Counseling for 2nd trimester abortion within the health care system or without a clinician

Background: Counseling for second trimester abortion patients can look like different processes within the health care system and without a clinician. The purpose of this presentation is to highlight the challenges and practices of counseling for second trimester abortion patients in both contexts.

Within the Health Care System:

• Informed Consent:
  • Developed from human rights principles
    •  Bodily integrity, autonomy, and self-determination.
  • Ethical and legal process of communication that enables patients to make informed and voluntary decisions.
    • A woman’s ability to give voluntary consent can be constrained by many factors including stigma, reproductive coercion, biased counseling laws, and social, economic and structural inequities.
• Documenting Informed Consent:
  • Disclosure requirements
    • Description of patient’s medical condition and treatment options (including no treatment)
    • Benefits and risks of each option.
• Later Abortion Procedures:
  • Dilation and Evacuation (D&E)
  • Induction of Labor (IOL) using a combination of mifepristone and misoprostol or misoprostol alone.
  • Compared to IOL, D&E is:
    • Preferred by patients.
    • More efficient.
    • Comparably safe, although types of complication differ.
    • Associated with less reported pain and post-procedure bleeding.
• Issues with Counseling:
  • Ambivalence
    • Even when patients are certain of their decision to have an abortion, they may express some uncertainty.
  • Setting expectations for coping
    • Some women may feel sad.
  • Personal beliefs about abortion
  • Identifying sources of anxiety and how to decrease them.
  • Some women may want to view products of conception to help them cope.
    • Other women may use rituals or songs
    • Some states require fetal tissue to be buried, which can be stigmatizing and burdensome for women who would prefer not to or cannot afford this option.
  • Addressing social or financial needs
  • Referrals to other clinics
    • If patient exceeds their local clinic’s maximum gestational age limit.

D&E procedure:

• Safe, but can be challenging in some situations (e.g., history of multiple C-sections)
  • Factors that affect safety: gestational age, cervical dilation, experience of the provider.
• After confirmation of pregnancy through ultrasound, and administration of lab tests to determine hematocrit levels and Rh, cervical preparation can begin,
  • Osmotic cervical dilators.
  • Mifepristone and/or misoprostol
  • Injection to cause fetal demise (digoxin or potassium chloride)
  • Antibiotics.
• Procedure
  • Pain management
    • IV Sedation
    • General anesthesia
  • Removal of cervical dilators
  • Evacuation of the uterus
  • IUD or Nexplanon can be placed immediately post-procedure, if desired
• After Care:
  • Recovery area care
  • Contraception, if desired
• Home care instructions:
  • Bleeding and cramping (ibuprofen)
  • Resolution of pregnancy symptoms
  • Warning signs for possible complications (fever, heavy bleeding)
  • 24-hour emergency number
• Follow-up visit appointment, if desired
  • Not routinely necessary.

Without a Clinician:

• Outside of the formal healthcare sector, the line between consent and counseling are blurred.
• Women Help Women with support from its partners Samsara in Indonesia and the Socorristas in Argentina, has developed guidelines for supporting those self-managing their abortions in the second trimester.
  • WHW is a world-wide telehealth service
  • Counseling and giving information on self-managed abortion, contraceptives, and access to other reproductive health services via over 12,000 emails each month, in 6 languages.
• Counseling for Self-Managed Later Abortion:
  • The aim of counseling for self-managed abortion is to prepare people via email, text, and in-person, for every step of the abortion process. Especially for later abortion, women must be prepared for:
    • What she will see
      • Should inform patients that the longer the pregnancy, the larger the products will be. The fetus may look more like a baby.
    • Amount of pain
      • More pain and cramping in second trimester abortion than first trimester. After 18 weeks, the process is more like premature labor.
      • Counseled on pain management (ibuprofen) and to have someone with them for support.
    • Higher rates of complications and what they should say if they go to a doctor or hospital
      • Informed that there is a slightly higher risk of hemorrhage or infection, but it is still much safer than other types of self-managed abortion or a full term birth
      • Cautioned not to pull down the placenta.
      • Advised to tell doctors that they had a miscarriage and in many contexts, to act distraught about losing the pregnancy.
    • A plan to dispose of the fetus
      • Women are not told what kind of plan to make, but instead they are encouraged to make a plan before taking the pills.
      • The plan must come from the woman because it is legally risky to suggest how to go about disposing the fetus. Sharing information on what other women have done, however, is okay.
    • Emotional issues
      • Inform women that they may feel a range of emotions after the abortion, including sadness.

Conclusion: The practice of doing abortion at any gestational age is about trusting women.