EXERCISE TEACHING POINTS: INCREMENTAL EXPANSION OF ABORTION CARE
EXERCISE 12.1
- Depending on the legal status of abortion in your setting, how comfortable are you being involved in abortion with advancing gestational duration in the following ways?
- Referring for an abortion
- Observing or performing ultrasound procedural guidance
- Looking at pregnancy tissue (i.e. products of conception)
- Assisting or performing abortion
- Taking on a medically complex patient for care (especially for someone coming from a restricted setting with minimal prior work-up/risk stratification).
There are no correct/incorrect answers. If you struggle with your level of involvement, here are considerations to think about:
- What happens between gestational durations that feel acceptable and those that do not?
- When seeing fetal parts of increasing size, how do you feel about it? Were there any factors that influenced that?
- Consider how the situation differs from other medical circumstances where you might value evidence-based information and patient autonomy.
- How do personal experiences with infertility, seeking abortion care, pregnancy, parenting, etc. inform your answers?
- Are there ways to respect a person’s moral autonomy, without undermining your own?
- Each provider is different and needs to find their own comfort level.
- What is your biggest concern about providing abortions beyond 14 weeks gestation?
- Do your responses have to do with your understanding of fetal development, physical risk to the abortion seeker, perceived ethical concerns or stigma, or potential protesters or legal repercussions?
- If no alternative abortion services were accessible, what kind of patient hardship might motivate you to offer information, referral or services (to the extent of legality in your setting)?
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- Recall that delays underpinned by economic, geographic, and legal factors impact abortion care-seeking, and delay when care is sought (Coast 2021).
- There are many settings globally that include no exceptions for rape, incest, or to save a pregnant person’s life.
- People will travel farther, spend more, face criminal penalties, or have forced births.
- People denied an abortion are more likely to remain tethered to abusive partners, have decreased financial security and are at four times the risk of living below the federal poverty level compared to those who had an abortion (ANSIRH).
- If you are trying to help someone find appropriate abortion services (or referral) > 14 weeks, what might be some key steps, precautions, and supports?
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- People seeking abortion care may use resources such as abortionfinder.org or ineedana.com in the U.S., or country-specific websites.
- Providers may use formal or informal referral networks, with provider to provider communication, using pager or cell phone, or warm lines for second opinions depending on your legal constraints and the legal status of abortion in your setting.
- People may take records of the visit, ultrasounds, ectopic evaluations, lab records, or their medication list with them if they are going to receive care at another site. In the U.S., people may also self-order labs from Quest or Labcorp.
- Providers should have partnerships with lawyers, and involve legal team early, as needed
- Providers and abortion seekers can work with local/regional abortion fund(s) to assist with financial coverage issues and logistics.
- If in a setting where referral for an abortion is legally restricted, how might you provide general enough information that it is non-directive and not an actual referral? It is advised to keep language general, such as “one can visit the following website or call the following hotline to discuss options.”
EXERCISE 12.2: Understanding people’s reasons or situation
- Describe why pregnant people might present > 14 weeks for abortion care?
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- People who were delayed in recognizing their pregnancies were more likely to lack pregnancy symptoms, to be using hormonal contraception, to have never previously had a birth, and to have health conditions with symptoms similar to pregnancy (Foster 2021).
- People’s need for later abortions may be higher in communities with limited access to reproductive health services and among those living in areas with greater economic disadvantage. Bans, restrictions, andlaws that narrow gestational limits increase long-distance travel for later abortion care and cause a concentration of needed services which may impact wait times, disproportionately affecting those with fewer resources (KFF 2024).
- Delays underpinned by economic factors can thwart care-seeking, affect the type of care sought, and impact the gestational duration at which care is sought or received (Coast 2021).
- Nearly 60% of people who experience a delay in obtaining an abortion cite the time it took to make arrangements and to raise money as the reason for delay (Jerman 2017).
- Changing life circumstances may change how a person feels about pregnancy, including tenuous finances with recent job loss or increasing financial instability, childcare and transportation reasons, and/or an unreliable or abusive partner.
- People may experience multiple or inappropriate referrals, (i.e. from a health center/clinician otherwise unable to complete the procedure or a crisis-pregnancy center), or only learn of a fetal diagnosis after amniocentesis or chorionic villus sampling.
- In addition to gestational duration restrictions and bans, there are also regional provider shortages.
- What kind of provider and staff support might be helpful in abortion care settings that regularly provide care > 14 weeks gestation?
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- Abortion care at advancing gestational durations is stigmatized in many settings. In addition to supporting clinical training opportunities, provider share workshops are one supportive group intervention that have been shown to help create connections, and foster resilience (Debbink 2016).
- Speaking in safe spaces fosters interpersonal connections, and may serve as an effective stigma management tool (Harris 2011).
Consider this passage: “Those with the most resources—money, a car, childcare, and ability to take time off from work—may travel hundreds of miles to find legal services in another state or setting. Others, with a different set of required resources—Internet access, knowledge of sites, a credit card, and an address—will order medication abortion pills online. But those without resources and information will be at greatest risk for the worst health and economic outcomes—delaying needed care (which they may have to travel further to achieve, or wait longer due to fewer second trimester providers), attempting less safe methods of inducing an abortion, or carrying an unwanted pregnancy to term. The evidence that not being able to get an abortion leads to greater poverty and a worsening of physical health outcomes (Ralph 2019), means that we are about to see a deepening of existing inequalities. Poverty and poor health make it more likely that one will be denied an abortion.” (Foster 2022)
EXERCISE 12.3: Technical considerations, skills, and cases
- Beyond the standard screening and preparations for abortion < 14 weeks, what additional screenings or plans might you need for an abortion procedure > 14 weeks?
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- Complete or make a plan for ultrasound placental localization for people with a history of uterine scar, with appropriate referral to higher level of care if evidence of low-lying placenta or concern for placenta accreta spectrum, as needed.
- Make a plan for cervical preparation (Misoprostol +/- osmotic dilators), including possibility of a long health center visit and/or multiple visits
- Make a plan with abortion seeker for pain management, with likely increased need for IV sedation.
- Use procedural ultrasound guidance
- Consider options to minimize bleeding, including vasopressin or epinephrine in local anesthetic, or post-procedure TXA prn bleeding.
- Consider needs for and pros and cons of different forceps, and adequate dilation for the use of chosen forceps
- Some providers consider the use of wider (¾”) suction tubing
- A person at 17 weeks is undergoing an ultrasound-guided D&E procedure, and experiences localized pain as you make a lateral instrument pass which feels deeper than previous passes, and without fundal landmarks felt previously. How would you proceed?
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- Immediately stop. Locate your instruments by ultrasound to confirm placement and perforation then gently remove the instrument or cannula (some providers jiggle cannula before removing, to free up adherent contents prior to removing).
- Evaluate for sharp or localized pain, unstable vital signs, and bleeding.
- A lateral perforation is more likely to occur by larger vessels than a medial one, with greater risk of bleeding. Consider uterotonics if bleeding is significant.
- Use US to assess expanding hematoma, fetal parts in the abdomen, or viscera / omentum in the uterus.
- If perforation was with an instrument (without suction) and uterine cavity can be re-identified with US guidance, an experienced provider may choose to finish the procedure. If the person remains asymptomatic for pain or bleeding, consider observation for two hours, antibiotic coverage (Paul 2009; p. 241), and precautions before discharge.
- If perforation was with suction, evaluate the aspirate for omental fat or other visceral fragments, which confirm perforation with suction.
- Hospitalization is indicated if there is:
- evidence of cannula or forceps entering the abdomen
- Free fluid in the abdomen
- Pregnancy tissue outside of uterus in abdomen
- Visualization of bowel in POCs/cannula/in uterus
- Heavy bleeding diagnosed (from cervix) or suspected (intraabdominal)
- vital signs are unstable
- Inability to complete procedure after pregnancy disrupted after 13 weeks
- significant pain
- evidence of a large perforation, laceration, or expanding hematoma
- A person at 16 weeks gestation is undergoing an ultrasound-guided D&E, and after easily removing most of the pregnancy, you have significant difficulty removing the calvarium. What techniques might you consider to safely complete the procedure?
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- Assess for adequate pain control.
- Add additional dilation, which may help with instrumentation
- Switch to forceps with more substantial grasp or teeth
- Use a suction cannula to pull the calvarium into the lower uterine segment or out through the cervix
- Add additional misoprostol 400-600 mcg for a minimum of 30 minutes and give some time for uterine contractions to assist in bringing down parts.
- Have another provider assist if present in the health center
- If still unsuccessful, consider transferring to a higher level of care.
- What overarching considerations and information might you need for a medically complex individual > 14 weeks that appears at your health center?
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- Consider having the person bring visit records, US, clinical notes, lab records, medication list, if available
- See Ch 3: Pre-Abortion Evaluation for detailed considerations for pre-abortion evaluation
- Consider the appropriateness of the clinical setting early
- Consider using formal or informal referral networks by direct provider-to-provider contact,using pager or cell phone, or warm lines for “second opinion”
- Work with local/regional abortion fund(s) to assist with coverage issues and logistics
- Have resources or work with support organizations about where abortion seekers can stay, obtain transportation, childcare, and other resources they may need
- Have agreements in place to transfer for in-hospital care, as needed
- Build partnerships with lawyers and involve the legal team early, as needed
- A person at 16 weeks has undertaken a medication abortion at home using mifepristone and misoprostol. They call you 4 hours after fetal expulsion, with a concern that the placenta has not expulsed. What would you recommend?
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- It is safe to wait at least 4 hours after fetal expulsion for placental expulsion.
- Delayed placental expulsion can be treated safely with 400 mcg miso q3 hours, using the ample supply you sent home with them, (or returning to the health center for aspiration which may be indicated with ongoing bleeding or hemorrhage) (SFP 2023).