EXERCISE TEACHING POINTS: INCREMENTAL EXPANSION OF ABORTION CARE

EXERCISE 1. Feeling about abortions with advancing gestational ages and your role

In spite of our efforts to be objective, we all hold personal values and belief systems that can influence how we respond to patients. These exercises can help you explore your values about pregnancy options with advancing gestational ages in the context of professional judgments you may be called to make. In multiple global settings, participants who undertake abortion values exploration show improved knowledge, attitudes, and behavioral intentions with regards to abortion care (Turner 2018).

1. Depending on your state’s legal status of abortion, how comfortable are you being involved in abortion with advancing gestational ages in the following ways?
   1. Referring for an abortion
   2. Observing or performing ultrasound procedural guidance
   3. Looking at pregnancy tissue (i.e. products of conception)
   4. Assisting or performing abortion
   5. Taking on a medically complex patient for care (especially given that if coming from a ban state, they may have minimal patient work-up and risk stratification).
      • If you struggle with your level of involvement, here are considerations to think about:
      • What happens between an EGA that feels acceptable and one that  does not?
      • When seeing fetal parts of increasing EGA, 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.
      • Are there ways to respect a patient’s moral autonomy, without undermining your own?
      • Each provider is different and needs to find their own comfort level.

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2. What is your biggest concern about providing abortions beyond ≥ 14 weeks EGA?
   • Do your responses have to do with your understanding of fetal development, physical risk to the patient, perceived ethical concerns or stigma, or potential protesters or legal repercussions?

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3. 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 state)?
   • Recall that delays underpinned by economic, geographic, and legal factors impact abortion care-seeking, and delay when care is sought. (Coast 2021)
   • Following Dobbs, there are many states including no exceptions for rape, incest, or to save a pregnant person’s life.
   • People will travel farther, spend more, face criminal penalties, or forced births.
   • Patients denied an abortion are more likely to remain tethered to abusive partners, have decreased financial security and four times the odds of living below the federal poverty level compared to those who had an abortion. (ANSIRH Turnaway Study)

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4. If you are trying to assist a patient find appropriate abortion services (or referral) beyond ≥ 14 weeks, what might be some key steps and precautions?
   1. Patients may use abortionfinder.org
   2. Providers may use formal or informal referral networks, with warm hand-off using pager or cell phone, or warm lines for second opinions depending on your legal constraints and the legal status of abortion in your state.
   3. Patients 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.
   4. Providers should have partnerships with lawyers, and involve legal team early, as needede.     Providers and patients can work with local / regional / state abortion fund(s) to assist with coverage issues and logistics
   5. If in a state 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”.

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EXERCISE 2: Understanding patients’ reasons or situation

1. Describe why pregnant people might present beyond 12-14 weeks EGA for abortion care?
   1. 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)
   2. 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. State bans and laws that narrow gestational limits increase long-distance travel for later abortion care, cause a concentration of needed services which may impact wait times, and disproportionately affect those with fewer resources (Upadhay 2014).
   3. Delays underpinned by economic factors can thwart care-seeking, affect the type of care sought, and impact the gestational age at which care is sought or reached. (Coast 2021)
   4. Nearly 60% of patients who experience a delay in obtaining an abortion cite the time it took to make arrangements and to raise money (Jerman 2017).
   5. Fragile life circumstances may change how a patient feels about pregnancy, including tenuous finances with recent job loss or increasing financial instability, childcare and transportation reasons, unreliable or abusive partner.
   6. Patients may experience multiple or inappropriate referrals, (i.e. from a crisis-pregnancy center, or a service otherwise unable to complete the procedure), or find that some fetal diagnoses cannot be made in early pregnancy.
   7. In addition to state gestational age restrictions and bans, there are also regional provider shortages. 

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2. What kind of provider and staff support might be helpful in abortion care settings that provide care beyond the first trimester?
   1. Abortion care provision, and especially care beyond the first trimester is stigmatized in many countries. Provider share workshops are one supportive group intervention that have been shown to help create connections, and foster resilience. (Debbink 2016)
   2. Speaking in the safe space fostered interpersonal connections, bolstered compassion, resilience, and appeared to serve as an effective stigma management tool. (Harris 2011)

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3. How might abortion bans contribute to delays and further disparities?

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. 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)

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EXERCISE 3: Technical considerations, skills, and cases

1. In addition to the standard screening and preparations for abortion up to ≥ 14 weeks, what other screenings or plans might you need for an abortion > 14 weeks? 
   1. Ultrasound with placental location for all patients ≥ 14 weeks
   2. In a patient with a prior uterine scar, after appropriate evaluation to exclude placenta accreta spectrum, the patient may have a procedure in the outpatient setting. (NAF CPG 2022).
   3. Make a plan for cervical preparation (Misoprostol +/- osmotic dilators)
   4. Make a plan with patient for pain management, with increasing likelihood to offer conscious sedation if desired
   5. Evidence supports routine US guidance during procedural abortion >13w6d EGA
   6. Consider adding vasopressin to paracervical blocks beyond the 13wk6d, for assisting with decreased blood loss
   7. Consider needs for and pros and cons of different forceps, and adequate dilation for the use of chosen forceps
   8. Some providers consider the use of wider suction tubing

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2. A 30 year-old G3P2 patient 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?
   1. Immediately stop and gently remove the instrument or cannula (some providers jiggle cannula before removing, to free up adherent contents prior to removing).
   2. Evaluate for sharp or localized pain, vital signs, and bleeding.
   3. 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.
   4. Use US to assess expanding hematoma, fetal parts in the abdomen, or viscera / omentum in the uterus.
   5. 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 patient remains asymptomatic for pain or bleeding, consider observation for two hours, antibiotic coverage (Paul 2009; p. 241), and precautions before discharge.
   6. If perforation was with suction, evaluate the aspirate for omental fat or other visceral fragments, which confirm perforation with suction.
   7. Hospitalization is indicated if:
      1. There was suction in the abdominal cavity
      2. The patient is hemodynamically unstable. Place IVs and initiate IV fluid.
      3. The patient has significant pain.
      4. There is evidence of large perforation, laceration, expanding hematoma, fetal
         parts in the abdomen, or any viscera / omentum in uterus or aspirate

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1. For a 22 year-old G1P0 patient at 16 weeks EGA, you are completing an ultrasound-guided, 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?
   1. Assess for adequate pain control.
   2. Add additional dilation, which may help with instrumentation
   3. Switch to forceps with more substantial grasp or teeth
   4. Use a suction cannula to pull the calvarium into the lower uterine segment or out through the cervix
   5. Add additional misoprostol and giving some time for uterine contractions to assist in bringing down parts
   6. Have another provider assist if present in the clinic
   7. If still unsuccessful, consider transferring to a higher level of care.

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4. What overarching considerations and information might you need for a medically complex patient beyond ≥ 14 weeks that appears at your clinic? 
   1. Consider having patient bring visit records, ultrasound, ectopic records, lab records, medication list, if available
   2. See Chapter 3: Pre-Abortion Evaluation for detailed considerations for pre-abortion evaluation
   3. Consider the appropriateness of the clinical setting early
   4. Consider using formal or informal referral networks with warm hand-off using pager or cell phone, or warm lines for “second opinion”
   5. Work with local / regional / state abortion fund(s) to assist with coverage issues and logistics
   6. Have resources or work with support organizations for where patients can stay, obtain transportation, childcare, and other resources they may need
   7. Have agreements in place to transfer for in-hospital care, as needed
   8. Build partnerships with lawyers and involve the legal team early, as needed