Transcript No Slide Title

Basic 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)
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Basic Concepts for Delivering Postabortion Care
Factors that contribute to maternal mortality
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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
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Basic Concepts for Delivering Postabortion Care
The current state of PAC in many health clinics
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Medical equipment is obsolete or in poor condition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
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Basic Concepts for Delivering Postabortion Care
Potential difficulties in providing PAC services
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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
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Basic Concepts for Delivering Postabortion Care
Potential difficulties in providing PAC services
(cont’d)
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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)
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Basic Concepts for Delivering Postabortion Care
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Elements and Purposes of PAC elements
ELEMENT
PURPOSE
Emergency treatment services for
complications of spontaneous or
unsafely induced abortion
Reduce maternal mortality and morbidity
Postabortion contraceptive counseling
and services
Prevent repeat unwanted pregnancies
and abortion
Links between emergency abortion
treatment services and comprehensive
reproductive health care
Ensure that women have access to the
full range of reproductive health services
they need to protect their health
Basic Concepts for Delivering Postabortion Care
Health care providers should:
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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
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Basic Concepts for Delivering Postabortion Care
Empathetic people are:
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Genuine, pleasant and friendly
Honest
Quick to establish relationships with others
Compassionate
Helpful
Good listeners
Gentle and affectionate
Nonjudgmental
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Basic Concepts for Delivering Postabortion Care
Counseling before the MVA procedure can be
affected by:
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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
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Basic Concepts for Delivering Postabortion Care
Techniques for effective communication
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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
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Basic Concepts for Delivering Postabortion Care
Nonverbal communication techniques:
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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
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Basic Concepts for Delivering Postabortion Care
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?
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Basic Concepts for Delivering Postabortion Care
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Patients’ rights
All patients have the right to:
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Information
Accessible services
Safe services
Choices
Privacy
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Confidentiality
Dignity
Comfort
Opinions
Follow-up care
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Principles for interacting with abortion patients
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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
Basic Concepts for Delivering Postabortion Care
Purpose of patient assessment
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Identify any pre-existing conditions that may affect treatment.
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Confirm that abortion has occurred.
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Determine cause of abortion.
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Determine duration of symptoms.
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Determine patient’s emotional state.
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Determine patient’s physical condition.
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Determine uterine size and position.
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Classify abortion.
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Identify any presenting complications.
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Make an accurate diagnosis.
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Develop a treatment plan.
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Basic Concepts for Delivering Postabortion Care
Emergency treatment of postabortion complications includes:
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Performing an initial evaluation to confirm the existence of complications due to abortion.
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Talking to the patient about her clinical condition and the treatment plan.
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Performing a medical evaluation (accurate history, physical and pelvic exams focused on the
problem).
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Referring and transferring the patient quickly if she needs treatment beyond the capacity of
the clinic.
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Stabilizing emergency conditions and treating any complications.
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Vacuuming remaining tissue to evacuate the uterus.
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Bimanual Exam
Basic Concepts for Delivering Postabortion Care
Before starting the procedure
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Ask the patient to urinate.
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Place her in gynecological position with her buttocks approximately 2 inches (5 centimeters)
over the edge of the treatment table.
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Cover her legs, abdomen and buttocks with clean or sterile cloths.
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In most cases, shaving the genital area is not necessary.
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In most cases, cleaning or wetting the vulva is not necessary.
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Basic Concepts for Delivering Postabortion Care
Preparing the patient for MVA
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Evaluate her emotional state.
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Answer all her questions, be empathetic and do not judge her.
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Explain the procedure, its advantages and risks (use simple language).
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Attempt to calm and relax her.
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Demonstrate relaxation breathing exercises.
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Ask about her needs for contraception.
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Earn her trust (be attentive, patient, gentle and sensitive).
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Basic Concepts for Delivering Postabortion Care
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.
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Basic Concepts for Delivering Postabortion Care
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
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Ways that pain is amplified
Fear
Stimulus
Pain
CNS
Response
Tension
Basic Concepts for Delivering Postabortion Care
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Goal of pain management
–To minimize the woman’s
anxiety and discomfort
with the least amount of
risk to her health
LEAST RISK
LEAST PAIN
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Types and origins of pain
•Cervical dilation and/or
stimulation
Deep intense pain
Scraping of uterine wall,
movement of uterus or
muscle spasms
Diffuse lower abdominal pain
with cramping
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Nerves that transmit pain
T12
L1
L2
L3
L4
Hypogastric plexus -body, fundus of
uterus
Uterus
S2
S3
S4
Cervix
Vagina
Uterovaginal plexus -cervix, upper vagina
Basic Concepts for Delivering Postabortion Care
Requirements for effective pain management
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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
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Basic Concepts for Delivering Postabortion Care
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
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Basic Concepts for Delivering Postabortion Care
Types of pain medication
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Analgesia - eases sensation of pain
Anxiolytic - depresses central nervous system
functions (reduces anxiety, relaxes muscles)
Anesthesia - deadens all physical sensation
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Basic Concepts for Delivering Postabortion Care
Preferred characteristics of anesthetics
for use with MVA
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Rapid-acting
Easy-to-use
Low-risk
Induces amnesia
Quick recovery
Low-cost
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Basic Concepts for Delivering Postabortion Care
Types of anesthesia
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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
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Basic Concepts for Delivering Postabortion Care
Effective pain management for MVA
• Gentle handling of the patient
• The proper combination of drug types (anesthetics and analgesics)
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Basic Concepts for Delivering Postabortion Care
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Paracervical block
• Use a 22-gauge spinal
needle or needle extender
with a 10cc syringe.
• Aspirate before each
injection.
Injection
Sites
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Paracervical block (cont’d)
Optional
Injection
Sites
Injection
Sites
• 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
Basic Concepts for Delivering Postabortion Care
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 lightheadedness 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
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Basic Concepts for Delivering Postabortion Care
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
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Instruments
for MVA
Cannulae
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.
Basic Concepts for Delivering Postabortion Care
Use MVA in postabortion care for:
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Threatened or imminent abortion
Inevitable abortion
Incomplete abortion
Infected abortion
Missed abortion
Anembryonic pregnancy
Hydatidiform mole
Retained placental products
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Basic Concepts for Delivering Postabortion Care
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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
Basic Concepts for Delivering Postabortion Care
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Efficacy of MVA
Treatment of Incomplete Abortion
Studies
Procedures
Aspiration time
Efficacy rate
Adapted from Greenslade et al. 1993
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>5,000
Generally from 3 to 5 minutes
>98%
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Safety
Rate of complications in vacuum aspiration
(electric and manual) vs. D&C in abortion
reported in JPSA study
Type of procedure
Percentage of women sustaining complications
Total complications
Serious complications
Vacuum Aspiration
5.0
0.4
D&C
10.6
0.9
Adapted from Grimes et al. 1977
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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
Loss
Vacuum Aspiration
Sharp Curettage
Adapted from Baird et al. 1995.
5.3
10.8
Uterine
Perforation
0.13
0.3
Averages Across Three
Studies
Pelvic Infection
3.8
4.5
Cervical Injury
1.1
2.9
Basic Concepts for Delivering Postabortion Care
Advantages of MVA in treatment of
incomplete abortion
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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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Resource savings associated with MVA
Average cost per patient in $US
Decrease in costs in Kenya
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Decrease in length of
hospital stay in Mexico
D&C
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MVA
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16
14
D&C
MVA
30
12
10
25
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15
6
4
10
20
5
2
0
0
Hospital 1 Hospital 2
Adapted from Johnson et al. 1993
Hospital 1
Hospital 2
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Comparison: Treatment of incomplete abortion
MVA
D&C
Efficiency
Very efficient
Efficient*
Complications
Lower rates
Higher rates
Cervical Dilation
Occasionally required
Usually required
Pain Management
Usually local anesthesia
Often general anesthesia
Service Delivery Site
Usually treatment room
Often operating room
Hospital Stay
Usually less than 6 hours
Frequently more than 24
hours
*Efficiency is defined as a successful uterine evacuation with no remaining tissue
Basic Concepts for Delivering Postabortion Care
Preliminary steps
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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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Basic Concepts for Delivering Postabortion Care
Possible presenting complications
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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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Basic Concepts for Delivering Postabortion Care
Precautions
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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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Basic Concepts for Delivering Postabortion Care
Instruments and materials needed for MVA
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Vaginal speculum
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Tenaculum
Forceps
Uterine or gynecological tweezers
Basins for antiseptic and tissue
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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)
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Antiseptic solution
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Small gauze (20)
Sterile gloves
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Sterile fields
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Selecting the 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
Adapters for the double-valve syringe are color-coded to the dots on the
corresponding cannula.
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Selecting adapters
Select the adapters based on the cannula
and the type of syringe to be used
Cannulae
Syringe
Adapter
4,5, and 6 mm
Single
Not needed
4, 5, and 6 mm
Double
Blue
7 mm
Double
Brown
8 mm
Double
Beige
9 mm
Double
Dark brown
10 mm
Double
Dark green
12 mm
Double
Not needed
Basic Concepts for Delivering Postabortion Care
Preparing MVA instruments
• Inspect the syringe
• Connect the adapter
• Inspect the plunger and the
buttons of the valve
• Close the safety valve
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Basic Concepts for Delivering Postabortion Care
Preparing MVA instruments (continued)
• 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
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Basic Concepts for Delivering Postabortion Care
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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
Basic Concepts for Delivering Postabortion Care
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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Basic Concepts for Delivering Postabortion Care
Cervical dilation
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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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Basic Concepts for Delivering Postabortion Care
Cervical dilation (continued)
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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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Basic Concepts for Delivering Postabortion Care
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Inserting the cannula
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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
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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
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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
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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
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Do not grasp the syringe by the plunger arms!
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
Basic Concepts for Delivering Postabortion Care
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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If the cannula has been withdrawn from the
external os:
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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 contamination occurs, use another cannula!
Basic Concepts for Delivering Postabortion Care
If tissue clogs the cannula’s aperture:
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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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Basic Concepts for Delivering Postabortion Care
Signs of completion of the procedure
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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 perforation
Signs:
Instruments inserted beyond
the fundus
Excessive bleeding
Fat or organ fragments in the
aspirated tissue
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
Basic Concepts for Delivering Postabortion Care
After the procedure
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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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Basic Concepts for Delivering Postabortion Care
Inspecting the tissue
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Follow protocols for infectionprevention
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
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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:
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Take patient’s vital signs
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Allow the patient to rest
comfortably where staff can
monitor her recovery
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Check that bleeding and cramping
have lessened
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
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Patient recovery
Performing the MVA
procedure with a low level
of medications for pain
management leads to a
quick recovery of the
patient.
Basic Concepts for Delivering Postabortion Care
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.
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Postabortion contraception: breaking the cycle of
repeat unwanted pregnancy and unsafe abortion
Postabortion Contraception
Contraceptive non-use,
non-availability or
failure; involuntary or
unplanned sex
Unwanted or highrisk pregnancy
Restricted access to
safe abortion services
Emergency
abortion care
Unsafe abortion
Basic Concepts for Delivering Postabortion Care
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.
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Basic Concepts for Delivering Postabortion Care
General recommendations
• 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.
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Basic Concepts for Delivering Postabortion Care
Factors that can affect contraception selection
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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
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Basic Concepts for Delivering Postabortion Care
Access to resources
To use a contraceptive method efficiently, women need:
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Continuous access to services and supplies
Access to a qualified provider, in case of complications or if she wants
to change methods
What factors affect access to resources?
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Basic Concepts for Delivering Postabortion Care
Protocols for dispensing contraceptive methods
and making referrals
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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?
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Basic Concepts for Delivering Postabortion Care
Possible complications of incomplete abortion
• Infection or sepsis
• Trauma to the genital tract and internal organs (perforation of the uterus,
vaginal lesions, cervical leisonss)
• Hemorrhage and severe anemia
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Basic Concepts for Delivering Postabortion Care
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Contraception in case of suspected or
confirmed infection
• Postpone surgical sterilization and IUD insertion until the infection is completely
resolved or has been ruled out.
• All other methods may be considered.
Basic Concepts for Delivering Postabortion Care
Contraception when trauma has occurred
to the genital tract
• 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.
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Basic Concepts for Delivering Postabortion Care
Contraception after hemorrhage
• 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.
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Basic Concepts for Delivering Postabortion Care
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Contraception after second-trimester abortion
• 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.