unsafe abortion worldwide

1Basic Concepts for Delivering Postabortion Care

Unsafe abortion worldwide

The WHO estimates that:

• 20 million unsafe abortions occur worldwide each year.

• Each year more than 70,000 women die as a result of unsafe abortion.

• One out of every eight deaths related to pregnancy is due to unsafe abortion. (not indicated in text – NJ)


Factors that contribute to maternal mortality

• Poverty

• Poor nutrition

• Illiteracy

• Lack of access to health clinics

• Lack of sexual education

• Inferior quality of services (perceived or real)

• Women’s lack of control over their own sexual and reproductive lives

• Legal restrictions on abortion


The current state of PAC in many health clinics

• Medical equipment is obsolete or in poor condition

• Abortion patients are not treated with respect and sympathy

• Services are not well organized and supervision is poor

• Services are not accessible in rural and outlying areas

• Patient satisfaction is not the central focus

• Contraceptive counseling is not considered part of comprehensive patient care

• A limited variety of contraceptive methods is offered

• Patients’ medical, social and cultural circumstances are not taken into account


• Lack of adequate staff

• Inadequate physical conditions

• Lack of necessary equipment and medicine

• Lack of training in PAC

• Problems communicating with patients

• Lack of political decision making

• Lack of support from leaders

• Lack of respect and understanding for patients

• Increased staff workload and burnout

Potential difficulties in providing PAC services


• Inadequate infection-prevention programs

• Inadequate referral systems

• Inadequate monitoring and follow-up of training processes

• Administrative separation of emergency and contraceptive services

• Resistance to using manual vacuum aspiration (MVA)

Potential difficulties in providing PAC services(cont’d)


Elements and Purposes of PAC elements

Ensure that women have access to the full range of reproductive health services they need to protect their health

Links between emergency abortion treatment services and comprehensive reproductive health care

Prevent repeat unwanted pregnancies and abortion

Postabortion contraceptive counseling and services

Reduce maternal mortality and morbidityEmergency treatment services for complications of spontaneous or unsafely induced abortion

PURPOSEELEMENT


Health care providers should:

• Respect and support patients and their personal situations

• Exhibit nonjudgmental attitudes

• Respect patients’ confidentiality

• Respect each patient’s right to obtain information and make health care decisions

• Never coerce patients

• Provide opportunities for patients to express feelings and ask questions

• Show sensitivity to patients’ concerns


Empathetic people are:

• Genuine, pleasant and friendly

• Honest

• Quick to establish relationships with others

• Compassionate

• Helpful

• Good listeners

• Gentle and affectionate

• Nonjudgmental


Counseling before the MVA procedure can be affected by:

• Short amount of time to establish trust between patient and provider

• Lack of privacy and comfort

• Patient’s physical pain

• Patient’s feeling afraid, angry, relieved or anxious

• Patient’s inability to concentrate on detailed information

• Patient’s unwillingness to talk with a counselor about contraception

• Patient’s suspicion or fear regarding the purpose of the counseling


Techniques for effective communication

• Use short sentences and language the patient understands

• Repeat important points

• Encourage patient’s questions and give clear answers

• Listen to and acknowledge the patient’s feelings and concerns

• Use appropriate nonverbal language, such as tone of voice, gestures, eye contact and posture


Nonverbal communication techniques:

• Be comfortable and poised

• Face the patient

• Make eye contact

• Use friendly gestures – for instance, nod your head and lean forward

• Use a tone of voice that conveys interest and understanding

• Notice patient’s nonverbal communication

• Avoid appearing distracted – for example, do not fidget or look at the clock

• Avoid appearing tired, annoyed or bored – do not frown, shake your head or yawn

• Avoid appearing judgmental – do not point or look accusingly


Active listening

Active listening requires more than simply hearing what a patient says. Active listening is listening in a way that communicates empathy, understanding and interest.

1. How do you know if a person is really listening?

2. How do you know when someone is not listening?


Patients’ rights

All patients have the right to:

• Information

• Accessible services

• Safe services

• Choices

• Privacy

• Confidentiality

• Dignity

• Comfort

• Opinions

• Follow-up care


Principles for interacting with abortion patients• Respect patients’ privacy

• Respect patients’ rights

• Demonstrate concern and willingness to help

• Listen actively

• Respond to patients’ fears, problems and concerns

• Treat promptly

• Manage pain with support and medication

• Provide comprehensive information


Purpose of patient assessment

• Identify any pre-existing conditions that may affect treatment.

• Confirm that abortion has occurred.

• Determine cause of abortion.

• Determine duration of symptoms.

• Determine patient’s emotional state.

• Determine patient’s physical condition.

• Determine uterine size and position.

• Classify abortion.

• Identify any presenting complications.

• Make an accurate diagnosis.

• Develop a treatment plan.


Emergency treatment of postabortion complications includes:

• Performing an initial evaluation to confirm the existence of complications due to abortion.

• Talking to the patient about her clinical condition and the treatment plan.

• Performing a medical evaluation (accurate history, physical and pelvic exams focused on the problem).

• Referring and transferring the patient quickly if she needs treatment beyond the capacity of the clinic.

• Stabilizing emergency conditions and treating any complications.

• Vacuuming remaining tissue to evacuate the uterus.


Bimanual Exam


Before starting the procedure

• Ask the patient to urinate.

• Place her in gynecological position with her buttocks approximately 2 inches (5 centimeters) over the edge of the treatment table.

• Cover her legs, abdomen and buttocks with clean or sterile cloths.

• In most cases, shaving the genital area is not necessary.

• In most cases, cleaning or wetting the vulva is not necessary.


Preparing the patient for MVA

• Evaluate her emotional state.

• Answer all her questions, be empathetic and do not judge her.

• Explain the procedure, its advantages and risks (use simple language).

• Attempt to calm and relax her.

• Demonstrate relaxation breathing exercises.

• Ask about her needs for contraception.

• Earn her trust (be attentive, patient, gentle and sensitive).


Pain

Pain is the sensory and emotional experience associated with actual or potential tissue damage. Pain includes not only the perception of an uncomfortable stimulus but also the response to that perception.


Pain depends on:

• The intensity of stimulus on nerve endings (frequency and breadth)

• Individual predisposition for perceiving stimuli (anxiety and previous tension)

• Fear from previous experiences, expectations or misunderstandings

• Emotions


Ways that pain is amplified

Stimulus Tension

Pain

Response

Fear

CNS


Goal of pain management–To minimize the woman’s anxiety and discomfort with the least amount of risk to her health

LEAST PAINLEAST RISK


Types and origins of pain•Cervical dilation and/or stimulation

Deep intense pain

Diffuse lower abdominal pain with cramping

Scraping of uterine wall, movement of uterus or muscle spasms


Uterus

Vagina

Cervix

T12L1L2L3L4

S2

S3 S4

Nerves that transmit pain

Uterovaginal plexus -- cervix, upper vagina

Hypogastric plexus -- body, fundus of uterus


Requirements for effective pain management

• Personal interaction between patient and health care providers

• Quiet, private treatment room

• Friendly, calm, attentive health workers

• Clear explanation of what is happening

• Efficient, well-trained team

• Counseling and reassurance provided during the procedure


Purposes of supportive interaction

Ease fears:

Instill confidence in the health care team, provide counseling, clarify concepts

Reduce tension:

Humane treatment, understanding, empathy, deep-breathing exercises, distraction

Control pain:

Intensity, frequency, duration


Types of pain medication

• Analgesia - eases sensation of pain

• Anxiolytic - depresses central nervous system functions (reduces anxiety, relaxes muscles)

• Anesthesia - deadens all physical sensation


Preferred characteristics of anesthetics for use with MVA

• Rapid-acting

• Easy-to-use

• Low-risk

• Induces amnesia

• Quick recovery

• Low-cost


Types of anesthesia• General - affects pain receptors in

brain, produces complete unconsciousness

• Regional - blocks sensation from a specific point on the spine, patient awake

• Local - interrupts transmission of sensations in local tissue only


Effective pain management for MVA• Gentle handling of the patient

• The proper combination of drug types (anesthetics and analgesics)


Paracervical block

• Use a 22-gauge spinal needle or needle extender with a 10cc syringe.

• Aspirate before each injection.

InjectionSites


Paracervical block (cont’d)

• About 2 ml lidocaine into each injection site

• Inject at 3, 5, 7, 9 o’clocks (maximum dose = 10-20 ml, based on patient’s body weight)

• Wait 2-4 minutes for effect

OptionalInjectionSites

InjectionSites


Lidocaine for paracervical block

• Duration: 60-90 minutes

• Advantages: very few allergic reactions

• Toxic reactions to lidocaine:

• Mild: numbness in the mouth or on the tongue, dizziness and light-headedness and/or buzzing in the ears

• Severe: sleepiness and disorientation, muscle twitching, shivering, slurred speech, tonic-clonic convulsions and/or respiratory depression-arrest

• Latency period: short

• Maximum concentration: 5 to 20 minutes after administration

• Degradation: hepatic metabolism


Complications of local anesthetics

• Allergic reaction (rare):

• If hives or rash: give diphenhydramine (Benadryl) 25-50 mg IV

• If respiratory distress: give epinephrine 0.4 mg subcutaneously, and support respiration

• Toxic reaction (rare):

• If mild: give verbal support, monitor closely for a few minutes

• If severe: give immediate oxygen and slow IV diazepam 5 mg


Instruments for MVACannulae

Denniston Dilators

Ipas MVA Syringe

Note: The MVA syringe is also known as an aspirator. Some vacuum aspiration devices look different than the one pictured.

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Use MVA in postabortion care for:

• Threatened or imminent abortion

• Inevitable abortion

• Incomplete abortion

• Infected abortion

• Missed abortion

• Anembryonic pregnancy

• Hydatidiform mole

• Retained placental products

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Two types of vacuum aspiration

Electric Manual

Electric pump Manual syringe

Constant suction Suction not constant

350 – 1,200 cc of storage capacity 60 cc of storage capacity

Cannulae Cannulae

Rigid or flexible Flexible

Diameter of 4 to 16 mm Diameter of 4 to 12 mm

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Adapted from Greenslade et al. 1993

Efficacy of MVA

Treatment of Incomplete Abortion

Studies 19

Procedures >5,000

Aspiration time Generally from 3 to 5 minutes

Efficacy rate >98%

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Safety

Adapted from Grimes et al. 1977

Rate of complications in vacuum aspiration (electric and manual) vs. D&C in abortion

reported in JPSA study

Type of procedure

Total complications Serious complications

Vacuum Aspiration 5.0 0.4

D&C 10.6 0.9

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Percentage of women sustaining complications


Adapted from Baird et al. 1995.

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Average Number of Complications per 100 Procedures in Six Studies Comparing Vacuum Aspiration and Sharp Curettage

Type of Procedure Averages Across Six Studies

Excess Blood Uterine

Loss Perforation

Averages Across Three Studies

Pelvic Infection Cervical Injury

Vacuum Aspiration

Sharp Curettage

5.3 0.13

10.8 0.3

3.8 1.1

4.5 2.9


Advantages of MVA in treatment of incomplete abortion

• Requires only slight dilation and scrapes gently

• Lower risk of complications

• Lower cost of services

• Lower resource use

• Decreased need for hospitalization

• Outpatient procedure

• Local anesthesia

• Patients recover and return home more quickly

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Decrease in costs in Kenya Decrease in length ofhospital stay in Mexico

Resource savings associated with MVA

0

2

4

6

8

10

12

14

16

18

20 D&C

MVA

Hospital 1 Hospital 2Ave

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10

15

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25

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MVA

Hospital 1 Hospital 2

43

Adapted from Johnson et al. 1993


Comparison: Treatment of incomplete abortion

Frequently more than 24 hours

Usually less than 6 hoursHospital Stay

Often operating roomUsually treatment roomService Delivery Site

Often general anesthesiaUsually local anesthesiaPain Management

Usually requiredOccasionally requiredCervical Dilation

Higher ratesLower ratesComplications

Efficient*Very efficientEfficiency

D&CMVA

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*Efficiency is defined as a successful uterine evacuation with no remaining tissue


Preliminary steps • Take a clinical history

• Perform physical and pelvic exams

• Notice how she feels

• Ask the patient to urinate

• Place the patient in the gynecological position and cover her with a clean cloth

• Follow infection prevention protocols

• Evaluate and treat any complications

• Talk to the patient about contraception

• Determine appropriate type of pain management in order to decrease discomfort and pain

• Explain procedure to patient

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Possible presenting complications• Rapid pulse• Falling blood pressure• Excessive bleeding• Repeat abortions• Cervical/uterine perforation• Vagal reaction • Hemorrhage• Hypotension• Incomplete evacuation• Pelvic infection• Acute hematometra• Air embolism

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Precautions• Determine uterine size and position

– Because of the possibility of fibroids or other anomalies, do not perform MVA until uterine size and position are determined.

• Use appropriate cannula size

– Cannula of incorrect size may result in damage to cervix, loss of suction or retained tissue.

• Insert cannula carefully

– Do not insert cannula forcefully as forceful movements may damage the cervix or uterus.

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Instruments and materials needed for MVA• Vaginal speculum

• Tenaculum

• Forceps

• Uterine or gynecological tweezers

• Basins for antiseptic and tissue

• Needle extenders

• Denniston or Pratt Dilators, of 3 to 14 mm in diameter

• 10cc syringe with spinal needle #22 of 3.5 inches or needle #23

• Local anesthesia (1% or 2% lidocaine without epinephrine)

• Antiseptic solution

• Small gauze (20)

• Sterile gloves

• Sterile fields

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Selecting the cannula

Adapters for the double-valve syringe are color-coded to the dots on the corresponding cannula.

Approximate uterine size

(weeks LMP)

Approximate size of the cannula

5 to 7 LMP 4 to 6 mm

8 to 9 LMP 7 to 8 mm

10 to 12 LMP 9 to 12 mm

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Selecting adapters

Cannulae Syringe

4,5, and 6 mm Single

4, 5, and 6 mm Double

7 mm Double

8 mm Double

9 mm Double

10 mm Double

12 mm Double

Select the adapters based on the cannula and the type of syringe to be used

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Adapter

Not needed

Blue

Brown

Beige

Dark brown

Dark green

Not needed


• Inspect the syringe

• Connect the adapter

• Inspect the plunger and the buttons of the valve

• Close the safety valve

• Inspect the syringe

• Connect the adapter

• Inspect the plunger and the buttons of the valve

• Close the safety valve

Preparing MVA instruments

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• Prepare the vacuum in the syringe

• Make sure the syringe holds a vacuum

• Check that the instruments, the materials and medications are in the tray

• Prepare the vacuum in the syringe

• Make sure the syringe holds a vacuum

• Check that the instruments, the materials and medications are in the tray

Preparing MVA instruments (continued)

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Preparing the cervix

• Place the speculum

• Wipe the cervix and the vagina with an antiseptic

• Stabilize the cervix with the tenaculum

• Apply paracervical block, if required

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Options for stabilizing the cervix

1. Place the two arms of the tenaculum in the anterior position

2. Place the two arms of the tenaculum in the posterior position

3. Place one arm of the tenaculum inside the cervical canal and the other at the 10 o’clock position

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Cervical dilation

• Grasp the narrowest dilator in the middle

• Hold it between the thumb and index finger with your hand below the dilator

• Insert it gently until it passes through the internal os

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Cervical dilation (continued)

• Grasp the dilator in the middle

• Hold it between the thumb and index finger with your hand above the dilator

• Withdraw the dilator

• Rotate it carefully and insert it again

• Dilate the cervix up to the size of the Denniston dilator that is required for the selected cannula

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Inserting the cannula

• Apply traction to the tenaculum gently

• Insert the selected cannula gently through the cervix with a rotation movement

• Do not touch the end that will be inserted into the uterus

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Uterine sounding

6cm

There are 6 cm from the tip of the cannula to the first dot, and 1 cm between each dot.

• Push the cannula slowly inside the uterine cavity until it touches the fundus

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Connecting the cannula to the syringe

• Hold the cannula with the thumb and index finger, while holding the syringe with the other hand

• Connect the cannula to the syringe

• Do not push the cannula forward in the uterus

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Creating a vacuum

• When the safety valve is released, the vacuum is transferred to the uterus through the cannula

• The passage of blood and tissue through the cannula to the syringe begins

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Evacuating uterine contents

• Hold the cannula with the thumb and index finger and the syringe with the ring and little fingers

• Move the cannula back and forth gently and slowly, rotating the cannula and the syringe at the same time

• Do not withdraw the aperture of the cannula beyond the external cervical os

Do not grasp the syringe by the plunger arms!

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Loss of vacuum during the procedure

The MVA Syringe may lose suction if:

• Syringe is full

• Cannula has come out of the external os

• Cannula is not properly attached

• Cannula is too small

• Black O-ring is not properly placed in the plunger

• Uterine perforation has occurred

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If the syringe becomes full:

1. Close the valve

2. Disconnect the syringe, leaving the tip of the cannula inside the uterus - Do not push the plunger in when disconnecting the syringe!

3. Open the valve

4. Empty the contents of the syringe in a container

5. Re-establish the vacuum, reconnect the syringe, and continue, or connect another prepared syringe and resume the aspiration

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• Reinsert the cannula

• Detach the syringe and empty its contents

• Re-establish the vacuum

• Reconnect the syringe

• Resume the procedure

Do not allow the cannula to come in contact with anything that may not be sterile.

If the cannula has been withdrawn from the external os:

Cannula withdrawn through cervix

If contamination occurs, use another cannula!

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If tissue clogs the cannula’s aperture:

• Withdraw the cannula slowly up to the external os. The release of air will cause the tissue to pass through to the syringe.

• Reinsert the cannula in the uterus, detach the syringe, empty its contents, re-establish the vacuum and resume the procedure.

• Never try to unclog the cannula by pushing back into the barrel.

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Signs of completion of the procedure

• There is pinkish foam in the cannula

• No more tissue is seen passing through the cannula

• A gritty sensation is felt

• The uterus grips the cannula and it is difficult to move it

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Recognizing and managing uterine perforationSigns:

Instruments inserted beyond the fundus

Excessive bleeding

Fat or organ fragments in the aspirated tissue

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Treatment:

Usually seals itself off as uterus contracts

May require laparotomy or laparoscopy

Begin IV fluids and/or antibiotics

Give blood transfusion, if necessary

Repair the damage by suturing

Give oxytocics after the surgery

Monitor vital signs

Give ergotamine

Observe patient until her vital signs are normal


After the procedure

• Disconnect syringe

• Withdraw cannula and tenaculum

• Check for active bleeding in the uterus or in the cervix

• Withdraw speculum if bleeding has stopped

• Place all instruments in 0.5% chlorine solution

• Perform bimanual exam

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Inspecting the tissue

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• Follow protocols for infection- prevention

• Strain and rinse the tissue

• Using a transparent container, inspect the material by examining it with a light from behind

• Make sure all the tissue has been withdrawn

• Send the tissue to the pathology lab as indicated


Inspecting the tissue (cont’d)

Inspect the tissue, looking for:

villi, tissue, membranes or fetal parts (after 9 weeks LMP)

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Patient recovery and discharge

In recovery:

• Take patient’s vital signs

• Allow the patient to rest comfortably where staff can monitor her recovery

• Check that bleeding and cramping have lessened

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Discharge when:

• Her vital signs are normal

• She can walk without assistance

• She has received information about follow-up care and recovery

• She has been counseled and informed about her return to fertility and contraception


Patient recovery

Performing the MVA procedure with a low level of medications for pain management leads to a quick recovery of the patient.

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What the patient needs to know

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• She should expect some uterine cramping and bleeding.

• Her normal menstrual period should begin within 4-8 weeks.

• She should take medications as prescribed.

• She should not have sex or put anything into the vagina until a few days after bleeding stops.

• She could become pregnant before her next period is expected.

• Contraception can prevent or delay pregnancy, if she so desires.

• She should schedule a follow-up visit.

• Where to seek medical attention if she experiences prolonged cramping, excessive bleeding, severe pain, fever, chills, malaise or fainting.


Postabortion contraception: breaking the cycle of repeat unwanted pregnancy and unsafe abortion

Unwanted or high-risk pregnancy

Restricted access to safe abortion services

Unsafe abortion

Emergency abortion care

Postabortion Contraception

Contraceptive non-use, non-availability or failure; involuntary or unplanned sex


Return to fertility

First-trimester abortion: A woman usually recovers her fertility during the first two weeks after the abortion.

Second-trimester abortion: A woman usually recovers her fertility during the first four weeks after the abortion.


• All modern methods can be considered for use after an abortion, barring contraindications.

• If a woman does not want to become pregnant again, she needs a method that will be efficient and easy to use.

• Begin the use of hormonal methods during the first week after treatment for an incomplete abortion.

• Postpone the use of natural contraception until a full, normal cycle has resumed.

General recommendations


• The woman’s reproductive plans

• Tension and pain

• The woman’s previous experience with contraception

• The woman’s level of knowledge about contraception and reproduction in general

• Potential risk of contracting STDs or AIDS

Factors that can affect contraception selection


• Continuous access to services and supplies

• Access to a qualified provider, in case of complications or if she wants to change methods

Access to resources To use a contraceptive method efficiently, women need:

What factors affect access to resources?


Protocols for dispensing contraceptive methods and making referrals

• Are there national, regional or local regulations for different levels of care?

• Are they followed?

• Are they adequate for local circumstances and needs?

• Is there an efficient referral system? • Are referral cards or notes provided at all levels of care?


• Infection or sepsis

• Trauma to the genital tract and internal organs (perforation of the uterus, vaginal lesions, cervical leisonss)

• Hemorrhage and severe anemia

Possible complications of incomplete abortion


• Postpone surgical sterilization and IUD insertion until the infection is completely resolved or has been ruled out.

• All other methods may be considered.

Contraception in case of suspected or confirmed infection


• Postpone surgical sterilization and IUD insertion until the trauma has healed.

• The site and severity of the lesions can affect the use of a diaphragm or spermicides.

Contraception when trauma has occurred to the genital tract


• Hemorrhage may result in temporary anemia which resolves quickly.• Female surgical sterilization should be postponed because of the risk of

excessive blood loss and increased risks associated with anesthesia.

Contraception after hemorrhage


• The fallopian tubes may be difficult to locate, hindering surgical sterilization.

• IUD rejection is more likely.

• Wait six weeks after a second-trimester abortion to measure for placement and use of a diaphragm.

Contraception after second-trimester abortion

unsafe abortion worldwide

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