CORE COMPETENCIES FOR ABORTION CARE BY PRIMARY CARE CLINICIANS: FIRST TRIMESTER ASPIRATION ABORTION

Prevention is increasingly recognized as the most effective means of ensuring health. An approach addressing patients’ pregnancy preferences is an essential component of prevention within a public health framework (Samari 2020, Taylor 2011). Important expectations fall on primary care clinicians, including screening for reproductive needs, counseling for pregnancy options, providing contraception, and providing or referring for early pregnancy loss and abortion services.

This document describes the entry-level specialty competencies for primary care clinicians providing early abortion care, regardless of setting. These specialty competencies are the essential knowledge, behaviors, and skills that primary care clinicians should be able to demonstrate. They are intended to supplement the health-professional core competencies for primary-care clinicians (e.g. CNM, DO, MD, NP, PA) (Informed by HWPP 171, TEACH 2020, and UK SRH 2012 Curricula).

I. Competence Level Descriptors: Measurement of achievement and progression

Competence is a baseline level for safe independent practice, with further (post-training) exposure and experience leading to proficiency and subsequent expertise. Attainment and assessment of any competency should progress through all three of the following stages.

Level 1 (Observation or indirect methods) 

• Demonstrate thorough understanding of the principles of the competency/clinical skill/situation, including indications and common complications
• Observe procedure before direct supervision of clinical skill
  Use other methodologies (e.g. practice drills, simulation, e-learning, case-based discussion assessments) if direct experience is not possible

Level 2 (Direct supervision across different clinical situations) 

• Perform the clinical skill/manage case under supervision
  The number of times the competency/clinical skill/situation needs to be supervised depends on the complexity of the case and individual aptitude
• No limit to the number of times the procedure can be supervised; both trainee and trainer must be certain that the procedure can be safely performed in a number of different clinical situations and levels of complexity
• Be able to manage unexpected complications and know when to summon help

Level 3 (Independent practice) 

• Ability and confidence to perform the clinical skill/situation competently when senior staff is not immediately available
• Willingness to move on to experiential learning with further case exposure.
  Keep a record of the numbers of cases/procedures subsequently managed (including any complications and their resolution).

II. Specific competencies to be attained

Prerequisite to training: Unintended Pregnancy Care Competencies

• Perform comprehensive pregnancy options counseling and care coordination (for adoption, prenatal care, abortion)
• Effectively communicate with patients and accompanying persons, respecting diversity of beliefs
• Effectively counsel the psychosocially complex patient (e.g. ambivalence, mental health conditions, religious belief conflicts)
• Perform pregnancy test, including appropriate type (urine v. serum), interpret results and deliver results neutrally
  • If positive, calculate estimated gestational age and discuss pregnancy options in an unbiased, non-directional manner
• If patient indicates desire to continue: Initiate antenatal/adoption care pathways/clinical guidelines
• If patient indicates desire to terminate: Initiate abortion care pathways/clinical guidelines
• Assess and manage identified clinical and non-clinical risks
• Perform relevant STI screening, providing risk reduction counseling (including  PrEP) and referrals as necessary. Provide contraceptive education and counseling and provide selected method, or refer, as appropriate
• Provide supportive counseling and education (written, verbal, electronic) to promote closure of encounter, including follow-up & care coordination or referral

Pre-Procedure Assessment Competencies 

• Perform pre-abortion clinical history including medical, reproductive, and social history and risk assessment
• Manage positive responses appropriately by providing necessary screenings, counseling and referrals and partner notification if positive STI screening results
• Perform appropriate clinical examination including assessment of gestation
  • Arrange/perform laboratory and ultrasound investigations, and specific investigations as prompted by history and examination
  • Conduct assessment to determine/confirm gestational age (ultrasound for pregnancy elements, bimanual exam for uterine size)
• Manage unexpected findings from routine assessment as per clinical guidelines (e.g. early pregnancy loss, ectopic gestation, molar pregnancy)
• Communicate effectively with patients and accompanying persons they wish to have present
  • Explain clearly and without bias—treatment regimens, potential side effects of drugs and complications of procedures
  • Demonstrate consistent respect for diversity of beliefs and values
  • Counsel the psychosocially complex patient (e.g. ambivalence, mental health conditions, family conflicts) and engage other health professionals as needed (e.g. therapist, social worker) to ensure effective communication and management plan
• Arrange abortion procedure or refer to another agency, including cervical priming and follow-up as necessary
• Prescribe drugs required for chosen procedure including cervical priming/local antibiotic prophylaxis policy/contraception as per clinical guidelines
• Formulate, implement and, if necessary, modify management plans in consultation with patient
• Complete documentation including consent
  • Seek informed consent after assessment of cognitive competency
  • Document episode accurately
• Provide contraceptive and sexual health advice and supplies

First-Trimester Aspiration Abortion Procedure Competencies 

To 14 weeks, by manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA)

• Confirm consent for procedure and see if patient wants to discuss contraception, then make plan according to their wishes
• Confirm all medications prescribed and administered/taken including cervical priming, antibiotics and contraception
• Check equipment and supplies for procedure including for analgesia, sedation
• Manage pain appropriately using local anesthesia and analgesia
• Manage pain using moderate/conscious sedation – optional depending on institutional guidelines
• Complete abortion procedure by MVA and/or EVA
  • Position patient
  • Use “no-touch” clean technique throughout procedure
  • Perform:
    • Bimanual examination (empty bladder)
    • Speculum examination
    • Stabilization of cervix
    • Application of local anesthetic to cervix
    • Cervical dilation
    • Aspiration of uterine contents
    • Use of ultrasound during the aspiration procedure when needed
    • Gross identification of products of conception and their disposal with respect and dignity
• Manage if inadequate products of conception (i.e. incomplete or failed abortion, rule out ectopic or molar pregnancy)
• Manage immediate complications including: dilation difficulties, poor aspiration of uterine contents, blockage of cannula, excessive bleeding/hemorrhage, uterine atony, incomplete abortion, continuing pregnancy, vasovagal reaction, allergic reaction, uterine false passage/perforation, cervical laceration, air embolism, acute hematometra
• Provide requested immediate post-abortion contraception (including IUDs, implants, DMPA)

Post-Procedure Assessment and Follow-up Competencies 

• Perform immediate post-procedure clinical assessment and routine follow-up.
  • Conduct investigations with ultrasound and/or laboratory assessments to confirm resolution of pregnancy (e.g. beta HCG, hemoglobin) as necessary
• Confirm procedure complete by gross or additional examination of uterine contents (i.e. products of conception examination) by identifying pregnancy elements consistently and accurately
• Assess physical and psychological well being of patient; review counseling and support needs
• Review needs for social support and assistance following procedure with special attention to patients with particular vulnerability (e.g. minors; those with psychiatric conditions/mood disorders, limited social support, or high risk for intimate partner violence, repeat unintended pregnancy or STI)
• Contact patient after discharge to assess problems and/or to determine return to primary prevention methods of unintended pregnancy or reproductive life plan
• Manage delayed complications including bleeding, infection, retained products of conception, ongoing pregnancy, and emotional distress
• Complete documentation