with antibiotics. ™ If retained tissue is also present and is suspected to be the cause of the infection, re-evacuate the uterus using vacuum aspiration (not dilatation and curettage). ™ Health workers should not wait to finish administering a dose of antibiotics before evacuating retained tissue in patients who are clinically unstable. Women with severe infections may require hospitalization. Continued 110 SECOND TRIMESTER ABORTION Type of complication Cause of complication Presentation Management ™ Intensive antibiotic therapy plus uterine evacuation should be done as soon as possible. Atonic haemorrhage Not very common in abortion. Can result from retained tissue, uterine atony, trauma or damage to the cervix, coagulopathy or, rarely, uterine perforation or uterine rupture Excessive bleeding per vaginam Unstable vitals (tachycardia +/-hypotension) ™ Resuscitation (oxygen and IV fluids as indicated), careful inspection for cervical or vaginal injuries, re-evacuation of the uterus using vacuum aspiration (not dilatation and curettage) ™ Uterine massage ™ Administration of uterotonic drugs ™ Uterine compression with packing or large Foley balloon catheter ™ Blood transfusion ™ Replacement of clotting factors ™ Exploratory surgery (laparoscopy or laparotomy) with repair or hysterectomy Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 111 Type of complication Cause of complication Presentation Management Cervical laceration Can occur during dilatation if not done gradually or with prostaglandin use or with precipitate delivery of the fetus Excessive bleeding per vaginam Local examination –cervical tear may be present Repair of injuries under good exposure to light Uterine perforation By intrauterine instrumentation such as a dilator, curette, ovum forceps, suction cannula. May involve adjoining viscera such as bowel or bladder Uterine perforation is suspected when ™ There is sudden loss of resistance during cervical dilatation or vacuum aspiration ™ This complication usually goes undetected and resolves without the need for intervention. ™ When available and clinically indicated, laparoscopy is the investigation of choice. ™ If the woman’s status or findings during laparoscopy suggest damage to the bowel, blood vessels or other structures, a laparotomy to repair any damage may be needed. Continued Continued 112 SECOND TRIMESTER ABORTION Type of complication Cause of complication Presentation Management ™ The instrument passes well beyond the expected length of the uterus ™ Other signs of perforation are severe pain/ feeling of something giving away/ absence of POC in MVA syringe/ persistent PV bleeding ™ If after surgical abortion at ≥14 weeks of gestation the tissue inspection indicates that the abortion may not have been successful (unable to find all of the fetal parts), even after re- evacuation of the uterus, the provider should have a high degree of suspicion of uterine perforation with fetal parts in the abdomen, and should therefore attempt to use ultrasound, if available, to check for intrauterine or intra-abdominal fetal parts, and then as needed perform laparoscopy/ laparotomy on-site or else refer and transfer the patient to a higher-level facility where appropriate management can be provided. Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 113 Type of complication Cause of complication Presentation Management ™ If a perforation is suspected while using sharp forceps (such as Bierer) during D&E, laparoscopy (or, if unavailable, laparotomy) should be used to further investigate and repair injuries. Uterine rupture Uterine rupture is a rare complication, may occur due to incorrect misoprostol administration ™ Sudden and severe abdominal pain ™ Vaginal bleeding ™ Sudden loss of uterine contractions ™ Inability to palpate fetal parts ™ Occasionally haematuria Uterine rupture is a rare complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with advanced gestational age. The dose of misoprostol should be reduced for induced abortion beyond 24 weeks scarred uterus and IUFD beyond 28 weeks, due to limited data. Clinical judgement should be used to determine the appropriate dosage, recognizing the greater sensitivity of the uterus to prostaglandins. Continued Continued 114 SECOND TRIMESTER ABORTION Type of complication Cause of complication Presentation Management Incomplete abortion Increased abdominal pain, bleeding per vaginam, fever, foul- smelling discharge, pelvic and/or abdominal tenderness, enlarged os and open or closed cervical os ™ Small amount of POC and no evidence of infection – wait for 24 hours for spontaneous expulsion ™ If excessive bleeding and uterus size is <16 weeks – surgical method (suction evacuation/ dilatation &evacuation) ™ Uterus size >16 weeks and cervical os is open – oxytocin drip 20 units in drip or misoprostol 400 mcg S/L or 600 mcg ™ Uterus size >16 weeks and cervical os is closed then misoprostol 400 mcg S/L 4 hourly Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 115 Type of complication Cause of complication Presentation Management Failed abortion Patient continues to have signs and symptoms of pregnancy On examination, the size of the uterus corresponds to the period of gestation and ultrasound will confirm the diagnosis Abortion can be completed by repeating the medical or surgical method Anaesthesia- related complications Anaphylactic reaction can occur following local anaesthesia History of allergic reaction ™ Personnel trained in cardiopulmonary resuscitation should be present ™ Reversal agents (e.g. opioid antagonist [naloxone], benzodiazepine antagonist [flumazenil], anticholinesterases) should always be readily available in settings where narcotics or benzodiazepines are used. Continued 116 SECOND TRIMESTER ABORTION 9.2 Complications resulting from the method used to induce abortion Unsafe abortion procedures used to induce abortion may cause seceral complications. Some of the causes and complications could be: ™ ingestion/application of material leading to poisoning: example lead poisoning; ™ abdominal trauma; and ™ presence of foreing bodies in the genital tract. A woman with abortion-related complications should be stabilized and treated or referred for appropriate treatment. 9.3 Complications that are not specific to the abortion procedure or method The complications listed below are not specific to the abortion procedure or method used: ™ Anaphylaxis ™ Asthmatic reactions ™ Seizure POCKETBOOK FOR HEALTH-CARE PROVIDERS 117 ™ Syncope/vasovagal reaction ™ Upper respiratory obstruction (choking) ™ Venous thromboembolism These complications should be managed as per standard protocol used in any situation. References 1. Clinical practice handbook for safe abortion. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/handle/10665/97415, accessed 27 July 2023). 2. Complications of abortion: technical and managerial guidelines for prevention and treatment. Geneva: World Health Organization; 1995 (https://apps.who.int/ iris/handle/10665/40349. Key message ™ One must be aware of all possible complications. ™ Initial management of any complication involves evaluation of the general condition of the patient and resuscitation, if required, by maintaining the airway, breathing, and circulation followed by prompt specific management. ™ Broad-spectrum antibiotics followed by removal of the source of infection as early as possible are important in managing cases of incomplete abortion with sepsis due to retained products of conception. Post-abortion contraception10 To counsel and provide concurrent contraception to a woman seeking second trimester abortion according to her choice. Objective 10.1 Rationale Post-abortion contraception aims to avert unintended pregnancies in future and avoid abortion-associated morbidity and mortality. Resumption of fertility is quick following an abortion, usually within 2 weeks of a first trimester termination or miscarriage and around 4 weeks after a second trimester termination or miscarriage. Therefore, there is an imperative need for efficacious contraception almost immediately(1). POCKETBOOK FOR HEALTH-CARE PROVIDERS 119 To counsel her about the benefits of appropriate timing and spacing of pregnancy To help the woman avoid unintended pregnancies in the future To guide the woman to continue its correct and consistent use To help a woman begin an appropriate, acceptable and effective contraceptive method immediately following abortion, preferably before leaving the health-care facility Goals of post-abortion contraceptive counselling 10.2 Goals of post-abortion contraceptive counselling 10.3 Guiding principles of post-abortion contraceptive counselling Timing of contraceptive counselling: Counselling can be done before or after the abortion process is completed. 120 SECOND TRIMESTER ABORTION Counsel with compassion: Good counselling gives support to the woman who has just had or has been treated for post-abortion complications. The counsellor should: y try to understand what she has been through; y treat her with respect and avoid judgement and criticism; y ensure privacy and confidentiality; and y ask if she wants someone she trusts to be present during counselling. Provide important information: y Inform her that fertility returns quickly. y She can choose a method for immediate protection from the available family planning methods. She should be made aware that methods that cannot be used immediately after abortion and after treatment of abortion- associated complications. y Respect the decision of the woman to discuss or not discuss contraceptive options after abortion. y Understand that the woman’s acceptance of contraception must NOT be a precondition for providing abortion services. POCKETBOOK FOR HEALTH-CARE PROVIDERS 121 y She should consider using a back-up while she waits to make a choice of contraceptive method and is sexually active. y Providers should offer information on the available methods and the place to obtain them if the woman decides not to accept a contraceptive method in the same sitting. In addition, condoms, oral contraceptives, or emergency contraceptive pills can be offered to the woman to take home and use later. y She should avoid sexual contact until the bleeding stops, which usually takes about 5–7 days. If she has been treated for infection or has undergone repair for vaginal or cervical tears, she should refrain from sexual contact till she has fully recovered. y She should be encouraged to wait if desirous for early pregnancy. Waiting for at least 6 months may reduce the chances of low birth- weight infant, premature birth, and maternal anaemia. y Support the woman in selecting the contraceptive method best suited to her needs according to her clinical and personal situation. y Provide method-specific counselling for the chosen contraceptive method. 122 SECOND TRIMESTER ABORTION Counselling about the effectiveness of a family planning method: The effectiveness of family planning methods varies greatly. Describing and discussing the effectiveness of each is an important part of counselling. It is prudent to compare the effectiveness of methods rather than expressing in terms of pregnancy rates, which a woman can find difficult to understand. Equally important is to discuss whether the client feels confident to use the method effectively (1). 10.4 Post-abortion contraception options All methods of contraception can be started immediately after an uncomplicated second trimester abortion. Contraceptive options after second trimester abortion are as follows: ™ Condoms ™ Hormonal contraceptive pills ™ Implants ™ IUCD ™ Minilap tubectomy (laparoscopic ligation not advocated)* * If laparoscopic ligation is done following second trimester abortion, there are chances of injury to the fallopian tubes as the tubes are edematous and there is a possibility of slipping of the rings from the tubes, leading to failure of the procedure. POCKETBOOK FOR HEALTH-CARE PROVIDERS 123 10.5 Medical eligibility recommendations for post-abortion contraception Definition of medical eligibility criteria (MEC) categories: ™ A condition for which there is no restriction on the use of the contraceptive method ™ A condition where the advantages of using the method generally outweigh the theoretical or proven risks ™ A condition where the theoretical or proven risks usually outweigh the advantages of using the method ™ A condition that represents an unacceptable health risk if the contraceptive method is used. Post-abortion contraception ,≥12 weeks of gestation MEC categories Combined oral contraceptives 1 Combined injectable contraceptives 1 Patch and vaginal ring 1 Progesterone-only pill 1 DMPA and NET-EN progestogen-only injectables 1 LNG and ETG progestogen-only implants 1 Copper-bearing intrauterine device (IUD) 2 Continued 124 SECOND TRIMESTER ABORTION Post-abortion contraception ,≥12 weeks of gestation MEC categories LNG-releasing IUD 2 Condom 1 Spermicide 1 Diaphragm and cap 1 Female sterilization* uncomplicated 1 Continued DMPA: depot medroxyprogesterone acetate; ETG: etonorgestrel; LNG: levonorgestrel; NET-EN: norethisterone enanthate * Delay in certain post-abortion conditions (sepsis, fever, or severe haemorrhage; severe trauma to the genital tract; cervical or vaginal tear at the time of abortion; acute haematometra). In special circumstances can be done in case of uterine perforation Source: Family planning: a global handbook for providers, new edition. 2018:389. 10.6 Time of initiation of contraceptive methods after second trimester abortion After surgical abortion: Immediate start of contraception after surgical abortion means that it can be started on the same day as the procedure, after the success of the abortion has been confirmed. After medical abortion: Immediate start of contraception after medical abortion means that it can be started after taking the first pill (mifepristone or misoprostol) of the medical abortion regimen, except for IUDs. Evidence is POCKETBOOK FOR HEALTH-CARE PROVIDERS 125 currently unavailable on the immediate start of contraception after using a medical abortion regimen using letrozole. 10.6a Timing of contraceptive methods in women following uncomplicated second trimester abortion Contraceptive method For termination >12 weeks Condoms As soon as sexual activity is resumed Diaphragm or cervical cap Refitting of diaphragm should be delayed six week to allow the uterus to return to its normal size Combined oral contraceptive pills Can be started immediately or within seven days of abortion Injection medroxyprogesterone acetate (MPA) Can be started immediately or within seven days of abortion Implant Can be started immediately or within seven days of abortion Intrauterine contraceptive device (IUCD) Can be inserted immediately or within 12 days after the procedure is complete and contraindications are ruled out Tubal ligation Minilap sterilization can be performed concurrently or up to seven days after an abortion in the absence of any infection or severe blood loss (laparoscopic sterilization is not recommended) Vasectomy Can be performed at any time 126 SECOND TRIMESTER ABORTION 10.6b Timing of contraceptive methods in women with complications of second trimester abortion ™ Combined oral contraceptives, progestin-only pills, progestin-only injectables, monthly injectables, combined patch, implants, male condoms, female condoms, and withdrawal can be started immediately in every case, even if the woman has injury to the genital tract or has a possible or confirmed infection. ™ IUDs, female sterilization, and fertility awareness methods can be started once infection is ruled out or resolved. ™ IUDs, combined vaginal ring, spermicides, diaphragms, cervical caps, female sterilization, and fertility awareness methods can be started once any injury to the genital tract has healed. 10.7 Special considerations while providing post-abortion contraceptives ™ Intrauterine device (IUD) y This can be inserted immediately or within 12 days of second trimester abortion, if no infection is present. If it is more than 12 days have passed after second trimester abortion and no infection is present, she can have the IUD inserted any time if it is reasonably certain that she is not pregnant. There is no need for a back-up method. POCKETBOOK FOR HEALTH-CARE PROVIDERS 127 y If infection is present, treat or refer, and help the client choose another method. If she still wants the IUD, it can be inserted after the infection has completely cleared. y IUD insertion after second trimester abortion or miscarriage requires specific training. If the person is not specifically trained, delay insertion until at least 4 weeks after miscarriage or abortion. Technique of post-abortion IUCD insertion Condition Technique of insertion immediately after abortion After surgical evacuation when uterine size is above 12 weeks (or uterus size after evacuation is similar to the size of a second trimester pregnant uterus) The technique of insertion is same as that of postpartum IUCD insertion with a little modification The insertion can be done with ring forceps or sponge holders because it might be difficult to introduce postpartum IUCD (PPIUCD) insertion forceps through the cervical os. (The height of the uterus after evacuation is smaller as compared to the size of uterus after full-term vaginal delivery and the cervical os may be tighter. So it might be difficult to introduce PPIUCD insertion forceps into the cervix. Hence, it is advisable to do the insertion with ring forceps/sponge holder following the same technique as that of immediate postpartum IUCD insertion). 128 SECOND TRIMESTER ABORTION ™ Female sterilization: It must be decided upon in advance, and not while a woman is sedated, under stress or in pain. Counsel carefully and be sure to mention an available reversible method. ™ Combined vaginal ring, spermicides, diaphragms and cervical caps: They can be used even in cases of uncomplicated uterine perforation. ™ Diaphragm: After uncomplicated second trimester miscarriage or abortion, use should be delayed up to 6 weeks for the uterus to return to normal size, and then the diaphragm should be fitted. ™ Fertility awareness methods: A woman can start symptom-based methods once she has no infection- related secretions or bleeding due to injury to the genital tract. She can start calendar-based methods with her next monthly period. 10.8 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 POCKETBOOK FOR HEALTH-CARE PROVIDERS 129 ™ Poorly controlled hypertension: All hormonal methods can be avoided, preference for IUCD, barrier, non- hormonal pill and natural methods ™ Well-controlled diabetes mellitus (DM): All methods are suitable, MEC category 2 for COC 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 2. References 1. Family planning: a global handbook for providers, new edition. Geneva: World Health Organization; 2018:383 (https://www.who.int/publications/i/ item/9780999203705, accessed 27 July 2023). 2. Abortion care guideline. Geneva: World Health Organization; 2022 (https://www. who.int/publications/i/item/9789240039483, accessed 27 July 2023). Key message Acceptance of post-abortion contraception is NOT a prerequisite for providing abortion services. All contraceptive options may be considered after a second trimester abortion but informed choice and the client’s wishes are paramount and the provider should support the woman in selecting the contraceptive method. Monitoring, recording and reporting of second trimester comprehensive abortion care 11 Describe the points to be considered during monitoring the quality of second trimester CAC and post-abortion care services. Objective ™ The aim of monitoring is to ensure that all the staff is competent to provide all components of quality second trimester CAC services. ™ Monitoring of second trimester CAC services must be done regularly at facilities providing these services. It must be an ongoing process with the four steps of the Plan–Do–Check–Apply (PDCA cycle) to ensure quality. POCKETBOOK FOR HEALTH-CARE PROVIDERS 131 11.1 Examples of abortion services monitoring matrix Types of services (which services to monitor) Indicators (what will be used to monitor activities) Information sources (from where to get this information) Checklists, questionnaires, exit interviews (what questions to ask?) Infection prevention (IP) Percentage of cases in which IP practices were fully adhered to Observe services using performance checklist Was a no-touch technique used? Were EVA instruments properly processed? Management and organization of services Average amount of time clients spend in the facility Average amount of time from arrival to procedure Hours during which services are available Review records of clinic, finances, personnel and inventory Observe and evaluate clinic flow Review client records and conduct interview with staff During what time of the day does the waiting time for clients increase? Continued 132 SECOND TRIMESTER ABORTION Counselling Number and percentage of women receiving high-quality counselling services Observe contraceptive counselling services using performance checklists Review recent cases in logbooks Were women with special needs given appropriate referrals when necessary? Contraceptive counselling and services Number and types of post- abortion contraceptives dispensed on site Number and percentage of post-abortion women who received contraceptive counselling Number and percentage of post-abortion women desiring contraception who received a method of their choice Observe counselling services using checklists Conduct exit interviews with women Review recent cases in logbooks How well was the woman counselled about the available contraceptive methods? Did the woman leave with the desired method or information? Did the woman have to go to another facility to receive a contraceptive method? Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 133 11.2 Documentation and reporting of second trimester CAC services ™ All facilities providing second trimester CAC services must record the services regularly on the prescribed formats as per the guidance of the individual country’s laws on abortion and report them monthly in the reporting format along with other services of the facility. ™ The facility must report the data to the head of the facility (including adverse events during abortion or post abortion), who further sends the report to the district and state authorities for their information and records. The state/province will share the data periodically, monthly or quarterly with the concerned national officials and division. All data must be recorded and service sites should report to the National Hospital Management Information System (HMIS). Client satisfaction Percentage of women who indicate that they received respectful care Percentage of women who agree that clinic costs are reasonable Conduct exit interviews with women Review financial records Did you feel that you were treated respectfully? Do you think the amount you had to pay for the service was reasonable? Continued 134 SECOND TRIMESTER ABORTION ™ It is important that every country has the correct statistics of women seeking second trimester induced abortions in a safe setting and those resorting to unsafe means of termination of pregnancy. References 1. Towards a supportive law and policy environment for quality abortion care: evidence brief. Geneva: World Health Organization; 2022 (https:// apps.who.int/iris/bitstream/handle/10665/364081/9789240062405-eng. pdf?sequence=1&isAllowed=y, accessed 26 July 2023). Key message ™ Every health facility providing medical termination of pregnancy MUST document and report the data on abortions regularly, including that for adverse events. ™ It is important for countries to report the abortion data periodically to the global data recording system. ™ Confidentiality of data records and reports need to be maintained at all levels unless inspection is asked for under the authority of the law. 12.1 WHO definition of telemedicine (or telehealth) ™ Telemedicine is a mode of health service delivery where providers and clients (client-to-provider telemedicine), or providers and consultants, are separated by distance. The interaction may take place either synchronously in real time using a telephone or video link or asynchronously using a store-and-forward method when a query is submitted and an answer is provided later (e.g. by email, text or voice message) (1). ™ Telemedicine can be used to provide information on abortion services through remote access, harm- reduction models and community-based outreach, 12 Role of telemedicine and self-management in second trimester abortion To understand how telemedicine can be used for provision of second trimester abortion and self- administration of drugs for medical abortion or cervical priming. Objective 136 SECOND TRIMESTER ABORTION as an alternative to in-person interaction. The information provided by telemedicine should be accessible, understandable and specifically aimed to address the population with low literacy and those who are differently abled. ™ A telemedicine approach for medical abortion of pregnancies less than 12 weeks is well known. However, the evidence supporting its use for abortion services in pregnancies beyond 12 weeks is inconclusive (2). 12.2 What can be done via telemedicine Provision of telemedicine will be based on the country’s policies and guidelines. The following components of CAC can be considered via telemedicine Assessment of eligibility for medical abortion Counselling and/or instruction relating to the abortion process Instruction for and active facilitation of the administration of medicine Follow-up post-abortion care (including emergency care if needed) Post-abortion contraceptive counselling 01 02 0304 05 POCKETBOOK FOR HEALTH-CARE PROVIDERS 137 12.3 Self-management of abortion ™ Self-management involves interactions with trained health-care workers in the community or at a health- care facility, including a pharmacy. ™ Ideally, the individual would decide which aspects of abortion care they want to self-manage, based on their individual circumstances and preferences. ™ For some women, self-management of some or all elements of a medical abortion may be the only feasible option within their context, while for others it may be an active choice and preference among available options. 12.4 What is included in self-management ™ Self-assessment of the eligibility for medical abortion ™ Self-administration of medicines (mifepristone and misoprostol) without direct supervision of a health worker. The provider should ensure that the individual knows how to contact a trained health-care worker in the event of questions, concerns or complications. ™ For those undergoing surgical abortion that requires cervical priming, women can also play an active role in self-managing cervical priming if this is to be done using pharmacological methods, i.e. mifepristone and/ or misoprostol. 138 SECOND TRIMESTER ABORTION ™ The option of self-administration of injectable contraception in the post-abortion period (as a self- management approach) should be considered and offered as an alternative for individuals who wish to use injectables but cannot return regularly to access repeat injections. References 1. Safe abortion: technical and policy guidance for health systems, second edition. Geneva: World Health Organization; 2012 (http://apps.who.int/iris/bitstream/ handle/10665/70914/9789241548434_eng.pdf, accessed 27 July 2023). 2. Abortion care guideline. Geneva: World Health Organization; 2022 (https://www. who.int/publications/i/item/9789240039483, accessed 27 July 2023). Key message ™ There is no single recommended approach to providing abortion services. A plurality of service delivery can coexist within any given context. Across the range of service delivery options, telemedicine is the only approach recommended as an alternative to in-person interaction. ™ Telemedicine and self-administration have a role in assessment of the eligibility for medical abortion, counselling and/or instruction relating to the abortion process, active facilitation of the administration of medicines, and follow-up post-abortion care. Abortion in the second trimester can be conducted by one of two methods – medical or surgical. The medical method is performed by ingestion of drugs, which are taken by the buccal, vaginal or oral route. These drugs may lead to side-effects such as nausea, vomiting, fever, shivering and allergic reaction. The expected outcome and likelihood of success is very high. If the medical method for termination of pregnancy fails and the pregnancy continues, then there may be a chance of developmental defects in the fetus. The surgical method is usually performed under local anaesthesia. The cervix is carefully dilated until there is enough room to pass a suction cannula/curette/instrument into the womb. The products/fetus in the uterine cavity will be sucked out with the suction cannula. The tissue/fetus may be sent to the pathology laboratory for examination and autopsy if deemed necessary. The expected outcome and likelihood of success for both the methods is similar and as high as 95–99%. ™ The woman can resume her routine activities a day after the abortion. Patient information sheet1aAnnexure 140 SECOND TRIMESTER ABORTION ™ The woman will be required to report to the provider if there are warning signs such as excessive bleeding, pain, fever or continued nausea and vomiting. There are risks and complications associated with these procedures, which should be explained to the woman. They include, but are not limited to, the following: ™ I have been explained that the procedure may take a longer time than expected. ™ Damage may occur to the uterus, such as rupture or perforation. This may require a laparoscopy and/or laparotomy. There is a risk of damage to other organs, such as the bowel or bladder, which may require further corrective surgery. ™ 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 medical and surgical interventions may be necessary. ™ Widening of the mouth of uterus may lead to cervical incompetence. The uterus might be unable to hold a pregnancy in future and may result in recurrent pregnancy loss. ™ Rarely, adhesions may develop in the uterus leading to amenorrhoea/subfertility. POCKETBOOK FOR HEALTH-CARE PROVIDERS 141 ™ Infection can occur in the uterus. This can cause heavy bleeding, offensive 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. ™ An allergic reaction can occur from the medicines. ™ Excessive bleeding can occur, which may require a blood transfusion. ™ The available options for choosing a method of contraception during/after the procedure are oral contraceptive pills, POP, DMPA, IUCD, tubal ligation, vasectomy for the husband, among others. Name of the patient: ………………………………………………………………………...……… Sex: ……………. Age ……………. Registration no:…….............………...………….. Address:…..………………………………………………………………………………………................. ………………………………………………………………………….........................…………………………… Diagnosis ………….....................………………………………………………………………………… Operation title…….............…………………………………………………….………………………. I, …………………………………………….....…………………………………… the undersigned give consent for MY OWN/AFOREMENTIONED PATIENT’S operation and/or medication/ investigation/anaesthesia/ therapy/etc. Informed consent for second trimester abortion (sample form) 1bAnnexure POCKETBOOK FOR HEALTH-CARE PROVIDERS 143 I acknowledge that the doctor has explained the following: ™ The procedure may take 48–72 hours or longer than expected ™ 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 anaesthesia 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 ™ Tissues/fetus and blood may be removed and could be used for diagnosis or management of my conditions, stored and disposed of sensitively by the hospital ™ Excessive bleeding, infection, cardiac arrest, pulmonary embolism and complications like these can arise suddenly and unexpectedly while undergoing medicat ion/invest igat ion/operat ion/therapy/ procedure or anaesthesia 144 SECOND TRIMESTER ABORTION ™ I give consent for any change in the anaesthesia or operative procedure as deemed necessary by the doctors at the time of medication/investigation/ therapy/surgical procedure. ™ I have been made aware that after the above procedure/ medication/investigation/therapy and anaesthesia, some complications that may arise and laparotomy may be required. ™ I was able to ask questions and raise concerns 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 regarding the result and understand these limitations. POCKETBOOK FOR HEALTH-CARE PROVIDERS 145 I have read the above writing/the above writing has been read out to me and explained to me in the ………………………………………...........…. language by ……….......……………………………. (interpreter), which I understand. I have understood the aforesaid and I am giving my consent willingly while in a sound mental state without any coercion, undue influence, fraud, misrepresentation, or mistake of facts. I request Dr ……………………………………………….............………………………………… to perform the above-mentioned procedure upon me. Patient/guardian Sign/thumb Impression: ……......................................................……………. Name: …………….............................................................................…………....……… Address: …………….........................................................................…………....……… …………….........................................................................………….....................………… Age…………….........… Date…………....................…………… Doctor Sign.: …………………............................................................................................…… Name: …………….............................................................................…………....……… Address: …………….........................................................................…………....…… …………….........................................................................………….....................………… One of the major reasons for abortion-related morbidity and mortality is infection. Abortion procedures involve contact with blood and other body fluids. All clinical and support staff that provide these services should understand and apply standard precautions for infection prevention and control. A2.1 Standard precautions, also called universal precautions These should be applied in all situations where health- care workers anticipate contact with blood/anybody fluid other than perspiration; non-intact skin; and mucous membranes. These should always be followed, regardless of a person's presumed infection status or diagnosis. The components of standard precautions are given below. Infection prevention practices for second trimester abortion 2Annexure POCKETBOOK FOR HEALTH-CARE PROVIDERS 147 ™ Hand hygiene: Handwashing with soap and running water should be routine before and after each contact, including after contact with potentially contaminated items. Gloves should be worn and replaced between contact with different clients and between vaginal (or rectal) examinations of the same woman. ™ Respiratory hygiene and cough etiquette: Maintain at least a 1 m (3 ft) distance from patients who are sneezing/coughing and perform hand hygiene if the hands are soiled with respiratory secretions. ™ Personal protective attire/equipment (PPE): PPE acts as a barrier that prevents direct contact between the health provider and client. These are: cap, mask, goggles, gown, gloves, apron and footwear. ™ Processing instruments: It is important to have clean, germ-free instruments 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. 148 SECOND TRIMESTER ABORTION Steps of processing are: precleaning of the soiled instruments before washing, washing with detergent and water, high-level disinfection (HLD) or sterilization, storage. ™ Safe injection practices, sharps management and injury prevention: Needles are made unusable after a single use by burning the tip in a needle destroyer and/ or in hub-cutter and disposed of in a puncture-proof container. ™ Environmental cleanliness: All examination/OT tabletops and surfaces, lamp shades, almirah, lockers, trollies, etc. should be cleaned with a low power disinfectant (2% carbolic acid or 0.5% chlorine solution). ™ Safe handling and cleaning of soiled linen: Linen (drapes, sponges, scrub suits, etc. are washed with soap and water and then autoclaved in a drum (should be used within one week of autoclaving). ™ Segregation of waste and disposal: Disposal of biomedical waste poses health risk to health-care providers and the community. All waste in a health facility can be divided into general waste, medical/ biomedical waste and sharps, and should be disposed of as per the country’s policies. POCKETBOOK FOR HEALTH-CARE PROVIDERS 149 A2.2 Facilitating expulsion of the fetus in second trimester medical abortion All standard precautions for infection prevention should be followed and important points to be considered are as follows: ™ Pubic hair should not be shaved. ™ Avoid repeated per vaginal examination. ™ There is no need to clean the cervix with antiseptics. ™ Routine antibiotics are not required. Antibiotics are given only if indicated as for prolonged rupture of the membranes. A2.3 Infection prevention for surgical abortion All standard precautions for infection prevention should be followed throughout the procedure. The important components are given below: Continued Cleaning the operative field Preparation of the skin ™ Pubic hair should not be shaved. ™ The operative field should be cleaned with an antiseptic solution. 150 SECOND TRIMESTER ABORTION Draping the operative field During the procedure After the procedure Follow the clinical guidelines of the hospital ™ The vagina should be cleaned with 2.5% betadine. ™ Spirit or alcohol should never be used to clean the vagina. ™ The perineum and lower abdomen should be draped with sterile drapes to avoid contact of the instrument with the body surface. ™ The cervical os should be cleaned from the centre to the periphery. ™ The instruments going inside the uterus should not touch the vagina. ™ Disposable consumables should be discarded. ™ Used reusable instruments should be soaked in water till cleaned and should be processed as per protocol. ™ MVA if used is disassembled fully after use and the vacuum aspirator can be sterilized either by autoclaving / boiling /submerging the instrument in glutaraldehyde (2%). Continued Contraceptive effectiveness 3Annexure Method How it works Effectiveness: pregnancies per 100 women per year with consistent and correct use Effectiveness: pregnancies per 100 women per year as commonly used Combined oral contraceptives (COCs) or “the pill” Prevents the release of eggs from the ovaries (ovulation) 0.3 7 Progestogen-only pills (POPs) or "the minipill" Thickens cervical mucus to block the sperm and egg from meeting and prevents ovulation 0.3 7 Implants Thickens cervical mucus to block the sperm and egg from meeting and prevents ovulation 0.1 0.1 Progestogen- only injectables Thickens cervical mucus to block the sperm and egg from meeting and prevents ovulation 0.2 4 Monthly injectables or combined injectable contraceptives (CIC) Prevents the release of eggs from the ovaries (ovulation) 0.05 3 Continued 152 SECOND TRIMESTER ABORTION Method How it works Effectiveness: pregnancies per 100 women per year with consistent and correct use Effectiveness: pregnancies per 100 women per year as commonly used Combined contraceptive patch and combined contraceptive vaginal ring (CVR) Prevents the release of eggs from the ovaries (ovulation) 0.3 (for patch) 0.3 (for vaginal ring) 7 (for patch) 7 (for contraceptive vaginal ring) Intrauterine device (IUD): copper containing The copper component damages the sperm and prevents it from meeting the egg 0.6 0.8 Intrauterine device (IUD) levonorgestrel Thickens cervical mucus to block the sperm and egg from meeting 0.5 0.7 Male condom Forms a barrier to prevent the sperm and egg from meeting 2 13 Female condom Forms a barrier to prevent the sperm and egg from meeting 5 21 Male sterilization (vasectomy) Keeps the sperm out of ejaculated semen 0.1 0.15 Continued Continued POCKETBOOK FOR HEALTH-CARE PROVIDERS 153 Method How it works Effectiveness: pregnancies per 100 women per year with consistent and correct use Effectiveness: pregnancies per 100 women per year as commonly used Female sterilization (tubal ligation) Eggs are blocked from meeting the sperm 0.5 0.5 Lactational amenorrhoea method (LAM) Prevents the release of eggs from the ovaries (ovulation) 0.9 (in six months) 2 (in six months) Standard days method or SDM Prevents pregnancy by avoiding unprotected vaginal sex during the most fertile days 5 12 Basal body temperature (BBT) method Prevents pregnancy by avoiding unprotected vaginal sex during the fertile days Reliable effectiveness rates are not available Two-day method Prevents pregnancy by avoiding unprotected vaginal sex during the most fertile days 4 14 Sympto- thermal method Prevents pregnancy by avoiding unprotected vaginal sex during the most fertile days <1 2 Continued Continued 154 SECOND TRIMESTER ABORTION Method How it works Effectiveness: pregnancies per 100 women per year with consistent and correct use Effectiveness: pregnancies per 100 women per year as commonly used Emergency contraception pills (ECPs) (ulipristal acetate 30 mg or levonorgestrel 1.5 mg) Prevents or delays the release of eggs from the ovaries. Pills can be taken to prevent pregnancy up to 5 days after unprotected sex <1 for ulipristal acetate ECPs 1 for progestin- only ECPs 2 for combined estrogen and progestin ECPs Calendar method or rhythm method The couple prevents pregnancy by avoiding unprotected vaginal sex during the first and last estimated fertile days, by abstaining or using a condom Reliable effectiveness rates are not available 15 Withdrawal (coitus interruptus) Tries to keep the sperm out of the woman's body, preventing fertilization 4 20 Continued Source: Family planning: a global handbook for providers, new edition. 2018:383 POCKETBOOK FOR HEALTH-CARE PROVIDERS 155